To the best of our knowledge, this is the first scoping review to synthesise the available evidence on factors supporting international medical travel from Indonesia. It is noted that the number of Indonesian patients from low, middle, and upper class participating in international medical travel has increased in recent years [23, 51, 62]. Our findings suggest that international medical travel by Indonesian patients is linked to five domains:(i) the availability of health services, medical specialities, and person-centred care in the designated countries, (ii) region adjacency, transport, and health agency, (iii) affordability of medical treatment in other countries, (iv) religious and socio-cultural factors, and (v) reasons patients reported distrust in Indonesian doctors.
Overall, our findings have highlighted that patient’s perceive low quality of Indonesian health care and treatment, resulting in Indonesia becoming the major supplier of patients to neighbouring countries, such as Malaysia, Singapore, and Thailand [18–20]. This scoping review shows that patients seeking medical treatment outside of Indonesia do so due to a number of reported issues, including the unavailability of medical equipment, inadequate qualified doctors, and inadequate trained staff in healthcare facilities in remote and border areas of Indonesia. These factors have been identified as heavily influencing patients’ preferences to seek medical treatment overseas. This scoping review supports previous findings which have reported that Indonesia has a comparably low ratio of qualified doctors to patients, and most prefer to work in private hospitals in urban areas within Indonesia [63–65], resulting in understaffing and the maldistribution of skilled staff within periphery areas [66, 67]. It is suggested that with a population of about 270 million, Indonesia needs 270,000 doctors [68]. Currently, Indonesia has only 110,000 doctors with the ratio of doctors to patients being 0.6:1000, which is very low compared to other countries, such as Malaysia with the ratio of 2.2:1000 [68].
Across studies, patients reported feeling frustrated, neglected and that they were not being provided with person-centred care within Indonesian health settings. Further, evidence suggests patients felt undervalued in Indonesian health systems and that their care was not prioritised. This was identified as stemming from factors including sparseness of health facilities, a shortage of qualified doctors, and trained staffs [69]. There is also evidence that patients sought more timely health care and treatment overseas as a consequence of long waiting time periods for medical treatment within Indonesia [70].
Reflecting upon geographical proximity, it is understandable that inequality of health facilities and medical staff distribution between Java and border areas or eastern part of Indonesia has contributed to patients’ decision to take international medical travel to the nearest neighbouring countries. Some regions in Malaysia such as Penang, Melaka, and Kuching are the most popular destinations for Indonesian patients. For example, Kuching can be accessed by air taking about 45 minutes and by land taking about 10–12 hours, allowing lower-middle class patients from West Kalimantan to easily have access to medical services [30, 32, 33, 39, 52]. Having treatment in Malaysia is also supported by inexpensive transport costs compared to travel to Jakarta by plane which is 3–5 times more expensive. Reliable transport was also a contributing factor for patients seeking medical treatment overseas due to the convenience it afforded them [30, 33, 39]. Similarly, the reliability of services from health agencies overseas in connecting patients with foreign healthcare providers played a significant role in supporting Indonesian patients’ medical tourism and were reported to have accelerated medical tourism growth in countries, such as Malaysia, Singapore and Thailand [71, 72]. Health agencies were acknowledged to have added values to services, such as arranging pre- and post-treatment, travel arrangements, and scheduling tours in destination countries which increased the appeal of international medical tourism [71, 72]. Our findings indicate that Indonesian patients participate in international medical tourism due to having limited access to adequate quality healthcare within the borders of Indonesia. Improvements in the access, coverage, and quality of healthcare throughout Indonesia, (specifically in less urban areas) may reduce the occurrence of international medical tourism and improve patient perception of local health services.
High cost of medical treatment in hospitals in Indonesia was another common theme discussed in the majority of studies [31–33, 39, 40, 46, 47, 50, 51, 58, 60]. Medical treatment in Jakarta, for example, was considered more expensive than in Malaysia which is well known as the most preferred international medical travel destination due to its excellent service and cost affordability [15]. Our findings suggest that healthcare facilities with modern technologies are also available in some hospitals in big cities in Indonesia, such as Jakarta, East Java, West Java, and Central Java, however some studies reported issues in the quality of medical services and treatment being offered [39, 40]. This seemed to have resulted in an increased tendency for Indonesian patients to travel internationally to seek medical treatment and a second opinion from doctors. Moreover, different diagnostic results and faster recovery time received overseas undoubtedly have increased suspicion and distrust in medical treatment and doctors within Indonesia. Studies reported this was due to inaccurate diagnoses, ineffective medicines, incomprehensive assessment, and patients receiving inconsistent explanations regarding diseases [73, 74]. Such negative experiences have shown to have implications on both interpersonal trust in doctors who provide treatment to patients and institutional trust, particularly with the education system that trained the doctors [75]. This in turn created negative perceptions towards the country’s health system.
Findings of this review have suggested similarities in religion (Islam) and culture (Malay and Chinese) were also factors that strengthened Indonesian patients’ preferences for medical treatment in other countries, such as Malaysia and Singapore [31, 42]. In addition, the growing level of dissatisfaction towards healthcare services in public or government owned hospitals has also become the underlying reason for many Indonesian people from upper class or secure economic backgrounds seeking medical treatment overseas. Our findings strengthen previous reports suggesting a lower satisfaction of patients towards healthcare service and treatment in public hospitals compared to private hospitals in Indonesia [76, 77]. The findings imply the need for the improvement of healthcare systems, medical treatments, and service delivery within the Indonesian public hospital sector.
Implication for future intervention
This study emphasises the importance of prioritising the improvement of domestic health systems within Indonesia, particularly within periphery areas. This includes ensuring the equitable distribution of quality healthcare facilities, medical equipment, technology, and the fostering of a strong national healthcare workforce. Increasing the number of medical specialists within Indonesia and improving standards of care nationwide (and not just in urban areas) may promote engagement with Indonesian medical services over international ones. It is anticipated that such improvements would result in increased local service utilisation and reduced medical tourism as patients regain trust in the healthcare system within Indonesia. These findings could also be used to inform Indonesian healthcare workers on patients’ perceptions and concern with care.
Implication for future study
This review suggests that there have been very limited studies involving Indonesian health workers or doctors in peripheral areas. Also, there have been very limited studies involving patients from Jakarta and other regions in Java that have contributed more than 50% of Indonesian patients taking medical tourism. None of the included studies involved policy makers from the Indonesian government and private sectors to explore their perspectives on the increased medical tourism among Indonesians. As there have been millions of Indonesian people travelling overseas for medical treatments, there is a need for further studies exploring the continuity and management of care for the patients returning home to Indonesia. Future studies that address all these aspects are recommended as the results can be used to inform and improve health policy and system and healthcare practice and delivery in Indonesia.
Strength and limitation of the study
Although there are many studies on international medical travel among Indonesian patients, to our knowledge, this is the first scoping review on international medical travel taken by Indonesians. The use of several databases for data search helped researchers identify a broad range of themes on this topic involving Indonesian patients. However, as this review only included articles published in English, we may have missed studies on this topic reported in other languages.