Developing Equitable Policies for Task-Shifting from Supervisors to Resident Doctors in Indonesian Teaching Hospitals: A Legal and Ethical Framework
DOI:
https://doi.org/10.52609/jmlph.v5i4.197Keywords:
Healthcare Regulations, Patient Safety, Resident Doctors, Specialist Medical Education, Super, Task ShiftingAbstract
Background: Task-shifting from supervisors to resident doctors is critical to specialist medical education in Indonesia. While broadly regulated under Law No. 17 of 2023, the absence of specific derivative regulations creates significant challenges, including role ambiguity, increased risk of medical errors, and inequities in supervision.
Aims: This study aims to critically evaluate the proposed implementation of international best practices within Indonesia’s unique healthcare system and formulate a legal and ethical framework for equitable task delegation.
Methods: Employing an empirical juridical approach, the study integrates in-depth interviews, document analysis, and legal doctrinal reviews across multiple teaching hospitals.
Result: Findings indicate that the absence of derivative regulations leads to ambiguity in authority, inconsistent supervision practices, and heightened medical risks. International models such as the ACGME and EU directives offer useful insights but require contextual adaptation. This study further highlights systemic barriers in Indonesia, including resource constraints, logistical challenges, and political inertia. The critical role of supervisors is emphasised, necessitating clear training, certification, and accountability standards.
Conclusion: There is an urgent need for a structured and localised task-shifting policy framework that integrates global standards while addressing Indonesia's practical realities. The proposed model outlines legal clarity, equitable delegation mechanisms, competency-based assignments, and institutional accountability.
References
K. Bwalya. Physical education and sport for social development: Implications and prospects in the COVID-19 era. Journal of Preventive and Rehabilitative Medicine. 2021;3(2):5–6. doi: 10.21617/jprm2021.322.
Sulistiono MA, Purwadi H. Doctor’s legal responsibility for unlawful actions against medical action errors. Russian Law Jour-nal. 2023;11(1):88–94. doi: 10.52783/rlj.v11i1.352.
Gumelar IE, Ravena D. Delegation of au-thority for medical action from doctors to nurses in health services facilities. Interden-tal Jurnal Kedokteran Gigi (IJKG). 2022;18(1):14–19. doi: 10.46862/interdental.v18i1.4309.
Baine SO, Kasangaki A. A scoping study on task shifting: The case of Uganda. BMC Health Services Research. 2014;14(1). doi: 10.1186/1472-6963-14-184.
Rokhim A. Kewenangan Pemerintahan Dalam Konteks Negara Kesejahteraan (Welfare State). Jurnal Ilmiah Dinamika Hukum FH Unisma Malang Edisi Pebru-ari-Mei 2013. Malang, 2013.
Wulandari P, Hidayat R. Legal review of physician malpractice cases: A narrative literature review. Open Access Indonesia Journal of Social Sciences. 2022;5(6):871–879. doi: 10.37275/oaijss.v5i6.144.
Orkin AM, et al. Conceptual framework for task shifting and task sharing: an inter-national Delphi study. Human Resources for Health. 2021;19( 1):1–8., 2021, doi: 10.1186/s12960-021-00605-z.
Efendi F, Aurizki GE, Yusuf A, McKenna L. ‘Not shifting, but sharing’: stakehold-ers’ perspectives on mental health task-shifting in Indonesia. BMC Nursing. 2022;21(1);1–11. doi: 10.1186/s12912-022-00945-8.
Rizaldy HM, Slamet S, Azizah N. Legal responsibility for negligence performed by doctors specialist education doctors pro-grams. 2020; 6(2):265–276.
Das S, Grant L, Fernandes G. Task shift-ing healthcare services in the post-COVID world: A scoping review. PLOS Global Public Health. 2023;3(12):e0001712. doi: 10.1371/journal.pgph.0001712.
Pradana YA, Koentjoro T, Indrayati Y. Legal protection to general practitioners towards authority delegation of medical services given by medical specialists in emergency unit of Mitra Keluarga Hospital Tegal. Soepra. 2019;5(1):55. doi: 10.24167/shk.v5i1.1605.
Na SY, Cheon SH. Role delegation in role-based access control. Proceedings of the ACM Workshop on Role-Based Access Control. 2000:39–44. doi: 10.1145/344287.344300.
World Bank. Physicians (per 1,000 peo-ple): Indonesia [Internet]. Washington (DC): World Bank. Available from: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=ID
Lehmann U, van Damme W, Barten F, Sanders D. Task shifting: The answer to the human resources crisis in Africa? Hu-man Resources for Health. 2009;7:1–4. doi: 10.1186/1478-4491-7-49.
Galvin M, Byansi W. A systematic review of task shifting for mental health in sub-Saharan Africa. International Journal of Mental Health. 2020;49(4):336–360. doi: 10.1080/00207411.2020.1798720.
Maier CB, et al. Task shifting between physicians and nurses in acute care hospi-tals: Cross-sectional study in nine coun-tries. Human Resources for Health. 2018;16(1):1–12. doi: 10.1186/s12960-018-0285-9.
Raams TM, Browne JL, Festen-Schrier VJMM, Klipstein-Grobusch K, Rijken MJ. Task shifting in active management of the third stage of labor: A systematic review. BMC Pregnancy Childbirth. 2018;18(1). doi: 10.1186/s12884-018-1677-5.
Peresu E, Heunis JC, Kigozi NG, de Grae-ve D. Task-shifting directly observed treatment and multidrug-resistant tubercu-losis injection administration to lay health workers: stakeholder perceptions in rural Eswatini. Human Resources for Health. 2020;18(1):1–12. doi: 10.1186/s12960-020-00541-4.
Coales K, et al. Perspectives of health workers engaging in task shifting to deliver health care in low-and-middle-income countries: A qualitative evidence synthesis. Global Health Action. 2023:16(1). doi: 10.1080/16549716.2023.2228112.
Sarvestani AS, Coulentianos M, Sienko KH. Defining and characterizing task-shifting medical devices. Globalization and Health. 2021;17(1):1–7. doi: 10.1186/s12992-021-00684-6.
Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Ujicic M, Soucat A. Health workforce skill mix and task shifting in low income countries: A review of recent evidence. Human Resources for Health. 2011; 9:1–11.
Boatright D, et al. Strategies and best prac-tices to Improve diversity, equity, and in-clusion among US graduate medical edu-cation programs. JAMA Network Open. 2023;6(2):1–11. doi: 10.1001/jamanetworkopen.2022.55110.
Drolet BC, Sangisetty S, Tracy TF, Cioffi WG. Surgical residents’ perceptions of 2011 Accreditation Council for Graduate Medical Education duty hour regulations. JAMA Surgery.,2013;148(5):427–433. doi: 10.1001/jamasurg.2013.169.
Groenewegen P, et al. Task shifting from general practitioners to practice assistants and nurses in primary care: A cross-sectional survey in 34 countries. Prim Health Care Res Dev. 2022;23. doi: 10.1017/S1463423622000470.
Leong SL, Teoh SL, Fun WH, Lee SWH. Task shifting in primary care to tackle healthcare worker shortages: An umbrella review. European Journal of General Practice. 2021;27(1):198–210. doi: 10.1080/13814788.2021.1954616.
van Tuyl L, Vrijhoef B, Laurant M, de Bont A, Batenburg R. Broadening the scope of task shifting in the organisation of healthcare. International Journal of Care Coordination. 2021;24(3–4):91–95. doi: 10.1177/20534345211039988.
Putra IW, Asmuni. Legal responsibility of fetal diagnosis by objective specialists in hospital. International Journal of Social Science and Human Research. 2022;5(7):3225–3230. doi: 10.47191/ijsshr/v5-i7-63.
Bolme S, Austeng D, Gjeilo KH. Task shifting of intravitreal injections from phy-sicians to nurses: A qualitative study. BMC Health Services Research. 2021;21(1):1–9. doi: 10.1186/s12913-021-07203-8.
Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: A cross-country comparative study. European Journal of Public Health. 2016;26(6):927–934. doi: 10.1093/eurpub/ckw098.
Pandhika R, Fakih M. Doctor’s responsi-bility in providing telemedicine services among health care facilities: Legal and pro-fessional dimensions. Administrative and Environmental Law Review. 2021;2(1):21–30. doi: 10.25041/aelr.v2i1.2251.
Das S, Grant L, Fernandes G. Task shift-ing healthcare services in the post-COVID world: A scoping review. PLOS Global Public Health. 2023;3(12):1–26. doi: 10.1371/journal.pgph.0001712.
Fowler N, Wyman R; editors. Residency Training Profile for family medicine and enhanced skills programs leading to Certif-icates of Added Competence. Canadian Family Physician. 2021;68:240.
Baine SO, Kasangaki A, Baine EMM. Task shifting in health service delivery from a decision and policy makers’ per-spective: A case of Uganda. Human Re-sources for Health. 2018;16(1):1–8. doi: 10.1186/s12960-018-0282-z.
Kusumaningrum AE. Doctor’s responsibil-ity for actions of delaying and termination of life support of terminal patients during the Covid-19 pandemic. Sasi. 2022;28(4):670. doi: 10.47268/sasi.v28i4.1167.
Karan A, DeUgarte D, Barry M. Training to build antiracist, equitable health care systems. AMA Journal of Ethics. 2017;19(6):617–628.
Engle RL, et al. Evidence-based practice and patient-centered care: Doing both well. Health Care Management Review. 2021;46(3):174–184. doi: 10.1097/HMR.0000000000000254.
Jedro C, et al. The acceptability of task shifting from doctors to allied health pro-fessionals. Deutsches Arzteblatt Interna-tional. 2020;117(35–36):583–590. doi: 10.3238/arztebl.2020.0583.
Dacey RG, Nasca TJ. Seniorization of tasks in the academic medical center: A worrisome trend. Journal of the American College of Surgeons. 2019;228(3):299–302. doi: 10.1016/j.jamcollsurg.2018.11.009.
Riisgaard H, Nexøe J. Successful task del-egation in general practice–a way to main-tain primary health care in the future. Scand J Prim Health Care. 2017;35(2):111–112. doi: 10.1080/02813432.2017.1335056.
Malterud K, Aamland A, Fosse A. How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway. Scandina-vian Journal of Primary Health Care. 2020;38(1):24–32. doi: 10.1080/02813432.2020.1714143.
Das S, Grant L, Weller D. Conceptualisa-tion of the SHIFT–SHARE: A new strate-gic healthcare implementation framework for task shifting, sharing and resource en-hancement. Global Implementation Re-search and Applications. 2024:394–403. doi: 10.1007/s43477-024-00132-8.
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H. Health professionals for a new century: transforming education to strengthen health systems in an interde-pendent world. Lancet. 2010 Dec 4;376(9756):1923-58. doi: 10.1016/S0140-6736(10)61854-5. Epub 2010 Nov 26. PMID: 21112623.
Noya FC, Carr SE, Thompson SC. Attract-ing, recruiting, and retaining medical workforce: A case study in a remote prov-ince of Indonesia. International Journal of Environmental Research and Public Health. 2023;20(2). doi: 10.3390/ijerph20021435.
Fiah FMA, Lewar ESB, Ritti IF. Juridical analysis of nurses’ knowledge of legal re-sponsibility for medical actions based on delegation of doctors at Korbafo Health Center. Soepra. 2022;8(1):67–72. doi: 10.24167/shk.v8i1.4158.
Van Der Wal MA, Schönrock-Adema J, Scheele F, Schripsema NR, Jaarsma ADC, Cohen-Schotanus J. Supervisor leadership in relation to resident job satisfaction. BMC Medical Education. 2016;16(1):1–7. doi: 10.1186/s12909-016-0688-z.
Bokaba DD. (2024). Exploring inter-professional collaboration between com-munity health workers and health care pro-viders in two clinics in the City of Johan-nesburg district Dorah Dorothea Bokaba. A research report submitted to the Faculty of Health Sciences, University of the Wit-watersrand, Johannesburg, in partial ful-filment of the requirements for the degree of Master of Public Health (MPH) in the School of Public Health (Student no. 1925469).
Absori A, Quinncilla KH, Rizka R, Budi-ono A, Surbakti N. Doctor placement’s policy and its implications in Indonesia: Legal qualitative study. Open Access Mac-edonian Journal of Medical Sciences. 2022;10(E):386–391. doi: 10.3889/oamjms.2022.8692.
Finn KM, et al. Effect of increased inpa-tient attending physician supervision on medical errors, patient safety, and resident education: A randomized clinical trial. JAMA Internal Medicine. 2018;178(7):952–959. doi: 10.1001/jamainternmed.2018.1244.
Lägervik M, Thörne K, Fristedt S, Henric-son M, Hedberg B. Residents’ and super-visors’ experiences when using a feedback-model in post-graduate medical education. BMC Medical Education. 2022;22(1):1–10. doi: 10.1186/s12909-022-03969-5.
Sandhu G, Magas CP, Robinson AB, Scal-ly CP, Minter RM. Progressive entrustment to achieve resident autonomy in the operat-ing room: A national qualitative study with general surgery faculty and residents. An-nals of Surgery. 2017;265(6):1134–1140. doi: 10.1097/SLA.0000000000001782.
Karimi-Shahanjarini A, et al. Barriers and facilitators to the implementation of doc-tor-nurse substitution strategies in primary care: A qualitative evidence synthesis. Cochrane Database of Systematic Reviews. 2019;2019(4). doi: 10.1002/14651858.CD010412.pub2.
Ferguson C, Low G, Shiau G. Resident physician burnout: Insights from a Canadi-an multispecialty survey. Postgraduate Medical Journal. 2020;96(1136):331–338. doi: 10.1136/postgradmedj-2019-137314.
Munyai O, Mudau AG, Mashau NS. Strat-egies for effective and efficient delivery of primary health care by village health work-ers: A scoping review using the Rodgers' Evolutionary Concept Analysis Frame-work. Afr J Prim Health Care Fam Med. 2024 Dec 18;16(1):e1-e13. doi: 10.4102/phcfm.v16i1.4554. PMID: 39846110; PMCID: PMC11736494.
Shahmalak U. Task-shifting psychological interventions for common mental disor-ders: The training and supervision of non-traditional Providers. The University of Manchester: 2021:1–24.
Todd BR, Traylor S, Heron L, Turner-Lawrence D. SPRINT through tasks: A novel curriculum for improving resident task management in the emergency de-partment. MedEdPORTAL: The Journal of Teaching and Learning Resources. 2020;16:10956. doi: 10.15766/mep_2374-8265.10956.
Robertson FC, et al. Global perspectives on task shifting and task sharing in neuro-surgery. World Neurosurgery: X. 2020;6:100060. doi: 10.1016/j.wnsx.2019.100060.
Robertson FC, et al. Task-shifting and task-sharing in neurosurgery: An interna-tional survey of current practices in low- and middle-income countries. World Neu-rosurgery: X. 2020;6. doi: 10.1016/j.wnsx.2019.100059.
Kongnyuy P. Delegation of authority as a tool for effective secondary school man-agement in the north west region of Came-roon. International Journal of Education and Social Science Research. 2020;3(6):271–281. doi: 10.37500/ijessr.2020.3624.
Ohta R, Yawata M, Sano C. Doctor clerk implementation in rural community hospi-tals for effective task shifting of doctors: A grounded theory approach. International Journal of Environmental Research and Public Health. 2022;19(16). doi: 10.3390/ijerph19169944.
Dangelico RM, Vocalelli D. ‘Green Mar-keting’: An analysis of definitions, strategy steps, and tools through a systematic re-view of the literature. Journal of Cleaner Production. 2017;165:1263–1279. doi: 10.1016/j.jclepro.2017.07.184.
Bebko CP. Service intangibility and its im-pact on consumer expectations of service quality. Journal of Services Marketing. 2016;14(1):9–26. doi: 10.1108/08876040010309185.
Coales K, et al. Perspectives of health workers engaging in task shifting to deliver health care in low-and-middle-income countries: A qualitative evidence synthesis. Global Health Action. 2023;16(1). doi: 10.1080/16549716.2023.2228112.
Jacobs L. Task and shift scheduling of emergency physicians with different skill sets: a case study [master’s thesis on the Internet]. Ghent (Belgium): Ghent Univer-sity, Library; 2021. Available from: https://libstore.ugent.be/fulltxt/RUG01/002/481/137/RUG01-002481137_2018_0001_AC.pdf
Mascini P, Holvast N. Does delegation of drafting duties to law clerks result in judgments that show lack of confidence in terms of writing style? A stylometric anal-ysis. Journal of Law and Courts. 2023:1–22. doi: 10.1017/jlc.2023.10.
Adnani NTS, Syofyan S, Mannas YA. “… Dokter Spesialis (PPDS) Terhadap Pelim-pahan Wewenang Dokter Spesialis dalam Pelayanan Medis di Rumah Sakit (Studi Kasus di Rumah Sakit Umum Pusat Dr …” UNES Law Review. 2023;6(1):1209–1216.
Feiring E, Lie AE. Factors perceived to in-fluence implementation of task shifting in highly specialised healthcare: A theory-based qualitative approach. BMC Health Services Research. 2018;18(1):1–10. doi: 10.1186/s12913-018-3719-0.
van Schalkwyk MC, et al. The best person (or machine) for the job: Rethinking task shifting in healthcare. Health Policy. 2020;124(12):1379–1386. doi: 10.1016/j.healthpol.2020.08.008.
Coser RL. Authority and decision-making in a hospital: A comparative analysis. Med-ical Professionals and the Organization of Knowledge. 2017;23(1):174–184. doi: 10.2307/2088624.
Kilminster S, Cottrell D, Grant J, Jolly B. AMEE Guide No. 27: Effective educa-tional and clinical supervision. Medical Teacher. 2007;29(1):2–19. doi: 10.1080/01421590701210907.
World Health Organization. Task Shifting. Global Recomendations and Guidelines. World Health Organization. 2008:1–88. doi: 10.1080/17441692.2011.552067.
Rawls J. (2006) Teori Keadilan (A Theory of Justice). Pustaka Pelajar, Yogyakarta.
Adlhiyati, Zakki, Achmad. Kajian Filsafat Keadilan Aristoteles, Thomas Aquinas, dan John Rawls (A study of the philoso-phy of justice of Aristotle, Thomas Aqui-nas, and John Rawls). UNDANG: Jurnal Hukum, Fakultas Hukum Universitas Jam-bi. 2020;2(2).
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