From leadership research to district action: A Dual Hospital–University Specialist Training Reform to Address Workforce Shortage and Geographic Maldistribution in Indonesia: Integrative Qualitative Policy Process Review

AI-assisted editorial implementation guide. Proposed district actions are separate from the original authors’ findings and recommendations. Independent peer review of this guide is not asserted.

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Abstract Background Indonesia faces 3 interlocking medical workforce crises: an absolute specialist deficit projected to reach 70,000 by 2032 (national density of 0.18 per 1000 population vs the Ministry of National Development Planning [Bappenas] target of 0.28), severe maldistribution (with nearly 59% of specialists concentrated in Java), and a structural anomaly in which residents pay tuition while performing essential clinical work. The 2023 Health Law (Law 17/2023) authorized a transformative reform: a hospital-based residency pathway (Rumah Sakit Pendidikan Penyelenggara Utama [primary teaching hospital; RSPPU]) operating in parallel with the long-established university-based system. Objective This study aimed to examine the rationale, policy design, and early implementation of Indonesia’s dual hospital–university specialist medical education reform, interpreted through an 8-step change management framework developed by Kotter, and to identify transferable lessons for low- and middle-income countries. Methods We conducted an integrative qualitative policy process review combining two evidence streams: (1) systematic documentary analysis of 19 source documents (17 primary legal, regulatory, and policy instruments plus 2 interministerial joint monitoring site-visit reports) and (2) engagement of 34 key informants through semistructured interviews and focus group discussions (45‐120 min), comprising policymakers, collegium representatives, hospital leaders, and residents across all 6 pilot sites, recruited purposively until thematic saturation. Interview and focus group data were analyzed using a hybrid deductive-inductive thematic approach with an 8-step change management framework developed by Kotter as an a priori coding frame, and member checking was completed with 7 of the 34 informants. Results The reform designated 6 top-tier national referral hospitals as RSPPUs and enrolled 52 residents from 412 applicants (an acceptance rate of 12.6%) across 6 high-need specialties (ophthalmology, cardiology, pediatrics, orthopedics, neurology, and oncology). All 6 pilot sites established functional education units and designated institutional officials, adopted dual accreditation, and operationalized an integrated e-logbook for competency tracking, real-time monitoring of 80-hour duty limits, and anonymous bullying reporting. An interministerial joint monitoring team visited all 6 sites and scored each site as satisfactory or better across governance, curriculum, faculty, infrastructure, and learner support. Four cross-cutting themes emerged: financial-barrier removal, dual-governance pragmatism, accreditation strain, and equity-anchored deployment. Persistent tensions include variable educator compensation across hospitals; however, a standardized national framework remains under development. Mapping to the framework developed by Kotter demonstrated strong evidence for steps 1 to 6 and early evidence for steps 7 to 8. Conclusions Indonesia’s dual hospital–university residency model is a scalable, equity-oriented, and competency-based reform that is operationally feasible and globally aligned in its early implementation. While long-term effectiveness and sustainability await longitudinal evaluation, the design offers a transferable, not yet definitively replicable, template for low- and middle-income countries confronting parallel workforce crises.

Study methods

We used an integrative qualitative policy process review design to examine the design and early operational dynamics of Indonesia’s dual-track specialist education reform. An 8-step change management framework developed by Kotter [27-29] served as both an a-priori interpretive lens and a deductive coding frame. Each step was mapped to observable indicators in the RSPPU rollout: (1) establishing urgency: quantification of the specialist deficit and high-stakes political articulation; (2) forming a guiding coalition: cross-ministerial governance arrangements involving the Ministry of Health (MoH), Ministry of Higher Education, KKI, Indonesian Accreditation Agency for Higher Education in Health (Lembaga Akreditasi Mandiri Pendidikan Tinggi Kesehatan Indonesia [LAM-PTKes]; IAAHEH), and the specialty collegia; (3) developing a change vision: Law 17/2023 and its successor regulations; (4) communicating the vision: subsequent public communication; (5) empowering broad-based action: Government Regulation 28/2024 [30], Permenkes 14/2024 [31], and Lembaga Pengelola Dana Pendidikan (Indonesia Endowment Fund for Education; LPDP) financing; (6) generating short-term wins: pilot cohort enrollment and the unified digital platform; (7) consolidating gains: joint monitoring, dual accreditation, and expansion to additional RSPPUs; and (8) anchoring change in culture: embedding mechanisms including the integrity pact, Pangkalan Data Pendidikan Tinggi (Higher Education Database; PDDikti) recognition, and the Badan Penyelenggara Jaminan Sosial (National Social Security Agency; BPJS)–linked financing pipeline.

Limitations

The integrative design captures policy-process complexity unavailable in single-method studies; member checking with 7 of 34 informants and triangulation across documentary and interview streams reduce interpretive bias; Kotter operationalization provides an auditable analytic frame; and reporting follows the Standards for Reporting Qualitative Research [33].

A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Select one recurring district decision. Publish the decision owner, evidence requirements, consultation process and appeal route; test the process on a bounded low-risk decision. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Track decision time, unresolved objections, documented reasons, appeals and access differences. Review whether the process changes who can participate and who carries the burden. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Asnawi Abdullah; Yuli Farianti; Lupi Trilaksono; Arianti Anaya; Anna Kurniati; Oos Fatimah Rosyati; Etik Retno Wiyati; Mimi Sumiarsih; Christa Gumanti Manik; Nyiayu H A Sonia; Farizal Rizky Muharram; Kevin Tadeus Simanjuntak; Sydney Tjandra; Akemat Akemat; Else Mutiara Sihotang; Leni Kuswandari; Siti Yunianti; Fialisa Asriwhardani. A Dual Hospital–University Specialist Training Reform to Address Workforce Shortage and Geographic Maldistribution in Indonesia: Integrative Qualitative Policy Process Review. JMIR Medical Education (2026-09-09). https://doi.org/10.2196/90270

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.