CHAPTER I INTRODUCTION 1.1. Background The healthcare industry, one of the world’s fastest growing industries (Vogenberg & Santilli, 2018), is defined as an integration of sectors that provides goods and services to maintain and re-establish health. The industry consumes over 10% of gross domestic product (GDP) of most developed countries and enormously contributes to a country’s economy (Bank, 2022). Global spending on healthcare has been steadily increasing over the years, reaching US$ 8.5 trillion or 9.8% of global GDP in 2019. According to the World Health Organization (WHO), Indonesian health spending per capita in 2019 was US$ 120,12, 3,63 times lower than its neighbouring country Malaysia whose health spending per capita was US$ 436,61 in the same year. Furthermore, Indonesian health spending% GDP was 2,9% in 2019, lower than Malaysia that recorded 3.83% of health spending% GDP. Compared to a developed Asian nation like Japan, whose health spending per capita was US$ 4360,47 and health spending% GDP was 10,74%, Indonesia still has a long way to go (WHO, 2022). Figure 1. 1. Current health expenditure in Indonesia (CHE%GDP and CHE per capita, constant US$ 2019). Health spending per capita was US$ 120,12 while the health spending% GDP was 2,9%. Source: (WHO, 2022) 2 One of the components in the healthcare industry is healthcare providers and professionals, which includes physicians, nurses, midwives, dentists, pharmacists, and other healthcare personnel’s. Healthcare industry is one of the largest segments of the workforce, with estimated 9.2 million physicians, 19.4 million nurses and midwives, 1.9 million dentists and other dentistry personnel’s, 2.6 million pharmacists and other pharmaceutical personnel’s, and 1.3 million community health workers around the globe (WHO, 2021). In comparison with other healthcare professionals, physicians bear bigger responsibilities as the care provider, decision maker, communicator, community leader and manager together known as five star doctors (Kuhn, 2022). All these lead to heavier workload and more work-related stress for physicians in clinical practice. Physicians play a pivotal role in ensuring the quality of healthcare; however, they often have poor well-being due to heavy workload(Watson, McCoy, Mathew, Gundersen, & Eisenstein, 2019). The situation in some countries like Indonesia is worse since physicians usually work in more than one place (Kemenkes-RI, 2007). Indonesia, the largest archipelago country with over 17.000 islands, is the world’s fourth most populous nation with a population of more than 270 million. Difficult geographical conditions and huge population present great challenges to health service delivery in Indonesia (Efendi, 2012). To ensure the availability of healthcare service across the country, the Indonesian government allows physicians to work at a maximum of three healthcare facilities. Since 2014, Indonesia implemented Jaminan Kesehatan Nasional (JKN), a mandatory national health insurance program covering basic primary health service and essential secondary and tertiary healthcare services and emphasizing on referral systems (Maharani, Afief, Weber, Marx, & Loukanova, 2019). Primary healthcare is delivered by general physicians at government-owned centers or private clinics while secondary and tertiary healthcare services are provided at the hospitals. The number of patients visiting health centers has been increasing since the implementation of JKN. Working in more than one place means longer working hours and more patients to see, resulting in heavier workload for Indonesian physicians (Jia et al., 2021). The situation is worse for physicians working at tertiary hospitals that provide sub 3 specialist medical services like Dr. Zainoel Abidin General Hospital (RSUDZA), Aceh, where the patients are abundant and the cases are more complicated. This condition results in increased workload for the physicians. Physicians’ workload, refers to the amount and structure of the work, is often measured as total work hours or time pressure. In regards to work hours, doctors tend to have longer work weeks than the general population, not to mention on-call weekends (Williams, Rondeau, Xiao, & Francescutti, 2007). In terms of the amount of work, physicians are not only responsible to take care of patients, but also do administrative work such as prior authorizations, clinical documentation, medication reconciliation, and maintenance of certification. Some physicians are also responsible for managerial duties as some of them also serve as the head of departments or hospitals. All these results in increased workload for the physicians (S. K. Rao et al., 2017). Excessive workload increased work-related stress and job dissatisfaction, which might lead to burnout (Tung, Chou, Chang, & Chung, 2020; Williams et al., 2007). Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. The World Health Organization (WHO) defined burnout as an occupational phenomenon (Moss, 2021). Investigation showed that burnout negatively affects the professional and personal life of physicians. From personal aspect, burnout might lead to broken relationships, alcohol abuse and substance use, depression, and even suicide. Meanwhile, from professional point of view burnout can lead to decreased quality of care, patients satisfaction, productivity and professional effort, increased medical errors and physician turnover (Shanafelt & Noseworthy, 2017). The rate of physician burnout varies by clinical discipline, however those at the front line such as family medicine, general internal medicine, and emergency medicine doctors have the highest risk (Rothenberger, 2017). The positive antithesis of burnout is Engagement that is characterized by vigor, dedication, and absorption in work. Reports suggested that work engagement was a predictor of better health, lowered sickness absence, and promoted better occupational functioning (Loerbroks, Glaser, Vu-Eickmann, & Angerer, 2017; S. Rao et al., 2020). The key drivers of burnout and engagement can be viewed from 4 7 dimensions: workload, efficiency, flexibility/control over work, work-life integration, alignment of individual and organizational values, social support/community at work, and the degree of meaning derived from work, where each of these dimensions is influenced by individual, work unit, organizational, and national factors (Shanafelt & Noseworthy, 2017). Working in more than one place might lead to increased workload, inefficiency, less flexibility or control over work, poor work-life balance, misalignment of individual and organizational values, low support from the community at work, and loss of meaning derived from work. All these will result in poor performance and quality of care One of the solutions proposed to cope with this problem is the implementation of a mono-loyalty practice in healthcare facilities. Mono-loyalty, refers to a regulation in which physicians working at only one facility, has been a debatable topic among physicians and hospitals owners in Indonesia. Some people think that the idea is against the law, for it restricts physicians' right to work in more than one facility as regulated by the government (Budisuroso, 2019). Meanwhile, some others argue that working at only one facility will reduce Indonesian physicians’ burnout and improve their well-being, all of which lead to better performance and quality care.