{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T10:08:32Z","timestamp":1789034912532,"version":"build-2803163510"},"reference-count":40,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Med Educ"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aimed to examine the rationale, policy design, and early implementation of Indonesia\u2019s dual hospital\u2013university 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.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n 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\u2010120 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.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Indonesia\u2019s dual hospital\u2013university 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/90270","type":"journal-article","created":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T09:19:06Z","timestamp":1789031946000},"page":"e90270-e90270","source":"Crossref","is-referenced-by-count":0,"title":["A Dual Hospital\u2013University Specialist Training Reform to Address Workforce Shortage and Geographic Maldistribution in Indonesia: Integrative Qualitative Policy Process Review"],"prefix":"10.2196","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4104-032X","authenticated-orcid":false,"given":"Asnawi","family":"Abdullah","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1299-9977","authenticated-orcid":false,"given":"Yuli","family":"Farianti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-3029-018X","authenticated-orcid":false,"given":"Lupi","family":"Trilaksono","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-7471-8241","authenticated-orcid":false,"given":"Arianti","family":"Anaya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2000-3543","authenticated-orcid":false,"given":"Anna","family":"Kurniati","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3616-8256","authenticated-orcid":false,"given":"Oos Fatimah","family":"Rosyati","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7142-9483","authenticated-orcid":false,"given":"Etik Retno","family":"Wiyati","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-1956-7468","authenticated-orcid":false,"given":"Mimi","family":"Sumiarsih","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0787-4021","authenticated-orcid":false,"given":"Christa Gumanti","family":"Manik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-5411-4416","authenticated-orcid":false,"given":"Nyiayu H A","family":"Sonia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5353-8603","authenticated-orcid":false,"given":"Farizal Rizky","family":"Muharram","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0257-0061","authenticated-orcid":false,"given":"Kevin Tadeus","family":"Simanjuntak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5770-2570","authenticated-orcid":false,"given":"Sydney","family":"Tjandra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-9048-1758","authenticated-orcid":false,"given":"Akemat","family":"Akemat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-9905-172X","authenticated-orcid":false,"given":"Else Mutiara","family":"Sihotang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0050-4618","authenticated-orcid":false,"given":"Leni","family":"Kuswandari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3778-1482","authenticated-orcid":false,"given":"Siti","family":"Yunianti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5526-6354","authenticated-orcid":false,"given":"Fialisa","family":"Asriwhardani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,9,9]]},"reference":[{"issue":"8","key":"R1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0308225","article-title":"What medical specialists want to stay in remote areas of Indonesia: discrete choice experiments","volume":"19","author":"Kurniati","journal-title":"PLOS One"},{"key":"R2","unstructured":"Direktorat Jenderal SDM Kesehatan, Kementerian Kesehatan Indonesia. 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