Developing Equitable Policies for Task-Shifting from Supervisors to Resident Doctors in Indonesian Teaching Hospitals: A Legal and Ethical Framework

Introduction

The practice of medicine epitomises a profound hu- man endeavour to serve others, rooted in a purity of intention and commitment to patient safety that make it a highly respected profession [1,2]. A doc- tor’s actions, executed consciously and purpose- fully, are described as actus humanus, reflecting deliberate and responsible decision-making [3,4]. In Indonesia, "task-shifting" is embedded within the frameworks of public and private law. The term "authority," often interpreted from the Dutch term bevoegdheid , is understood as the legal right or power to perform specific actions and implement and enforce laws. According to Mochtar Kusumaatmadja, formal authority inherently grants an individual the power to act within the scope of legal provisions [5,6]. Task-shifting, defined as the delegation of clinical responsibilities from senior to junior medical staff, is increasingly relevant in Indonesia's healthcare system due to a significant shortage of specialist doctors. While Law No. 17 of 2023 on Health pro- vides a general mandate for supervision in medical education, the absence of derivative regulations creates inconsistencies and gaps in implementa- tion. This legal vacuum contributes to unclear ac- countability, increased risk of medical errors, and professional inequity [2,7-10]. For instance, a case involving a surgical resident doctor at a satellite teaching hospital in Purworejo underscores the risk of unclear delegation proto- cols. The death of a patient during a surgical proce- dure performed by the resident led to a dispute over accountability; the supervising doctor denied re- sponsibility due to the lack of formal documenta- tion. This incident highlights the need for transpar- ent and standardised task delegation protocols to ensure accountability and patient safety [11,12].

Task-shifting is critical in addressing the workforce challenges in Indonesia’s healthcare system, partic- ularly given the country's low doctor-to-patient ra- tio of 0.7 doctors per 1,000 patients—one of the lowest in Southeast Asia [13]. In this context, effi- cient delegation mechanisms are essential to opti- mise limited resources while maintaining patient safety and quality care standards [14]. On a global level, task-shifting is strictly regulated within medical education frameworks [15]. Alt- hough Indonesia references global medical educa- tion standards, such as those of Accreditation Council for Graduate Medical Education (AC- GME) in the United States or European Union di- rectives, the application of these models must con- sider Indonesia’s institutional capacity and socio- political landscape. This study investigates how in- ternational practices can be adapted to local reali- ties and what legal frameworks are necessary to en- sure safety, accountability, and equity in task dele- gation [10,16]. The enactment of Law No. 17 of 2023 on Health represents an important step in establishing guide- lines for task-shifting in specialist medical educa- tion. It emphasises supervision based on the com- petence and qualifications of resident doctors. However, without standardised formats or deriva- tive regulations, the implementation of task delega- tion remains inconsistent, leading to overlapping duties and potential legal conflicts. [17,18]. The objectives of this research are: (1) to identify regulatory gaps in the current legal system related to task-shifting; (2) to assess challenges in imple- menting international standards in Indonesia’s healthcare settings; and (3) to propose a justice- based model of delegation, grounded in compe- tency, transparency, and professional development.

Literature Review

Task-shifting, the delegation of medical authority from senior to junior doctors, is an important aspect of specialist medical education programs, particu- larly in resource-limited settings such as seen in In- donesia [19,20]. This approach addresses the scar- city of healthcare professionals while fostering the professional development of junior doctors [12]. However, significant challenges arise from the ab- sence of specific regulations under Indonesia's Law No. 17 of 2023, including heightened risks of med- ical errors and inequities in supervision. Without derivative regulations defining criteria, mecha- nisms, and standards for task-shifting, the practice

jeopardises patient safety and the quality of special- ist medical education [7,8]. Task-shifting in the context of medical education refers to transferring clinical tasks from fully li- censed physicians to supervised trainees, often to maximise limited human resources. In high-income countries, such practices are highly regulated, sup- ported by frameworks like those of the ACGME and EU directives. These guidelines emphasise the importance of supervision protocols, written dele- gation procedures, and evaluation mechanisms based on performance metrics [22,23]. Similarly, the EU’s directives on medical education establish structured frameworks that emphasise adequate su- pervision, patient safety, and quality training [24,25]. In contrast, Indonesia’s regulatory framework re- mains incomplete, offering only broad guidelines under the Health Law and Ministry of Health regu- lations. This regulatory gap results in inconsisten- cies in implementation, leading to potential legal ambiguities and inefficiencies in task delegation [26,27]. A notable case from a teaching hospital in Pur- worejo Regency illustrates the very real dangers of inadequate task-shifting regulations. In this in- stance, a surgical procedure, conducted under re- mote supervision by a resident doctor, resulted in the death of a patient. The absence of formal docu- mentation led to disputes over accountability be- tween the supervising doctor and the resident [28]. This case underscores the urgent need for transpar- ent and structured delegation protocols to mitigate risks and ensure accountability [27,29]. International literature highlights the benefits of structured task-shifting: enhanced workforce effi- ciency, improved training quality, and reduced cli- nician burnout. However, these benefits are contin- gent on robust institutional systems, including su- pervisor training, feedback loops, and legal protec- tion for both parties. In Indonesia, where infrastruc- ture disparities exist between teaching hospitals, the absence of uniform procedures exacerbates in- equity [23,25,29]. Several measures are proposed to address the chal- lenges of task-shifting in Indonesia. First, detailed derivative regulations should be developed to de- fine the mechanisms, criteria, and processes for task delegation, including competency evaluations and structured supervision [27,32]. Standardised formats for delegation, such as clear documentation and reporting protocols, should be introduced to

enhance transparency, clarify responsibilities, and prevent legal ambiguities [30,33]. Finally, ele- ments from international standards should be inte- grated to improve the quality of supervision and align Indonesia’s medical education practices with global benchmarks [34]. Beyond regulatory frameworks, task-shifting raises critical legal and ethical questions [35]. Informal communication methods, such as telephone calls or text messages, are often used to delegate tasks, in- creasing the risk of miscommunication and medical errors [36]. Formalising such processes is essential to ensure accountability and safeguard patient safety [33,37]. Furthermore, ethical considerations require that delegation protocols respect the professional devel- opment of resident doctors while prioritising pa- tient welfare [38]. Clear legal guidelines can help to balance these competing interests in an equitable manner [39,40]. Indonesia’s incomplete regulatory framework for task-shifting underscores the need for comprehen- sive reforms. By adopting international best prac- tices and addressing the unique challenges within its healthcare system, the country can enhance pa- tient safety, improve the quality of specialist medi- cal education, and ensure equitable task delegation [41,42]. Building supervisor capacity is essential. A recur- ring issue identified is the lack of dedicated training for supervisors, who often rely on ad-hoc experi- ence rather than formal instruction. International models incorporate leadership development for su- pervisors to support residents while maintaining quality of care. Integrating such elements would strengthen Indonesia’s approach [43,44]. This in- quiry evaluates whether existing practices ensure equitable opportunities and responsibilities for res- ident doctors while fostering professional growth and maintaining patient safety [45,46]. In sum- mary, although international models offer valuable guidance, their implementation must be recali- brated to Indonesia’s context. Legal reform, re- source investment, and supervisory training are prerequisites to effective, equitable task-shifting.

Research Methodology

This study employs an empirical juridical ap- proach, integrating normative legal analysis with qualitative field research to investigate the practice of task-shifting from supervising doctors to resi- dent doctors in teaching hospitals in Indonesia.

This approach is chosen to critically examine how existing legal norms are implemented in practical, institutional contexts—particularly in regions where regulatory application remains inconsistent. Field research was conducted at several teaching hospitals in Central Java and the Special Region of Yogyakarta, selected purposively due to their stra- tegic roles as referral centres and their affiliation with specialist medical education programs. These institutions also reflect varying levels of readiness and compliance in implementing supervisory struc- tures and task delegation procedures. Primary data were obtained through in-depth inter- views, with participants including supervising phy- sicians, resident doctors, hospital administrators and medical education coordinators. The inter- views explored participants’ experiences, chal- lenges, and strategies related to clinical task dele- gation, especially in the absence of specific deriva- tive regulations. Direct field observations were also conducted in clinical settings, particularly in surgical and inter- nal medicine departments. These observations aimed to document how supervision and delegation actually take place during daily clinical routines, revealing gaps between normative expectations and operational realities. Observed phenomena in- cluded informal delegation practices, lack of writ- ten documentation, and varying levels of supervi- sor presence. Secondary data consisted of relevant statutory in- struments such as Law No. 17 of 2023 on Health, Ministerial Regulation No. 2052/Men- kes/Per/X/2011, hospital bylaws, and medical edu- cation policies. The study also reviewed profes- sional codes of conduct issued by organisations such as the Indonesian Medical Association (IDI) and relevant collegia, as well as published aca- demic literature and judicial case records involving disputes over the delegation of clinical authority. Data analysis was performed thematically to iden- tify patterns related to legal ambiguity, supervisory practices, patient safety risks, and institutional re- sponses. Legal interpretation was carried out using doctrinal methods to evaluate the clarity, enforcea- bility, and sufficiency of the current legal frame- work in regulating clinical delegation. Compara- tive insights from international models, including the ACGME and EU directives, were used to assess the feasibility of adapting global best practices to the Indonesian context. This methodological framework is intended not

only to map legal and ethical shortcomings, but also to formulate evidence-based recommenda- tions. Particular attention was given to real-world barriers such as limited supervisory training, ad- ministrative resistance, and the lack of standardized delegation protocols, which collectively impede consistent and just implementation of task-shifting in Indonesian teaching hospitals.

Result and Discussion

This study first explores the gaps in the current reg- ulations governing task-shifting from supervisors to resident doctors, identifying specific weaknesses in the legal framework that contribute to risks such as medical errors, unclear accountability, and in- consistencies in implementation. Justice in Indone- sia must be interpreted through the lens of Pan- casila , emphasising the principles of fairness, hu- manity, and legal certainty for all stakeholders in- volved in healthcare service delivery [47,48]. According to Pancasila , laws must protect citizens by preventing arbitrary actions and creating hu- mane social conditions that allow individuals to reach their full potential. These philosophical prin- ciples must be integrated with practical regulation in the medical field [7,8,21]. Often equated with power, authority represents a form of formal power derived from law, while power encompasses a broader scope beyond formal structures [27]. Authority is legitimised by law and structured regulation, whereas this may not always be the case for power [39]. Theoretically, authority derived from legislation is obtained through attrib- ution, delegation, and mandate [49,50]. Attribution involves granting new authority through legislation [33]; delegation refers to the transfer of existing au- thority to another party [40]; while a mandate en- tails the execution of authority by a subordinate on behalf of the principal authority holder [30,51]. Regulations governing task-shifting in Indonesia are intended to ensure that clinical tasks are per- formed by competent personnel [10]. While patient safety is prioritised, the lack of precise protocols for delegation and supervision often leads to uncer- tainty over accountability, a heightened risk of er- rors, and reduced quality of care [12,52]. The reg- ulations aim to clarify the scope of delegable tasks and establish supervision standards [12,53]. In practice, however, field data from teaching hos- pitals in Central Java and Yogyakarta reveal that delegation is often carried out informally, without written guidelines, competency evaluations, or

structured supervision, thereby undermining legal certainty and patient safety. Supervision was incon- sistent and frequently limited due to high work- loads and lack of formalised policies. This misa- lignment between legal expectations and clinical practice elevates the risk of both medical error and legal disputes. Although regulations governing task-shifting em- phasise the requirement that medical actions be performed by competent individuals, the absence of derivative technical rules often causes uncer- tainty regarding accountability, which in turn can compromise patient safety and reduce the quality of care. Ideally, these regulations should clarify the scope of tasks that can be delegated, while also es- tablishing enforceable standards of supervision. [54]. In the context of medical education, task-shifting should support residents’ professional growth through structured delegation preceded by compe- tency evaluation—an approach that is consistent with national and international standards. For in- stance, ACGME in the United States mandates de- tailed delegation guidelines and performance benchmarks for residents before they may under- take specific clinical tasks. In contrast, as revealed through interviews and observations, such compe- tency frameworks have not yet been institutional- ised in Indonesian teaching hospitals. Indonesian legislation, and particularly Law No. 17 of 2023 on Health, provides a general framework for task-shifting. Relevant provisions address dele- gation between medical personnel and other health workers and call for more detailed derivative regu- lations. The Ministry of Health’s Regulation No. 2052/Menkes/Per/X/2011 authorises written dele- gation to nurses or midwives, yet no equivalent procedural clarity exists for residents, causing con- fusion and legal vulnerability [2,6,44]. Article 290 of Law No. 17 of 2023 mandates that all delegation should be just and transparent, with proper documentation. Yet, according to on inter- views, most hospitals have no formal records or SOPs for delegation. Such absence increases the likelihood of favouritism, discrimination, and in- consistent supervision outcomes. These findings support the need for detailed regulation that stipu- lates formats for written delegation, supervisory roles, and documentation retention requirements [9,10]. Countries such as Malaysia and Singapore provide

useful comparative insights. The Malaysian Medi- cal Council defines general training and supervi- sion standards, though it lacks detailed delegation mechanisms. In contrast, Singapore's Health Pro- fessions Act explicitly delineates supervisory boundaries and includes mandatory feedback mechanisms—an element that Indonesia may con- sider integrating. Similarly, the UK’s General Medical Council (GMC) offers detailed guidance on supervision and clinical responsibility, espe- cially within hospital training systems [25,56,57]. Furthermore, the findings demonstrate that current task-shifting practices are not yet aligned with the core principles of justice, equity, and professional- ism. Internal hospital policies (hospital bylaws), governed under the Ministry of Health’s Regula- tion No. 772 of 2002, outline broad relationships among physicians, hospital managers, and owners [49,59]. These relationships, known as the triad, re- quire regulation to prevent conflicts that might oth- erwise arise due to the complexity of modern hos- pitals transitioning from social units to socio-eco- nomic entities [60,61]. The study also emphasises the importance of safe- guarding medical confidentiality, as regulated un- der Law No. 17 of 2023. In the context of task- shifting, this includes ensuring that delegation does not lead to breaches of patient privacy or inappro- priate access to sensitive information—a concern raised during observations in several hospital units [62]. Effective task-shifting must prioritise not only le- gal protection, but also professional development. Supervisors retain legal accountability, while resi- dents are responsible for operational tasks within the scope of their certified competencies [63]. As endorsed by several hospital-based respondents, delegation should be formalised in writing and ac- companied by competency certification from the academic department or the head of the study pro- gram [64]. This structured model would ensure clarity around roles and responsibilities, and miti- gate legal risk for both parties [12,65]. Indonesia should develop derivative regulations within a standardised delegation framework to en- sure that task-shifting aligns with international best practices [49]. These regulations should include criteria for competency evaluation of resident doc- tors, supervision standards for supervisors, and pre- cise documentation protocols to enhance transpar- ency and accountability [66].

By learning from international frameworks, Indo- nesia can build a contextually adapted model for clinical delegation. This would need to be adjusted for resource limitations and the fragmented govern- ance structures inherent in Indonesia’s healthcare system—a challenge repeatedly emphasised by the participants in this study. Finally, the research aims to advocates for the de- sign of a comprehensive and equitable model a comprehensive and equitable model for task-shift- ing that addresses legal, ethical, and practical chal- lenges in teaching hospitals [67]. This model should integrate global best practices while accom- modating Indonesia’s unique healthcare and regu- latory context, ensuring clarity, structured supervi- sion, and fairness in task delegation [68]. Equitable task-shifting requires a transparent and structured system that provides equal opportunities for all resident doctors to develop professionally [39]. It involves clear delegation procedures, ongo- ing supervisor training, and mechanisms for feed- back and complaints [45,69,70]. The theories of justice proposed by John Rawls and Aristotle provide foundational principles for equi- table task-shifting. Rawls’ Justice as Fairness em- phasises equal access to opportunities and the equi- table distribution of resources to benefit the least advantaged [32,71]. Aristotle’s Distributive Justice advocates for proportional allocation based on in- dividual needs and contributions [72]. As described in the Republic , Plato’s concept of justice, centred on role-specific contribution, is ap- plicable to clinical settings, supporting harmony within medical teams. Supervisors should guide and support resident doctors, fostering an environ- ment where roles align with individual competen- cies [32]. Equitable task shifting should also consider the well-being of resident doctors. This includes mech- anisms for psychological support, such as counsel- ling programs and stress management training. By addressing these aspects, teaching hospitals can create a supportive environment prioritising both patient safety and professional development [45]. In summary, the study highlights the urgent need to address the regulatory gaps left by Law No. 17 of 2023 via derivative regulations that operationalise task-shifting practices. Educational institutions and healthcare providers must collaborate to implement these reforms through structured training, policy enforcement, and regular evaluations. By adopting international benchmarks while tailoring them to

local conditions, Indonesia can build a fair, safe, and high-quality system of task delegation that strengthens both medical education and patient care.

Conclusion

The implementation of task-shifting from supervis- ing doctors to resident doctors in Indonesian teach- ing hospitals, as regulated under Law No. 17 of 2023, remains substantively inadequate. Although the law provides a foundational framework, the ab- sence of specific derivative regulations has led to significant legal and operational gaps—particularly in terms of authority structure, supervision proce- dures, and documentation requirements. Field data from teaching hospitals in Central Java and Yogya- karta further confirm that the delegation of clinical responsibilities is often informal, undocumented, and lacking in standardised competency-based mechanisms, thereby exposing both supervisors and residents to professional and legal risks. The inconsistent application of delegation proto- cols across institutions has compromised not only patient safety, but also the fairness and quality of clinical education. Without a unified regulatory standard, disparities in supervision and learning op- portunities continue to affect the professional de- velopment of resident doctors. These findings point to the urgent need for clear, enforceable, and con- text-sensitive derivative regulations that align del- egation processes with clinical competencies and supervisory accountability. To address these issues, the Ministry of Health must prioritise the formulation of detailed regula- tory instruments that articulate the legal, ethical, and administrative requirements for task-shifting. These instruments should mandate written delega- tion protocols, periodic competency evaluations, clear lines of supervisory responsibility, and insti- tutional oversight mechanisms such as audits and grievance procedures. Only through this level of clarity and structure can task delegation be carried out in a manner that is legally sound and ethically defensible. Furthermore, Indonesia stands to benefit signifi- cantly by adopting and adapting key elements from international frameworks such as the ACGME in the United States and the EU directives on medical education. These models emphasise accountability, structured supervision, and performance-based del- egation. However, their implementation in Indone-

sia must be accompanied by systemic support, in- cluding supervisory training, administrative coor- dination, and equitable distribution of clinical re- sponsibilities. Ultimately, task-shifting reforms that emphasise le- gal clarity, fairness, and transparency will not only enhance the quality and safety of healthcare ser- vices, but also strengthen the integrity of Indone- sia’s specialist medical education system. By build- ing a just and structured delegation framework, In- donesia can serve as a model for other low- and middle-income countries grappling with similar regulatory and workforce challenges in the medical education sector.

Recommendations

In response to the persistent gaps identified in the implementation of task-shifting from supervisors to resident doctors, the Indonesian government— particularly the Ministry of Health—must urgently develop derivative regulations to operationalise the mandates of Law No. 17 of 2023. These regulations should provide a comprehensive and enforceable framework that defines the legal boundaries, pro- cedural mechanisms, and clinical scope of delega- tion. By addressing current ambiguities, these reg- ulatory instruments will promote legal certainty, strengthen institutional compliance, and uphold the principle of patient safety. Clear competency evaluation criteria must be em- bedded within the regulatory structure to ensure that resident doctors only undertake delegated tasks after demonstrating adequate preparedness. Legal frameworks must explicitly delineate the roles and responsibilities of both supervisors and residents, reducing the potential for conflict and building a transparent, trust-based supervisory culture. These frameworks must also be adaptable to local re- source constraints while maintaining fidelity to professional standards. Effective and equitable implementation of task- shifting regulations requires multi-sectoral collab- oration involving healthcare institutions, academic entities, professional associations, and regulatory bodies. To ensure consistency, all stakeholders must commit to conducting regular, mandatory training for both supervisors and resident doctors. Such training should emphasise ethical delegation, competency-based task allocation, documentation protocols, and dispute prevention strategies. In addition, a national evaluation system should be

instituted to measure the effectiveness of delega- tion practices, with regular audits and supervisory performance reviews incorporated into hospital ac- creditation criteria. This will help enforce standard- isation and continuous improvement in task-shift- ing governance. Raising awareness and building an institutional culture around equity, accountability, and patient-centred care is essential to embedding these practices in daily operations. Policies must also prioritise fair and structured op- portunities for all resident doctors to develop clini- cal competencies. Tasks should be assigned based on objectively assessed readiness, rather than sen- iority alone. Transparent documentation proce- dures—including written delegation, supervisor identification, and confirmation of resident compe- tency—should be standardised across teaching hos- pitals. Structured mentorship systems and ongoing feedback mechanisms will further support resi- dents’ growth while reducing risks to patient care. Indonesia is encouraged to adopt and adapt best practices from global regulatory leaders, including ACGME in the United States and the European Un- ion's directives on clinical training. These models offer established principles of structured supervi- sion, accountability, and fairness in task delegation. International collaboration—whether through benchmarking, capacity building, or academic part- nerships—can accelerate Indonesia’s progress in building a credible, just, and high-quality frame- work. To facilitate this transition, Indonesia should also leverage digital technologies in the fields of super- vision, documentation, training, and monitoring. Electronic delegation records, e-supervision tools, and integrated feedback platforms will support transparency, real-time accountability, and national standardisation. By aligning its regulatory ap- proach with global benchmarks while accommo- dating its national context, Indonesia can build a re- silient, ethically grounded task-shifting model that protects patients, supports residents, and promotes excellence in medical education.

Acknowledgment

The authors express their heartfelt gratitude to all contributors to this study, especially Prof. Dr. Sigit Irianto, Dr. Anggraeni Endah Kusumaningrum, Dr. Sri Retno Widyorini, and Dr. Hadi Karyono. Thank you for your expertise and guidance. Their invalu- able insights and support significantly shaped the direction and outcomes of this research.

We also thank the academic staff at UNTAG Se- marang for their critiques, our colleagues and re- search assistants for their support, and our families for their patience and encouragement. We acknowledge the Government of Indonesia for advancing healthcare legal frameworks with Law No. 17 of 2023 and the Ministry of Health for de- veloping specific regulations. We appreciate edu- cational and healthcare institutions' collaboration and commitment to effectively implementing these regulations. We are grateful to health regulators and policymakers for formulating detailed guide- lines for equitable and transparent delegation prac- tices and fostering a high-quality healthcare envi- ronment that supports Resident Doctors' profes- sional development and patient care standards. Lastly, we recognize the contributions of Dr. Chusni Mubarakh, PhD, and all healthcare profes- sionals whose dedication to these regulations and patient care advances the overall quality of healthcare services in Indonesia.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was conducted independently, and all expenses were covered by the authors.

Conflict of Interest Disclo-

Sure

The authors declare no conflicts of interest associ- ated with this research. The findings and recom- mendations presented are solely based on the re- search and analysis conducted.

Ethics Approval Statement

Ethical approval for this study was obtained from the ethics committee of the teaching hospital where the research was conducted. All procedures were performed in compliance with institutional guide- lines to ensure the protection and confidentiality of all participants involved.

Patient Consent Statement

As this study did not involve direct patient interac- tion or data collection from patients, a patient con- sent statement is not applicable.

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