Eka J. Wahjoepramono
Dean, Faculty of Medicine, Universitas Pelita Harapan
Chair, Neuroscience Center, Siloam Hospital

Being a neurosurgeon is an exclusive and expensive occupation, especially in a developing country with limited resources. Although we are highly skilled in the clinical aspect of our work, we must also develop our sense of entrepreneurship to advance our profession. We must recognize opportunities and take risks to move forward, while helping each other along the way.

I work in Indonesia, a developing country where the government does not provide universal health coverage and has not invested a lot of resources in neurosurgery at the time. We are an archipelago of 17,000 islands with 272 million population, stretching 5,245 km from the east to the west. The government was focused on building up the population centres, and many places have not received adequate healthcare. Early on, I recognize that I need the help of the private sector to expand neurosurgery.

There are always wealthy and successful individuals in developing countries, but not many are interested to invest in healthcare. Government regulations are often complicated, and many think healthcare is not a good investment. Neurosurgery requires a lot of infrastructure, expensive tools, and other specialists to work, so we must operate in good hospitals. I am determined to appeal to these wealthy people, usually the families of my patients, so they can see that participation in health care is not only a business investment but also building up the honor and respect for their companies, and as a contribution for the nation.

My center, Siloam Hospitals, was founded in 1996 by a banker and philosophist, Mochtar Riady. Initially, it was to become a cardiology center, and 2 of us - neurosurgeon-entrepreneurs - wanted to make it a neurosurgery center. We were located in the suburbs, and we had to convince the founder that people will come far for high quality neurosurgery, even to our location. So we did many things to make the public know we were here. We made seminars and talkshows on neurosurgery, we invited experts from abroad to come and perform difficult operations, and worked hard to increase the number of surgeries. We made Siloam a trustworthy name for neurosurgery, and patients came from the capital to have surgery in our hospital. We started receiving complicated cases such as AVMs, giant aneurysms, brainstem tumors, and others which were usually sent abroad for operations.

My main principle was, that Indonesian neurosurgery must be on par with neurosurgery in advanced countries. Patients in Indonesia should not have to look for help abroad due to our lack of skill. We are determined to give the same quality service as our colleagues in Japan, Singapore, or America. To achieve this, I realized that I cannot do it alone. I wanted to provide subspecialty services, and so I recruited 4 other neurosurgeons into my hospital, so each can study and develop their own subspecialties. This was unheard of in Indonesia at the time, where usually one surgeon will serve many hospitals to get a lot of cases.

In 2001, an orphaned fisherman was brought to our hospital with a ruptured brainstem cavernoma. As we were a private hospital, we could not help this man because he did not have the money. Brainstem cavernoma surgery had not been attempted in Southeast Asia at the time, due to technical difficulties and risks. I did the operation free of charge and asked for funding from other wealthy patients to cover hospital costs. The operation was a success and put our hospital in the international spotlight. Learning from this, I created the Indonesia Brain Foundation, a charity to help fund neurosurgery cases with good prognoses. For these cases, the doctors’ fees are waived. The hospital also started receiving government insurance, so we can serve more patients.

In 2006, Siloam Hospitals group started expansion. The group’s founder analyzed that Indonesia needs more hospitals, especially in remote places, and has since built or acquired 40 other hospitals. I saw this as a chance to expand neurosurgery and talked with management to provide neurosurgical equipment in other hospitals. We started recruiting surgeons, preferably those who came from the same area as the new hospital, so they will be happy to return and serve their own birthplace instead of staying in the capital. If there are no neurosurgeons in their area, they may also work in the public hospitals.

In 2021, we now have 28 full-time neurosurgeons working in our system nationwide. When our younger colleagues meet complicated or difficult patients, they will consult with us, and our subspecialty neurosurgeons will fly to their area with specialized equipment to perform the operation in their center. This will increase the confidence of our younger colleagues until they can perform the operation independently, and increase the public trust in our team.

Being in our system also gives bargaining power to the young neurosurgeons. Private hospitals will always consider costs when investing in a specialty, and neurosurgery with its expensive tools may not be a priority. Our group can guarantee results to the management based on our experience and convince them to buy equipment. We also talk about their pay, with a guaranteed fixed income for our younger surgeons to help them survive, while increasing their skills and building up their reputation to get more patients.

In developing countries, we must look for opportunities to grow, take calculated risks, and help each other so we can move forward. We need to have good communication with hospital stakeholders. Having a solid team helps to increase subspecialty skills and increase our bargaining power. I believe this is a good way to develop global neurosurgery, so we can serve more patients.

Figure: Siloam Hospitals in Indonesia with Neurosurgery – 2021

December 2023