Overseas Job Opportunity among Fresh Graduate of Healthcare Workers: A SWOT Analysis

The chronic reasons why Indonesian healthcare workers are reluctant to work abroad are allegedly due to inadequate English language proficiency and family encouragement. The demand, opportunities, and benefits of working abroad are increasing from year to year. Unfortunately, the opportunity is poorly anticipated. This research highlights the opportunities for entry-level healthcare professionals and involves nursing, midwifery and environmental health. This is what makes it different from previous research. The objective is to explore the current demand, challenges and offer strategies to elevate the interest of Indonesian healthcare workers to work abroad. This study used a quantitative method with the Strength, Weaknesses, Opportunity, Threats (SWOT) Analysis supported by the PICOT (Participants, Intervention, Comparison, Outcome, Time) model to differentiate the demand, interest, and challenges of the professions. A mixed questionnaire was distributed among the population of 148 students from 3 majors: nursing (n-84), midwifery (n=23), and environmental health (n=61) collected randomly as the purposive sampling. The population were graduates holders (n=87) and diploma holders (n=61), i.e. nursing (n=84), midwifery (n=23), and environmental health (n=61). Results showed that nursing professional was more dominant and demanded abroad. The participants were interested if the training was provided (n=141 or 84%). The weakness was lack of language proficiency (n=93), and lack of preparation (n=76). The challenges mainly were due to inadequate preparation (languages, family support, and financial). The main finding of this research was that the increasing demand for overseas job is not matched by the language preparation and family support. The study recommended a structured preparation program with an integrated approach during college time INDEX TERMS Overseas jobs, Indonesian healthcare workers, SWOT Analysis.


I. INTRODUCTION
Issues related to the migration of healthcare workers from one country to another have been widely discussed in the last two decades [1]. Many studies elaborated the causes and problems as the background for the migration of healthcare workers (HCW) on an international scale [2]. The phenomena show how important the roles of healthcare workers in health services are [3]. During the Covid-19 era for example, the shortage of nurses reached 20% [4]. Yet, in many rich and developed countries, the tendency of people to take the healthcare profession as a choice of work is decreasing which is worsening the health care services condition faced by the modern world [5]. International Council of Nurses (INC) reported 13 million of nurses will be needed to fill the gap in the future [6]. In general, the need of healthcare workers from other countries of the third world countries seems endless [7]. As a result, the high demand of HCW from other countries such as India, the Philippines and Indonesia keep on increasing. Unfortunately, due to some problems, there is an imbalance between demand and supply during the recruitment process [8]. It is acknowledged worldwide that working abroad offers various benefits, both economically, socially, culturally, educationally to religious interest [9]. The benefits vary depending on the country of residence, the institution of employment, forms and sizes of the healthcare services, position offered, work experience, and the candidate's specialization [10]. In general, in terms of the profession, working abroad as a HCW has never subsided and is always needed. Nurses are the most needed healthcare professional, besides midwives and environment health professionals [11] The demand for Indonesian HCW began in the late 80s for placement in Saudi Arabia, followed by other countries i.e. the United Arab Emirates (UAE), Malaysia, Singapore, Brunei, the Netherlands, Qatar, Oman, Bahrain, Australia, Canada, USA, Japan, and Germany [12]. The opportunities was not well anticipated [13]. Allegedly the main cause was lack of the language proficiency and support from family, parents, or spouses for those who are married [14]. The number of workers needed is in hundreds to thousands. Nevertheless, the trends of sending Indonesian HCW abroad for the last three decades have not shown a significant increase [15]. At the same time domestically, Indonesian HCW face employment problems due to overproduction, lack of opportunities, and remunerations [16].
Previous studies have revealed a lot about the correlation between the wages and job satisfaction which is closely related to the welfare of HCW [17]. The relationship between competence and well-being of HCW migrants is also widely discussed [8]. A research in Australia and Canada explored how stress was experienced by migrant workers in the workplace [8], [18]. Not a few who discussed in detail HCWs' contributions, for example in the USA [19], Japan [20], and in Norway [21], to countries that are members of the OECD (Organization for Economic Co-operation Development) [22]. Migrant workers have expectations [8], the most common of which are gaining experience [21], professional development [8], and improving economic conditions [8]. It must be admitted that achieving those expectations and goals are not easy because migrant workers are always faced with challenges, as faced by HCWs from India and the Philippines in the UK [18].
Researchers agreed that despite its challenges and drawbacks, working abroad is highly profitable [23]. Healthcare workers in developed countries such as the USA, Canada, and Australia continue to spread to other continents, namely the Middle East, Africa, Europe, and even Southeast Asia is a concrete example [24]. Those facts prove that working abroad has its own charm. In the nursing profession, for instance, there is professional a Travel Nurse, a nurse whose job is to accompany mobile clients from one country to another. It is indeed interesting to study the occurrence of Indonesian HCW' interests which seems constant amid the incessant demand for overseas placement for years.
This article tried to analyze the strengths, weaknesses, opportunities and threats of the Indonesian fresh graduate HCWs' interest in working overseas by implementing SWOT Analysis. PICOT formula was also used to help researchers differentiate the demand, interest and the challenges of each healthcare profession. The implication of the study is to complement the results of previous researches that have not been discussed, especially on fresh graduates who are interested in working abroad, healthcare education providers, lectures and authorized government agencies. The objective is to explore the current situation, demand, and challenges faced by Indonesian new starters of HCWs and offer the right strategy to fill gap of overseas job opportunity. Many studies discussed the opportunities, advantages, and challenges of HCWs, but the majority focus on the global nursing profession. The fundamental difference with this research is that the emphasis is more on entry-level healthcare professionals which also involves midwives and environmental health.

II. METHODS
This research method is quantitative with a SWOT analysis design. The method was chosen because it enabled us to identify the organization's Strengths and Weaknesses, possible Opportunities and potential Threats of fresh graduates of HCWs' interest-related factors [25]. Similar method was used in nursing by previous researcher [26].

A. DATA COLLECTION
The primary data collection that we used was a questionnaire distributed through the assistance of Google Forms. It was used to ensure that information on the variable of interest took place systematically and allowed respondents to answer questions and evaluate results. This initial data collection stage was carried out during a webinar at the Institute of Health Sciences (Stikes) of Widyagama Husada Malang. The questionnaire was a mixed questionnaire extracted from a validated questionnaire [27]. It was conducted on 16 October 2021. The population was randomly and purposively taken from 168 students (n=168) taking part the webinar in which 14% (n=23) of them were midwifery students, 36% (n=61) were environmental health students, and 50% (n=84) were nursing students. It was carried out online, after obtaining ethical clearance from the institute

B. DATA GROUPING
In the second stage, we conducted data grouping, namely separating data based on certain criteria. Kriteria inklusi dan eksklusi These criteria are based on the results of classifying 8 questions in which 2 questions were on education background, 2 questions on overseas work opportunities, 2 questions on the preparedness to work abroad, and 2 questions on the challenges.

C. DATA MEASUREMENT
The third step was data measurement in which we used nominal (numeric) scales to label the variables. The independent variable is job, and the dependent variable is nurses. The measurements were carried out using a selfcompleted questionnaire.The SWOT Analysis diagram is as follows.
The above diagram projected two groups of analysis, positive and negative. The positive group covers the Strengths (S) and Opportunities (O), and the negative group covers Weaknesses (W) and Threats (T). The strengths are internal factors that include the advantages possessed by Indonesian HCWs that may attract users from other countries. Meanwhile, the weaknesses contain the fatigue or shortcomings of the HCWs that hinder the recruitment process.
The opportunity (O) and Threats (T) are the external factors. The opportunity consists of the identified factors that provide opportunities for the HCWs. The threats are the potential external risks that burden the recruitment process. The summary was then combined with the selected data according to the research focus, namely interests and work opportunities abroad with a sample population of 168 students of Stikes Widyagama Husada Malang. To differentiate to demand or requirements, interest and challenges of each healthcare profession we used PICOT (Population, Intervention, Comparison, Outcome, Time) formula as the instrument. The Population was fresh graduate of health care profession), Intervention was the interest to work abroad, Comparison was nurses, midwives and environmental health, Outcome was healthcare professionals who fulfill the requirement and Time was after graduation year of 2021-2022. After entering the data in the formula, we identified the gaps and suggested the possible solution

A. Study Selection
The study selection was taken from the tabulated questionnaire i.e. self-competed questionnaire which was processed by using a numbering system. The number of students participating in the study was 168 (n=168), respectively from the department of midwifery (n=23 or 14%), environmental health (n=61 or 36%) and nursing (n=84 or 50%) of the Health Institute (Stikes) of Widyagama Husada Malang. They were undergraduate (Strata 1) (87%) and the diploma holders (13%). Most of them believed that overseas job opportunities were always available (n = 136 or 81%) and for HCWs (n=53 or 91%). However, those who felt that HCWs in Indonesia were ready to pick up the job opportunity was 75 (n=75 or 45%), and 66 people (n=66 people or 39%) were not ready and those who did not know was 27 people (n=27 or 17%). Almost half of them (n=82 or 49%) were interested in working abroad. Their obstacles were language skills (76 or 45%), family support (n=45 or 27%), and 17% (n=27) who felt that they were less well off financially. Nonetheless, 84% (n=141) were confident in their training if given opportunities. The summary is as projected in the below figures: The above figure shows the biggest obstacle faced by healthcare workers is the language acquisition (n=84 or 50%).

B. SWOT Analysis
The following SWOT diagram content was extracted from the questionnaire tabulation supported by scientific journals. The Regarding the Opportunities O) according to the government agency (BP2MI, 2021) the demand is still high. The choices are available in different countries from the Netherlands, Germany, Middle East countries, until Japan [28]. Whereas about the threats (T), India and the Philippines are two countries that send more nurses abroad, and they play as major global competitor [18]. Besides, technology changes [29]; and current the Covid-19 Pandemic [30]. The figures above (3 and 4) portray the current condition of fresh graduates of HCWs who are academically potentials and competent because of their majors in healthcare education expertise, namely nursing, midwifery, and environmental health produced by an accredited university, but at the same time facing language barrier, minimum of family support and lack of fund. They are in high demand and needed by many developed countries.

C. PICOT Formula
The table above is the result of data identification which were put in the PICOT formula. The same formula was implemented to support his evidence-base change of nursing practice project in which he used SWOT Analysis to measure the effect of team work with the support of PICOT formula [31]. The results show that nursing profession is dominant as HCWs (50%). All HCWs express that the biggest obstacle was the language barrier (50%). However, if trained, their interest to go abroad is enormous (84%). From the three data groups that were processed by SWOT Analysis and mapping using the PICOT Formula with the support of journals and various sources related to the issue of health worker migrants, the need for healthcare workers is very promising. Indonesia has the potential to meet its demand due to the high number of its healthcare education institutions [32]. However, the data of this study projected the readiness of healthcare workers in Indonesia is relatively lacking and is still stagnant.

III. DISCUSSION
The basis for the discussion below is each review contained in the SWOT Analysis (Figures 3 and 4) in which each aspect (strengths, weaknesses, opportunities, threats) contains problems that need to be solved. In addition, in the PICOT Formula (Table 2), the aspect discussed is the point outcome (O) regarding the problems faced by respondents.

A. STRENGTHS
Some of the potential poses as strong elements by Indonesian HCWs as professional as stated in the results of the questionnaire collection are the number of graduates (86.9%), their interest (45.8%), and the professional education background especially nursing (50%). The main requirements for working abroad is minimum to be a diploma or bachelor's degree, having a minimum of two or three years of work experience, possessing a Registration Certificate (STR), passing an interview/written test, and medical checkup [33]. In the SWOT analysis, what is included in the Strengths category are human resources, infrastructure, training, support, and technology (hardware and software) [34]. As the fourth largest country in terms of population, Indonesia has a large number of human resources in healthcare [35]. In the educational institutions view point, more than 3,000 public and private campuses available [36]. Nursing and midwife majors reach more than 1,400 [26]. For the diploma education level, 38 Polytechnic of Health (Poltekkes) of Ministry of Health campuses with more than 54,700 students from various majors are accessible [32]. Students from various health majors have wide practice area in the country, from laboratory technician, pharmacy, physiotherapy, radiology, nutritionist until nursing. Indonesia has more than 2,800 units and more than 9,900 units of Public Health Centers (Puskesmas) [37]. Not to mention other practical facilities and infrastructure, including large number of patients as case study material for students.  Indonesia possesses a Health Manpower Council (MTKI) that regulates the health workforce system as well as a regulator that determines National Health Service standards [38]. The curriculum applied to educational institutions is regulated by the Ministry of Higher Education, Research and Technology and the Ministry of Health. They standardize the health professionals studies who can compete on the international stage, especially in the global era [39]. Therefore it is expected that HCWs must be competent and able to compete in the global market [40]. Some campuses with an "A" accreditation are equipped with adequate facilities, highly qualified lecturers who have graduated from overseas campuses and modern laboratory practice tools [41]. The modernization of those campuses is strived to answer the challenges of the era of globalization and industry. The Indonesian Healthcare workers Council (MTKI) is a regulator that provides registration status for professional healthcare workers whose certificates are not only needed for practice purposes domestically but also abroad [37]. The registration status of the healthcare workers is also required to ensure that HCWs are competent [42]. Moreover, Indonesia owns a non-ministerial institution called the Indonesian Migrant Workers Protection Agency (BP2MI) that directs, bridges and protects Indonesian healthcare workers who are interested in working abroad [43]. So, there should be no question why too many overseas job opportunities available every year are not fulfilled.

B. WEAKNESSES
The data processing result in the study showed three main problems faced by Indonesian HCWs, namely lack of mastery of foreign languages (55.4%), poor family or parental support (27.4%) and less preparation (45.2%). Only some felt that they were economically unable to finance the recruitment process (14%). According to the SWOT Analysis theory, those that fall into the category of weaknesses include all internal elements that hinder the achievement of goals such as lack of support, resources, lack of technology, and infrastructure [44]. The weaknesses in the foreign language proficiency and from parents' support or family were dominantly felt by respondents who were interested in working abroad. The language barrier occurred because the curriculum refers to the national curriculum without maximizing the 'local wisdom' (muatan lokal). The portion of credit semester of foreign languages such as English, Japanese Arabic in the curriculum is little. Although several campuses organize foreign language training, they have not been effective [45]. The reasons can be due to an unsupportive speaking practice environment and unavailability of competent lecturers. Meanwhile, the encouragement of parents or family is still low because of their traditional understanding of the concept of professional globalization [46]. Those two main problems can be overcome through an organized program. For example, the introduction of work abroad for health professions has been introduced in the early study (semester one). In that stage students are gradually provided with study materials related to overseas work programs such as Transcultural, effective language development, bringing in experienced practitioners abroad or foreign student exchanges to share their experiences, etc. Special guidance can also be given to students who are interested in the program by involving their parents or guardians. Thus, after graduation, they will have received sufficient provisions without having to undergo lengthy and expensive overseas job preparation training program

C. OPPORTUNITIES
Most respondents in this study have the same perception of the hefty overseas job opportunities (91.7%). They admitted that there were always work opportunities abroad (81%). The evidence shows that the information on job opportunities abroad has spread widely in the information technology era. Overseas programs organized by the government or the private sector, both Government to Government (G to G) and Private to Private (P to P) can be accessed very easily and quickly through various media [47]. The implementation of the selection does not have to come physically unnecessarily to the capital city of Jakarta. Medical check-ups can also be carried out in the nearest city that has international medical check-up facilities. Several countries have provided financial assistance scheme for language training program, document processing, and ticketing [48]. Certain countries offer handsome packages i.e. free accommodation, transportation, and even food. Indonesian HCWs in many countries such as the Netherlands, Kuwait, Qatar, Kingdom of Saudi Arabia, Australia and the USA can study while working. The opportunities prove that welfare insurance and professional development for HVWs working abroad have received considerable attention. Those golden opportunities should have been introduced early because the demand for Indonesian HCWs had existed since the late 80s. Colleges with health-related departments should ensure a major role of their graduates in fostering young generation to prepare their world-class healthcare workers. Working abroad for HCWs is not merely limited to improving the level of welfare of the population, but also the introduction and equality of world-class professionals.

C. THREATS
The data of this study indicate that not all healthcare professions have interest in working abroad. Challenges from family or parental support may pose major obstacle if not anticipated from the start. From year to year, the challenges and hindrances are always changing. From one country to another one, their policies towards migrant healthcare workers also changes. Domestic employment policies and procedures have also developed. The working conditions and requirement abroad in the future will be more and more complicated. A concrete example is during the Covid-19 pandemic where there was a change in the recruitment process, at least a multilevel Polymerase Chain Reaction (PCR) test [49]. Not to mention the mastery of foreign languages and the medical technology, which are not always delivered in English. Competitions from other countries' healthcare workers keep on increasing [50]. Those challenges need to be anticipated from the beginning, so that novice enthusiasts can prepare themselves better. The existence of institutions such as BP2MI in Indonesia is a concrete example in anticipating the various challenges faced by migrant workers in the future. Yet, more importantly, is back to the inner interest of the HCWs.
In short, apart from the positive and negative sides of this SWOT analysis of Indonesian HCWs, what must be emphasized is that the increasingly stringent requirements for foreign demand require a concrete strategy. It would be simpler if an international program was established from a campus that is interested in providing opportunities for students to pursue their employment careers abroad. Thus, there is no need for various screening systems to capture them, because from the outset of the educational objective is already clear. The international program is a concrete solution to the job demand for HCWs who are interested in working abroad. Apart from the candidate's strong interest from the start, their families and parents have already agreed, and mastery of foreign languages is no longer in a big question mark. The weakness of this research is that it was not carried out directly by involving more potential candidates of registered healthcare professionals across the country, due to the Covid-19 pandemic and the government restriction. The research could have involved more respondents from many campuses, lecturers, government organizations, and manpower agencies. The difference with previous researches is that many previous researches only focused more on nurses recruitment especially in Indonesia than other health professions in the entry level.

IV. CONCLUSION
The objective of this study is to explore the constant interest of Indonesian HCWs working abroad in which language barrier, lack of family support are found as the major challenges among fresh graduates and offer some solution. The findings in this study indicated that the biggest challenge faced by Indonesian HCWs is language acquisition, followed by lack of family support and financial condition. Those three problems were found as they were in the final stage of their studies. On the contrary they are highly potentials and enthusiasts to work abroad. The study suggested a structured program during the college time by introducing overseas preparatory program earlier, and involving parents, manpower agencies and the government to be more prepared. Therefore, to measure its effectiveness, further studies are definitely required in the future.