Indonesian perspectives in a healthcare focus group discussion on initiating health checkups for returning migrant workers: a preliminary report

Abstract

Objectives

Indonesian migrant workers face significant occupational health risks abroad, yet Indonesia currently lacks a comprehensive, continuous post-employment health-monitoring framework, resulting in delayed diagnosis and treatment of work-related diseases for returning migrant workers. This study aimed to explore the perspectives of Indonesian healthcare stakeholders regarding the necessity, feasibility, and strategic steps of implementing Japan’s Overseas Health Checkup Initiative (OHCI) for returning migrant workers.

Methods

A qualitative phenomenology study was conducted using focus group discussions to explore participants’ perceptions and expectations of implementing OHCI in their workplace. Five discussion groups were composed to reflect perceived variations in attitudes to OHCI, with consideration to account differences in professional and educational background, geographical setting, and class of health facility. The discussions were conducted either in hospital meeting rooms or via an online platform. Each session was facilitated by a moderator and supported by a note-taker. For in-person sessions, participants were seated in a round-table arrangement to encourage open discussion and interaction.

Results

Findings demonstrated a strong consensus among all stakeholders on the urgent need to implement the OHCI to safeguard returning migrant workers’ health. Key challenges identified included establishing a standardized cross-border data-sharing mechanism, defining clear OHCI protocols, and securing financial sustainability. The OHCI is viewed as a critical policy intervention.

Conclusions

Successful initiation of the OHCI in Indonesia requires immediate collaboration between sectors to establish the necessary regulatory, technical, and financial frameworks, potentially by adapting international models of continuous health surveillance.

Introduction

Labor migration is a central feature of the global economy, but it exposes workers to substantial occupational and environmental health risks¹⁾. Indonesia, as one of the largest labor-sending countries, has a responsibility to protect its migrant workers²⁾. However, the current health surveillance system remains focused on pre-departure screening and does not adequately monitor the long-term health consequences of overseas employment. Limited healthcare coverage and insurance further increase vulnerability among returning migrant workers, often resulting in delayed diagnosis and treatment of work-related conditions^3,4). These gaps highlight the need for a continuous health-monitoring framework.

Japan has experienced rapid growth in its migrant workforce, and Indonesians are among the fastest-growing group. Migration through structured pathways such as the Technical Intern Training Program and Specified Skilled Worker System has expanded substantially, which has in turn increased the demand for robust health protection mechanisms. Under Japan’s Industrial Safety and Health Act, workers engaged in high-risk occupations receive a Notebook of Personal Health Record (nPHR), which enables ongoing health surveillance that continues after employment ends. The nPHR is part of Japan’s broader health and medical information platform, which integrates Personal Health Records (PHR), Electronic Health Records (EHR), and data systems to facilitate information sharing between individuals and healthcare providers⁵⁾. However, due to regulatory constraints and technical limitations, Indonesian workers face major barriers in utilizing the nPHR once they return home, thereby limiting its intended protective function^6,7).

The lack of integration between the nPHR system and Indonesia’s healthcare framework undermines both worker protection and public health capacity. To address this gap, the Overseas Health Checkup Initiative (OHCI) has been proposed⁸⁾. OHCI refers to a collaborative framework within occupational health systems that facilitates coordination among stakeholders, including employers, healthcare providers, and occupational health professionals. Based on the referenced report, OHCI plays an important role in ensuring the continuity of occupational health services, integrating health check-up data, and supporting worker health management across different settings.

In this study, we assessed the feasibility of implementing a standardized post-migration health checkup system in Indonesia, informed by the Japanese nPHR model. Using focus group discussions (FGDs) with stakeholders in multiple sectors, this research aimed to provide evidence to inform the regulatory, technical, and financial frameworks needed for OHCI implementation. This work is conducted as part of the OHCI Project, and is supported by the Ministry of Health, Labour and Welfare of Japan⁸⁾.

Methods

Study Design and Setting

This study utilized a qualitative phenomenology design to explore stakeholders’ perceptions of the feasibility of implementing the OHCI in Indonesia and the policies required for doing this. Data were collected through FGDs involving representatives from hospitals and institutions related to migrant worker health services that had been selected to reflect a diversity in professional background, geographic setting, and facility type. The study was conducted in Indonesia through a collaboration between three institutions: the Department of Community Medicine in the Faculty of Medicine at Universitas Indonesia, Universitas Indonesia Hospital, and Kochi University, Japan. The overall objective was to gain insight into the potential for implementing the OHCI in Indonesia.

Participant Selection and Group Formation

To ensure that data critical for developing comprehensive policy recommendations were collected, participants were recruited using purposive sampling to ensure inclusion of stakeholders with relevant expertise and decision-making roles in migrant worker health policy and service delivery. Invited participants represented relevant ministries, professional organizations, academia, and healthcare providers from primary to tertiary care facilities.

To capture diverse operational perspectives, participants were grouped into five FGDs based on institution type and geographic location: (1) professional representatives from national medical and occupational health organizations (e.g. occupational medicine specialists, pulmonologists, internists, and clinical pathologists), (2) tertiary (Type A) and secondary (Type B) referral hospitals in Greater Jakarta, (3) healthcare facilities and basic specialized hospitals (Type C) and essential medical services (Type D) in Greater Jakarta, (4) Type A–B hospitals outside Greater Jakarta, and (5) Type C–D hospitals and services outside Greater Jakarta.

Data Collection Session (FGD Protocol)

FGDs were directed according to a semi-structured discussion guide which explored four domains: (1) current health examination practices, (2) challenges in providing health examinations for returning migrant workers, (3) perceived value of health examinations, and (4) recommendations for strengthening implementation. Each session was facilitated by a moderator and note-taker and conducted either in person or through an online platform via Zoom to accommodate participants who were unable to attend physically. All sessions were audio-recorded to facilitate accurate transcription and capture the nuances of participant interactions.

Data Analysis

Data were analyzed using framework analysis and the systematic text condensation (STC) method. For the framework analysis, transcripts were reviewed multiple times, and a coding framework was developed using deductive codes (e.g., needs, feasibility, barriers, system readiness) and inductive codes that emerged from the data. Coded data were organized into a thematic matrix to allow comparison across participants and groups and to support theme development.

STC analysis followed four steps: decontextualization, condensation, theme generalization, and synthesis. Meaning units were identified, condensed, grouped into major themes, and compared across FGDs to identify key patterns and differences. The final synthesis translated the generalized themes and validated patterns into a conceptual framework for OHCI.

Artificial intelligence tools Google Gemini (Gemini 3 Pro, Google DeepMind) and Chat-GPT (GPT-5.1, OpenAI)) were utilized during the preparation of this manuscript, specifically to write data analysis output sentences, to enhance the formal tone, and to ensure grammatical precision within the qualitative data interpretation.

Results

Participants and Data Characteristics

The five distinct FGDs comprised a total of 64 participants. Each group consisted of 8 to 17 participants. The distribution of participants is detailed in Table 1. The FGD sessions yielded a substantial volume of data, with individual sessions averaging approximately 90 minutes’ duration. This diverse composition ensured that the analysis could robustly examine not only the consensus regarding the OHCI’s necessity but also the context-specific nuances required for its complex initiation across different institutional and geographic settings.

Table 1. Distribution of Focus Group Discussion Participants.

Variable		G1	G2	G3	G4	G5	Total
Number of participants, (n)		13	13	17	13	8	64
Gender, n (%)
	Male	61,5	38,5	52,9	23,1	62,5
	Female	38,5	61,5	47,1	76,9	37,5
Occupation, n (%)
	Occ-Med Specialist	23,1	30,8	23,5	15,4	50
	Other Specialist	46,2	0	11,8	0	0
	GP / Physician	30,8	69,2	64,7	84,6	50

G1, Group 1; G2, Group 2; G3, Group 3; G4, Group 4; G5, Group 5; Occ-Med, Occupational Medicine; GP, General Practitioner; Other Specialist, (e.g.: Pulmonary Specialist, Clinical Pathology Specialist, Internal Medicine Specialist)

Framework Analysis

Familiarization and Initial Coding

Deductive codes (policy-driven) were derived directly from the study objectives, including perceived necessity, operational feasibility, regulatory barriers, financial mechanisms, and data interoperability. Inductive codes (emergent from the data) were identified from recurring terminology and concepts expressed by participants. These included the shortage of occupational medicine specialists; the limited availability of high-resolution computed tomography (HRCT); the potential bottleneck in implementing the OHCI due to the limited number of accredited companies providing occupational health and safety services (PJK3) relative to those providing services to migrant workers (PJTKI); and concerns regarding bias in declaring workers fit or unfit for employment.

The potential bottleneck mentioned was that while OHCI may rely on accredited PJK3 facilities to deliver standardized examinations and reporting, an imbalance in these facilities among regions in Indonesia could lead to delays and uneven service coverage. A speculated bias in fit-to-work and unfit-to-work determinations in settings where medical certification is directly linked to employment eligibility was also a potential problem. In such contexts, non-clinical pressures from employers or recruitment agencies may influence clinical judgment. These structural and ethical challenges provide important context for interpreting the results that follow.

Systematic Application and Charting (Thematic Matrix)

In the thematic matrix, data were organized by FGD group (in rows) and by code/theme (in columns), with each cell containing summaries and illustrative quotations. This process generated the thematic structure that underpins the Results section. The analysis produced a robust coding framework that linked policy objectives with practical realities in the Indonesian health system. As shown in Table 2, the framework comprised deductive codes that reflected the study’s core constructs and inductive codes that captured issues emerging from stakeholders’ lived experiences. Deductive themes (Table 2, Core Themes), namely perceived necessity and scope, operational feasibility, regulatory barriers and governance, and financial integrity, were used to assess the conceptual viability of the OHCI and ensure alignment with national policy priorities in Indonesia. Inductive themes (Table 2, Illustrative Findings) revealed context-specific challenges often overlooked in policy design. These included a shortage of occupational medicine specialists and limited HRCT availability, indicating significant gaps in capacity and infrastructure. Additional emergent findings, such as the PJK3/PJTKI ‘bottleneck’ and bias in fit/unfit decisions, highlighted systemic and ethical concerns. These findings suggest that OHCI success depends not only on funding, but also on addressing perverse incentives and administrative barriers within the recruitment–healthcare interface.

Table 2. Thematic Findings of the Focus Group Discussions.

Core themes	Sub-themes	Illustrative findings	Inter-group comparison
Necessity & scope	Need for OHCI	Unanimous agreement on high necessity due to inadequate pre-departure screening	Consensus: Universal affirmation across all five groups
	Standardization	Must be a dedicated occupational MCU (not a general MCU), requiring HRA and job-specific protocols	Differentiation: Clinical groups (G3, G5) emphasized the specific clinical tests (e.g., pneumoconiosis) and the need for a “tiered fit-to-work card”
Operational feasibility	HR/Competency	Critical shortage of occupational medicine specialists, especially in regional hospitals Delegation to general practitioners or other specialists is common	Contrast: More prevalent issue outside Greater Jakarta (G4)
	Equipment/Logistics	Core facilities (Lab, X-ray) exist, but advanced diagnostic tools (HRCT) are scarce Mobile services are desired but face logistical hurdles and operator shortages (e.g., radiologists, USG operators)	Consistent: ‘Bottleneck’ reported by clinical groups (G3, G5) and regional groups (G2, G4)
Regulatory barriers & governance	Policy mechanism	Need for clear national regulations/guidelines to mandate the service and define stakeholder roles	Consensus: Universal demand for top-down policy intervention
	Accreditation/PJK3	Current third-party accreditation (PJK3/PJTKI) is viewed as a ‘bottleneck’ and a source of bureaucratic friction	Strong Opinion: Highly emphasized by professional organizational representatives (G1) and clinical (G3) groups advocating for an OSS-based, streamlined system
	Data interoperability	No concrete mechanism for cross-border data-sharing or nPHR integration exists. This is a technical governance failure	Crucial Gap: Identified as a core technical barrier by clinical and professional organizational representative groups (G3)
Financial integrity	Field practice	The current field practice payment mechanism creates an ethical bias that encourages facilities to declare workers “fit” to secure payment	High Risk: Strongly articulated by the professional organizational representative group (G1) as a major threat to clinical objectivity

G1, Group 1; G2, Group 2; G3, Group 3; G4, Group 4; G5, Group 5; HR, Human Resources; HRA, health risk assessment; HRCT, high-resolution computed tomography; MCU, medical checkup; nPHR, Notebook of Personal Health Record; OHCI, Overseas Health Checkup Initiative; OSS, online single submission; PJK3, occupational health and safety service providers; PJTKI, Indonesian migrant workers agencies; USG, ultrasonic generator

STC Analysis

Decontextualization and Interaction Coding

The interaction coding guideline (Table 3) presents the patterns of meaning and group dynamics within the qualitative transcripts. Three key interaction symbols were applied: ↑↑ to denote strong agreement, ↗ for differentiation or nuance, and I^R to indicate integrity risk. Collectively, these codes enabled a more nuanced interpretation of consensus, elaboration, and ethical tension within the group discussions.

Table 3. Interaction Coding Guideline.

Interaction symbol	Meaning	Example in transcripts
↑↑ (Strong agreement)	High consensus on a point	OHCI necessity: Universal agreement on the urgent need for a standardized checkup for RMWs
↗ (Differentiation/nuance)	Adding complexity without disagreement	Scope: Defining OHCI as an occupational MCU, distinct from general checkups (Group 3)
IR (Integrity risk)	Statements signaling ethical/integrity problems	Financial model: “If someone is unfit and doesn’t have to pay, then I would be encouraged to always declare someone fit.” (Group 1)

MCU, medical checkup; OHCI, Overseas Health Checkup Initiative; RMWs, returning migrant workers

Condensation and Categorization

Table 4 summarizes four themes derived from the condensed meaning units. The first theme, necessity and scope, reflected consensus that the program should prioritize continuous health surveillance, integrate health risk assessment, and produce clear fit/unfit criteria based on returning migrant workers’ needs. The second theme, operational feasibility, highlighted key implementation barriers, including shortages of occupational medicine specialists, limited access to advanced diagnostics (e.g., HRCT), and logistical challenges in delivering mobile services. The third theme, regulatory barriers and governance, identified systemic issues such as the lack of cross-border interoperability for nPHRs and bureaucratic constraints within the PJK3/PJTKI system, which in turn prompted calls for clearer regulations and standardized implementation guidance. The final theme, financial integrity, raised concerns about service sustainability and ethical risks, as limited market attractiveness may undermine long-term viability.

Table 4. Condensed Unit Categorization.

Core themes	Example of condensed unit
Necessity & scope	Policy goal: continuous health surveillance ↑↑ Must include HRA ↗ Output needs definitive fit/unfit criteria based on the RMWs needs
Operational feasibility	Critical shortage of occupational medicine specialists, so general doctors perform exams ↗ HRCT (advanced equipment) is scarce Mobile services face logistical hurdles and operator shortages
Regulatory barriers & governance	No cross-border data interoperability for nPHR Current PJK3/PJTKI system is a bureaucratic ‘bottleneck’ Need for clear national regulations and guidelines
Financial integrity	Service is not market attractive Payment bias risks integrity (IR) so funding model needs to decouple payment from result

HRA, health risk assessment; HRCT, high-resolution computed tomography; nPHR, Notebook of Personal Health Record; PJK3, occupational health and safety service providers; PJTKI, Indonesian migrant workers agencies; RMWs, returning migrant workers

Theme Generalization and Pattern Identification

Table 5 presents higher-level thematic interpretation across stakeholder groups. There was strong consensus that the current system inadequately protects returning migrant workers and that an occupationally oriented medical checkup should become the standard. This indicated agreement on both the problem and the direction for reform. Geographic disparities were evident, with participants noting a more severe shortage of occupational medicine specialists in public hospitals outside Greater Jakarta compared with those in Greater Jakarta.

Table 5. Finding and Interpreting Generalized Themes.

Pattern identified	Interpretations and findings
Universal convergence (↑↑ in all groups)	Consensus on the problem: All stakeholders agree that the current system fails RMWs and the occupational MCU must be the standard
Geographic difference (G4 vs. G2)	HR gap: The lack of certified occupational medicine specialists is significantly more acute and pressing in RSUDs outside Greater Jakarta, highlighting a regional capacity divide
Inter-professional conflict (IR vs. ↑↑)	Integrity risk: Professional Organizational representative/policy groups (G1) explicitly raised the ethical risk of the financial model, whereas clinical groups (G3, G5) focused more on technical challenges. This emphasizes that the fit/unfit bias is a high-level policy concern
Technical impediment (↗on data/HRCT)	Systemic failure: The inability to integrate the nPHR is consistently identified by technical experts (G3) as the most critical governance barrier, making continuous surveillance impossible without new policy implementations

G1, Group 1; G2, Group 2; G3, Group 3; G4, Group 4; G5, Group 5; HR, Human Resources; HRCT, high-resolution computed tomography; MCU, medical checkup; nPHR, Notebook of Personal Health Record; RMWs, returning migrant workers; RSUDs, regional public hospitals

Differences across stakeholder roles also emerged: policy and organizational stakeholders emphasized ethical and financial integrity risks, whereas clinical groups focused primarily on operational challenges. Finally, technical stakeholders consistently identified poor integration of the nPHR system as a critical systemic barrier, which highlighted the importance of digital infrastructure for effective implementation. In addition to facilitating data transfer from host to sending countries, such systems should also enable reverse feedback. The identification of late-onset occupational diseases in the sending country could provide important feedback to the host country. Building an expert network for such cross-national feedback may help improve risk control at the source of exposure.

Synthesizing (Conceptualization)

Further synthesis of the core themes into higher-order STC-derived findings is shown in Table 6. The synthesis was then translated into explicit policy implications. Under the theme of necessity and scope, the analysis validated OHCI as a mandatory specialized service rather than an optional general health intervention. Participants’ accounts supported the need for immediate regulatory action to mandate protocols based on health risk assessments for the occupational medical checkup as a national standard.

Table 6. Conceptualization through Policy Implications.

Core theme	STC-derived finding (policy implication)
Necessity & scope	The OHCI is validated as a mandatory specialized service Policy Action: Immediately issue a regulation mandating HRA-based occupational MCU protocols
Operational feasibility	Gaps in specialized resources (occupational medicine specialists, HRCT) are the main implementation hurdles Policy Action: Strategic investment to build specialized HR networks and fund shared pools of advanced diagnostics tools
Regulatory & governance	Technical and bureaucratic systems prevent integration and efficient provider accreditation Policy Action: Create a data interoperability gateway and implement a streamlined OSS-based accreditation system
Financial integrity	The existing payment model is ethically compromised Policy Action: Establish a sustainable funding model that fundamentally decouples payment from the clinical result to ensure objectivity

HR, Human Resources; HRA, health risk assessment; HRCT, high-resolution computed tomography; MCU, medical checkup; OHCI. Overseas Health Checkup Initiative; OSS, online single submission; STC, systematic text condensation

The theme of operational feasibility highlighted substantial gaps in specialized resources, particularly the shortage of occupational medicine specialists and limited access to advanced diagnostic tools such as HRCT. These constraints were consistently identified as the primary barriers to implementation, which in turn lead to the policy implication that strategic investment is required to develop specialized human resource networks and shared diagnostic infrastructure.

Within the theme of regulatory barriers and governance, participants’ experiences revealed that both technical limitations and bureaucratic procedures hinder system integration and efficient provider accreditation. This finding underpins the recommendation to establish a national data interoperability gateway and to implement a streamlined accreditation framework based on a single online submission to improve coordination and accountability.

Finally, the theme of financial integrity indicated that the current payment model is perceived as ethically problematic and potentially distorts professional judgment. This finding supports the policy implication that a sustainable funding mechanism must be established to protect professional independence and ensure the long-term viability of the service. The STC model confirms that initiating the OHCI requires a coordinated effort which simultaneously addresses clinical standardization, technical governance, and financial integrity to achieve the desired output of effective health surveillance for returning migrant workers.

Discussion

The robustness of this study stems from the high degree of consensus captured across sampled participants in the five FGDs, which validates the OHCI as an urgent national policy response. As a preliminary report derived from a specific national context, the external validity of these findings is limited. Furthermore, the study primarily reflects the perspective of the sending country (Indonesia) and does not include stakeholders from receiving countries, such as Japan. Consequently, the findings may not fully capture the operational, regulatory, and healthcare considerations present in destination countries, which may limit the comprehensiveness and transferability of the proposed framework across different migrant worker contexts. Further studies involving more diverse populations and settings are necessary to confirm their generalizability.

The unanimous affirmation of the OHCI’s necessity and scope highlighted a fundamental shift from reactive to proactive occupational health policy. This finding is consistent with the global recognition that continuous health surveillance is vital for returning migrant workers, whose exposure to occupational and environmental hazards often results in delayed, long-term chronic disease^9,10). This vulnerability is particularly evident among Indonesian migrant workers, who face higher health risks than local workers due to employment in high-risk sectors and greater exposure to physical, chemical, biological, ergonomic, and psychosocial hazards. Limited access to healthcare and insurance abroad, along with poor continuity of care upon return, contributes to delayed diagnosis of work-related conditions¹⁾. Reported risks include occupational lung diseases (e.g., pneumoconiosis), chemical-related illnesses, musculoskeletal disorders, and mental health conditions. These risks are further exacerbated by fragmented health systems and a lack of post-employment surveillance¹¹⁾. These gaps highlight the unmet health needs of migrant workers and reinforce the urgency of implementing OHCI as a targeted intervention. Stakeholders emphasized the need for standardized occupational medical checkups based on health risk assessment, which requires a shift from general screening toward protocols aligned with international standards (e.g., WHO/ILO) that recognize specific risk stratification¹²⁾.

While this study focuses on post-return health monitoring, primary prevention, namely reducing hazardous exposures during employment, is fundamental in occupational health. Post-return checkups should be part of a continuous prevention approach, including pre-departure training, exposure control in the host country, and follow-up after return. Although the policy intent is strong, the operational feasibility theme revealed a critical divide between political will and the ability to execute it. The most significant finding is the shortage of specialized human resources, notably the limited availability of certified occupational medicine specialists, particularly in regional health facilities. As a result, specialized tasks are delegated to general practitioners, which risks undermining the integrity and accuracy of the screening process and potentially leading to missed diagnoses¹³⁾. This finding is consistent with an article from Rantanen et al.¹⁴⁾ which noted that, despite the availability of an occupational health system, a shortage of occupational health experts might lead to misdiagnosis of occupational diseases. It is widely recognized that in many low- and middle-income countries, fewer than 15% of workers have access to an occupational health specialist because of the limited availability of certified occupational health professionals. This capacity deficit is further compounded by a lack of equipment, particularly the scarcity of advanced diagnostics like HRCT. The diseases that develop after migrant workers return to their home country need to be quickly screened in a proper screening or through diagnostic tools. Limited access to HRCT will lead to the underdiagnosis of disease¹⁵⁾. Addressing this issue requires a targeted policy intervention: not just funding general health services but strategically investing in the specialized human resource capital and diagnostic tools necessary to implement the required Tiered Occupational medical checkup protocols, thereby raising the national capability to meet the OHCI’s clinical demands.

Regulatory and Governance Friction

The regulatory and governance theme identified systemic policy friction that threatens to stall the OHCI before full implementation. The core technical governance failure lies in the lack of cross-border data interoperability, which renders the highly valued concept of integrating external health records (such as Japan’s nPHR) largely non-functional within the Indonesian health system. The sharing of relevant information across the health ecosystem to create a continuum of care has demonstrated significant potential to improve health outcomes by enhancing medical diagnosis, data-driven treatment decisions, digital therapeutics, clinical trials, self-management of care, and person-centered care, while also strengthening evidence-based knowledge, skills, and competencies among healthcare professionals¹⁶⁾. However, a lack of electronic health record systems into which the nPHR can be integrated, lack of user experience, and computer and health illiteracy have been identified as barriers to adopting the nPHR¹⁷⁾.

International models offer useful insights for OHCI development. The European Union enables continuity of care through interoperable cross-border health data systems, supported by strong governance frameworks¹⁸⁾. In contrast, South Korea’s Employment Permit System (EPS) provides structured migration management and healthcare access during employment but lacks mechanisms for post-return health monitoring and cross-border data transfer^19,20). These comparisons suggest that OHCI should integrate both governance and interoperable health systems to ensure continuity of care for migrant workers.

Based on the findings from these FGDs, addressing this challenge necessitates a technical and policy-oriented solution, namely the establishment of a data integration gateway and the development of clear national OHCI guidelines. These should be supported by modern, streamlined governance mechanisms, such as an online single submission system, that integrate health services across all levels of healthcare delivery in Indonesia. The development of digital health services in Indonesia is ongoing. Initial efforts materialized through the application of Satu Sehat, which aims to integrate healthcare data for Indonesian citizens; however, this innovation has yet to reach its full potential due to the absence of legally binding regulations governing its implementation²¹⁾. In addition to regulatory uncertainty, infrastructural limitations, disparities in digital literacy, and sociocultural barriers have been identified as persistent challenges to healthcare digitalization, particularly in regional and remote areas of Indonesia²²⁾. Moreover, the FDGs identified the existing provider accreditation mechanism for PJK3 and PJTKI as a ‘bottleneck’, which highlighted a further systemic bureaucratic inefficiency that would create a tangible barrier to expanding the network of accredited OHCI providers. Collectively, these findings emphasize that policy action must prioritize the establishment of an agile, standardized regulatory environment before a successful large-scale clinical rollout can be achieved.

Although establishing the OHCI is a complex process, several priority actions can be initiated early. These include developing standardized protocols for post-return occupational health checkups, piloting implementation in selected referral facilities, and integrating services with existing digital platforms such as Satu Sehat. Strengthening human resources and establishing sustainable financing mechanisms should be followed as medium-term priorities. These phased steps demonstrate that OHCI can be implemented incrementally without requiring full system readiness at the outset.

Financial Integrity Risk and Sustainability

Finally, the theme of financial integrity revealed a critical threat to the ethical and sustainable foundation of the OHCI. The Japanese nPHR system has exposure-based requirements for issuance and provides coverage for the cost of health checkups and transportation for individuals issued an nPHR. Therefore, it seems there may have been a misunderstanding among the FGD participants when discussing the current payment scheme in which they interpreted individual payment as possibly incentivizing facilities to certify workers as “fit” in order to secure payment, and thereby potentially compromising clinical objectivity.

The OHCI financing model, which covers the costs of health checkups for eligible individuals, warrants comparison with existing Indonesian government-funded health programs, particularly the Pemeriksaan Kesehatan Gratis (Free Health Checkup) program for vulnerable populations, including migrant workers. The current mechanism and coverage of free health checkups in Indonesia are determined by age group and screening findings, which limit the scope of examinations and tests included in the government-funded package²³⁾. Although government-funded health checkups reduce financial barriers for workers, findings from the FGDs suggest that payment mechanisms linked to fit/unfit certification may still raise concerns regarding the integrity and objectivity of clinical decision-making.

The initiation of the OHCI must therefore acknowledge that merely shifting the financial burden from workers to the government, as in a free-of-charge model, is insufficient. The implication is profound: any OHCI funding model must fundamentally decouple payment mechanisms from clinical outcomes (fit/unfit) to protect professional integrity and ensure that workers receive honest and objective assessments of their health risks. This concern is consistent with the pay-for-performance model described by Coleman et al²⁴⁾, who highlighted that incentive-based programs may unintentionally exacerbate existing health disparities between population groups. These findings mandate immediate policy intervention to establish a robust and sustainable funding mechanism that prioritizes worker health over provider payment incentives and preserves the objective clinical purpose of the OHCI.

Conclusions

Indonesian healthcare stakeholders unanimously regard the OHCI as an essential policy measure to fulfill the government’s responsibility for post-repatriation health surveillance of returning migrant workers. The framework analysis indicates that this consensus must be translated into a coordinated strategy to address critical barriers. Operational constraints, particularly the limited availability of occupational medicine specialists and advanced diagnostic equipment, require targeted investments in workforce development and service standardization.

At the policy level, immediate governance reform is needed to establish national standard operating procedures for the OHCI and ensure cross-border data interoperability with systems such as Japan’s nPHR. In addition, long-term program integrity depends on separating payment mechanisms from clinical outcomes to safeguard objectivity and prevent financial conflicts of interest. Overall, the successful implementation of the OHCI demands strong political commitment to build a resilient, ethically grounded, and specialized health surveillance system for returning migrant workers.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Sources of funding

This work was supported financially by Industrial Disease Clinical Research Grants (230101-01) funded by the Ministry of Health, Labour and Welfare of Japan. The findings and conclusions of this article are solely the responsibility of the authors and do not represent the official views of the above government.

Ethical issues

This study protocol received a waiver from the Ethical Review Board of Kochi Medical School.

Author contributions

NA, MM, SK, NAJ-P, ME: study design; ND, AL, AR, LI: data collection; NA, AL, AR, ND, MM: writing—draft of discussion; NA, AL, AR, ND, MM: writing—draft manuscript. All authors reviewed, edited, and approved the final manuscript.