RI expected to undergo significant shift in health paradigm

By Does Sampoerno

JAKARTA (JP): Health and sickness concepts keep changing along with our understanding on the value and role of health. Since the golden era of the Greeks, health has been a virtue, something to be proud of, whereas sickness is considered as useless. The philosophy during that time was that the Cartesian had its orientation in physical health only. It stated that a healthy person is when there is no dysfunction of body organs. Mental and spiritual health were not issues handled by physician but by religion.

After the discovery of germs as a source of diseases, the definition of health changed. A healthy person is someone without any causes of illness after thorough examination. In the 1950s, the World Health Organization (WHO) definition on health was a state of well-being, physically, mentally and socially, not just being free from diseases and weaknesses. WHO's further definition of health, as stated in the Republic of Indonesia's Health Law No. 23/1992 includes a productive life, both socially and economically.

The last definition is applied in developed countries such as Canada, which emphasizes on the productive-health concept. Being healthy is a tool for productive life daily. Without proper health, a person cannot be productive. Health efforts should be aimed at developing appropriate health for the community in order to lead a productive life.

After 1974, there have been significant findings on the concepts of health, which are meaningful for all public health experts worldwide. The year 1974 is considered as the era of new public health development because during that year, there was an intensive discussion at national and international levels on the characteristics, concepts and methods on how to improve equal distribution of health services to the community.

During the past three decades, particularly after the Alma Alta declaration, HFA Year-2000 (1976), the Mexico meeting (1990) and Saitama (1991), the attention of health experts and policymakers has gradually changed from sickness orientation to health orientation. The change of orientation is due to: a) a shift in the number of illnesses and death due to infectious diseases to chronic degenerative diseases; b) a change of concept and definition of health; c) our understanding on the factors affecting public health.

Lalonde (1974) and Hendrik L. Bluum (1974) in their papers clearly stated that the public health status is not a result of medical services only but contributed to by other more determining factors such as environment, behaviors and genetics.

Unfortunately, the change in understanding and knowledge on those determinants are not immediately followed by change in policy toward health services effort in Indonesia. This is due to the lack of understanding at the central level of decisionmakers on the paradigm shift, which has happened since the 1970s. Although there was a change in the 1993 State Policy Guidelines (GBHN) on the objective of health programs, there has been no change in the government's efforts, including implementation of some important regulations in Health Law No. 23/1992.

The government's efforts on health are, to date, oriented toward disease management; the indicators used include service coverage, ratio of doctors per community, number of hospitals, community health centers (Puskesmas) and others. If we think critically, those indicators do not guarantee a healthy community. Efforts on health by the disease-treatment approach lead to the perception that health efforts are consumptive and not productive in nature. This has placed health services on its neglected side in national development. Efforts in health reorientation should have started from the implementation of the 1993 GBHN, where the government aimed at developing quality human resources.

Therefore, the government should now immediately plan the change in health efforts to the maintenance of national health, i.e., a health effort which, in the long term, can guarantee the community independence and survivability and reduce community dependence on doctors and drugs.

Those health efforts should encourage the community to attain knowledge to avoid and protect themselves from any disease and live a productive life. This will place health at the center of national development efforts. In the long term, this health- oriented approach will also guarantee more independence and improved community resistance, both mentally and physically, from diseases and create quality human resources.

Minister of Health Dr. F.A. Moeloek, in a meeting with members of the House of Representatives on Sept. 15, 1998, stated that the Ministry of Health will introduce a new paradigm, the Health Paradigm. The emphasis of this new paradigm is on promotion and prevention efforts, and not on curative and rehabilitative ones. The minister also stated that this health paradigm has long been known by all health experts but has never materialized into a health policy. "It is going to be implemented now because in the past, we slept too much," he said (Kompas, 16 September 1998).

The paradigm shift also means that health programs will place emphasis on shaping the health of the nation, not just curing diseases. Thomas Kuhn, in his influential book The Structure of Scientific Revolutions, as also cited by Covey, states that almost all breakthroughs have to be initialized by a paradigm shift to break or change old habits and old ways of thinking.

Shaping the nation's health is more than just curing sickness in the community, it means developing the nation's health or creating a healthy, smart and skillful nation, which is not the sole responsibility of the health sector. Neither is it the main responsibility of the Ministry of Health only. It requires a holistic, multisectoral and release approach, i.e., creating a healthy, productive, independent, disease-resistant nation that is also free from a dependency on drugs and excessive medical services.

Future health efforts should create and produce healthy and productive human resources. This obsession should lead each member of the community to an adequate health status. The new orientation in health efforts is to create a healthy community; a positive and healthy orientation as an opposite to curing, fixing and repairing what has been done.

The paradigm shift, if it is implemented, will bring forth a wide impact. This is due to the fact that to support the implementation of the health paradigm, with its orientation toward efforts in promotion, prevention, proactive, community- centered, active participation and community empowerment, will require adjustment or even reform in all existing means, facilities, and the workforce, including the activities and program under the directorate generals of Contagious Disease Eradication (PPM) and Healthy Environment for Settlement (PLP) these two acronyms should be explained.

To date, there is a perception in the community that health is the responsibility of the government because the government is the one which provides health services if people are sick. The community is also inundated with misleading drug advertisements. Therefore, each individual in the community does not make an effort, or does not know how to practice a healthy lifestyle, such as exercising, consuming healthy food, avoiding smoking and having enough rest. The responsibility to create a healthy lifestyle in the community, which has been neglected so far, is on the government.

During the crisis, in which drugs and medication have become expensive, the government should put more emphasis on education and public awareness campaigns to avoid sickness and implement healthy living standards, thus saving on treatment costs.

The same situation applies to life expectancy during birth. WHO states that increased life expectancy is to be interpreted as increased productivity, not in increased years but in sickness. WHO emphasizes on "add life to years rather than merely add years to life." Adding years to life should also mean adding "years of disability-free life" and not "years of disabled life."

Health problems are basically political problems. Therefore, to solve them requires political commitment. A good socioeconomic development requires a healthy workforce with adequate resistance to diseases.

Nowadays, there is still a perception that public health has little to contribute to socioeconomic development. The policymakers still consider the health sector as a consumptive sector rather than a productive sector providing quality human resources. Therefore, if there is an economic disturbance in a country, the allocation of this sector is not increased.

Meanwhile, health experts also fail to be convincing regarding the benefit of health-sector investment in supporting national development. The gap in public health status among regions should be overcome soon. To date, investments which emphasize more on the addition of facilities, equipment and medical staff should be reassessed. The number of hospitals, Puskesmas, Polyclinics, midwives and doctors is no guarantee to the increase of public health status.

Therefore, it is no exaggeration to state here that the solution to health problems is not found in hospital wards or the waiting rooms of polyclinics or Puskesmas, but in the Ministry of Health, district offices of the central government located in the provinces, health offices and at the people representatives' offices. The paradigm shift from medical services to health development requires a reform in political commitment from the government.

To develop a nation's health is more than treating diseases. Therefore, it cannot be conducted by one sector only. To prepare a new generation which is healthy, smart and skilled is a multisector responsibility.

In the former New Order, although it was stated clearly that development in Indonesia was to develop a wholly Indonesian people, it placed more emphasized, in reality, on economic development.

The writer is a permanent professor in Health Policy Administration at the University of Indonesia, Jakarta.