RI expected to undergo significant shift in health paradigm

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.