Graphic Illustration is taken from Michigan Medicine
Fadjar Wibowo and Aghnia Jolanda Putri
The global Sustainable Development Goals highlight the importance of curbing high rates of hypertension to achieve the target of a one-third reduction in deaths from non-communicable diseases by 2030. Meanwhile, a study from the American Heart Association in 2016 showed that over the past decade, the number of people suffering from hypertension has decreased in higher-income countries, yet increased in lower-income countries.
According to the World Health Organization last year’s report, in Indonesia — which has experienced rapid economic growth followed by epidemiological transition over the past few decades — around 36 percent of deaths are attributable to hypertension, such as stroke, ischemic heart disease and hypertensive heart disease. Epidemiological transition refers to a period of sudden and stark increase in population growth brought by improved food security and innovations in public health and medicine, followed by a releveling of population growth following decreasing fertility rates.
In 2015, a national health insurance (JKN) report revealed approximately one-fifth of the budget was spent on hypertension-attributable diseases. If current trends continue, the number of people living with hypertension in Indonesia is projected to increase from 25 percent to 40 percent of the population, between 2016 and 2025. Beyond wasting the country’s healthcare budget, the long-awaited demographic dividend might turn into a demographic disaster.
Along with rapid urbanization and social and environmental changes, Indonesians are now developing hypertension at a younger age, affecting half of people at productive age. And since merely one-third of cases are reported to be diagnosed by health workers, too many are left untreated and therefore have a worse outcome than their counterparts in high-income countries.
Hypertension cannot be cured and most of the time shows no apparent symptoms. Certain lifestyles, such as having an unhealthy diet, physical inactivity, alcohol abuse and smoking, can put people at a higher risk of developing hypertension. According to the Health Ministry, a third of Indonesians are physically inactive, only 6.5 percent of them consume enough vegetables and 34 percent are active smokers.
Even worse, according to the latest National Socioeconomic Household Survey (Susenas 2016), among low-income families, cigarettes comprise the second-largest household expenditure after food, which resonates with low spending on quality food and development of poor health outcome.
Theoretically, hypertension can be managed effectively through lifestyle changes and, when needed, medication. But as evidence shows, engaging in healthy behavior plays a minor role in determining one’s health. Social and environmental factors a play bigger role. Thus, what can we do about this situation?
Imagine this: If cities are more walkable or have better public transportation, people might drive less and walk more. If healthy eating options are more affordable, people might make healthier food choices. If cigarette advertising follows restrictions and cigarettes made less affordable, cigarette consumption among youths and children might get under control. And so on.
Since 2011, the Health Ministry has held a community-based program designed to screen and monitor hypertension and related communicable diseases. The program should create demand for preventive health care supported by the Healthy Indonesia Program through Family Approach (PIS-PK), a promotive and preventive healthcare program offering extensive health outreach and improved access to primary health care (Puskesmas).
Together, the two help balance disease prevention and health promotion with curative interventions through appropriate coordination mechanisms. But both measures are not enough.
However, since health outcome is the result of determinants that vary from socioeconomic, cultural and environmental conditions, improving public health status, including addressing the hypertension epidemic, attempts to include public policies targeting these determinants are imperative. This could be done through varied strategies, from establishing regulations to developing innovative policies, to innovating and improving existing facilities that support healthy behavior.
In Indonesia, realizing such an approach is not impossible. One mayor has put evidence into action. He is Hasto Wardoyo of Kulonprogo in Yogyakarta, a gynecologist who regards his people, especially children, as both future assets and investments. His vision on realizing affordable food is realized through modifying the national “rice for the poor” program (Raskin) into “locally cultivated rice” (Beras Daerah - Rasda). Not only can people purchase staple foods at affordable prices, the policy also allows the authority to purchase it from local farmers, therefore ensuring its sustainability.
Having grown up in the poorest subdistrict of his thriving small town, Mayor Hasto perceived tobacco-related epidemics among the threats to his vision in developing the city and its people, especially as hypertension-related diseases is a leading cause of death in the town.
Concerned with the rapid increase of youth smoking, in coordination with district education office, he has implemented a peer-based youth smoking surveillance program, which allows student council members to act on peers smoking in school environment. Local public order officers are also encouraged to fine violators for smoking in public areas. Mayor Hasto said the policy complements the national policy on excise tax increase, which aims to make prices unaffordable for vulnerable, poor families and children.
With decentralization, the roles of mayors and heads of local units have never been as vital as today. Studies have proven that significant health and economic gains are associated with prevention, early detection, adequate treatment and good control of hypertension. To achieve this, beyond strengthening health systems and improving frontline healthcare workers’ capacity, maximizing political will and strengthening regulation enforcement at the national and local levels through public policy targeting the social determinants of health are crucial. Given the enormous economic and public health benefits of hypertension control, now is the time for a concerted action toward health in public policy.
Fadjar Wibowo, a global health master from Karolinska Institute in Sweden, and Aghnia Jolanda Putri, a graduate of Andalas University in Padang, West Sumatra, work with the Center for Indonesia’s Strategic Development Initiatives (CISDI). Both are physicians.
This article has been published in The Jakarta Post, August 11th, 2018.