During the presidential candidate debates, the notion of a preventive and promotive program for healthy lifestyle was raised many times. Prabowo Subianto and vice presidential candidate Sandiaga Uno promised to embark on a healthy lifestyle campaign by promoting 22 minutes of exercise daily, while incumbent President Joko “Jokowi” Widodo and his VP candidate Ma’ruf Amin promoted a program that focuses on health promotion. 

Both presidential candidates shared the same view about the importance of a preventive program to decrease the incidence of disease in the future because sustainability of universal health coverage also depends on disease prevention and health promotion. 

Indonesia’s approach to disease prevention and health promotion was highlighted in 2017, under Presidential Instruction No. 1 on the People’s Movement for Healthy Lifestyle, better known as “Germas”. The presidential instruction was issued to strengthen multi-sectoral efforts for health promotion.

 In Thailand, an integrated prevention program has been managed by the Thai Health Promotion Foundation (Thai Health) since 2001, around the same time as the establishment of the Universal Health Coverage Scheme. The Thai Health programs have been implemented with two key strengths: a multi-sectoral management body that is responsible for planning, coordinating and evaluating the impacts; and a strong financial mechanism utilizing a cigarette surcharge tax.

 Although Germas is different from Thai Health, there are some lessons we can learn to further improve the implementation of the preventive and promotive program in Indonesia. 

Thai Health is a state-owned body developed to actively reduce risky behaviors, including tobacco and alcohol use; traffic injuries and disaster management; physical exercise and sports for health; and healthy food and diet. Thai Health designed a health promotion as an integrative program, not limited to the educational program, but also to ensure a policy environment conducive to behavioral change. Therefore, they have research and policy advocacy in their mandate complementing the public campaign. 

Rather than being part of the Public Health Ministry, Thai Health is organized under the supervision of the Prime Minister. Thai Health is structured to maintain the representativeness of various sectors that have influence over healthy behavior. Their flexibility as an independent body enables them to coordinate with diverse institutions and organizations, including government institutions, research centers and civil society organizations. 

In Indonesia, a set of orders for each state ministry and body to implement policies or programs that support health promotion are included in the presidential instruction document. For example, the Finance Ministry is instructed to study the impact of raising the excise rate for tobacco and alcohol, the Agriculture Ministry must promote the production of fruit and vegetables, while mayors and regents have to develop the facilities that support active physical activities. 

So, Germas is a great start to mainstreaming health issues in all government sectors and expand health promotion beyond the responsibility of the Health Ministry. In this sense, Germas resembles Thai Health in its multi-sectoral and integrative approach to health promotion. 

However, Germas, as a presidential instruction but without a fullyresponsible management body, has limited power to steer the government programs. Without the capacity to add, change or abolish the existing policy or programs, it would be hard to enforce Germas to generate actual behavior change. 

Learning from Thai Health, it would be much more effective if Germas could be upgraded into a stronger policy tool that aims to align national programs and policies from all sectors with a health promotion strategy. The upcoming 2020- 2024 medium-term development plan could be an opportunity for the government to strengthen Germas, to be more powerful to initiate policy change that can effectively influence public behavior.

Besides its structure, Thai Health also has another strength regarding the financing mechanism. Thai health promotion is 100 percent financed by the cigarette surcharge tax. Therefore, in Thailand as in many other countries, cigarette surcharge plays a double role: first, as a policy instrument to reduce the affordability of cigarettes, one of the risk factors that contributes to many noncommunicable diseases, and second, as a sustainable financing mechanism for the health promotion program. 

Without sustainable financing, it would be hard for Thai Health to sustain the programs that create positive impact. Besides, Thai Health has proven that increasing the tax on tobacco products can reduce tobacco consumption without decreasing the revenue from cigarette taxation yearly. 

Comparatively, rather than having a specific source of money like the cigarette surcharge tax, Germas does not have additional financing mechanisms other than the existing ministerial or institutional budget from the national budget, because all programs included in the presidential instruction have been incorporated in the central government work plan. Using the existing budget does not provide an incentive for institutions to create more prevention programs or change the policies to support a healthy lifestyle.  

Apparently, it is rather difficult to implement the idea of utilizing a tobacco tax for public health service promotion. Law No. 28/ 2009 on regional tax and retribution stipulates that 50 percent of the tax revenue received by regency/city administrations should be used for public health service and law enforcement. This law was followed up by the Health Ministry with a regulation on the use of cigarette tax revenue. But the effectiveness of this regulation depends on the commitment and attitude of local administrations. Hence, the multi-sectoral approach to promote a healthy lifestyle should be fully implemented. 

This article written by Lara Rizka and Emmy Nirmalasari has been published in The Jakarta Post 

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Nasional Youth Town Hall (Indonesia)

Nasional Youth Town Hall (Indonesia)