Not a money of matter, RI’s health inequities

Sudirman Nasir ,  Melbourne   |  Sat, 10/04/2008 8:15 AM  |  Opinion

Why is life expectancy in Indonesia so much lower compared with the Australians, Canadians, Japanese or the people living in West European countries? Why is the maternal mortality rate among poor Indonesian women three to four times higher compared to the middle class and rich Indonesian women?

Why are the risks of death among Afghan pregnant women so much higher than the Swedish? Why is the life expectancy of Australian Aborigines 17 years shorter than for Australian Caucasians? Why are the rates of HIV infections among African-Americans and Latinos in the United States so much higher than the Caucasians?

Biomedical explanations are not able to sufficiently answer the causes of health inequity between developed and developing countries or between people from different socio-economic backgrounds within countries as illustrated above.

It is quite clear that biomedical factors which affect life expectancy, maternal mortality rates or many infectious diseases are similar in many countries around the world. However, abundant studies have indicated that there are stark public health indicators between and within countries.

Economic explanations are also insufficient to fully explain the causes of health inequity. Here, the obvious example is the United States, the biggest economy in the world which has spent the largest amount of money on health services but has a lower life expectancy and other public health indicators compared to other industrialized and high-income countries. It is obvious that economics and wealth alone do not determine the health of a nation’s population.

After all, some low- and medium-income countries such as Cuba, Costa Rica, Thailand, Sri Lanka, the state of Kerala in India and the state of Porto Allegre in Brazil have achieved better levels of public health indicators compared to other developing countries, despite their relatively low national incomes.

In order to better understand the health inequity between and within countries, the World Health Organization (WHO) has just launched the report of a three-year study examining health inequity and social determinants of health from all over the world.

WHO Director General, Dr. Margaret Chan, strongly advocated that heads of states and policy makers around the world learn from this report in order to better understand the causes of health inequity, which should result in the design and implementation of more comprehensive public health and community development programs to reduce the gaps.

“The toxic combination of bad policies, economics and politics is, in large measure, responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible,” Dr. Chan said.

Additionally, Dr. Chan emphasized that health inequity really was a matter of life and death.

However, it is obvious that health systems in many countries, particularly developing countries including Indonesia, will not naturally gravitate towards equity.

Therefore, unprecedented leadership is needed which compels all actors, including those beyond the health sector, to examine their impact on health. The WHO report also addressed that primary health care, which integrates health in all of a government’s policies, is the best framework for doing so.

Policies, programs and solutions from beyond the health sectors are crucial to reduce health inequity. In fact, much of the work to redress health inequities lies beyond the health sector.
The WHO’s report clearly reminds us of many examples such as, “Water-borne diseases are not caused by a lack

of antibiotics but by dirty water, and by the political, social and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods.”

As a result, the health sector — globally and nationally — needs to focus attention on addressing the root causes of inequities in health.

To reduce health inequity, the WHO report also advocates for the urgent need to orchestrate comprehensive community development that reaches beyond health programs such as improving people’s access to education, employment, housing, clean water, food and nutrition and sanitation that in the long run will significantly enhance people’s health and wellbeing.

Reducing poverty, unemployment, social exclusion, economic inequality as well as reducing the practice of corruption in many government agencies and the practice of discrimination based on gender, race, ethnicity, religious or political affiliation are crucial to improving people’s health and wellbeing.

In the context of Indonesia, it is noteworthy that several areas within the country such as Jembrana in Bali, Sragen and Kebumen in Central Java as well as Solok in West Sumatra at certain levels have shown a significant achievement in orchestrating comprehensive community development programs which in the long term have potentially increased public health indicators in these areas.

Good governance, strong political leadership and commitment as well as sufficient knowledge and skills in designing and implementing community development and public health programs are clearly present in those areas and need to be sustained to improve people’s health and wellbeing.

The central government in Jakarta as well as provincial and district governments in many areas should learn from the experiences of Cuba, Costa Rica, Thailand, Sri Lanka and the State of Kerala in India. They also should learn from the local governments of Jembrana, Sragen and Solok how to design and implement comprehensive community development and public health programs which clearly aim to reduce health inequities.

The writer is lecture/researcher at the Faculty of Public Health, the University of Hasanuddin, Makassar, and a PhD candidate at the School of Population Health, the University of Melbourne, Australia.

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