One of these days I found an old book published by WHO in the year of 1977 titled Global Strategy Health for All by 2000. As I kept reading the book, there were a lot of questions I could not answer. This is 2011 and I don’t feel like anything closer to health for all.

From 1977 to 2011, if we talk about human being, I believe they has grown up to be an adult right now. I was only born in 1989 and now I’m a university student. So let’s imagine if this Global Strategy proposed by WHO was a human being, he would be 12 years older than me. He probably graduated from medical school, then continue to study cardiology and he’s a cardiologist right now. 34 years is a long time. However he might be raised in a poor neighborhood. His dad was a drunkard and his mom left him since he was age 2. He never finished high school and his main job is drug dealer. One day police caught him and now he’s imprisoned. 34 years is a long time. Everything can changes in 34 years, changes to be better or change to be worse.

One of the major changes in the world during 34 years are their population. From 1975 to 2000, the population in South East Asia Region has increased 61%. It means by the year of 2000 country in South East Asia region should have increased every public facilities, food, housing, clean water, and etc to accommodate the 61% increasing.¹ Failure to provide them might contribute a new population problem which can lead to away from achieving health for all by 2000. How can a country provide health for all if it cannot contend people’s basic need?

The other population problem which needs to be focused on is the changing population proportion. Population who are less than 15 years has declined 8% from the 1975-2000 while population aged 65 years and above has increased 1,2% in south east Asia.¹ This proportion changing can be expected to shift the health problem from communicable disease to non communicable diseases (NCDs).  Of the 57 million global deaths in 2008, 63% were due to NCDs. Indeed, it is one of the barriers to achieve health for all.

When WHO proposed health for all by 2000 in 1977, they dreamed to have health issue to be integrated with other policy such as, economy. However until today, the year of 2011 the problem to seek for health care in every country is still the same with 34 years ago, hard cash. Primary health care which has been declared as the fundamental health care in Alma Ata declaration in the year of 1978 has only done a half of its job. Why half? Because most of primary health care are lack of facilities. In a study done by Gadallah et al., about patient satisfaction with primary health care in Egypt shows that patient satisfaction is high for accessibility, waiting area conditions and performance of doctors and nurses while availability of prescribed drugs, laboratory investigations and privacy in the consultation room are unsatisfactory.² This is the core problem which later will keep us away from achieving health equity as one of Alma Ata declaration principle.

National Social Economy Survey held in Indonesia revealed that only 34% of sick people will seek help to primary health care while 25% will directly go to doctor practice, 10% to hospital (public and private), and the rest (31%) to non medical practice. This data shows that primary health care still not the choice of most people. There are still a lot of people who still seek help to non medical treatment for their diseases. The inequity is there.

The main barrier to be considered in this problem is probably the health care system of the country. Country like Indonesia where out-of-pocket spending accounts for more than a third of all health spending, has an overall wide acceptance to use private sector providers for a range of health services and products – even among the poorest socioeconomic groups. These people do not covered by any kind of health insurance. Ironic, isn’t it? Compared to UK who apply national health system and provide national insurance for every of their citizens³ the inequity about seeking whether its medical treatment or non medical treatment they prefer to go is never a problem. To further compare the health indicator between this country shows that from infant mortality, maternal mortality and life expectancy UK is ahead of Indonesia.

However, since 1977 until today there are also a lot of things that has been achieved. The expanded programme on Immunization has succeded to decrease the number of infant mortality by protecting children from polio, measles, diptheri, pertussis, TB, and tetany. Some countries have considerably strengthened their health services, establishing a network  of facilities and making health care available close to where people live. Also, the success treatment of TB which once declared as global emergency by WHO has been increased 50% than earlier before DOTS implementation.

Indeed there are a lot of things that has been achieved if we look backward in the 1977. But still, there are a lot of things need to be done. The core principles declared in Alma Ata declaration still remains a principle that has not been successfully applied, Universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approaches to health.⁴ Back in 1978, member of state who joined this declaration was none of them disagree and object with what was declared. However 34 years from the declaration, the implementation for this declaration is hardly can be seen. Health inequity and disparity do still exist around the world.

What can be seen from here might be the spirit to eliminate health inequity and disparity that has been existed since a long time ago. Perspective of social determinants of helath is not a new approachment to it as Alma Ata Declaration has been implied it into the Primary Care. However, a lot of improvement are still needed to develop the programme.

The main barrier to get a proper health care is finance. Primary health care has been solved the problem since the health fare is very cheap. However many of primary health care service are still lack in facilities and human resources. In Indonesia, primary health care in a remote town, Jayapura, only has 22 general practicioner whereas in Jakarta, the capital city, there are 12.000 general practicioners.⁵ This example resamble how health care is not well distributed in Indonesia. This condition might be not much different in similar continental country like Phillipines.

The availibility of the health care is merely one of important factor of social determinants of health. However there still not enough solution for this problem. I don’t want to take the blame to government since they already had so many programs to attract the health provider especially physician. As a medical students and a future health provider, we should have some awareness and aim to not only work in a big famous hospital but also to have some will to foster the health of every people including them who live in remote areas.

I believe that in our deepest heart we still have those good willing of why we want to be a doctor. To help people. Not only people in a big city but also people in remote small island far away from our hometown. What’s the good of educating people who already smart? What’s the good of offering some medical advice to them who already had a private doctor? Let’s do the real act on social determinants of health and become doctor in remote areas.

By: Shela P. Sundawa (Marketing, Campaign, and Advocacy Director CIMSA 2011-2012)

References

1. South-East Asia Progress Towards Health For All 1977-2000. World Health Organization Regional Office for South-East Asia. New Delhi: Facet. 2000.

2. Gadallah M, Zaki B, Rady M, Anwer W, Sallam I. Patient satisfaction with primary health care services in two districts in Lower and Upper Egypt. La Revue de Santé de la Méditerranée orientale, Vol. 9, NO 3, 2003.

3. Health care system in transition. United Kingdom. 1999.

4. World Health Report. Health system: principle integrated care. World Health Organization. 2003

5. Database Puskesmas. Departemen Kesehatan RI. Available at: http://www.bankdata.depkes.go.id/puskesmas/public/report/