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 unaffordablefor 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.

Written By   Fadjar Wibowo and Aghnia Jolanda Putri

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