How Cultural Values transfer into the Basis for Health Services in the Industry Revolution Era: A Critical Perspective

Article History: Received: 1 Mar 2020 Revised: 28 Apr 2020 Accepted: 25 Jun 2020 Public health servicesneed serious attention in Indonesia. In fact, the number of health workers is sufficient enough and even excessive in certain areas. This situation is caused by lack of observing principles of the local and national cultural values in carrying out the public health services. We reviewed the published literature over the current satisfactory level of people with regard to thehealth services. Furthermore, we compared the results between residents of the suburb and urban areas regarding the national health services. This critical perspective offerred a concept of health services based on the cultural values with the belief that these values can influence the perceptions, attitudes, and behaviour of individuals, including health workers in rendering health services through health consultations. The purpose was to design a situated cultural learning, through which they can learn to respect and apply cultural values in implementing health services. To implement such cultural values, the concept of industrial revolution 4.0 and 5.0 is also needed, where individuals utilize and work together with machine learning technology or artificial intelligence.


Introduction
n the Law of the Republic of Indonesia concerning Health, article 52 paragraph 2 indicates that the public health services are an effort to make the community healthy in the form of promotive, preventive, rehabilitative, and curative conducts. According to the data provided by Ministry of Health during 2018-2019 (1), the ratio of health workers and population is adequate in Indonesia. It seems that the problem lies in the distribution of health personnel through the whole territory of the unitary Republic of Indonesia, particularly in suburb areas. Laksono, et al. (2), showed a disparity in health center utilization between regions in rural Indonesia. People of Indonesia feel dissatisfaction with the health services due to the regional disparity and since the "centralised, one-size-fits-all" approach did not address the complexity and diversity of the population density. Furthermore, dispersion was observed across islands with regard to the residents' diets, diseases, local living styles, health beliefs, human development, and community participation (3). As a result, the regional disparity and "the centralised, one-size-fits-all" approach are considered as the basis of dissatisfaction.
Some studies over health services reported dissatisfaction of the participants concerning health services in some districts. A research conducted by Alayyannur and Dwiyanti (4) investigated 14 variables in health services and found thatsix factors were at a poor level in relation to the community satisfaction. The factors included: ease of procedures, suitability of the requirements, staffs' sense of responsibility, staffs' skills, fairness of services, and health center location. Sandhyaduhita et al. (5) mentioned that the health services were not at a satisfactory level and suggested to implement Information Technology (IT) as a supportive plan. Purba (6) suggested that health institutions need to further improve the quality of services in a way that is more responsive and friendly to patients' requests, more applicable in increasing the staffs' skills to help patients, better in improving the health workers' skills in rendering services and providing information to patients. A survey conducted by Fahri, Purwaningsih, and Sari (7) showed a lower rate of satifaction by participants (58.9 %). Dissatisfaction was not actually influenced by application of IT because services were mostly mediated by the technology and it is difficult for people in the districts to have access to govermental public health system through technology.
Public health is never separated from promotive, preventive, rehabilitative, and curative efforts, but health care services must involve other variables such as cultural values, a shared concept among members of a community in a cultural context (8,9). Considering cultural values on the basis of health services makes adequate cultural competence in health workers and community members. Cultural competence is a multilevel and multidimensional personal development process that implies gaining critical awareness, responsiveness to diversity, as well as capacity to act in organizations and community to provide safe health services (10,11).
Health services must involve good communication between the health workers and the community by including cultural values in a health consultation. Health consultations containing cultural values can effectively complement the existing services to improve diagnostic and treatment assessments for culturally diverse populations (12). Therefore, all patients must receive language assistance that is appropriate to their culture (13). The principle of emphasizing on the cultural values in health services through the interaction of health consultations can influence the perceptions, attitudes, and behaviour of individuals (8) about public health.
In this regard, the current study reviewed the role of cultural values in health care. More specifically, this study focused on how cultural values can act in health services to enhance public health. concerning health services and Number 4 of 2019 concerning technical standards for fulfilling the quality of basic services at minimum service standards in the health sector, clearly instruct how the public should obtain standardized health services. However, discrepancies exist between the government and society in this regard.

Current Health Services
In 2018, the Ministry of Health of the Republic of Indonesia stated that the number of health workers was sufficient to serve the Indonesian population, but dissatisfaction was still felt by the community (1,14). Several government programs have also been initiated to improve health services, but these programs are considered detrimental to the community due to the convoluted procedures, improper services rendered by physicians, and procedures not in accordance with community needs (15,16). As a result, the present public services are not at an acceptable level in the health sector (17).

Cultural Values and Health Services -Understanding
Culture is complex but rich in concepts, beliefs, practices, symbols, norms, and values that are prevalent among people in a society (8,18). Due to the richness of culture values, it can affect the individuals' perceptions, attitudes, and behaviour. Cultural values embodied in health services not only can achieve a shared desirable conception between health workers and patients but also is "a source of creative inspiration that influences the way they understand creativity" (19). By understanding creativity, the basic principles of contextual health services can work properly even in a multicultural context.
Considering that Indonesia is a country with a variety of ethnicities, cultures, and languages, it is necessary to truly understand and implement the health services with a load of cultural values. So, the problem of health services is not only in the number and ratio of health workers with population, but also in the way these services can be adapted to the context of local and national culture. Conformity between local and national culture in Indonesia should be well established to facilitate equitable health services. To this end, national cultural context should show cultural characteristics interpreted uniformly. Moreover, these cultural characteristics should be applied consistently throughout the country to guide the behaviour of all citizens (20).

Cultural Values-based Consultation Needed in Health Services
A part from the content of cultural values in health services, the ratio of health personnel to population, distribution of the health personnel, pattern of relationships between local and national cultures, as well as the linguistic principle in conducting health services, specifically in terms of health consultation, must be considered. Magaña (21) pointed out that practitioners' awareness of metaphorical (linguistic) expressions in health is very important to promote advanced cultural and linguistic competencies that ultimately results in patient-centred care. Although this principle is often ignored by health workers in serving public health, appropriate and effective communication in one culture may be inappropriate and ineffective in another culture (22). An interaction in communication can establish a common ground through which the offenders determine the behaviour by expressing their mental attitudes, including health behaviours. However, health behaviours can be facilitated when they are consistent with cultural values (23). Speech acts are a part of a cultural pattern in which verbal and non-verbal interactions are intertwined with a load of appreciation values because culture is an instrument of appreciation (24), affection and courage, which may become a construction of beliefs and norms. These interaction values can bridge a health consultation when conducting the public health services.

Public Health as Social Practices and Situated Learning
Health behaviours that emerge as a form of interaction with the content of cultural values can certainly be a part of the social practice that can take place in the case of consensus on these cultural values. Furthermore, community health is  (25) mentioned that social practice is an entity that explains social action and a performance that depends on individuals as effective actors. Reich and Hager (26) stated that practice was a collective and located process that connects knowledge, work, organizing, learning, and innovation as a sociomaterial phenomenon. Therborn (27) argued that social practice was not merely related to the subjective orientation of the actor, but to an objective process of transformation. Here, it appears that if the public health, created from health services loaded with cultural values, is a social practice, it can be considered as situated learning. In such a learning, the community and health workers jointly facilitate health attitudes and behaviours as a form of learning process in the society. Situated learning suggests practices in an authentic context in social communities that can help us to understand multicultural conditions (28).
So, the relationship between cultural values, public health, social practices, and situated learning is an integrative approach to health care. This principle is in line with the concept of situated cultural learning approach, as a process that takes place in a community of practice. This learning process includes integration of cultural contexts, authentic activities, reflection, facilitation, and building collaborative learning communities (29).

Challenges
The ideal health service must always consider application of the cultural values in health services and should not only rely on the ratio of the number of health workers to the population. The real challenge is how health services can facilitate the community in accordance with times. However, the fourth era of the industrial revolution has presented a very innovative concept showing a digital society that prioritizes machine learning in carrying out human jobs. The question is about the principle of cultural values when digital society is more machine-oriented: Can cultural values be integrated into the concept of the fourth industrial revolution?  As shown in the figure 1, a concept is needed, which is appropriate for applying cultural values affecting perceptions, attitudes, and behaviours, which can load health services with local and national cultural values. In this regard, public health services generally appear clear. The aim is to help the health workers and the public to enter the situated cultural learning process and take advantage of the industrial revolution 4.0 and 5.0 concepts in facilitating public health services.
These two questions have been substantively answered by the concept of the industrial revolution 5.0, which represents societies that are not only oriented towards machine-learning, but also prioritize the function of humans as the main centre. In other words, the human-robot principle works together (30), which in the case of health services will handle the medical process needed for the intervention of lower health workers. However, the practitioner will do the work with a higher level, so it is very encouraging to manufacture high-quality medical components to meet the personal demands of patients (31). Thus, cultural values can be integrated into the concept of revolution 5.0 and at the same time become a characteristic of the human function in health care.

Conclusion
The problem of health services in Indonesia lies in the ratio of health workers and population. To meet this challenge, Indonesia has increased the number of health workers since 2018. However, the health staff were not evenly distributed throughout the regions and exceeded the ratio set by WHO, specifically in certain regions. Nevertheless, patients' dissatisfaction concerning health care has continued as a controversy. It seems clear that perceptions, attitudes, and behaviours of the local and national cultural values have not become the main principle in the health services. In other words, the situated cultural learning did not help the health workers and the community to cooperate in building cultural values in health services. In addition, health workers who are sent to certain areas mostly do not understand the culture of that local community. Furthermore, they lack the required health technology to provide services to the community. Therefore, the concept of cultural health services is needed to facilitate the multicultural situations and conditions of the public health services in Indonesia.