From Periphery to Centre: Local Government and the Emergence of Universal Healthcare in Indonesia

Abstract

While the debate on universal healthcare coverage (UHC) often focuses on policy prescription and technical issues, the expansion of access to healthcare in developing countries is an eminently political process. This article analyzes the historical background of the adoption of UHC in Indonesia to articulate two intertwined arguments. First, in decentralized young democracies such as Indonesia, local government can play an important role in health policy by experimenting with innovative health insurance schemes. Although such activism may widen subnational inequalities, it can also contribute to the adoption of UHC by increasing the salience of health reform and by allowing policy learning. Second, institutional developments such as decentralization and the introduction of local direct elections can have a substantial impact on incentives for political elites to provide broad-based social services. This article discusses the relevance of these findings for the comparative literature on UHC and social policy in low and middle-income countries.

Growth and welfare in mixed health system financing with physician dual practice in a developing economy: a case of Indonesia

“…To examine the overall implications of dual practice, as well as the growth effects of public and private health care financing, we calibrate the model to Indonesia, a Southeast Asian developing economy whose health care financing system reform towards achieving universal coverage in the previous decade has been well-documented (Rokx et al 2009;Fossati 2017;González et al 2017;Pisani et al 2016). Further, the public availability of micro-data from 5 waves of Indonesia Family Life Survey (IFLS 1-5) conducted by RAND researchers (see, for instance, Strauss et al 2004Strauss et al , 2009Strauss et al , 2016 allows some model parameters in model equations to be empirically estimated, which we believe vastly improves reliability of findings from numerical policy experiments.…”

“…private health financing (through private insurance), for Indonesia both of these financing elements are ultimately led back to the fiscal budget. Indeed, since its conception in 2014, the national system of BPJS Kesehatan has been facing a deficit, therefore providing a source of persistent pressure to the fiscal budget (Fossati 2017;Pisani et al 2016). As seen later, these provide the main rationales for the design of our model.…”

The Dynamics of Health Care and Growth: A Model with Physician in Dual Practice

“…To examine the overall implications of dual practice on an economy, as well as the growth effects of public and private health care financing, we calibrate the model for Indonesia, a Southeast Asian developing economy whose health care financing system reform towards achieving universal coverage in the previous decade has been well-documented (Rokx et al, 2009;Fossati, 2017;González et al, 2017;Pisani et al, 2017). Further, the public availability of microdata from 5 waves of Indonesia Family Life Survey (IFLS 1-5) conducted by RAND researchers (see, for instance, Strauss et al, 2004Strauss et al, , 2009Strauss et al, , 2016 Canuto 2015, which yields κ = 0.342.…”

“…1 In an attempt to achieve universal health coverage by 2019 (Thabrany, 2008), Indonesia launched its current BPJS Kesehatan system in 2014 and effectively doubled down on the government's role in financing a mixed health system, since BPJS administers the national health insurance, Jaminan Kesehatan Nasional. However, ever since 2014, the system has been facing a deficit, in that the system incurs significantly more expenses than the revenue it receives, yet without a marked improvement in the aggregate health outcome (Fossati, 2017;Pisani et al, 2017).…”

A Tale of Three Cities: Electoral Accountability in Indonesian Local Politics

“…The outcomes of decentralisation in Indonesia, however, suggest that such reforms have failed to substantially advance democratic accountability and development. In some cases, regional autonomy has indeed enabled local government to promote a reformist agenda by implementing policies that have benefited large segments of society, including the most vulnerable (see Fossati 2017;Rosser and Wilson 2012;Leisher and Nachuk 2006).…”