Academic journal article Contemporary Southeast Asia

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

Academic journal article Contemporary Southeast Asia

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

Article excerpt

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.

Keywords: Indonesia, healthcare, democratization, decentralization, policy diffusion.

Access to healthcare has long been a topical issue in developing countries, in which healthcare services are often underprovided, of low quality and too costly for a large proportion of the population. In recent years, as an increasing number of low and middle-income countries have taken significant steps to address this issue, the idea of universal health coverage (UHC) has gained traction among policymakers, advocates and citizens. For its proponents, UHC is a crucial tool to balance inequities in access to healthcare in developing countries, as it ensures the removal of financial barriers and reduces overall healthcare costs by pooling a large base of users. Key international institutions such as the World Health Organization (WHO) and the United Nations (UN) have embraced the UHC reform agenda, repeatedly referring to access to healthcare as a human right, and to UHC as a requisite to fulfill this right in developing countries. (1)

The literature on UHC has long been dominated by policy-oriented approaches and health economics. Studies of UHC reform typically tackle some technical aspect of policy design; for example, how best to finance UHC plans or gradually expand health system capacity, or they assess policy impacts on outcomes such as healthcare utilization, out-of-pocket expenditures and health indicators. (2) The result is that this literature focuses on policy prescription rather than explanation of reform adoption, and that it often presents a view of UHC as a consensual, technical project. (3) Yet reforming health systems to include a large number of previously excluded citizens is, of course, an eminently political and potentially contentious issue, as it is a question of economic redistribution and because it requires substantial fiscal resources.

While most studies of UHC do not delve into the politics of reform adoption, some exceptions, and a larger comparative literature on social policy in developing countries, have identified a few key determinants of social policy expansion. A first group of explanations studies the role of leftist political parties in expanding health coverage. (4) From this perspective, UHC policies are more likely to be adopted when ruling political elites are supportive of economic redistribution because of their partisan and ideological orientations. While this framework was developed from the experience of welfare state expansion in the West, some support has been found for other world regions. (5) A second approach focuses on voter-politician linkages in the developing world, and argues that the clientelistic relationships that often dominate politics in new democracies impede the provision of broad-based social services. (6) In many young democracies, leftist programmatic parties are absent, and clientelistic politics entails the provision of selective benefits conditional on political support rather than universalistic social programmes. …

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