Campaigning for all Indonesians: the Politics of healthcare in Indonesia.

AuthorJung, Eunsook

Many scholars argue that democratization fosters redistribution through electoral competition and inclusiveness. (1) By extending the franchise to the poor, they argue, democracy provides electoral incentives that promise social protection for its citizens. In addition, voters can penalize governments when they fail to carry out their promises. However, regime type is not sufficient to explain social policy outcomes. Although democracy does provide incentives for politicians to promise social protections to the newly enfranchised poor, it does not guarantee the enactment or implementation of inclusive social reform policies. What then explains social policy expansion in developing countries? This article explores this question by examining Indonesia's implementation of universal healthcare reform in January 2014.

As a new democracy and emerging economy, Indonesia provides an interesting case study for analyzing what enabled the implementation of universal healthcare expansion. After thirty-two years of authoritarian rule, Indonesia started democratizing after the fall of President Soeharto in 1998. More than ten years later, in 2011 the Indonesian government passed the Social Security Administering Bodies bill (Badan Perencanaan Pembangunan Nasional, BPJS), which enabled the National Social Security System Law [Sistem Jaminan Sosial Nasional, SJSN) to be implemented. In 2004, the last year of Megawati Sukarnoputri's presidency (2001-04), parliament had enacted the SJSN law, which could have provided comprehensive reform of the existing social care system. This law covered four social security programmes--health insurance, employment injury, old-age pensions and death benefits--and seemed to provide a springboard for comprehensive social policy reform to include formal and informal sector workers, the unemployed and the poor.

However, the SJSN law was not put into effect immediately. Implementing this law required detailed provisions of social security programmes to be determined by presidential regulations, including policy options for benefits and benefit parameters. While government agencies and the House of Representatives had discussed the law, no progress was made until October 2011. Neither President Susilo Bambang Yudhoyono nor the existing social security agencies and ministries were enthusiastic about the reform. (2) Nevertheless, the House of Representatives passed the BPJS bill and Presidential Decree 111/2013 was subsequently issued. Both pieces of legislation enabled the Indonesian government to establish a comprehensive healthcare programme beginning on 1 January 2014. Other social security programmes were subsequently implemented on 1 July 2015. Under this social welfare reform, all Indonesian citizens--as well as residents of the country--are required to join the national healthcare insurance scheme, and the Indonesian government aims to achieve universal healthcare coverage by 2019.

Why did the implementation of universal healthcare take ten years after the initial enactment? I argue that social welfare reform has an institutional prerequisite, such as an advocacy coalition, which represents the broad interests of society. An advocacy coalition is a "group of actors from various public and private organizations who share a set of beliefs and who seek to realize their common goals over time". (3) Without such a coalition, electoral competition does not necessarily provide incentives for politicians to undertake inclusive social welfare reform. In concrete terms, the 2004 SJSN reform bill was introduced in a top-down manner by the government without a broad societal consensus. In contrast, the 2011 BPJS reform was a bottom-up initiative. The successful implementation of the BPJS law demonstrates that the coordinated efforts of an advocacy coalition going beyond their own narrow interests can pressure politicians into implementing inclusive social welfare reforms.

This article consists of four sections. First, it reviews the literature on social policy expansion to elucidate competing arguments and identifies what is missing in the literature to verify the causal mechanism linking democratization with social welfare. Second, I offer an historical overview of Indonesian healthcare policies and the reasons behind their slow expansion. Third, I examine pre-existing challenges to comprehensive social welfare reform in Indonesia. Finally, I explain how an advocacy coalition consisting of various organizations was able to press the government to implement social welfare reform despite pre-existing challenges.

Explaining Social Welfare Reform

The existing literature on social policy expansion focuses mainly on cases from Western countries or East Asia such as South Korea and Taiwan. Theoretical insights gained from Western case studies primarily concern countries that are economically developed, (4) have strong bureaucracies, (5) party institutionalization or strong left-wing political parties and trade unions. (6)

Scholarship focusing on Asia emphasizes that democratization has been a significant factor for social policy expansion. (7) Joseph Wong argues that the process of democratization shaped social policy reforms in South Korea and Taiwan. Democratic reform and the political incentives of electoral competition initiated universalization of healthcare when conservative parties turned to social policy reform as winning electoral platforms. (8) Furthermore, the degree of electoral competition helps shape the outcome of social policies: the high degree of electoral competition in South Korea obliged the government to implement a quick-fix reform while the ruling party in Taiwan adopted a more transformative policy due to the low degree of electoral competition. With respect to Indonesia, Edward Aspinall argues that the country's democratization has led to healthcare policy expansion because of an open policymaking process and an incentive structure that is sensitive to social pressures in a democratic environment. (9) Aspinall acknowledges that "in terms of policymaking dynamics, the Indonesian experience is reminiscent of the pattern of health care policy expansion identified by Wong in Korea". (10) Similarly, Andrew Rosser and Ian Wilson argue that democratic decentralization contributed to pro-poor policy reforms in Indonesia by examining two districts in Bali: Jembrana and Tabanan. (11) Jembrana has taken a much more pro-poor approach than Tabanan because of their respective district heads' political strategies. When the votes of politicians depend solely on the masses instead of the party machine or mafia networks, the district head is likely to produce pro-poor policies.

While the existing literature rightly highlights the importance of democratization in social policy expansion, the causal mechanisms linking democratization with social welfare reform is missing. (12) In particular, the literature falls short in not discussing the importance of social forces. Although an open policy-making process and an incentive structure that is sensitive to social pressures exist in Indonesia, these cannot explain why the 2004 SJSN law could not be implemented while the 2011 BPJS law was able to be put into effect. Therefore, it is vital to examine how social pressures are mobilized, and how the policy-making process and incentive structures are shaped by social forces. By paying attention to social forces, we can understand the causal mechanism linking democratization with social welfare reform. Furthermore, I argue that democratization is a necessary but not a sufficient condition for social welfare policy implementation. What is needed for an inclusive social welfare reform is a broad-based advocacy coalition that represents cross-class interests.

Advocacy Coalitions

I use the term "advocacy coalition" to encapsulate a broad-based organization that represents cross-class interests. The concept of advocacy coalitions is not new. Many scholars argue that advocacy coalitions play a significant role in public policy-making. (13) While social movements do not always produce tangible policy outcomes, advocacy coalitions can increase the possibilities for achieving policy outcomes in three ways. First, advocacy coalitions can create political opportunities in both authoritarian and democratic states by effectively setting an agenda and bargaining with governments. Authoritarian states seeking to increase their legitimacy and social control can be susceptible to advocacy coalitions. For example, in the case of Singapore, where the role of civil society is circumscribed, civil society organizations like the Association of Women for Action and Research (AWARE) and Nature Society Singapore (NSS) have successfully engaged in advocacy politics vis-a-vis the state. (14) In democracies, competitive elections and the urge for bureaucratic accountability enables advocacy coalitions to take advantage of political institutions. Second, advocacy coalitions increase the chances of social movements attaining their goal by orchestrating various movement strategies, including protests and political alliances. Given that an advocacy coalition has a discernable leadership, it makes coordination feasible. Moreover, utilizing both protest and political alliances can produce a joint effect. (15) Lastly, advocacy coalitions with cross-class alliances can raise issue salience more effectively for their movements, as they appeal to broader constituencies. An advocacy coalition in Indonesia is able to set an agenda, utilize various means of protests while collaborating with sympathetic politicians, and gain a broader audience by refraining the issue to be of concern to all citizens.

Before I...

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT