The limits of healthcare reforms in Indonesia: Interrogating the Dutch colonial legacies’ influence within the logic and principles of welfare

Abstract

In recent decades, governments in developing countries have been inclined to introduce greater redistributive policies, placing greater emphasis on universal programs than on targeted ones. This article elaborates on the different theoretical perspectives of social policy development in the Global South to explain the emerging features of contemporary healthcare in Indonesia. It is argued that although certain political and structural factors may have collectively created favorable conditions for policy reforms, these factors do not necessarily cause the country to shift toward a universal welfare state. Possible explanations for this may rest on institutional factors, such as the historical-colonial legacy, which changed the incentive structures within which both new and old welfare institutions operated. Thus, transformation remains stuck at stratified universalism. Moreover, the expansion has not generated a significant reduction in decommodification, defamilization, and declientelization. The case of Indonesia may illustrate the current welfare expansion challenges faced by many developing countries.

Healthcare expansion in Indonesia and Thailand: a causal mechanism and its implications for welfare regimes

“…The development of healthcare represents the evolution of welfare regimes in Indonesia and Thailand. As described in the previous section, intertwined democratisation and AFC have shaped the political terrain within which subsequent welfare regimes have developed, resulting in a new trajectory diverging from previous approaches but converging to be more inclusive, placing the greater role of the state in welfare provision (Pholpark, 2018; Tangcharoensathien et al, 2019; Yuda, 2021b). In the context of healthcare, the new trajectory, as reflected in the social health insurance system, was selected by policymakers to consolidate all populations under a state-driven welfare system, as the National Health Insurance Program (JKN) (2014) in Indonesia and the UCS (2001) in Thailand (Bazyar et al, 2021).…”

“…This argument is exemplified in the provision specified in the updated law of 2020, in which inpatient room facilities received are dependent on the selected monthly contribution package, ranging from $10.46 USD (first-class room), $6.97 USD (middle-class room), to $2.93 USD (low-budget room). Despite this, the institutionalisation of the internal market in publicly funded healthcare systems, commonly for additional medical equipment and medications, has also pressured patients to make additional payments when accessing their entitlements (Yuda, 2021b). This causation has generated unexposed inequality among individuals in receiving healthcare.…”

“…However, as asserted in some studies, SBY set his policy priorities more on noncontributory healthcare, which was politically beneficial for his party's popularity. The measures taken by SBY were thus criticised by Megawati and her party, which considered SBY's decision to have violated the mandate of the NSSS law (Yuda, 2021b). Nevertheless, for most people, the policy was considered reasonable, as those years were an important period for Indonesia to recover from the economic crisis (Van Diermen, 2018).…”

Who should care? Exploring the views and experiences of individuals in negotiating solutions for health security

“…However, social welfare systems were reformed “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” (Fossati, 2017, p. 179). Several studies (for example, Aspinal, 2014; Yuda, 2021a, b) confirmed that implemented social protection had no positive outcome in terms of the provision of broad-based social services as the benefits provided were conditioned under a clientelistic relationship rather than social citizenship. Despite the controversy, the implementation of large-scale social protection laid the foundations for a thorough overhaul of its welfare regimes, with a focus on expanding the welfare benefits to formerly excluded groups, such as the elderly, children and people with disabilities (Tan, 2019).…”

“…Officially introduced in 2014, BPJS-Kesehatan has provided coverage to the increasingly large sector outside the formal labour market. Its wide coverage has turned BPJS-Kesehatan into the largest single-payer healthcare system in the world (Fossati, 2017; Yuda, 2021a, b). Another striking feature of the Indonesia healthcare reform has been the encouragement of “growing reliance on [household] expenditure, in the form of out-of-pocket payments and health insurance contributions” (He, 2018, p. 751).…”