Campaigning for All Indonesians: The Politics of Healthcare in Indonesia

Abstract

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. …