- Knowledge Sector Initiative

AUSTRALIA INDONESIA PARTNERSHIP
FOR DECENTRALISATION (AIPD)
POLICY DIFFUSION:
A FOUR DISTRICT STUDY OF THE REPLICATION
OF HEALTH INSURANCE (JAMKESDA )
AND BOSDA IN INDONESIA
Written by: Diane Zhang and Dr. Dave McRae
June 2015
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TABLE OF CONTENTS
GLOSSARY
...........................................................................................................................................................................
ii
I. BACKGROUND ....................................................................................................................................................................
1
II. POLICY DIFFUSION: A THEORETICAL FRAMEWORK ........................................................................................................
2
III. METHODOLOGY ................................................................................................................................................................
III.1. Objective ................................................................................................................................................................
III.2. Key research questions .......................................................................................................................................
III.3. Data collection .......................................................................................................................................................
5
5
5
5
IV. FINDINGS .......................................................................................................................................................................
IV.1. Top-down process is most effective for large-scale replication .........................................................................
IV.2. Horizontal processes leads to a slower pace of replication ..............................................................................
IV.3. The Bupati and the bureaucracy are the key policy actors ..............................................................................
IV.4. The DPRD did not drive policy, but wielded significant power through the APBD negotiations .......................
IV.5. The media is influential but their coverage is predominantly case-focused. .....................................................
IV.6. CSOs have limited influence and their activities are driven by funding ...........................................................
IV.7. Electoral incentives and establishment of norms were factors that motivated reforms, ideology was not ......
IV.8 Success of outcomes was not important for replication ...................................................................................
IV.9. Fiscal capacity and the head of district’s priorities influence the substance of Jamkesda and BOSDA ..........
IV.10. Political incentives, fiscal capacity, a new district head, new senior bureaucrats and change in national
policies all influenced how BOSDA and Jamkesda changed during implementation ........................................
7
7
8
10
12
13
14
15
17
18
19
V. PROGRAM IMPLICATIONS ................................................................................................................................................. 22
CASE STUDY 1: MALANG DISTRICT .......................................................................................................................................
CASE STUDY 2: MALANG MUNICIPALITY ............................................................................................................................
CASE STUDY 3: NGADA DISTRICT
................................................................................................................................
CASE STUDY 4: WEST LOMBOK DISTRICT ..........................................................................................................................
26
39
50
64
ANNEX 1 INTERVIEW QUESTIONS ...................................................................................................................................... 75
ANNEX 2 INTERVIEWEE LIST .............................................................................................................................................. 77
REFERENCES
i
...................................................................................................................................................................... 79
Table of Contents
GLOSSARY
AIPMNH
APBD
Askeskin
Badan Hukum
Bappeda
BOS
BOSDA
BPJKD
BPJS Kesehatan
BPK
BSM
BSMDA
Bupati
Camat
DAK
DAU
Dinas Kesehatan
Dinas Pendidikan
Dinas Sosial
DPRD
Jamkesda
Jamkesda NTB
Jamkesmas
Jamkesmasda
Jampersal
JKMN
JKN
JMS
JPI
Kepala daerah
Kepala Dinas
Kesehatan
Kepala Dinas
Pendidikan
Kinerja
MA
Madewa
Menpan
: Australia Indonesia Program for Maternal and Neonatal Health
: Anggaran Pendapatan Belanja Daerah, the sub-national government annual budget.
: Body responsible for implementing Jamkesmas, the national health scheme that commenced
in 2007. BPJS Kesehatan absorbed the body in 2014 when a new national health insurance
scheme commenced.
: Legal office
: Badan Perencanaan Pembangunan Daerah or Local Development Planning Agency
: Bantuan Operasional Sekolah or School Operational Assistance program
: Bantuan Operasional Sekolah Daerah or Regional Schools Operational Assistance program
: Badan Pelaksana Jaminan Kesehatan Daerah, the body responsible for implementing the
East Java health insurance program for the poor.
: Badan Penyelenggara Jaminan Sosial Kesehatan, the body responsible for implementing the
national health insurance scheme that commenced in 2014.
: Badan Pemerikaan Keuangan or National Audit Board
: Bantuan Siswa Masyarakat, the national scholarship program for poor students financed by
the central government.
: Bantuan Siswa Miskin Daerah, a scholarship program for poor students financed by a subnational government.
: Head of the district
: Head of the sub-district
: Dana Alokasi Khusus or Special Allocation Grant
: Dana Alokasi Umum or General Allocation Grant
: Sub-national health office
: Sub-national education office
: Sub-national social welfare office
: Dewan Perwakilan Rakyat Daerah or sub-national legislature
: Jaminan Kesehatan Daerah or sub-national health insurance program that provides free
health care coverage for the poor and financed by the APBD
: NTB Province’s health insurance program (financed by the province’s APBD)
: Jaminan Kesehatan Masyarakat, the national health insurance program financed by the
central government.
: West Lombok District’s health insurance program (financed by the district APBD)
: Jaminan Persalinan, a government program that provides free health care to mothers and
children for maternal and neonatal care.
: Jaminan Kesehatan Masyarakat Ngada, health insurance scheme for all Ngada residents.
: Jaminan Kesehatan Nasional, health insurance program where premiums are financed by the
government.
: Jaringan Masyarakat Sipil or NGO network in West Lombok that was established as part of
DFAT’s ACCESS program.
: Jawa Pos Institute
: Head of the district or province
: Head of the health office
: Head of the education office
:
:
:
:
Musrenbang
PAD
PAUD
PBID
:
:
:
:
Perbup
Perda
:
:
Pergub
:
Literally 'performance', name of aid program
Islamic religious equivalent to SMA (senior high school).
Malang Development Watch, a NGO network in Malang.
Kementerian Pendayagunaan Aparatur Negara dan Reformasi Birokrasi or Administrative and
Bureaucratic Reform Ministry
Musyawarah Perencanaan Pembangunan, community development planning meetings
Pendapatan Asli Daerah or Own-source Revenue
Pendidikan Anak Usia Dini or early childhood education
Penerima Bantuan Iuran Daerah or participants of JKN (national health insurance program)
where the members’ premiums are financed by sub-national governments.
Peraturan Bupati or Bupati Regulation
Peraturan Daerah or Local Regulation and refers to either district regulation or provincial
regulation.
Peraturan Gubernur or Governor's regulation
Glossary
ii
Perda
Pergub
Perwali
Pesantren
Petunjuk Teknis
Pilkada
Puskesmas
Pustu
RKPD
RPJMD
RPJP
SD
SK Bupati
SK Walikota
SKPD
SMA
SMK
SMP
SPM
Studi banding
Surat daran
TAPD
Tenaga honor
UU
Visi-misi
Walikota
iii
Glossary
: Peraturan Daerah or Local Regulation and refers to either district regulation or provincial
regulation.
: Peraturan Gubernur or Governor's regulation
: Peraturan Walkota or Mayoral Regulation
: Private Islamic schools
: Technical Guidelines that sets out the operating procedures for programs such as BOS and
Jamkesmas
: Direct election for local heads of districts and provinces
: Health clinic
: Puskesmas pembantu or Village Health Centre
: Rencana Kerja Pemerintah Daerah – local government annual workplan
: Rencana Pembangunan Jangka Menengah Daerah or mid- term development plan (five years)
: Rencana Pembangunan Jangka Panjang or long-term development plan (20 years)
: Sekolah Dasar or Primary School
: Bupati Decree
: Mayoral Decree
: Satuan Kerja Pemerintah Daerah or local government work units (for example, the education
office or health office)
: Sekolah Menengah Atas or Senior Secondary School
: Sekolah Menengah Khusus or Vocational School
: Sekolah Menengah Pertama or Junior Secondary School
: Surat Pernyataan Miskin or letter of proof of one’s poverty
: Comparative study/study tour
: Circular
: Tim Anggaran Pemerintah Daerah or budget team responsible for formulating the APBD.
: Contract or honorary workers, this report generally refers to contract teachers or health
workers working for the government but without civil servant status.
: Undang-Undang or Law
: Vision and mission statements of candidates in election campaigns.
: Mayor/Head of a Municipality
I. Background
In 1999, Indonesia commenced a sweeping set of decentralization reforms that devolved the main elements of service
delivery – health, education and infrastructure provision – to almost 300 district governments.1 Globally, decentralization
contributed to a boom of policy experimentation (Sugiyama, 2008a; Kim, 2013). A key assumption of decentralization was
that devolution of the policy-formulation function would result in policies that are more specialized and tailored to the
specific needs of the sub-national entity. International experience shows, however, that there is in fact a large similarity
between the policies adopted by the sub-national entities, or a ‘diffusion’ of policies.
In Indonesia, the ‘diffusion’ is particularly noticeable in the provision of universal health and education services.
Nationally, the central government adopted the Bantuan Operasional Sekolah (BOS) and Jaminan Kesehatan Masyarakat
(Jamkesmas) schemes. BOS, commencing in 2005, aims to provide free basic education, consisting of primary school
(SD) and junior secondary school (SMP), to poor students. BOS transfers block grants to primary and junior secondary
schools to compensate them for loss of income due to a policy to waive school fees initially only for poor students but as
of 2012 for all students in state schools and poor students in private schools. Jamkesmas, which commenced in 2007, is
a health insurance scheme that provides free healthcare for the poor and near poor and covered approximately 76 million
people in Indonesia (World Bank, 2013). In 2014, Jamkesmas was integrated into BPJS Kesehatan that aims to provide
health insurance to all Indonesians by 2019.
Since neither BOS nor Jamkesmas allocates sufficient funds to achieve its policy goals, sub-national governments have
initiated their own programs – Bantuan Operasional Sekolah Daerah (BOSDA) and Jaminan Kesehatan Daerah
(Jamkesda). According to the World Bank (2012) a survey conducted by the Ministry of National Education in 2009
showed that approximately 60% of districts in Indonesia were providing BOSDA to at least some of their schools.
Furthermore, at least 243 districts in Indonesia have adopted some form of Jamkesda, according to SMERU data (SMERU,
2015). The ubiquity of these programs facilitates their use as cases to study policy diffusion processes in Indonesia.
The ‘diffusion’ of the Jamkesda and BOSDA policies reflects that governments rarely adopt policies that are developed
solely internally, but often look to experiences of other governments who have faced similar policy problems.
Technological advancements also allow ready communication of information across geographical regions.
The role that policy diffusion plays in how Jamkesda and BOSDA has spread to so many districts in Indonesia is the topic
of this study. Understanding policy diffusion is important because it assists policy-makers with understanding why
governments adopt particular policies and why policy replication takes place.
Understanding policy diffusion is also relevant to governance programs, such as the Australia Indonesia Partnership for
Development (AIPD) or a successor program, because it provides insights as to why certain policies recommended by
external parties gain traction and others do not. It also helps to explain where district governments source policy ideas
and which policy transfer process is most effective for encouraging district governments to adopt new policies.
This study also aims to contribute to the academic literature on policy diffusion. The spread of BOSDA and Jamkesda has
not been systematically researched in Indonesia and this study aims to contribute to this gap in literature by analysing how
the schemes spread to four districts in Indonesia. This report presents the findings of the study.
This rest of this report is broken into four sections. Section II presents the policy diffusion theoretical framework and the
key ways that policy diffusion is analysed. Section III sets out this study’s methodology including key research questions,
data collection approach and how the four districts were selected. Section IV details the key findings from this research
and section V concludes with the policy and program implications that emerged from the study.
1
Law 32/2004 on Local Government.
Background
1
II. Policy Diffusion: A Theoretical Framework
Shipan and Volden (2012) define policy diffusion as ‘one government’s policy choices being influenced by the choices of
other governments’. Although Shipan and Volden’s definition suggests a government-to-government relationship, the
definition does not preclude the role of non-governmental actors such as international organisations and civil society
organisations in the policy diffusion process, particularly in relation to communicating and standardizing policies and
norms – that is, facilitating the process for which policy ideas are transferred.
There are five main ways of analysing policy diffusion:
a. Policy diffusion processes: Kim (2012) identifies three types of policy diffusion processes. The first refers to horizontal
interactions between approximate jurisdictions. In this instance, it refers to policy learning among officials from
geographically proximate jurisdictions from the same level of government. In the case of Indonesia, this may refer to
LGs adopting policies sourced or inspired by policies of other local governments (LGs) in Indonesia, or policy learning
between districts within a province. The second is horizontal interactions beyond regional boundaries. This refers to
policy learning that transcends countries and continents. For instance, Indonesian LGs adopting policies inspired by
policies of governments outside of Indonesia, for examples, LGs in Brazil or China. Third, vertical transitions of
influence between different levels of government. This process refers both to the central government’s influence
towards LGs (a “top-down” process), as well as the idea that policy diffusion at local level can inspire the central
government to adopt a policy nationally (a “bottom-up” process).
In Indonesia, the expansion of universal health and education services has been a joint effort by the central
government, the provincial governments and the district governments. For example, health care is covered by a
combination of national schemes (Askeskin, Jamkesmas and the BPJS Kesehatan), districts schemes (as of 2014, at
least 243 districts in Indonesia have adopted some form of Jamkesda, according to SMERU data) and provincial
schemes (generally a cost sharing arrangement with the district governments). In education, the national government
has BOS and Bantuan Siswa Miskin (BSM) – a scholarship program for children from poor families. Sub-national
governments also run BOSDA and BSMDA (Bantuan Siswa Miskin Daerah) at the regional level.
These efforts were not always complementary as each government may sometimes adopt parallel regimes. For
example, the Makassar municipal administration entered into a dispute with the provincial government because of
Makassar municipality’s “subsidised education” policy, rather than adopting the provincial government’s policy to
provide “free education” (Rosser and Sulistiyanto, 2013). Despite the myriad of free health and education regimes,
little research has been conducted on whether each level of government’s policies have influenced those adopted by
other governments.
b. Mechanisms of policy diffusion: Shipan and Volden (2008) identify four mechanisms of policy diffusion: learning,
economic competition, imitation and coercion. Learning refers to the idea that policy makers learn from each other.
Under the learning mechanism theory, districts are more likely to adopt a policy if it has been adopted elsewhere
within its geographic region such as within a province.
The economic competition mechanism argues that governments consider the economic effects of the policy and
policy diffusion may take place where there are economic spillover effects across jurisdictions. For example, the
economic competition theory suggests districts are less likely to adopt the policy if there are negative economic
spillovers (i.e. if the government will be disadvantaged by adopting a policy that other districts have not adopted).
Conversely, if the policy can be shown to have a positive economic spillover (for example, the uniformity of
infrastructure), the district is more likely to adopt the policy.
An imitation mechanism, sometimes referred to as emulation, involves copying the action of others in order to look like
the other. This mechanism distinguishes itself from the learning mechanism because the former focuses on the actor,
and the latter on the action. Shipan and Volden’s hypothesis is that the district will adopt the policy if a bigger or more
developed neighbour adopted the policy.
The coercion mechanism refers to financial incentives from central to sub-national governments, which often
stimulates policy adoption. Two hypotheses are attached to this mechanism. First is that a higher-level government’s
provision of financial incentives (through conditional grants, for instance) may increase the likelihood that a policy is
adopted. Conversely, a high-level government that adopts a policy that covers the jurisdiction of a lower-level
government, the lower-level government may not adopt the policy. For example, where both the central government
and the provincial government provide health insurance, the district government may not feel the need to provide
district-level health insurance.
2
Policy Diffusion: A Theoretical Framework
c. Agents of policy diffusion: there are many parties who may drive the process of policy diffusion and each group may
have different motivations. Moreover, the various motivations may not be mutually exclusive and their interactions are
fundamental to determining whether the policy transfer takes place. Agents may be elected officials, members of the
bureaucracy, members of parliament, the academic community and non-government entities such as international
organisations, media, and civil society (Evans, 2009).
Edward Aspinall (2014a) suggests that one of the key reasons for the expansion of universal health care in Indonesia
is because of the emergence of new political actors at the national level during the democratic era after the fall of
Soeharto in 1998. Aspinall argued that democratisation resulted in the institutionalisation of the national parliament
and the institutionalisation of civil liberties and social rights movements, which allowed new political players to
emerge.
Rosser and Sulistiyanto (2013) assert, however, that the elected regional head (kepala daerah) – either a bupati (head
of a district) or walikota (head of a municipality) – is the key driver of policy at the district level because the regional
head proposes the majority of district-level legislation. Moreover, many of the programs in relation to universal health
and education are enacted through a regional head regulation (Peraturan Bupati or Peraturan Walikota) which only
needs the support of the bupati or walikota, rather than a local regulation (Peraturan Daerah or Perda), which needs
the support of the local parliament.
Although Aspinall identified national civil society movements as key political players that emerged to push expansion
of social services, there was no similar finding on the influence of civil society at the district level. The literature also
does not discuss the role of the bureaucracy in the policy process in Indonesia.
d. Motivations for policy diffusion: Sugiyama (2008b) classifies motivations for policy diffusion into three types: electoral
incentives, ideology and socialisation of norms. Electoral incentives refer to the idea that political competition for
positions of elected office creates incentives to replicate policies. The expansion of universal health care and universal
education policies in Indonesia has generally been explained in terms of electoral incentives. For example, in addition
to the emergence of new political players, Aspinall (2014a) argues that the changed incentive structures as the result
of the introduction of elections was another key reason for the expansion of universal health care policies by the
central government in Indonesia. Rosser and Wilson (2012) argue that the political strategies of the elected heads of
districts influenced whether universal health care policies were adopted. Heads of districts that relied on mass
mobilisation of support were more likely to adopt universal health care (generally in the form of health insurance).
Whereas heads of districts that had a political strategy for garnering support from the local elite were less likely to
adopt pro-poor policies such as provision of health insurance or free education.
Sugiyama (2008b) argues that left-leaning progressive actors are more likely to be willing to enact policies that extend
social services to marginalized groups. In Indonesia, however, ideology is not considered an important motivation for
expansion of universal health and education services. Although Aspinall (2013) identifies that PDI-P, as a party that
many identify with, supports the expansion of social security, Rosser and Wilson (2012) cite numerous authors that
argue that Indonesia’s political parties are merely “vehicles for hire” and their policy positions are not bound by
ideology.
The third motivation – socialisation of norms – refers to the idea that formal and informal social networks can link
individuals and encourage greater policy emulation. This form of motivation hypothesises that formal social networks
may encourage individuals or institutions to seek to “keep up with the Joneses” (Sugiyama, 2008b), for example,
policies adopted by “more developed” regions may be adopted by “less developed” regions. Norms established by
formal networks such as the Association of Local Governments or head of districts forums may promote members of
the network to adopt its norms.
e. Internal Factors: according to Kim (2013), local policy making can also be influenced by various internal factors of the
local policy environment. He identifies two internal factors. First, the perception of the urgency to adopt the policy. In
South Korea, for example, the low birth rate in the local jurisdiction was important to understanding whether the
jurisdiction needed a childbirth support policy. Second, socioeconomic conditions may also enhance opportunities or
impose constraints for policy adoption. For example, the availability of resources for policy development and
implementation may influence policy adoption. Thus, the wealthier jurisdictions are more likely to adopt policies
needed. Similarly, low social indicators may spur districts to adopt policies of districts with higher indicators.
There are two gaps that exist in international literature. First, the literature does not cover whether demonstrated
“success” of policies was important to a government’s decision on whether to replicate the policy. This is particularly
pertinent in Indonesia where there is insufficient quality data to readily measure the success of social service delivery
(Lewis and McCulloch, 2014). In the absence of achievement of outcomes, are there other indicators that demonstrate
“success” of universal health and education policies?
Policy Diffusion: A Theoretical Framework
3
In addition to that, policy diffusion studies only analyse the policy diffusion process up to the point of policy adoption.
Thus, existing studies do not look at how policies might change during implementation, which might account for the
variations between LGs. Nor do existing studies cover why policies may be continued, discontinued or adapted.
The scope of this study includes analysing the contribution of “success” to whether policies are replicated and analysing
the policy implementation process.
4
Policy Diffusion: A Theoretical Framework
III. Methodology
III.1. Objective
This study aims to better understand how and why policies are replicated by district governments so that donor programs
can more effectively promote replication of good policies. To achieve this objective, this study analyses the spread of
BOSDA and Jamkesda, two key policies contributing towards the provision of universal health and education services to
four districts in Indonesia.
Although the theoretical framework focuses on policy diffusion, this study does not preclude the possibility that a policy
may be purely indigenous with no influence from external parties. It does assume that given the ubiquitous nature of
policies relating to the provision of universal health and education services, most policies adopted at the district level
were influenced from models used elsewhere.
III.2. Key research questions
The key research questions for this study are:
a. What policy diffusion processes and mechanisms drive policy replication?
b. Who are the agents of policy diffusion?
c. What are the motivations of the agents of policy diffusion?
d. Does “success” in other jurisdictions matter?
e. Are there internal factors that influence policy replication?
f. How does implementation affect the evolution of the policy?
III.3. Data collection
This study used a case study approach to analyse policy diffusion processes, that is, each case study traced and analysed
in detail the process for which four districts adopted Jamkesda and BOSDA policies. The data from each district was
collected through semi-structured interviews and was qualitative in nature. See Annex 1 for the list of interview questions.
The data collected from interviews was also supplemented with documents collected during the field visits. Where
possible the research team gathered each district’s relevant planning and budgeting documents as well as relevant
legislation and agreements that set out the legal basis for Jamkesda and BOSDA.
District Selection
The four districts were selected on the basis of the following four criteria:
• Identify districts and provinces supported by AIPD: AIPD operates in five provinces (NTT, NTB, East Java, Papua
and West Papua). The districts must be within the five provinces supported by AIPD.
• Identify districts that have adopted both Jamkesda and BOSDA: the pre-requisite for this study is that each
district must have adopted Jamkesda and BOSDA within the last ten years, as each case study will research the
policy process for the adoption of each policy. An exhaustive internet search was conducted to find evidence of
adoption of each policy at the district level in Indonesia. Furthermore, Smeru provided a list of districts that had
adopted Jamkesda and the year the policy was adopted.
• Revenue: international experience suggests that governments with higher fiscal capacity are more likely to adopt
policies because of their ability to finance programs and policies. By selecting districts with high and low revenue,
this study can assess whether the fiscal capacity of the districts influenced the model of Jamkesda and BOSDA that
they adopted. The indicator for fiscal capacity is per capita revenue and total revenue.
• Human Development Index: there are two hypotheses in relation to social development indicators. First is that
districts with low social indicators are likely to emulate or imitate the policies of those with higher social outcomes.
A second hypothesis is that districts with higher revenue have greater discretion to fund social spending that may
Methodology
3
improve social indicators. Thus, it is worth selecting districts that have high and low social outcomes as
represented by the human development index.
Based on the above four criteria, the following four districts were selected as part of this policy reform study.
District
Jamkesda
Year
Year BOSDA
was adopted
Malang Municipality,
East Java
Malang District, East
Java
West Lombok, NTB
2009
2010
2008
2010/2011
467
20
276
2009
400
188
465
Ngada, NTT
2010
Bupati
Regulation
2014
2012/2013
182
422
333
was adopted
Ranking out of 474 districts
(with available data)
Per capita
Total revenue
HDI
revenue
363
76
33
Source: Jameskda adoption year from Smeru; BOSDA adoption year from researchers’ interviews; Revenue and population figures
from 2012 BPS data, HDI data from 2011 BPS data. Revenue and HDI data extracted from the World Bank Indonesia-Dapoer database
in February 2015.
A team of two researchers spent five weeks in the field conducting 64 interviews with the head of district, senior
bureaucrats, DPRD members (particularly members of the commission responsible for health and education), advisors to
the head of district, members of the academic community, CSOs and the media in each district. A full list of interviewees
is attached in Annex 2.
6
Methodology
IV. Findings
This section presents the ten key findings from this study.
IV.1. Top-down process is most effective for large-scale replication
One of the main questions that this study aims to answer is how Jamkesda and BOSDA programs spread across so many
districts in Indonesia. Did these schemes emerge because of horizontal learning or imitation processes whereby districts
learn from or imitate each other? Did they emerge from a bottom-up process whereby communities lobbied the
government to provide free health and education, particularly for the poor? Or did these schemes spread through a
top-down process whereby a lower-level government adopts policies because of influence from a higher-level government?
In Malang Municipality, Malang District, Ngada District and West Lombok District, both Jamkesda and BOSDA emerged
because the equivalent national-level programs, Jamkesmas and BOS, did not allocate sufficient funds to provide free
health and education services for the poor. District governments responded to the gap in funding by allocating their own
budget to similar programs.
Thus, the diffusion of BOSDA and Jamkesda policies followed a top-down process, whereby the district government’s
policy was predominantly sourced from the central government. In literature, top-down processes generally employ a
“coercion” mechanism, where the higher-level government coerced the lower-level government to adopt the policy, either
through financial incentives or formal authority.
In the case of Jamkesda and BOSDA, however, a new mechanism emerged whereby district governments enacted
programs that were similar to national programs as a “response” to a perceived deficiency in the national policy. All of the
four district governments surveyed agreed that Jamkesda emerged because the national health insurance scheme
(Jamkesmas) did not cover those who could not afford health care. In addition to being “responsive”, the districts in East
Java and NTB were also “coerced” into adopting a Jamkesda scheme.
Malang Municipality and Malang District both adopted the Jamkesda scheme as part of a province-wide effort initiated by
the current governor. Although initial plans for Jamkesda commenced under the previous Governor, Imam Sutomo, when
the current governor, Sukarwo commenced his term, he convinced the districts in East Java to join his Jamkesda scheme
through a 50-50 cost sharing incentive and the threat that he would expose any head of district who did not agree to his
scheme to the press as not supporting their communities.
West Lombok district has two Jamkesda schemes: a cost-sharing scheme with the provincial government and one
financed solely by the district’s budget (Anggaran Pendapatan Belanja Daerah or APBD). Similar to East Java, the
provincial government entered into a cost-sharing agreement with NTB districts for a Jamkesda program. A senior official
from the West Lombok Government said that districts did not reject offers of cost-sharing schemes for two reasons. First,
cost sharing is a way for a district government to increase its budget. Second, maintaining good relations with the
provincial government is important because they have the power to review and reject budget items in the APBD. The
senior government official stated that the district shows its support (or lack thereof) for the cost-sharing scheme by the
amount of funding it allocates to the program. The authority that the provincial government exerts over districts allows it
to “coerce” district governments to enter into cost-sharing schemes.
The national Jamkesmas program also influenced the design of Jamkesda. All four districts adopted Jamkesda whereby
the benefits were essentially the same as the national program. In order to prevent discrimination between the
participants of the different schemes both the national and sub-national schemes provide free treatment at the health
clinics for scheme participants. Members also receive free hospital treatment if they receive a referral from a health clinic
(Jamkesda participants, however, can only access local hospitals). The Ngada District Government said that the only
reference they used to design their health care scheme (Jaminan Kesehatan Masyarakat Ngada or JKMN) was the
Jamkesmas’ technical guidelines.
The “responsive” mechanism is also how BOSDA spread to three of the four districts surveyed. Malang Municipality and
District and Ngada District adopted BOSDA because the national BOS scheme, which commenced in 2005, was
insufficient to cover the operational costs of schools. Although the district governments admit that BOS funds assisted to
reduce the fees levied on parents, the national program did not eliminate the need for fees. In Ngada District, for example,
BOS was insufficient to overcome the teacher shortage problem facing the district. In Ngada, they held sub-district-level
meetings with the Education Office and school principals. At these meetings, it emerged that the district faced a shortage
of official civil servant teachers (guru PNS) because the district had not been able to replace those who retired with new
civil servant teachers (presumably because of a freeze on civil servant recruitment). As a result, the district is reliant on
“honorary teachers” (tenaga honor).
Findings
7
According to the Ngada District Government, BOS funds can only be used for 13 operational cost components and only
15% of BOS funds can be used to pay the honorary teachers’ salaries, which is insufficient to resolve the teacher shortage
problem. In response, the Ngada District Government adopted the BOSDA scheme where funds were used to pay
“honorary teachers” salaries in order to increase the number of teachers in the district.
Unlike the other three districts, in West Lombok district, BOSDA has not been implemented. Instead, the district
government has included the program in a Bupati Regulation (Perbup) on the administration of free education.2 Accordng
to the Education Office, the main reason for the inclusion is due to a central government regulation that stipulates that
public school education must be free. As BOS grants are insufficient to achieve this, district governments need to provide
supplementary grants in order for district governments to fulfil the central government’s policy of fee-free education. The
spread of BOSDA in West Lombok district is due to a combination of “coercion” by the national government” and
“responding” to a deficiency.
The key feature in the spread of Jamkesda and BOSDA schemes to all four districts is that governments expressed the
view that their local schemes were supplementing the “gap” in the national programs. All four districts said the
participants of the Jamkesda scheme were citizens who were not eligible for Jamkesmas (although interviews revealed
that there was in fact some overlap). Interviewees were also very explicit in stating that the BOSDA was developed to
supplement the BOS funding and to fill the “gap”. The policy diffusion of Jamkesda and BOSDA, therefore, was
predominantly a top-down process in “response” to deficiencies in the equivalent national policy.
IV.2. Horizontal processes leads to a slower pace of replication
Although there is regular sharing of information between districts for horizontal learning or imitation, it does not generally
lead to actual replication of policies. Where replication does happen, the scale is small and replication happens slowly.
For instance, during the BOSDA and Jamkesda design process, three of the four districts visited other districts to study
their policies to help them develop their initiative. These visits are typically known as studi banding (a comparative study).
Despite the horizontal learning, no government official would admit their health and education initiatives (or elements of
them) were modelled on that of another district. They also did not know of visiting districts adopting their innovations.
The mayor of Malang municipality and several members of the local legislature (DPRD) visited Surabaya to study the free
education scheme that had been running for seven years and the head of Malang Municipality Education Office also took
some school principals to study Semarang’s free education program. Interviewees who went on those trips claimed that
the schemes in the other districts were too complex to be applied in Malang Municipality.
The East Java Provincial Government visited South Sulawesi, South Sumatra and West Java,3 when designing the
Jamkesda program. The NTB government also went to East Java, Yogyakarta Special Region and Palembang to study their
provincial education regulations. Neither the NTB nor East Java governments could specify what lessons they learnt from
these trip.
Interviewees also said they found information from the Internet on BOSDA and Jamkesda programs in other districts. For
example, the West Lombok Health Office claimed that they read Internet materials on the Jamkesda schemes in
Purbalingga and Musi Banyuasin in South Sumatra Province, but did not specify as to what lessons they learnt from that
research.
The small scale and slow speed at which replication takes place from a horizontal policy diffusion process is reflected in
the conclusions in the Jawa Pos Institute’s (JPI) study on the sustainability of its Otonomi (Autonomy) Award winners,
which is an award that recognises local government innovations and good governance. In 2014, JPI conducted a study
that examined the sustainability of a sample of 55 initiatives that won the Otonomi Awards between 2004-2013 in East
Java. The study assessed whether these initiatives were developing, stagnant or wilting. In contrast to BOSDA and
Jamkesda, initiatives that win Otonomi Awards are sourced from local activities and programs, thus if replication occurred
it would be through bottom-up and horizontal processes. Of the 55 initiatives examined in the sustainability study, 33 were
sourced from district-level work units (SKPD), 15 from district heads, 3 from donors, 2 from Non-Goverment Organisations
(NGOs), and one each from the provincial government and the central government.
The study found that of the 55 innovations, 44% (24) were developing. This means that the innovation had either
improved the quality of the initiative or increased its coverage. Another 23 innovations were considered stagnant, that is,
the innovation still existed but had not changed in form (did not increase coverage or improve quality). Finally, 8 initiatives
2
Despite its inclusion in the District Head's Regulation, the West Lombok Education Office suggested that the program is unlikely to be funded in the
short to medium term as not everything in the education regulation will be implemented immediately and BOSDA is “only for the long-term”.
3
‘Dua Daerah Jatim Setujui Layanan Gratis', Kompas.com, 7 April 2009.
8
Findings
were “wilting” as the initiatives were discontinued. Although the study found that 24 of the initiatives had either expanded
their coverage (were replicated elsewhere) or had improved in quality, the study did not identify which initiatives had been
replicated.
When asked for examples of whether Otonomi Awards innovations were replicated, JPI interviewees identified an initiative
from Ponogoro District, where a local official had discovered that his predecessor had been falsifying population data. In
response, he developed a simple software program that captured population data more accurately. This methodology and
software was subsequently replicated throughout the district. According to JPI, Lamongan District in East Java is now
starting to implement Ponogoro’s software program. JPI also claimed that Situbondo is starting to think about replicating
the community participation program in Banyuwangi and that Banyuwangi was also considering adopting Gresik’s
sanitation program, despite the fact that Gresik itself did not replicate this program on a larger scale.
The JPI sustainability study shows that the spread of innovations generally took place between districts within a province
and intra-province adoption of innovations was rare. Even evidence of one district adopting the innovation of another
district within a province is not conclusive. Of the three examples of innovations provided by JPI, none had been
definitively adopted by another district –there were merely plans to do so.
A potential reason for horizontal policy diffusion only taking place on a small scale is that the way districts learn from each
other is generally through comparative studies, which has several limitations and rarely leads to policy adoption. JPI said
that one of the key after-effects of winning an Otonomi Award was that the district may get inundated with visit requests.
Unfortunately receiving many visitors, they said, rarely led to policy transfer.
Why are comparative studies not an effective way to share knowledge that will lead to policy replication? One potential
reason is that visits are too fleeting to allow meaningful exchange of knowledge. Interviewees said that comparative
studies typically only take a day and consist of approximately a one-hour meeting with the district government and may
also include a field visit. Interviewees said that follow-up visits by technical staff may also take place. The nature of such
visits is that they are too short to learn any meaningful detail about the policy, particularly if visitors are not able to speak
directly to the person who has in-depth knowledge of the scheme.
Another potential reason is that comparative studies come up against districts’ inherent resistance to learning from
districts due to reasons of pride and prestige. As an example, when asked whether Malang Municipality and District’s free
health and education schemes (not just Jamkesda or BOSDA) were derived from learning from another district through a
comparative study, the government officials typically responded by saying that they were leaders in their fields and receive
far more visitors compared to going on study tours. Both the Malang District Health Office and Education Office reported
that they receive visitors weekly because other districts had heard about the awards they won. The former mayor of
Malang Municipality also expressed pride at the number of awards the municipality had won during his tenure.
In fact, officials from all four district governments were reluctant to admit they went on comparative study tours, instead
always claiming that they received far more visitors compared to any outbound study tours. Districts also keep data on
incoming visitors, but there is no centralised database showing outbound visits (that the researchers could identify).
Human resource and fiscal capacity to research about other districts may also be an obstacle to horizontal learning
processes. In Ngada District, for example, interviewees openly admitted the need to improve human resource capacity,
but also said neither their JKMN (Jamkesda equivalent) nor their BOSDA programs were a result of comparative studies.
The JKMN mirrors the central government Jamkesmas scheme, and the BOSDA is based on discussions with school
principals. Ngada officials said they had very limited budget to travel for study tours although a trip did take place when
the district head took his school principals on a trip to Bali to visit high performing schools as a reward for achieving a
100% high school pass rate.
The limited success of comparative study tours does not mean that horizontal learning is not useful. The research team
found two examples of effective horizontal learning. First, an innovation that numerous Ngada District interviewees cited
as a local innovation was the sister-hospital arrangement between the Bajawa Public Hospital and the Sardjito Hospital in
Yogyakarta. The sister-hospital arrangement allows for specialists from the Sardjito Hospital to consult on cases in
Bajawa. Moreover, Bajawa Hospital interviewees said they also received capacity building in hospital management
practices such as the billing system.
This program is so well received that many interviewees characterised this sister-hospital arrangement as a local
government innovation with no mention of the role of the donor program AIPMNH, which supported this initiative. The
Bajawa Hospital did explicitly state AIPMNH’s role, their appreciation for the activity as well as the view that it may not be
continued when AIPMNH is discontinued. One of the features that may have led to the success of the sister-hospital
arrangement was that it allowed for more intensive exchange of knowledge than was possible in a study tour.
The research team also observed that the spread of broad ideas seemed to take place using a horizontal process.
Specifically, there was a great deal of similarities between the broad political strategies of district heads. District heads
Findings
9
from all four districts employed a political strategy whereby they created an image of being “pro-people”. The need to be
“pro-people” commences at the election campaign. As one interviewee said all election candidates rarely deviate from
four issues in their campaign: health, education, infrastructure and the economy.
Once in office, they all initiate programs that are easily identifiable as the district head’s flagship programs as the
programs provide direct benefits to the community. Programs such as infrastructure projects (schools, hospitals, roads),
grants directly to the poor and vulnerable populations such as village grants, scholarships and health insurance are
common political tools. Moreover, each district head employs strategies to engage directly with the community in an
attempt to be a “man of the people”. The clear replication of political strategies, even whilst using different methods to
achieve the same strategic goal, shows the effectiveness of the horizontal learning process to spread broad ideas,
particularly those that generate a “buzz”.
Given that horizontal learning processes still have value, who is more likely to learn from which districts? Interviewees
from East Java broadly believed that only districts in Java were comparable and a suitable source of ideas. One
interviewee from Malang municipality said that districts outside Java are not comparable because of their low human
resources capacity. Interviewees from outside of Java wanted to learn from districts that were “more developed” such as
Java or Bali. One Ngada interviewee, however, pointed out that it was difficult to adopt ideas from Java and Bali, both of
which had much higher levels of revenue and technology than Ngada.
Where do districts hear about innovations for horizontal learning? Interviewees identified central government agencies
(such as the Administrative and Bureaucratic Reform Ministry (Menpan)) as a key source of ideas. When prompted,
interviewees also identified innovations that have won awards such as the Jawa Pos Otonomi Awards as a source of ideas.
When GIZ and Kinerja (a USAID financed local governance program) were considering establishing an innovation hub to
disseminate best practices, they commissioned JPI to run a survey of 40 district heads to determine whether this
information hub should be launched at the national or provincial level. JPI reported that the response was split. Half of the
survey’s respondents preferred a national level innovation hub because of the potential larger scope. Those who preferred
a provincial-level hub reasoned that it would fit within the coordination role of the provincial government, particularly with
respect to the possibility of cost sharing. Interviewees in this study did not mention the provincial government as a source
of policy ideas, unless cost sharing was included.
This study found that horizontal processes have mostly led to an exchange of broad ideas but have not, thus far, been an
efficient way of replicating programs or policies that require a detailed level of understanding. When horizontal learning
takes place through a mechanism where there is a meaningful exchange of knowledge over a longer period of time, it can
lead to cross-fertilisation of processes and policies.
IV.3. The Bupati and the bureaucracy are the key policy actors
Another key question this study aims to answer is who are the agents of policy diffusion, namely, who were the key parties
responsible for the adoption of the Jamkesda and BOSDA programs. To answer this question, the study analysed the
Jamkesda and BOSDA policy formulation process and the roles that each party played in this process, including the
elected regional heads, the bureaucracy, the legislature (DPRD), media, civil society as well as provincial and central
governments.
This study concludes that the main driver of policy at district government level is the partnership between the elected
head of district and the bureaucracy. The elected head of district has ultimate authority over which policies are adopted
and more importantly financed by the APBD, whereas the bureaucracy is responsible for translating the district head’s
strategic priorities into details policies and programs.
In all four districts, the elected head of district made the final decision to adopt and fund Jamkesda and BOSDA. The
initiating actor may differ – the head of district, the district bureaucracy, a donor or NGO (BOSDA in Malang Municipality),
and the provincial government (Jamkesda cost sharing schemes in NTB and East Java) – but no scheme receives APBD
financing without it being supported by the head of district.
For instance, the level of funding allocated to BOSDA in each of the four districts reflects whether education and in
particular universal free education is a priority for the district head. In Ngada District, for instance, BOSDA is the district
head’s flagship program and receives significant funding despite opposition to universal free education from the DPRD
and NGOs. BOSDA is also well financed in Malang Municipality because education is the mayor’s top priority. When a new
mayor took office in 2013, he increased funding to BOSDA and regulated that schools were prohibited from charging fees.
Conversely, free education was not a priority for the head of district in West Lombok and Malang Districts. In West
Lombok, there is widespread opposition to fee-free education and although a District Head Regulation stipulates that
schools are to receive BOSDA, the government does not allocate any APBD funds to the BOSDA program. In Malang
10
Findings
District, free education is also not a priority – when asked about their programs to support free education, the initial
answer from the district Education Office was that none exists. Reflecting this stance, although BOSDA receives APBD
funding, the amount is very small at only IDR 180 million in 2013.
Whether or not free access to health services was a priority for the head of district also reflects the funding allocated to
Jamkesda. In Ngada District, for instance, the Jaminan Kesehatan Masyarakat Ngada (JKMN) is the district head’s
flagship program and the program covers almost 50% of the district’s population. In the other three districts, Jamkesda
are cost-sharing schemes. As discussed earlier, districts do not typically reject cost-sharing offers from the provincial
government but if the program is not aligned with the district head’s priorities, it will receive little funding allocation.
Malang Municipality, for instance finances 32,000 Jamkesda participants whereas Malang District only finances 11,000
participants despite having a far larger population and a higher poverty rate.
The head of district, as the budget holder and decision-maker, works in cahoots with the bureaucracy, which has the sole
responsibility to design, implement, monitor and evaluate all policies and programs. In all four districts, the bureaucracy
led by their respective health and education offices designed and implemented Jamkesda and BOSDA, respectively. The
education offices also made key decisions such as the value of the BOSDA grant for each school; eligible expenditure
criteria; and which schools are eligible for BOSDA grants. The health offices made key decisions such as Jamkesda
benefits, participant criteria and unit cost per participant. The Social Welfare Office estimated the number of participants
to fulfil the scheme’s criteria. The health and education offices negotiated with the budget team (Tim Anggaran
Pemerintah Daerah or TAPD) on the APBD allocation. As one head of Health Office explained, a policy idea may come from
the district head, but it is the health office’s job to translate his idea into something concrete.
The bureaucracy’s power is also derived from the very centralised and rigid planning and budgeting process, which means
few outside of the bureaucracy can meaningfully influence the process. Interviewees from the bureaucracy all
emphasised that under Indonesian law, the budget (APBD) must be “synchronised” with the programs in the planning
documents. Drafted by the bureaucracy, these planning documents include the 20-year long-term development plan
(Rencana Pembangunan Jangka Panjang Daerah or RPJPD), the five-year medium term development plan (Rencana
Pembangunan Jangka Menengah Daerah or RPJMD) and the annual work plan (Rencana Kerja Pemerintah Daerah,
RKPD). Each of these plans sets out the government’s policies and programs. In effect, the need to be “synchronised”
allows the bureaucracy to exert authority over what can be financed in the APBD.
The RPJMD drafting process illustrates the authority of the bureaucracy. The five-year plan is one of the most important
policy documents of the district government as it sets out the policy platform for each head of district’s term of
government. Senior officials from district planning agencies said that the drafting of the RPJMD typically commences a
year before the end of the current head of district’s term. Once a new term of government starts, the winning candidate’s
election promises, as set out in the vision-mission statement, is incorporated into the RPJMD.
Apart from incorporating the district head’s vision-mission, senior officials from the planning agencies in all four districts
stated that the draft does not undergo significant change. The detailed list of programs and targets are not amended
significantly as a result of the vision-mission and the bureaucracy drafts the RPJMD. One interviewee in Ngada attributed
the limited impact of the vision-mission to the fact that little substance differentiates the candidates in the direct elections
for local heads (Pilkada). While candidates may use different methods to express themselves, they all have
poverty/economy, education and health as their top three priorities.
Another reason for the bureaucracy’s policy formulation power is because the district head spends very little time working
on policy. One academic interviewed said that he estimates that the district head only spends around 5% of his time
looking at policy and the rest of his time is spent engaged in the politics of governing. Instead, the head of district
exercises his policy power by deciding on what should be funded in the RPJMD, a power that is shared with the DPRD.
The rigid planning and budgeting process and the focus on “synchronisation” also limit external parties’ role in the policy
formulation process. External parties are only afforded two official points in which they can contribute to the planning and
budgeting process, neither of which results in meaningful influence. First, citizens (including NGOs and CBOs) have the
opportunity to voice their aspirations at community planning meetings (Musrenbang), which start at the beginning of the
planning process. Unfortunately Musrenbang have been widely criticised as ineffective because participants do not
believe that their requests are then incorporated into government policy (Purba, 2010).
Additionally, the DPRD has authority over the APBD and has the opportunity to influence policy through the APBD
negotiations with the district head and the district's budgeting team (TAPD). However, with policy details already
established through the planning and budget document drafting process, the DPRD neither has the knowledge nor the
incentive to engage in debate so late in the policy cycle. Interviewees stated that the DPRD does not generally add
programs or activities, but may request changes to specific details of activities such as location, volume or value of budget
allocation.
Findings
11
District governments do not apply the “synchronisation“ principle strictly, particularly if the district head initiates a new
program. For example, during his third year in office the Ngada district head commenced the BOSDA program, which was
not originally included as a program in the RPJMD. The way around this, however, was to list it as an activity under an
existing RPJMD program. The head of the Planning Agency in Ngada also identified activities that emerged in emergency
situations as another circumstance when non-RPJMD programs can be financed by the APBD.
The rigid planning and budgeting process is also a way for the central government to exert authority over districts. The
National Audit Board (BPK) evaluates whether the budget is consistent with the planning documents. The Ministry of
Home Affairs has authority to remove budgetary items if they are not in line with regulation. Moreover, senior officials from
both the district education and health offices admit that their policies are dominated by following national regulations.
In conclusion, the authority of the district head, the technical expertise of the bureaucracy and the rigid planning and
budgeting process are factors that make the district head and the bureaucracy a formidable policy team at district
governments.
IV.4. The DPRD did not drive policy, but wielded significant power through the APBD negotiations
This study found that the DPRD in all four districts surveyed did not play a strong role in the formulation and adoption of
the Jamkesda and BOSDA programs. The research team found that the DPRD rarely engaged in detailed policy debate
with the TAPD and mostly exercised their authority through ensuring that the APBD included “aspirational” projects that
parliamentarians can report back to their constituents. There are three main reasons for why the DPRD are weak policy
actors, despite wielding significant authority over the budget.
First, the DPRD does not believe it has a role to propose programs and policies. One DPRD member, in fact, stated that
proposing programs is the role of the executive; the legislature merely assesses whether the program is appropriate.
Members of the DPRD said they perform three functions: 1) budgeting; 2) legislating; and 3) oversight. DPRD members
reported that budgeting is their top focus, followed by legislating. As mentioned above, interviewees said that the DPRD
uses its budgeting powers for patronage purposes to ensure that funding is allocated to projects in their electorate.
The DPRD also does not use its legislating role to exert greater policy influence as the bureaucracy proposes the majority
of local regulations (Perda). One academic interviewed estimated that the DPRD only proposes 10-15% of Perda. He
asserted that the executive both formulates and implements policies to which he believes the DPRD is merely the rubber
stamp. Consistent with the academic’s observations, interviewees in Ngada could only recall three perda initiated by the
DPRD. In West Lombok, interviewees said there was typically no more than one DPRD-initiated Perda per year.
Moreover, the DPRD’s legislating authority is weakened by the fact that the bureaucracy has authority to pass regulations
without the DPRD’s official sign-off. Except for BOSDA in West Lombok, none of the regulations that underpin Jamkesda
and BOSDA in the four districts needed DPRD approval. These regulations included Bupati regulations (Perbup), mayor
regulations (Perwali), governor regulations (Pergub) and Bupati decrees (SK Bupati).
The DPRD also chooses not to provide substantial input into the policy implementation process, reflecting the low priority
that DPRD members place on the oversight function. DPRD members conduct their monitoring through their field visits
where their constituents may report denial of services at health centres, or parents may report schools for levying fees.
The DPRD then contacts the relevant agency (SKPD) to provide an explanation. SKPDs report that they are generally able
to respond to the DPRD’s requests without needing to change the policy or program.
DPRD members are also unlikely to have the knowledge and capacity to successfully engage in a policy debate with
members of the bureaucracy. As one interviewee from the academic community said the bureaucracy has the data, they
have the authority to execute a budget and they understand the bureaucratic processes (such as the rigid planning and
budgeting processes). This information asymmetry makes the bureaucracy a much more significant policy actor.
DPRD’s lack of capacity is further exacerbated by the high turnover in its membership every election cycle. For instance,
only 14 of the 25 Ngada District DPRD members elected in 2014 were new members. Similarly, reportedly 26 of the 45
members in Malang Municipality and around 40 of the 50 Malang District DPRD members were first timers to the
legislature.4
The DPRD recognises this capacity gap. The NTB Provincial DPRD requested funding to finance an expert staff member
for each member of the legislature, but the Ministry of Home Affairs rejected the request as violating regulations. Whether
expert staff would significantly change the way the DPRD operates remains to be seen. At the provincial level, an expert
staff member has been provided but the DPRD admits they are not a significant part of the decision-making process.
4
12
‘26 Wajah Baru, 19 Wajah Lama,' Malang Times, 24 August 2014; '80 % DPRD Wajah Baru,' Memo Arema, 13 May 2014.
Findings
Third, DPRD members have no incentive to engage in the policy formulation process because they are generally able to
achieve their goals without needing to request policy changes. As mentioned above, one of the core interests of DPRD
members’ in the budgeting process is ensuring that they deliver benefits and projects to their electorates. An interviewee
from the DPRD in NTB Province said that, the DPRD typically does not request that policies or programs undergo any
significant change such as adding new activities. Instead, their interests are largely satisfied by changes to specific details
in the activities such as location, volume or value of budget allocation. Jamkesda, therefore, received strong support from
the DPRD because it aligned perfectly with the DPRD’s interests. For example, officials from the West Lombok Health
Office reported that the DPRD were highly supportive of any programs like Jamkesda that were “pro-community”.
However, the DPRD does engage in the policy debate if a proposed policy is in conflict with a member’s personal interest.
For example, opposition to BOSDA was strong in West Lombok and Ngada because of the presence of members with a
personal interest to promote the status of private schools. In West Lombok, between 25-30% of DPRD members own
private Islamic schools (pesantren) and in Ngada many members have strong links to the private catholic schools.
Private school supporters opposed BOSDA because the program promotes a free education policy, which disadvantages
private schools as they risk becoming less competitive than the state schools as they cannot afford to eliminate fees.
BOSDA opponents thus prefer a policy of free education for the poor whereby assistance is given directly to poor students.
Although opposition to BOSDA is strong in both districts, in Ngada it is funded and expanding. In contrast, in West Lombok
BOSDA has not yet commenced and is unlikely to receive funding in the short-term. The difference between the districts
can be attributed to the position of the district heads. In Ngada, the district head supports a free education policy and
BOSDA is one of his flagship programs. No such support from the district head exists in West Lombok. The NTB Provincial
Education Office said that whether universal free education becomes a priority largely depends on the head of the district.
In the face of opposition from the DPRD, it is the role of the district head and the TAPD to negotiate an agreement. The
main way the executive secures agreement from the DPRD is to co-opt members through providing patronage in return for
passing the overall APBD. Patronage may include agreeing to projects in the electorate of the DPRD members or even
agreement on using specific providers so that the DPRD can receive kickbacks. The DPRD therefore has little incentive to
engage in the policy debate when their interests can be accommodated through patronage agreed upon with the
executive.
In conclusion, the way the DPRD executes its responsibilities, the limited capacity of the DPRD, the information asymmetry
between the DPRD and the bureaucracy are all factors contributing to the DPRD's status as a weak policy actor.
IV.5. The media is influential but their coverage is predominantly case-focused
This study found that the media did not play a strong role in the spread of Jamkesda or BOSDA. This study found that
media at the district level largely did not report on policy but rather focused on showcasing community experiences in
health and education services provided by the government. For example, the media might report on cases of children who
cannot afford to go to school because of the high fees or poor people who cannot afford medicine. Media reportage,
however, is unlikely to include interviews with academics or policy makers to discuss what potential solutions are needed
to overcome these problems. As a result, the media has limited success in influencing government policy.
A DPRD member criticised this case-focused approach as being too focused on one small aspect of a problem, with the
consequence that those held responsible are then judged on that one aspect. The problem with case-based reporting is
that it does not engage with the policy that is the source of the problem and responding to individual cases is relatively
easy if the government can do so without making fundamental policy changes. For example, if the media reports that a
specific school’s facilities are in disrepair, the government can easily address this report by fixing the individual school
without tackling the overall problem of the cost of maintaining school facilities and whether the APBD allocated is
sufficient for this.
Numerous senior government officials from all four districts said that while they investigated media reports and provided
clarifications to journalists, the reports did not influence their policies. One senior government official said that the
policies in the vision-mission go through both a planning and evaluation process, and are held to account in the
Accountability Report (LAKIP). Thus, he argued that it would be naive to think that the government would go outside of this
framework because they were criticised by CSOs and media.
Despite the limited policy influence, the media is very effective in influencing local government behaviour in two ways.
First, the media is powerful in its ability to exert pressure on district governments to expand their provision of services.
This study found pressure from media, coupled with reports from the DPRD and CSOs, may have led to an increase in the
provision of services in instances where the government had already committed to provide the service but had either
under-funded or under-provided. For example, after Malang District significantly under-budgeted for the uptake of its
Findings
13
Jamkesda scheme, an aversion to public controversy through media reports about poor people without access to
healthcare may have been a factor that led the government to expand access to the scheme. Whereas the scheme initially
only included 11,000 participants, the eligibility requirements were changed to any person with a Malang District ID card
and a Surat Penyataan Miskin (SPM) – a letter confirming that the person is poor.
Not unexpectedly, the large number of SPM-holders using Jamkesda resulted in a significant budget overrun for the
Malang district government. As a result, the government changed the process so it became harder to get a SPM. Similarly,
despite the need to control costs, the governor issued a policy that hospitals in East Java needed to operate on the basis
of a “treatment before administration” policy, where even those who are not eligible for Jamkesda would still get
treatment.
When North Lombok Health Office officials attempted to restrict the issuance of SPM letters in order to control its costs,
it faced significant objection from its citizens through complaints to the DPRD members, CSOs and the media. As a result
of this objection, the government backed down on its plan to restrict issuance of SPM letters.
In addition, the media is very effective in spotlighting specific problems in service delivery. Most interviewees said that the
media plays a positive role as it has the power to highlight problems that are not known by the executive and the
legislature. A member of the DPRD suggested that media is only effective when it sustains attention on a particular issue.
For example, she cited the media’s extensive coverage of illegal school fees in Malang municipality was effective in
highlighting the issue to the government.
The media’s focus on reporting individual cases pertaining to service provision limits its ability to influence district
government policy because the government is able to respond to media reports without necessarily changing policy.
Despite this limitation, the media is very powerful and is effective in highlighting problems faced by the community to both
the executive and the legislature and this reporting does exert pressure on district governments to expand the services
provided.
IV.6. CSOs have limited influence and their activities are driven by funding
This study found limited circumstances under which non-governmental entities were effective in their advocacy that
influenced the adoption of BOSDA. Under what circumstances was the advocacy effective?.
First, when a NGO represented a set of constituents who were influential in the community and voters. The Catholic
Schools Association advocated for the position of Catholic schools in the education system in Ngada. They advocated for
private schools to have the same level of government funding as state schools so that there is even competition for
students. The association is a powerful political interest group because they have the ear of the district head and are
politically engaged through having supporters in the DPRD and thus are relatively effective in their advocacy efforts.
A former head of the association spoke out to the media opposing the district head’s independence-day speech calling for
free education. The district head immediately called him in for a meeting to discuss his opposition and while BOSDA was
adopted, the Education Office reported that the district did not have a free education policy. Private Islamic schools
occupy the same position in West Lombok as Catholic schools in NTB, especially as reportedly between 25-30% of all
DPRD members own Islamic schools. This parliamentary representation gives Islamic schools a direct voice in debates on
free education, with a senior District Education Office official saying that those DPRD members who owned schools were
particularly vocal on the issue.
Additionally, in the absence of an influential constituency, advocacy may be effective if it is conducted within a broader
context where such advocacy is aligned with the interests of the district government. For example, according to Pattiro the
adoption of BOSDA in Malang Municipality was a result of a multi-stakeholder campaign involving CSOs, media and the
DPRD. Pattiro asserted that the NGOs in the municipality working as part of a donor-funded program calculated the per
student costs for schools as well as the shortfall in funds after BOS payments. Based on the calculations, they lobbied
both the executive and the legislature to allocate funds to a BOSDA program. Pattiro attributed their success to a
multi-stakeholder campaign and the use of media pressure to maintain attention on the issue. According to Pattiro, they
would make a statement through the media and the mayor would respond and then DPRD. Funds were allocated in the
2010 APBD and the program remains in place, even after a change in mayor in 2014.
While the CSO claimed the effectiveness of their campaign, government officials did not recall any pressure from CSOs or
the media. Instead, interviewees remembered it as the moment when the statements of President Susilo Bambang
Yudhoyono and his ministers promising free education to achieve re-election was the context under which BOSDA was
adopted in Malang Municipality. A possible outcome was that Pattiro and USAID, advocated for BOSDA at a key moment
under which the national context provided an impetus for it to be adopted at the sub-national government level.
14
Findings
Third, donor programs that have strong relationships with the district government may also improve advocacy
effectiveness by facilitating direct discussions between NGOs and the government. For example, an interviewee in West
Lombok asserted that NGOs changed their advocacy approach as a result of working with AIPD. Previously, NGOs lobbied
governments indirectly via media and the DPRD. Through AIPD facilitation, they were able to work directly with the West
Lombok Education Office to achieve quick results including the endorsement of several Bupati regulations (Perbup) on
public service delivery. Although this approach inevitably leads to compromise, district governments are more likely to
accept them because the government has a personal stake in the policy.
CSOs like Pattiro without their own influential constituents are reliant on two main sources of funds. Governments
contract CSOs to deliver services and donor programs contract them for both service provision and to conduct advocacy.
Advocacy by CSOs is thus reliant on donor funding, which is inevitably short-term. Thus, the type of advocacy CSOs
conduct is largely determined by the demands of the donor program. For example, the BOSDA advocacy was part of a
USAID education program. Madewa, the CSO alliance in Malang Municipality, provided support to the Malang district
government in drafting the local regulation (Perda) on health (although it made no mention of Jamkesda advocacy) as part
of a governance program. Madewa claims that this Perda led to an increase in the allocation of funds to the health sector
in the APBD. Interviewees in West Lombok also said that the issues CSOs advocate largely depend on the request from
donors.
Over-reliance on donor funding weakens CSOs as a policy actor in two ways. First, CSOs are unable to build long-term
expertise in one sector. An interviewee from the CSO sector charted his advocacy experience, which had evolved over
more than a decade from peace-building to economic issues, then onto budgeting and now it is public service provision.
Second, once programs end, the main people involved move onto other activities and the advocacy lapses. As an
anecdotal example, the Jaringan Masyarakat Sipil (JMS), a CSO network established as part of DFAT’s ACCESS program,
greatly reduced its activities when the head of the network was elected to the Central Lombok DPRD shortly after ACCESS
funding ceased. Thus, a particular challenge for NGOs is their ability to regenerate once a key person moves on. Moreover,
in the areas where NGOs predominantly work in service provision, the government perceives those organisations as
rent-seekers, not always without justification.
This study found CSOs that represent influential constituents are far more effective in their advocacy. Most CSOs working
with donor programs do not fulfil that condition and must rely on operating in a context under which their advocacy is
aligned with the priorities of the district government. Unless they represent a key interest group, CSOs are also reliant on
donors to fund advocacy activities. This lack of ongoing funding weakens CSOs as a policy actor.
IV.7. Electoral incentives and establishment of norms were factors that motivated reforms,
ideology was not
Why did district governments adopt BOSDA and Jamkesda? What were the motivations for adopting these programs? The
first key motivation is electoral incentives.
Direct elections at both the national and sub-national level created a demand for all candidates to be “pro-people”, that
is, in order to win elections, candidates need to be seen to be working towards fulfilling the needs of the people. The
similarities between different candidates’ election campaign slogans demonstrate this “pro-people” approach was widely
adopted by politicians.
The East Java governor’s campaign slogan was “budgeting for the people” (APBD untuk rakyat); the NTT Governor had
“budgeting for the welfare of the people” (anggaran untuk rakyat menuju sejahtera); the Malang Municipality Mayor,
Anton Abang, used “caring for the ordinary people” (peduli wong cilik); and Marianus Sae, the Ngada Bupati, used
“developing Ngada from the villages” (membangun Ngada dari desa).
The need to be working for the lower classes pressured leaders to create programs where the funds go directly to the
people, or at least in a way that the community obtains tangible benefits. For example, one CSO representative said that
the approach of Marianus Sae, Ngada’s Bupati, was to flood money down to the grass roots (“gelontorkan uang ke
bawah”).
The context of the spread of “pro-people” programs commenced at the national level, where the former President, Susilo
Bambang Yudhoyono, adopted a suite of social protection programs including BOS - assistance to schools to cover
operational costs, JKN – national health insurance, BSM - scholarships for poor students, PNPM - grants to villages
predominantly for village-level infrastructure and PKH – a conditional cash transfer to poor families.
In the health and education sectors, the national BOS and Jamkesmas programs created a public expectation that it was
the responsibility of the government to provide free health and education services, particularly for the poor. In Ngada
District, for instance, as part of the BOS program a banner stating that education is now free was put up in all state
Findings
15
schools. CSO representatives, government officials and DPRD members alike agreed that this banner prompted
expectations from the community that fees would no longer be charged at state schools. However, neither of these
national programs received sufficient funding to realistically achieve that goal. District Governments, particularly the
regional heads, thus saw a genuine need to bridge that funding gap. Responding to this need also resonated with the
DPRD’s need to provide benefits to their constituents. For example, as mentioned above, the promises of free education
made by SBY and his ministers as part of his strategy to win the 2009 presidential elections set the context for Malang
Municipality to adopt BOSDA.
The combination of the need to be “pro-people”, the community’s expectation for free health and education created by
the national government, and the genuine need to bridge funding deficiencies in national programs led to the
establishment of the norm that health and education were important issues for the community (as voters), and that the
provision of quality and free (or cheap) health and education services was a way for the government (regional heads,
bureaucracy and the legislature) to show that it genuinely cared about the welfare of its “ordinary people”.
Thus, the second motivation factor for why district governments adopted BOSDA and Jamkesda was that working towards
providing free or cheap health and education was a ubiquitous demand from the community that all politicians needed to
fulfil (or at least is seen to be working towards).
The ubiquitous nature of health and education in election campaigns demonstrates the establishment of the
aforementioned norm. Numerous interviewees commented that all election candidates’ campaigns incorporate the same
five themes in their vision-mission: economy, health, education, infrastructure and poverty. Many promise quality free
health and education, while others promise quality cheap health and education. In whichever form, these promises are
present in all election campaigns.
Thus, promising quality free or cheap health and education services is no longer relevant to winning elections because
candidates do not differentiate themselves based on their policy platform as everyone campaigns on the same issues.
Free or cheap health and education services is now the accepted practice or norm that all governments must work
towards due to the demand from the community, and this motivates governments to adopt programs (such as BOSDA and
Jamkesda) that contribute towards achieving that goal.
Without electoral incentives and the establishment of norms as motivation, the research team suspects that district
governments would expend less effort to reduce the burden of health and education costs on households. The research
team was very surprised at the level of opposition to the term “free” (gratis) in relation to health and education services.
Bureaucrats and politicians (and former politicians) cited numerous reasons for opposing free education. They argued
that free education disempowers parents and discourages participation; parents who can pay should subsidise those less
able; and that both the government and parents should be responsible for the provision of education.
One senior health official expressed disappointment that members of the community were willing to be categorised as
poor in order access the JKN – national health insurance scheme where the premium is covered by the government when
many of those people have the ability of pay for their own premiums. He suggested that if a person can afford a packet of
cigarettes per day, they could afford to pay for health insurance premiums.
One reason for the opposition to free health and education services could be that none of the districts that the research
team visited adequately funded health and education service providers to genuinely provide fee-free services. Malang
Municipality and West Lombok District schools are prohibited from charging fees for primary and junior secondary
education. A Radar Malang journalist said that as a result of the prohibition, schools had reduced extra-curricular
activities. In Ngada District, for instance, the low budget allocated to JKMN (Ngada’s version of Jamkesda) effectively
meant that patients had to buy their own medicine once the JKMN funds for the year were exhausted, even for items that
should have been covered under JKMN.
A more charitable explanation for the opposition to the word “free” is the belief that governments should not create
expectations of free health and education if they cannot deliver. After all, interviewees expressed almost universal
agreement that those who genuinely cannot pay should receive free health and education services and be subsidised by
those who can pay. The problem with this opinion is that many interviewees also believed that when poverty decreases,
education costs such as scholarships for the poor should also decrease as more people have the means to pay for
education. Moreover, a DPRD member suggested that if the data used to select participants was re-verified and checked,
the number of “poor” would decrease. This view suggests that many believe the government’s role in education and
health is only to pay for those who “really do not have the means”.
The final point on motivation is that ideology is not a motivation for adopting BOSDA and Jamkesda in the four districts
surveyed. This finding is consistent with existing research on social policies in Indonesia.5 In contrast, studies on the
5
16
See, for example, Aspinall (2014).
Findings
replication of conditional cash transfer (CCT) programs in Brazil suggested that governments governed by left-leaning
parties were more likely to adopt CCT programs.
The evidence from this study is that political parties did not hold ideological positions that differentiated them from one
another. Politicians (district heads and DPRD members) do not adopt a position on health and education based on
ideology in any consistent way across a political party. Moreover district heads are frequently not genuine long-standing
cadre. They require parties as electoral vehicles and sometimes switch parties when their initial choice becomes
unviable. For example, the Ngada District head was a non-party aligned businessman before taking over the local PAN (a
political party) branch in 2008 and running for head of district in 2010. Another example is the governor of NTB who was
a PBB (a political party) representative in the national parliament prior to becoming governor and was nominated by PBB
and PKS (another political party) for his first gubernatorial term. When PBB fared poorly in the 2009 legislative elections,
he first sought to move to Golkar and when that move proved unviable he became the provincial head of Demokrat
instead. The West Lombok district head also ran for governor in 2008 on a PPP (another political party) ticket, before
becoming the provincial branch head of Golkar (Kingsley, 2012). The same applies to many DPRD members. One
interviewee said they had chosen PKS, Hanura and Demokrat when first entering into politics, all of which had offered the
now DPRD member to join their party.
When the government needed agreement from the DPRD on its policies, interviewees were consistent in saying that the
DPRD members did not make decisions along party lines. One government official said that while issues were discussed
at the factional level, agreement by a faction does preclude the possibility that individuals within the faction might express
a different view at the DPRD plenary session.
Securing support for BOSDA and Jamkesda was relatively simple because they allowed DPRD members to bring tangible
benefits to their constituents. The one example where there were two distinct positions within the DPRD on a policy issue
resulted from personal interests that crossed party lines. Local officials in West Lombok said that DPRD members who
owned private schools were particularly insistent on their schools receiving funding for teachers, whereas members who
didn’t own schools were not particularly animated by the issue.
In conclusion, direct elections pressured candidates to be “pro-people” and to be seen to be governing for the “ordinary
people”, who remain the most numerous constituency in most Indonesian electorates. An established strategy for building
this “pro-people” image is to deliver social programs such as Jamkesda and BOSDA that provide direct benefits to the
community.
IV.8. Success of outcomes was not important for replication
Related to the idea of motivation and why certain policies are replicated, a key question that this study aims to better
understand is whether success was an important factor that contributed to whether a program was replicated or not
within the Indonesian context. More specifically, what are the indicators for “success”? This study found that success in
achieving outcomes, access to health and education services and improved outcomes were not important considerations
in the decision to adopt Jamkesda and BOSDA.
When assessing whether to adopt Jamkesda and BOSDA, this study found no evidence to suggest that the four district
governments considered whether BOS or Jamkesmas (equivalent national programs) were successful in increasing
access to education and health services or whether education and health outcomes improved. Nor did they assess
whether access and outcomes improved in other Jamkesda and BOSDA districts.
Where data was readily available, district governments did monitor whether access and outcomes had improved. If
improvements were evident, interviewees automatically attributed those improvements to Jamkesda and BOSDA. For
example, interviewees from hospitals in several districts reported that Jamkesda generally results in an increased
demand for health services. Interviewees in Ngada attributed the improvement in the pass rate of its senior high school
students as owing to the success of BOSDA. None of the four districts had conducted evaluations that assessed whether
the improved access and outcomes could be attributed to Jamkesda or BOSDA. Thus, continuation or termination of
BOSDA and Jamkesda programs had little relationship with success in outcomes.
The Jawa Pos Institute’s (JPI) study on the sustainability of its Otonomi Award winning initiatives also found that success
in improving access and outcomes was not an important factor for a program to continue. JPI analysed the reasons behind
why these innovations flourished, wilted or stagnated. The study found that the three top reasons for why an initiative
bloomed was (a) commitment of the head of district; (b) the response from the community; and (c) a stable and conducive
bureaucracy. Conversely, the study also found the five main reasons for why programs terminated was because (a) the
commitment from the bureaucracy decreased; (b) a change in central government regulation; (c) a change in the head of
district; (d) a weak response from the community; or (e) a donor program ended.
Findings
17
In fact, the JPI study did not seem to use achievement of outcomes as an indicator for “success”. The study assessed an
initiative as “blooming” if it had improved in quality or expanded in scope or geography. What the study does not assess
is if achievement of outcomes contributed to the initiative’s blooming status. Moreover, the JPI study did not question
whether the discontinued initiatives may have stopped because they were not effective.
If success of outcomes was not a factor that contributed to a policy maker’s decision to continue a program or policy, what
factors were considered? Specifically, how do programs survive when there has been a change in the head of district? As
mentioned above, the district head is the key decision-maker in the districts surveyed in this study and makes the final
decision on whether a program of a previous government continues.
According to Jawa Pos Institute, vocal demand for a program from the community is the key to it being continued after a
change in government. JPI said that the district head is unlikely to stop a program if it is something the community will
notice if they no longer have access to its benefits. Both Jamkesda and BOSDA fit within this description. As a result, even
if the program is not optimal, it is likely to be continued but perhaps using a different name.
Re-branding a previous government’s program rather than replacing is a tactic many leaders use regularly. President Joko
Widodo, for instance, introduced the Healthy Indonesia Card (KIS) program, which is a renamed version of the
government-funded component of BPJS Kesehatan, which commenced during Yudhoyono’s term. Jokowi needed to
introduce his own signature health program because it was such a key part of the electoral campaign. KIS, however,
merely introduced confusion for those rolling out BPJS and for beneficiaries who did not understand why there are two
programs.
Many interviewees were uncertain whether the current district head’s flagship health and education programs are likely
to continue, should there be a change in leadership in Ngada District after the election in December 2015.6 During his
first term in office, the current District Head introduced a suite of reforms to support the policy of providing free health
and education including BOSDA, Jamkesda, BOKDA (operational support to health facilities) and various scholarship
schemes to support Ngada students to further their tertiary studies.
The district facilitator for AIPD, however, asserted that some forms of these health and education programs are likely to
continue, even if the name changes. If Jamkesda was discontinued, it would certainly affect up to 70,000 participants.
Similarly, schools would face a significant cut in their budgets, which would lead to an increase in school fees. In the face
of the pressure from the community if either of these scenarios occurs, it is unlikely that either BOSDA or Jamkesda will
be discontinued if a change of government takes place.
What is clear, however, is that decisions on the future of BOSDA and Jamkesda will not be based on whether both
programs are actually successful in contributing towards meeting education and health outcomes. The decision will be a
political decision.
IV.9. Fiscal capacity and the head of district’s priorities influence the substance of Jamkesda and
BOSDA
Although both Jamkesda and BOSDA were adopted through a top-down policy diffusion process, there were some key
differences between the districts in the model each district adopted. Overall, two factors influenced the form of the
schemes: fiscal capacity and the district head’s identified priorities.
Fiscal Capacity
Each district’s Jamkesda scheme differed on the number of participants and the unit cost covered by the APBD and both
of these were a function of the fiscal capacity of each district. For instance, despite Malang District’s significantly higher
number of people living below the poverty line, its Jamkesda program only had around 11,000 participants. In contrast,
Malang Municipality’s poor population (based on BPS statistics) is significantly smaller but its Jamkesda scheme has over
32,000 participants. In Ngada District, the number of participants is high at around 70,000, but the district only covers
IDR 7,000 per person, lower than Malang District and Municipality’s unit cost. All three schemes are similar in their
professed benefits (free health clinic treatment and free hospital treatment with a referral from a health clinic), but the
key factor that influenced the number of participants and the unit cost was the fiscal capacity of each district.
6
18
The district head’s term ends in September 2015, but all local elections scheduled for 2015 will be held on a single day in December.
Findings
Head of district’s priority sectors
The sectors the district head identifies as his key priorities, as the main decision-maker on district government policy,
influences the level of funding to Jamkesda and BOSDA programs. While all election candidates name education and
health in their top five priorities, limited fiscal space means that each district can only meaningfully focus on one or two
areas. Health and education do not always feature in a district head’s real priorities.
While Malang District has both BOSDA and Jamkesda schemes, free education and free health is not necessarily a key
priority for the district head. As mentioned earlier when questioned about their free education policies, the District
Education Office’s initial response was that none existed. A close examination of the APBD showed that while the district
had a BOSDA program, it only allocated a budget of IDR 170 million with an additional IDR 80 million from the provincial
government. Similarly, apart from the technocrats in the District Health Office, very few interviewees could recall specific
aspects of the district’s Jamkesda scheme. The scheme was initiated by the provincial government and the district also
only allocated funding for around 11,000 participants representing a very small proportion of the over 200,000 people
recognised as living below the poverty line. Although Jamkesda resulted in a significant budget over-run because of the
number of SKTM (document confirming someone is poor) holders who also received free treatment under the Jamkesda
scheme – these SKTM holders were not part of the budget calculations.
Instead, the district head focused on disadvantaged villages in Malang District. The district head’s signature policy has
been to reduce the number of disadvantaged villages. He claims to have reduced the number from 121 to 16 over the
course of his first term. He has also linked his main populist forum to meet with constituents to discuss the issue of
disadvantaged villages. Each month, the head of district conducts government business from the most disadvantaged
village in a different sub-district and requires all SKPD Heads to stay overnight in the village and conduct rapid impact
programs.
In contrast to Malang District, health and education were both leading priorities for Ngada District. All interviewees could
clearly name all of the head of district’s flagship health and education schemes (JKMN/Jamkesda, BOSDA/BOSDIK,
BOKDA, BSM, outlined in the appended case studies). The government has allocated a significant budget to these
programs (relative to their overall revenue) and the programs are ambitious in their coverage. For instance, the JKMN
aims to cover all remaining Ngada residents who do not have access to some other form of health insurance, estimated
to be around 70,000 residents out of a total population of only 156,180 people (BPS, 2013).
In addition to whether health or education is a priority for the district head, whether they support a free education policy
influences whether a BOSDA scheme is adopted and the level of funding for the program. For example, education is clearly
Malang Municipality’s biggest priority - almost half of its budget is allocated to the education sector. Until 2014, however,
Malang Municipality did not have a free education policy. Instead, the municipality’s affordable education policy allowed
it to focus on quality as the city prides itself as an education centre in Indonesia. The district, therefore, has a BOSDA
program but allocates a relatively small amount of its overall budget to BOSDA. When a new mayor was elected in late
2013, he changed Malang Municipality’s affordable education to free education, and according to the Education Office
increased BOSDA funding to schools.
Thus, whether or not free health and education is a real priority for the district head influences the substance of the
Jamkesda and BOSDA schemes and the level of funding each scheme receive.
IV.10. Political incentives, fiscal capacity, a new district head, new senior bureaucrats and
change in national policies all influenced how BOSDA and Jamkesda changed during
implementation
This study has thus far analysed the various factors that led to the adoption of BOSDA and Jamkesda - processes and
mechanisms, the key policy actors and their motivations; and factors that influence the form of each scheme. A key
question is what happens to these policies after they have been adopted? How do they change during implementation and
what are the factors that influence that change? This study identified five factors that influenced the ways that BOSDA and
Jamkesda schemes changed during implementation: political incentives, fiscal capacity, a new district head, new senior
bureaucrats, and changes in national policy.
Political incentives push the expansion of schemes
There are two sets of incentives for politicians. First, they want to provide the scheme to as many people as possible.
Second, once they provide a service to a recipient, the service cannot be taken away. Both these two factors push
expansion, both scope of the service and the number of recipients receiving the service.
Findings
19
The BOSDA program in Ngada District initially only paid the salaries of honorary teachers at primary and junior high
schools and subsequently expanded to senior high/vocational schools and preschools. The district then changed the
nomenclature from BOSDA to BOSDIK so that it could include higher education. They currently fund scholarships for
Ngada residents to undertake tertiary study and they aspire to start a university.
Most of the Jamkesda schemes this study examined allowed treatment for non-scheme members if they could obtain a
letter stating that they were poor (variously called SKTM, SKM or SPM). Each area that allowed these letters complained
that non-poor were regularly able to obtain them causing cost overruns in the scheme.
They frequently highlighted the way political incentives were causing village officials, charging for issuing the letter in the
first instance, to fail to exclude the spurious claims. These officials were elected by the same people who were requesting
the letters, thus, there was no incentive not to issue them to everyone. Malang District sought to solve this problem by
transferring the responsibility of issuing the letters to midwives. Their advantage was that they were present in villages but
were not elected officials.
The East Java Provincial Government, where there was a cost sharing Jamkesda scheme, complained that the districts
were indiscriminately making province-financed health services available to their residents. As covered in the next
section, their solution was to shift the financial burden onto the districts to counteract this political incentive.
Fiscal capacity pushes governments to restrict access
A consistent feature of these schemes is that they are under-financed. In the case of BOSDA programs it just means the
schools are left with a shortfall and either have to cut services or charge fees. For the Jamkesda schemes the financial
shortfalls have pushed districts to try to restrict the number of people who can access the services. Malang District
changed both the criteria for who would be eligible for the proof of poverty letter and the process for issuing such letters.
The East Java Provincial Government also sought to restrict Jamkesda costs by making districts solely responsible for the
cost of treatment for anyone holding a “proof of poverty” letter issued by the district in question.
Political incentives and fiscal capacity push social programs in opposite directions. For Jamkesda, the result was an
unpredictable pool of recipients that made proper planning for financing impossible.
New head of district can change policy direction
Various interviewees observed that new district heads face an imperative to distinguish themselves from their
predecessors. Even a successful program risks discontinuation if it is too closely associated with the previous incumbent.
This was evident in officials in Ngada District who questioned whether programs such as BOSDA and JKMN (Ngada’s
Jamkesda) would continue beyond the term of the current district head, who faces re-election in December.
By coincidence, only one of the four districts experienced a change in district head during the known lifespan of the
programs this study examined, hence we do not have sufficient data to test for discontinuities. In Malang Municipality,
where a new mayor was elected in 2013, both Jamkesda and BOSDA continued. In fact the mayor sought to distinguish
himself with his predecessor by making education free for all Malang Municipality residents, whereas his predecessor
only made education free for the poor. Anecdotal reports indicate he achieved this outcome as much by cracking down on
fees as by actually adequately financing the shortfalls left by national BOS payments.
In the absence of definitive data, the research team’s hypothesis is that a new district head is unlikely to end Jamkesda
or BOSDA programs unless they can provide a substantially similar benefit to existing recipients. Politicians are likely to be
wary of the cost of taking away services that people have come to see as their entitlement. The Malang Mayor, for
example, is consistent with this hypothesis – the way he sought to distinguish himself was to expand BOSDA, by increasing
the per student allocation, rather than discontinuing it.
New heads of health and education offices can change the substance of the policy
Several senior bureaucrats said once the head of district sets the broad policy direction, it is left to the bureaucrats to
translate that into actual programs. These statements suggest that changes in senior bureaucrats, such as the head of
education and health offices or members of the district budgeting team (TAPD) could substantially change programs.
New appointees could have different ideas of how to achieve the district head’s policy direction. A comment by the Ngada
Head of the Education Office suggested the power of bureaucrats was the form of programs. He claimed to have taken
the decision to discontinue any operational subsidy components of the BOSDA scheme because schools were not
20
Findings
acquitting these subsidies on time. As a consequence, the scheme only covered honorary teachers’ salaries.
Important policy processes may also be stalled because of a change in leadership. For example, the Education Office in
West Lombok attributed the protracted process drafting the education regulation (Perda) was due to the loss of
momentum from the constant changes in the head of the Education Office. Whenever the head of the Education Office
was changed, education regulations were stalled and time was needed to restart the process.
Central government policy shifts forces districts to follow suit
Jamkesda and BOSDA schemes are set up as complementary schemes to national government programs because neither
Jamkesmas nor BOS are sufficiently resourced to achieve the policy outcomes the central government promised. The
explicit status of these local programs as complementary programs makes them vulnerable to any shifts in central
government policy.
The shift from Jamkesmas to BPJS Kesehatan provides a clear example. The BPJS Kesehatan aims to achieve universal
health care to all Indonesians by 2019. Under the BPJS Kesehatan, the central government will pay the premiums of the
poor and near poor Indonesians whereas anyone else is expected to self-finance. The government-funded component,
called Jaminan Kesehatan Nasional (JKN) explicitly provides for sub-national governments to add recipients financed
from sub-national budgets.
On paper there are clear advantages for sub-national governments to integrate their existing Jamkesda schemes into JKN.
It provides greater budgetary certainty – sub-national governments pay a fixed premium for any additional JKN
participants rather than paying the actual cost of their treatment as was the case in all of the Jamkesda schemes this
study examined. Consistent with this advantage, three of the four districts have already integrated their Jamkesda
schemes into JKN or plan to do so.
The exception was Ngada District, where political incentives worked against the district government following the central
government’s policy lead. Ngada was the only district visited in the study where the Jamkesda and BOSDA programs were
attributed solely to the achievement of the Bupati. All interviewees referred to these programs as his flagship programs.
Ngada district refused to integrate its Jaminan Kesehatan Masyarakat Ngada (JKMN) into the JKN. JKMN is an extremely
ambitious program that covers approximately 70,000 Ngada residents for free health clinic care and hospital care.
According to officials from the Health Office, the budget funds allocated to JKMN in the APBD, were based on a unit cost
of IDR 7,000 per person per month, which is much lower than the JKN monthly premium.
Thus, if Ngada district integrated all of its 70,000 JKMN participants into the JKN, the budget would have required almost
three times the current allocation. The other reason integration has not taken place is because it is one of the current
Bupati’s flagship program and he is seeking re-election in December this year. Despite the clear deficiencies in JKMN, the
Bupati needs to claim credit for the string of programs he introduced into the district to promote free health and free
education.
Despite various local actors identifying the advantages of integrating JKN, they said it would not be possible to discontinue
JKMN because of its status as a flagship program. A Health Office senior official stated that if it were to be integrated it
would somehow need to maintain a separate program identify, perhaps as JKMN ‘plus’.
Findings
21
V. Program Implications
The findings from this study have clear policy and program implications for donor programs such as AIPD or its successor.
This section sets out these implications and where relevant, also provides recommendations for the design of future
programs.
1. For widespread replication, work through central and provincial governments
This study found that the most effective way to achieve widespread replication of best practices relatively quickly is
through a top-down process where a higher-level government influences the policies of a lower level government.
Therefore, if a donor program wants widespread replication, it either needs to work with the central government or a
provincial government so that the higher-level government can (a) pressure district governments through their legal
authority or through financial incentives (coercive); or (b) Implement policies that create opportunities for district
governments to “respond” with voluntary co-financing (responsive, as happened with BOSDA and Jamkesda).
The legal authority of the central government is sufficient for district governments to respond without financial incentives.
District governments, however, typically implement provincial government policies only with financial incentives, such as
cost sharing arrangements.
2. District governments need support to improve implementation quality
Several interviewees suggested that the implementation of both BOS and Jamkesmas was much better than their local
government counterpart programs. For instance, interviewees from public hospitals said that the Jamkesda claims
process was convoluted and payments from local governments was far less prompt and certain than those from the
central government. Journalists in Ngada said that the use of BOS funds is more transparent than BOSDA funds.
The poor implementation of largely similar programs suggests that there remains a need to support district governments
in improving the quality of the implementation of national and provincial policies.
3. Integrate evaluations into district practice
This study found that success in achieving outcomes was not an important consideration in a district’s decision to
replicate a policy. A key challenge to evaluating whether a policy contributed towards the achievement of a particular
outcome is the absence of data to make that assessment. Districts do not typically conduct rigorous program evaluations
that assess whether any changes in outcome indicators can be attributed to the existence of a particular policy. Instead,
district governments assume that improvements in outcome indicators are attributed to the policy change.
Donor programs can play a role in integrating evaluations into district government practice by demonstrating the benefits
of using more rigorous evaluations. Ultimately, if district governments do not conduct meaningful policy evaluations,
replication of policies because they contribute to successfully achieving outcomes is unlikely to happen. Conducting policy
and programmatic evaluations is crucial if district governments are to move towards a more evidence-based policy
approach.
Entering into the evaluation sphere does pose two main risks for donor programs, both related to sustainability. First,
sustainability may be undermined by the fact that the likelihood of APBD funding being made available to conduct
evaluations remains small, particularly in the short term. Thus, once donor funding ends, there is a strong likelihood that
evaluations may discontinue due to lack of funds.Second, district governments are more likely to continue conducting
evaluations after a donor program ends if they can see a tangible benefit from those evaluations. Using the results from
an evaluation to win further funding is potentially one such benefit. At the Australasia Evaluation Conference 2014, one
of the speakers spoke of how her evaluations were used, and focused particularly on how she successfully found
evaluation ‘champions’ because her results were used to win further funding. Unfortunately, one of the key findings from
AIPD’s evidence-based policy study was that district governments do not believe that funding proposals are assessed on
merit (provision of evidence and justification) but are assessed solely based on political considerations. If the availability
of evaluations does not create tangible benefits (funding, recognition), it is unlikely to be used and maintained.
Although supporting district governments to integrate evaluations into their practices poses risks, it remains a worthy task.
Without data and analysis for measuring whether policies contribute towards outcomes, or whether a program contributes
to the achievement of outcomes is never going to be a consideration in deciding whether to continue a policy/program.
22
Program Implications
4. Anticipate the next wave of populism
Establishment of norms is the golden standard for replication, thus it is important to anticipate the next wave of populism.
Programs that are aligned with district head’s populist attempts are more likely to be adopted and replicated. Heads of
Districts tend to copy each other’s tactics to become populist leaders. Increasing spending to expand access to basic
government services has typified the current wave of populism. As free or affordable health and education programs have
become standard and expanded access to services and service utilisation, it is possible the next wave of populist policies
will involve visible measures to increase the quality of health and education services. Scholars highlight poor quality as a
persistent feature of these sectors (e.g. see Aspinall and Warburton, 2013).
5. Policies that offer community tangible benefits are more likely to endure
A key finding from this study is that once a service is provided to the community and citizens feel entitled to that service,
governments find it politically impossible to then take that service away. Therefore, policies and programs that provide a
tangible benefit to the community are more likely to be sustained after a change in leadership, even if they are
re-branded.
6. Policies that are not “populist” are more likely to endure if there is top-down pressure to maintain that policy
Many donor programs promote policies that are not necessarily going to be “populist” policies, in that they do not
necessarily provide tangible, direct benefits to the community. For instance, policies that improve public financial
processes are generally invisible to communities.
Policies that are not “populist” are more likely to endure if there is external pressure (such as pressure from the central
government) to maintain those policies. Donor programs working on policies with a more process or administrative
orientation, for instance, they are recommended to achieve replication through a top-down process using a “coercive”
policy diffusion mechanism tend to be more endurable. When there are changes in the head of district or senior positions
in the bureaucracy, these policies are more likely to be maintained because of pressure from the central government. For
instance, district governments are less likely to discontinue a policy if they risk being reprimanded by the Ministry of Home
Affairs or receiving a negative finding from the National Audit Board (BPK).
The limitation of the “coercive” mechanism, however, is that district governments are selective in which central
government policies they will follow, particularly if a policy is not aligned with the districts’ interests. The West Lombok
government’s resistance to adopting BOSDA despite central government regulation that basic education must be fee-free
is an example of the limitation of central government regulation. Regardless of central government policy, universal free
education was not aligned with the interests of the key policy actors in the district and is unlikely to be adopted until there
has been a change in those district actors.
7. Donor program support should follow an electoral Pilkada and RPJMD cycle
Donor programs should, where possible, align their support so that it commences at the start of the RPJMD drafting
process (approximately one year before the Pilkada) and continues until at least the final year of the government’s
five-year term (around five to six years).
There are two main reasons for the importance of alignment to the electoral and RPJMD timeframes. First, the RPJMD
remains the key policy document that sets out the district’s agenda for the head of district’s entire term of government.
Being part of the RPJMD drafting process is a key opportunity for the donor program to influence the district government’s
policy direction for the next five years. The drafting process is also an ideal opportunity to engage with multiple SKPDs and
not just one counterpart. Second, donor programs are likely to experience more stability in government personnel, which
makes engagement easier. Senior positions in government (for instance the head of the Education or Health Offices) are
semi-political positions occupied by the district head’s own appointees. Changes to leadership positions generally take
place at the beginning of a district head’s term. Constantly changing leaders in the bureaucracy is one of the main
disruptions donor programs face and aligning donor support with the electoral cycle reduces that disruption.
8. In improving planning and budgeting processes, focus on substance not just compliance.
Donor programs should consider pairing activities/programs that influence the policy process with programs/activities
that influence the substance of policies. AIPD has mostly focused on the former, probably by design, but it does not exert
strong influence on the substance of policies. For instance, a follow-up AIPD program may consider not just supporting the
Program Implications
23
RPJMD drafting process but try to exert greater influence on the substance of the policies and programs in the RPJMD in
strategic sectors, given the fact that the RPJMD is the key opportunity for introducing significant reforms.
Determining which RPJMD programs are financed is a function of the head of the district’s priorities and the APBD
process, thus, AIPD could also consider providing support that influences the substance of the annual plans and annual
budgets to supplement the technical support to improve the process of drafting annual planning and budgeting
documents.
9. DPRD is a minefield – proceed with more knowledge and caution
This study found that the DPRD does not regularly engage in policy debates unless personal interests are at risk. Thus,
although the DPRD holds budgetary power, it is a weak policy actor and prefers to engage in rent seeking. How can donor
programs encourage the DPRD to engage more with policy substance? Overall, this study found that little is known about
the operations of the DPRD. Who are the powerful figures? What are the potential incentives for engaging with policy?
Scholarly literature provides several theories to explain why the DPRD is weak on policy. Some scholars outline the
weakness of Indonesian political parties, particularly at the sub-national level, with personal networks more important to
local politicians than their affiliations with political parties (Tomsa, 2014; Aspinall, 2014b) Certainly, almost all
interviewees (DPRD, bureaucracy, CSO, media) said that the DPRD did not operate along party or fraction lines. Budget
discussions occur at three levels: at the banggar (Budget Board), the fraksi (factions) and the komisi (commissions
responsible for a specific sector). According to interviewees, gaining the agreement of the leadership group from the
banggar, fraksi and komisi is the key for getting laws passed at the DPRD.
Others argue that unless electoral laws are reformed, DPRD members will continue to rent-seek as they need to recoup
the costs of running for office (Aspinall, 2014b). Certainly many interviewees highlighted that the DPRD was most
concerned with gaining access to projects. An academic stated that the DPRD used budget negotiations to gain access to
projects and kickbacks. A DPRD interviewee asserted that members have their own patronage activities approved in
return for agreeing to the district head’s policies. With only their five-year term to extract rents, he said they typically did
not oppose policies. Many interviewees expressed that in order to get re-elected, legislators need to demonstrate to their
constituents that they have brought benefits to the community such as roads, schools and sanitation units. These are all
strong incentives for rent seeking that are difficult to overcome.
Another theory is that DPRD members do not engage with policy because they have limited knowledge and capacity in
matching the bureaucracy in discussions of substance. There are two challenges to capacity building. First, it is far from
certain that increasing capacity overcomes the rent-seeking, which in turn prompts DPRD members not to oppose
policies. Second, is the issue of whether DPRD members would admit to needing capacity building. One former DPRD
member said his district was a small place and although everyone knew who was more or less capable, no one would ever
be caught admitting they lacked capacity. Program staff also highlighted the extensive incentives they had to attach to
capacity building to ensure DPRD members would take part. Staff indicated the DPRD often demanded that the training
had to be held in Jakarta, for example. The need to provide these incentives draws into question whether DPRD members
are genuinely interested.
While there is space for DPRD to improve their performance through capacity building, little is known about the internal
operations of the DPRD to understand whether increasing capacity would overcome rent seeking incentives. Donor
programs should therefore exercise caution when working with the DPRD. More research is needed to better understand
the DPRD and why they do not meaningfully engage in the policy process. Who are the key actors? Why are parties so
ill-disciplined? Is rent seeking mutually exclusive to engaging in policy substance? Who influences DPRD
decision-making? This study recommends that donor programs seek answers to some of these key questions before
engaging too intensively with the DPRD.
10. Governments do listen to the media but donors need to be aware of limitations
Donor programs need to be aware of both the power and limitation of the media in order to effectively use it as an
advocacy tool. Overall, the media exerts considerable influence on the government. When the media reports cases of poor
services such as the poor physical condition of schools or when poor people are refused free health treatment, the
government responds relatively quickly. The media’s case-focus reporting means it is an effective medium to advocate for
an expansion of services through its ability to both highlight problems and reward positive developments.
Conversely, media coverage in the districts where AIPD is present typically does not engage in policy debates and is
unlikely to do so in the near future. A potential disincentive for the media to not engage in policy debate is that cases of
good and bad experiences with government services are far more newsworthy than policy debates, particularly in areas
24
Program Implications
where there are few media outlets (such as Ngada).
Where national papers such as Kompas and Tempo publish opinion pieces from academics, current and former public
servants on policy issues on a daily basis, regional newspapers often do not have an opinion page. According to its
editor-in chief, Radar Malang7 does not publish opinion pieces from external writers.
Moreover, the influence of the media is not even across all districts. Districts that are either an urban centre or are close
to an urban centre, such as Malang Municipality and District, have a strong media landscape. As one of its journalists
asserted, Radar Malang has the largest circulation in the area; the heads of district read it every day and the government
always provides a response to problems the newspaper highlights. The media landscape in Ngada District, however, is
very sparse. The only mainstream journalists are correspondents for island wide (Flores Pos) or province wide newspapers
(Pos Kupang) where Ngada is likely to only occupy one section of the paper. Although there is now a smattering of new
community-based newspapers, they only publish every two weeks and have a very small distribution. The journalists in
Ngada themselves admitted that the community do not often report government service issues to them directly, although
it was increasing because of improvements in communication. Thus, the weak media presence in more rural settings such
as Ngada limits the influence of the media.
11. Lack of a long-term funding mechanism weakens CSOs as a policy actor
This study found that CSOs can be effective in advocacy at the district level in two circumstances: (a) if the CSO represents
an influential set of constituents (religious schools); or (b) if advocacy is conducted in a context where the advocacy is
aligned with the interests of the government.
District-level CSOs lack of long-term funding options weakens their effectiveness as a policy actor. This study found that
CSOs have two main sources of funding, donors and the government. Typically, the government finances CSOs to deliver
services whereas donors finance both the delivery of services and policy advocacy. As a result, policy advocacy conducted
by CSOs typically follows the priorities set by the donors and funding is rarely long-term. In order to attract funding, CSOs
regularly shift their advocacy focus to suit the needs of donor programs.
Limited long term funding mechanisms weaken CSOs as a policy actor for several reasons. First, the constant shifting of
advocacy focus means that it is hard for CSOs to build strong capacity in one area. As a result, the technical capacity of
CSOs may limit their influence. Second, the lack of long term funding limits CSOs’ ability to recruit and maintain
experienced staff, and third, it also makes them reliant on government funding, which may discourage them from
criticising the government as their focus is on winning government projects.
The focus on service provision also means that the capacity of CSOs to implement advocacy activities is uneven across
districts. Most areas where donor programs are likely to operate are actually unlikely to have a national-level CSO like
Pattiro with existing capacity and connections to conduct advocacy. In Ngada District, for instance, interviewees said that
local CSOs mostly focused on service provision. The focus on service provision was also a trend of CSOs in the AIPD
districts: Trenggalek; Sampang; North Lombok; Keerom; and Merauke, the areas visited by the researchers as part of
another study.
7
Radar Malang is the Malang Raya area’s largest newspaper and is part of the Jawa Pos group.
Program Implications
25
Case study 1: Malang District
Malang District adopted the Jamkesda in 2009 and commenced operations in 2010. Conflicting information exists on
whether the district adopted BOSDA in 2008 or 2011. This case study sets out the political, socio-economi and political
contexts under which the district adopted these two programs (see Sections A, B and C). Moreover, the case study
explains how and why Jamkesda and BOSDA spread to Malang District (Sections D and E).
A. POLITICAL CONTEXT
Malang District is led by Rendra Kresna, a first term district head elected in 2010 (his deputy is Achmad Subhan) with 62%
of the vote, after he was deputy district head from 2005-2010. Kresna is a career politician, having been a DPRD member
for six years from 1999-2005 prior to his election to an executive position.8 At the time of his election, Kresna was the
head of the district Golkar9 branch nominated by the Golkar and Demokrat parties (Department of Home Affairs –
Directorate General for Regional Autonomy data on local government elections).
Upon his inauguration, he announced three priority areas of government: infrastructure, health, and staff personnel.10
Once in office, however, free health and education policies have not been an important part of Kresna's program. This may
reflect that free health and education are not a policy priority for him but it may also reflect that Jamkesda and possibly
BOSDA commenced before he took office. Although both programs continued, neither received much attention from
Kresna.
Instead, his signature policy has been to reduce the number of disadvantaged villages, which he claims to have reduced
from 121 to 16 during his term of government.11 His main populist mechanism to interact with voters is directly linked to
this focus on disadvantaged villages, as he stays overnight and conducts government business from a disadvantaged
village in each of Malang's sub-districts once a month, in what he calls the "bina desa" (fostering the village) visits.12
Kresna's re-election prospects in December 2015 are unclear. Golkar experienced a noticeable increase in support in the
DPRD following his election, increasing its share of Malang District's 50 seat legislature from 8 seats in 2009 to 12 in
2014, second behind PDI-P who won 13 seats on each occasion.13 Golkar’s surge in the DPRD elections may reflect
Kresna’s popularity. Conversely, PDI-P maintains a strong political base in East Java and will provide strong competition in
the forthcoming local government elections (Pilkada).
B. SOCIO-ECONOMIC CONTEXT
Compared to other districts in East Java, Malang District has a moderate level of development. Owing to its large
population, it has one of the highest numbers of people living below the poverty line (272 500 in 2012), but the proportion
of people living below the poverty line, at 11%, is lower than the provincial average. At 71.17, the district’s human
development level is slightly lower than the provincial average and ranked 21st out of 38 districts in East Java. Reflecting
the moderate level of development, per capita household expenditure is slightly lower than the provincial average, while
the per capita household expenditure for the poorest 20% of households is slightly higher than the provincial average.
8
'Baru Dilantik, Bupati Malang Siap Tancap Gas', Tempo, 26 October 2010.
9
'Kepala SKPD Kabupaten Malang Harus Bisa "Mengaji"', Antara, 25 October.
10
'Baru Dilantik, Bupati Malang Siap Tancap Gas', Tempo, 26 October 2010.
11
‘Ada 16 Desa Tertinggal di Malang’, Sinarharapan.co, 21 October 2014.
12
Kresna announced these visits in late 2011. See 'Bupati Malang "Ngantor" Di Rumah Warga', Antara, 22 December 2011.
13
DPRD statistics drawn from "Jumlah Kursi DPR-RI - DPRD di Dapil JATIM V Malang & Membaca Peta Terbaru Kekuatan Parpol & Caleg di Malang
Raya", malangjurnal.com, 16 January 2014; "Ini Perolehan Kursi Partai di DPRD Kabupaten Malang Yang Ditetapkan KPU", Surya Online, 12 May
2014.
26
Case study 1: Malang District
Table 1: Summary of key district indicators, 2012
Malang District
Poverty Rate (%)
East Java Province
11% (25/38)
13.4%
272,500 people (2/38)
5,071,000
71.17 (21/38)
72.18
Household per Capita Expenditure
IDR 476,927 (21/38)
IDR 524,226
Household per Capita Expenditure (poorest 20%)
IDR 224,890 (18/38)
IDR 217,547
Number of People Living Below the Poverty Line
Human Development Index
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
In terms of health outcomes, however, Malang District performs moderately compared to other East Java Districts. It is
ranked 13th out of 38 districts for immunization coverage for children under 5 years old, 20th for morbidity rate and 29th
for births attended by skilled health workers. In terms of health infrastructure, it has a small number of facilities for its
population, generally also ranking in the bottom half for the province.
Table 2: Summary of health indicators, Malang District
Malang District
East Java Province
Immunization Coverage for Children under 5 Years (in %
of the population of children under 5 years old) (2011)
81.46% (13/38)
78.84%
Morbidity Rate (2011)
27.76% (20/38)
27.2%
Births Attended by a Skilled Health Worker (in % of total
birth) (2012)
92.54% (29/38)
93.13%
Number of Doctors per 100,000 People (2011)
9.79 (25/38)
17.86
Number of Midwives per 100,000 People (2011)
29.45 (31/38)
36.62
Number of Hospitals per 100,000 People (2011)
0.61 (21/38)
0.73
Number of Polindes (Village Maternity Posts) per
100,000 People (2011)
10.92 (24/38)
13
5.26 (35/38)
8.42
Number of Puskesmas (Community Health Centre) and
its network per 100,000 People (2011)
Source: BPS (2011 and 2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang District has a moderate literacy rate. At 90.73%, it is higher than the East Java average, and is ranked 21st of 38
districts. In terms of schools performance, Malang District has relatively good net enrolment rates at primary (SD) and
junior secondary (SMP) school levels. The net enrolment rate at senior secondary school (SMA and SMK) is one of the
lowest in the province.
Table 3: Summary of key education indicators, Malang District, 2012
Malang District
Literacy Rate for Population Aged 15 and Over (in % of
total population)
Net Enrolment Ratio: Primary Level (SD)
Net Enrolment Ratio: Junior Secondary Level (SMP)
Net Enrolment Ratio: Senior Secondary Level (SMA/SMK)
East Java Province
90.73% (21/38)
89.28%
96.25% (1/38)
92.92%
73.21% (25/38)
74.52%
43% (30/38)
52.12%
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Case study 1: Malang District
27
Malang District has a moderate level of socio-economic development in comparison to other districts in East Java. On
most indicators including household expenditure, poverty and human development, health and education, it is ranked in
the middle of the 38 districts in East Java.
C. FISCAL CONTEXT
Total nominal revenue for Malang District increased significantly from IDR 949 billion in 2007 to IDR 2.13 billion in 2009.
In 2010, revenue decreased and only returned to the 2009 levels in 2012 where total revenue was IDR 2.2 billion. The
2009 revenue was abnormally high which could be due to a sale of assets.
Figure 1: Revenue has increased significantly 2007-2012
Source: SIKD data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Although 63% of Malang District’s funds are sourced from the General Allocation Grant (DAU) and the Special Allocation
Grant (DAK), the district’s reliance on inter-governmental transfers from the central government has decreased
significantly since 2007 when 93% of its revenue was DAU.
Figure 2: Since 2007, Malang District has become far less reliant on DAU and DAK
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
28
Case study 1: Malang District
The proportion of total revenue derived from “other revenue” has increased significantly since 2007. It now represents IDR
474 billion or 21% of total revenue for the district. Other revenue consists of grants, emergency funds, shared taxes from
provincial or other district governments, and assistance funds from provincial and/or other district governments. “Other
revenue” also includes proceeds from asset sales.
Since 2007, the proportion of total revenue derived from own-source revenue (PAD) has increased slightly from 7% of the
total revenue in 2007 to 9% of the total revenue in 2012. In nominal terms, PAD increased from IDR 67 billion in 2007 to
IDR 197 billion in 2012. Increasing PAD is particularly important to districts because this source of funds is not earmarked
and the districts are free to allocate these funds to local priorities. Such a small increase in over six years implies that the
fiscal space available for Malang District to allocate to its own priorities has not increased significantly.
Malang District also has one of the lowest per capita revenues in East Java. It has the second lowest per capita total
revenue, and is ranked in the bottom half for all types of revenue. Overall, fiscal capacity of Malang District is relatively
low, particularly when the district has a large poor population.
Table 4: Malang district has one of the lowest per capita revenues in East Java
2012 Revenue
Per Capita General Allocation Grant (DAU)
Per Capita Natural Resource Revenue Sharing (DBH SDA)
Malang District
IDR 514,521 (35/38)
East Java Average
IDR 721,115
IDR 22,401 (13/38)
IDR 38,439
IDR 190,174 (32/38)
IDR 253,030
Per Capita Own Source Revenue (PAD)
IDR 79,191 (35/38)
IDR 19,0828
Per Capita Special Allocation Grant (DAK)
IDR 47,468 (28/38)
IDR 56,967
Per Capita Tax Revenue Sharing (DBH tax)
IDR 36,854 (37/38)
IDR 74,806
IDR 890,610 (37/38)
IDR 1,335,183
Per Capita Other Revenue
Per Capita Total Revenue
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Total nominal expenditure (APBD) for Malang District has more than doubled from IDR 1 trillion in 2007 to IDR 2.2 trillion
in 2012. Expenditure experienced a massive increase in 2008, but since 2010, the growth rate has steadied to around
15% per year.
Figure 3: Malang District’s total expenditure has been increasing consistently
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
The pattern of spending under the current District Head, Rendra Kresna has experienced some changes. A comparison of
the expenditure pattern in 2010 under the previous district head with the expenditure in 2012 under Kresna showed that
he significantly increased infrastructure and health spending while maintaining (even increasing slightly) funding for
general administration and education.
Case study 1: Malang District
29
Between 2010-2012, nominal infrastructure expenditure increased by IDR 326 billion (1119%) while health expenditure
increased by IDR 139 billion (245%) The increase in infrastructure and health reflects his identified priorities. Health and
infrastructure spending fluctuates significantly from year-to-year. The abnormally large increase in infrastructure and
health spending from 2010-2012 may also be due to data error or to a sudden change in classification of expenditure
function.
Figure 4: Health and infrastructure spending increased significantly under a new district head
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Health expenditure increased significantly in 2012, the first budget year under the current district head. Kresna was
inaugurated in November 2010, so was not involved in the 2011 budget. Despite the significant nominal increase,
however, health expenditure still only represents 9% of total expenditure.
Figure 5: Health expenditure increased significantly in 2012
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang District’s per capita health expenditure is the lowest in East Java Province. At only IDR 78,604, it is only 55% of
the provincial average per capita spent by district governments on health. Conversely, monthly per capita household
30
Case study 1: Malang District
health expenditure in Malang District, at IDR 28,513 per household, is one of the highest in East Java and is significantly
higher than the provincial average of IDR 19,750 per household.
Table 5: Per capita health expenditure in Malang District, 2012
Malang District
Per Capita APBD Health Expenditure
Monthly Per Capita Household Health Expenditure (in IDR)
East Java Province
IDR 78,604 (38/38)
IDR 148,405
IDR 28,513 (6/38)
IDR 19,750
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
In contrast to health, the proportion of total expenditure spent on education has not changed significantly under Rendra
Kresna. In nominal terms, from 2010-2012, education expenditure increased by IDR 229 billion (or 44%).
Figure 6: The proportion of total APBD spent on education has not changed significantly
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang District has one of the lowest per capita education expenditure in East Java. In 2012, the district spent IDR
298,601 per person, which is significantly lower than the provincial average of IDR 545,049. The per capita education
spending from the APBD is in fact lower than the average household education expenditure. On average, per households
in Malang District spend IDR 32,658 per month/per person or IDR 391,896 per annum/per person.
Table 6: Per capita education expenditure in Malang District, 2012
IDR
Annual Per Capita Education Expenditure (IDR)
Monthly Per Capita Household Education Expenditure (in IDR)
IDR
298,601 (37/38)
545,049
32,658 (12/38)
33,239
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang District is a district with relatively low fiscal resources, with a large poor population. As a result, its resources are
spread quite thinly as reflected by the low per capita health and education spending.
Case study 1: Malang District
31
D. JAMKESDA IN MALANG DISTRICT
Jamkesda was implemented in a district with relatively low fiscal resources, a large poor population and poor health
outcomes compared to other districts in East Java. The current district head, elected in 2010, has increased the health
expenditure significantly reflecting what numerous interviewees said was his top priority. Despite the significant increase
in health funding, the proportion of total expenditure spent on health is still only 9%. Moreover, the research team found
that knowledge on the Jamkesda scheme was low perhaps reflecting the fact it was a provincial government program and
adopted prior to Rendra Kresna taking office, thus was potentially not a strong priority for the district head.
1. Description of Jamkesda in Malang District
Form of scheme: This scheme covers the cost of health treatment for recipients, who are required to first seek treatment
at a community health clinic. If the health clinic lacks the resources or a recipient's health requires more specialised
treatment, the health clinic can refer them to a district hospital, which can in turn refer them to a provincial hospital if
needed. Service providers (health clinics and hospitals) invoice the district and provincial governments for the treatment
they provide to Jamkesda patients.
Initiating Actor: The former head of the Malang District Health Office attributed the provincial scheme to East Java’s
Governor, Soekarwo, who was elected in 2008 based on the pledge of spending the "Regional Budget for the People". In
fact, Soekarwo's predecessor, Imam Utomo, initiated the scheme, but it only commenced operation under Soekarwo. In
Malang district, the former district head, Sujud Pribadi signed the original MoU in 2009, but the first ten months of
Jamkesda's operation have taken place under the current Head of District Rendra Kresna. All interviewees, however,
recognised the scheme as initiated by the province. One respondent recounted that the governor had threatened to
expose any Bupati reluctant to sign on to the press with the claim that they did not want to help their people.
Recipients: The scheme targets poor residents of East Java who are not covered by the national health insurance
scheme, namely Jamkesmas, replaced in 2014 by BPJS Kesehatan where participants whose premiums are paid by the
government are part of the Jaminan Kesehatan Nasional (JKN) scheme. Each district and municipality was responsible
for nominating the number of its residents who would be covered by the scheme. Malang District nominated 11,000, and
around 6000 Malang residents still hold Jamkesda cards. Non-members can also obtain free treatment by obtaining a
SKTM, a letter proving the resident’s poverty status, from local authorities. The number of people receiving treatment
using a SKTM greatly exceeded the number of Jamkesda card holders receiving treatment in the early years of the
scheme's operation.
Legal Basis and Implementing Body: The scheme is ultimately governed by East Java Local Regulation no 4/2008 on A
Regional Health Guarantee System in East Java, promulgated by the former Governor Imam Utomo. Several governor
regulations provide the implementing instructions. The cost sharing arrangement between the province and districts is
governed by an annual MoU, the first of which was concluded in 2009. At the provincial level, Local Regulation no 4/2008
establishes an implementing agency for the scheme, called Badan Pelaksana Jaminan Kesehatan Daerah (BPJKD).
BPJKD's primary role is to verify claims to be paid under the scheme. There is no specific implementing agency in Malang
District; instead the District Health Office administers the scheme, with treatment provided by health clinics (Puskesmas)
and hospitals.
Duration: Jamkesda commenced operation in Malang in 2010. In 2016, provincial cost-sharing will cease, and Jamkesda
will be integrated into the national JKN program, with Malang District paying the JKN premiums for Jamkesda participants.
Once integrated into JKN, Jamkesda participants will be called PBID (recipients of regionally-funded premiums).
Funding: The MoU between the province and district essentially establishes 50-50 cost-sharing. Malang initially allocated
IDR 3.9 billion to the scheme in its first year of operation in 2010. This allocation was insufficient, and the district and
provincial governments rapidly incurred significant debts for hospital treatment. In 2012, the provincial-run Saiful Anwar
Hospital in Malang began to refuse treatment for Jamkesda patients, owing to this outstanding debt, and hospital
treatment under the scheme was restricted to Malang's two district-level hospitals. The provincial government also
ceased cost-sharing for patients obtaining treatment using a SKTM as of late 2012, decreeing that districts would be
solely responsible to cover the cost of treatment to anyone they provided with a SKTM.
District authorities attributed the funding overrun to non-poor residents obtaining SKTM to access free treatment when
sick. It is not clear that any systematic effort was made to verify claims that SKTM recipients were not poor - lists of small
numbers of SKTM holders who were subject to an eligibility audit seen by the authors showed around 10 percent to be
non-poor.
Two other explanations for cost overrun are also plausible. First, districts appear to have budgeted only for Jamkesda card
holders, meaning SKTM holders would have caused cost overruns irrespective of whether they met eligibility requirements
or not. Second, the scheme envisaged health clinics playing a gatekeeper role to control the cost of the scheme. Given the
32
Case study 1: Malang District
large bill incurred at the provincial hospital, they may not have played this role.
2. How did Jamkesda spread to Malang District?
Agents: Who pushed for the adoption of Jamkesda?
Four parties were identified as pivotal to the adoption of the Jamkesda scheme in Malang District:
1. Central government: Multiple respondents from the Health Office reported that the Jamkesda was initiated as a
response to the central government’s Jamkesmas scheme. The Jamkesmas, which commenced in 2007, provided
health insurance coverage for poor and near poor people in Malang District. The district government said that
inaccurate targeting meant that the Jamkesda’s coverage was insufficient to cover all those who consider
themselves ‘poor’ and as a result, additional funding was required to supplement the Jamkesmas scheme. The
Jamkesda scheme was designed to provide access to free health services to residents who the district identified as
having met Jamkesmas criteria but were not Jamkesmas recipients.
2. Provincial government: although a response to a perceived gap in the central government’s Jamkesmas scheme,
the Jamkesda scheme was a provincial government initiative, where the Governor enticed the districts to adopt the
scheme with a combination of financial incentive (50-50 cost sharing) and through a threat from Governor
Soekarwo that if the district did not adopt Jamkesda, he would inform the press that the district head concerned
did not want to help their people.
3. District head: the Jamkesda scheme is governed by an agreement between the district government and the
provincial government. Thus, the district head’s agreement to adopt the Jamkesda program is vital to both its
commencement and continued implementation even once the cost-sharing ceased.
4. Bureaucracy: although the decision to adopt the Jamkesda is one made by the district head, the bureaucracy has
overall responsibility for both integrating it into the planning and budget process, including identifying the availability
of funds to allocate to the Jamkesda scheme. It is also responsible for the implementation of the scheme.
The DPRD, CSO and media all played differing roles in the policy diffusion process, but none could be considered to be key
agents.
• DPRD: the DPRD only had very limited involvement in the adoption of the Jamkesda for several reasons. First,
DPRD approval was not needed to provide a legal basis for the program, as the program was regulated through a
governor’s regulation. Second, the main way for the DPRD to influence policy is through the budget (APBD), which
needs DPRD approval. The provision of health insurance for the poor is a populist policy that had broad support
within the DPRD. Health Office staff reported that feedback from the DPRD was to allocate more funds, rather than
any opposition to the policy. Third, the DPRD did not have sufficient technical capacity or the resources to acquire
technical expertise, to properly assess whether the policy was appropriate for Malang District.
• CSO: According to the Malang District government staff, there was no pressure from civil society to provide health
insurance. The Malang CSO alliance, Madewa, had provided technical support to the government in drafting the
local regulation (Perda) on Health. According to Madewa, this health perda was then used as a basis for increasing
health funding.
• Media: no interviewees indicated that media played any role in pressuring the local government to adopt a
Jamkesda scheme.
What processes and mechanisms led to the adoption of the Jamkesda scheme?
There were three processes and mechanisms for the adoption of Jamkesda in Malang District:
1. Top-down/coercive: The dominant policy diffusion process was a top-down process using a coercive mechanism.
The provincial government convinced district governments to join the Jamkesda scheme through both a 50-50 cost
sharing, and the threat made by the East Java Governor to expose each district’s head of district should they decide
not to join in the Jamkesda program.
2. Top-down/responsive: there was also evidence of a top-down process using a responsive mechanism. One of the
reasons for the acceptance of the Jamkesda schemes was the recognition that the national Jamkesmas could not
cover all citizens that needed health insurance. Thus, staff from the District Health Office identified that those who
received Jamkesmas would not receive Jamkesda. Thus, the central government became both a source of policy
ideas (health insurance) as well as a party that generated demand for health insurance.
Case study 1: Malang District
33
3. Horizontal/learning: during the design and implementation of the Jamkesda scheme, the provincial government
had visited South Sulawesi, South Sumatra and West Java Provinces.14
Motivation: Why was Jamkesda adopted?
There were two motivations for the adoption of the Jamkesda scheme:
1. Electoral incentive: it was clear that electoral incentive was a key factor in the introduction of the Jamkesda
scheme in East Java. Although the process for introducing Jamkesda started under the previous governor, Governor
Soekarwo re-branded the initiative as his own within the first months of this term. Most of the interviewees
identified Governor Soekarwo as the instigator of Jamkesda, despite the fact that the local regulation for the
scheme was drafted in 2008 under the previous governor, Imam Sutomo.
2. Socialisation of norms: provision of free health services to the poor is a standard that all those in government –the
executive and legislative branches – accept as a general standard for good governance. The acceptance of this
norm is reflected by the fact that provision of health services is in the campaign statements of most local election
(Pilkada) candidates. A Malang academic asserted that promising free health does not actually differentiate one
candidate from another as all candidates must include that promise within their campaign. Thus, a key motivation
of elected officials to implement Jamkesda is to fulfil an election promise, but that election promise is made
because of the general acceptance that free health for the poor is a general standard of good governance.
Were there internal factors that influenced the adoption of Jamkesda?
The main internal factor that influenced the adoption of the Jamkesda scheme was the availability of fiscal space to
finance Jamkesda. The provincial government entered into individual agreements with district governments in East Java,
and the number of recipients was based on the availability of each district government to enter into cost-sharing
agreements. For example, Malang District with smaller per capita revenue only nominated around 11,000 recipients. In
contrast, Malang Municipality, with much higher per capita revenue and a smaller population financed approximately
32,000 recipients in 2010.15
How did Jamkesda change during implementation and what factors led to that change?
There were two factors that influenced the Jamkesda scheme during implementation:
1. Public expectation: After the Jamkesda scheme in Malang District commenced, many people who considered
themselves to be ‘poor’ and thus eligible for Jamkesda were not enrolled in the scheme. In response to this
demand, non-members could also access free treatment under the Jamkesda scheme by obtaining a SKTM from
local authorities. The number of people receiving treatment using an SKTM greatly exceeded the number of
Jamkesda card holders receiving treatment under the scheme in the early years of the scheme's operation. A
provincial government evaluation found that SKTM holders accounted for 72 per cent of Jamkesda patients and 82
per cent of costs across East Java in the first eight months of 2012. Jamkesda membership cardholders
contributed to only 26 per cent of patients and 17 per cent of costs.16
2. Fiscal space: Jamkesda costing only budgeted for free treatment for Jamkesda card-holders. The large number of
STKM holders receiving Jamkesda benefits led to a significant overrun of the budget and as a result, the Malang
district government incurred significant debts. To rein in this budget overrun, two changes were made. First, the East
Java Governor issued a Circular (Surat Edaran) in 2012, which stipulated that the Provincial Government treatment
provided for STKM holders would no longer be co-financed by the provincial government. Second, the Malang district
changed the procedures for citizens to obtain the SKTM, with the purpose of restricting the number of SKTM holders.
3. Central government policy: Staff from the Health Office stated that the Malang district government plans to
integrate its Jamkesda card holders into the national Jaminan Kesehatan Nasional (JKN) insurance plan under
BPJS Kesehatan.
14
'Dua Daerah Jatim Setujui Layanan Gratis', Kompas.com, 7 April 2009.
15
Budiarto and Ristrini (no date: 197) list 31.963 Jamkesda participants in Malang Municipality in 2010, or 3.9 percent of the municipality's population. They provide an overall provincial participation rate in 2010 of 3.35 percent.
16
Tjatur Prijambodo, 'Evaluasi Pelaksanaan Program Jamkesda Tahun 2012', slides from presentation to Rapat Evaluasi Pelaksanaan Program
Jamkesda di East Java Tahun 2012, 24-25 October 2012.
34
Case study 1: Malang District
The integration into JKN has two implications: a) the cost implication for the program is more predictable as the district
government is merely responsible for the premium, rather than the cost of treatment. Moreover, a Malang District
health official tasked with administering Jamkesda was confident that the Jamkesda card holders could be part of the
JKN, where recipients could be incorporated into the national scheme as central government financed participants,
replacing other central government-funded participants who had died or moved out of Malang. b) by becoming JKN
cardholders, the recipients would have a greater range of health service coverage. The Malang District Government did
not indicate whether SKTM holders will also be integrated into JKN.
E. BOSDA IN MALANG DISTRICT
Education spending represents 33% of total expenditure, and is the second largest sector behind general administration
(34% of total expenditure). The proportion spent on education did not change significantly under Rendra Kresna
compared to the previous district head. The limited attention paid to education is also reflected by the research team’s
observation that apart from the Malang District Education Office, government officials had little knowledge pertaining to
education policies. The DPRD, for example, could not identify a specific aspect of education policy that was to be their
focus. In contrast, the Malang District DPRD stated that the implementation of BPJS Kesehatan is their main health
priority.
Moreover, free education did not appear to be an education priority. Initially, the Malang District Education Office staff
reported that the district did not have a BOSDA program. Moreover, during an interview with senior Education Office
officials, one interviewee initially said that Malang district did not have any programs that supported free education. The
Secretary of the Education Office quickly corrected the interviewee, however, by saying that the district ran BOSDA and
numerous scholarship and financial assistance programs for the poor.
Interviewee’s limited knowledge coupled with conflicting information in relation to BOSDA meant that this study’s analysis
pertaining to Malang Municipality’s BOSDA is at times scant on detail. Only three sources were available to provide
specific details on BOSDA and other free education programs: 1) an interview with the District Education Office (Secretary,
the Head of Department responsible for Pre-school and Primary School and the Head of Department responsible for
Reporting and Evaluation); 2) an examination of the 2014 education expenditure in the General Budget Policy –
Provisional Budget Funding Priorities and Funding Levels Draft Local Regulation (Raperda KUA-PPAS); and 3) other
secondary sources such as media reports. The limited information means that both the description of the program and
an analysis of the policy process are relatively shallow.
1. Description of BOSDA in Malang District
Form of scheme: BOSDA pays operational funds to schools (with a proportion possibly paid to students according to
interviews) at primary and junior high school level. The head of the Malang Education Office was quoted in a media report
in 2011 saying that 23,000 out of 210,000 primary school students in Malang received free education via a subsidy
payment of IDR 400,000 per year per student, whereas more than 10,000 of the district's 60,000 junior high school
students received free education via a yearly subsidy of IDR 570,000. He did not differentiate between BOS and BOSDA
payments in the report.17 The same media report quoted a DPRD member saying the district provided free school supplies
to poor students as a substitute for free education. The district also provides some scholarships for poor students at
pre-school, targeting recipients who do not receive funding from national programs. There was no consensus among
interviewees as to whether Malang district actually had a BOSDA program, either at the District Development Planning
Agency (Bappeda) or the Education Office, although the 2014 draft budget shows a small allocation.
Legal Basis: Unclear. The head of Malang District Bappeda, who was formerly the head of the District Education Office,
suggested the scheme was based on a Head of District Decree (SK Bupati) issued in around 2007, whereas officials at
the Education Office suggested the BOSDA scheme began under the current district head, who took office in 2010.
Duration: The program may have started in around 2007, or sometime after 2010. Again, different interviewees proposed
different details. An Antara media report mentions the scheme in 2011.
Funding: The funding allocation for the BOSDA scheme appears to be very small. Local Regulation No. 10/2014 listed an
allocation of IDR 250 million consisting of IDR 170 million from the District Government and IDR 80 million.
17
'Diknas: Pendidikan Gratis Diprioritaskan Bagi Warga Miskin', Antara, 21 December 2011.
Case study 1: Malang District
35
2. How did BOSDA spread to Malang District?
Agents: Who pushed for the adoption of BOSDA?
The slogan for education in Malang district is “cheap and affordable”, that is, the district does not advocate free education
for all. The Secretary of the Education Office, however, asserted that the district has already achieved free education for
the poor, which he estimates at 10-20% of the population. According to the Education Office, the two key policy drivers are
the district head and the bureaucracy:
• District head: the Secretary of the Education Office said that all policy ideas came from the district head. There is
no doubt that a head of district sets the overall direction for education policy, but it is unlikely that he is the source
of all policy ideas. As one Malang academic commented, the head of district only spends a fraction of his time on
policy, with the large majority occupied with managing the politics of the district. The head of district does, however,
decide which sectors he prioritises in budget allocation decisions. Even if not all policy decisions are sourced from
the district head, he makes the ultimate decision on which proposals put forward by the various work units (SKPD)
should be funded, a crucial part of the policy process.
• Bureaucracy: the Education Office and Bappeda are key players in formulating education policy. The planning and
budgeting process at districts is a fairly top-down linear process and is rigidly regulated. The bureaucracy’s control
of this process is the main reason for it being the main source and driver of policy at districts. For instance,
Bappeda is responsible for drafting the medium-term expenditure plan (RPJMD), the main policy document that
sets out the district head’s policy agenda for his entire term. The Education Office proposes the policies to be
included in the RPJMD. Interviewees from the bureaucracy said that the RPJMD drafting process commenced about
a year before the local elections (Pilkada) and once the new head of district is inaugurated, his/her vision and
mission is then incorporated into the RPJMD. Interviewees from the bureaucracy all said that incorporating the
vision/mission did not result in significant changes being made to the RPJMD. The Jawa Pos Institute which runs
the Jawa Pos Otonomi Awards claimed that the majority of policy ideas came from SKPDs (JPI, 2014).
• Central government: the DPRD asserted that to a large extent the Education Office largely followed central
government education policy, leaving limited space for formulating its own policy direction.
The Education Office said that neither the provincial government, nor the DPRD played a strong role in the policy process:
• DPRD: Both the District Head and the Secretary of the Education Office said that the DPRD was generally
supportive of free education schemes such as BOSDA. The Education Office claimed that DPRD members, at the
Commission B (on education) hearings, question the bureaucracy about the specific details of the scheme and the
budget allocated. In general, they support the policies and even suggest that more money should be allocated. The
budget allocation for BOSDA and other free education for the poor schemes are small, and as a result may be
unlikely to capture the attention of the DPRD. Members of the Commission B also did not cite any specific
education policy as a focus of their work. Instead, they will focus on ensuring proper implementation of the
minimum service standards. Commission B members believed that the minimum service standards provided for a
‘measurement tool’ to hold the bureaucracy accountable for their work. Moreover, Commission B members did not
seem to have a strong grasp of specific policy details, perhaps due to the fact that reportedly only 13% of the DPRD
was re-elected in the 2014 general elections.
• Provincial and central government: The Malang District Education Office asserted that the provincial and central
government had no influence on Malang district’s education policy. The DPRD, however, disagreed as members of
Commission B said that education and health in Malang District merely follows central government policy. Certainly
the descriptions of the policies contributing to providing free education for the poor including BOSDA and
scholarships for the poor are top-ups to the central government programs. The provincial government itself says
that it enters into cost sharing agreements with district governments to implement their policies and programs. The
East Java Provincial Government said that some districts, namely Surabaya, Malang Municipality and Pacitan, have
their own resources so are therefore not interested in cost sharing. This suggests that they do influence Malang
District’s policies through cost sharing agreements.
• CSO and media: The Education Office painted a very rosy picture of its relationship with CSOs and media. They
claimed that all CSOs supported the district government and nothing came up in the media that required significant
correction from the government. A local journalist suggested that media coverage of health issues were more
frequent than education (a reverse of the trend in Malang Municipality), but said that district governments were
generally responsive when media highlighted any issues. There was no indication that CSOs and the media
influenced the adoption of free education initiatives in Malang District.
36
Case study 1: Malang District
What process and mechanism led to the adoption of the BOSDA?
Schemes to provide free education for the poor, including BOSDA and scholarships for poor students, are similar to the
BOS and BSM (scholarship program for poor students) national programs. This suggests that the programs were
implemented in response to funding gaps from the central government, thus policy diffusion process is top-down using a
responsive mechanism. However, the research team did not collect sufficient information to confirm this conclusion.
Motivation: Why was BOSDA adopted?
One possible reason for why Malang district adopted BOSDA and scholarships for the poor was the “socialisation of
norms”, that is, district governments felt obliged to implement such programs because being seen to be providing free
education to the poor is a standard that all governments accept as the “norm” or the minimum standard all good
governments need to achieve, in order to show that they are supporting the poor or are “pro-people”. The Malang District
government has both BOSDA and scholarships for the poor, but these programs’ budget allocation is small. Thus,
allocating some funds to these programs would be seen as adhering to this “norm” despite the fact that free education
was not the policy direction of the Malang District Government.
The research team, however, did not collect sufficient information on why Malang District adopted BOSDA and other free
education initiatives to support the “socialisation of norms” conclusion.
Were there internal factors that influenced the adoption of free education schemes?
The main internal factor that influenced the adoption of the free education schemes was the fact that education was not
the top priority in Malang District nor was “free education” a district government policy. As a result, although those
programs exist, the budget allocated to these initiatives was small. Moreover, knowledge of those initiatives was extremely
limited, as several staff members from the Education Office did not even know they existed.
How did BOSDA change during implementation and what factors led to that change?
Interviewees did not provide any information on how free education to the poor changed over time.
F. CONCLUSION
Health insurance was clearly an issue that has gained greater attention in Malang District than BOSDA (or free education
for the poor). Many more people knew about Jamkesda than the free education for the poor initiatives. Part of the reason
for the attention to Jamkesda was because the BPJS Kesehatan program has been dominating health policy discussions
within the government.
In both Jamkesda and free education initiatives, the main process leading to policy diffusion was top-down pressure from
central and provincial governments. The provincial government employed coercive tactics to persuade district
governments to adopt Jamkesda, while BOSDA was adopted in response to the gaps in funding from an equivalent central
government program.
The key policy actors in Malang district that led to the adoption of Jamkesda and BOSDA were the Bupati, the bureaucracy
and the provincial and central governments. The DPRD did not drive policy formulation but exerted its power through the
budget negotiation process. In terms of Jamkesda and BOSDA, the research team’s impression was that they had
questioned whether more funding could be allocated, but accepted the costing proposed by the Bupati and his
government. Numerous people implied that budget negotiations between the DPRD and the Bupati were predominantly
about patronage, not policy outcomes.
Electoral incentives and socialisation of norms were the key motivating factors that led to the adoption of Jamkesda and
BOSDA. The electoral incentives were primarily at provincial level - Governor Soekarwo promised "pro-people" spending,
and free health care in particular was an important component of this promise. "Pro-people" spending has become an
accepted ‘norm’ that most or all elected officials (regional heads and DPRD) adhere to; however, it does not always result
in extensive free health and education programs. Rendra Kresna undoubtedly also depicts himself as a "pro people"
leader, but this case suggested that Jamkesda and BOSDA were not an important part of his efforts of seemingly
Case study 1: Malang District
37
delivering such promises to voters.
Finally, the form in which Jamkesda and BOSDA is adopted largely depends on the fiscal space of the district. For instance,
Malang Municipality has much larger per capita revenue than Malang District and therefore can incorporate more
participants in the Jamkesda program, despite having a smaller number of poor people than Malang District. Availability
of funds also influences how Jamkesda changed over time – changes to the cost sharing arrangement, the benefits
provided under Jamkesda and the number of participants evolved in order to constrain costs. The need to reduce the
number of people eligible for Jamkesda was tempered with public expectation that they were part of the population who
were eligible for Jamkesda. Even when issuance of the SKTM letters was restricted, there was still pressure on the
provincial and district governments to provide care to those who did not have SKTM or Jamkesda cards.
38
Case study 1: Malang District
Case study 2: Malang Municipality
Malang Municipality adopted the Jamkesda program in 2009 as part of Governor Soekarwo’s province-wide scheme. The
scheme commenced operations in 2010. The municipality also adopted BOSDA in 2010. This case study sets out the
political, socio-economic and political contexts under which the municipality adopted these two programs (see Sections
A, B and C). Moreover, the case study explains how and why Jamkesda and BOSDA spread to Malang Municipality
(Sections D and E).
A. POLITICAL CONTEXT
H. Mochamad Anton is a first term mayor, who was elected in 2013, after being nominated by PKB and Gerindra. His
running mate was DPRD member Sutiaji, who was the head of PKB's faction in the legislature. Anton, often called Abah
Anton, is a Chinese Moslem sugar cane businessmen. Various interviewees attributed his win to the use of religious
themes (such as funding 50,000 residents to go on a pilgrimage to the tombs of local Islamic saints), the larger campaign
than that of their rivals, and the internal split within the biggest political party in Malang Municipality, PDI-P. The previous
two term mayor, Peni Suparto, who intended for his wife to run as PDI-P candidate was from PDI-P. Suparto was trumped
by the party's provincial chairperson, who arranged for his wife to become a PDI-P candidate instead. In the end, the two
men's wives ran against each other on separate tickets, splitting the PDI-P vote.
Anton and Sutiaji's campaign slogan was "peduli wong cilik" (caring for the ordinary people). The clearest manifestation of
this was in the health and education spheres with Anton's insistence that education in Malang be genuinely fee free, as
set out in a mayoral regulation promulgated soon after his election.
B. SOCIO-ECONOMIC CONTEXT
Malang Municipality is unique amongst the four districts in this study in that it has relatively high development levels and
high fiscal resources. The large resources and high development levels means that it can invest in its own priorities,
particularly on education.
Malang Municipality has one of the highest levels of development in East Java. At only 5.19%, Malang Municipality has
one of the lowest poverty rates in East Java and is considerably lower than the provincial-wide poverty rate of 13.4%.
Malang Municipality’s HDI is also one of the highest in East Java, ranking fifth in the province. Its household per capita
expenditure is the highest in the province, and is double that of the provincial average. The household per capita
expenditure of its poorest 20% of the population is the third highest in the province, also significantly higher than the
provincial average.
Table 7: Summary of key district indicators, Malang Municipality, 2012
Poverty Rate (%)
Malang Municipality
5.19% (37/38)
East Java Province
13.4%
Number of People Living below the Poverty line
43,100 people (31/38)
5,071,000 people
HDI
Household per Capita Expenditure
Household per Capita Expenditure (poorest 20%)
77.07 (5/38)
72.18
IDR 1,040,091 (1/38)
IDR 524,226
IDR 315,192 (3/38)
IDR 217,547
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang Municipality has very mixed health indicators. It has one of the lowest immunization coverage for children under
5 years old in the province. On the other hand, it also has one of the lowest morbidity rates and 100% of the municipality’s
births are attended by a skilled health worker. The city has a relatively large number of doctors but a small number of
midwives, reflecting the city’s ability to attract highly skilled health workers. Predictably, as an urban municipality, it has a
relatively high number of hospitals but a small number of health clinics (Puskesmas).
Case study 2: Malang Municipality
39
Table 8: Summary of health indicators, 2012
Malang Municipality
East Java Province
Immunization Coverage for Children under 5 Years Old (in %
of children population under 5 years old)
77.37% (29/38)
78.84%
Morbidity Rate (in %)
22.36% (33/38)
27.2%
% Births Attended by a Skilled Health Worker
100% (1/38)
93.13%
Number of Doctors per 100,000 People
38.62 (6/38)
17.86
16.66 (38/38)
36.62
5.79 (34/38)
8.42
0.97 (8/38)
0.73
Number of Midwives per 100,000 People
Number of Health Clinics (Puskesmas) and their Line
Services per 100,000 People
Number of Hospitals per 100,000 People
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang Municipality’s performance in the education sector is also mixed. The city has the highest literacy rate in East
Java, but its net enrolment rate at primary school level is relatively low compared to other districts. Its junior secondary
school net enrolment rate is slightly higher than the provincial average, but its senior secondary net enrolment rate is
significantly higher than the provincial average. Given that fees for senior secondary school are much higher than primary
and junior secondary school, the higher senior secondary school enrolment rate probably reflects the spending power of
Malang Municipality’s residents.
Table 9: Summary of key education indicators, 2012
Malang Municipality
Literacy Rate of Population Aged 15 and Over (in % of
total population)
East Java Province
98.34 (1/38)
89.28
Net Enrolment Ratio: Primary (in %)
89.26 (37/38)
92.92
Net Enrolment Ratio: Junior Secondary (in %)
76.98 (20/38)
74.52
Net Enrolment Ratio: Senior Secondary (in %)
60.86 (14/38)
52.12
Source: BPS (2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
C. FISCAL CONTEXT
As mentioned above, Malang Municipality is unique amongst the four districts because it has a relatively strong fiscal
capacity, particularly one that is not as reliant on central government transfers. Total nominal revenue for this municipality
has been steadily increasing by an average of around 15% per annum. In 2012, the revenue increased by 23%.
Figure 7: Revenue has increased significantly from 2007-2012 in Malang Municipality
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
40
Case study 2: Malang Municipality
The increase in revenue has been predominantly driven by an increase in own-source revenue (PAD) and other revenue,
which has allowed Malang Municipality to become less dependent on central government transfers (DAU and DAK).
Although DAU still represented almost half of Malang Municipality’s revenue in 2012, this decreased from 65% in 2007
to 51% in 2012. Conversely, in 2007, other revenue and PAD only represented 22% of the total revenue. By 2012, the
proportion had increased to 40% of total revenue. The lower reliance on DAU potentially means that Malang Municipality
had greater fiscal space to finance its own programs and activities.
Figure 8: Malang Municipality has become less reliant on DAU and DAK transfers
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Malang Municipality’s per capita revenue is the 11th highest in the province, and is almost IDR 300,000 higher than the
provincial average. In particular, Malang Municipality has high per capita own-source revenue or PAD (9th) and other
revenue (6th).
Table 10: In 2012 Malang Municipality has one of the highest per capita revenues in East Java
Malang Municipality
Total General Allocation Grant (DAU)
IDR 797,971 (17/38)
East Java Average
IDR 721,115
Total Natural Resource Revenue Sharing (DBH SDA)
IDR 51,940 (13/38)
IDR 38,439
Total Other Revenue
IDR 369,555 (6/38)
IDR 253,030
Total Own Source Revenue (PAD)
IDR 27,5378 (9/38)
IDR 190,828
Total Special Allocation Grant (DAK)
IDR 26,239 (35/38)
IDR 56,967
Total Tax Revenue Sharing (DBH tax)
IDR 104,233 (10/38)
IDR 74,806
IDR 1,625,316 (11/38)
IDR 1,335,183
Total Revenue
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Total expenditure in Malang Municipality increased significantly from 2007-2009, where it increased from IDR 611 billion
to IDR 1.07 trillion. In 2010, however, expenditure decreased to IDR 968 billion and spending only exceeded the 2009
level in 2012, when total APBD expenditure was IDR 1.25 trillion. The fluctuation in expenditure is predominantly due to
abnormally high expenditure levels in 2009, which may be a result of a large one-off expenditure such as infrastructure.
Case study 2: Malang Municipality
41
Figure 9: Malang Municipality’s total expenditure has been consistently increasing
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
In 2012 almost half of Malang Municipality’s expenditure was spent on education, reflecting that it was the Mayor’s
highest priority. The proportion of APBD spent on education was twice as much as that for general administration, the
function with the second highest spending. Senior government officials also identified education as the municipality’s top
priority. The local newspaper, Radar Malang, also said that education was one of the most covered issues for the
newspaper for the city. In contrast, health expenditure only represented 6% of total APBD spending.
Table 11: In 2012, two thirds of total APBD is spent general administration and education
IDR Billion
% Total Expenditure
% Change from
2011
Education
552
44%
17%
General Administration
272
22%
-4%
Infrastructure
172
14%
172%
76
6%
8%
Health
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
The proportion of APBD spent on health increased from 4% in 2007 to 6% in 2012, although the proportion spent on
health was still low compared to other districts in Indonesia. Change in nominal health spending from year-to-year has
fluctuated significantly. In 2008, health spending increased by 64.6%, then decreased by 20% in 2009 and then
increased by 57.6% again in 2010. Despite Malang Municipality’s high fiscal resources, the municipality is not spending
it on health.
Figure 10: Health expenditure not experienced significant growth in Malang Municipality
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
42
Case study 2: Malang Municipality
The low priority for health in Malang Municipality is also reflected by the fact that per capita health spending is one of the
lowest in the province. At only IDR 91,184, Malang Municipality’s per capita health spending is ranked 31st out of 38
districts and is only around 60% of the provincial average (but is still higher than Malang District). In fact, household
spending on health is far higher than government spending.
Table 12: Health Expenditure in Malang Municipality, 2012
Malang District
Per Capita APBD Health Expenditure
Monthly Per Capita Household Health Expenditure
East Java Province
IDR 91,184 (31/38)
IDR 148,405
IDR 36,360 (3/38)
IDR 19,750
Source: BPS data (household expenditure) and Ministry of Finance data (APBD) extracted from the World Bank Indonesia-Dapoer
database in February 2015.
Even though per capita health spending is low and the proportion of total expenditure spent on health is also low, Malang
Municipality provides a higher level of free health treatment than the other three districts in this study. Even before the
adoption of Jamkesda, Malang Municipality provided free health clinic (Puskesmas) treatment to all residents with a local
ID card (KTP). Thus, the only additional service Jamkesda provided was free treatment at state hospitals.
Total education expenditure has been increasing every year. From 2007-2012, education expenditure increased from IDR
206 billion to IDR 551 billion, an average of 31% per year. Education expenditure is now 44% of the total expenditure,
reflecting its importance to the municipality. The head of the East Java Provincial Education Office, in fact, said that
Malang Municipality has sufficient resources, thus it generally rejects all forms of cost sharing arrangements offered by
the provincial government.
Figure 11: The proportion of total APBD spent on education has increased significantly since 2009
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Despite the large share spent on education in Malang Municipality, the per capita household education expenditure is
higher than APBD spending. The high household spending reflects both Malang Municipality’s high economic
development, and the importance that its citizens place on education.
Case study 2: Malang Municipality
43
Table 13: Per Capita Education Expenditure in Malang Municipality, 2012
IDR
Annual Per Capita Education Expenditure (IDR)
Monthly Per Capita Household Education Expenditure (in IDR)
IDR
660,870 (17/38)
545,049
83,757 (1/38)
33,239
Source: BPS data (household expenditure) and Ministry of Finance data (APBD) extracted from the World Bank Indonesia-Dapoer
database in February 2015.
D. JAMKESDA IN MALANG MUNICIPALITY
The Jamkesda was therefore adopted in a district where health was not an identified priority, either under the previous
mayor or the current mayor. The per capita health spending from the APBD is one of the lowest in the province, despite
the fact that even before Jamkesda, health clinic (Pukesmas) treatment was free for all Malang Municipality residents.
Although government spending is low, per capita household education expenditure is almost twice that of the provincial
average, suggesting that many residents may be using private sector providers.
1. Description of Jamkesda in Malang Municipality
Form of scheme: The scheme in Malang district covers costs of health treatment for recipients, who must first seek
treatment at a community health clinic (Puskesmas). If the health clinic lacks resources or the recipient's health requires
more specialised treatment, patients can be referred for treatment to three government hospitals, namely Tentara, Saiful
Anwar or Dr Soetomo Hospital. Health clinic treatment in Malang Municipality was free even before the Jamkesda
scheme. Hospitals bill the district and the province directly for treatment. Malang Municipality has started rolling its
Jamkesda scheme into the national health insurance scheme -Jaminan Kesehatan Nasional (JKN) in 2014, a process that
is scheduled to be completed in 2016.
Initiating Actor: Soekarwo's predecessor Imam Utomo initiated a province-wide Jamkesda scheme, but it only commenced
operation under his successor, Soekarwo, after the MoU between the provincial and district governments was signed.
Duration: Jamkesda commenced operations in Malang municipality in 2010. In 2014, Malang Municipality commenced
the process of integrating the Jamkesda participants into the national JKN scheme. Under an integrated scheme, which
will be completed by 2016, the provincial cost sharing will end and the Malang Municipality Government will be paying the
JKN premiums for the Jamkesda participants. Once integrated into the JKN, Jamkesda participants will be called
Penerima Bantuan Iuran Daerah – local premium beneficiaries (PBID).
Recipients: The scheme targets poor residents in East Java, who are not covered by the national health insurance
scheme, namely Jamkesmas, replaced with JKN in 2014. Each district and municipality was responsible for nominating
the number of its residents who would be covered by the scheme. Malang Municipality nominated around 32,000 in the
first instance, or roughly 3.9 percent of the municipality’s population (Budiarto and Ristrini, no date: 197). Malang
residents who are not Jamkesda members can also access benefits if they can obtain a “proof of poverty” letter (Surat
Pernyataan Miskin or SPM). According to a municipal health office official, there were around 500 SPM holders in 2014.
Malang municipality has already rolled most of its Jamkesda recipients into the JKN scheme, and the former Jamkesda
recipients have become PBIDs. There were 20,190 PBID participants in 2014 and 21,038 participants in 2015 in Malang
Municipality.
Legal Basis and Implementing Body: The scheme is ultimately governed by the East Java Local Regulation No 4/2008
on A Regional Health Guarantee System in East Java, promulgated by former Governor Imam Utomo. Several governor
regulations (Pergub) provide the implementing instructions. The cost sharing arrangement between the province and
districts is governed by an annual MoU, the first of which was concluded in 2009. At the provincial level, Local Regulation
No 4/2008 established an implementing agency for the scheme, called Badan Pelaksana Jaminan Kesehatan Daerah
(BPJKD) or Local Health Insurance Implementing Agency. The specific legal basis for Jamkesda in Malang Municipality, if
any, is unknown - Budiarto and Ristrini (no date: 197) state the scheme is governed by a mayoral regulation (Perwali), two
mayoral decrees (SK Walikota), as well as the MoU with the provincial government and agreements with the hospital
directors and there is a mayoral decree for the PBID. As in Malang District, there is no specific implementing agency in
Malang Municipality.
Funding: The MoU between the province and district established 50-50 cost-sharing. It is assumed that hospitals bill the
district and province directly. Details were not available of Malang Municipality's early allocations to the scheme. More
recently, Malang Municipality interviewees said the municipality allocated IDR 3 billion for Jamkesda in 2014 and
44
Case study 2: Malang Municipality
IDR 2 billion for 2015. These numbers appear not include the PBID participants though, as the premium payments (IDR
19,225 per person per month) for 20,000 or so PBID participants would in itself come to a higher amount than these
figures.
2. Why did Jamkesda spread to Malang Municipality?
Agents: Who pushed for the adoption of Jamkesda?
The Jamkesda scheme in Malang Municipality followed the same trajectory as the Jamkesda district scheme: a cost
sharing scheme was offered by the Governor and each district in East Java entered into individual agreements with the
provincial government. The Jamkesda scheme itself targets providing free health care for the poor but for those who were
not included as recipients in the national Jamkesmas scheme. Therefore, the four main parties identified as central in the
adoption of the Jamkesda scheme in Malang Municipality are:
1. Central government: central government’s Jamkesmas scheme was insufficient and led to the provincial and
district governments to provide a similar scheme to those not included as participants in the Jamkesmas scheme.
2. Provincial government: the Governor enticed the districts to adopt the scheme with a combination of financial
incentive (50-50 cost sharing) and threats from Governor Soekarwo that if the district did not adopt Jamkesda, he
would expose them to the press as district heads who were not “pro-people”.
3. District head: the Jamkesda scheme is governed by an agreement between the district and provincial government.
Thus, the district head’s agreement to adopt the Jamkesda program is pivotal both in its commencement and
continued implementation after cost-sharing ceases.
4. Bureaucracy: although the decision to adopt the Jamkesda is one made by the district head, the bureaucracy had
overall responsibility for both integrating Jamkesda into the planning and budget processes including identifying
the availability of funds to allocate to the Jamkesda scheme. It is also responsible for the implementation of the
scheme, including the identification and verification of participants.
What processes and mechanisms led to the adoption of the Jamkesda scheme?
As in Malang District, the dominant policy diffusion process was a top-down process using a coercive mechanism. The
provincial government convinced district governments to join the Jamkesda scheme through both a 50-50 cost sharing,
and the threat made by the East Java Governor to expose district heads who disagreed to join in the Jamkesda program.
Jamkesda policy diffusion was also through a top-down process using a responsive mechanism. The provincial and district
government responded to the fact that the targeting of participants in the Jamkesmas was poor. As a result, the Malang
Municipality government officials believed that there were still poor people who were not covered by Jamkesda. Thus, the
central government became both a source of policy ideas (health insurance) as well as a party that generated demand for
health insurance.
Malang Municipality Health Office staff could not recall that they had visited any other districts to learn about their
implementation of Jamkesda. They reported that a visit had been made to Bali to learn about their hospitals, but not for
Jamkesda.
Motivation: Why was Jamkesda adopted?
As was the case in Malang district, the two main incentives for the adoption of Jamkesda were electoral incentives and
socialisation of norms:
1. Electoral incentive: Although the process for introducing Jamkesda started under the previous governor, Governor Soekarwo
re-branded the initiative as his own within the first months of his term as the program was in line with his “APBD untuk rakyat”
(budget for the people) campaign slogan. Most of the interviewees identified Governor Soekarwo as the instigator of
Jamkesda, despite the fact that the local regulation for the scheme was drafted in 2008 under the previous governor.
2. Socialisation of norms: provision of free health services to the poor is a standard that all of those in government
–the executive and legislative branches – accept as a general standard for good governance. The acceptance of
this norm is reflected by the fact that provision of health services is in the campaign statements of most Pilkada
candidates. A key motivation of elected officials to implement Jamkesda is to fulfil an election promise, but that
election promise is made because of the general acceptance that district heads need to be “pro-people” and
providing free health for the poor is an accepted indicator of being “pro-people”.
Case study 2: Malang Municipality
45
Were there internal factors that influenced the adoption of Jamkesda?
The main internal factor that influenced the adoption of the Jamkesda scheme was the availability of fiscal space to
finance Jamkesda. The provincial government entered into individual agreements with district governments in East Java,
and the number of recipients was based on the availability of funds in each district government to enter into cost-sharing
agreements. For example, Malang Municipality, with relatively high per capita revenue and small poor population financed
approximately 32,000 recipients in the initial agreement. In contrast, Malang District with smaller per capita revenue and
many more poor people only nominated around 11,000 recipients.
How did Jamkesda change during implementation and what factors led to that change?
The main factor that changed the program during implementation was the change in central government regulations. The
Malang Municipality Government expects that all Jamkesda recipients (including SPM recipients) will be integrated into
the national JKN program by 2016. Integration into JKN means that Jamkesda recipients will now receive a broader range
of benefits and the cost to the Malang Municipality Government will be more predictable as the cost is calculated based
on the number of participants with a unit cost for the premium to be paid to BPJS Kesehatan, instead of the cost of
provision of services by hospitals, under the current Jamkesda scheme.
While limiting the number of SKTM holders was a priority in Malang District as it led to budget over-runs, no interviewee
indicated that the SPM holders were a significant issue for Malang Municipality. This problem may be less acute in Malang
Municipality as the number of SPM holders was relatively small as the government had registered a higher number of
participants despite having a smaller poor population – according to one Health Office official, the municipality only had
500 SPM holders in 2014. Moreover, the municipality already provided free Puskesmas treatment for all residents even
before the Jamkesda commenced, thus limiting its impact on the APBD.
E. BOSDA IN MALANG MUNICIPALITY
Education is both the previous and current mayor’s top priority and also receives the largest share of the municipality’s
budget. In 2012, 44% of the APBD was allocated to education. The value that Malang Municipality citizens place on
education is also reflected by the fact that the municipality has one of the highest per capita household spending on
education. The focus on education means the municipality has the highest literacy rate in the province and one of the
higher enrolment rates for senior high school. It is under this context that BOSDA was adopted in Malang Municipality.
1. Description of BOSDA in Malang Municipality
Form of scheme: The municipality government pays operational costs to each school to cover a proportion of the gap
between national BOS payments and the actual per student monthly operational costs of the school. An Education Office
official estimated that BOSDA payments at the primary school level covered approximately half of the gap between BOS
payments and the actual unit cost of the schools' operational expenses. Another official confirmed that BOSDA payments
at the SMP level also fell short of the actual gap between BOS payments and operational expenses. Schools have
responded to this shortfall by reducing extra-curricular activities, as they are prevented from charging fees by Mayoral
Decree No 53/2013.
Initiating Actors: A budget advocacy case study book attributes the enactment of BOSDA in Malang Municipality to a
CSO-led campaign spearheaded by Pattiro Malang, in which the initial step was to calculate unit costs with the assistance
of USAID experts (Muslih and Darsono). Building on this assessment, Muslih and Darsono attributed adoption of BOSDA
to a multi-faceted campaign, involving media pressure, approaches to DPRD members, and the establishment of a BOSDA
alliance of CSOs. Government interviewees did not attribute the scheme to such a campaign, however. Instead, they cited
the national-level promises made by the Yudhoyono Government of free education in the context of seeking re-election for
a second term as providing the enabling environment for the scheme. The expansion of the scheme and the ban on
charging fees were a promise made by a first term mayor, H. Mochamad Anton during the 2013 local election (Pilkada).
Various interviewees doubted that his promise of free education was a decisive factor in his victory but rather his use of
religious imagery and funding of entertaining events for voters. An advisor to the former mayor in fact cast doubts that free
education was universally popular, stating that the better off voters were more focused on quality.
Recipients: Under the previous mayor, BOSDA aimed to make education free for the poor, with most schools allowed to
charge fees despite receiving BOSDA funds; under the current mayor, all schools receive BOSDA and fees cannot be levied
on any student in a government school, except at senior high school level.
46
Case study 2: Malang Municipality
Legal Basis and Implementing Body: Malang Municipality Local Regulation No 3/2009 on the Education Administration
System does not specify fee-free education, instead it states that education will be financed by the government,
sub-national government, and the community (Article 26). The regulation stipulates (Article 33(3) a) that community funds
are to be used to meet the shortfall in meeting national education standards. The current mayor, H. Mochamad Anton
enacted the Mayoral Regulation 53/2013, which stipulates that government primary and junior high schools could not
levy fees,18 although voluntary "contributions" are permitted.
Duration: BOSDA in Malang Municipality started in 2010, with an allocation of IDR 9.9 billion for primary and junior high
schools. During its initial period of operation, schools could not charge fees to poor students, but most schools were
permitted to charge fees to wealthier households. The new mayor in 2013 decreed that no fees could be charged to
anyone.
Funding: BOSDA is wholly funded by the Malang Municipality’s APBD. The budget allocation in 2010 was IDR 9.9 Billion,
of which IDR 5.1 Billion was paid to primary schools (SD) and IDR 4.8 Billion to junior high schools (SMP) (Muslih and
Darsono 2011: 42). According to an Education Office official, the scheme received a large budgetary increase in 2014,
but the 2015 budget was in line with 2014 funding levels, despite the known shortfall in funding.
2. What led to the spread of BOSDA to Malang Municipality?
Agents: Who pushed for the adoption of BOSDA?
Differing accounts of how BOSDA commenced means that the adoption of the program was attributed to many parties.
Madewa members attributes BOSDA to a multi-faced campaign involving media pressure, approaches to DPRD members
and the establishment of a BOSDA alliance of CSOs. Government interviewees, however, attribute it to national level
promises made by the Yudhoyono Government of free education in the context of seeking re-election for a second term as
providing the enabling environment for the scheme. Conversely, a member of Malang Municipality DPRD asserted that
free education for the poor was an issue that emerged in the second term as a result of the ‘fenomena lapangan’ (or
conditions in the field). The following describes each party’s role in the adoption of BOSDA:
• District head: Malang Municipality’s BOSDA scheme commenced in 2010 under the previous Mayor under the
guidance of a Mayoral Regulation. At that time, BOSDA was enacted to achieve his aim of providing free education
for the poor. As a result, although BOSDA payments were made to all schools, most schools were still permitted to
charge fees.19 When a new mayor was elected in 2013, he changed the program so that all schools received BOSDA
payments as part of his promise to provide free education for all.
• Bureaucracy: while the mayor is responsible for setting the direction of the education policy (promising free
education for the poor), the bureaucracy is responsible for translating that into concrete policies and programs. The
bureaucracy determines which schools are eligible, the value of the grant and calculates the budget needed.
• Central government: the BOSDA program was a direct response to meet the funding shortfalls in the national BOS
program. Moreover, SBY’s promise of free education at the national level may have established the enabling
environment for districts to adopt programs that provide free education. Moreover, national law on education (Law
20/2003) mandates fee-free "minimal basic education" at primary and junior secondary school level.20
• CSO/media/donor: Pattiro carried out a USAID-funded program to calculate per student costs for schools in Malang
Municipality as well as the shortfall after BOS payments, which they claimed as the basis for the enactment of BOSDA.
On the basis of this calculation, they targeted members of the DPRD and the media to pressure the government to adopt
a BOSDA program. Madewa, the CSO network working in the broader Malang area, claimed that statements they made
through the media would then elicit responses from both the mayor and members of the DPRD. Madewa members also
acknowledged that this campaign took place against the backdrop of SBY's promises in the context of the 2009
presidential election to provide free education, although they did not attribute a determining role to these promises.
• DPRD: Madewa claims that the BOSDA was adopted as a result of CSOs approaching DPRD members to pressure
the mayor. One of the DPRD members they approached is the current deputy mayor, who took a special interest in
education issues.
18
Perwali 53/2013, Article 3(1): Satuan Pendidikan dasar yang diselenggarakan oleh pemerintah daerah dibebaskan/digratiskan dari segala jenis
pungutan).
19
A list of BOS and BOSDA payment rates and maximum allowable fees for each school in the 2010/2011 school year is provided in the appendices
of Mayoral Regulation no. 46/2010.
20
Article 34 (2), Law 20/2003 on a National Education System.
Case study 2: Malang Municipality
47
Ultimately, there is no doubt that national policy provided an enabling context for which BOSDA was adopted at the district
level. The actual adoption could have been through a direct response of the district head to both the national context and
to demands from the grass roots.
What processes and mechanisms led to the adoption of the BOSDA scheme?
The main process that led to the adoption of the BOSDA was the top-down process using the “responsive” mechanism.
Although there was grass roots pressure to provide free education for the poor, policy diffusion took place because the
national BOS program allocated insufficient funds to finance the operations of schools without needing to collect fees.
The Malang municipality government stepped in and financed the shortfalls in certain schools so that poor students could
attend schools without paying fees.
In anticipation of the new mayor’s policy of free education for all, the District Education Office, with several heads of
schools, went to Semarang for a comparative study, as Semarang had free education for all. The head of the District
Education Office also accompanied members of the DPRD to Surabaya to learn about their free education program, which
had been operating for seven years. Interviewees said that both programs were too complex to apply to Malang
municipality. One DPRD member said that in terms of learning from other districts, anywhere within Java was comparable
to Malang municipality, but due to a significant disparity between human resources in districts outside of Java, they were
not generally used as districts that East Java can learn from. Furthermore, a senior official within the District Education
Office said that she and a Semarang colleague discussed their free education program at a BOS socialisation event in
Solo, indicating that information sharing also happens at provincial-level events.
Motivation: Why was BOSDA adopted?
Similar to the adoption of Jamkesda schemes, adoption of BOSDA was also motivated by two factors: socialisation of
norms and electoral incentives. Like the provision of free health to the poor through Jamkesda schemes, the provision of
education services has become a “norm” for good governance in Indonesia. As a result, all local election candidates
feature health and education as part of their election campaign. Some even promise free health and education, although
there is not clear evidence that promises of free services are a winning strategy. Upon election, the successful candidate
(such as Malang Municipality’s new mayor) needs to try to fulfil these promises. In Malang Municipality, the new mayor
insisted on keeping to the promise of free education for all without providing sufficient funding. Some interviewees
reported that schools have had to reduce extra-curricular activities due to the funding shortfall.
Moreover, provision of free education, particularly for the poor, is such a core political issue in Malang that it also generally
receives universal support from the DPRD. Most interviewees said that the adoption of BOSDA was broadly supported by
the DPRD, and in fact some members raised the idea of allocating more funds to the scheme. When the new mayor
changed the policy to make education at all primary and junior high schools free, there were reportedly differences in
opinion within the DPRD, but ultimately the mayor’s policy prevailed.
Were there internal factors that influenced the adoption of BOSDA?
An advisor to the former mayor said that the main challenge with education policy in Malang Municipality was balancing
the demand from two groups. The first group was the poorer population who demand free education. The second group
was the better off population who demanded quality education and thus are more willing and have greater capacity to pay
fees. The former mayor said the poorer population is the more important political grouping (owing to their greater
numbers) in Malang Municipality, so they tried to balance the two group’s interest by adopting a "cheap and affordable"
education policy. Under this policy, education for the poor was to be free, whereas those who wanted to pay for better
education could do so. All schools thus received BOSDA, but only certain schools were prohibited from charging fees.
How did BOSDA change over time and what factors led to that change?
There were two main factors that influenced the BOSDA program during implementation:
1. Change in leadership: The new mayor's policy platform of preventing any primary school or junior secondary school
from charging fees required him to increase the per student rate for BOSDA grants. An education official said an
adjustment had been made in 2014, although there was no increase between 2014 and 2015. Even the increased
rate was not sufficient to cover all school operational costs. As a result, schools reduced extra-curricular activities
that could not be funded without collecting fees. The Education Office claimed that they have asked the DPRD for
additional funding to cover the expansion of the BOSDA program.
48
Case study 2: Malang Municipality
2. Fiscal capacity: According to the District Education Office, the Malang Education Board calculated that the unit
cost not covered by BOS to be IDR 179,000/student/month at junior high school level. The Education Office said
that the total budget allocated to BOSDA in 2014 of IDR 27 billion was insufficient to cover the total shortfall. [Note:
the research team was not successful in collecting the relevant budget documents to confirm the amount allocated
to BOSDA in 2014].
F. CONCLUSION
Most of the actors, processes and mechanisms of policy diffusion for Malang Municipality are the same as for Malang
District. The key difference between the two cases is Malang Municipality's greater fiscal capacity, enabling it to be more
responsive to policy stimuli from higher levels of government.
The effect of fiscal capacity is clearly visible in the differing responses of the two districts first to the provincial
government's move to initiate a Jamkesda scheme, and then to the commencement of the central government JKN
scheme. Although health was the greater priority in Malang District, it was Malang Municipality that was more responsive
in each instance. Malang Municipality chose to include roughly three times as many recipients in its Jamkesda scheme
than Malang District, despite having a lot less poor residents. Malang Municipality also immediately integrated most of its
Jamkesda participants into JKN in 2014. Malang District was still planning this integration at the time of writing, and was
hoping to achieve integration by transferring the burden of funding the Jamkesda participants over to the central
government.
Malang Municipality also responded to a national moment of pressure for free education in 2009 by enacting a BOSDA
scheme, although this decision was also in line with the local prioritisation of education. Insufficient information was
available to the study to conclude whether district decision to enact a BOSDA scheme only on a symbolic scale was the
result of its more limited fiscal capacity.
Case study 2: Malang Municipality
49
Case study 3: Ngada District
Ngada District probably adopted Jamkesda in 2011 and BOSDA in 2012/2013 as part of the new head of districts series
of flagship social and economic programs. This case study sets out the political, socio-economic and political contexts
under which the district adopted these two programs (see Sections A, B and C). Moreover, the case study explains how
and why Jamkesda and BOSDA spread to Ngada District (Sections D and E).
A. POLITICAL CONTEXT
Marianus Sae was a first term district head elected in 2010 with Deputy Paulus Soliwoa, beating the previous incumbent
Piet Jos Nuwa Wea, whose support base was split by the carving off of Nagakeo District from Ngada District in 2007. The
pair won 44 percent of the vote. Sae has been the PAN chairperson since 2008, and before entering politics was a
businessperson. He was nominated by a coalition of Islamic parties (PAN, PKB, PKS) and minor parties.
Sae has based his government around direct community spending. A community empowerment program, PERAK, and a
health insurance scheme for all Ngada residents, Jaminan Kesehatan Masyarakat Ngada (JKMN), were both election
promises, according to interviewees. He has since added a free education program (BOSDA, now rebranded as BOSDIK).
In line with his slogan, "Develop Ngada from the Villages" (Membangun Ngada dari Desa), Sae personally inaugurates
each village chief in the district. As part of a shift from spending on the government to spending on the community, Sae
has also kept the district head's office and DPRD in modest buildings.
Interviewees expect Sae to win re-election in 2015. His party PAN has experienced a surge in support during his tenure,
increasing its share of the legislature from two seats in a 30-member legislature in 2009 to seven seats in a 25-member
legislature in 2014.
B. SOCIO-ECONOMIC CONTEXT
Although Ngada District’s human development index in 2012 was ranked 333rd out of 474 districts in Indonesia (where
data is available), it performed relatively well within NTT Province. The district has one of the lowest poverty rates and the
highest human development index (HDI) scores in the province. Both its household per capita expenditure for the overall
population and for the poorest 20% of the population is relatively high, potentially reflecting the spending power of Ngada
residents.
Table 14: Summary of key district indicators, Ngada District, 2012
Ngada District
Poverty Rate (%)
NTT Province
11.33% (18/21)
20.88%
16,900 people (19/21)
1,012,500 people
70.13 (2/21)
67.75
Household per Capita Expenditure
IDR 488,132 (4/21)
IDR 410,907
Household per Capita Expenditure (poorest 20%)
IDR 242,712 (3/21)
IDR 171,055
Number of People Living below the Poverty Line
HDI
Source: BPS 2012. Data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Ngada District has relatively good health indicators in comparison to other NTT Districts. It performs well in the maternal
and infant related indicators with one of the highest proportion of births attended by a skilled health worker and it has one
of the highest immunisation coverage for children under five years old. Ngada also has one of the lowest morbidity rates
in the province.
50
Case study 3: Ngada District
Table 15: Summary of health indicators, Ngada District
Ngada District
NTT Province
Births Attended by Skilled Health Worker (in % of
total birth) (2011)
90.21% (2/21)
60.46%
Immunization Coverage for Children under 5 Years
Old (in % of children population under 5 years old)
(2011)
80.45% (5/21)
77.27%
34.52% (15/21)
39.81%
Morbidity Rate (in %) (2012)
Source: BPS (2011 and 2012) data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Compared to the rest of the NTT, the district has a moderate level of skilled health workers and health facilities. In terms
of numbers of village health clinics (Polindes), district health clinics (Puskesmas) and hospitals, it is ranked between 8th
and 12th in a province of 21 districts. Similarly, the number of midwives and doctors is similar to the provincial-wide
average.
Table 16: Summary of health facilities, Ngada District, 2011
Ngada District
NTT Province
Number of Doctors per 100,000 People
12.85 (12/21)
13.69
Number of Midwives per 100,000 People
76.41 (10/21)
71.95
Number of hospitals per 100,000 People
0.68 (12/21)
0.78
Number of Puskesmas and their Line Services per
100,000 People
27.72 (9/21)
25.58
Number of Polindes (Village Polyclinic) per 100,000
People
27.05 (8/21)
22
Source: BPS 2011. Data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Compared to the rest of the NTT, the district has a relatively strong education performance. It has one of the highest
literacy rates and primary school enrolment rates. Ngada also has higher junior and senior secondary school enrolment
rates than the provincial-wide average.
Table 17: Summary of key education indicators, 2012
Ngada District
NTT Province
Literacy Rate for Population Aged 15 and Over
96.92% (2/21)
88.73%
Net Enrolment Ratio: Primary
96.06% (2/21)
92.28%
Net Enrolment Ratio: Junior Secondary
60.53% (7/21)
55.89%
Net Enrolment Ratio: Senior Secondary
42.62% (7/21)
38.37%
Source: BPS 2012. Data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Case study 3: Ngada District
51
C. FISCAL CONTEXT
From 2007-2012, Ngada District’s nominal revenue only increased by 14.5% from IDR 397 billion to IDR 455 trillion. Real
revenue has actually decreased over this time.
Figure 12: Revenue has not increased significantly between 2007-2012
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Approximately 75% of Ngada’s revenue is sourced from DAU and DAK, thus it remains extremely reliant on transfers from
the central government. From 2007-2012, the proportion of total revenue derived from own-source revenue (PAD)
increased slightly from 4% to 6% although it remains small. A combination of no real increase in revenue for the district
over a six-year period and the continued reliance on DAU and DAK means that Ngada has limited discretionary funds to
finance its own priorities.
Figure 13: Ngada district remains extremely reliant on inter-governmental transfers
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Despite the limited total fiscal resources, Ngada’s per capita revenue of approximately IDR 3 million per person is ranked
7th out of 21 districts in NTT and is significantly higher than the provincial-wide average of IDR 2.2 million. Importantly, it
has one of the highest per capita own-source revenue in the province.
52
Case study 3: Ngada District
Table 18: Ngada District has relatively high per capita revenue amongst NTT Districts
Ngada District
NTT Average
Total General Allocation Grant (DAU)
IDR 2,277,860 (6/21)
IDR 1,618,836
Total Special Allocation Grant (DAK)
IDR 323,379 (9/21)
IDR 252,763
IDR 57,108 (1/21)
IDR 3,700
Total Natural Resource Revenue Sharing (DBH SDA)
Total Tax Revenue Sharing (DBH tax)
IDR 41,918 (20/21)
IDR 77,894
Total Other Revenue
IDR 184,594 (7/21)
IDR 170,445
Total Own Source Revenue (PAD)
IDR 188,601 (3/21)
IDR 118,520
IDR 3,073,460 (7/21)
IDR 2,242,158
Total Revenue
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
From 2007-2012, Ngada District’s APBD nominal expenditure only increased by 19% from IDR 377 billion to IDR 450
billion. In real terms, the APBD expenditure has decreased.
Figure 14: Ngada district’s APBD expenditure has been fluctuating.
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Approximately 76% of the APBD was spent on education, general administration and infrastructure in 2011. A comparison
of the 2010 APBD expenditure under the previous head of district with the expenditure in 2011 under the current district
head suggests that in his first year of office, the incumbent district head increased the proportion spent on education,
health and infrastructure, but reduced the proportion of total APBD spent on general administration, however, this change
in spending pattern may not be related to a change in leadership. Fluctuations from year-to-year are quite common.
Moreover, since the current district head was only elected into office at the end of 2010, the 2011 budget was actually
passed under the previous district (although budgetary amendments were made under the current district head’s
leadership).
Case study 3: Ngada District
53
Figure 15: The expenditure of total proportional spending
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Total nominal health expenditure has also not increased significantly from 2007-2011, when it only increased by 19%
from IDR 33 million to IDR 40 billion. The level of health expenditure in Ngada fluctuated significantly during this period,
with a peak of IDR 70 million in 2008 and a low of IDR 32 billion in 2010. With the exception of 2008, however, the total
proportion of health expenditure has remained between 8-10% of total expenditure. The spike in health expenditure in
2008 is probably due to a one-off activity, such as building a piece of health infrastructure.
Figure 16: With the exception of 2008, health expenditure has hovered between 8-10% of total expenditure in Ngada District
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Per capita health expenditure in Ngada is higher than the provincial average and is ranked 7th out of 21 districts.
Conversely, the monthly per capita household health expenditure is slightly lower than the provincial average.
Table 19: Health Expenditure in Ngada District, 2011
Ngada District
Per Capita APBD Health Expenditure
Monthly per Capita Household Health Expenditure
NTT Province
IDR 269,535 (7/21)
IDR 200,500
IDR 7,132 (9/21)
IDR 8,444
Source: BPS data (household expenditure) and Ministry of Finance data (APBD) extracted from the World Bank Indonesia-Dapoer
database in February 2015.
54
Case study 3: Ngada District
From 2007-2011, nominal education expenditure increased by 21% from IDR 108 billion to 130 billion. The proportion of
total APBD spending on education has also remained relatively steady at between 26-29% of the total budget. With the
exception of 2010, the level of funding for education has remained relatively stable.
Figure 17: The proportion of total APBD spent on education also remains relatively steady at between 26-29% of total expenditure
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Both the per capita education expenditure (from APBD) and the monthly per capita household education expenditure was
one of the highest in the province, potentially suggesting that education is an important spending item for both the Ngada
government and its residents.
Table 20: Per Capita Education Expenditure in Ngada District, 2011
Ngada District
Annual Per Capita Education Expenditure
Monthly Per Capita Household Education Expenditure
NTT Province
IDR 880,428 (6/21)
IDR 721,425
IDR 21,514 (3/21)
IDR 20,079
Source: BPS data (household expenditure) and Ministry of Finance data (APBD) extracted from the World Bank Indonesia-Dapoer
database in February 2015.
D. JAMKESDA IN NGADA DISTRICT
The Jamkesda scheme was adopted in a district where free health services were an election promise made by the current
district head. Fiscally, the district’s reliance on DAU and DAK funds means that it has limited fiscal capacity to finance its
own priorities. With 9% of its budget allocated to health spending, a proportion similar to other districts in Indonesia, the
spending mix does not suggest that health was a particular priority for the district.
Although Ngada District’s HDI is ranked 333 out of 471 districts (with data), the district performs well in all its
socio-economic indicators compared to other districts in NTT Province. Ngada has one of the lowest poverty rates and one
of the highest HDI in NTT. Its household expenditure was also one of the highest in the province. The district also performs
well in its health outcomes as it has one of the lowest morbidity rates and one of the highest immunisation coverage rates
for children under five in the province. This is the context under which Jamkesda was adopted.
1. Description of Jamkesda in Ngada District
Initiating Actor: The Ngada Head of District, Marianus Sae, promised a form of Jamkesda (locally funded health insurance
scheme) during the 2010 election and the scheme Jaminan Kesehatan Masyarakat Ngada (JKMN) was established after
the head of district issued a Bupati regulation (Perbup) in 2010. The scheme is considered one of his iconic programs, to
the extent that various interviewees said that it could not be discontinued while he was in office but that there was no
Case study 3: Ngada District
55
certainty it would continue if he was not re-elected.
Duration: Although the district head regulation was issued in 2010, the JKMN commenced shortly after (probably in
2011).
Form of scheme: JKMN mirrors the national Jamkesmas scheme, by funding treatment at community health clinics
(Puskesmas) and in the third class ward at the Bajawa Public Hospital (in the district capital). JKMN's technical guidelines
are copied directly from Jamkesmas, with the explicit aim that the two schemes provide the same coverage. As an
example, when the availability of government-funded maternity treatment was restricted to JKN (national health scheme
financed by the central government) participants, maternity treatment was added to JKMN to maintain equity between the
two schemes. However, referral to health facilities outside Ngada is not possible under JKMN, in contrast to the national
Jamkesmas/JKN scheme.
Legal Basis and Implementing Body: JKMN is regulated by a Bupati Regulation (Perbup), issued annually. Implementing
guidelines were issued in 2012, mirroring the Jamkesmas scheme. The budget for the treatment in health clinics is paid
to the District Health Office; the budget for hospital treatment is paid to the hospital. The district head rejected the use of
a third party insurance provider or integration with BPJS, ostensibly on the basis that use of a third party provider would
mean that the district forfeited unused premium funds each year.
Recipients: All Ngada residents who are not members of another government-funded insurance scheme are eligible to
receive JKMN. At the scheme's inception there were 71,000 participants. Health officials estimated there are now 83,000
participants. Although anyone is eligible to receive treatment by showing a Ngada residential ID card or a JKMN card,
there is an informal expectation that only the poor will access treatment under the scheme. A Health Office senior official
said wealthy residents would be embarrassed to use the scheme, and hospital staff clearly felt wealthy residents were
ineligible to receive free treatment, although they said they had no authority to deny treatment.
Funding: Different officials provided different estimates of the annual funding to the scheme, with IDR 6 billion the most
commonly cited figure. The commonality in descriptions of the scheme by those who administer it directly is that the
funding allocation is insufficient. Both the hospital and health office said funds run out late in the year, with no funds
remaining during the October-December period. A senior health official said increases in funding to the scheme had not
kept pace with increasing numbers of participants.
2. How did Jamkesda spread to Ngada District?
Agents: Who pushed for the adoption of Jamkesda?
All interviewees were in agreement that the head of district (Bupati) was responsible for the decision to adopt the Jaminan
Kesehatan Masyarakat Ngada (JKMN). Ngada District’s Regional Secretary (Sekda) said that prior to 2010, Jamkesda
already existed on paper but was not supported with funding. When the current head of district took office in 2010, he
made Jamkesda a strategic program in the RPJMD and allocated funding.
The Ngada Health Office then designed and created the JKMN program based on the Jamkesmas’s technical guidelines.
The budget team (TAPD) and the Health Office agreed to the budget allocation before presenting it to the DPRD for
discussion. According to the Ngada Public Hospital, the Health Office did not consult the hospital during the JKMN design
process. The hospital said that the actual cost was higher than initially forecasted because the Health Office based the
calculations on pre-JKMN utilisation rates, whereas the availability of JKMN had led to an increase in the utilisation of
hospital services.
Overall, the DPRD was supportive of the JKMN scheme and did not question the need for the program. Although the
research team did not obtain specific details, the team’s overall impressions from the interviews was that JKMN
discussions between the budget team (TAPD), the Health Office and the DPRD was not protracted or heated.
Numerous interviewees in fact characterised the DPRD’s involvement in health policy reporting health service problems
faced in the field and requesting the bureaucracy to provide an appropriate response. The Ngada Public Hospital, for
example, said that when there is a dispute over payments, the patient often takes the dispute to the DPRD (with a small
number reporting such disputes to the media) to seek their assistance in resolving the dispute. The Ngada Health Office
also said that when a user complains about Puskesmas services to the DPRD, the Health Office is then called upon to
provide clarification.
The DPRD may also request additional budget to be allocated based on findings from the field. For example, the DPRD
may find that the villages they visited lack midwives and thus may request funding for villages to hire more midwives.
Thus, disputes between the DPRD and the Health Office are more likely to arise due to differences in implementation
details, rather than the policy itself. Another example cited by the Regional Secretary was when DPRD members
questioned the location of ambulances (not all Puskesmas have ambulances) and whether the budget for ambulances
56
Case study 3: Ngada District
included costs for a driver and petrol.
Ultimately, the DPRD are weak policy actors as they rarely engage in the overall policy direction but focus on specific
details of implementation that emerge in their field visits. The limited policy engagement may also reflect the limited
knowledge and capacity of the DPRD members. For example, 14 out of the 25 DPRD members elected in 2014 are
first-time members. Overall, the research team did not obtain any information that would suggest that the DPRD played a
meaningful role in the adoption of the JKMN.
Similarly, there was no evidence to suggest that CSOs were important to the adoption of Jamkesda. Ngada did not have
many CSOs and donor-funded programs and Catholic school-related organisations dominate the non-governmental
institutional landscape. Moreover, most local non-governmental organisations worked in the field of service provision
rather than policy advocacy. As a result, the research team did not identify a CSO that worked on health policy advocacy.
The media landscape in Ngada District was similarly small. The two mainstream newspapers are Pos Kupang and Flores
Pos, the former a province-wide newspaper and the latter an island-wide newspaper. Neither newspaper is dedicated to
reporting on Ngada. Two new Ngada-based newspapers emerged in 2015 but only publish on a fortnightly basis.
Moreover, the majority of health-related media coverage is case-centric, where coverage can be both positive and
negative. Journalists interviewed said they often write about cases of maternal and infant deaths, about Pusling (mobile
Puskesmas) and Puskesmas facilities and services (or lack thereof). The journalists admitted that they rarely engage with
the substance of the health policy. One journalist said that he once wrote a longer piece on Ngada where he used health
data to show the proportion of villages that do not have any health facilities and the difficulty of reaching health facilities.
This longer piece seemed an exception to the otherwise case-based reporting.
Overall, interviewees from the DPRD, bureaucracy, CSOs and media all associate the program as one of the district head’s
flagship programs that commenced after he took office in 2010.
Process and mechanism: What led to the adoption of the Jamkesda (JKMN) scheme?
Similar to other districts, Jamkesda was a response to the fact that Jamkesmas did not cover all residents in the district
who were poor and could not pay. The Secretary of the Health Office said that Jamkesmas created discontentment within
the community because their criteria for membership was unclear and residents who believed they were “poor” were not
part of the scheme.
Ngada’s JKMN scheme, however, did not just extend free health coverage to those who were poor. The scheme
theoretically covered all Ngada residents who did not have access to other health insurance schemes such as
Jamkesmas. According to the Secretary of the Health Office, the district extended the scheme to 71,000 participants
initially, which then expanded to 83,000 (around half of the district’s population).
According to the Health Office, while they did do internet research on Jamkesda schemes elsewhere, the only reference
they used to design the JKMN scheme was the Technical Guideline of the Jamkesmas program. The Health Office was
careful to ensure that the benefits for JKMN were the same as those for the Jamkesmas in order to avoid any resentment.
The only difference between the two schemes is that JKMN only covers state hospitals in Ngada whereas Jamkesmas
covers hospital treatment outside of Ngada.
The District Health Office said that they did not conduct any study trips to other districts to develop the JKMN scheme,
although they had heard that Kupang municipality and Jembrana also ran local health insurance schemes without
indicating whether they conducted any further research.
The main form of horizontal learning from other districts often cited by the Ngada government was the sister-hospital
partnership with Sarjito Hospital in Yogyakarta and the Udayana and Sanglah Hospitals in Bali. These partnerships were
facilitated by the Australia Indonesia Program for Maternal and Neonatal Health (AIPMNH). Under this sister partnership
program, the Ngada Public Hospital brought specialists and residents from the sister hospitals to both provide medical
treatment support and capacity building. Interviewees from the Ngada Public Hospital said that the partnerships had
been effective in improving various aspects of hospital administration, including the referral and billing systems.
Motivation: Why was Jamkesda adopted?
The district head commenced the JKMN program as part of a string of programs that commenced shortly after he took
office to both fulfil his campaign promises and to establish his “pro-people” image. One interviewee said that the current
head of district differentiated himself from the previous district head by the way he allocated the APBD. The previous
district head was a bureaucrat and the funds stayed with the bureaucracy (presumably to pay for the costs of the
bureaucracy). In contrast, the current head of district allocated money directly to the community for health and education.
Case study 3: Ngada District
57
A critique from some interviewees was that although spending money on the community was a positive development, the
district head did not establish the systems needed to ensure proper use of funds. This critique is supported by accounts
from other interviewees. For example, the Ngada Hospital said not only were the funds from JKMN exhausted after nine
months, and the reimbursement process was more complex than the Jamkesmas/JKN process. Moreover, journalists in
Ngada also said that the use of BOSDA funds was less transparent than BOS funds.
Numerous people discussed the JKMN program as part of the district head’s ambition to be seen to be “merakyat” or “for
the people” in order to be re-elected in 2015. One interviewee said that the district head’s key political capital is his ability
to highlight all the programs he has initiated. In addition to the “pro-people” programs, his man of the people image was
further strengthened through his approach to community engagement. The head of the District Planning Agency said the
district head reserves Tuesdays and Thursdays to “coffee mornings” when he meets members of the community and
listens to their concerns. The district head also insists on inaugurating every village head personally. He also often rides
out to the villages wearing shorts and a helmet so that the head of the sub-district (Camat) does not recognise him. The
district head also plays soccer matches between the community and the district government.
Both his flagship programs (including JKMN) and the direct engagement with the community were therefore part of the
district head’s political strategy in his quest for re-election.
Internal factors: Were there internal factors that influenced the adoption of Jamkesda?
Availability of funds was clearly a factor in the design of JKMN. The District Health Office said that the budget team (TAPD)
provided a total amount for the scheme and the Health Office then forecasted a unit cost and the number of participants.
Although the budget forecast was based on a unit cost of IDR 7,200 per person per month, the actual cost of the program
was based on the treatment provided at the health clinics and hospitals. The TAPD had informed the Health Office that if
the budget was insufficient, they could request additional funds through the budget amendment process.
As with so many Jamkesda schemes in the country, the budget allocated was insufficient. The Health Office admitted that
the JKMN budget was completely absorbed after only nine months and reimbursements to the hospital for the final three
months could only be paid using the following year’s budget. The Ngada Hospital said that the shortfall had a significant
impact on the hospital’s ability to pay for medicine thus patients had to cover this shortfall. Numerous interviewees did
assert that medicine was in fact not free for JKMN participants, despite the government’s promise of free healthcare.
Despite budgetary troubles, the JKMN received a significant share of the district’s health budget because free health was
a top priority for the district head. Due to its importance, the program was extremely ambitious in its coverage.
Was “success” an important factor for adopting Jamkesda?
The research team did not find any evidence that the “success” of Jamkesda programs elsewhere were important to the
district’s decision to adopt the program. As mentioned above, the district government did not seek to learn lessons from
other districts, but followed the national Jamkesmas program.
Moreover, there was limited indication that “success” towards achieving health outcomes was an important consideration
for the continuation of the program. No evaluations were conducted to better understand whether health outcomes were
improved as a result of greater access to free health services. The Ngada Hospital said that the hospital and Bappeda did
evaluate the JKMN and the outcome of the evaluation was the simplification of the administrative program. The hospital,
however, said that the evaluation did not resolve the bigger problem that it was not a well-targeted program and costs
were unclear. The DPRD also has never conducted an evaluation of JKMN, but has mostly reported complaints and
organised meetings to clarify those complaints.
Numerous people indicated that the JKMN would continue in its current form, despite the implementation problems
encountered, because it was a key political tool for the district head.
Implementation: How did Jamkesda change over time and what factors led to that change?
Changes in national policy: The main factor that resulted in a change in the JKMN program was the change in national
policy. Initially, JKMN did not cover maternity because it was covered by a central government scheme Jaminan Persalinan
(or Jampersal). Under BPJS, however, only BPJS participants were covered for maternity treatment. The district then
changed the JKMN so that the scheme covered maternal care.
Where national policy is in direct opposition to the interests of the district head, however, districts can successfully resist
following the national policy. Unlike other districts surveyed in this study, Ngada District has no intention of integrating its
58
Case study 3: Ngada District
JKMN scheme with the national JKN scheme under BPJS despite the clear incentives to do so.
Hospital staff expressed their preference for JKN because it would simplify their administrative burden as they would only
need to do one claim, eliminating the duplication of JKMN and JKN participants. Moreover, the hospitals found that BPJS
was more reliable in paying claims. From a planning perspective, costs are much more predictable because the unit cost
is the cost of the premiums rather than cost of actual treatment.
Two reasons account for Ngada’s resistance to integration. First, the district does not have the budget to cover premiums
for all 83,000 JKMN participants. JKMN cost forecasts are based on a monthly unit cost of IDR 7,200 per person. JKN’s
monthly premium is IDR 19,225 and would almost triple the district’s burden if every JKMN participant became a PBID
(JKN participants with its premiums paid for by the sub-national government). Second, the JKMN is a political tool for the
district head and as he faces re-election in September 2015, he needs to demonstrate the benefits he has delivered to
his people during his first term in office. Integrating JKMN into JKN would dilute this message. A senior health official said
under the current government, it would be impossible to stop JKMN. Even if integration took place, the official said, there
would probably still need to be a JKMN “plus” program that remained associated with the district head.
Change in district head: Opinions differ as to whether the JKMN would continue under a new district head, should the
incumbent head not be re-elected in September 2015. The Ngada Hospital, for instance speculates that given that JKMN
is the flagship program under the current district head, a change in leadership may result in the program being
discontinued. The district facilitator for AIPD, however, believes that it would be politically impossible for a new district
head to stop a program like JKMN because of the potential impact on the community. He argued that if the program is
terminated, it must be replaced with a program that provides an equivalent service.
E. BOSDA IN NGADA DISTRICT
Free education was not an election promise. The district head announced it as a priority during an Independence Day
address part way through his term after identifying a need to reduce the number of students leaving school due to
financial difficulties. Fiscally, there was no indication that education was a particular priority for Ngada with between
26-29% of the APBD spent on education, which is comparable to other districts in Indonesia. Ngada performs well in the
education sector compared to other districts in NTT (although lower than both Malang District and Municipality). It has one
of the highest literacy rates in NTT and also has relatively high enrolment rates for all levels of schooling.
1. Description of BOSDA in Ngada District
Initiating Actor: BOSDA is personally associated with the current Head of District, Marianus Sae. The Education Office
head said the district head provided the scheme's broad orientation, and his office was given the task to articulate the
idea into a program.
Duration: The scheme appears to have started in 2013, based on media reports, although some interviewees said 2012.
Form of scheme: The district government finances an honorarium for contract teachers (tenaga honor) at primary and
secondary schools, which is currently IDR 750,000 per month. Prior to the scheme, these teachers were paid by means
of fees levied on students by local school committees. In its original form, the scheme may have also paid operational
funds to schools, in the manner of BOSDA schemes in Malang for instance, but the District Education Office head said he
had stopped these payments as the schools had failed to acquit them on time. Both government and private (Catholic)
schools were eligible to receive these payments.
The scheme also pays IDR 5 million in operational funds to pre-school education centres (PAUD). Since its inception, the
scheme has expanded to fund IDR 2.5 million of annual payments to Ngada university students studying anywhere in
Indonesia. In order to incorporate these payments, and in anticipation of establishing a university in Ngada, the scheme
has changed name from BOSDA to BOSDIK.
The district also finances a number of Ngada students to study medicine, but it is not clear whether these payments are
considered to be part of BOSDIK.
Legal Basis and Implementing Body: Interviewees did not identify a specific regulation governing BOSDA and BOSDIK. As
the schemes started in the middle of the government term, they are not specifically mentioned in the RPJMD. They are
deemed to be part of a program in the RPJMD, possibly the 9 years of compulsory education program.
Recipients: according to the Education Office 1,130 contract teachers are financed by BOSDA payments. PAUD centres
receive IDR 5 million in operational funds. Any Ngada student studying at a university is eligible for a BOSDIK scholarship
payment.
Case study 3: Ngada District
59
Funding: BOSDA/BOSDIK is funded from the APBD through the Education Office. The Education Office Head estimated
the current allocation to the scheme was over IDR 10 billion.
2. How did BOSDA spread to Ngada District?
Agents: Who pushed for the adoption of BOSDA?
Similar to JKMN, BOSDA is one of the district head’s flagship programs that commenced under his leadership. One
interviewee said that district head expressed his ambition to provide free education through BOSDA at an Independence
Day speech. Although the program was not included in the initial RPJMD, BOSDA still received APBD funding because
Askeskin justified it as an activity under the “children can go to school” program. The insertion of BOSDA into the RPJMD
during the district head’s third year in office both highlights the power and the limitation of the bureaucracy. The
bureaucracy exerted its power over elected officials by using the RPJMD to control which programs would be eligible to
receive APBD funding. On the other hand, the bureaucracy was relatively powerless in the face of pressure from the
district head.
The bureaucracy also played an important role in BOSDA because the Education Office was responsible for designing the
program, specifically the grant amounts for schools and how they could be used. In doing this, the head of the Education
Office gathered principals to identify what funding challenges schools faced. Based on these discussions, the BOSDA
grants were used to pay for honorary teachers (tenaga honor). According to the head of the Education Office, schools were
initially permitted to use the BOSDA funds to pay for operational costs, but that ceased because the schools were not
acquitting the funds on time.
The discussion with the DPRD on the adoption of BOSDA was allegedly protracted. Interviewees identified two points of
difference. First, DPRD members tend to favour physical projects. A former member of the DPRD said that the district
head had obtained the support of the head of the DPRD and he assisted with persuading the rest of the legislature.
Second, debate on BOSDA was protracted because of differences in opinion on the merits of providing free education for
all citizens. As one DPRD interviewee said, the problem was that BOSDA provided the same benefits to all students,
regardless of their ability to pay.
Most interviewees said that the differences of opinion in the DPRD were not generally along party lines, but more based
on individual interests. While political party differences were not important, one interviewee did say that four of the five
factions in the DPRD supported BOSDA indicating that factions do play some role, even if small, in DPRD operations.
Despite the differences in opinion, the head of district prevailed and the DPRD passed the budget allocation for BOSDA.
One member of the DPRD who opposed BOSDA said that he was penalised for his opposition as his “aspirational” projects
were reduced, namely the community initiatives specifically allocated to his electorate.
The debate over whether the government should adopt a free education policy also extends to CSOs. Catholic schools in
Ngada were not necessarily anti-BOSDA because the grants were also extended to private schools. Catholic schools,
however, are vehement opponents of a free education policy because private schools cannot compete against free state
schools. They are a strong constituency with sway over both the district head (who is always Catholic) and the DPRD. For
example, a former head of the Catholic schools organisation (Yasukda) and a former DPRD member said that after the
Independence Day speech when the head of district announced that the government would provide free education, he
immediately condemned the announcement in a media interview.
The current head of Yasukda said that they wrote directly to the President and the Ministry of Education protesting the
central government’s move towards providing free education for all because it goes against the century-old tradition that
education is not free. The opposition to free education was part of an ongoing campaign by the CSO to promote the
position of Catholic education in the region, which included dialogue with the district head, the DPRD, the media and
school committees and public discourse at seminars.
The success of the Catholic schools’ advocacy against free education was reflected by the fact that according to the head
of the Ngada Education Office, the district does not have a free education policy. The district’s priority is to improve the
quality of education, despite the fact that their flagship funding programs is BOSDA, a program focused on increasing
access rather than improving quality. Ngada’s other significant education program is a scholarship scheme, which also
focus on improving access rather than quality.
In contrast to the strong role that CSOs played in the education policy debate, there was no suggestion by interviewees
that the media played any role in the process of adopting BOSDA. One interviewee said they thought the Ngada
District Government used the media to socialise the BOSDA program.
The journalists themselves said they do not cover broader education policy issues. They said media coverage generally
consists of two types of stories. First journalists report on criminal cases such as sexual abuse and assault and the
60
Case study 3: Ngada District
government fully supports this type of coverage. Second, the media report on cases in relation to provision of education
services. These stories may be positive or negative. For example negative stories may highlight cases of schools
deteriorating and the poor physical facilities. The journalists interviewed said that even without media coverage, the
government would eventually respond to a problem but it would be prolonged as it considers each individual story a minor
case that does not have broader implications. The media, however, prompts governments to respond faster as they are
able to portray the issue in more emotive terms.
The Ngada District, for example, shows both the power and limitation of the media. Their news stories influence
government behaviour but as the media does not engage in the policy debate, they do not pressure governments to policy
reform or change.
Process and mechanism: What led to the adoption of the BOSDA scheme?
Similar to other districts, the BOSDA program spread to Ngada District as a response to the fact that the central
government’s BOS program did not provide sufficient funding to cover the operational costs of schools. Thus, the spread
of BOSDA was through a top-down process, where the central government policy influenced the development of the
District Government.
The district government decided to use BOSDA funds to pay for honorary teachers (tenaga honor), because of the central
government policy to limit hiring civil servants. As a result, the government was not able to recruit sufficient civil servant
teachers to replace those that retired. As explained by the head of the Education Office, only 15% of the BOS funds were
allowed to be used to pay for teachers, and thus BOSDA was needed to provide monetary incentives for honorary teachers.
Thus, both the decision to adopt BOSDA and earmarking funds for teachers’ salaries was a “response” to the perceived
deficiencies in the central government policies and programs.
There was also a “coercive” element to the central government’s policy. When BOS first commenced, the grants were part
of the national government’s policy to provide free education to the poor. In 2012, the policy changed to free elementary
education (primary and junior high school) and to support this policy the central government increased the value of the
BOS grants. Numerous interviewees said that around that time, the BOS program put up banners at all the state schools
stating that education was free and schools should not be charging fees. The Head of the Education Office said that the
problem with the banners was that in reality education was not free because BOS only covered 13 components in schools
and schools still needed to raise funds for other activities. He said the expectation of free education means that parents
are now unwilling to pay for education, leading to many people complaining directly to the DPRD and to the Education
Office.
The research team was not able to ascertain whether other districts influenced Ngada’s BOSDA program. Although one
DPRD member said that BOSDA was a result of the district head’s visit to Java, most interviewees from the bureaucracy
said that Ngada government did not have the budget for visits to other districts.
The Ngada Government, similar to the three other districts surveyed in this study, was reluctant to admit that they went
on any study trips. The only example of a study trip cited by the Education Office was in 2014 when the district head and
the regional secretary (Sekda) led a study trip with all state and religious high school principals to schools in Denpasar
(Bali) and Bandung. One interviewee said the trip was also used to reward principals for the 100% pass rate of their Ngada
high school students, placing them number one in the province.
On this trip they visited two high-performing schools chosen by the mayors of the two municipalities. According to the head
of the Education Office, the main lesson learnt from the trip was teachers’ effectiveness in disciplining students (for
example, if students arrived late to class). By contrast, the interviewee said that the Education Office in Ngada spent their
time disciplining their teachers. After the study trip, a MoU was signed between the principals and the district head on the
agreement that all schools would integrate the lessons learnt from Bali.
Motivation: Why was BOSDA adopted?
The BOSDA program was not part of the series of pro-people programs initiated by the district head to meet election
promises. The program only started in 2012/2013 in his third year in office. The emergence of the program was both a
combination of the government’s realisation of a genuine need, an expectation from the community that education should
be free and aligning with the district head’s “pro-people” political strategy.
According to the head of the District Education Office, the district head believed that the government needed to intervene
to prevent students from dropping out of school because it was unaffordable and due to physical access problems.
Moreover, the central government banners that were placed in schools proclaiming free education created an expectation
amongst communities that schools should not be charging. Thus, the government needed to act to meet this expectation.
Case study 3: Ngada District
61
Finally, BOSDA was a program that channelled funds directly to the community and further strengthened the district
head’s pro-people credentials.
In fact, according to an interviewee who opposed the BOSDA program, one of the key threats placed on DPRD members
was that they would be shamed as not being “pro-people” if they did not support the allocation of funds to BOSDA by
terminating “aspirational” projects for his electorate.
Were there internal factors that influenced the adoption of BOSDA?
Numerous interviewees pointed out that BOSDA was limited by the Ngada Government’s fiscal space. The head of the
District Education Office said that of the IDR 21 billion for non-salary related spending, the district only had around IDR 3
billion of discretionary funds. This is because DAU is generally used to implement mandatory activities and the DAK funds
are already earmarked. The head of Yasukda (CSO advocating for Catholic education) said that while BOSDA was meant
to bridge the difference between actual costs and BOS, it was in fact allocated based on the fiscal capacity of the district.
Was “success” an important factor for adopting BOSDA?
The research team found no evidence that the District Government assessed whether BOSDA was “successful” in other
districts before the program commenced operations.
In terms of success towards improving education outcomes, senior government officials told the research team that
Ngada had improved its school pass rate significantly. The head of the Education Office said that Ngada was previously
ranked 16th or 17th in senior high school pass rate. In 2014, however, it was ranked number one in NTT as one of only
two districts in the province to achieve a 100% pass rate at the senior high school level. Ngada was also one of 10 districts
in NTT to have a 100% pass rate at the junior high school level. The difficulty is that no evaluations were conducted to
assess whether it was BOSDA that contributed to the improved pass rates. The research team have not confirmed the
Ngada government’s claims of success with published data.
Implementation: How did BOSDA change over time and what factors led to that change?
BOSDA has expanded its coverage of schools since the program commenced in 2012/2013. The initial program only
covered basic education and senior high school. The program was subsequently expanded to cover pre-school education.
In 2014, BOSDA became BOSDIK and its coverage included providing scholarships to Ngada students for tertiary
education.
The research team did not gather sufficient data as to what were the factors that led to the expansion of BOSDA. The
Education Office said that they believed that improving education access needed to start at the pre-school levels, and that
the district head’s ambition to establish a university in Ngada led to the change from BOSDA to BOSDIK. A DPRD member
who opposed BOSDA from the outset believed that providing scholarships for tertiary studies was part of the district
head’s re-election strategy as the recipients are of voting age. Speculatively, the BOSDA expansion is probably a
combination of both a legitimate demand for more funding education service providers and as part of the district head’s
political strategy.
BOSDA also changed as a result of lessons learnt during the implementation process. The head of the Education Office
said that they now check and validate whether teachers show up to schools, rather than believing data submitted by
schools. The Education Office also found that teachers hired were often based on personal connections rather than
competency and that the teachers were not always evenly spread based on needs. Thus, the Education Office intervened
in the recruitment and placement decisions of the schools, which resulted in many complaints from school boards,
principals and the families of the students.
Two other factors may result in a change to BOSDA during implementation: a change of district head and a change of the
head of the Education Office. In Ngada, interviewees said that a change in the district head would inevitably result in
changes to government programs whereas the head of the Education Office merely implements the district head’s orders.
The head of the District Education Office did in fact change in 2012 with reportedly no significant changes to the districts’
education programs. Conversely, senior officials from the Education Office expressed doubt as to whether
BOSDA/BOSDIK would be continued under a new district head.
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Case study 3: Ngada District
F. CONCLUSION
The Ngada case exhibits several factors familiar to other cases. The district adopted BOSDA and JKMN in response to
central government programs that the district government perceived had not achieved their aims in the district. JKMN was
closely modelled on one of these programs, Jamkesmas. The district head and bureaucracy were key actors to the policy
process, whereas DPRD, media and CSOs were not influential. The imperative to be pro-people was an important
motivation for adoption, and labelling programs as not pro-people could be used to silence critics.
Ngada was distinct in several ways, however. In particular, the role of the district head was much more pronounced in
Ngada than in other districts. Direct community spending was clearly a central platform of the district head’s political
program. JKMN and BOSDA were just two of the district’s ambitious direct-spending programs. Both programs were
personally associated with the district head, and the scope of each program expanded over time. This personal
association meant that the programs were less responsive to changes in central government policy – although JKMN was
amended to make sure that central government-provided health benefits did not outstrip their coverage. Ngada was the
only district to refuse integrating its health security program with BPJS Kesehatan.
The personal association of JKMN and BOSDA with the district head also reflects the degree of power wielded by the
district head in Ngada, which seemed distinct to the other districts visited. His power appeared consistent with the
observation of one interviewee that claimed as you move east in Indonesia, transparent governance decreases and power
becomes more concentrated in the figure of the district head. The district head was personally associated with every
aspect of his flagship programs, and may have played a greater role in budget discussions than in other districts.
Finally, the media and CSO landscape was much smaller than in the other districts visited. This may reflect Ngada’s
location, as the only district in this study that is far away from the provincial capital or other significant urban centres. The
strongest non-government actor was in fact the Catholic Church, which maintained an extensive school network. Although
few CSOs were active, the strength of the Catholic schools shows the power of non-governmental groups that have a
strong constituency.
Case study 3: Ngada District
63
Case study 4: West Lombok District
West Lombok District adopted Jamkesda in 2009. The district has not yet adopted a BOSDA program, but in 2014 it
passed a Bupati Regulation (Perbup) that included reference to a BOSDA program. No funding has been allocated to
BOSDA, however. This case study sets out the political, socio-economic and political contexts under which the district
adopted Jamkesda (Sections D and E). Moreover, this case study discusses the process towards passing the education
regulation and the district’s resistance to BOSDA despite its inclusion in the regulation.
A. POLITICAL CONTEXT
West Lombok was led by Zaini Arony, a second-term district head who was also chairperson of the provincial Golkar branch
until his arrest on corruption charges in March 2015. Arony was re-elected with 61 percent of the vote after a first term
centred on infrastructure development.21 Prior to his arrest he was tipped as a strong candidate to succeed Governor
Muhammad Zainul Majdi at the conclusion of his second term, after also running unsuccessfully for governor in 2008
(Kingsley, 2012). He was formerly a bureaucrat in the national Education Ministry. Arony’s deputy, former provincial
election commissioner Fauzan Khalid, has taken over while Arony faces prosecution.
B. SOCIO-ECONOMIC CONTEXT
West Lombok is one of the poorer and less socio-economically developed districts in NTB. At 17.91%, the district has the
4th highest poverty rate in NTB, although the rate is slightly lower than the provincial average of 18.63%. The district also
has one of the highest numbers of people living in poverty in the province and one of the lowest Human Development
Indexes (HDI). The district’s household per capita expenditure is also lower than the provincial average.
Table 21: Summary of key district indicators, West Lombok District, 2012
West Lombok
Poverty Rate (%)
Number of People living Below the Poverty Line
NTB Province
17.91% (4/10)
18.63%
110,500 (3/10)
852,600
HDI (2011)
62.5 (8/10)
66.23
Household per Capita Expenditure
IDR 416,522 (7/10)
IDR 510,918
Household per Capita Expenditure (poorest 20%)
IDR 196,084 (7/10)
IDR 204,790
Source: BPS 2011 and 2012. Data extracted from the World Bank Indonesia-Dapoer database in February 2015.
West Lombok has a mixed performance in health outcomes. It has the lowest morbidity rate in the province, and the 3rd
highest proportion of births attended by a skilled health worker. Conversely, the proportion of children under five immunised is lower than the provincial average.
Table 22: Summary of health indicators, West Lombok District, 2011
West Lombok
Births Attended by a Skilled Health Worker (in % of
total birth)
Immunization Coverage for Children under 5 Years
Old (in % of children population under 5 years old)
Morbidity Rate (in %)
NTB Province
88.36% (3/10)
82.11% (7/10)
83.62%
23.39% (10/10)
34.75%
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
21
64
Vote count based on the Constitutional Court Decision on the election.
Case study 4: West Lombok District
84.02%
West Lombok also does not have as many health facilities and health workers, compared to other districts in NTB, ranking
either 7th or 8th out of 10 districts in NTB, and lower than the provincial average.
Table 23: Summary of health facilities, West Lombok District, 2011
West Lombok
Number of Doctors per 100,000 People
NTB Province
6.74 (7/10)
11.10
Number of Midwives per 100,000 People
24.86 (8/10)
39.21
Number of Hospitals per 100,000 People
0.16 (8/10)
0.37
Number of Polindes (Village Polyclinic) per 100,000 People
2.25 (7/10)
6
11.39 (8/10)
14.63
Number of Puskesmas and their Line Services per 100,000 People
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
West Lombok District performs relatively poorly in education outcome indicators. Although it’s primary and junior
secondary school net enrolment rates are similar to the provincial average, it has one of the lowest literacy rate and the
lower senior secondary school net enrolment rate in the province.
Table 24: Summary of key education indicators, 2012
West Lombok
NTB Province
Literacy Rate for Population Aged 15 and Over (in %
of total population)
78.59% (8/10)
83.68%
Net Enrolment Ratio: Primary
95.54% (1/10)
93.56%
Net Enrolment Ratio: Junior Secondary
79.56% (4/10)
77.81%
Net Enrolment Ratio: Senior Secondary
34.59 % (10/10)
53.31%
C. FISCAL CONTEXT
From 2007-2012, the total revenue (nominal) in West Lombok increased by 52% from IDR 559 billion to IDR 852 billion.
Figure 18: Revenue in West Lombok has fluctuated between 2007-2012
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
The increase in revenue was predominantly due to significant increases in own-source revenue (increased by 157%) and
other revenue (580%). Despite the increase in own-source revenue, West Lombok remains reliant on DAU and DAK, which
still represents 72% of the total revenue.
Case study 4: West Lombok District
65
Figure 19: West Lombok district remains extremely reliant on inter-governmental transfers (DAU and DAK) but own-source
revenue (PAD) has been increasing
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
West Lombok has one of the lowest per capita revenues in NTB and has one of the lowest per capita revenues in
Indonesia (ranked 400 out of 471 districts). Compared to other districts in NTB, however, it has a relatively high own
source revenue.
Table 25: West Lombok District has a relatively low per capita revenue amongst NTB Districts, although has a relatively high per
capita own-source revenue (PAD)
West Lombok District
NTB Average
Total General Allocation Grant (DAU)
IDR 888,256 (8/10)
IDR 1,080,694
Total Special Allocation Grant (DAK)
IDR 96,823 (7/10)
IDR 117,490
IDR 8,174 (9/10)
IDR 30,521
Total Natural Resource Revenue Sharing (DBH SDA)
Total Tax Revenue Sharing (DBH tax)
IDR 59,665 (9/10)
IDR 86,670
Total Other Revenue
IDR 162,020 (8/10)
IDR 213,379
Total Own Source Revenue (PAD)
IDR 151,449 (4/10)
IDR 122,946
IDR 1,366,388 (8/10)
IDR 1,651,700
Total Revenue
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Similar to other districts surveyed in this study, approximately two-thirds of the total APBD is allocated to education and
generation administration functions. Since 2007, the function that has grown the quickest in the APBD is infrastructure,
reflecting the district head’s focus on this sector during his first term in office (2008- 2013).
Table 26: Two thirds of total APBD in 2011 is spent general administration and education
IDR Billion
% Total Expenditure
% Change (2007-11)
Education
304
36%
53%
General Administration
247
29%
33%
Infrastructure
107
13%
105%
80
10%
58%
Health
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
66
Case study 4: West Lombok District
From 2007-2012, the total APBD expenditure increased by 56% from IDR 554 billion to IDR 866 billion.
Figure 20: West Lombok District’s expenditure has been fluctuating
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Although health spending has increased since 2008 from IDR 51 billion to IDR 80 billion in 2011, the total budget
allocated to health has actually decreased since 2008.
Figure 21: The proportion of the total APBD spent on health fluctuates in West Lombok
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Per capita health expenditure, both APBD and household per capita, is one of the lowest in NTB Province. The reduction
in total health expenditure since 2008 and the small per capita spending reflects that health may not be a significant
priority for the district.
Case study 4: West Lombok District
67
Table 27: Health Expenditure in West Lombok, 2012
West Lombok
Per Capital APBD Health Expenditure (in IDR)
Monthly Per Capita Household Health Expenditure (in IDR)
NTB Province
IDR 130,489 (8/10)
IDR 142,396
IDR 5,619 (10/10)
IDR 12,662
Source: BPS data (household expenditure) and Ministry of Finance data (APBD) extracted from the World Bank Indonesia-Dapoer
database in February 2015.
Education expenditure has also increased 53% from IDR 199 billion in 2007 to IDR 304 in 2011. The proportion of APBD
spent on education generally hovers around 36% and receives the largest budget.
Figure 22: The proportion of total APBD spent on education fluctuates
Source: Ministry of Finance data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Per capita education expenditure is also one of the lowest in NTB Province with both per capita APBD expenditure and the
per capita household education expenditure some of the lowest in NTB Province.
Table 28: Per Capita Education Expenditure in West Lombok, 2011
West Lombok
Annual Per Capita Education Expenditure
Monthly Per Capita Household Education Expenditure (in IDR)
NTB Province
IDR 496,786 (10/10)
IDR 656,708
IDR 15,866 (8/10)
IDR 21,058
Source: BPS data (household expenditure) and Ministry of Finance data (APBD) extracted from the World Bank Indonesia-Dapoer
database in February 2015.
D. JAMKESDA IN WEST LOMBOK DISTRICT
The provincial government initiated West Lombok's original Jamkesda scheme through a cost-sharing arrangement, after
the governor had promised free healthcare during his successful election campaign. The district government
subsequently introduced its own scheme, which unlike the cost-sharing program did not primarily target poor recipients.
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Case study 4: West Lombok District
1. Description of Jamkesda in West Lombok District
Form of scheme: To describe Jamkesda schemes accurately in West Lombok, we need to describe the pre- and post-BPJS
Kesehatan eras separately.
2009-2013 (pre-BPJS): 1) Jamkesmas NTB was a scheme for poor residents not included in Jamkesmas, funded through
a cost-sharing arrangement with the provincial government. Between 2010 and 2012 it also provided cover for pregnant
women if they were not already Jamkesmas and Jamkesmas NTB recipients. 2) Jamkesmasda West Lombok - in 2010 the
district government started an additional scheme to cover religious figures, healthcare workers, and village officials, as
well as poor people not covered by Jamkesmas or Jamkesmas NTB.22
Both Jamkesmas NTB and Jamkesmasda West Lombok used the national Jamkesmas technical guidelines, funding
treatment at community health centres (Puskesmas) and in the third class wards of hospitals.
2014-present (post-BPJS): 1) Jamkesmas NTB: Jamkesmas NTB has been integrated with JKN, but with different
recipients. The provincial government fully funds JKN premiums for eligible recipients who have not received central
government JKN places, whereas the provincial government cost shares with district governments to fund JKN premiums
for pregnant women and at risk babies. 2) Jamkesmasda West Lombok has also been integrated with BPJS, although
possibly not with JKN as its recipients may not be eligible.
Initiating Actor: The Provincial Health Office claims to have initiated Jamkesmas NTB, with input from GTZ. The District
Health Office also claimed Jamkesmasda West Lombok as a District Health Office initiative, based on a central
government regulation. Media reportage though indicates that NTB Governor M Zainul Majdi promised free basic health
and basic education in his 2008 campaign, and held a road-show to promote these policies soon after taking office. It is
possible the governor's broad policy direction presented an opportunity for the bureaucracy to fill in the policy details with
the Jamkesmas NTB scheme.
Duration: Jamkesmas NTB ran from 2009-2013 as a cost-sharing scheme (with a maternal health component from
2010-2012), and as a province-funded scheme from 2014 to the present (with a cost-sharing maternal and infant health
component). Jamkesmasda West Lombok commenced in 2010 and continues to operate.
Recipients: 2009-2013 (pre-BPJS): 1) Jamkesmas NTB covered 56,336 people in West Lombok (2010 figure, unclear
whether this figure included the maternal health participants). 2) In 2011, Jamkesda NTB covered 85 religious figures,
1,505 village officials, and 2,753 health workers. The Bupati Decree (SK Bupati) that established the lists of recipients
did not include data of any poor people covered by the scheme.
2014-present (post-BPJS): 1) Jamkesmas NTB: The province funds 5,552 West Lombok residents and cost shares with
West Lombok district government to fund places for 10,833 pregnant women and babies 2) Jamkesmasda West Lombok:
District Health Office officials said they initially funded 1000 BPJS places in 2014, although this increased to 3,164 over
the course of 2014 as people enrolled as they fell ill. 3,164 then became the starting point for the number of scheme
participants in 2015.
Both the Provincial and District Health Offices said that participants enrolled for these sub-national funded BPJS places
only as they became ill requiring in-patient treatment in hospital. Although speculative, the government may have chosen
this system because the higher BPJS premiums meant they were funding health security for fewer people than in the
pre-BPJS era. The pre-BPJS Jamkesda NTB funded premiums for approximately 301,000 people province-wide, whereas
the post-BPJS scheme funded premiums only for 41,376 people (solely province funded) as well as 90,632 pregnant
women and babies (cost-sharing).
Legal Basis and Implementing Body: Jamkesmas NTB was established by a MoU between the governor and all district
heads and mayors, with an annual MoU governing the payment of each district's contribution to the cost-sharing pool of
funds, and separate MoUs covering the provision of treatment by service providers. The initial MoU was signed by the
acting West Lombok district head, just before Zaini Arony took office in 2009. A Cooperative Agency for the Health Security
Program (BKS PJK) was established to receive the cost-sharing payments, to make capitation and claim payments to
service providers, and to verify claims.
Jamkesmasda West Lombok's ultimate legal basis is unclear. Bupati decrees establish the implementation guidelines
and recipient lists but do not list a Bupati or local regulation as further reference, however, it is possible such a regulation
was subsequently enacted. Coordination, implementing and verification teams were established to support the program's
implementation.
22
Implementing guidelines suggest Jamkesmasda West Lombok started in 2011, but a powerpoint presentation provided by the West Lombok Health
Office details utilisation and budget allocation in 2010, so the earlier year is used here.
Case study 4: West Lombok District
69
Funding: 2009-2013 (pre-BPJS): 1) Jamkesmas NTB - This scheme employed a cost-sharing mechanism with a 50-50
cost split between the province and district governments. 2) Jamkesmasda West Lombok: this scheme was fully funded
from the district APBD. Implementing guidelines anticipated the scheme would require a budget of IDR 500 million
annually. In fact, it cost IDR 1.16M in 2010 and rose in cost each year, peaking at IDR 2.96 billion in 2013 for an overall
cost over four years of IDR 8.89 billion.
2014-present (post-BPJS): 1) Jamkesmas NTB - This province-funded component cost IDR 1.28 billion in West Lombok in
2014, whereas the cost-sharing component received a contribution of IDR 1.25 billion each from the province and the
district in 2014. 2) Jamkesmasda West Lombok - Health Office interview figure was approximately IDR 1 billion in 2014.
2. How did Jamkesda spread to West Lombok District?
Agents: Who pushed for the adoption of Jamkesda?
As mentioned above, Jamkesda first commenced in West Lombok through a cost-sharing scheme called Jamkesmas NTB,
initiated by the provincial government. While the Provincial Health Office claims to have initiated Jamkesmas NTB with
input from GTZ; media reportage indicates that the NTB governor promised free basic health and basic education in his
2008 campaign, and held a roadshow to promote these policies soon after taking office. Thus, it is possible the governor's
broad policy direction presented an opportunity for the bureaucracy to fill in the policy details with the Jamkesmas NTB
scheme.
The District Health Office also claimed Jamkesmasda West Lombok as a District Health Office initiative, based on a
central government regulation. Regardless of whether the Jamkesda idea was sourced from the governor or the Health
Office, both the elected official and the bureaucracy were the key policy actors who were most responsible for the spread
of scheme to West Lombok.
Similar to other districts surveyed, the DPRD were not very involved in the policy formulation process. A senior official from
the Health Office said that the legislature was very supportive of the initiative because it provided benefits to their
constituents. He said that the budget allocation for Jamkesda NTB and Jamkesmasda was passed with no real discussion,
which he said was rare. Instead, the director of the West Lombok Public Hospital said that DPRD members tend to limit
their involvement in the Jamkesmas NTB to conveying any complaints from the community in relation to the provision of
hospital services and clarifying requests at hearings.
Neither CSOs nor the media were involved in the process to adopt Jamkesda in West Lombok (both provincial and district
schemes). The role of both parties in health service delivery is similar to the DPRD in that they monitor and report on the
poor provision of health services, or if someone who cannot pay does not receive free health coverage. The director of the
West Lombok Public Hospital, for instance, said that CSOs sometimes reported unequal treatment of paying patients and
Jamkesmas/Jamkesda NTB/Jamkesmasda patients (that is, insurance scheme participants received poorer services – a
claim the hospital denies). Other issues CSOs highlighted included the fact that Jamkesda patients are told to pay for their
own medicines, which was then further clarified at the district.
Process and mechanism: What led to the adoption of the Jamkesda scheme?
Top-down process/coercive mechanism: the first Jamkesda commenced in West Lombok as part of a province-wide
cost-sharing scheme between the NTB Provincial Government and the District Government. A senior district government
official said that when the provincial government offers cost-sharing initiatives, district governments do not typically reject
such offers for two reasons. First, cost sharing is one way for district governments to increase their budget. Second,
maintaining good relations with the provincial government is important because they have the power to review and reject
budget items in the district APBD. Thus, the provincial government “coerced” the district government to adopt Jamkesda
by providing financial incentives and through the authority they exert over the district governments. Instead of rejecting
cost-sharing offers, the senior government official stated that the district shows its support (or lack thereof) for the
cost-sharing scheme by the amount of funding it allocates to the program.
Top-down process/responsive mechanism: Similar to the other three districts studied, Jamkesda NTB and
Jamkesmasda was adopted as a response to the fact that the national Jamkesmas program did not provide free health
service to all people considered poor in the district. Thus, both the provincial scheme and the West Lombok scheme all
aim to provide free health service to the poor that are not covered by the other programs. The programs largely follow the
national program providing the same services and using a claims process. The District Education Office said that they
designed the local scheme to follow national health policy.
70
Case study 4: West Lombok District
Horizontal process/learning mechanism: the NTB Provincial Government claims not to have been on any comparative
study trips to other districts to learn about their Jamkesda programs. They said the program arose from discussions with
GTZ who had studied the Jamkesda programs in Bali and Aceh, although did not indicate why those two districts were
selected. The District Health Office also claims they did not make any field visits but studied the schemes of Purbalingga
and Musi Banyuasin in South Sumatra Province through online research. The West Lombok Government did claim that
other districts and provinces such as East Java were impressed with their scheme, in particular their focus on providing
health insurance for religious figures.
Motivation: Why was Jamkesda adopted?
Interviewees suggested that the adoption of Jamkesda was essentially part of the broad trend in politics in Indonesia
whereby heads of districts and provinces promise free health care for its citizens. The Provincial Health Office also said
that the DPRD supported Jamkesda NTB because it was “pro-community” as it channelled funds directly to its
constituents.
The motivation for adopting Jamkesda is therefore similar to that of the other three districts studied. Politicians accept
that in order to win elections, they must appear to be “pro-people”. There are currently two main strategies for building
that “pro-people” image. First, district heads or governors implement programs and policies that funds activities that
directly benefit the community, such as BOSDA, Jamkesda, grants to villages, scholarships and infrastructure. Second, is
to engage with the community directly such as through village visits. Providing Jamkesda to supplement Jamkesmas is
therefore a generally accepted tool to build the “pro-people” image.
Were there internal factors that influenced the adoption of Jamkesda?
Interviewees did not indicate there were broader internal factors that influenced the adoption of Jamkesda in West
Lombok.
Was “success” an important factor for adopting Jamkesda?
The research team did not find any information that suggested either the provincial government or the district government
assessed the success of Jamkesmas or Jamkesda in other districts before commencing Jamkesmas NTB and
Jamkesmasda West Lombok.
After the provincial program commenced, the provincial government said that they conducted periodic evaluations of the
implementation of the scheme, including utilisation rates, obstacles and solutions. The district government said they had
a cross-agency coordination team that assessed the Jamkesmasda’s administrative processes.
Both the province and the district governments claimed that through the free health care for maternal and neo-natal care
the province significantly reduced maternal mortality. Although the researchers could not obtain the maternal mortality
figures, the below graph shows that in 2010, the proportion of births attended by a skilled health worker did increase
significantly. The NTB government claimed that the success of their free health care for maternal and neo-natal care was
one of the reasons for the adoption of the Jampersal program by the central government.
Figure 23: The proportion of births attended by a skilled health worker increased significantly in 2010 but has remained steady since
Source: BPS data extracted from the World Bank Indonesia-Dapoer database in February 2015.
Case study 4: West Lombok District
71
Implementation: How did Jamkesda change over time and what factors led to that change?
There were two factors that influenced the implementation of Jamkesda in West Lombok. First, the increased number of
SPM as the basis for receiving Jamkesmas NTB and Jamkesmasda West Lombok put budgetary pressures on the
provincial and district governments. Village officials who issued SPMs said protests from villagers meant that these proof
of poverty letters were always issued regardless of the villagers’ economic status.
As a result, the District Health Office did try to restrict the issuance of SPM. However, the restrictions were abandoned
shortly thereafter. The DPRD, CSOs and media all protested about the restrictions and it became a political issue that
called on the involvement of the district head.
The second factor that influenced Jamkesda during implementation was the change in national policy where by the
Jamkesmas program was replaced with BPJS Kesehatan. In response, the provincial government with all NTB District
Governments agreed to integrate its Jamkesmas NTB with the national JKN program. The integration with JKN changed
the number of people covered by the provincial and district governments because of an increase in unit cost.
The integration with JKN also changed the way participants were selected and registered. Instead of nominating people
eligible for JKN, both district and provincial governments signed people up to the program as they become sick and sought
treatment at the West Lombok Hospital. BPJS objected to this “first-in-first-serve” approach and through negotiation the
arrangement it was amended whereby a patient would first be registered as a self-paying participant for the first month
and then premiums would be taken over by the district governments from the second month onwards. As mentioned
above, the district initially financed 1000 BPJS places in 2014, although this increased to 3,164 over the course of 2014
as more people enrolled as they fell ill.
E. BOSDA IN WEST LOMBOK DISTRICT
West Lombok was the only district visited during this study that was not implementing a BOSDA program. The lack of such
a scheme reflected the lack of support for universal free education. Most local interviewees supported free education only
for the poor.
1. Description of BOSDA in West Lombok District
Form of scheme: West Lombok does not have a BOSDA scheme, although it has stipulated that schools should receive
BOSDA through the Head of District Regulation 33/2014. Instead it funds a national scholarship program for poor
students (BSM) for approximately 24,000 recipients at primary and junior high school level. 18,000 primary school
students receive IDR 250,000 per student per year; 5,833 junior high school students receive IDR 600,000 per student
per year. The district scheme pays funds exclusively to students in public schools and a separate provincial-funded
scheme pays BSM to students in private (typically religious) schools.
Legal Basis and Implementing Body: Bupati Regulation 33/2014 governs the payment of district-funded BSM; however
the scheme commenced prior to the enactment of this regulation. A District Education Office official answered a request
for the program's technical guidelines by saying they were the same as for the central government scheme.
Recipients: The district scheme targets students who are eligible for central government-funded BSM but who are not
recipients of the central government scheme. According to district government data, it funds a greater number of students
than the central government (18,000 district-funded primary school students as opposed to 12,496 centrally-funded;
5,833 district-funded junior high school students as opposed to 2,714 centrally-funded). The district, however, pays less
per student at both primary and junior high schools level than the central government.
Funding: The district disbursed IDR 8 billion of BSM funds to students in 2014.
2. How did BOSDA spread to West Lombok District?
Agents: Who pushed for (or opposed) the adoption of BOSDA?
The West Lombok Education Office claimed that the inclusion of BOSDA in the Bupati Regulation was its own initiative.
Interviewees said that the main parties involved in the drafting of the education regulation were the District Education
Office and a legal office (Badan Hukum). However, an official from the Education Office implied that BOSDA is unlikely to
be financed in the short or medium term as not everything in the education regulation will be implemented immediately
and BOSDA is “only for the long-term”.
72
Case study 4: West Lombok District
The lack of support for a BOSDA program to supplement BOS reflects the fact that free education for all is not a priority
for the government, nor does the policy enjoy any support from the DPRD or civil society groups. Instead, the West Lombok
government has a large-scale BSMDA scheme (a district version of the national BSM program) which may further reflect
that district’s support for free education for the poor rather than universal free education.
One of the key potential reasons for the lack of support for universal free education in West Lombok is because of the
strength of the private Islamic schools (pesantren) in the district. The Education Office estimates that between 25-30% of
all DPRD members own Islamic schools because it is an effective vehicle to reach political office. Similar to Ngada, private
schools in West Lombok do not agree with a free education policy as it weakens the competitiveness of private education.
Civil society advocacy also does not have a focus on BOSDA or universal free education. The former head of the NGO
network Jaringan Masyarakat Sipil (JMS), for instance, does not support universal free education because he said it was
appropriate that people contribute different amounts of funds to receive the same service. The Education Office also said
that NGO advocacy does not focus on the provision of free education. Recent advocacy, in fact, has been focused on
government support for uniforms as parents’ inability to pay for uniforms is one of the obstacles in high school enrolments
for many families.
In the face of opposition for universal free education and BOSDA, the Education Office believes that whether BOSDA will
be financed or not largely depends on the district head. This implies that even if there is broad opposition to BOSDA in the
DPRD, the district head can still overcome that opposition if the policy becomes a sufficient political priority for the elected
head of district.
Process and mechanism: What led to the adoption of the BOSDA scheme?
Top-down process/coercive mechanism: The main form of pressure for the adoption of a universal free education policy
comes from central government legislation and it is probably this pressure that led to the inclusion of BOSDA in the Bupati
regulation on education. As one interviewee from the Education Office said, the legislation requires that all elementary
education (SD and SMP) is free.
Horizontal process/learning mechanism: The provincial government is currently also drafting their education regulation
and debating the inclusion of BOSDA. The Provincial Education Office said that while the BOS program had inspired
BOSDA, they had also studied BOSDA in Yogyakarta, East Java and Palembang Provinces. The government was
particularly interested in the provision of BOSDA payments to private religious schools in East Java. West Lombok chose
these three provinces because both Palembang and East Java have a heterogeneous population including many Javanese
people. East Java was also selected because it is an industrial area that needs to equip its people with vocational skills,
something that NTB is also trying to achieve. Yogyakarta was selected it is renowned as an “education city”.
Since universal free education is not a district government priority and BOS funding alone is insufficient to achieve
fee-free education, however, contributions from the community remains a key source of revenue for schools.
Motivation: Why was BOSDA included in regulation but not funded?
In addition to the pressure from the central government on district governments to provide fee-free education, there was
also demand for free education from the community. The Provincial Education Office, for instance, said there is a broad
community expectation that elementary education (SD and SMP) should be free, but that expectation does pertain to
secondary education level.
An interviewee from the DPRD said that he believed the community wanted low cost education but did not want to
compromise quality. He referred to a class divide between those in the middle to upper class, and those in the lower to
middle class. For the first group, he believed cost is not a significant issue, as long as quality education is available. For
the second group, however, they want maximum funding from the government to reduce household education costs. This
group also demands quality but it has to be cheap and affordable. Politically, the second group is the most important.
Demand from the community therefore does drive considerations on whether BOSDA will be adopted. The West Lombok
Government decided to meet community expectations through their BSMDA scheme to focus on making education more
affordable for the poor.
Internal factors: Were there internal factors that influenced why BOSDA is unlikely to be funded?
Interviewees suggested two reasons for why BOSDA is unlikely to be funded in the short or medium term. First, universal
free education is not a priority for the district. The Provincial Education Office, for instance, said that increasing education
Case study 4: West Lombok District
73
indicators in the human development index and improving religious education was the main educational priorities for the
province. Second, interviewees also believed that they do not have the funds to finance BOSDA. The AIPD District
Facilitator also believed that the reluctance to include BOSDA into the education regulation was also due to scepticism
that the district government would not have the budget to finance the program. The West Lombok Education Office said
that there is a possibility of providing BOSDA if the transfer of secondary education responsibilities to the provincial level
results in freeing up budget.
F. CONCLUSION
The context for the enactment of Jamkesda in West Lombok was broadly similar to the other districts in the study. The
program commenced as a response to the central government's Jamkesmas program. The district head and bureaucracy
were the key actors, whereas the DPRD, media and CSOs were not influential and compliance with a pro-people norm was
an important motivation.
West Lombok differs to the other districts in its resistance to BOSDA as it provides no funds for a BOSDA program, even
though the district governments own regulations require it to do so. A general aversion to universal free education made
it unlikely that BOSDA would be funded in the near term. The DPRD was dominated by members who owned private
schools, and therefore opposed free education. Local CSOs were also not supportive. Some of this opposition to free
education was also evident in Ngada, but the differing stance of the district heads differentiates the two cases. Whereas
BOSDA is a flagship program for the Ngada District head, the district head in West Lombok appears to have no particular
commitment to the program.
74
Case study 4: West Lombok District
Annex 1 Interview questions
Policy/program formulation
1.
•
•
•
•
•
Please describe the kinds of Jamkesda/bosda/bsm programs that are running in this region?
When did it commence?
Who are the beneficiaries?
Program model?
Financing model?
Legal basis?
2.
•
•
•
How was this program initiated?
Who was the program initiator?
What was the motivation?
From our observations, this policy has been adopted by hundreds of districts in Indonesia only within a five to ten year
timeframe. Why do you think this has happened?
3. Policy formulation process:
• Who had a role in it?
• Where did the program model come from? Was there one or many choices?
4. Where did you get information about the model from? How did you know where you could obtain information on this
program?
• Comparative studies?
• Donors?
• Academics?
• Other?
5. Were there consultations with other local governments? Why did you select a particular local government? (the district
resembled this district; a neighbouring district; a more affluent district; or because the district already had a program)
6. Why was this model chosen?
• Was it because it had been successful in other places? What were the indicators of success?
• Other reasons?
7. When this program first commenced, were there any other similar programs running from central government or the
provincial government?
• If yes: why was the local government program needed?
• What is the relationship with the top level program?
• Has the central/province program influenced district programs? (motivation, model, implementation, funding,
beneficiaries).
• Did the central government/provincial government consult with the local government before their program
commenced?
8. Has the program responded to requests or demands from parties outside of the government? Or is it a local
government initiative?
• CSO/NGO, DPRD, media, academics etc.
• If it is a local government initiative, does the local government consult with other parties?
• If there are any demands, in what form are they? General demands? Specific model?
9. What was the role of your agency in formulating this policy/program?
Annex 1 Interview questions
75
10. What is the role of DPRD?
• Is there a certain party/individual that is more active or less active? Or that strongly supports or objects to this policy?
• What aspect of this policy is DPRD concerned with?
o Technical matters
o Allocation of funds
o Recipients
o Other
11.
•
•
•
•
•
•
What other agencies have a role aside from your agency?
DPRD
Askeskin
Health Office
Education Office
Social Welfare Office
District head
12.
•
•
•
•
Outline the deliberation process of this policy?
What matters were discussed?
What obstacles needed to overcome? (Availability of funding, other priorities, parties that are do not agree etc)
Who was involved in discussing this policy?
Who was the decision maker and what was the decision making process?
13. Once this policy was formulated, what were the steps for implementation?
• Is the budget allocation as a program or an activity in the APBD?
14. What is the legal basis of this policy? And why was that legal basis chosen? (Local regulation, Bupati regulation,
decree etc).
Program/policy implementation
15.
•
•
•
•
•
Describe the implementation of this program.
Was it successful? Success indicators?
What was the public’s response to this program?
Were there any specific changes or adaptations during the implementation of this program?
Why?
Who encouraged the adaptation/change?
16. Has the provincial government or central government changed any of their policies in this field while this program was
running?
• How did that impact on the program?
17. Is this program still running or has it stopped?
• Why?
18. Have changes to regional heads impacted on this program?
19. Is there any impact on the program when officials are transferred?
20. Do legislative elections and changes to the composition of DPRD have an impact on the program?
21. Has there been any interest from other local governments?
22. Has there ever been a presentation on this program? At which forum? How was the response?
76
Annex 1 Interview questions
Annex 2 Interviewee List
Title
Affiliation
Head of the Family Health Section, BPPKM Section (Improving
Community Health Services); Head of Health Services Section,
PPKM Section (Improving Community Health Services)
Health Office, Malang district
Head of Office
Agriculture Office, Malang district
Faculty of Administrative Science, Unibraw; PhD Student,
University of Melbourne; Members of the Malang Bupati’s
Success Team
Assistant 3 (Ex- Head of Health Office)
Bupati’s Office
Head of Askeskin
Askeskin, Malang district
Around 12 representatives
Malang Development Watch (alliance of
~20 NGOs and CSOs)
Radar Malang
Journalists covering the city government, previously covering
the district government
Around 10 representatives
Malang district
Head of Empowerment Section,
Health Office, Malang district
Head of Government and Society Section
Askeskin, Malang district
Lecturers
University of Brawijaya
Chief Editor
Radar Malang
Head of Community Resource Based Healthcare Section,
Community Health Division
Health Office, Malang municipality
Secretary;
Education Office, Malang district
Regional Secretary
Malang district
Ex- Regional Head
Malang district
Section Head
Education Office, Malang municipality
Chairperson of Malang Municipality Hanura Party DPC, DPRD
members, Head of Hanura Faction, Commission B Members
(Economy); Ex- Commission D members (Education and
Health)
Section Head of Junior High School, Senior High School and
Vocational School Institutes
Head of Socio-Cultural Section
DPRD, Malang municipality
Researchers
Jawa Pos Institute
Staff
BPJS Kesehatan, East Java
Secretary
Health Office, East Java
Regional Secretary
Bupati’s Office, Ngada district
Head of Office
Health Office, Ngada district
Secretary
Person-in-charge, Ngada district Ngada
Komisi Penanggulangan HIV AIDS – HIV
AIDS Commission, Ngada district
BPJS Kesehatan, Ngada district
Bupati
Ngada district
Head of office
Education Office, Ngada district
Director
Yayasan Mitra Swadaya –Mitra Swadaya
Foundation, Ngada district
Cermat, Ngada district
Chief editor
Education Office, Malang municipality
Askeskin, Malang municipality
Annex 2 Interviewee List
77
78
Title
Affiliation
Chairperson
Head of Askeskin
Yayasan Persekolahan Umat Katolik
Ngada – Ngada Catholic School
Foundation (Yasukda)
Askeskin, Ngada district
DPRD Chairperson
DPRD, Ngada district
Arkadius Togo, Flores Pos; Ovan Lado, Victory News; Toni, Pos
Kupang; Urbanus, Chief editor of Media Flores; Andreas Gosu,
Media Flores
Media Flores, Flores Pos, Victory News,
Kupang Pos
Senior Officials
Ngada District Health Office
Head of Administration
Bajawa Hospital
Chairperson
Education Board, Nagada district
Secretary
Health Office, Ngada district
District Facilitator
AIPD, Ngada district
District Officer, LPPM
AIPD, Ngada district
DPRD members (Hanura Party)
DPRD, Ngada district
DPRD & Commission E members (Ex- West Lombok DPRD
members)
DPRD, NTB province
DPRD Deputy Chairperson, Head of Budgetary Board
DPRD, NTB province
DPRD Deputy Chairperson
DPRD, NTB province
Assistant III
Governor’s office, NTB province
Regional Secretary
Bupati’ Office, East Lombok district
Members, Commission IV
DPRD, East Lombok district
Assistant III
Bupati’s Office, West Lombok district
Head
Askeskin, West Lombok district
Head of the BPJK section
Health Office, West Lombok district
Director
Hospital, West Lombok
Head
Education Office, West Lombok district
Members
Somasi and YPKM (previously of
Jaringan Masyarakat Sipil)
Annex 2 Interviewee List
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