Decentralization and Primary Health Care Innovations in Indonesia

A well-functioning primary health care system (PHCS) is fundamental for a nation's overall health performance. PHCSs are designed to improve universal access to health care, which likely leads to healthier communities, higher quality of care, and a more effective and efficient health care system. The present chapter investigates how the two large-scale decentralization waves in Indonesia affected the processes, product and structural innovations in its PHCS. We argue that adequate organizational capacity and local level innovations are a major requirement to improve the performance of a PHCS. The study uses the decision space approach (DSA) to analyse the impact of decentralization on the decision space, accountability mechanisms and organizational capacity to facilitate health improvement. To achieve the aim, first, the study uses institutional analysis to describe the transformation of the decision space and accountability mechanism from the first and second waves of decentralization based on changes to laws and regulations. Second, the study investigates the sequence of innovation of PHCS by analysing studies on cases of innovation in the two waves of decentralization. The study found that the first wave of decentralization in Indonesia resulted in institutional changes that were detrimental to innovation. Whereas discretion for local-level decision makers increased compared to the situation under the former centralized system, requirements for accountability did not. This pattern was reversed during the second wave of decentralization, suggesting that the conditions for innovation have improved. The cases of successful innovation share a specific combination of initiative, commitment and social capital of a key decision maker as a fundamental enabler of innovation.