On Thursday (19/5), the Research and Community Engagement Unit (PPM) of the Faculty of Law, Universitas Gadjah Mada (FH UGM), held its regular academic discussion, Bulaksumur Legal Discussion (BLD), featuring Mailinda Eka Yuniza, S.H., LL.M., a lecturer at the Department of Administrative Law. This BLD focused on the regulation of local government authority in the health sector within the framework of broad regional autonomy. The topic was selected based on several considerations. First, the right of Indonesian citizens to access health services is guaranteed under Article 28H paragraph (1) of the 1945 Constitution. The state has a responsibility to provide health services and facilities. Within this framework, decentralization is expected to serve as one of the solutions for improving health services for the Indonesian people, although in practice, the division of responsibilities between the central and local governments remains subject to debate. Under Law No. 32/2004 and Government Regulation No. 38/2007, the division of governmental affairs, including health services, has been assigned to local governments as part of efforts to improve the quality of health services. In other words, the central government no longer acts as the direct provider of health services, but rather as the policymaker for health services at the regional level.
Ideally, health decentralization can be considered successful when it leads to improvements in the quality of health services, which can be assessed through two indicators: the Human Development Index (HDI) and the achievement of the Millennium Development Goals (MDGs). According to the United Nations Development Programme, Indonesia ranked 110th out of 188 countries surveyed in 2014, with an HDI score of 0.684. In general, the 2014 MDGs Achievement Report showed that Indonesia had made considerable progress toward meeting the MDG targets, although further efforts were still needed to achieve all targets by 2015. These developments indicate that, despite more than a decade of implementation, regional autonomy had yet to produce an evenly distributed improvement in public health services. Similarly, the special autonomy policy implemented in Papua to help the province catch up with other regions in terms of health services, including the Special Region of Yogyakarta (DIY), had not yet produced optimal results.
This situation provides the basis for examining the direction of policies regulating local government authority in the health sector under broad regional autonomy, as well as how such authority has been implemented. The aim is to ensure that implementation remains consistent with the intended objectives. By examining the direction of these policies, it is possible to identify the relationship between the regulatory authority granted to local governments in the health sector and the actual exercise of that authority following the implementation of broad autonomy. Ultimately, the effectiveness and efficiency of such authority should be measured by improvements in public health, which constitute the primary objective of the policy.
Regarding the national implementation of local government regulatory authority in the health sector, the study identified several findings. First, the exercise of regulatory authority by local governments in Indonesia varies considerably, both in terms of the number and substance of regulations issued. Second, differences in regional performance in exercising delegated authority demonstrate that the implementation of regulatory authority does not necessarily correspond directly to the extent of authority granted by the central government. Third, local governments differ in their willingness and capacity to exercise regulatory authority. Following decentralization, central government allocations for the health sector have continued to increase. However, the combined allocation of the central and local governments for health has yet to meet the expected 15% of the state budget. Fourth, local governments remain highly dependent on regulations issued by the central government. Guidelines issued by the central government, including those of the Ministry of Health, such as Minimum Service Standards (SPM), Norms, Standards, Procedures, and Criteria (NSPK), and technical guidelines, are essentially intended to provide clearer direction for the implementation of health decentralization. In practice, however, these regulations are sufficiently detailed that local governments are required to closely follow them.
Research conducted in Jayapura and Yogyakarta found that the implementation of local government regulatory authority in the health sector varies significantly. In Jayapura, the exercise of such authority remains very limited, whereas Yogyakarta has demonstrated stronger implementation, both in terms of the number and substance of regulations. The considerable gap between Yogyakarta's exercise of delegated authority and that of its counterpart, Jayapura, illustrates the varying implementation of health-sector regulatory authority following the adoption of broad regional autonomy. It also reflects differences in the readiness of local governments to implement health decentralization.
Although available data indicate a considerable improvement in Indonesia's health status during the decentralization period, research by Kristiansen and Santoso suggests that decentralization in Indonesia was implemented too rapidly, as not all regions were adequately prepared to assume the transferred powers, including in the health sector. The findings also reveal significant disparities in HDI across provinces and regencies/cities in Indonesia over the previous five years. The gap between the province with the lowest HDI and the province with the highest remained at 21 points, while the largest HDI disparity at the regency/city level was found in Papua, where Jayapura recorded the highest HDI and Nduga the lowest. In terms of life expectancy, Indonesia experienced an increase over the same period, while disparities in life expectancy between provinces gradually narrowed, although they remained relatively significant. Interestingly, Indonesia's HDI had already been increasing even before decentralization. Between 1996 and 1999, for example, Indonesia's HDI increased from 64.40 to 62.20. This suggests that decentralization had not yet significantly altered Indonesia's HDI outcomes.
When viewed from the perspective of regulatory authority, these findings are consistent with the fact that although the central government granted broader regulatory space to local governments following decentralization, its implementation remained varied and, in some cases, limited. Nevertheless, improvements were still achieved through regulations issued by the central government, particularly guidelines from the Ministry of Health in the form of SPM, NSPK, and technical guidelines, which helped fill regulatory gaps at the regional level. These central regulations are sufficiently detailed that local regulations often function primarily as a form of formalistic decentralization, as demonstrated in the research of Enny Nurbaningsih. Furthermore, the central government exercises relatively strict oversight and imposes sanctions against local regulations that conflict with national regulations. This raises a fundamental issue concerning local government regulatory authority. As discussed in the literature, the essence of autonomy and decentralization lies in the authority to regulate. If local governments merely implement central government policies without adequately exercising the regulatory authority granted to them, or if the central government regulates the implementation of decentralization too strictly, the essence of decentralization is undermined. The detailed regulations issued by the Ministry of Health can be understood given that health is a mandatory governmental affair that must be fulfilled, while local governments have varying levels of capacity. This supports the findings of Stein Kristiansen and Pratikno, who argue that Indonesia needs time to strengthen local government capacity so that the objectives of decentralization can be properly achieved
To prevent overlapping authority in the division of health-sector responsibilities, as previously occurred under Law No. 22/1999 and Law No. 32/2004 and their implementing regulations, the Government should promptly issue a Presidential Regulation governing the division of health-sector responsibilities, particularly for sectors and subsectors that have not yet been regulated in the health-sector annex to Law No. 23/2014. The existence of Law No. 23/2014 has not, by itself, resolved inconsistencies between sectoral regulations. Discrepancies also remain between national and local regulations. At least two measures can be taken to address these overlaps: first, the Government should continue to harmonize regulations across sectors; and second, the Ministry of Health should make effective use of the renewed technical relationship between the Ministry and local health offices, particularly in harmonizing health-sector regulations. Certain areas of health governance, such as communicable disease control and surveillance, have experienced a decline in effectiveness during the implementation of broad regional autonomy. Following decentralization, these responsibilities were transferred to provincial and regency/city governments. To improve the regulation of these two areas, there are two possible approaches: either responsibility for communicable disease control and surveillance should be returned to the central government, or these areas should remain decentralized while being accompanied by adequate technical guidance from local health offices and incorporated into the Government Regulation on Regional Apparatus Organizations currently being developed. To further improve the exercise of local government regulatory authority in the health sector, the central government should promptly issue health-sector Minimum Service Standards (SPM) and their corresponding technical guidelines. The future SPM should use simple indicators and, as far as possible, accommodate the considerable variation among local governments. Regarding NSPK, regulations governing the Ministry of Health's monitoring and evaluation mechanisms are also necessary.
