Nearly forty-four percent of Indonesia’s population is living on less than $2 a day, making it near impossible for some to seek proper health treatment. One way to improve this situation is through Indonesia’s conditional cash transfer (CCT) programs, Margaret Triyana says.

The CCT program, first piloted by the World Bank in 2007 and expanded from 2009–10, encourages Indonesia’s most destitute to pursue health-seeking behaviors by reducing barriers to health care through cash incentives. Payment is given for receiving treatments at a local clinic. Essentially, the poor are reimbursed simply for “showing up” for health services.

Triyana, a Jakarta native and postdoctoral fellow in the Asia Health Policy Program, has been in residence at the Shorenstein Asia-Pacific Research Center in the Freeman Spogli Institute for International Studies studying the effects of the CCT program on Indonesia’s poor. She has been evaluating the household CCT program’s two-year implementation, focusing on the maternal and child health initiatives.

She plans to produce multiple papers that focus on issues related to CCT interventions and its impact on mothers and children. Triyana will continue this research after leaving Shorenstein APARC this July, accepting an academic teaching position at Nanyang Technological University in Singapore. 

Recently, Triyana discussed her research with Shorenstein APARC. 

What types of health initiatives does the CCT program sponsor, and for whom?

The CCT program targets Indonesia’s most poverty-stricken by selecting approximately the bottom 30 percent of the poorest households, with preference toward households with pregnant women or school-aged children. Eligibility depends on socioeconomic factors per district such as expenditure, education and asset ownership. The program stretches the rural-urban divide, covering people in and off Java (this is the main island where 60 percent of the population resides). Many initiatives in the household CCT program are focused on child and maternal health. For mothers, they include a series of prenatal care visits, an iron tablet prescription, childbirth assistance and postnatal care. For children, they cover vaccinations, monthly height and weight measurements at the clinic and vitamin A pills. Overall the CCT program is a combination of poverty reduction and human capital investments, attempting to induce good behavior that instills long-term health in low resource settings.

Who is the typical primary care provider in Indonesia?

The primary care provider is often a midwife. This is because Indonesia doesn’t have enough trained doctors to support the growing demand. Clinics operate at the sub-district level, which comprise of 10-15 villages each. Every village is assigned one midwife. Midwives can perform most procedures just short of surgery. For example, midwives offer typical delivery services but refer patients to a district-level hospital for a Caesarean section. This system, for the most part, functions well, but midwives do have an expanded scope of care that can be unsettling. Children have their cuts taken care of by midwives; adults can get antibiotics through them. This diffused system is perhaps more efficient, but it can call into question the legitimacy of their authority. Midwives receive only three years of training for their certification. This is something the Indonesian government intends to inspect and will likely restructure.

What behavior changes do you see as a result of the CCT program?

My initial findings show there is increased utilization of health care programs. The CCT program incentivizes certain behaviors – attending the clinic for a test or retrieving medication – which then, in theory, leads to better health. “Showing up” doesn’t automatically correlate with improved health, but if we think about the population at hand, it would in most cases. People who weren’t using health services before now are. Everyone that was offered the program signed up. Monthly attendance to CCT-linked programs is reported at a rate of 85 percent. In particular to maternal health, I noted a 10 percent increase in delivery fees. This trend follows what we would expect to see – because of increased utilization, there is a natural rise in price for the service. On the demand-side, I found a 40 percent increase in the use of midwives, and a rise in fees paid to providers for maternal and child services. These factors indicate with a high level of certainty that the CCT program lowers barriers to health care. 

Since health is effectively its own market, will increased demand for services cause a rise in price?

Yes, health care is its own market so the supply-demand relationship is relevant. My research looks at the local market because it depends upon the price being offered at the local clinic. Indonesia’s health care system is a public-private mixture, therefore public fees are regulated while private fees are less so. Indonesia now offers universal care, but people can pay a few for services beyond basic coverage. I saw a change in the private domain in terms of demand for services. The “demand shock” caused a bit of a higher price for services. It costs about $80 to meet all of the program requirements. Payment to midwives increased, while a slight decrease occurred for traditional birth attendants. I find no significant change in birth outcomes, and the quality provided by midwives does not appear to be affected by the program. These outcomes are exactly what we’d expect to see; it is consistent with the puzzle in the literature and economics, showing more women and children in the CCT program are seeking care from health care providers, but no change in health outcomes.

Can we expect increased utilization of health services in the long-run?

I anticipate there will be long-term increased utilization. The CCT program seeks to create habit formation by focusing on youth and pregnant mothers. For example, we can see this when expectant mothers attended the clinic for prenatal care, delivery assistance and postnatal care. With cost and travel barriers eliminated or reduced, participants should find it easier to initially come and then return. I did see repeat visits in my research as a positive outcome of the CCT program. A technique used to encourage commitment is a public education program as part of the program. Participants get a group briefing on how the program works, so that they are fully introduced to the incentives and guarantees of the program. 

Does Indonesia plan to extend this into a national program?

Yes, the CCT program is planned to go national later this year. The research shows that the benchmark of high attendance was met, program participants did “show up.” Next steps are to analyze health outcomes in maternal and child health, and then look at policy implications. Indeed, the Indonesian government is seeking ways to better target and deliver health services; it will be interesting to see the long-term effects of this program.

Shorenstein Asia-Pacific Research Center faculty and scholars have published a variety of publications in early 2014, covering topics from the Japanese fiscal condition to disability policy in North Korea. 

Publications are often products of long-standing research projects led by Center affiliates. New Challenges for Maturing Democracies in Korea and Taiwan, coedited by Shorenstein APARC Director Gi-Wook Shin and Center on Democracy, Development and Rule of Law Director Larry Diamond, emerged from the Stanford Korea Democracy Project, which seeks to understand social movements in South Korea.

Postdoctoral fellows who reside at Shorenstein APARC for a year of vigorous study and engagement in Center activities also support research publications. Former visiting scholar Dominik Müller, now at Goethe-University Frankfurt, published Islam, Politics and Youth in Malaysia: The Pop-Islamist Reinvention of PAS. Müller examined the religious bureaucracy of Malaysia at Shorenstein APARC in 2013.

Shorenstein APARC manages an active publishing program with Stanford University Press and the Brookings Institution Press. Center affiliates also publish extensively in external peer-reviewed academic journals and books, as well as in a working paper series led by the Asia Health Policy Program.

Publications released in recent months include: 

Comparative Institutional Analysis: Theory, Corporations and East Asia. Selected Papers of Masahiko Aoki, Masahiko Aoki, Edward Elgar Publishing, 2014

The volume is a collection of 22 articles that span the course of Aoki’s 45-year academic career. The essays cover a wide range of topics from the comparative perspective including corporate governance, institutional change and mechanism design in Japan, China and South Korea. The articles suggest policy responses for industry and governments.

 

Confronting Memories of World War II: European and Asian Legacies, Eds. Daniel Chirot, Gi-Wook Shin, Daniel C. Sneider, University of Washington Press, 2014

Comparing the European and Asian legacies, the book provides insight into the influence that World War II continues to have on contemporary politics and attitudes. The collection gathers a variety of perspectives that compare how Europe and Asia handle memories and reflections of guilt, and how wartime experiences are reinterpreted and used for domestic and international purposes.

 

“Defying Gravity: How Long Will Japanese Government Bond Prices Remain High?” Takeo Hoshi, Takatoshi Ito, Economic Policy, January 2014

The article examines the fiscal regime of Japan and considers if the country can withstand its high debt to GDP ratio. The paper shows that Japan’s fiscal situation is unsustainable through various simulations, and suggests that sufficiently large tax increases and/or expenditure cuts would put government debt on a sustainable path.

 

“Facts, Minds, and Formats: Scholarship and Political Change in Indonesia,” Donald K. Emmerson, Cornell University Press, March 2014

Indonesia has changed dramatically in recent decades, and a wealth of literature highlights divergent interpretations and perspectives surrounding those dynamics. The article considers the demise of liberal democracy, the rise of President Sukarno in 1959, and the latter’s replacement by General Suharto in 1965. The essay is part of the larger volume, Producing Indonesia: The State of the Field of Indonesian Studies.

 

“The Fukushima Nuclear Disaster and the DPJ: Leadership, Structures, and Information Challenges During the Crisis,” Kenji E. Kushida, Japanese Political Economy, Spring 2014

The Fukushima nuclear disaster was a critical event that shook Japan’s political economy, society and national psyche, as well as the world’s perspectives on nuclear energy policy. The article examines how the nuclear disaster unfolded and analyzes the response undertaken by the Democratic Party of Japan under Prime Minister Naoto Kan. Kushida is the Takahashi Research Associate at Shorenstein APARC.

  

“Japan-Korea Relations: Time for U.S. Intervention?” Daniel C. Sneider, National Bureau of Asian Research, January 2014

The paper describes current relations between South Korea and Japan, recognizing that their relationship has noticeably deteriorated in recent months. While the United States has attempted to promote dialogue, its hesitant intervention is unlikely to change the overall dynamic of the Japan-Korea relationship. Sneider suggests that a more active U.S. mediation role could encourage reconciliation and normalization of relations.

 

“People with Disabilities in a Changing North Korea,” Katharina Zellweger, Shorenstein APARC, 2014 

The working paper details the environment that people with disabilities face in the Democratic People’s Republic of North Korea. Despite its reputation as a repressive, closed society where human rights are routinely abused, there are in fact a number of institutions that work to address the needs of the disabled. Zellweger writes from a perspective of a senior aid worker with over thirty years of experience in Asia; she was the Pantech Fellow at Shorenstein APARC from 2011­–13.

 

To view the full listing of publications, as well as reviews and purchasing information, please consult the Publications page on Shorenstein APARC's website.

Southeast Asia Forum Director Donald K. Emmerson talks with media about the recent confrontations between Vietnam and China in the South China Sea, and what role ASEAN may play in managing the issues.