Moral Landscapes of Health Governance in West Java, Indonesia

Abstract

The democratic decentralization of government administration in Indonesia from 1999 represents the most dramatic shift in governance in that country for decades. In this dissertation I explore how health managers in one kabupaten (regency) are responding to the new political environment. Kabupaten health managers experience decentralization as incomplete, pointing to the tendency of central government to retain control of certain health programs and budgets. At the same time they face competing demands for autonomy from puskesmas (health center) heads. Building on Scott's (1985) idea of a "moral economy" I delve beneath the political tensions of competing autonomies to describe a moral landscape of underlying beliefs about how government ought to behave in the health sector. Through this analysis certain failures and contradictions in the decentralization process emerge, complicating the literature that presents decentralization as a move in the direction of "good governance" (Mitchell and Bossert 2010, Rondinelli and Cheema 2007, Manor 1999). Decentralization brings to the fore the internal divisions within government, yet health workers present a united front in their engagements with the public. Under increasing pressure to achieve global public health goals such as the Millennium Development Goals, health managers engage in multiple translations in converting global health discourses into national and local health policies and in framing these policies in ways that are comprehensible and compelling to the general public. Using the lens of a "cultural theory of state" (Corrigan and Sayer 1985) I describe how health professionals and volunteers draw on local cultural forms in order to render global frameworks compatible with local moralities. I introduce the term "moral pluralism" to describe how individual health workers interrelate several moral frameworks in their health promotion work, including Islam, evidence based medicine and right to health. My conclusion is that kabupaten health managers are engaging in two balancing acts. The first is between decentralization and (re)centralization and deals with the proper way to manage health programming. The second is between global health discourses and local cultural forms and concerns the most effective way to convey public health messages in order to bring about behavior change in line with national and global public health goals. This is the first anthropological study of how government officials at different levels negotiate the process of health decentralization in the face of increasing international pressure to achieve global public health goals.