Clientelism and Public Health: Explaining Variation in Healthcare Services in Three Indonesian Cities

Abstract

What explains Indonesia’s persistent regional disparities in healthcare delivery? This study argues that the answer lies not only in resources or capacity, but in politics, specifically, in how clientelism shapes the way health services are governed. Patronage, clientelism, rent-seeking, and informal political practices influence who gets appointed within the healthcare system, which programs are prioritised, and how budgets are allocated and used. Yet these dynamics have been largely overlooked in studies of Indonesia’s health sector. By comparing three cities—Kupang, Makassar, and Semarang—this research shows that the political logic behind clientelism helps explain Indonesia’s persistent regional inequalities in healthcare delivery. A mixed-methods design underpins the analysis. Quantitative data from the Clientelism Perception Index (Berenschot, 2018b) helps identify cases with contrasting patterns of health-sector performance, while interviews, policy analysis, and process tracing reveal how clientelistic exchanges operate on the ground. Three questions guide my study: (1) How does variation in clientelism influence the delivery of healthcare services? (2) What contextual factors modify this relationship? And (3) Through what mechanisms does clientelism affect healthcare quality? Five findings stand out. First, the intensity of clientelism shapes health sector performance. Cities with entrenched political clientelism, such as Kupang, tend to exhibit poor health outcomes, while cities with lower levels of clientelism, such as Semarang, perform better. Differences in fiscal capacity alone do not explain these disparities; instead, political incentives are more decisive. Makassar, however, presents an anomaly: despite high levels of clientelism, it achieves relatively strong healthcare outcomes, suggesting that intensity alone cannot account for variation. Second, the form of clientelism matters. In Makassar, local leaders strategically insulate certain sectors—particularly healthcare—from excessive political interference while concentrating clientelistic practices in rent-rich areas such as infrastructure, land, and business licensing. This hybrid model of governance demonstrates how elites can combine programmatic and clientelist approaches to maintain performance legitimacy while sustaining political networks. Third, clientelism is not uniformly applied but sectorally differentiated. Local politicians often preserve service quality in highly visible sectors like health and education to demonstrate competence and maintain coalition stability while concentrating clientelist activities in less scrutinised, profitable domains. Effective healthcare thus functions as both a governance achievement and a political strategy for regime survival. Fourth, four contextual factors shape the extent to which clientelism distorts healthcare governance: the size of the middle class, the strength of civil society, the degree of market competition, and the availability of alternative patronage sectors. Where civic oversight, healthcare market competition, and alternative rent channels are strong—as in Semarang and parts of Makassar—health systems are more insulated. Where these factors are weak, as in Kupang, clientelism permeates all levels of governance. Fifth, clientelism distorts healthcare through two primary mechanisms: patronage and rent-seeking/corruption. Patronage operates when politicians make politically motivated appointments of health officials and target programs toward political allies or supporters, while rent-seeking involves the extraction of resources through procurement and budgeting. These mechanisms are pervasive in Kupang, concentrated in big-ticket projects in Makassar, and largely contained in Semarang. This study offers three major contributions. It provides a framework for understanding how clientelism affects healthcare; it shows that governance often combines programmatic and clientelistic practices rather than fitting into either category; it explains why similar political systems can produce different outcomes. The policy implication is that improving healthcare in decentralised democracies requires more than technical fixes. Reform efforts must confront the political incentives that allow clientelism to thrive—by strengthening civic oversight, insulating key sectors from patronage and rent-seeking, and reducing politicians’ dependence on public resources for electoral mobilisation. In sum, Indonesia’s uneven healthcare performance reflects the political logic that governs it. Recognising how clientelism works and how it can be constrained is essential for building more accountable health systems in Indonesia and beyond.