Identifying barriers and enablers in accessing physical specific allocation funds for health (Dana Alokasi Khusus Fisik Kesehatan/DAK-FH)
This study identifies regulatory instability, planning misalignment, and limited technical capacity as key barriers, alongside improved information systems and local adaptability as enablers, to the effective utilization of Indonesia's Physical Special Allocation Fund for Health (DAK-FH) between 2020 and 2025, ultimately recommending strengthened national-subnational coordination to optimize decentralized health financing.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In Indonesia, the way the government delivers public services underwent a massive shift in 1999. Before that, the central government in the capital made almost all the decisions and held most of the money. The new system, known as decentralization, handed significant power and responsibility to local governments in the provinces, districts, and cities. The idea was that local leaders would know their communities better and could fix problems more effectively. To make sure these local governments had enough money to do their jobs, especially in poorer areas, the national government created a special system of transfers. One of the most important of these is a fund specifically for building and fixing health facilities, called the Physical Special Allocation Fund for Health. This money is meant to pay for things like new clinics, hospitals, and medical equipment, ensuring that a village in a remote part of the country has access to the same basic health infrastructure as a city.
However, having the money available is only the first step. The real challenge lies in getting that money from the national treasury to the construction site and actually using it to build something. A recent study by researchers from the Indonesian Ministry of Health, the World Bank, and Hiroshima University looked closely at how this specific health fund works in practice. They wanted to understand why some regions manage to use the funds quickly and effectively, while others struggle to spend even a fraction of what they are allocated. By talking to government officials at both the national and local levels and reviewing official rules, the team mapped out the journey of the fund, identifying the specific roadblocks that slow it down and the factors that help it move forward.
The researchers found that the system is designed to be flexible, changing its rules and priorities often to match the country's evolving needs. For instance, the categories of projects the fund can support have shifted over the years, moving from broad groups to more specific focuses like strengthening the overall health system or family planning. While this flexibility allows the government to react to new crises or priorities, it creates a difficult environment for local planners. The rules governing how to apply for the money, what documents are needed, and which projects are eligible can change frequently, sometimes even after a local government has already started preparing its proposal. One local official described this as a constant struggle to adapt, noting that when the guidelines change, the entire plan can become unstable or fall apart. This lack of predictability means local teams often have to redo their paperwork multiple times, wasting valuable time and energy.
Another major hurdle is the gap between what the central government expects and what local governments can actually deliver. The process requires local officials to submit detailed plans through a digital system called KRISNA, which acts as a central hub for budgeting and performance tracking. While this system is intended to make things more transparent and efficient, it often becomes a source of delay. The system requires precise data, such as proof of land ownership for the proposed construction site. In many remote areas, land is not formally registered or is owned by village communities rather than the district government. Getting the legal paperwork to transfer this land can take months or even years, yet the application deadlines are tight. If the land documents are not perfect, the proposal is rejected, and the project cannot proceed. This issue is particularly severe in eastern Indonesia, where officials reported that the time limits for applications make it nearly impossible to resolve complex land disputes before the deadline.
The study also highlighted a human element that often gets overlooked: the people doing the work. In many districts, the staff responsible for managing these funds are few in number and frequently transferred to different jobs. When a trained employee leaves, the institutional knowledge they held leaves with them. New staff members often have to learn the complex rules and digital systems from scratch, leading to mistakes and further delays. This is especially true in remote regions, where there are already fewer skilled workers available. The researchers noted that this high turnover disrupts the continuity of projects, making it hard for local governments to build the long-term capacity needed to manage these funds effectively.
Despite these challenges, the researchers identified several factors that help local governments succeed. The most significant enabler is the adaptability of local teams. Governments that have strong internal communication and a clear understanding of the national priorities are better able to navigate the changing rules. When local leaders and staff work closely together, they can align their needs with the available funding menus more quickly. Additionally, the digital systems, when they work smoothly, provide a clear path for tracking progress and identifying gaps. The study found that regions with stable internet connections and reliable access to the online platforms were able to submit their proposals and monitor their projects much more effectively than those without.
The researchers concluded that while the fund is a vital tool for improving health infrastructure across Indonesia, its potential is currently limited by the friction in the system. The frequent changes in policy, the rigid requirements for land ownership, and the lack of consistent staffing create a barrier that is hardest to cross for the very regions that need the help the most. To fix this, the study suggests that the government needs to provide more predictable guidance, perhaps by announcing priority locations and rules well in advance of the budget planning cycle. They also recommend offering more technical support to remote areas to help them navigate the complex application process and secure the necessary legal documents. By smoothing out these administrative wrinkles and strengthening the capacity of local teams, the country can ensure that the money intended to build health clinics actually reaches the communities that need them, turning the promise of decentralization into a reality for everyone.
Drowning in papers in your field?
Get daily digests of the most novel papers matching your research keywords — with technical summaries, in your language.