Date of Award

1-1-2018

Language

English

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College/School/Department

Department of Public Administration and Policy

Content Description

1 online resource (ii, vii, 226 pages) : illustrations (some color)

Dissertation/Thesis Chair

Erika G. Martin

Committee Members

Ashley M. Fox, Gang Chen

Keywords

decentralization, expenditure spillover, health disparities, Indonesia, maternal health services, social capital, Community health services, Decentralization in government, Local government, Public health administration

Subject Categories

Public Administration | Public Health | Public Policy

Abstract

Decentralization has become one of the most important public-sector reform programs globally since the 1990s with mixed results. In this four-paper dissertation, I explored how decentralization reforms affect public goods and services delivery, by analyzing how post-decentralization institutional changes shape local expenditure decisions and health service utilizations in Indonesia. The main goal of this dissertation was to improve understanding on a better approach to studying public goods and services delivery under a decentralized governance. I used primarily quantitative methods in this dissertation. I started with a systematic review of quantitative studies on the impacts of decentralization reforms and health system performance. I found mixed results regarding the effects of decentralization on health system indicators with seemingly beneficial effects on health system performance and health outcomes and proposed research agenda that focus on institutional factors and mechanisms affecting health system performance and outcomes. The second papers examined local expenditure spillovers under Indonesia’s fiscal decentralization, focusing on district health, education, and infrastructure expenditures. This paper showed that expenditure spillovers, through benefit and crowding spillovers, were present in a developing country context implementing decentralization reforms. The third paper examined if social capital associated with changes in utilization of cardiovascular care. I found little support of contextual effects of social capital but consistent positive compositional effects of social capital. I also found the cross-level interaction effects between individual linking social capital and community deprivation. The last paper investigated the effects of territorial splitting on maternal health services utilization. I showed consistent general trends of lower utilization of maternal health services, particularly the institutional childbirth delivery outcome, for districts experienced splitting. Collectively, these findings suggest that understanding of the specific aspects of institutional changes within the context of decentralized governance has provided more useful practical and substantive knowledge for the improvements of public goods and services.

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