Use of medicine pricing and reimbursement policies for universal health coverage in Indonesia

Variation in Price of Cardiovascular and Diabetes Medicine in Indonesia, and Relationship with Quality: A Mixed Methods Study in East Java

Lower-middle income Indonesia, the world's fourth most populous country, has struggled to contain costs in its mandatory, single-payer public health insurance system since the system's inception in 2014. Public procurement policies radically reduced prices of most medicines in public facilities and the wider market. However, professional associations and the press have questioned the quality of these low-cost, unbranded generic medicines. We collected 204 samples of four cardiovascular and one antidiabetic medicines from health facilities and retail outlets in East Java. We collected amlodipine, captopril, furosemide, simvastatin, and glibenclamide, sampling to reflect patients' likelihood of exposure to specific brands and outlets. We recorded sales prices and maximum retail prices and tested medicines for dissolution and percentage of labeled content using high-performance liquid chromatography. We conducted in-depth interviews with supply chain actors. All samples, including those provided free in public facilities, met quality specifications. Most manufacturers make both branded and unbranded medicines. Retail prices varied widely. The median ratio of price to the lowest price for an equivalent product was 5.1, and a few brands sold for over 100 times the minimum price. Prices also varied between outlets for identical products because retail pharmacies set prices to maximize profit. Because very-low-cost medicines were universally available and of good quality, we believe richer patients who chose to buy branded products effectively protected medicine quality for poorer patients in Indonesia because manufacturers cross-subsidize between branded and unbranded versions of the same medicine.

Analysis of e-catalogue drug prices in the era of Universal Health Coverage in the Indonesian pharmaceutical industry

Context: Since the implementation of the Universal Health Coverage (UHC) policy in Indonesia, the drug procurement system has changed to using the e-catalogue system. The impact of this policy change on the pharmaceutical industry in Indonesia is unclear and has not been widely studied.

Objectives: This study analyzes the impact of the UHC policy on drug pricing by the pharmaceutical industry in Indonesia.

Methods: This study collects data from 3 pharmaceutical industries that won the e-catalogue drug tender. Data on drug prices produced by these 3 industries in 2013 were taken from the Drug Price Ceiling List, while drug prices in 2015 and 2018 were obtained from the e-catalogue drug list. The drug price data is compared from year to year to see the trend of change and the magnitude of the change. Data were analyzed using a price index calculation adapted from the concept of Median Price Ratio (MRP) calculation to compare drug prices in 2013 with drug prices per each region in 2015 and 2018 in the Microsoft Excel Office application as a measuring tool.

Results: There was a change in drug prices from the era before UHC (in 2013) and after the UHC era (in 2015 and 2018). There are drugs that have increased in price and some have decreased in price. The price increase ranged from 0.01–6.15 in 2015 and 0.01–6.46 in 2018. The price decrease ranged between 0.04–0.75 in 2015 and 0.01–0.83 in 2018.

Conclusion: Drug prices from before the UHC era (2013 and 2015) to after UHC (in 2018) experienced a change in the form of an increase or decrease in price.

Disclosure, transparency, and accountability: a qualitative survey of public sector pharmaceutical committee conflict of interest policies in the World Health Organization South-East Asia Region

BACKGROUND

Weak governance over public sector pharmaceutical policy and practice limits access to essential medicines, inflates pharmaceutical prices, and wastes scarce health system resources. Pharmaceutical systems are technically complex and involve extensive interactions between the private and public sectors. For members of public sector pharmaceutical committees, relationships with the private sector can result in conflicts of interest, which may introduce commercial biases into decision-making, potentially compromising public health objectives and health system sustainability. We conducted a descriptive, qualitative study of conflict of interest policies and practices in the public pharmaceutical sector in ten countries in the World Health Organization (WHO) South-East Asia Region (SEAR) (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) between September 2020 and March 2021.

RESULTS

We identified 45 policy and regulatory documents and triangulated documentary data with 21 expert interviews. Key informants articulated very different governance priorities and conflict of interest concerns depending on the features of their country's pharmaceutical industry, market size, and national economic objectives related to the domestic pharmaceutical industry. Public sector pharmaceutical policies and regulations consistently contained provisions for pharmaceutical committee members to disclose relevant interests, but contained little detail about what should be declared, when, and how often, nor whether disclosures are evaluated and by whom. Processes for preventing or managing conflicts of interest were less well developed than those for disclosure except for a few key procurement processes. Where processes for managing conflicts of interest were specified, the dominant strategy was to recuse committee members with a conflict of interest from relevant work. Policies rarely specified that committee members should divest or otherwise be free from conflicts of interest.

CONCLUSIONS

Robust processes for conflict of interest prevention and management could ensure the integrity of decision-making and build public trust in pharmaceutical processes to achieve public health objectives. Upstream approaches including supportive legislative frameworks, the creation of oversight bodies, and strengthening regulatory institutions can also contribute to building cultures of transparency, accountability, and trust.

Forming a medicines pricing policy for low and middle-income countries (LMICs): the case for Pakistan

Equitable access to medicines has played a vital role to improve patient health outcomes and reducing mortality globally. However, it is important to note that medicines pricing is a key determinant in promoting access to medicines. The studies and empirical data have shown that there are wide variations in prices across countries for the same brand of medicines. World Health Organisation (WHO) has provided guidelines to formulate country pharmaceutical pricing policies. However, little is known how these guidelines will be used in the country-specific setting. This commentary provides guiding principles and outlines the basis to form a medicines pricing policy in a low and middle-income country, Pakistan. It discusses the current medicines pricing policy and provides suggestions for future work. The suggested medicines pricing structure and lessons learned in this commentary can also be applied in other low-resource settings.

Challenges in maintaining medicine quality while aiming for universal health coverage: a qualitative analysis from Indonesia

Introduction

Indonesia, the world’s fourth most populous nation, is close to achieving universal health coverage (UHC). A widely-publicised falsified vaccine case in 2016, coupled with a significant financial deficit in the national insurance system, has contributed to concern that the rapid scale-up of UHC might undermine medicine quality. We investigated the political and economic factors that drive production and trade of poor-quality medicines in Indonesia.

Methods

We reviewed academic publications, government regulations, technical agency documents and news reports to develop a semi-structured questionnaire. We interviewed healthcare providers, policy-makers, medicine regulators, pharmaceutical manufacturers, patients and academics (n=31). We included those with in-depth knowledge about the falsified vaccine case or the pharmaceutical business, medicine regulation, prescribing practice and the implementation of UHC. We coded data using NVivo software and analysed by constant comparative method.

Results

The scale-up of UHC has cut revenues for physicians and pharmaceutical manufacturers. In the vaccine case, free, quality-assured vaccines were available but some physicians, seeking extra revenue, promoted expensive alternatives. Taking advantage of poor governance in private hospitals, they purchased cut-price ‘vaccines’ from freelance salespeople.

A single-winner public procurement system which does not explicitly consider quality has slashed the price paid for covered medicines. Trade, industrial and religious policies simultaneously increased production costs, pressuring profit margins for manufacturers and distributors. They reacted by cutting costs (potentially threatening quality) or by market withdrawal (leading to shortages which provide a market for falsifiers). Shortages and physician-promoted irrational demand push patients to buy medicines in unregulated channels, increasing exposure to falsified medicines.

Conclusion

Market factors, including political pressure to reduce medicine prices and healthcare provider incentives, can drive markets for substandard and falsified medicines. To protect progress towards UHC, policy-makers must consider the potential impact on medicine quality when formulating rules governing health financing, procurement, taxation and industry.

Pulmonary Arterial Hypertension in Indonesia: Current Status and Local Application of International Guidelines

Recent advances in the diagnosis and management of pulmonary arterial hypertension (PAH) have led to a significant improvement in the outcomes for patients with PAH. However, prompt and accurate diagnosis of PAH remains an unmet challenge due to lack of awareness and lack of meticulous data to profile the etiology and pathophysiology of this rare progressive disease, especially in low- and middle-income country. In Indonesia, the true prevalence and incidence of different subtypes of PAH in general population is still unknown. The Congenital HeARt Disease in adult and Pulmonary Hypertension (COHARD-PH) registry was the first single-center prospective registry in Indonesia, which indicated that almost 80% of adult patients with congenital heart disease (CHD) had experienced PAH and even Eisenmenger syndrome due to delayed diagnosis. Screening for early detection of asymptomatic CHD in children is yet to be systematically established in Indonesia, leading to undiagnosed and uncorrected CHD in adulthood. There are no specific national guidelines focusing on diagnostic workup and treatment of PAH in Indonesia. Furthermore, the lack of adequate diagnostic facilities, limited treatment availability, and limited drug coverage under the National Health Insurance Scheme are key issues that remain unaddressed. This review focuses on the diagnosis, treatment, and management of PAH associated with CHD in Indonesia as per international guidelines. We have proposed recommendations to effectively control and prevent PAH associated with CHD in Indonesia. The paper should be of interest to readers in the area of medical management and policy makers especially in low- and middle-income countries.

Key factors influencing the prescribing of statins: a qualitative study among physicians working in primary healthcare facilities in Indonesia

OBJECTIVES

To elicit key factors influencing physicians' decision to prescribe statins.

DESIGN

A qualitative study using a phenomenological approach within a pragmatism interpretive framework. A combination of purposive and snowball sampling was used to recruit physicians. Data were collected through face-to-face, semistructured interviews with physicians working in primary healthcare facilities in a capital of a province in Indonesia. We recorded and verbatim transcribed the interviews. Coding was done independently by two researchers and data were analysed using phenomenological data analyses. Key factors influencing physicians' decision to prescribe statins were classified into factors at the microlevels, mesolevels and macrolevels according to the structural model by Scoggins et al. PARTICIPANTS AND SETTING: Physicians working in primary healthcare facilities in a capital of a province in Indonesia.

RESULTS

Ten physicians were included in the study. Key factors at the microlevel were that physicians knew guidelines in general, but there was uncertainty how to take into account the level of total cholesterol in combination with other cardiovascular risk factors such as diabetes and hypertension. At the macrolevel, the new National Health Insurance System (NHIS) that appeared to facilitate the prescription of statins though more clinical information should be integrated in the system's platform to support appropriate prescribing.

CONCLUSIONS

The findings indicate lack of awareness of specific details in current guideline recommendations. Appropriate prescribing of statins should be enhanced using the new NHIS.

The implementation of HTA in medicine pricing and reimbursement policies in Indonesia: Insights from multiple stakeholders

Objectives

This study aimed to identify the barriers and facilitators to improve the use of health technology assessment (HTA) for the selection of medicines listed in the e-Catalogue and the national formulary in Indonesia.

Methods

Semi-structured interviews were conducted to collect qualitative data. Purposive sampling was used to recruit the stakeholders consisting of policymakers, a pharmaceutical industry representative, healthcare providers, and patients. The data were analyzed using directed content analysis and following the COnsolidated criteria for REporting Qualitative studies (COREQ).

Results

The twenty-five participants interviewed agreed with the use of HTA for supporting the e-Catalogue and the national formulary and perceived the advantages of HTA implementation outweighed the disadvantages. Barriers mentioned were a lack of capability of local human resources, financial incentives, a clear framework and insufficient data. Strategies suggested to overcome the barriers were establishing (inter)national networks to build up capacity, setting up departments of HTA in several universities in Indonesia, and introducing a clear HTA framework. Facilitators mentioned were the ambition to achieve universal health coverage, the presence of legal frameworks to implement HTA in the e-Catalogue and the national formulary, and the demands for appropriate medicine policies.

Conclusions

Several barriers are currently hampering broad implementation of HTA in medicine pricing and reimbursement policy in Indonesia. Solutions to these issues appear feasible and important facilitators exist.

Gap analysis for drug development policy-making: An attempt to close the gap between policy and its implementation

Introduction

Most drug development policies in developing countries are enacted without achieving the desired results. This study aims to determine the prioritization of drug development in Indonesia through the evidence-based policymaking process in order to close the distance between stated policy goals and the realization of planned goals.

Methods

A quantitative approach in the form of cross-sectional research using a structured survey was adopted and validated using a set of techniques involved in the calculation of a structural equation model. An independent samples t-test was used to test the significance of the differences between two views: pharmaceutical industries and the government of Indonesia.

Findings

The study reveals that pharmaceutical industries and governments were highly consistent in their perceived challenges in facing the drug development. It also reveals drivers and weaknesses of drug development, including market opportunities, push-pull-regulatory pull factors and regulation, as priorities for improvement.

Conclusions

Gap analysis based on a structural model was borne out to address gap challenges between policy and its implementation, with the use of evidence-based policymaking.

Identifying market risk for substandard and falsified medicines: an analytic framework based on qualitative research in China, Indonesia, Turkey and Romania

Introduction: Substandard and falsified medicines undermine health systems. We sought to unravel the political and economic factors which drive the production of these products, and to explain how they reach patients. Methods: We conducted in-depth case studies in China, Indonesia, Turkey and Romania. We reviewed academic papers and press reports (n = 840), developing semi-structured questionnaires. We interviewed regulators, policy-makers, pharmaceutical manufacturers, physicians, pharmacists, patients and academics (n=88). We coded data using NVivo software, and developed an analytic framework to assess national risks for substandard and falsified medicines. We tested the framework against cases reported to the World Health Organization, from countries at all income levels. Results: We found that increasing political commitment to provision of universal health coverage has led to public procurement policies aimed at lowering prices of medical products. In response, legitimate, profit-driven pharmaceutical companies protect their margins by cutting costs, or withdrawing from less profitable markets, while distributors engage in arbitrage. Meanwhile, health providers sometimes protect profits by 'upselling' patients to medicines not covered by insurers. Cost-cutting can undermine quality assurance, leading to substandard or degraded medicines. Other responses contribute to shortages, irrational demand and high prices. All of these provide market opportunities for producers of falsified products; they also push consumers outside of the regular supply chain, providing falsifiers with easy access to customers. The analytic framework capturing these interactions explained cases in most high and middle-income settings; additional factors operate in the poorest countries. Conclusions: Most efforts to secure medicine quality currently focus on product regulation. However, our research suggests market mechanisms are key drivers for poor quality medicines, including where political commitments to universal health coverage are under-resourced. We have developed a framework to guide country-specific, system-wide analysis. This can flag risks and pinpoint specific actions to protect medicine quality, and thus health.