Impact of Currency Crisis on Impact of Currency Crisis on Availability, Affordability, and Use of Availability, Affordability, and Use of Medicines in Indonesia: A 5-Year Medicines in Indonesia: A 5-Year

Longitudinal StudyLongitudinal Study

Sri SuryawatiSri SuryawatiCenter for Clinical Pharmacology and Center for Clinical Pharmacology and

Medicine Policy StudiesMedicine Policy Studies

Gadjah Mada University, Yogyakarta.Gadjah Mada University, Yogyakarta.

AbstractAbstract

Problem Statement:Problem Statement: Evaluation of the implementation of the Indonesian National Drug Policy in 1997 Evaluation of the implementation of the Indonesian National Drug Policy in 1997 showed satisfying results, especially in the availability and affordability of essential medicines. Unfortunately, showed satisfying results, especially in the availability and affordability of essential medicines. Unfortunately, an acute currency crisis occured in 1998, followed by a slow recovery.an acute currency crisis occured in 1998, followed by a slow recovery.

Objective:Objective: To monitor the availability, affordability, and use of medicines during the currency crisis, To monitor the availability, affordability, and use of medicines during the currency crisis, covering the acute phase (January–September 1998) and recovery phases (January 1999–March 2002). covering the acute phase (January–September 1998) and recovery phases (January 1999–March 2002).

Indicators: Indicators: Availability of key essential medicines, average prescription cost, average pneumonia treatment Availability of key essential medicines, average prescription cost, average pneumonia treatment cost, percentage of medicines from the National Essential Drugs List (NEDL) prescribed, average number of cost, percentage of medicines from the National Essential Drugs List (NEDL) prescribed, average number of medicines per prescription, percentage of patients receiving injections, percentage of patients receiving medicines per prescription, percentage of patients receiving injections, percentage of patients receiving antibiotics, Consumer Price Index (CPI), and the exchange rate of Indonesian rupiahs to U.S. dollars.antibiotics, Consumer Price Index (CPI), and the exchange rate of Indonesian rupiahs to U.S. dollars.

Design: Design: A proportional sampling technique, involving 21 public hospitals, 11 private hospitals, 32 public A proportional sampling technique, involving 21 public hospitals, 11 private hospitals, 32 public health centers, 38 private pharmacies, and 36 private drugstores, randomly selected from 3 purposively health centers, 38 private pharmacies, and 36 private drugstores, randomly selected from 3 purposively assigned provinces. assigned provinces.

Population: Population: Pharmacy outlets of the health facilities.Pharmacy outlets of the health facilities. Outcome Measures: Outcome Measures: Dynamics of all indicators over time. Dynamics of all indicators over time. Results: Results: The availability of key essential medicines at public health facilities was >80% throughout the crisis The availability of key essential medicines at public health facilities was >80% throughout the crisis

period (94% at baseline). Generic products were also available throughout the study period (>94%, compared period (94% at baseline). Generic products were also available throughout the study period (>94%, compared with 94% before the crisis). Prescription costs were well maintained during the acute phase, but then slowly with 94% before the crisis). Prescription costs were well maintained during the acute phase, but then slowly increased during the recovery phase, along with the increases of CPI and the exchange rate. Lower costs were increased during the recovery phase, along with the increases of CPI and the exchange rate. Lower costs were observed in public facilities, especially in health centers. At baseline, >50% of medicines prescribed in private observed in public facilities, especially in health centers. At baseline, >50% of medicines prescribed in private facilities were nonessential, and this did not change over time. During the recovery phase, public hospitals facilities were nonessential, and this did not change over time. During the recovery phase, public hospitals (and later health centers) were encouraged to be self-funding, and this might contribute to the increase of (and later health centers) were encouraged to be self-funding, and this might contribute to the increase of medicine costs.medicine costs.

Conclusions: Conclusions: The results showed the success of the government in maintaining the availability of key The results showed the success of the government in maintaining the availability of key essential medicines throughout the crisis, and in providing drugs at affordable prices through public health essential medicines throughout the crisis, and in providing drugs at affordable prices through public health facilities. However, the unchanged prescribing practices did not show any sense of crisis among private facilities. However, the unchanged prescribing practices did not show any sense of crisis among private providers. These findings indicated the need of better selection of medicines in private health facilities with providers. These findings indicated the need of better selection of medicines in private health facilities with emphasis on essential medicines, and control of medicine costs through rational prescribing. Self-funding of emphasis on essential medicines, and control of medicine costs through rational prescribing. Self-funding of public health facilities should have been carefully implemented, with rational selection and cost containment public health facilities should have been carefully implemented, with rational selection and cost containment as the basis of the local government medicine policy.as the basis of the local government medicine policy.

BackgroundBackground

The implementation of the Indonesian National Drug Policy has The implementation of the Indonesian National Drug Policy has been evaluated in 1997, and the results showed that the been evaluated in 1997, and the results showed that the achievement of the implementation was satisfying, especially achievement of the implementation was satisfying, especially in the availability and affordability of essential medicines. The in the availability and affordability of essential medicines. The currency crisis in 1998-1999, however, might have altered the currency crisis in 1998-1999, however, might have altered the level of achievement. level of achievement.

A serial survey was therefore conducted in July 1998, October A serial survey was therefore conducted in July 1998, October 1998, March 1999, October 1999, and March 2002, aimed to 1998, March 1999, October 1999, and March 2002, aimed to monitor the availability, affordability, and the use of medicines monitor the availability, affordability, and the use of medicines during the currency crisis. during the currency crisis.

Objective: To monitor the availability, affordability, Objective: To monitor the availability, affordability, and use of medicines during the currency and use of medicines during the currency crisis. crisis.

MethodologyMethodology

A A ponderated samplingponderated sampling technique was applied, technique was applied, involving 21 public and 11 private hospitals, 32 involving 21 public and 11 private hospitals, 32 healthcentres, 38 pharmacies, and 36 drugstores. healthcentres, 38 pharmacies, and 36 drugstores.

Nine WHO indicatorsNine WHO indicators11 were utilized, e.g., OT1, OT2 were utilized, e.g., OT1, OT2 (availability), PR31, PR32, OT3 (affordability), and PR9, (availability), PR31, PR32, OT3 (affordability), and PR9, OT7, OT8, OT11 (prescribing practices). OT7, OT8, OT11 (prescribing practices).

The results were compared to the 1997 study (as The results were compared to the 1997 study (as baseline)baseline)22

1.1. WHO, 1994, Indicators for Monitoring National Drug Policies. WHO, 1994, Indicators for Monitoring National Drug Policies. WHO-DAP, Geneva.WHO-DAP, Geneva.

2.2. Center for Clinical Pharmacology and Drug Policy Studies, Gadjah Mada Center for Clinical Pharmacology and Drug Policy Studies, Gadjah Mada University, 1998, Evaluation of the Implementation of Indonesian University, 1998, Evaluation of the Implementation of Indonesian National Drug Policy: 1997. Ministry of Health of Indonesia, Jakarta. National Drug Policy: 1997. Ministry of Health of Indonesia, Jakarta.

Indicators (WHO, 1994)Indicators (WHO, 1994) Availability:Availability:

Affordability:Affordability:

PrescribingPrescribing practices:practices:

% key drugs available at health facilities (OT1)% key drugs available at health facilities (OT1) % key drugs at the lowest price available (OT2)% key drugs at the lowest price available (OT2) % key drugs available as generics (OT2*)% key drugs available as generics (OT2*)

Average expenditure per prescription (PR31) Average expenditure per prescription (PR31) Value of a basket of drugs as brandnames (PR32)Value of a basket of drugs as brandnames (PR32) Value of a basket of drugs as generics (PR32*)Value of a basket of drugs as generics (PR32*) Average retail price of standard treatment of Average retail price of standard treatment of

pneumonia (OT3)pneumonia (OT3)

% drugs from the National Essential Drug List % drugs from the National Essential Drug List prescribed (PR9)prescribed (PR9)

Average number of drugs per prescription (OT7)Average number of drugs per prescription (OT7) % prescription with at least one injection (OT8)% prescription with at least one injection (OT8) % prescription with at least one antibiotics (OT11)% prescription with at least one antibiotics (OT11)

Average medicine costAverage medicine cost

0

10000

20000

30000

40000

50000

60000

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ar JunSepDec

Mar-99JunSepDecMar Ju

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nSepDec

Mar-02

Average treatment cost (Rp)

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4000

8000

12000

16000

Exchange rate to US$1 (Rp)

Private pharmacy Private hospital Public hospitalHealthcenter Consumer Price Index

Treatment cost for pneumoniaTreatment cost for pneumonia

Average standard pneumonia treatment cost (Rp) Exchange rate to US$1 (Rp)

Private pharmacy Private hospital Public hospitalHealthcenter Drug store Consumer Price Index

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3000

6000

9000

12000

15000

Dec-97 M

ar JunSepDec

Mar-99JunSepDecMar Ju

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Mar-02

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4000

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12000

16000

Availability vs. use of essential medicines!Availability vs. use of essential medicines!

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20

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100

Dec

-97

May

Oct

-98

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-99

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Jan-

00 Jun

Nov Ap

r

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Percentage of NEDL prescribed in various health facilities (% )

Public healthcenter Priv ate pharmacyPublic hospital Priv ate hospital

0

20

40

60

80

100

Dec-97

May-98

Oct-98

Mar-99

Aug-99

Jan-0

0Ju

n-00

Nov-00

Apr-01

Sep-01

Feb-02

Availability of key medicines (% ) in various health facilities (as generics)

Public healthcenter Remote public healthcenterPriv ate pharmacy Priv ate drugstore

Medicine useMedicine use

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20

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60

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100

Dec-97 Jun Dec Jun Dec Jun Dec Jun Dec

% patients receiv ing injection in various health facilities (% )

Public healthcenter Priv ate pharmacyPublic hospital Priv ate hospital

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100

Dec-97 Jun Dec Jun Dec Jun Dec Jun Dec

% patients receiv ing antibiotics in various health facilities

Healthcenter PharmacyPublic hospital Priv ate hospital

Discussions (1)Discussions (1)

The availability of key essential medicines at public The availability of key essential medicines at public health facilities was >80% throughout the crisis health facilities was >80% throughout the crisis period (94% at baseline). Generic products were also period (94% at baseline). Generic products were also available throughout the study period (>94%, 94% available throughout the study period (>94%, 94% before the crisis). before the crisis).

Prescription costs were well maintained during the Prescription costs were well maintained during the acute phase, but then slowly increased during the acute phase, but then slowly increased during the recovery phase, along with the increases of recovery phase, along with the increases of Consumer Price Index and the exchange rate. Consumer Price Index and the exchange rate.

Lower costs were observed in public facilities, Lower costs were observed in public facilities, especially in health centers. At baseline, >50% of especially in health centers. At baseline, >50% of medicines prescribed in private facilities were non-medicines prescribed in private facilities were non-essential, and these did not improve over time. essential, and these did not improve over time.

During the recovery phase, public hospitals (and later During the recovery phase, public hospitals (and later health centers) were encouraged to be self-funding, health centers) were encouraged to be self-funding, and this might contribute to the increase of medicine and this might contribute to the increase of medicine costs.costs.

At baseline, % patients receiving antibiotics were At baseline, % patients receiving antibiotics were approx. 44-51% at all facilities, and those for injection approx. 44-51% at all facilities, and those for injection were approx. 4-13%. However, the % drugs prescribed were approx. 4-13%. However, the % drugs prescribed from the NEDL were 95% and 68% at public facilities from the NEDL were 95% and 68% at public facilities (health center and public hospital, respectively), and (health center and public hospital, respectively), and only 38% and 41% at private facilities (private hospital only 38% and 41% at private facilities (private hospital and pharmacy, respectively). and pharmacy, respectively).

It was surprising It was surprising (or not?)(or not?) that the prescribing that the prescribing practices did not improve during the crisis, especially practices did not improve during the crisis, especially in private facilities.in private facilities.

Discussions (2)Discussions (2)

ConclusionsConclusions

The results showed the success of the government in The results showed the success of the government in maintaining the availability of key essential medicines maintaining the availability of key essential medicines throughout the crisis, and in providing drugs at affordable throughout the crisis, and in providing drugs at affordable prices through public health facilities. However, the prices through public health facilities. However, the unchanged prescribing practices did not show any sense of unchanged prescribing practices did not show any sense of crisis among private providers. crisis among private providers.

These findings indicated the need of better selection of These findings indicated the need of better selection of medicines in private health facilities with emphasis on medicines in private health facilities with emphasis on essential medicines, and control of medicine costs through essential medicines, and control of medicine costs through rational prescribing. rational prescribing.

Self-funding of public health facilities should have been Self-funding of public health facilities should have been carefully implemented, with rational selection and cost carefully implemented, with rational selection and cost containment as the basis of the local government medicine containment as the basis of the local government medicine policy.policy.