Sri Suryawati Center for Clinical Pharmacology and Medicine Policy Studies

1. Impact of Currency Crisis on Availability, Affordability, and Use of Medicines in Indonesia: A 5-Year Longitudinal Study Sri Suryawati Center for Clinical Pharmacology and Medicine Policy Studies Gadjah Mada University, Yogyakarta.

2. Abstract • Problem Statement: 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, an acute currency crisis occured in 1998, followed by a slow recovery. • Objective: 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). • Indicators: 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 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. • Design: 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 assigned provinces. • Population: Pharmacy outlets of the health facilities. • Outcome Measures: Dynamics of all indicators over time. • Results: 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 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 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 (and later health centers) were encouraged to be self-funding, and this might contribute to the increase of medicine costs. • Conclusions: 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 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 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 as the basis of the local government medicine policy.

3. Background • The implementation of the Indonesian National Drug Policy has been evaluated in 1997, and the results showed that the achievement of the implementation was satisfying, especially in the availability and affordability of essential medicines. The currency crisis in 1998-1999, however, might have altered the level of achievement. • A serial survey was therefore conducted in July 1998, October 1998, March 1999, October 1999, and March 2002, aimed to monitor the availability, affordability, and the use of medicines during the currency crisis. Objective: To monitor the availability, affordability, and use of medicines during the currency crisis.

4. Methodology • A ponderated sampling technique was applied, involving 21 public and 11 private hospitals, 32 healthcentres, 38 pharmacies, and 36 drugstores. • Nine WHO indicators1were utilized, e.g., OT1, OT2 (availability), PR31, PR32, OT3 (affordability), and PR9, OT7, OT8, OT11 (prescribing practices). • The results were compared to the 1997 study (as baseline)2 1. WHO, 1994, Indicators for Monitoring National Drug Policies. WHO-DAP, Geneva. 2.Center for Clinical Pharmacology and Drug Policy Studies, Gadjah Mada University, 1998, Evaluation of the Implementation of Indonesian National Drug Policy: 1997. Ministry of Health of Indonesia, Jakarta.

6. Indicators (WHO, 1994) • Availability: • Affordability: • Prescribing practices: • % key drugs available at health facilities (OT1) • % key drugs at the lowest price available (OT2) • % key drugs available as generics (OT2*) • Average expenditure per prescription (PR31) • Value of a basket of drugs as brandnames (PR32) • Value of a basket of drugs as generics (PR32*) • Average retail price of standard treatment of pneumonia (OT3) • % drugs from the National Essential Drug List prescribed (PR9) • Average number of drugs per prescription (OT7) • % prescription with at least one injection (OT8) • % prescription with at least one antibiotics (OT11)

7. Average medicine cost Average treatment cost (Rp) Exchange rate to US$1 (Rp) 60000 16000 50000 12000 40000 30000 8000 20000 4000 10000 0 0 Jun Jun Jun Jun Sep Dec Sep Dec Sep Dec Sep Dec Mar Mar Mar Mar-99 Mar-02 Dec-97 Private pharmacy Private hospital Public hospital Healthcenter Consumer Price Index

8. Private pharmacy Private hospital Public hospital Healthcenter Drug store Consumer Price Index Treatment cost for pneumonia Exchange rate to US$1 (Rp) Average standard pneumonia treatment cost (Rp) 15000 16000 12000 12000 9000 8000 6000 4000 3000 0 0 Jun Jun Jun Jun Sep Dec Sep Dec Sep Dec Sep Dec Mar Mar Mar Mar-02 Mar-99 Dec-97

9. Availability vs. use of essential medicines!

10. Medicine use

11. Discussions (1) • 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%, 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 Consumer Price Index and the exchange rate. • Lower costs were observed in public facilities, especially in health centers. At baseline, >50% of medicines prescribed in private facilities were non-essential, and these did not improve over time.

12. Discussions (2) • During the recovery phase, public hospitals (and later health centers) were encouraged to be self-funding, and this might contribute to the increase of medicine costs. • At baseline, % patients receiving antibiotics were approx. 44-51% at all facilities, and those for injection were approx. 4-13%. However, the % drugs prescribed from the NEDL were 95% and 68% at public facilities (health center and public hospital, respectively), and only 38% and 41% at private facilities (private hospital and pharmacy, respectively). • It was surprising (or not?) that the prescribing practices did not improve during the crisis, especially in private facilities.

13. Conclusions • 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 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 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 as the basis of the local government medicine policy.