Transcript Currency crisis - NDP

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.
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.
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.
Methodology
 A ponderated sampling technique was applied, involving 21
public and 11 private hospitals, 32 healthcentres, 38
pharmacies, and 36 drugstores.
 Nine WHO indicators1 were 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.
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)
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
Private pharmacy
Healthcenter
Private hospital
Consumer Price Index
Public hospital
Treatment cost for pneumonia
Average standard pneumonia treatment cost (Rp)
15000
Exchange rate to US$1 (Rp)
16000
12000
12000
9000
8000
6000
4000
3000
0
0
Private pharmacy
Healthcenter
Private hospital
Drug store
Public hospital
Consumer Price Index
Availability vs. use of essential medicines!
Availability of key medicines (% ) in various health facilities (as generics)
Percentage of NEDL prescribed in various health facilities (% )
De
Priv ate pharmacy
Priv ate hospital
M
Public healthcenter
Public hospital
c-9
7
ay
-9
8
Oc
t-9
8
M
ar
-9
9
Au
g99
Ja
n00
Ju
n00
No
v-0
0
Ap
r-0
1
Se
p01
Fe
b02
0
Feb
0
Sep
20
Apr
20
Nov
40
Jun
40
Jan-00
60
Aug
60
Mar-99
80
Oct-98
80
May
100
Dec-97
100
Public healthcenter
Priv ate pharmacy
Remote public healthcenter
Priv ate drugstore
Priv ate pharmacy
Priv ate hospital
Healthcenter
Public hospital
Ju
n
De
c
Ju
n
De
c
De
c
Public healthcenter
Public hospital
De
c
0
Ju
n
0
De
c
20
Ju
n
20
-97
40
De
c
40
Ju
n
60
De
c
60
Ju
n
80
De
c
80
Ju
n
100
De
c
100
Ju
n
% patients receiving antibiotics in various health facilities
-97
% patients receiving injection in various health facilities (% )
De
c
Medicine use
Pharmacy
Priv ate hospital
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.
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. 4451% at all facilities, and those for injection were approx. 413%. 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.
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.