Hasnida Amalia, Kok Maarten Olivier, Pisani Elizabeth
Health Care Governance, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Zuid-Holland, Netherlands
Migunani Research Institute, Yogyakarta, Indonesia.
BMJ Glob Health. 2021 May;6(Suppl 3). doi: 10.1136/bmjgh-2020-003663.
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.
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.
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.
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.
印度尼西亚是世界第四人口大国，已接近实现全民健康覆盖（UHC）。2016年一起广泛传播的疫苗造假事件，再加上国家保险系统的巨额财政赤字，引发了人们对全民健康覆盖快速扩大可能会损害药品质量的担忧。我们调查了推动印度尼西亚劣质药品生产和贸易的政治和经济因素。
我们查阅了学术出版物、政府法规、技术机构文件和新闻报道，以制定一份半结构化问卷。我们采访了医疗服务提供者、政策制定者、药品监管者、制药商、患者和学者（共31人）。我们纳入了那些对疫苗造假事件或制药业务、药品监管、处方行为以及全民健康覆盖的实施有深入了解的人。我们使用NVivo软件对数据进行编码，并通过持续比较法进行分析。
全民健康覆盖的扩大减少了医生和制药商的收入。在疫苗事件中，有免费的、质量有保证的疫苗，但一些医生为了获取额外收入，推销昂贵的替代疫苗。他们利用私立医院管理不善的情况，从自由销售人员那里购买低价“疫苗”。单一赢家的公共采购系统没有明确考虑质量，大幅降低了所涵盖药品的采购价格。贸易、产业和宗教政策同时增加了生产成本，挤压了制造商和经销商的利润率。他们的应对方式是削减成本（可能威胁质量）或退出市场（导致药品短缺，为造假者提供了市场）。药品短缺以及医生推动的不合理需求促使患者在不受监管的渠道购买药品，增加了接触假药的风险。
包括降低药品价格的政治压力和医疗服务提供者激励措施在内的市场因素，可能会推动劣质和假药市场的发展。为保护全民健康覆盖所取得的进展，政策制定者在制定有关卫生筹资、采购、税收和产业的规则时，必须考虑对药品质量的潜在影响。
