Managing medicines in decentralization: discrepancies between national policies and local practices in primary healthcare settings in Indonesia.

In Indonesia, primary health centres (PHCs) are mandated to provide essential medicines to ensure equal access to medication for all Indonesians, as stated in the national medicine policy. However, limited information is available regarding the actual practices of health workers within the context of decentralized governance. This paper investigates the discrepancies between national policies and local practices in two Indonesian districts, shedding light on coping mechanisms employed in each phase of medicine management within PHCs. The mixed-method study began by identifying pertinent policies addressing medicine management in PHCs. Subsequently, panel data on patient visits to tuberculosis, maternal and neonatal health (MNH), and noncommunicable disease (NCD) services were collected from 2019 to 2022. After analysing the panel data, interviews were conducted with 56 health workers including physicians, nurses, pharmacists, midwives, and public health programme managers regarding their views on fluctuations in medicine stocks and the patient visit data. These participants included pharmacists and programme managers specializing in tuberculosis, MNH, and NCD care and were affiliated with PHCs and district health offices. Our findings highlight the occasional unavailability of essential medicines in PHCs, with stockouts being attributed to supplier shortages at provincial and national levels and to variations in the capacity of the local health system. Low-skilled pharmaceutical staff are a contributing factor in each phase of medicine management. Additionally, health workers employ coping mechanisms, such as deviating from policy on the use of capitation funds to purchase medicines, to manage temporary stockouts. To tackle systemic stockouts, central government should prioritize capacity-building among health workers, by establishing a continuous and easily accessible local learning system.