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Jurnal Manajemen Pelayanan Kesehatan

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Sistem ekonomi di Indonesia memberikan kesempatan kepada lembaga pelayanan kesehatan swasta untuk bekerja, dan pihak masyarakat diberi kesempatan pula untuk memberikan sumber dayanya bagi pelayanan kesehatan. Keadaan ini sudah ada sejak jaman kolonial Belanda. Konsekuensinya, sektor kesehatan di Indonesia saat ini sudah berkembang menjadi industri dengan dasar hukum pasar. Selama 10 tahun terakhir pertumbuhan Rumah Sakit (RS) Swasta di Indonesia lebih besar (2,91% rata-rata per tahun) dari RS pemerintah (1,25% rata- rata per tahun). Pada tahun 1998, jumlah RS Pemerintah (589) lebih banyak dari RS Swasta (491) dengan selisih 98 buah. Sejalan dengan pesatnya perkembangan RS Swasta, pada tahun 2008 jumlah RS swasta meningkat menjadi 653 buah dan sakit pemerintah menjadi 667 Buah. Dengan demikian, selisih semakin mengecil yaitu 14 buah.
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Jurnal
Manajemen
Pelayanan Kesehatan
The Indonesian Journal of Health Service Management
Volume 12/Nomor 01/Maret/2009
Daftar Isi
Editorial
Peran Departemen Kesehatan Sebagai Regulator dan Operator Rumah Sakit
1
Makalah Kebijakan
Usulan-Usulan Untuk Menghadapi Permasalahan Non–Paten
yang Mempengaruhi Distribusi dan Ketersediaan Obat-Obat Esensial di Indonesia
Tomi Suryo Utomo
2
Artikel Penelitian
Medical Error dan Perilaku Klinis Petugas Kesehatan dalam Penatalaksanaan Malaria
di RSU Gunung Sitoli Nias
Oktavianus Hulu, Contesa Prihatin Familynard Maruhawa,
Ari Probandari, Adi Utarini, Soesanto Tjokrosonto
12
Clinical Pathway Dalam Pelayanan Stroke Akut: Apakah Pathway Memperbaiki Proses Pelayanan?
Rizaldy Pinzon, Sugianto, Laksmi Asanti, Kriswanto Widyo
20
Community Empowerment Through Inter-Sectoral Action,
A Case Study of Gerbangmas in Lumajang District
Siswanto, Evie Sopacua
24
Persepsi Stakeholders Terhadap Latar Belakang Subsidi Premi, Sistem Kapitasi dan
Pembayaran Premi Program Jaminan Kesehatan Jembrana
Pande Putu Januraga, Chriswardani Suryawati, Septo Pawelas Arso
33
Profil Komite Medis di Indonesia dan Faktor-Faktor yang Mempengaruhi Kinerjanya
dalam Menjamin Keselamatan Pasien
Herkutanto
41
Resensi Buku
Leadership, Theory and Practice
48
Korespondensi
Hubungan Kinerja Bidan dalam Penatalaksanaan Antenatal Care dengan
Quality Work Life di Kota Tasikmalaya Tahun 2007
50

JURNAL MANAJEMEN PELAYANAN KESEHATAN
VOLUME 12
No. 01 Maret 2009
Halaman 1
Jurnal Manajemen Pelayanan Kesehatan
Editorial
PERAN DEPARTEMEN KESEHATAN SEBAGAI REGULATOR
DAN OPERATOR RUMAH SAKIT
Sistem ekonomi di Indonesia memberikan
buruk. Pertanyaan yang sama juga dapat diberikan
kesempatan kepada lembaga pelayanan kesehatan
ke RS Pemerintah. Sayang pertanyaan ini sulit
swasta untuk bekerja, dan pihak masyarakat diberi
dijawab karena memang belum ada sistem
kesempatan pula untuk memberikan sumber
pencatatan mutu RS yang dapat diandalkan.
dayanya bagi pelayanan kesehatan. Keadaan ini
Mengapa hal ini terjadi?
sudah ada sejak jaman kolonial Belanda.
Sampai saat ini belum ada sistem yang
Konsekuensinya, sektor kesehatan di Indonesia
memisahkan antara regulator dan operator di sektor
saat ini sudah berkembang menjadi industri dengan
kesehatan. Tanpa adanya regulator yang tepat maka
dasar hukum pasar.
monitoring mutu pelayanan bukan hal yang mudah
Selama 10 tahun terakhir pertumbuhan Rumah
untuk dilakukan. Hal ini berbeda dengan sektor
Sakit (RS) Swasta di Indonesia lebih besar (2,91%
penerbangan yang sudah tegas memposisikan
rata-rata per tahun) dari RS pemerintah (1,25% rata-
Departemen Perhubungan sebagai regulator
rata per tahun). Pada tahun 1998, jumlah RS
sementara berbagai perusahaan transportasi
Pemerintah (589) lebih banyak dari RS Swasta (491)
(termasuk Garuda) berfungsi sebagai operator.
dengan selisih 98 buah. Sejalan dengan pesatnya
Departemen Perhubungan tentunya mempunyai
perkembangan RS Swasta, pada tahun 2008 jumlah
catatan tentang mutu pelayanan penerbangan
RS swasta meningkat menjadi 653 buah dan sakit
termasuk angka kecelakaan. Perbandingan dengan
pemerintah menjadi 667 Buah. Dengan demikian,
sektor perhubungan merupakan hal penting karena
selisih semakin mengecil yaitu 14 buah.
sektor kesehatan dan sektor transportasi
Dalam waktu lima tahun terakhir, RS swasta
menempatkan keselamatan (safety) sebagai isu
berbentuk perseroan terbatas naik dua kali lipat
penting.
menjadi 85. Pertambahan terutama di daerah-daerah
Departemen Kesehatan sendiri saat ini, masih
dengan ekonomi kuat. Rumah Sakit (RS) Yayasan
rancu dalam memposisikan diri apakah sebagai
mengalami pertumbuhan antara tahun 1998 sampai
regulator ataukah operator sistem pelayanan
dengan 2002. Setelah itu, jumlah RS yayasan tidak
kesehatan. Sebagai gambaran Direktorat Jenderal
bertambah secara signifikan. Rumah Sakit (RS)
Bina Pelayanan Medik masih bersifat rangkap:
Perkumpulan sedikit bertambah pada tahun
sebagai operator sekitar 40-an RS pemerintah pusat,
2001.Selama 10 tahun terjadi perpindahan bentuk
sekaligus sebagai regulator lebih dari seribu RS di
(migrasi) RS Swasta. Ada 26 RS Yayasan berubah
Indonesia. Keadaan ini diharapkan tidak berlangsung
menjadi RS PT. Sebaliknya 5 RS PT berubah
lama lagi. Perlu ada kebijakan jelas untuk
menjadi RS Yayasan. Sebagian besar RS yang
memisahkan kedua fungsi tersebut di pemerintah.
melakukan migrasi berada di kota-kota besar.
Kebijakan hal ini tidak hanya menyangkut aspek
Data ini menggambarkan dinamika kuat dalam
teknis kesehatan namun juga politis dimana pasti
sektor RS di Indonesia. Dinamika ini terpengaruh
banyak pihak yang akan diuntungkan oleh
oleh kekuatan pasar yang besar di Indonesia.
perubahan ini, sementara itu juga ada banyak pihak
Sebagaimana suatu sektor yang dipengaruhi oleh
yang akan dirugikan. Namun, membiarkan Direktorat
pasar, akan terjadi variasi dalam mutu pelayanan.
Jenderal Pelayanan Medik Departemen Kesehatan
Pertanyaan pentingnya adalah bagaimana mutu
mempunyai fungsi rangkap, jelas merupakan hal
pelayanan RS Swasta di Indonesia. Apakah sama
yang tidak baik untuk pembangunan kesehatan.
mutunya atau bervariasi dari mutu baik sampai mutu
Laksono Trisnantoro, trisnantoro@yahoo.com
Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009 1

JURNAL MANAJEMEN PELAYANAN KESEHATAN
VOLUME 12
No. 01 Maret 2009
Halaman 2 - 11
Tomi Suryo Utomo: Usulan-Usulan Untuk Menghadapi ...
Makalah Kebijakan
USULAN-USULAN UNTUK MENGHADAPI PERMASALAHAN NON – PATEN
YANG MEMPENGARUHI DISTRIBUSI DAN KETERSEDIAAN
OBAT-OBAT ESENSIAL DI INDONESIA
PROPOSALS TO ADDRESS NON-PATENT ISSUES THAT AFFECT THE DISTRIBUTION AND
AVAILABILITY OF ESSENTIAL MEDICINES IN INDONESIA
Tomi Suryo Utomo
Program Studi Ilmu Hukum, Universitas Janabadra, Yogyakarta
ABSTRACT
ABSTRAK
Background: Access to affordable essential medicines is
Latar Belakang: Akses terhadap obat esensial merupakan
critical for management of public health in Indonesia. This is
masalah besar bagi pemerintah Indonesia. Hal ini disebabkan
because the government budget for medications is limited.
karena anggaran pemerintah untuk pengadaan obat-obatan
Furthermore, Indonesian sale of generic drugs, which would
sangat terbatas. Di samping itu, penggunaan obat generik di
be an effective strategy of providing cheaper drugs to the
Indonesia yang hanya 10% dari obat-obatan yang ada dianggap
public, is only 10% of drug sales. This is lower than other
relatif lebih rendah dibandingkan dengan penggunaan obat
countries in Asia. Relating to HIV prevalence, there is a
tersebut di negara-negara Asia lainnya. Penyebab lainnya
significant increase number, particularly in some regions in
terkait dengan penyebaran penyakit HIV/AIDS yang
Indonesia. It is not impossible that it will increase at alarming
menunjukkan angka yang relatif tinggi, terutama di beberapa
levels in the near future. Finally, the enforcement of
daerah tertentu di Indonesia. Jika tidak ditangani, penyebaran
pharmaceuticals patent law in Indonesia has created a tension
tersebut dapat mencapai tingkat yang mengkhawatirkan di
between national needs and domestic developmental policy
masa yang akan datang. Perlindungan paten obat juga ternyata
and international patent standards. This tension has particularly
membawa dampak tersendiri bagi akses terhadap obat esensial.
affected Indonesia, since the TRIPS Agreement was introduced
Hal ini semakin terbukti saat pemerintah Indonesia melindungi
in 1994. The TRIPS Agreement’s protection of pharmaceutical
paten obat berdasarkan persyaratan perjanjian TRIPS yang
patent has had adverse consequences for the health needs
diluncurkan pada tahun 1994. Akibatnya, mayoritas masyarakat
of Indonesia since many patients cannot afford expensive
tidak mampu membeli obat paten yang harganya sangat tidak
patented drugs.
terjangkau.
Objective: This paper will consider the options or alternatives
Tujuan: Tulisan ini berisikan beberapa pertimbangan dan
open to the Indonesian government to address the access to
alternatif yang mungkin dapat diterapkan di Indonesia untuk
essential medicine issues that confront Indonesia as a member
mengatasi permasalahan akses obat esensial. Untuk tujuan
of the WTO. A number of questions will be considered. First,
tersebut, ada beberapa pertanyaan yang difokuskan dalam
what factors are major influences on access to essential
tulisan ini. Pertama, faktor-faktor apakah yang mempengaruhi
medicines, in Indonesia? Second, what strategies and policies
akses obat esensial di Indonesia? Kedua strategi dan kebijakan
will be recommended to the Indonesian Government to manage
apakah yang disarankan kepada pemerintah Indonesia untuk
the problems of limited access to affordable essential medicines?
mengatasi terbatasnya akses obat esensial?
Result: Patent law is not the only factor reducing access to
essential medicines. Non-patent issues that affect access to
Hasil Pembahasan: Hukum paten bukanlah satu-satunya
essential medicines include: rational selection and use of
faktor yang mengurangi akses masyarakat terhadap obat
medicines; sustainable adequate financing; affordable prices
esensial. Faktor-faktor tambahan lainnya yang sangat
and reliable health and supply systems are issues that must
berpengaruh terhadap akses obat esensial di Indonesia adalah
be prioritized by the Indonesian Government. Several optional
pemilihan dan penggunaan obat secara rasional, pendanaan
strategies and policies also need to be considered such as
yang mencukupi dan berkesinambungan, harga-harga obat
controlling drugs promotion, maximizing the use of generic
yang terjangkau serta sistem penyediaan obat dan kesehatan
drugs, improving administrative competence, drug
yang dapat diandalkan. Untuk mengatasi permasalahan
procurement, distribution and storage. Finally, prescribing
tersebut, beberapa strategi dan kebijakan penting seperti
practices by physicians, pharmacists and drug vendors should
pengawasan promosi obat-obatan, pengoptimalan penggunaan
be a priority. Meanwhile more complex long-term goals, such
obat generik, peningkatan kewenangan administratif, dan
as establishing an industry to produce raw materials for
distribusi, serta penyimpanan obat-obatan perlu
pharmaceuticals, can be considered. This could reduce the
dipertimbangkan oleh pemerintah. Kebijakan tambahan lain juga
impact of international pharmaceutical patents on price and
dapat menjadi alternatif untuk mengatasi terbatasnya akses
availability of essential medicines.
masyarakat terhadap obat esensial, diantaranya dengan
Conclusion: This paper concludes that the Indonesian
membangun industri yang memproduksi bahan-bahan
government must assess a set of non-patent issues affecting
pembuatan obat. Meskipun pendirian industri ini bersifat sangat
the use of available drugs, particularly generic drugs. The
rumit dan memerlukan waktu yang lama, kebijakan ini dapat
recommended policies and strategies will require careful
membantu pemerintah untuk mengatasi tingginya harga obat
consideration by a multi-disciplinary committee for selection
akibat perlindungan paten serta terbatasnya ketersediaan obat
and use of essential medicines.
esensial di Indonesia.
Kesimpulan: Pemerintah perlu mempertimbangkan beberapa
Keywords: patent law, distribution and availability of essential
faktor di luar hukum paten yang mempengaruhi penggunaan
medicines, access to essential medicines, public health
obat yang diperlukan oleh masyarakat, khususnya obat generik.
2 Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009

Jurnal Manajemen Pelayanan Kesehatan
Beberapa kebijakan dan strategi yang direkomendasikan oleh
protection affects only very small proportion of drugs
komite multidisipliner akan mensyaratkan pertimbangan yang
in developing countries because over 95% of the
hati-hati terkait dengan pemilihan dan penggunaan obat
WHO’s list of essential drugs, those are most needed
esensial.
for treatment in developing countries, are non-
Kata kunci: hukum paten, distribusi dan ketersediaan obat-
patented drugs. The protection of pharmaceutical
obat esensial, akses terhadap obat esensial, kesehatan
products, therefore, does not impact the drug prices
masyarakat.
listed in the WHO’s essential medicines.13
This paper will consider the options or
INTRODUCTION
alternatives open to the Indonesian government to
Access to affordable essential medicines is
address the non-patent issues that affect the
critical for management of public health in Indonesia.
distribution and availability of essential medicine in
As a member of WTO the Indonesian government
Indonesia. A number of questions will be considered.
must balance its policy of protecting pharmaceutical
First, what factors are major influences on access
patents according to the Trade Related Aspects of
to essential medicines in Indonesia? Second, what
Intellectual Property Rights (TRIPS) Agreement
strategies and policies will be recommended to the
(international standards) and its goal of providing
Indonesian Government to manage the problems of
cheaper drugs (domestic developmental policy). The
limited access to affordable essential medicines?
tension is more evident after the Indonesian
For these purposes, this paper discusses several
government complied with the TRIPS Agreement in
possible strategies for improving access to medicines
1997. The existence of the TRIPS Agreement under
in Indonesia that are described in international
the administration of the World Trade Organization
research. Some suggestions from scholars are also
(WTO) brought new approaches in protecting
considered in this section as a basis for
intellectual property internationally. Under the TRIPS
recommendations of what might be useful for
agreement, several aspects of patent were
Indonesia.
introduced. Unless the government provides sufficient
protection for pharmaceutical patents, it faces
Factors are Major Influences on Access to
sanctions from the WTO for violating the principles
Essential Medicines, Including Generic Drugs
of international trade.
in Indonesia
On the other hand, it is often argued that
According to the WHO, four factors influencing
pharmaceutical patent protection will hamper the
access to essential medicines include rational
development of local pharmaceutical companies in
selection and use of medicines, sustainable
developing countries upon which increasing access
adequate financing, affordable prices and reliable
to medicines.1, 2, 3 These concerns are understandable
health and supply systems.14 These are briefly
because a number of studies have shown that patent
reviewed below in the Indonesian context.
protection for pharmaceuticals increases the price
Decisions about rational use of drugs in
of drugs in developing countries before and after the
Indonesia have two problems. First, neither the
TRIPS Agreement.4,5 Pharmaceutical patent
government nor the Indonesian Medical Association
protection is associated with high prices for new
undertake monitoring of prescriptions patterns or
drugs because patent holders can charge the highest
corrective actions if the doctors prescribe non -
prices they estimate the market will pay. These for-
generic drugs.15 Pharmaceutical companies
profit companies justify their prices by referring to
influence doctors with various promotions and
their R&D expenditure, production advertising and
incentives. Secondly, hospital pharmaceutical and
promotion costs, and markups by retailers.6, 7, 8, 9
therapeutic committees have failed to promote the
However, patent law is not the only factor
rational use of drugs in hospitals.16
reducing access to essential medicines. Attaran
Drug financing from public and private sectors
notes that only 1.4% of the WHO Essential
is a serious problem in Indonesia. The government
Medicines List (EML) are patented so that the large
cannot increase its budget for drug financing due to
majority of essential drugs should be accessible.
other obligations. After health decentralization was
He draws attention to poverty, lack of donor funding,
instituted drug financing became the responsibility
and health system infrastructure as barriers to
of local governments.17, 18 They have concluded that
access.10, 11, 12
public health is a non profit sector and is not a priority
The International Federation of Pharmaceutical
in their development agendas.19, 20 Although social
Manufacturers Association (IFPMA) makes a similar
insurance is being promoted by the government it
argument. This association states that patent
has not been well received by private sectors which
Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009 3

Tomi Suryo Utomo: Usulan-Usulan Untuk Menghadapi ...
would bear some of its costs through taxation. Only
cause irrational use of drugs when doctors are
a small percentage of society purchases private
influenced by particular pharmaceutical companies.
social insurances.21
In order to minimize the influence of unethical drug
There are four main problems of affordable price
promotion on prescribing behaviour, the government
of drugs in Indonesia. The first one is because the
should cultivate cooperation with medical professional
government only controls the essential and certain
associations and monitor compliance with regulated
generic drugs but does not control patented drugs
promotion by the Indonesian pharmaceutical
and branded generics.22 The second one is due to
associations. Establishing a code of ethical promotion
the practice of unreasonable markups by
which regulates the way to promote drugs would
pharmaceutical companies through distribution and
improve the appropriate use of drugs.
dispensing systems.23 Thirdly, there is an
This strategy would add to other strategies by
assumption among patients in Indonesia that more
the association of pharmaceutical companies and
expensive drugs must be better drugs and are
the Indonesian government to handle the problems
desirable. Many people assume that better drugs
of unethical promotion. Since 2002, the Association
are more expensive.24 Fourthly, the Indonesian
of the Indonesian multinational pharmaceutical
insurance companies have little bargaining power to
companies has launched a code of ethical promotion
influence hospital purchase or drugs producers
for their members in Indonesia called the
regarding the type and price of drugs.25
pharmaceutical blue book. It has been revised once
after the first launching.26
Optional Strategies to Improve Access to
The government also regulated an ethical
Essential Medicines
promotion regulation under Health Ministerial Decree
Limited access to essential medicines is not just
No.437 of 1987 which prohibits pharmaceutical
caused by patent law but also caused by additional
companies to distribute drug samples to
factors, namely: 1) rational selection and use of
physicians27 and followed by the Ministerial Decree
medicines, 2) sustainable adequate financing, 3)
of 1989 requires doctors working in public health
affordable prices and 4) reliable health and supply
facilities to prescribe generic drugs to their patients.
systems. In order to solve the limited access to
The success of this strategy is dependent on
essential medicines in Indonesia caused by those
the level of commitment of the government, the
non-patent issues, this paper will offer several optional
association of pharmaceutical companies and the
strategies and policies that can improve access to
Indonesian medical association. In practice,
essential medicines. These are briefly reviewed
unethical promotion of drugs applied by
below.
pharmaceutical companies still occurs. Most
pharmaceutical companies use physicians to
1.
Rational selection and use of medicines (or
promote their drugs instead of generic drugs. Another
appropriate use)
problem is the failure of teaching hospitals in
From the perspective of rational selection and
Indonesia in training students, house officers, and
use of medicines, there are two important strategies
staff in the rational use of generic drugs and the effect
to improve access to essential medicines: (a).
of drug prices on patient use. Ironically, teaching
Ethical drug promotion and (b). Generic and essential
hospitals in Indonesia have contributed to the
drug promotion. These will be discussed below.
irrational use of drugs.28
a.
Ethical drug promotion through a code of
b.
Generic and essential drug promotion
conduct, regulation and the collaboration
A policy to promote the use of generic drugs is
between the government and related
very appropriate because generic drugs reduce the
professional associations.
“drug prices in sustainable way.”29 Establishing
Ethical promotion of drugs is an important tool
multidisciplinary Essential Medicines List (EML)
to reduce the problem in rational selection and use
committee and periodically updating EML are
of medicines. Pharmaceutical companies hope to
important if they are enforced by disseminated
influence new drug prescribing behavior through
standards of care that practitioners must comply with
advertising, seminars and symposiums held by
and actual prescription behavior is monitored. In
medical associations. Marketing and promotional
public sector, guiding use of generic and essential
costs are passed on to consumers and increase
drugs via treatment guidelines, standards of care,
the price of drugs. The relationship between
with reinforcement through training, supervision and
pharmaceutical companies and physicians can also
monitoring are also very important components for
4 Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009

Jurnal Manajemen Pelayanan Kesehatan
prescription of generics. Similarly, on-going public
because the Indonesian government is considering
education is important to promote generic drug
establishing a national health insurance to provide
efficacy and value for common problems. In private
affordable drugs to its people.31
sector, gaining support from medical professional
In private sector, the government can also
association, medical schools and residency training
encourage private sector to expand health insurance
staff is very important to promote the use of generic
both at national or local levels, including employer
and essential drugs. Similar tactics for pharmacists
schemes. The remaining two WHO
should also be applied.
recommendations, target external funding through
This strategy complements other Indonesian
grants, loans or donations and other financial
policies in public health sector to promote the rational
mechanisms, including debt-relief and fund solidarity
use of drugs, including establishing committee for
have less relevance for Indonesia as a sustainable
selecting and updating the EML regularly. This
financing because they are temporary and dependent
suggests support for this strategy may be easily
on the availability of other countries or international
realized. The only thing the government should do
organizations and NGO’s funds.
is to plan, evaluate and improve the implementation
Those three policies can potentially minimize
of the strategy. However, the success of
the unethical promotion of drugs applied by
implementing this strategy is dependent on
pharmaceutical companies. This also benefits
physicians and stakeholders. Since this involves a
pharmaceutical companies because under this
lot of parties, it can be complicated and time-
national insurance pharmaceutical companies do not
consuming despite the apparent the benefits of
have to spend their budget for unnecessary
rational use of drugs in Indonesia.
promotion involving physicians.
Since the purchasing power of Indonesian
2.
Sustainable adequate financing
people is very low, the introduction of health insurance
WHO states that there five key actions to
both in public and private sectors will need a lot of
improve access to medicines related to sustainable
efforts and is really dependent on the macro and
financing:
micro economy situation.
-
Increase public funding for health, including for
essential medicines;
3.
Affordable prices
-
Reduce out-of-pocket spending, especially by
The following subsections will discuss briefly
the poor;
three important optional strategies to reduce the price
-
Expand health insurance through national, local,
of drugs:
and employer schemes;
-
Eliminating duties, tariffs and taxes on essential
-
Target external funding-grants, loans, donations
medicines
– at specific diseases with high public health
-
Price controls and;
impact;
-
Health insurance promotion
-
Explore other financing mechanisms, such as
debt-relief and solidarity funds.30
a.
Eliminating duties, tariffs and taxes on
essential medicines
These strategies are relevant for Indonesia since
The WHO proposals to realize affordable prices
they must deal with the limited public budget and
of essential drugs includes the policy of eliminating
low purchasing power in private sectors.
duties, tariffs and taxes on essential medicines32
The increase public funding for health has a
as one of possible solutions. This policy is very
pivotal role in solving the problems of sustainable
important because duties, tariffs and taxes are
adequate financing. However, it would require good
components of determining the price of drugs in
cooperation between central and decentralized local
Indonesia. If the government eliminates duties, tariffs
governments since their priorities for public health
and taxes for particular essential medicines, it
and development are different.
significantly reduces the price of essential medicines
The expansion of health insurance and private
in Indonesia.
health insurance which covers all people in Indonesia
This policy can appeal to producers of essential
could support sustainable adequate financing.
medicines who could anticipate marketing their
Insurance coverage could reduce out-of-pocket
product at a lower price. This might also encourage
spending, especially important for the poor. It seems
other pharmaceutical companies to participate in
that this idea will be realized in the near future
producing essential medicines. However, this policy
Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009 5

Tomi Suryo Utomo: Usulan-Usulan Untuk Menghadapi ...
can affect the government’s revenues in trade and
of rational drugs and reduce unreasonable markups
commercial sector. It may also be not feasible to
of drugs.
realize it in a difficult economic situation.
However, national social health insurance
requires a large budget from the public sector. Since
b.
Price controls
the government decentralized public health in 2001
The Indonesian government policy of controlling
to local governments in Indonesia, the health budget
price of drugs is limited to some generic drugs and
in each province has fallen due to the low priority of
essential drugs list. This policy allows most
the public health sector among local governments.
pharmaceutical companies both local and
Decentralization makes the establishment of national
multinational, to set the price of their non-generic
social insurance which covers all people in Indonesia
and essential drugs according to their standards.
is a challenging program to achieve.
Since there is a demand for higher priced non-generic
drugs, the present price control policy has had little
4.
Reliable health and supply systems
effect on overall drug expenditures. Should
Making essential medicines available is an
Indonesia’s drug price control policy be extended to
important role of the government in promoting public
include non-generics? The policy on price control
health. The Government should regulate and monitor
can be an effective strategy to provide affordable price
the distribution of generic drugs and non generic
to the society. Indonesia should make its pricing
drugs from producers to consumers. The distribution
policy a critical issue for both central and local
system includes procurement, storage, and
government for the objective of improving access to
transferal to drug stores hospitals, and practitioners,
affordable drugs. Comprehensive price control would
the main target of companies promoting their
regulate the price of patented drugs produced by
pharmaceutical products.
private pharmaceutical companies, including both
In 2004 the WHO proposed a check list for
local and multinational companies.
policy makers to handle the problems related to
The advantage of this policy is that the price of
health and supply systems. There are five
drugs is set as stable as possible and it will minimize
recommendations for managing those problems:
unreasonable, unnecessary markups from
-
Integrate medicines in health sector
multinational companies. For Indonesia, this will
development;
benefit public since patented drugs dominate
-
Create efficient public-private-NGO mix
consumer purchases. However, a comprehensive
approaches in supply delivery;
price control policy could discourage foreign investors
-
Assure quality of medicines through regulatory
from investing their capital in a host country and
control;
reduce drug variety in market.
-
Explore various purchasing schemes:
procurement co-operatives;
c.
Health insurance promotion
-
Include traditional medicines in the health care
Limited government budget in public health
provision.34
sector and low purchase power of people in private
sector affect the feasibility of health insurance in
Among these policies, it seems that the policies
Indonesia. In other countries, such as Sweden, the
of a) integrating medicines in health sector
role of national health insurance not only provides
development; b) assuring quality of medicines
financing services, but is pivotal in providing affordable
through regulatory control and; c) exploring various
price of drugs because large-volume purchasers can
purchasing schemes would be the most feasible
negotiate lower drug prices. The profit margin of
strategies for improving health and supply systems
pharmaceutical companies is determined by the
in Indonesia. This is because all those policies have
Sweden National Social Insurance Council. It is not
already been applied in Indonesia although they have
surprising that the price of drugs in Sweden in the
not been maximized.
lowest one in West Europe.33 This potential effect of
Integrating medicines in health sector for
national health insurance should be considered by
example has been used by the government but
Indonesia to reduce the price of drugs in market.
insufficient public education about essential drugs,
This policy is attractive for Indonesia which has
inappropriate prescribing behaviour, and unethical
a huge population and could improve access to care,
promotion are barriers for appropriate use of
including drugs, for all society. If the use and price
medicines, including generic drugs. Similarly,
of drugs were controlled by the government through
Indonesia has a comprehensive regulation about drug
an insurance council, this policy could help the use
registration which assures the safety, efficacy, and
6 Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009

Jurnal Manajemen Pelayanan Kesehatan
quality of medicines. However, the problems of
Since 1998, Indonesia’s production of 26 types
counterfeit drugs still exist in the market. Regarding
of raw materials has fallen to 15 types of raw
various purchasing schemes, barriers are a limited
materials produced by 15 pharmaceutical
budget for health and the low purchasing power of
companies. Most local pharmaceutical companies
the people. Reviewing and evaluating these strategies
agree that establishing an Indonesian raw materials
for managing the problems of health and supply
industry for pharmaceuticals would reduce the local
systems will be important tasks for a
companies’ dependency on imported raw materials.
multidisciplinary task force.
But establishing an Indonesian capability will be
Creating efficient public-private-NGO mix
costly and could exceed the needs of pharmaceutical
approaches in supply delivery is feasible for Indonesia
companies in Indonesia. The use of imported raw
which has huge population and geographical barriers,
materials might be cheaper than establishing an
particularly in Irian Jaya and Kalimantan. However,
Indonesian industry. Even if current importation
it needs time to unify the different supply and
seems cheaper, variable Indonesia currency in the
distribution channels, including the storage systems
last 8 years will inhibit importation. Monetary swings
owned by public and private sectors, each with its
make importation more risky and expensive. On
well-established system.
balance, establishing an Indonesian raw materials
Providing inexpensive traditional medicines for
industry seems preferable because it will create more
health care is an appealing idea. However, it may
job opportunities for Indonesians and Indonesia has
not helpful because little is known about proven
abundant natural resources for producing raw
efficacy, safety or quality of traditional medicines
materials. If the capacity of the factories will exceed
based on modern pharmaceutical standards.
the need of the Indonesian pharmaceutical
companies, the materials might be exported although
Additional Strategies
other countries have a head start.37
The solution to some issues will be more difficult
Because 98% of raw materials for
and will require more time for planning, negotiation
pharmaceutical are imported from overseas, a local
and implementation. Some additional strategies,
industry might reduce production costs and
such as 1) the development of the Indonesian local
ultimately lower the price of drugs. In addition, having
pharmaceutical industry and 2) the policy of shifting
a sufficient raw materials supply domestically may
generic production oriented local pharmaceutical
assist local pharmaceutical companies to be more
companies to R&D based local pharmaceutical
independent and self reliance. However, establishing
companies could reduce the impact of international
an industry needs a lot of capital. In addition, raw
pharmaceutical patents on price and availability of
materials produced must be absorbed by local or
essential medicines.
multinational pharmaceutical companies. Due to
these factors, the establishment will take time and
1.
The policy of establishing industry for the
costly.
production of raw pharmaceutical
materials
2.
The policy of shifting the generic drugs
Indonesia could potentially deal with natural
production oriented local pharmaceutical
resources and the dependency of local
companies to R&D based local
pharmaceutical companies. Why cannot Indonesia
pharmaceutical companies
with its natural resources reach self sufficiency in
For more than 50 years, most local
raw materials? Although Indonesia has a lot of natural
pharmaceutical companies enjoyed privileges as
resources its local companies have to import raw
generic drugs producers from the government. As
materials from foreign countries. Natural resources
generic drug producers, they have not needed a
for drugs (material medika) such as Labiatae,
strong R&D climate in their companies38 reflected
Compositae, Rubiaceae, Umbiliferae, Solanaceae,
by a budgeted R&D of only 1%-2%. This number is
Apocyanaceae and Euphorbiacea are readily
very low compared to multinational pharmaceutical
available in Indonesia. Some research dealing with
companies which provide 15%-16% for R&D
the use of those plants for drugs has also been
activities.39
conducted in Indonesia.35 Unfortunately, that
Therefore, the government must encourage local
research has not affected the use of local materials
pharmaceutical companies to be more innovative and
and local pharmaceutical companies still import 95%
consider the benefits of encouraging those
of raw materials from India, China, Korea and South
companies to be R&D based companies. Such a
American countries. 36
development would be enormously costly because
Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009 7

Tomi Suryo Utomo: Usulan-Usulan Untuk Menghadapi ...
the government has to prepare infrastructures and
Each criterion is scored on a 1-4 basis (4
develop appropriate human resources. However,
meaning high and 1 meaning difficult or low). The
under the TRIPS Agreement, only established, well
resulting total scores are used to rank the options.
financed R&D based companies are likely to survive
The most feasible and important actions could be
and penetrate the international pharmaceutical
listed as “urgent” (U) or immediate targets (i.e. in 1-
market.
2 years). Since these are feasible, they could be
R&D based pharmaceutical companies can be
achieved early and give momentum to subsequent
more independent and not dependent on generic drug
objectives. The next groups are either “short term”
production. In addition, those companies can be a
(2-5 years) (S) or “long-term” (likely to take 5 + years
source of expenditure for the Indonesia economy if
for implementation) (L).
those companies export their pharmaceutical
Among these strategies, it appears that activities
products to other countries. However, this policy
1-2 are urgent; activities 3-6 are short-term and
would require a lot of capital, including the availability
activities 4, 5 and 7 are long-term. Because R&D is
of sufficient and competent human resources and
a complex activity, I include this activity as task force
good infrastructures. This policy seems not really
or advisory group. Activities 3-5 and 7-8 appear to
feasible because it is costly and time consuming.
need collaboration by several shareholders/sectors
cooperation to have any success.
A priority matrix and summary of proposed non-
patent recommendations Related to drug price
CONCLUSION
and generic availability
This paper found that pharmaceutical patent
Table 1 and 2 will conclude the discussion about
protection is not the only factor affecting drug prices.
supplemental or non-patent policies from previous
High price of drugs in Indonesia is influenced by
pages. Table 1 discusses the feasibility of these
pharmaceutical policy that results in weak control
strategies by considering three factors; importance,
of drug distribution and an absence of price controls.
feasibility and political – economic. Table 2 consists
Local pharmaceutical companies depend upon raw
of a set of short and long-term strategies with four
materials from abroad may encounter problems and
main focus; schedule, activity, advantage and
health insurance organizations have failed to use
problems.
volume purchases to negotiate the price of drugs.
The following table 1 provides criteria to compare
Because access to essential drugs has other
the objectives and strategies, such as importance,
barriers besides pharmaceutical patent protection,
feasibility and political-economic support for that
the Indonesian Governments should address non-
strategy. This makes their selection process more
patent barriers. These include rational selection and
clear to decision makers, rather than simply stating
use of medicines, sustainable adequate financing,
the recommendation.
price controls and reliable health and supply
Table 1. A priority matrix related to access to essential medicines and
generic availability
No.
Activity
Importance
(Advantage)
(Disadvantage)
Total Score;
Feasibility
Political-economic
Timetable

EM selection
4
3
2
9 (U)
2.
Promote generics
4
3
2
9 (U)

Appropriate drug use
4
2
1
7 (S)

Financing drugs (or subsidizing)
3
1
1
5 (L)

Affordable prices
3
2
1
6 (L)

System efficiency
3
2
2
7 (S)

Raw materials
2
2
1
5 (L)

R&D models
1
1
1
3 (TF)
Remarks:
-
The Highest score: 4
-
The lowest score: 1
-
U
: urgent or immediate targets (in 1-2 years)
-
S
: short-term (in 2-5 years)
-
L
: long-term (5 + years for implementation)
-
TF : task force (or advisory group)
8 Jurnal Manajemen Pelayanan Kesehatan, Vol. 12, No. 1 Maret 2009

Document Outline

  • Cover Jurnal
  • Daftar Isi
  • Editorial
  • Makalah Kebijakan - (Tomi Suryo Utomo) Usulan-Usulan Untuk Menghadapi Permasalahan Non…Paten Yang Mempengaruhi Distribusi Dan Ketersediaan Obat-Obat Esensial Di Indonesia
    • Abstract
    • Pengantar
    • Kepustakaan
  • Artikel Penelitian
    • Oktavianus Hulu, Contesa Prihatin FM., Ari Probandari, Adi Utarini, Soesanto Tjokrosonto - Medical Error Dan Perilaku Klinis Petugas Kesehatan Dalam Penatalaksanaan Malaria Di RSU Gunung Sitoli Nias
      • Abtract
      • Pengantar
      • Bahan & Cara Penelitian
      • Hasil Penelitian & Pembahasan
      • Kesimpulan & Saran
      • Kepustakaan
    • Rizaldy Pinzon, Sugianto, Laksmi Asanti, Kriswanto Widyo - Clinical Pathway Dalam Pelayanan Stroke Akut: Apakah Pathway Memperbaiki Proses Pelayanan?
      • Abstract
      • Pengantar
      • Bahan & Cara Penelitian
      • Hasil Penelitian & Pembahasan
      • Kesimpulan & Saran
      • Kepustakaan
    • Siswanto, Evie Sopacua - Community Empowerment Through Inter-Sectoral Action, A Case Study Of Gerbangmas In Lumajang District
      • Abstract
      • Pengantar
      • Bahan & Cara Penelitian
      • Hasil Penelitian & Pembahasan
      • Kesimpulan & Saran
      • Kepustakaan
    • Pande Putu Januraga, Chriswardani S., Septo Pawelas Arso - Persepsi Stakeholders Terhadap Latar Belakang Subsidi Premi, Sistem Kapitasi Dan Pembayaran Premi Program Jaminan Kesehatan Jembrana
      • Abstract
      • Pengantar
      • Bahan & Cara Penelitian
      • Hasil Penelitian & Pembahasan
      • Pembahasan
      • Kesimpulan & Saran
      • Kepustakaan
    • Herkutanto - Profil Komite Medis Di Indonesia Dan Faktor-Faktor Yang Mempengaruhi Kinerjanya Dalam Menjamin Keselamatan Pasien
      • Abstract
      • Pengantar
      • Bahan & Cara Penelitian
      • Hasil Penelitian & Pembahasan
      • Kesimpulan & Saran
      • Kepustakaan
  • Resensi Buku - Leadership, Theory and Practice
  • Korespondensi - Hubungan Kinerja Bidan dalam Penatalaksanaan Antenatal Care dengan Quality Work Life di Kota Tasikmalaya Tahun 2007

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