WHO Essential Drugs Strategy

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Impact of currency crisis on the availability
and affordability of essential medicines A case
study from Indonesia
Sri Suryawati WHO Collaborating Center for
Research and Training on RDU Yogyakarta -
Indonesia
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Introduction

• The implementation of Indonesian NDP was
  evaluated in 1997.
• Results showed that the achievement was
  satisfying, the use of essential medicines in
  public health facilities was high.
• The currency crisis in 1998-1999, however, might
  have altered the level of achievement.
• A serial survey was conducted in July 1998,
  October 1998, March 1999, October 1999, and March
  2002, aimed to monitor the availability, use, and
  the affordability of medicines during the crisis.
  

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Methods

• Ponderated (proportional) sampling technique,
  involving
• 21 public and 11 private hospitals,
• 32 public healthcentres
• 34 private pharmacies, and
• 33 private drugstores.
• Indicators

• Availability
• Prescribing
• practices
• Affordability

• key drugs available as generics
• key drugs available as cheapest brands
• drugs from the NEDL prescribed
• prescription with at least one antibiotics
• prescription with at least one injection
• Average number of drugs per prescription
• Average cost per prescription
• Average cost of standard treatment of pneumonia

WHO, 1994, Indicators for Monitoring National
Drug Policies. WHO-DAP, Geneva
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Currency crisis 1997-2002
Baseline survey (December1997)
Baseline survey (December1997)
Recovery phase

• Acute phase

Pre- crisis
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Availability of key medicines
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Use of essential medicines
The use of essential medicines in public
healthcenters is compulsory
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Antibiotics polypharmacy
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Injection use remains low..!!!
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Affordability of treatment
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Findings (1)

• The availability of key essential medicines was
  well-maintained throughout the crisis. Generic
  products were consistently available.
• However, the use of essential medicines was low,
  except in public healthcenters.
• Surprisingly (or not surprisingly?), prescribing
  practices did not improve during the crisis
• The impacts on affordability of the crisis is
  much less in public facilities where they have
  EDL as compared to the private ones which apply
  more liberal procurement/un-restricted
  purchasing.
• Hospitals were sensitive to the crisis, they too
  rely on medicines as a profit center.
• Prescription costs were fluctuating during the
  acute period, and then following the trend of
  Consumer Prices Index during the recovery period.

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Findings (2)

• These findings
• Prove the success of the MOH to maintain the
  availability of essential medicines throughout
  the crisis.
• Indicate the needs of interventions to promote
  the use of essential medicines in private health
  facilities.
• Indicate the needs to improve prescribing
  practices in private health facilities
• Indicate the needs of better financing scheme in
  hospitals and private facilities
• Underline the strong needs of MOH to control drug
  prices and
• treatment cost

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Access to essential medicines is a human right

• Health is a human right (Universal Declaration of
  Human Rights)
• The right to health care includes the right to
  emergency care and health facilities, goods and
  services (Covenant)
• The right to facilities, good and services
  includes the provision of essential drugs as
  defined by WHO (GCom.14)
• State parties are under immediate obligation to
  guarantee that the right to health care is
  exercised without discrimination, and that
  concrete steps are taken towards full realization
  with emphasis on vulnerable and marginal groups

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Misleading beliefs toward essential medicines

• Cheap medicines
• Medicines for healthcenter
• Medicines for poor people
• Medicines for paramedics
• Medicines for general practitioners
• Medicines for mild diseases, they do not work for
  severe diseases.
• Etc.?

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Why misleading?

• Factors influencing decision to use medicines

Commercial information
Knowledge of providers
Patients knowledge
Availability of medicines
Decision to use medicines
Workload
Peer group
Consultation
Etc.
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Lessons learnt

• The results indicated the success of the Ministry
  of Health in maintaining the availability of
  essential drugs during the crisis. However, this
  effort was not followed by better prescribing
  practices, especially in private health
  facilities.
• Strategies for interventions to improve
  prescribing should be carefully planned,
  especially for private facilities. Those
  strategies should include educational and
  managerial approaches, taking into consideration
  the insentives for better prescribing.
• The use of essential medicines in private
  facilities should be reinforced, access to
  essential medicines as a human right should be
  the basic message of any intervention to promote
  rational medicine use.
• The private market treat medicines as an ordinary
  trade commodity. MOH should take an active role
  to control the medicine price and treatment cost.