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ccess to affordable and good quality medicine is critical for the successful implementation of universal healthcare (JKN) in Indonesia. It also poses a major challenge for the government, which is responsible for meeting the demand for medicines from the 180 million participants of the JKN.

In addition, the JKN has to deal with a diverse set of health challenges, ranging from infectious diseases (dengue, malaria) and chronic diseases (diabetes, heart disease, cancer) to malnutrition and stunted growth among children. Healthcare delivery is also characterized by logistics, budgetary, informational and human resource constraints and a shortage of quality medicine.

As part of the introduction of the JKN, the government, through the National Procurement Agency (LKPP), introduced a system of tendering medicines based on the National Formulary.

Several tendering exercises have resulted in a massive reduction in the price of medicines, with further price reductions anticipated in the future.

While price reductions for medicines have been significant, and are clearly to be welcomed, this system has sparked a set of concerns and challenges that need to be addressed.

First, pharmaceutical producers have expressed concern that the tender process has been too aggressive and perhaps overly focused on price reductions, and that further price reductions will have unwanted repercussions on medical supplies.

This includes compromised quality, safety concerns, potential for medical complications and reduced efficacy of medicines, which, in turn, may result in longer hospital stays and recovery times for patients.

These undesirable ramifications will also have broader, longer-term implications in increased stress, pressure and costs on an already fragile healthcare delivery system and may, in turn, reduce public confidence and trust in the efficiency, value and sustainability of the JKN.

At a global level, balancing affordability and access with maintaining quality has been a challenge for many developing countries that are implementing universal healthcare coverage. For example, some key essential medicines, such as the antibiotic penicillin or methotrexate for cancer, are disappearing from the market globally partly because prices for these products have become so low that they are no longer commercially viable for manufacturers to supply them.

In this regard, five areas are deemed crucial by an international commission to ensure access to medicines: First, paying for a basket of essential medicines; second, making essential medicines affordable; third, assuring the quality and safety of medicines; fourth, promoting the proper use of medicines and finally, developing missing essential medicines.

New approaches are needed for setting prices that take into consideration factors that drive pricing strategies for new medicines. Another key factor relates to what is necessary for pharmaceutical companies to maintain a viable commercial model.

Second, and as a means of overcoming some of these concerns, we need better coordination among stakeholders involved in the JKN, including the Health Ministry, the LKPP and the Food and Drug Monitoring Agency.

Dialogue, coordination and harmonization of actions between these agencies, in close consultation with national pharmaceutical manufacturers, who are the key suppliers of medicines for the JKN, would go a long way toward developing a rational strategy and policy for access to affordable, quality medicines and ensure the sustainability of the JKN in the long term.

Third, how can we ensure that quality standards for medicines are not compromised in the pursuit of lower prices? How do we ensure that those who win the tender deliver the products and maintain future supplies to avoid “stock-outs” of key medicines?

In this regard, there is an urgent need for an effective monitoring and evaluation system, coupled with an ability to take punitive measures against offenders. Monitoring would include, for example, adherence to good manufacturing practices, batch-to-batch bioequivalence (a component of “therapeutic equivalence,” or the efficacy of a medicine), as well as safety standards set by the WHO.

Finally, at the heart of the matter is the survival and sustainability of the national pharmaceutical industry itself. Poor coordination among key government agencies and continued price reductions to commercially unsustainable levels may compromise the ability of national manufacturers to maintain quality and supply of medicines and generate much needed capital for re-investment in manufacturing facilities, quality control processes, distribution networks and research and development activities.

Such a state of affairs, in turn, risks these national manufacturers becoming takeover targets for acquisition by foreign pharmaceutical companies.

In shaping the Indonesian government’s future policies and strategies for sustaining the JKN, it is important to highlight to the government the key challenge of balancing affordability with quality, orchestrating better coordination among key agencies, maintaining supply and having an effective monitoring and evaluation system for access to medicines.

Importantly, the government must be committed to ensuring the survival and growth of the national pharmaceutical industry. Open and frank dialogue and collaboration between the government, manufacturers, academia, civil society, consumer groups and other stakeholders is necessary to deal with this critical issue.
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The writer is a visiting professor at Lee Kuan Yew School of Public Policy, National University of Singapore.