This study aimed to define the problems of the current use of the e-Catalogue and the national formulary NF —two elements of medicine pricing and reimbursement policies in Indonesia for achieving universal health coverage UHC —by examining the knowledge and attitudes of stakeholders. Specifically, to investigate 1 the perceived challenges involved in the further implementation of the e-Catalogue and the NF, 2 reasons of prescribing medicines not listed in the NF, and 3 possible improvements in the acceptance and use of the e-Catalogue and the NF. Semi-structured interviews were conducted with stakeholders policymakers, healthcare providers, a pharmaceutical industry representative, and experienced patients to collect the qualitative data. Interestingly, 20 of 45 participants decided to withdraw from the interview due to their lack of knowledge of the e-Catalogue and the NF. All 25 stakeholders who fully participated in this research were in favor of the e-Catalogue and the NF. However, interviewees identified a range of challenges.
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This study aimed to define the problems of the current use of the e-Catalogue and the national formulary NF —two elements of medicine pricing and reimbursement policies in Indonesia for achieving universal health coverage UHC —by examining the knowledge and attitudes of stakeholders.
Specifically, to investigate 1 the perceived challenges involved in the further implementation of the e-Catalogue and the NF, 2 reasons of prescribing medicines not listed in the NF, and 3 possible improvements in the acceptance and use of the e-Catalogue and the NF.
Semi-structured interviews were conducted with stakeholders policymakers, healthcare providers, a pharmaceutical industry representative, and experienced patients to collect the qualitative data. Interestingly, 20 of 45 participants decided to withdraw from the interview due to their lack of knowledge of the e-Catalogue and the NF. All 25 stakeholders who fully participated in this research were in favor of the e-Catalogue and the NF.
However, interviewees identified a range of challenges. A major challenge was the lack of harmonization between the lists of medicines in the e-Catalogue and the NF. Several system and personal reasons for prescribing medicines not listed in the NF were identified.
Important reasons were a lack of incentives for physicians as well as a lack of transparent and evidence-based methods of selection for the medicines to be listed in the NF. Some possible improvements suggested were harmonization of medicines listed in the e-Catalogue and the NF, restructuring incentive programs for prescribing NF medicines, and increasing the transparency and evidence-based approach for selection of medicines listed in the e-Catalogue and the NF. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files. Competing interests: The authors have declared that no competing interests exist.
Many countries strive for universal health coverage UHC , a concept recommended by the World Health Organization WHO to ensure that all people have access to health services they need without suffering financial hardship. One of the goals of UHC is to eliminate out-of-pocket payments OOPs , a direct payment made by an individual to healthcare providers at the time of service use [ 1 , 2 ]. OOPs can be a great catastrophe for the family of a sick individual [ 3 ].
Appropriate policies are needed to reduce OOPs on medicines and to control medicine expenditure [ 6 ]. HTA is a critical component of evidence-based policy decision making [ 8 , 9 ]. In line with the global trends, Indonesia also makes a concerted effort to achieve UHC. Prior to , Indonesians were supported by several social health insurances. The three biggest social health insurances were Asuransi Kesehatan Askes, for civil servants and the military , Jaminan Kesehatan Masyarakat Jamkesmas, for poor and near poor , and Jaminan Sosial Tenaga Kerja Jamsostek, social security program for labourers.
Notably, the fragmented health insurance schemes made health care spending and service quality difficult to control. Regarding medicines, previous studies have reported a large number of different medicine formularies existed with an unclear evidence-base [ 10 ]. In addition, OOPs were still dominant [ 11 , 12 ], e.
First, the e-Catalogue is a national medicine pricing policy and exists since The MOH proposes medicines, usually at the substance level e. Then, LKPP writes a tender for supply at a national scale and selects the preferred suppliers. As a result, the e-Catalogue provides a list of medicines with specifications, prices, and suppliers. All healthcare facilities are obliged to purchase medicines through the e-Catalogue. Nevertheless, healthcare facilities are allowed to perform their own tender for medicines that they need and are not listed in the e-Catalogue [ 14 — 16 ].
Second, the national formulary NF is a medicine reimbursement policy. All healthcare facilities and healthcare professionals may propose medicines to be included in the NF. These medicines are then selected by the NF committee using several criteria among which efficacy, safety, marketing authorization, and benefit-risk ratio.
The first NF was compiled in referring to formularies used in the previous health insurances in Indonesia and the last edition of the Indonesian essential medicines list. The list of medicines in the NF is revised at least every two years. The last revision was in All medicines listed in the NF should be available in the healthcare facilities. Third, the use of HTA was introduced to assess new medicines which might have potential to be included in the e-Catalogue and the NF.
The assessment is to be conducted by the HTA committee. This committee was formed by the MOH in April , then renewed in [ 19 , 20 ]. They are supported by a technical staff thirteen clinicians, two MOH employees, one engineer, and four secretaries. Currently, the main task of the HTA committee is to develop their program. Healthcare facilities seldom perform their own tender for procuring medicines [ 14 ]. Furthermore, instead of different formularies for each insurance scheme, there is a single NF.
The MOH introduced the e-Catalogue and the NF, expecting that they would improve effectiveness, efficiency, and transparency in medicines procurement, as well as ensure the availability of good quality, efficacious, and affordable medicines [ 16 , 22 ]. Thus, this should help Indonesia to achieve UHC.
However, problems regarding the practical use of the e-Catalogue and the NF have been reported. For instance, it was found that many public healthcare facilites rarely use the e-Catalogue to procure medicines [ 23 ]. The obstacles hindering medicine pricing and reimbursement policies in Indonesia are far from clear and need to be investigated. This research aims to shed light on the current use of the e-Catalogue and the NF by examining the knowledge and attitudes of stakeholders regarding the JKN-KIS program, especially concerning the e-Catalogue and the NF.
Therefore, this research will investigate 1 the perceived challenges involved in the further implementation of the e-Catalogue and the NF, 2 the reasons behind the prescription of medicines not listed in the NF, and 3 possible improvements in the acceptance and use of the e-Catalogue and the NF.
The COREQ checklist provides guidance for explicit and comprehensive reporting of qualitative studies. A purposive sampling method was used to recruit the stakeholders [ 27 ].
The stakeholders should have at least 5 years of relevant work experience. Experienced patients were selected based on the duration of their health insurance in Indonesia at least 5 years and their routine use of medicines at least 5 years. The selection criteria of at least 5 years of experience for stakeholders was used to ensure that they could explain the healthcare system of Indonesia during and before the implementation of the new medicine policies.
A rough estimation of participants needed for attaining saturation was then made. A total of at least twenty-two stakeholders were aimed at. This was based on at least two representatives for each group of policy makers, at least two pharmaceutical industry representatives, at least four interviewees from each group of healthcare providers, and at least four patients.
The reason for having more interviewees in the groups of healthcare providers and patients was our interest in the practical issues of the e-Catalogue and the NF, for instance prescribing medicines not listed in the NF. An overview of the research process is provided in the flowchart Fig 1. As a result, the initial themes and a list of questions S1 Table for each theme were created, covering two research objectives, namely 1 the use of medicine pricing and reimbursement policy in the JKN-KIS program and 2 the barriers and facilitators of the application of HTA as part of this policy.
Pilot interviews were then conducted with nine stakeholders pharmacists, physicians, and patients with the aim of testing the comprehensibility and appropriateness of the initial themes and the list of questions. Some adjustments for the final list of questions were made, based on the pilot findings S1 File , including skipping a theme and related questions into facts about health care costs that none of the pilot interviewees could answer.
Most importantly, the list of questions was split into two versions. The first version was used for policymakers, the pharmaceutical industry, and healthcare providers, and the second version was used for patients. The final list of questions was sent to the stakeholders in advance of the interview, in order to give interviewees some time for preparation.
The interviews were recorded and subsequently transcribed verbatim by RW and SI for further analysis. The transcripts were sent back to the participants for feedback as a method to establish the credibility of the results member checking. New interviews were conducted until no new issues arose, that is, until data saturation was obtained.
Directed content analysis was conducted to systematically organize the qualitative data into a structured format [ 29 ] using MAXQDA version They then coded the transcripts independently using the initial themes. The codes were compared, and the non-fitting items were discussed. Texts that did not fit into one of the initial themes and were mentioned by several interviewees were coded as new themes.
RW and SI then checked saturation by theme. Saturation was reached when no new information was generated. The two remaining initial themes were left aside. Written informed consent S2 File was obtained from all participants. All participants consented to review the verbatim transcript of their interview.
The research plan and the interviews to be conducted were reviewed by the University Medical Canter Groningen UMCG ethical review board, who deemed the study non-intrusive, and subsequently provided a formal waiver statement, i. Aiming at about 22 final participants, a total of 51 different individuals were approached during the recruitment process S2 Table. Out of this number, 45 agreed to participate in this research.
However, 9 withdrew after receiving list of questions; 7 decided to stop their interviews before they were finished, since they experienced difficulties in answering the questions and were not confident about their answers; and 4 had no time for an interview, leaving a final number of 25 participants.
This means that the remaining interviewed persons were, to a certain degree, a select group with better knowledge than most stakeholders. Classification of the twenty-five participants can be seen in Table 1. On average, the policymakers, the representative from the pharmaceutical industry and healthcare providers had a work experience of 26 years, with 14 years as the minimum. Furthermore, all patients interviewed had been enrolled in health insurance in Indonesia for an average of 11 years at the time of interview.
Semi-structured interviews were conducted with stakeholders between August and April by RW. Interviews were conducted face to face 16 participants or through video calls 9 participants in locations comfortable to the participants. One of the interviewees invited her colleague to answer the questions together.
One interview was conducted in English, while all others were in Bahasa. The average time spent on each interview was about an hour. All predetermined codes were covered by the interview results to a sufficient degree. Several texts from the transcripts could not be coded into one of the five initial themes S1 Table , and were mentioned many times by different stakeholders.
Overall, 24 final themes were identified from the transcripts, of which 17 S3 Table were used in this study while the 7 remaining themes were left for further research and concerned HTA. The 17 themes in the current research were categorized into 5 topics, which were given overarching names Fig 2. Thus, to obtain accurate information from the patients for the next theme, the interviewer explained the JKN-KIS program to the patients, as well as the role and development of the e-Catalogue and the NF, based on the guidelines of medicines policies in Indonesia [ 14 , 16 , 22 ].
However, they emphasized that there were still some challenges to optimizing the implementation of these policies. Why Universal Health Coverage by , I hope it can be achieved next year
Keputusan Menteri Kesehatan
Yulita Hendrartini, M. Background: Jamkesmas is social aid to ensure health of poor community in Indonesia financed by the government. An effort to reduce cost for health in the program of Jamkesmas is the utilization of prospective payment system, i. In this sytem health providers partially take the financial risk whenever they are inefficiency in budget utilization.
Use of medicine pricing and reimbursement policies for universal health coverage in Indonesia