Rationing for medicines by health care providers in Indonesia National Health Insurance System at hospital setting: a qualitative study

Abstract

Background Universal Health Coverage (UHC) in Indonesia is planned to be fully implemented in 2019 through the National Health Insurance (NHI) launched in January 2014. However, limited financial resources cause health care providers (HCPs) to perform rationing in providing medicine services. The purpose of this study was to analyze rationing strategies performed by HCPs for potentially beneficial essential medicines due to financial constraints and other reasons in the Indonesian NHI Plan and evaluate its fairness. Methods A qualitative study was conducted to find out the rationing performed by 24 HCPs in NHI medicine services at hospital setting. Research methods included semi-structured interviews with eight physicians, eight pharmacists and eight nurses, and observations of prescriptions undergoing dispensing process. Respondents were purposively selected, and interview results were analyzed thematically. The strategies for rationing were categorized using the matrix developed by Maybin and Klein (denial, selection, delay, deterrence, deflection, and dilution), while contradictions in fairness were evaluated using the four conditions of accountability for reasonableness (relevance, publicity, appeals, and enforcement). Results The results showed that the most frequent rationing performed by physicians was dilution (to replace medicines with others which were perceived by physicians as less effective or less safe), denial (not to provide medicines not listed in the National Formulary and/or expensive medicine), and deterrence (to encourage patients to pay for medicine). Among pharmacists, the most frequently rationing performed was dilution (to reduce the amount of medicines), denial, and deterrence as performed by physicians. Almost no rationing strategy was performed by nurses. No formal procedure was available to guide the rationing. The rationale for rationing strategies, especially for non-clinical reasons, was often not communicated to patients, and there were few opportunities for patients to appeal the rationing strategies applied to them. There was no difference between the government and private hospitals in the rationing strategies adopted. Conclusions Although rationing strategies were facilitating the implementation of National Formulary, they potentially raise problems related to the principles of medical ethics and distort a national health system’s ability to progress towards UHC. If performed in the more standardized decision-making process, rationing would be of great benefits to patients and the system. Guidance for more explicit, fair and transparent of rationing should be developed at the hospital level.

Challenges in maintaining medicine quality while aiming for universal health coverage: a qualitative analysis from Indonesia

“…Shortage of publicly-procured medicines facilitates the already common practice of encouraging patients to pay for medicines out of pocket. 20 This sometimes drives patients to shop in more affordable but unregulated outlets, increasing the risk of exposure to falsified medicines.…”

“…Participants also reported cases in which the search for cheaper medicines disincentivised due diligence, Shortage of publicly-procured medicines facilitates the already common practice of encouraging patients to pay for medicines out of pocket. 20 This sometimes drives patients to shop in more affordable but unregulated outlets, increasing the risk of exposure to falsified medicines. "The physician told us to look for the medicines outside the hospital since they have an insulin shortage.…”

A multicentre point prevalence survey of patterns and quality of antibiotic prescribing in Indonesian hospitals

“… 18 Although Indonesia national-level data have not been included in the AWaRe reports to date, 35 our survey found hospital consumption of Access antibiotics at 28% to be below the 60% target, mostly driven by ceftriaxone and levofloxacin use for CAI and HAI. Although these findings could partially be explained by the national health insurance scheme which determines available antibiotics based on the national formulary, 36 they also highlight significant challenges for AMS.…”

A multicentre point prevalence survey of patterns and quality of antibiotic prescribing in Indonesian hospitals

“…Although Indonesia national-level data have not been included in the AWaRE reports to date 33 , our survey found hospital consumption of Access antibiotics at 28% to be far below the 60% target, mostly driven by ceftriaxone and levofloxacin use for CAI and HAI. Although these findings could partially be explained by the national health insurance scheme which determines available antibiotics based on the national formulary 34 , they also highlight significant challenges for AMS.…”