Does consolidated procurement influence affordable access to medicines? An Indonesian experiment

Background

In 2014, Indonesia introduced one of the world's largest and most generous mandatory public health insurance schemes. To control costs, a transparent, consolidated tender system for medicine procurement was imposed. Predating policy guidelines for medicine pricing published by World Health Organization in 2020, Indonesia's procurement policies were nonetheless consistent with all of WHO's major recommendations.

From January 2023, Indonesia jettisoned those policies, abandoning consolidation of demand, public tendering, and price transparency in favour of facility-level, confidential negotiation with multiple potential suppliers through an Amazon-style sales platform. Aims, objectives and research questions

We aim to contribute to the better governance, management, integrated analysis and use of data to inform procurement policy choices in Indonesia, while contributing to the international evidence base about effective public procurement of medicines, through three main "Knowledge Deliverables": 1: National medicines data systems analysis

What are the efficiencies and inefficiencies of existing data systems, and what opportunities can we identify for improved governance, analysis and use? 2: Medicine procurement policy impact analysis

How do consolidated purchasing and transparency influence price, sustainable supply to patients, quality, and opportunities for rent-seeking? 3: Political economy analysis

Which interest groups most influence medicine procurement policy choices, through what mechanisms, to achieve what goals? Methods

The study combines records reviews, interviews, and the analysis of both primary and secondary quantitative data. We will: • Scrape and collate data from public medicine registration and procurement datasets; • Extend existing data use agreements to cover new transaction-level data;

• Integrate these with our existing data resources, containing 2.2 million transaction records and 13,500 unique products;

• Train machine learning models on pre-2023 data, and develop indicators that flag potential effects of system change on price, availability and procurement efficiency;

• Train citizen scientists to prospectively collect purchase, dispensing, price and stock-out data for 40 tracer medicines from 50 health facilities in 13 districts nationwide, quarterly; collect retrospective data on medicine stock-outs for 2021-22;

• Provide participating health facilities with a co-designed dashboard to allow them better to monitor their own procurement outcomes;

• Interview 140 people involved in medicine manufacture, supply, procurement, dispensing, regulation or audit (national and district) about 1) their experiences pre and post policy change; 2) the forces shaping that change.

• Integrate data from all sources into an analysis that iteratively examines the reasons for and impact of changes to procurement policies, in the context of each of the knowledge deliverables. Timeline, Dissemination and Impact

We are now piloting study instruments and procedures. We expect interim findings in year 1, and conclusive findings by late 2026. We developed this proposal with an intersectoral medicine policy forum.

We will consult forum members every 6 months, while also convening district medicine discussion groups. This provides a direct channel to people most likely to act on our findings.TIGH will share findings with international audiences through its well-established global health procurement seminar series.