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

Southern Med Review

Yayi Suryo Prabandari^2¹  Sri Suryawati^4²  Erna Kristin^3³  Endang Yuniarti^1⁴ 

[1] Department of Health Behavior Environment Health and Social Medicine, Faculty of Medicine Nursing and Public Health, Universitas Gadjah Mada, Yogyakarta, Indonesia^2;Division of Clinical Pharmacology and Medicine Policy, Department of Pharmacology and Therapeutics, Faculty of Medicine Nursing and Public Health, Universitas Gadjah Mada, Yogyakarta, Indonesia^4;Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Pharmacology and Therapeutics, Faculty of Medicine Nursing and Public Health, Universitas Gadjah Mada, Yogyakarta, Indonesia^3;Pharmacy Program, Muhammadiyah Health Science Institute of Gombong-Central Java and Pharmacy Department of PKU Muhammadiyah Hospital, Yogyakarta, Indonesia^1

关键词: Rationing;    Priority setting;    INA-CBGs;    Medicines in health insurance;    Indonesia National Health Insurance;   

DOI  :  10.1186/s40545-019-0170-5

学科分类：药理学

来源: BioMed Central

【 摘 要 】

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. 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). 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. 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.

【 授权许可】

Unknown