DECENTRALIZATION AS A CHALLENGE TO IMPROVE THE DRUG MANAGEMENT; AN EXPERIENCE FROM SLEMAN DISTRICT, YOGYAKARTA, INDONESI

1. DECENTRALIZATION AS A CHALLENGE TO IMPROVE THE DRUG MANAGEMENT; AN EXPERIENCE FROM SLEMAN DISTRICT, YOGYAKARTA, INDONESIA SUNARTONO HEAD OF SLEMAN DISTRICT HEALTH OFFICE, INDONESIA

2. ABSTRACT Problem statement: Pharmaceutical has importance role in health service, so it must be given big attention by stakeholders to ensure availability, accessibility and affordability, especially in health centers. Before year 2001 the drug management in Indonesia was more centralized, thus, the district has a smaller authority. Since January 1st, 2001 the decentralization was started as a national policy with 11 obligated authorities at district including health, meaning that the drug management as a part of health has become responsibilities of the district. Some of the district failed to maintain it which is characterized by: reducing pharmaceutical funding, increasing non generic name and irrational use at health centers. Actually, decentralization is an opportunity to improve the selection, procurement, distribution and use of drug at the district level. Therefore, the question is: “How the health district management can use to good advantage this opportunity?” Design: This abstract describe serial activities have been conducted in Sleman district, Yogyakarta, Indonesia, as a consequence to the decentralization policy. To evaluate the success of the activities, several indicators are presented, i.e. local regulation, finance, pharmaceutical with generic name, efficiency of money, availability, stock out of drug, percentage of antibiotic use, percentage of injection use, and number of drug per prescription. The period of data collection is 1999 to 2003 Result: Since 2002 Sleman district has reduced 33 to 24 health centers and recruited doctor it self for health center. Among district level policy others are practicing rationale drug use as one of the selective criteria of the new doctors in the district, no procurement at HC level, providing better incentive for doctors practicing in health center, and bioequivalence as a requirement for drug procurement. Drug management have succeeded in keeping local funding of drug about 60% and increasing per year with the mean 17.78%, although in 2003 reduced slightly (about 2.84%). The routine budget of pharmacy is also increased from 19 to 89 millions or 4.5 times. More than 96% pharmaceuticals being purchased are with generic name, and the efficiency of using money for purchasing drugs increased from 0.17 to 16.13%. The availability of pharmaceuticals can be maintained at the safety level that is 1.72 times of consumption level with the highest stocked out 5.1% (8 from 157 items in 4 months) in 2003. Furthermore, it can keep performance of the rational use on drug with indicators: reduced percentage of antibiotic use from 49.5 to 13.23%, reduced percentage of antibiotic use (less than 5 days) from 100 to 24.7%, maintained percentage of injection from 2.63 to 0.8%. Number of drug per prescription is maintained at 2.75-3. Conclusion: Decentralization is a chance for district health management to increase the quality of health services through improving the drug management efficiency. However, these effort need comprehensive approach involving all stakeholders and strong political support from the district authority.

3. BACKGROUND • Pharmaceutical has importance role in health service, so it must be given a big attention • Decentralization in Indonesia was started on January 1st, 2001 meaning that the drug management as a part of health care management has become responsibilities of the district. • Some of district have failed to maintain the drug management which are characterized by: • reducing pharmaceutical funding, • increasing non generic name, and • irrational use of medicines in health centers.

4. OBJECTIVE • To evaluate the success of the Sleman District Health Managers to maintain the drug management during the process of decentralization in Indonesia.

5. METHODS • Design: a case study • Location: Sleman District, Yogyakarta, Indonesia. • Period of data collection: 1999 – 2003, • Qualitative data: recruitment process of new doctor, drug procurement process, capacity building process, budget negotiation for drug, political will from local authority, etc. • Quantitative indicators: Budget allocation for drugs, efficiency of funding, availability, drug stock-outs, percentage of antibiotic use, percentage of injection use, drugs prescribed with generic name, and average number of drug per prescription.

6. TIMELINE Decentralization Process Advocacy to local authority for political will and budgeting New system for drug procurement New system of recruitment new doctor Capacity building Year 1999 2000 2001 2002 2003

7. QUALITATIVE FINDINGS • Reducing the number of health centers: 33 to 24 • Continuous training; Clinical Performance Development Management System for nurse and midwife, Monitoring-Training-Planning approach, regular supervision and feedback on drug use and management • Implementation of local government policies and regulations: • Rational drug use principles as a requirement in new doctor recruitment, • No drug procurement at health center level • Better incentive for prescribers in health centers • Bioequivalence data as a requirement for drug procurement

8. BUDGET FOR PHARMACEUTICALS

9. GENERIC PRESCRIPTION, ANTIBIOTICS, INJECTIONS

10. EFFECIENCY OF FUNDING IN DRUG PROCUREMENT

11. DRUG AVAILABILITY AND CONSUMPTION (Rp)

12. Centralization Diagnose Treat Follow up Evaluation • Decentralization -Organization -Finance -Human resource -Equipment (qualitative & quantitative) -Capacity building -Commitment building from the staffs -Advocacy to the local decision makers • Improving the drug management: • -Selection -Distribution • -Procurement -Use of drug -Sustainability of finance resource -Availability of drugs -Efficiency on procurement -Rationality on use of drug IMPLICATION DRUG MANAGEMENT ON DECENTRALIZATION PROCCESS

13. CONCLUSION • Decentralization is a chance for district health management to increase the quality of health services through improving the drug management efficiency. • The district health management needs comprehensive approaches involving all stakeholders, and strong political support from the district authority. • The main management support to comprehensive approach includes organizational, educational, and financial supports

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