Are quality medicines affordable? Evidence from a large survey of medicine price and quality in Indonesia

Background Since Indonesia implemented one of the world’s largest single-payer health insurance schemes in 2014, the price of many common medicines has fallen dramatically. Public narratives have questioned the quality of low-cost medicines, including those provided free to insured patients. We investigate the relationship between medicine price and quality, and the affordability of medicines paid for out of pocket. Methods We bought over 1,000 samples of five common prescription medicines -- allopurinol, amlodipine, amoxicillin, cefixime and dexamethasone -- online and from randomly-selected pharmacies and health facilities in four regions across Indonesia, recording price paid, and testing samples for quality using high performance liquid chromatography. We compared prices with the median price for the same medicine; tested for correlation between quality and price, and calculated affordability compared with the district minimum wage. Results Medicines available in the public procurement system were less likely to fail quality testing than other brands/varieties (4.2% vs 8.3%) but the difference was not statistically significant (p=0.086). There was no other relationship between quality and price, or branded status. Branded generic medicines sold at a large variety of price points, from 0.1 to 23.1 times the median price for the medicine and dose (interquartile range: 0.9 – 4.8, median 1.4). Unbranded generics traded in a narrower range (range: 0.1 – 3.2; IQR: 0.5 - 1, median 0.8). Medicines were most expensive in the region with the lowest wages, but even there, medicines selling at the 25th centile of available prices cost a maximum of 0.7% of one day’s wage for a course. Conclusion Though medicine price vary very widely in Indonesia, we found that affordable varieties of common prescription medicines were widely available across the country, and these medicines were no more likely to fail quality testing than those costing several times as much. ### Competing Interest Statement Yusi Anggriani is a member of the Indonesian Ministry of Health's advisory committee on medicine pricing, and a member of the World Health Organization Technical Advisory Group on Pricing Policies for Medicines. Elizabeth Pisani has worked as a consultant on research commissioned by the WHO Incidents and Substandard/Falsified medical products team. All other authors report no conflict of interest. ### Funding Statement The study was funded by UK taxpayers through the UK Department of Health and Social Care and the National Institute for Health Research, under NIHR Global Health Policy and Systems Research Commissioned Awards (https://www.nihr.ac.uk/), grant number NIHR131145. Thank you. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Thanks also to United States Pharmacopeia, who provided reference standards at discounted prices. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Additional data are available in three locations, all within the STARmeds repository: https://dataverse.harvard.edu/dataverse/STARmeds Supplementary. This includes a dataset for this specific paper (including the analysis code in Stata format for this paper and supplementary figures). Data and documentation related to STARmeds fieldwork more generally are also in the study archive. This archive is easiest to use in Tree view. It contains the sample level data produced by the STARmeds field study, including raw laboratory data, in csv format. This includes samples collected from illegal online sellers which were excluded from the analysis reported in this paper, using the code . Also included are laboratory protocols and a more detailed description of methods. The archive can be accessed at: https://doi.org/10.7910/DVN/RKYICP. Finally, we provide a free Toolkit to help researchers and regulators design and implement medicine quality field surveys using mystery shoppers. The toolkit contains downloadable and adaptable versions of data collection software, field control forms, field worker contracts and other potentially useful documentation. The Toolkit can be downloaded from: https://doi.org/10.7910/DVN/OBIDHJ