MATERIALS

1. THE DEVELOPMENT OF CLINICAL PHARMACY IN INDONESIA

The Pharmaceutical Journal Vol 264 No 7098p817-819
May 27, 2000 Articles

By C. K. Tan, PhD, MRPharmS, and M. Aslam, PhD, FRPharmS

This article describes the pioneering work of two British pharmacists in developing clinical
pharmacy teaching and a drug information center in Indonesia. Future plan include the
establishment of a center for pharmacy postgraduate education and a revamping of the
undergraduate curriculum to promote clinical skills while maintaining a healthy emphasis
on pharmaceutical science.

With a population of well over 202 million people, Indonesia is the fourth most populous
country in the world. Three fifths of the people live on the main island of Java, which is
roughly the size of England, making Java one of the most densely populated regions in the
world. There are about 350 different ethnic groups and 600 different local languages and
dialects. However, the majority speak the national language, Bahasa Indonesia. The whole
country is the size of Europe, and comprises over 13,600 islands, which stretch for 3,200
miles, like pearls, along the equator between Malaysia and Australia. There are more than
150 active volcanoes, and earthquakes occur. The average temperature is 23/30C and varies
little from month to month. Humidity is high, averaging 80 per cent throughout the year,
which makes the heat intense.

In recent years, Indonesia has been in the news for all the wrong reasons: political violence,
human rights abuses, the forced resignation of President Suharto after 32 years' rule,
economic meltdown, inter-ethnic violence, anti-Chinese riots, political and social
instability, separatist insurrections, huge forest fires, and, of course, East Timor. At the
same time a new development has largely passed unnoticed - the development of clinical
pharmacy.

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Pharmacy education
The pharmacy undergraduate course has recently been reduced from five to four years'
duration. The course is followed by a year's preregistration training. The pharmacy
curriculum is heavily biased towards pharmaceutics, pharmacognosy and laboratory work.
In the final year, every pharmacy undergraduate has to submit a research paper called a
skripsi (thesis), which is generally at a higher level than that of the average British final
year project.

In contrast to the British system, every preregistration trainee has to spend his or her year
attending lectures as well as gaining experience in hospitals, community pharmacies,
industry, and in the ministry of health offices. This gives the average Indonesian pharmacist
a wider knowledge of all areas of pharmacy practice but does not give him or her sufficient
experience in any branch of practice. Preregistration trainees must then submit themselves
to written and oral examinations.

There are 16 faculties of pharmacy in Indonesia, eight of which are part of private
universities. The ministry of education regulates pharmacy education. Practicing
pharmacists are registered with the Ikatan Sarjana Farmasi Indonesia (ISFI), which roughly
translated is the Pharmaceutical Society of Indonesia. The ISFI does not possess the legal
powers that are invested in the Royal Pharmaceutical Society of Great Britain. Its
disciplinary powers are also limited and it is very much a loose federation of provincial
branches.

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The University of Surabaya

The University of Surabaya, in its current form, was set up in 1968. Known locally as
Ubaya, it is a private university with seven faculties (pharmacy, law, economy, psychology,
engineering, business and management, postgraduate studies). Half of Indonesia's
universities are privately run but continue to be regulated by the ministry of education. The
total number of full-time and part-time students is 14,000.

In a recent evaluation by the national accreditation body, the faculty of pharmacy was
ranked among the top five in the country. The faculty of pharmacy has an internal teaching
staff of 30, supplemented by an external staff complement of 29 lecturers, who are drawn
from other universities and pharmacy practitioners. The total number of students in the
four-year undergraduate course is 900. Apart from the preregistration training of pharmacy
graduates, there is no other postgraduate training. However, moves are afoot to set up an
MSc in clinical pharmacy.

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Pharmacy practice
In 1995, out of the 7,802 registered pharmacists in Indonesia, 43 per cent (3,327) worked
in community pharmacy, 10 per cent (781) in hospitals and 11 per cent (876) in industry.
The remainder were employed in academia and in the food and drugs administration
(ministry of health). This means a ratio of only one pharmacist per 25,634 people
(compared with one pharmacist per 1,730 people in Britain in 1995). The situation is
further compounded by the overwhelming concentration of pharmacies in the cities.

The current situation in pharmacy education and practice is akin to that in Britain in the
1960s when traditional compounding roles were being superseded by industry. There is
still a lot of extemporaneous dispensing. Many community pharmacists, because of their
very poor salaries, have to take on two jobs or more. This means that it is unusual to find
a pharmacist in the pharmacy shop. In addition, apart from in some hospitals (which
provide a very basic ward pharmacy service), clinical pharmacy as we know it in Britain
does not yet exist. The majority of hospitals employ only one pharmacist who largely deals
with procurement, supply and distribution.

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British Council
One of us (CKT) went to Indonesia as a Christian volunteer worker with Overseas
Missionary Fellowship (OMF) International in early 1996. After some time studying the
language and culture, CKT was attached to the faculty of pharmacy at the University of
Surabaya, where the dean of the faculty asked for help in developing clinical pharmacy in
Indonesia.
We therefore helped to set up the British Council three-year higher education link between
Nottingham University and the University of Surabaya. (The British Council is part of
Britain's Department for International Development. It provides funds for training and
exchange visits.)

To date, two of our Indonesian colleagues have been on a study visit to the UK and two
British pharmacists have been to Indonesia to train Indonesian pharmacists in the skills of
drug information and clinical pharmacy. In early February this year, four British
pharmacists went to teach on two further courses in clinical pharmacy and drug information
in Surabaya [see p819], and it is expected that 70 pharmacists from throughout Indonesia
will attend these courses. The visiting pharmacists also conducted seminars in two of the
major cities, Jakarta and Yogyakarta.

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The center for drug information and pharmaceutical care (CDIPC) was set up as a result of
the higher education link. Its mission statement is "to promote the effective, safe, rational
and cost-effective use of medicines". The center will be linked up with the Centre for
Pharmacy Postgraduate Education (CPPE) and the Pharmacy Practice Research Resource
Centre in Manchester, the National Prescribing Centre in Liverpool and other equivalent
organizations in the UK. We have already established links with the school of pharmacy at
the University of Nottingham, the institute of pharmacy and chemistry at the University of
Sunderland, Chemist & Druggist, Barnsley District General Hospital trust, the Northern
General hospital in Sheffield, the North Staffordshire hospital and the Royal
Pharmaceutical Society.

One of us (MA) acts as the CDIPC's visiting professor and external examiner. The other
(CKT) is the center’s visiting lecturer and consultant. Eventually, several British
pharmacists will be appointed as specialist consultants to the various departments of the
CDIPC. Because the CDIPC is university based, it has had to establish a hospital base
where clinical pharmacy can be pioneered, developed and taught.

The St Vincentius a Paulo catholic hospital is one of the top hospitals in Surabaya. Founded
in 1925, it is a 395-bed private general hospital, which currently employs only one
pharmacist and a team of pharmacy technicians. Clinical pharmacy services do not yet
exist. However, co-operation between the hospital and the CDIPC has seen the start of a
basic clinical pharmacy service provided by the two drug information pharmacists based
at the University of Surabaya. It is a forward-looking hospital, whose executive director
and board are keen to implement new pharmacy services, with the stated aim of improving
patient care and reducing costs. This is important in a country where 40 per cent of the
population live below the poverty line.

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Training
Training is a planned activity to transfer or modify knowledge, skills and attitudes through
learning experiences. Pharmacists in Indonesia need continued professional training
because, without it, work performance will decline and a number of competencies will be
forgotten. Changing circumstances in the field of pharmacy and new approaches and
technologies demand new skills and attitudes.

However, training on its own cannot solve the structural, organizational or policy problems
within the pharmacy set-up in Indonesia. Training programs are being designed to improve
the performance of particular pharmacy tasks, taking into account the educational levels of
the personnel and the time and resources available for training. The activities at present
range from short courses run by trainers from the UK to long-term placements of
pharmacists in different departments under the supervision of the local trainers.

The major objectives in the planned training programs are to:

 Increase knowledge about the special needs of pharmaceutical systems
 Change attitudes about the importance of drug management, thus improving the
environment for change
 Improve the skills in specific tasks to be completed for efficient functioning of the
drug supply system in the hospital
 Improve work behavior, so that people function better at assigned activities and
fulfil their potential

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Future developments
The drug information unit, modelled on the UK regional drug information center, was set
up in February, 1999. We plan to set up the center for continuing education in 2001,
followed soon after by the pharmacy practice research center. We are in the process of
working with the British Council and our Indonesian colleagues in organizing a national
conference on the pharmacy curriculum, with a view to revamping the course so enabling
the development of clinical pharmacy while maintaining the strength of the course in the
pharmaceutical sciences. This is important as industry employs a large number of
Indonesian pharmacists, who play a key role in the pharmaceutical, food and cosmetic
industry.

Also, herbal medicine is widely and extensively practiced in Indonesia and the pharmacist's
knowledge of pharmacognosy must be maintained. We are also looking for sponsorships
from multinational pharmaceutical firms to build the center, which will house the six
departments and lectureships in clinical pharmacy. At the same time we are seeking help
from the World Health Organization to fund a new MSc course in clinical pharmacy. The
future development strategy will focus on the major problems in the drug management
process. The academic and practice-oriented developments will form the base from which
to establish clinical pharmacy practice in Indonesia.

We are very much in pioneer territory. There is a lot of resistance to change both from
inside and outside the pharmaceutical profession. Much credit for the hard won
achievements goes to the rector and head of international affairs of the University of
Surabaya, along with the present and past dean of the faculty of pharmacy and the first two
clinical pharmacists employed at the CDIPC. The British Council has provided invaluable
support and advice.

The contributions made by so many British pharmacists make us feel proud to be members
of a profession that has shared so freely with Indonesian colleagues who are trying to
develop the profession under very difficult conditions. It is interesting that many of our
Indonesian colleagues are enthusiastic about developing their profession along British
lines, with obvious modifications to suit local needs. It is our hope that the pharmaceutical
profession here will continue to help Indonesian pharmacy to bridge the gap with the West,
while maintaining its strength in pharmacognosy and pharmaceutics.

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Dr Tan is visiting lecturer, university of Surabaya, Indonesia, and Dr Aslam is visiting
professor, University of Surabaya, and director of clinical pharmacy, University of
Nottingham. Correspondence to Dr Tan (e-mail drcktan@iname.com)
Citation: The Pharmaceutical Journal, May 2000, online | URI: 20001584
http://www.pharmaceutical-journal.com/the-development-of-clinical-pharmacy-in-
indonesia/20001584.article

2. INDONESIAN PHARMACEUTICAL MARKET 2014 UPDATE

Indonesia, a country of more than 6,000 inhabited islands, has a population of over 250
million people — the fourth most populous country in the world. Indonesia’s GDP grew
slightly less than 6% in 2013, and is forecast to grow between 5-6% in 2014.

The Indonesian healthcare market is worth $24 billion, and this could reach $31 billion in
2016. At the same time, Indonesians are forecast to spend almost $150 per person on
healthcare in 2015, up from $35 in 2005. Indonesia has almost 10,000 primary care centers
and over 2,200 hospitals. Three percent of Indonesia’s GDP is spent on healthcare. But,
this should increase soon.

The pharmaceutical market in Indonesia is expanding quickly; it is valued at $6.5 billion

with an annual growth rate of 12.5%. This growth is expected to continue through 2018.
The Indonesian drug market grew 85% over the 2007-2013 period.

Over the past several years, the Indonesian government has passed laws to upgrade its
healthcare infrastructure and increase public spending on healthcare. For instance, 150 new
hospitals are planned for 2014. As Indonesians grow wealthier and spend more on their
healthcare, private insurance and out-of-pocket purchases will increase, offering better
prospects for foreign companies. Already, large private hospital chains such as Siloam
Group and the Mitra Keluarga group are expanding rapidly.

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Healthcare Policy
Indonesia introduced a universal healthcare system in January 2014, administered by the
National Social Security Agency (BPJS). The government plans to have complete, albeit
very limited, coverage by 2019. The universal healthcare scheme aims to provide better
standards, regulations, access and cost effectiveness. Though more than 1,700 hospitals
have signed up to participate in the scheme, the low reimbursement rates offered by the
government will likely dissuade many private facilities from joining, resulting in
overcrowding of public institutions.

While the introduction of universal healthcare may seem like a prime opportunity for
foreign pharmaceutical companies, it is unlikely that they will have much of a role — at
least initially. The program will mostly provide coverage for generic drugs, not branded
pharmaceuticals. Generics are widely accepted by Indonesians. There will also be
significant government pricing and reimbursement pressure on both generic and patent-
protect drugs, potentially further reducing potential opportunities.

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Drug Registration in Indonesia

There are four classes of drugs in Indonesia. Applications for registration go to the National
Agency of Drug and Food Control (NADFC). The Association of Southeast Asian Nations
(ASEAN) Common Technical Documents (CTD) must be used, and ASEAN standards
should be followed. It can take up to 3 years for a pharmaceutical product to be registered.
Generic pharmaceutical pricing is regulated by the government. Pharmaceuticals included
in the Essential Drugs List — 92% of which are generic and 2.5% of which are innovator
— cannot be sold for more than a 50% margin. Other generics are also subject to pricing
restrictions.

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Pharmaceutical Companies in Indonesia

Domestic pharmaceutical firms have 70% of the Indonesian drug market. Almost 60
foreign pharmaceutical companies control the remaining 30% of the Indonesian drug
market; the largest are Bayer, Pfizer, and GlaxoSmithKline (GSK). Foreign companies
focus mostly on the 25 million Indonesians with the most advanced healthcare coverage.
This pool could grow quickly starting this year, as universal healthcare is
implemented. Western diseases, such as hypertension and diabetes, are also increasingly
common — meaning increased opportunities for foreign drug companies that already
produce medications to treat these diseases.

Indonesia’s Kalbe Farma, founded in 1966, has a market capitalization of $7 billion and is
the largest listed drug company in the Association of Southeast Asian Nations (ASEAN).
The firm focuses on production of prescription drugs, nutritionals and consumer health
products. In 2013, Kalbe’s sales increased by almost 20%, and it has a 2014 sales target of
15%. In anticipation of the universal healthcare scheme’s increased demands for generics,
the company invested $12 million to build a new factory in West Java with a monthly
capacity of 87 million tablets. In cooperation with local sub-distributors, Kalbe is able to
reach over 1 million Indonesian outlets, and covers all hospitals and pharmacies in the
generics and prescription drugs market, as well as the majority of doctors. Kalbe is also
strong in Southeast Asia and Africa.

Sanofi’s Indonesian subsidiary has a tiered price-volume strategy, providing different types
of a drug — like insulin — to different population tiers. The company launched a diabetes
training program for local doctors in partnership with the Indonesian government and the
American Diabetes Association in 2012. Sanofi is focusing on expanding outside Jakarta
into tier 2 and 3 Indonesian cities.

Novartis Indonesia has a 20% growth rate and concentrates on primary care and,
increasingly, specialty care. The company has focused its primary care products in the
diabetes and cardiovascular areas. While Novartis previously sold drugs through
Indonesian third parties, the company is increasingly promoting its own pharmaceuticals
in Indonesia. Novartis also runs a public affairs and communication healthcare program
and collaborates with the government on various projects.

Foreign companies are also expanding their facilities in Indonesia. For example, Mitsubishi
Tanabe Pharma announced in September 2013 that its Indonesian subsidiary would build
a new production facility to expand capability and meet new GMP standards. Merck
opened an Indonesian packaging plant in 2012. Fresenius Kabi bought a 51% share of
Indonesian pharmaceutical manufacturer PT Ethica Industri Farmasi (EIP) for a reported
$200 million in August 2013. Fresenius Kabi and the other stakeholder of EIP, PT Soho
Global Healthcare (SGH), will together construct a $60 million IV generic drug and
infusion solutions plant in Indonesia. Fresenius Kabi and SGH also plan to invest about
$40 million in two new antibiotic plants.

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Challenges for Drug Companies in Indonesia

Growth in Indonesia is slowing primarily due to increased inflation, a poor exchange rate
and lower foreign investment. The economic outlook is also somewhat unstable because
of parliamentary and presidential elections scheduled for April and July 2014. In addition
to the weak currency, rising electricity prices and an increase in the minimum wage have
also hurt pharmaceutical companies, both domestic and foreign. Many drug companies saw
a year-on-year decline in profits in 2013.

Inflation hits the pharmaceutical industry particularly hard because up to 96% of the
materials used in drug production in Indonesia are imported. For instance, domestic
pharmaceutical giant PT Kalbe Farma saw a 19% increase in the costs of goods sold in the
first half of 2013. Another major Indonesian drug company, PT Kimia Farma, also saw
sales increase at a slower rate than its costs of goods sold.

In addition, foreign pharmaceutical companies face a variety of roadblocks in the

Indonesian market. Several laws protect the local industry from foreign competition.
Decree 1010 has, since 2008, required that all pharmaceuticals registered in the country be
locally produced. This law was relaxed in 2010, allowing labeling and packaging to meet
the definition of “local manufacturing.” Foreign drug companies have responded to Decree
1010 by partnering with domestic or other international companies or expanding their own
local manufacturing capacity in Indonesia.

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Another government restriction on foreign companies is the negative investment list, which
limits the amount of foreign ownership possible in different key sectors of the economy.
While this ownership percentage was capped at 75% for pharmaceutical companies, in
December 2013 Indonesia raised the limit to 85%.

There are other issues with the Indonesian pharmaceutical market. Unethical promotional
practices by domestic companies are common. Under the new universal healthcare rules,
as well as under a previous law applying to public healthcare institutions, doctors will be
required to prescribe generic drugs whenever possible.
Furthermore, there is precedent for the government-mandated generic licensing — in 2012
the Indonesian government gave compulsory licenses for generics of several HIV drugs,
including those made by Merck, Abbott Laboratories and GSK. The government suggested
in 2013 that it intended to control the prices of branded medicines and also regulated the
evaluation of new drugs via a more systematic assessment to support more “rational use.”
Several foreign pharmaceutical companies have indicated that they are worried about
government protectionist policies.

Potential future regulation for halal-certified drugs could place further restrictions on both
foreign and domestic companies. Indonesia is approximately 85% Muslim, and the
Organization of Islamic Cooperation (OIC) member countries agreed in October 2013 to
Indonesia’s proposal that it be the center of vaccine development and production for the
group. The OIC is composed of almost 60 member states and has a collective population
of about 1.7 billion.

Despite the above challenges, Indonesia still provides a significant opportunity for foreign
pharmaceutical companies. The country has a comparatively high growth rate, large
market, growing middle class, urbanizing population and strong demographics.

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Source: http://www.pacificbridgemedical.com/publication/indonesian-
pharmaceuticals-2014-update/