What is the cost of poor quality medicine? Estimating the prevalence, health impact and economic cost of substandard and falsified medicines in Indonesia in the age of Universal Health Coverage

Efforts by low and middle income countries (LMICs) to achieve universal health coverage (UHC) are often constrained by inadequate resources. As demands on health systems expand, pressure to contain costs can threaten quality, including the quality of medicines on which all health systems rely. While the WHO believes substandard and falsified medicines (S&F meds) are on the rise, there are no agreed methods for measuring the problem, and thus no way of tracking progress in ensuring that medicines newly available to poorer patients through UHC efforts are safe and effective. Indonesia has vastly expanded its national health insurance since 2014; it now undertakes to provide free medicine to 222 million people, over 80% of citizens in the world's fourth most populous nation. Procurement policies that prioritise low cost over quality aim to reduce the deficit of £1.9 bln but have raised concerns, magnified by several recent scandals, that UHC is expanding access to S&F meds. Objectives: We aim to support national efforts to ensure that Indonesians, especially the poorest who rely on insurance or informal markets, have consistent access to quality medicine. We will do this by working with the medicine regulator and intersectoral partners to better understand and quantify the prevalence and distribution of S&F meds nationally. In the process, we will:1. Trial new methods for risk-based sentinel surveillance for S&F meds;2. Develop robust, adaptable tools to estimate the prevalence, health impact and cost of S&F meds;3. Pioneer the use of the tools, making the first national estimates of S&F meds in any LMIC;4. Engage continuously with policy partners to facilitate appropriate intersectoral responses in Indonesia, and to adapt tools for other LMICs.5) Promote institutionalisation of academic-policy partnerships to support the ongoing production and use of medicine policy research in Indonesia.