Antibiotic sales in Indonesia reach IDR 10 trillion

Of the classes of drugs prescribed by doctors, sales of antibiotics are the highest.

KOMPAS/ADITYA DIVERANTA

The injection type Meropenem antibiotic was purchased by Kompas through a virtual pharmacy that trades on the market with the blue logo. Meropenem is a reserve class antibiotic which should be closely monitored and not sold freely on the market.

JAKARTA, KOMPAS — The sales value of antibiotics in Indonesia reaches more than IDR 10 trillion in one year with an increasing trend. This figure indicates the widespread consumption of antibiotics in the country, both via doctor's prescription and sold freely in pharmacies, market places and telemedicine applications.

After waiting a week, IQVIA finally sent sales data for antibiotics in Indonesia, Wednesday (13/3/2024). This multinational company in the field of information research and health technology agreed to Kompas's request to sample antibiotic sales data.

Also read: Many Doctors Still Carelessly Prescribe Antibiotics

In Indonesia, IQVIA is the only institution that collects the most complete data on antibiotic sales and is a reference for the pharmaceutical industry in analyzing the health market. To Kompas, the research institute from the United States sent two tables recording antibiotic sales for 2018-2022. One table details the sales value in rupiah, while the next sales data table is in volume form.

INSAN ALFAJRI

The Kompas Investigation Team bought antibiotics without a prescription at the K24 Pharmacy in Central Java, Tuesday (13/2/2024).

In 2018, antibiotic sales amounted to Rp 8.9 trillion. Sales briefly decreased during the COVID-19 pandemic (Rp 7.9 trillion in 2020). One year later, antibiotic sales increased to Rp 9.4 trillion. The antibiotic market is once again thriving with transaction values reaching Rp 10.4 trillion in 2022.

Senior Principal of IQVIA, Erwin Widjaja, explained that the sale of antibiotics in 2022 is equivalent to 12.12 percent of the total sales of all prescription drugs. "From the class of prescription drugs, the biggest sales of antibiotics, far surpassing diabetes drugs which are in second place (IDR 5.7 trillion) and digestive drugs (IDR 5 trillion)," he said.

Also read: Prescribing Antibiotics in Hospitals Without Supervision

As a prescription-only drug or a hard drug, antibiotics are labeled with a special symbol. There is a red circle on the label with a black letter K. All hard drugs have this symbol.

Pharmacy

Despite their status as hard drugs, antibiotics actually circulate freely on the market. At Pramuka Market, Jakarta—which is known as a black market for pharmaceutical products—this drug is still easy to get. In a number of pharmacies, antibiotics can also be purchased without a prescription. Kompas proved this by purchasing antibiotics at four pharmacies spread across East Java and Central Java, including the state-owned company Kimia Farma.

In mid-February 2024, the team purchased cefixime antibiotics at the Kimia Farma pharmacy in Surabaya, East Java. Cefixime is a "watch" antibiotic that is closely monitored in its usage. Even doctors cannot freely prescribe this category of antibiotics as its appropriateness with the patient's disease diagnosis must be assessed first.

Also read: Hospitals Save Costs from Antibiotic Control

However, the employee at Kimia Farma's pharmacy in Surabaya did not ask for a prescription when Kompas asked for the antibiotic Cefixime. Employees immediately offer cefixime under the brand name Cefila. "This is a bit expensive, sir, Rp. 611,000, the generic one is still out of stock," said the employee in a white coat with a pharmacist's name written on it.

KOMPAS/ADITYA DIVERANTA

Cefixime to Levofloxacin which are antibiotics in the "Watch" class that were obtained by Kompas, both by prescription and freely in Jakarta, Monday (18/3/2024). Doctors can only prescribe antibiotics in the watch" and eserve" classes after through examination procedures by the antibiotic stewardship team (PGA) at each hospital.

When confirmed, PT Kimia Farma Tbk stated that the purchase of antibiotics must be accompanied by a prescription from a doctor or dentist. "If there are any practices that do not comply with the delivery of antibiotics without a doctor's prescription, we will follow up on them," said Corporate Secretary of PT Kimia Farma Tbk, Dharma Syahputra, on Wednesday (13/3/2024).

Apart from Kimia Farma, the team also attempted to make purchases at the private pharmacy network K24, which has branches in several big cities. The visited pharmacy branches were located in Surabaya and Semarang, Central Java. The conditions in both places were the same: antibiotics can be bought without a prescription.

Also read: A little sick, don't run to antibiotics

K24 Indonesia Operations Manager Endah Ekayani said in writing that Kompas's findings were that there was a mismatch between applicable policies and conditions in society. This is a challenge for the K24 Pharmacy network. “The problem of antibiotic use is very complex and involves many sectors. "Public education must be carried out continuously to provide awareness regarding the use of antibiotics," said Endah.

AYU NURFAIZAH

Face view of telemedicine service provider Halodoc via device, Tuesday (4/10/2022).

Marketplace and telemedicine

Kompas is also trying to buy antibiotics online via market places and telemedicine applications. For the same amount of money as a pharmacy, they also provide antibiotics without a prescription.

From Kompas's search, there are market places that directly sell antibiotics like hotcakes. At one market place with a green logo, for example, there is an "attach doctor's prescription" feature as a form of verification before the transaction is carried out by potential buyers. However, this verification feature can be circumvented. Kompas tried attaching a newspaper photo to replace the prescription attachment and succeeded in getting Cefixime on Monday (11/3/2024).

On Thursday (14/03/2024) Kompas can also buy "reserve" category antibiotics, namely meropenem for injection at one of the market places without asking for any prescription. This highest category of antibiotics is sold at pharmacies in the Jakarta area Timur, who opened a virtual shop in one of the markets with the blue logo.

Also read: Questioning Doctors' Habits of Prescribing Antibiotics

Meanwhile, to get antibiotics in telemedicine applications such as Halodoc, buyers are asked to undergo a "consultation for a prescription". The device screen displays a conversation room with a doctor whose name is displayed. Then, buyers are asked to answer a number of questions, such as who the medicine is for, whether the woman is pregnant, what complaints they have, and whether there are any drug allergies. Kompas answered this question briefly.

KOMPAS/SARIE FEBRIANE

The Pramuka Market in Central Jakarta is known to be filled with drugstores and health equipment stores. Access and watch antibiotics medications can also be easily purchased here without a doctor's prescription.

Shortly after, an automated message popped up saying: "Hello Sir/Madam, I am willing and currently prescribing medications for you. Please be patient." In just three minutes since attempting to purchase, the purchase of the "watch" category antibiotics was confirmed, ready to be sent, and then received in about an hour.

Kompas asks Halodoc to respond in writing even if the content does not match the question. Kompas asks, among other things, why is the "consult first with a doctor" feature just a formality and requests to purchase antibiotics from the account owner are immediately granted?

VP Corporate Affairs of Halodoc, Adeline Hindarto, in her written response stated, "Halodoc always educates the public that if they have health complaints, they should consult a doctor as an expert and then receive recommendations for medicine if necessary based on the diagnosis. And, according to government directives, it is important for the public to buy medicine or vitamins only from pharmacies/health facilities or electronic pharmacy system provider platforms (PSEF)."

Also read:"Industrial-Medical Complex" is Increasingly Complex

KOMPAS/INSAN ALFAJRI

A patient at the Depati Hamzah Regional General Hospital in Pangkalpinang, Bangka Belitung Islands purchased medicine at the hospital pharmacy depot at the end of February 2024. The Antimicrobial Resistance Control Program (PPRA) at this hospital has not been fully implemented.

Misguided

According to the Coordinator of Antimicrobial Stewardship (PGA) at the Ministry of Health, Hari Paraton, the phenomenon of purchasing antibiotics without a prescription occurs in almost every city in Indonesia. This is due to the high sales value, causing some pharmacies to sell them even without a prescription. "In certain areas, there are also communities who become angry when they are not provided with antibiotics," said Hari.

Also read: Rational Medicine, Doctor is the Key

The community that consumes antibiotics without a prescription does not happen suddenly. This behavior is formed by doctors who have been prescribing antibiotics incorrectly for years. For example, for diseases such as dengue fever, coughs and colds, and sore throat, they would still prescribe antibiotics. "Eventually, the community is imprinted with the idea, 'Oh if I have a cough and cold, I must take antibiotics.' And so they end up buying them at the pharmacy," he said.

INSAN ALFAJRI

Rows of medicines at the pharmacy installation at Depati Hamzah Pangkalpinang Regional Hospital, Bangka Belitung Islands, at the end of February 2024.

The high circulation of antibiotics is also caused by the tight competition among pharmaceutical manufacturers to ensure the absorption of antibiotic products in the market. "It's like a trade war because the government allows one type of antibiotic to be produced by several pharmaceutical industries. For example, Dexa, Sanbe, Kalbe, all produce the same antibiotic," he added.

Chairman of the Trading and Industry Committee for Pharmaceutical Raw Materials of GP Farmasi Indonesia, Vincent Harijano, confirmed the data from IQVIA and stated that the survey by the agency was accurate. He also confirmed that the pharmaceutical industry continues to push for the sales of antibiotics. However, he claimed that the pharmaceutical industry does so through the right channels.

Purchasing antibiotics without a prescription is not the pharmaceutical industry's fault. What is wrong is the public and pharmacies that sell antibiotics without a prescription.

He continued, hard drugs were distributed to pharmacies and promoted through a detailing process to doctors. The hope is that after explaining the advantages of an antibiotic product, doctors will prescribe more of that product to patients and patients will buy it at the pharmacy. According to him, all of these routes are permissible and none of them are violated.

"We always follow the existing rules and that is indeed the regulation," he said. According to him, the purchase of antibiotics without a prescription is not the fault of the pharmaceutical industry. The wrongdoers are the community and pharmacies that sell antibiotics without a prescription.

NASRUN KATINGKA

A number of illegal drugs were displayed during the BPOM press conference that uncovered the sale of illegal drugs through local markets, in Jakarta, on Wednesday (7/6/2023).

Under supervision

Regarding the increasing antibiotic-resistant bacteria due to excessive use of antibiotics, Vincent refuses to discuss it. This is because antimicrobial resistance is a medical area. "If the amount of sales is not a problem, but if it touches on the increase in sales that can increase antimicrobial resistance and is asked how much, why, and so on, that is the point that I think is sensitive. We don't want to get into the medical field," he said.

Also read: Invulnerable Bacteria Take Our Lives

Acting Head of the Food and Drug Supervisory Agency (BPOM) Lucia Riska Andalusia stated that her agency already has special tools to monitor the circulation of antibiotics. "If violations are found, appropriate follow-up actions or sanctions will be given according to regulations," said Lucia.

BPOM routinely patrols cyberspace to catch accounts selling drugs that do not comply with regulations. If there is a violation, BPOM will coordinate with the Ministry of Communication and Information and the marketplace platform association to take down the content.

Also read:About Efforts to Change the Antibiotic Paradigm in Indonesia

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