Bridging the interagency silos: Taking a political economy perspective to tackle substandard and falsified medicines in Indonesia

Poor-quality medicines pose serious public health risks by harming patients, wasting resources, and hindering Universal Health Coverage (UHC). Current frameworks focus mainly on technical solutions and place national medicine regulators at the center, often isolating medicine quality from other critical pharmaceutical policy issues, such as medicine availability, affordability, and irrational use. The existing approach also downplays political and socioeconomic factors, limiting the involvement of other (policy) actors and the exploration of alternative solutions.

This thesis introduces a new and broader framing of the problem of poor-quality medicines using a political economy perspective. In addition, this thesis operationalizes the approach and tests its potential to tackle the issue better. It argues that combining this perspective with technical and regulatory approaches offers new opportunities to address the problem. The research was conducted in Indonesia, the world’s fourth most populous country and home to a competitive domestic pharmaceutical industry. Using mixed-methods case studies, the research focuses on amoxicillin, sampling it from diverse access points, including informal markets, and testing its quality in an independent laboratory to understand the usefulness of this broader approach.

This thesis presents four main findings. First, a political economy perspective highlights political and economic factors, such as pricing and shortages, and clarifies the roles of various actors. Second, these actors work in silos, limiting data and information sharing and leading to fragmented policy responses. Third, engaging a wider range of actors can strengthen efforts to address the problem, but it also brings challenges in defining problems, operationalizing alternative solutions, and maintaining intersectoral collaboration. Fourth, operationalizing this perspective is complex in practice, illustrated by the difficulty of treating price as a risk factor and the lack of association between medicine price and quality found in this thesis. Overall, this thesis expands the understanding and definition of the complexities surrounding poor-quality medicines, contributing to ongoing scientific and policy debates. Key findings underscore that the quality of medicine is closely connected to availability, affordability, and rational use within the UHC agenda. The usefulness of a political economy approach depends on strong collaboration – without mutual learning, transparent communication, and open data exchange among actors, regulatory efforts will fall short.