Systems in between: A mixed-methods study developing and using a local pharmaceutical system approach in Indonesia

Variations in subnational needs and capacities within larger countries pose challenges for the national government’s efforts to develop and bolster policies that balance the conflicting interests of all actors in ensuring access to medicines. Existing frameworks to ensure access to medicines rarely focus on the organisation of medicine supply at more local levels within a country. I aim to understand how local systems operating within a national system work to ensure equal access to medicines for all the citizens of the country. A local approach provides a better understanding of fundamental pharmaceutical system dynamics and challenges across a country, as it functions as a “system in between”. In Indonesia, decentralisation was implemented by delegating responsibility to local governments—including primary health centres (PHCs) and their associated District Health Offices (DHOs)—to manage the provision of medicines in public sector facilities. This thesis, therefore, focuses on understanding variations in the availability of essential medicines in PHCs in Indonesia and answers the main research question: “How do insights into the functioning of the local pharmaceutical system in Indonesia lead to a better understanding of efforts to improve access to medicines?”