An Indonesia National Agency of Drug and Food Control official displays food supplements, illegal cosmetics and fake or illegal drugs at their office in Cipayung, east of Jakarta on Aug. 25. Police in June 2016 smashed a criminal syndicate accused of selling fake vaccines for more than a decade to health clinics across Indonesia. (Photo by AFP)
Indonesia's business community is jumping into the health care business, in response to a growing middle class that is increasingly keen to access quality health services.
Unfortunately, a lack of oversight at every level of the industry encourages illicit practices, impacting everyone, particularly children.
In June and September, consecutive revelations of syndicates producing and circulating fake vaccines and medicine shocked the public. In both cases, the culprits had allegedly run their illicit businesses for years, targeting health care providers to prescribe their products for patients.
Hundreds of thousands of children are believed to be at risk of contracting diseases after receiving fake vaccines at health care facilities nationwide. According to authorities, health facilities were suspected of buying fake booster vaccines for hepatitis B, diphtheria, whooping cough and tetanus. Dozens of people, including midwives and doctors, were arrested.
Health officials have said the sham vaccines were not harmful and made up only 1 percent of total vaccines in Indonesia, and a re-vaccination plan has been implemented in some areas. Nonetheless public trust in the health system continues to erode.
In September, after another doctor was implicated in fake drug manufacturing, Indonesia Doctors Association (IDI) officials eschewed responsibility and blamed regulations for failing to provide clear guidance on whether a doctor can store and directly provide medication to patients. IDI deputy chairman Daeng Faqih went further by demanding the government expand the authority of doctors to improve public access to medicine.
The problem is demand, according to hospitals and other health care facilities implicated in counterfeit vaccine circulation. Rising income has boosted the market for imported vaccines but availability of medication has not increased quickly enough.
A nurse at a Jakarta hospital told Concord Strategic, a risk consultancy, that the hospital often only received five doses of Pediacel to last a month. The vaccine for tetanus, produced by Canada's Sanofi Pasteur, is among the most commonly forged vaccines. Such shortages provide opportunities for perpetrators.
Health officials and even President Joko Widodo have said that the fake vaccines do not include harmful ingredients. However, while there are no reports of serious illness or death from the use of the vaccines, they put do children at risk. Safe and hygienic manufacture cannot be guaranteed, and because they don't work they leave children exposed to crippling diseases.
Counterfeit and expired drugs
Counterfeit drugs are sold not only through the internet but also at pharmacies, where they are hard to detect because they look similar to the genuine product.
The trade in counterfeit medicine in Indonesia is lucrative. In 2012 Widyaretna Buenastuti, chairwoman of the Indonesian Anti-Counterfeiting Society (MIAP), estimated the value of the business as US$200 million a year. Worldwide, turnover in counterfeit medicine reaches up to US$75 billion annually.
This month, large operations distributing counterfeit and expired medicines were uncovered during separate raids in Banten and East Jakarta. Around 42 million doses of counterfeit medicines worth around US$2.3 million were seized during a raid at the Surya Balaraja warehouse complex in Tangerang regency, Banten, while in East Jakarta a man was arrested for allegedly distributing expired prescription medicines.
The actual impact of consuming the counterfeit medicines is hard to gauge. The government estimates that about 5,000 children out of 4.8 million targeted for inoculation have been given fake vaccines this year, but here have been no follow-up health tests on these children.
According to the World Health Organization's 2012 National Health Accounts, almost 15 percent of Indonesian children between one and three years old are highly likely to miss their tetanus immunizations. This number could be higher if fake vaccines are taken into account.
The WHO report estimated that counterfeit drugs could account for over 30 percent of all drugs in parts of Africa, Asia and the Middle East, compared with less than 1 percent in the U.S. and Western Europe.
Reforming the national drug and food control agency
The fake vaccine scandal sparked panic and anger among Indonesian families, who in July rallied outside hospitals demanding answers about their children's health. At least one rally turned violent, when a mob of furious patients punched and spat at a doctor, following an argument with him at the Harapan Bunda Hospital in East Jakarta, one of 14 hospitals in the capital reported to have used the fake vaccines.
Revelations that the national drug and food control agency (BPOM) was aware of the fake vaccine problem as early as 2013 only intensified public anger. Little was done until a police investigation earlier this year exposed the syndicate behind the fake vaccines.
Widodo urged concerned parents to remain calm and give authorities time to assess the scale of the problem. On July 15 the government ordered an immediate overhaul of BPOM. To curb expired and counterfeit drug circulation, the Health Ministry has proposed to take over distribution of generic drugs and halt the operations of privately-owned pharmacies.
It is doubtful that an overhaul of the BPOM will assuage the concerns of parents whose children may have been exposed to deadly and easily preventable diseases for years.
The closure of private pharmacies also fails to address the main problem of poor monitoring. Instead, it will deprive much of the public of affordable medicine, as the ministry's capacity to distribute the drugs to all levels of society remains in question.
Shinta Eka Puspasari is an analyst with Jakarta-based Concord Security. This piece was edited for length constraints.