Buying medicines on the internet saves time and money, but it could be deadly. Indonesia is working to regulate online pharmacies and improve public safety.

Shopping online is fast and easy, but sometimes when the order arrives it will be the wrong size or colour – or perhaps even a fake version of a brand-name item. That’s frustrating when it’s a T-shirt or a pair of shoes, but when it comes to medicines, low-quality and counterfeit products can kill.

Online shopping for pharmaceuticals is big business in Indonesia. It offers plenty of price options, and apps such as Halodoc and K-24. Some apps are approved by Indonesia’s food and drug authority, so consumers believe this is a safe way to get medicines. They are also glad to avoid the queues and administrative hassles of the puskesmas (government-run clinics), where it’s said the medicines are low quality anyway.

The Indonesian health ministry launched regulations in 2020 to control online pharmacies and protect society from fake medicines. Of the thousands of online pharmacies, only 12 have an online licence. The rest are illegal and potentially sell fake medicines. None of the pharmacies on popular e-commerce platforms are registered with the ministry, even if they seem to have an ‘official store’ logo and have been verified by the platforms. The regulation and e-commerce effort to control them seems far away from success, sellers are adept at manipulating the system trying to ban them. 

As online pharmacies grow, the risk consumers will receive fake medicine also grows. The trade in fake medicines is worth as much as 470 trillion rupiah (US$31 billion) in middle-income countries, according to the World Health Organization (WHO). 

In early January 2022, three men were arrested in Bogor, after producing fake ethical medicines in their automotive workshop. At  the end of 2020, two men were arrested in Mataram, Nusa Tenggara Barat, when they purchased fake medicines online from Jakarta and allegedly planned to re-sell them. At the peak of the COVID-19 pandemic, people became frantic about getting antimalarials because they were believed to be a cure. The total number of fake medicines distributed in the online market remains unknown, but the risk is high

Fake medicines imitate the genuine article, but they may endanger health, prolong illness and even cause death. For example, poor-quality antimicrobial medicines promote bacterial resistance to antibiotics. When patients develop antibiotic resistance, they need stronger antibiotics to battle infection, and may face death if their infection cannot be managed. 

In 2017, fake antimalarials in sub-Saharan Africa caused 64,000 to 158,000 deaths. Fake medicines lead to distrust of vaccines’ and medicines’ effectiveness, and cost consumers more because their low doses are less effective and can prolong treatment. They also burden the health system. 

The economic cost of fake antimalarials in sub-Saharan Africa averaged US$21.4 million to US$52.4 million per year because of the treatment needed to manage the additional cases they created.

Indonesia’s health-care program has struggled to stay within its budget and faces a deficit of 51 trillion rupiah (US$3.4 billion). One strategy to keep the program financially sustainable is to reduce the budget for medicines. Some might question whether this would lead to poor-quality medicines, but findings from Brawijaya University and The George Institute show that universal health-care provisions such as Indonesia’s national insurance scheme provide quality medicines. 

Given the constrained budget and complex procurement system, medicine manufacturers found it difficult to maintain their production quality.

Getting medicines through unlicensed channels carries a high risk, but formal and licensed channels carry risks too. In 2019 Indonesia’s Food and Drugs Administration launched a case against a pharmaceutical distributor that had repackaged generic and expired medicines into new packaging and sold it to 197 drug stores at a higher price. An investigation of an infant’s death in 2016 uncovered a fake-vaccine syndicate that had been operating for over 10 years. Members of the syndicate, including medical staff, had distributed the vaccines to 47 private hospitals and health clinics.

For the perpetrators of these schemes, the motive is clear: vast profits. For patients who buy medicines through unofficial channels, the incentive is usually to save money, because fake medicines tend to be cheaper. While fake medicines may be found anywhere, going to clinics or hospitals is safer than buying medicines online. Getting medicines through Indonesia’s national insurance program usually ensures good quality too.

Those queues at the puskesmas are worth it for safe, authentic medicines. And the time spent in the queue could be used to order a new pair of shoes online. With any luck, when they arrive they’ll be the real deal.

Yusi Anggriani is a lecturer of Public Health  in the Faculty of Pharmacy Pancasila University, Jakarta Indonesia. She leads Systematic Tracking of At-Risk Medicines (STARmeds) Her research interests are Pharmacoeconomics, and public health.   

Stanley Saputra is the Engagement Manager for the STARmeds study.

STARmeds is a joint research project among Pancasila University in Indonesia, Imperial College London in the United Kingdom, and Erasmus University in the Netherlands, . It is supported by the UK National Institute of Health Research.

Originally published under Creative Commons by 360info™.

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