Local systems, local solutions: which factors drive essential medicine availability in public health facilities...

Ensuring free access to essential medicines is a cornerstone of universal health coverage, yet many countries face persistent local disparities in medicine availability. This study investigates the factors driving variation in essential medicine availability in primary health facilities across Indonesia, focusing on the functionality of Local Pharmaceutical Systems (LOPHAS) and the influence of socioeconomic and geographical environments.

Enumerators visited each of the 514 district health offices and 9831 primary health centres (PHCs) to conduct a nationwide health facility assessment. These data were combined with publicly available information on spatial, geographical, socioeconomic and health system factors. Using regression analysis, multilevel modelling and spatial autocorrelation techniques, we identified facility-level, district-level and provincial-level factors associated with the availability of 50 essential medicines in public health facilities.

On average, 66% out of 50 surveyed medicines were available in PHCs, with district-level availability ranging from 83% in top-performing areas to just 43% in the lowest. PHCs with a pharmacist, clear guidelines and proper storage infrastructure had significantly higher availability, compared with those without. Other key drivers included the application of inventory management principles (eg, First-Expired, First-Out), autonomy in procurement and district level stock levels. Spatial analysis revealed strong clustering of medicine availability within a 2 km radius (Moran's I: 0.67), with high-availability clusters present even in low-performing districts, highlighting the role of localised factors.

Essential medicine availability in Indonesian PHCs varies substantially and is closely linked to the functionality of local pharmaceutical systems. Strengthening human resources-particularly by ensuring the presence of a pharmacist in every PHC-and improving physical infrastructure are critical priorities. Beyond PHC-level interventions, targeted efforts to enhance the capacity of district health offices in managing pharmaceutical supply chains are essential, especially in rural and remote districts of eastern Indonesia.