The Division of Expert Labor

Introduction

Pharmacy is longer known as one of major health care profession. Superior skills and knowledge on the medicine and the usage of medicine has been acclaimed by pharmacists as the privilege to gain professional status in the society. However, some pharmacists argue that the label of professional is not perceived by others. When a profession traditionally enjoys elite status and high reward regarding to its authority, for example medical practitioners, lawyers and accountants, pharmacists are perceived in the different perspectives. Different perception on pharmacist professional work compare to other established profession results various arguments on how to reward pharmacist. Although International Pharmaceutical Federation (FIP) clearly states that pharmacists should be adequately remunerated to achieve the goal of pharmaceutical care, fact shows that incomplete professionalization is the reason for rewarding different payment for pharmacists.

It is generally acceptable that the professional workers should be rewarded professionally based on the services that they have delivered, but there are also hierarchies within a profession, for example senior lawyer have higher rewards than the junior one. Thus even though the inputs are similar within professions, they are not rewarded equally. A professional pharmacist that provides wide range of pharmaceutical services should receive higher remuneration than a pharmacist that merely dispenses a drug. This level of work will be distinctive feature to create a remuneration system for pharmacist. Regardless the professional status, a remuneration system should calculate different scheme of payment for different level of provision. In other words, the more they provide, the more they paid. Different methods of remuneration system can be a hint to explore the professional work of pharmacists.

Study objective

The study will examine the relationship between pharmacist professional work and the remuneration system that is applied. To examine the professional work of pharmacist, we use The Pharmacy Practice Activity Classification initiated by American Pharmacist Association (APhA) to assess the level and the character of professional work provisioned by pharmacists. For remuneration system, we try to observe the level and the character of remuneration system applied. In the end, we try to find the relationship between the professional work and the current remuneration system and pharmacists opinion of a better remuneration system based on their professional work.

To study the circumstances and the context of the research, we conduct two different levels of studies. In the micro level, the studies will evaluate the professional role of pharmacist in the community, the current remuneration system applied and to some degree, their ideas about the appropriate remuneration system for professional role of pharmacist. In the macro level, the studies will analyze the views from the national association of pharmacist regarding the professional role of pharmacist and current remuneration system for the profession. This will bring us to final remarks, how they should organize the appropriate remuneration system based on the level and character of pharmacists' professional work.

Finally, we compare both studies in the Netherlands and Indonesia and find out the key aspects that determine the professional work and remuneration system of pharmacist in each countries.

Aim of the research

The aim of the thesis is to provide information regarding the role of pharmacist in community pharmacies and the remuneration system of pharmacists in the Netherlands and Indonesia. This will indicate the level and character of professional work and the relationship with the remuneration system applied. The result will be useful to concept ideal remuneration system for pharmacist role.

Research question

Based on the topic that is discussed on this study, the main research question are :

"What is the relationship between professional work of pharmacist in the community in the Netherlands and Indonesia, and the remuneration system that is currently applied. To some extent, how they should organize remuneration system based on different level and character of professional work"

The main research question derives sub question to answer the following chapters :

General

1. What is professional work and the relationship with remuneration ?
2. What is the role of pharmacist in the community setting and how do they apply the concept of pharmaceutical care ?
3. What is the remuneration system that currently applied for pharmacist ?

Empirical

1. Does the context of countries influences the role of pharmacist ?
2. Do pharmacists professionally work in the community ?
3. Are pharmacists proportionally rewarded ?
4. What is the position of pharmacist associations in the health care system and health policy making ?
5. What are the strategies of pharmacist organizations to improve the professionalism of pharmacist and to achieve a better remuneration system ?

Recommendation

1. What recommendation can be given to develop professionalism of pharmacist, gaining professional status and achieving better remuneration system ?

Research method

In the micro level, the study will use questionnaires to obtain data. The questionnaires will be distributed to community pharmacists through online system and post mail. The sampling methods will use convenience sampling with estimation of 100 respondents collected for each countries, the process will spend time from January to March 2010. Prior questionnaire will be validated and tested to 3 pharmacists.

In the macro level, we will conduct interview and phone call with the representatives of national pharmacist association in the Netherlands and Indonesia, the process will take time on March 2010. Prior interview question will be tested to 3 different people. In the Netherlands, the questionnaire will be tested to the head of young pharmacist association and the head of district pharmacist association. In Indonesia, we will test the questionnaire to former director of pharmacist association, head of pharmacist association in provincial and district level.

Method of Analysis

The data will be analyzed conform the theory of motivation and public agency by Julian Le Grand. This is used to figure out the position of pharmacist in health care system. To find out the relationship between professional role and remuneration system, we use SPSS as statistic tool to provide liner regression analysis. Whereas for comparative study, we use Analysis of Variance (ANOVA) to compare the result from the Netherlands and Indonesia.

Theoretical Background

Professionalism, the heart of a profession

In the modern society, there is no guarantee that any profession will possess professional status and recognition from the society. This assumption also linier to reward received by the profession. Even if the professional is successful to keep the status then it will need more hard work to maintain it in the same level. Professional values are threatened by many factors like Calder (Calder 2000) points out that the elite status of a profession is a result of strict monopoly that is maintained to keep their vital position. The skills and knowledge of professionals plus their concern with services are the primary factors to obtain supreme status and rewards.

Abbott (Abbott 1988) in his book The System of The Profession, An Essay of The Division of Expert Labor opens the discussion with interesting statement that "The professions dominate our world. They heal our bodies, measure our profits, save our souls". Abbott refers the statement to medical doctors, accountants and priests that are commonly known as traditional profession in the mankind history. He further explains that none of this professions are absolute of permanent, in fact they compete within the system. Nevertheless, from time to time they are successful to maintain the strengths and the weaknesses in order to make up an interesting system, an ecology that reflects their jurisdiction to claim the domain of professional work. Jurisdiction is the powerful tool to manage their monopoly on the profession, he adds that one profession jurisdiction preempts another that means there is always carnivorous competition among professions. The more they have jurisdiction, the more powerful they are.

In line to Abbott, Savage (Savage 1994) argues that "A profession is a network of strategic alliance across ownership boundaries among practitioners who share a core competence". She underlines professional competence as habitual and judicious use of skills, knowledge, communications, values that are emotionally reflected in daily practice for the benefit of individual and community. By network she means that professional has its own community to maintenance and develop the core competence of their profession by maximizing the value of the diversity among its members. These differences are the most important aspect to change and adapts with the current situation, therefore she further describes that a profession who is able to manage the differences will constantly increase position to extend their jurisdiction. Autonomy and authority, according to Savage, are another key elements to protect the profession with monopolistic command capabilities to challenge the market and reduce the involvement of non professional into the market.

No profession is assured to always enjoy elite status and that may considerably happen to pharmacy. Pharmacy that claims as the expertise on medication will suffer the erosion on the professional status if it is not improved in the practice, moreover possibility of conflict with the older established professions such as medical practitioners and nurses who understand about medicine, however in the limited scope, will be a pressure for the profession. Denzin and Mettlin (Denzin and Mettlin 1968) describes in their paper, that pharmacy is incomplete professionalization. Professionalization here refers to the process whereby occupation attempt to transform themselves into profession. By incomplete they mean "a failure to achieve the final condition of professionalization which accord the occupation the title of a profession". They argue that pharmacy has possessed number of characteristic of a profession. Unfortunately, pharmacy fails to escape the value of profession and still contain the elements of occupation. Pharmacy fails to accumulate systemic body of their scientific knowledge for the purpose of professional role, and due to proliferation of subspecialties within profession, they are vulnerable to exercise strict control over the members in a cohesive social organization which would ensure its professional continuation over time. The re-branding of "retail pharmacy" as "community pharmacy" indicates the profession's own awareness of a conflict between commerce and professionalism.

Empirical studies of pharmacist de-professionalization happens in Iceland, Denmark, Portugal and Norway where pharmacist lost their monopoly over a limited number of medicines (Mil and Schulz 2006). Morgall and Almarsdottir (Morgall and Almarsdottir 1999) describes that because of no struggle and no strength, pharmacist lost their monopoly. They explain three different factors to the break of the professional monopoly : (1) political desire to take advantage of new competition and deregulation policy, (2) desire to cut health budget and (3) internal divisions within the profession. The latter cause is in line with what Denzin and Mettlin has argued, the proliferation of subspecialities within profession. Furthermore, they argue that the profession is weakened by internal strife and that is used as the trigger by government to cut the activity of pharmacist. Seemingly, the studies is linier to arguments from Johnson (Johnson 1972). He describes that state intervention into an occupation is a major determinant why an occupational groups such as pharmacy have become (or could become) marginally professional. In this case, government regulation is successful in shaping wholly or partly of the professional value. This may happen because the professional is involved as the contracting agent in the health care system so they have to follow the bureaucratic rules instead of conducting their own ethics.

By contrast, several countries like USA, UK and the Netherlands appreciates pharmacy as a prominent profession in the health care system. In the USA, clinical pharmacist have important clinical role and are well integrated into the medical team. In addition, in UK, Ireland and USA, pharmacists to some degree are allowed to prescribe medicines. This would be impossible in the previous time because beyond the pharmacist's profession. However, the vital position of pharmacists in the drug use provides opportunity for this improving role.

Whatever the strategies to reach the social prestige in the society are, pharmacists have to show more definite works that meet with the real need of the public. Community pharmacists in these circumstances are having the biggest burden to handle the missions. In the practice, they have to deal with escalating problems from other professions and society as the results of several factors like increasing number of medicines, complexity of therapy, aging population etc. While internally they have to be aware of threat from pharmacy team such as prescriptionists, technicians and counters assistants that currently employed to take over general work of pharmacists. In such circumstances, Pharmaceutical care might be the answer to improve the professionalism of pharmacists. The key word of improving patient's life is the way to be closely positioned as the partner of other medical professions and friend for patients. The pharmacists association also holds the important role for establishing ethical and professional boundaries so the pharmacy is widely accepted as profession that provides professionalism and altruism in the same (progressive) level.

Remuneration system for Professional

Remuneration can be simply means amount of money received as consequences of service provided. A remuneration system can be considered as a key to achieve various strategic options that is demanded by a profession. For example for pharmacist, an appropriate type of remuneration system maybe an incentive to improve the quality of service and more responsible on the practice.

In the professional company, remuneration decision is made by the board of direction by calculating all possible features such as budget, type of work, manpower, improvement program etc. However, in deciding the remuneration system sometimes requires negotiation and expertise to select the best remuneration system for the employee. Whereas, in small company, mostly remuneration decision is made by the owner after hard-nosed contract negotiation with incoming employee or incumbent (in order to adjust new remuneration).

For health care professional like pharmacist, the type of the remuneration depends on the roles and service given and their goals regarding the mission of pharmaceutical care. Huttin (Huttin 1996) in 1995 has examined various system of remuneration for pharmacist, and she classified on two major criteria : product versus patient oriented and single versus multiple range of services. Product oriented such as mark-ups and graduated mark-ups system are focusing on the dispensing services. This system calculates number of prescription (and medicine) that has been dispensed by pharmacist. On the other hands, patient oriented system focus to value other forms of pharmaceutical services. This system rewards a full range of services, more than dispensing prescription. The example are capitation and fee for service.

Percentage mark up is a type of remuneration system that is used in competitive retailing system such as in USA and European Markets. The principle is fix percentage mark-up to all medicines. It represents system that focus on single services, dispensing. In this system, pharmacists have incentive to sell the medicine on high prices unless he gets discount as the result of selling higher volumes of product.

Graduated mark-ups firstly introduced in German to reduce cost and to fix different mark-up levels according to different manufacturers. This system encourages pharmacist to sell lower priced, for example generic products, than branded name which is more expensive. The system is suitable for pharmacists because they have authority to substitute drug product. The margin rate is based on the negotiation between pharmacist and the government, therefore strong bargaining power is needed to maintain fair level remuneration for pharmacists. However, this system is not applicable on the country which has already applied generic prescribing for treating patient, such as in United Kingdom.

Under capitation system, pharmacist revenue relied on the number of patient that has been treated, and not of the prescriptions dispensed. The concept implies that pharmacy will dispense all of the prescriptions from the patient and provides other pharmaceutical services that is required by patients. Pharmacist will receive fix amount of money for each enrolled patient, for example five dollars per month per enrolled patient. Capitation system is applied in Canada, particularly for nursing home, and by applying this system we can minimize the behavior of profit maximization. Unfortunately, capitation has several drawbacks. Capitation will increase risk selection for providers, this means that the providers will choose to treat patient with low risk, less symptoms or easy case in order to treat as many patients as possible in a month. As the consequence is under provision of care because the professional worker will be less aware to patient's problem and tend to ignore the quality of care.

The concept of fee for service system is paying pharmacist in a fix fee for every pharmaceutical services that he has delivered. This system is effective to improve the professional role of pharmacist because it weights more on services and not merely on dispensing amount. The major interest of this system is to provide larger scope to differentiate fees for various pharmaceutical services. The major weakness of this system, contrary to the capitation, is over provision of care and preferably so called - supplier induced demand -. Supplier induced demand means the provider tend to provide more services which are not necessary or even not required by the patient. The motive of this habit is to maximize the profit from various range of services.

In the reality, there is no system that is applied purely in a country. It is often that mixed with other systems, and combined with the other payments such as salary which is popularly used in developing countries to reward the professional role of pharmacists. Change in remuneration system will affect the professional role of pharmacist therefore the stakeholders should determine the appropriate policy for remunerating the pharmacists.

Motivation and Public Agency

Like the other professionals, pharmacists are also shaped by their personalities and by professional socialization. Professional behavior is the result of different, intermixed components such as knowledge, attitudes and value (Mill, Frokjaer and F.J Tromp 2004). In pharmacy, main tasks such as dispensing, counseling, drug substitution or pharmaceutical care activities incorporate public and private interest.

In private interest, pharmacist is conflicted with the economic demand, personal life, individual interest which sometimes resulting dilemma with the public life. While in the public life, potential conflict will become apparent, between the interest of the pharmacy profession and the demand from consumer.

As the health care profession, pharmacy is always tied up with the social dimension on its daily practice. Le Grand on his theory (Grand 2003), "Motivation, Agency and Public Policy : of knights and knaves, pawns and queens" underlines that professional is reflected on the terminology of knight, knaves, queen and pawn. From the motivation view, pharmacists can be imagined as a knight on the assumption of people that are predominantly public spirited or altruistic. On the other side, pharmacist can be assumed as knaves who motivated primarily by self interest on their practices. Queen and pawns reflect the individual capacity in the public sector. A queen means that a pharmacist is an active independent agent, while as a pawn describes person who receives benefits as the passive victims of circumstances. The agency of queen and pawn is advantageous to display the role of pharmacists in the health care system, is a pharmacy an active party to define its role or a passive one that follows the stream of change?

The relations of knight, knaves, queen and pawn is drawn in the axes of motivation and agency. The horizontal axes refers to the spectrum of motivation from purely altruism (left axes refers to knight) to extremely self interest (right axes refers to complete knaves). The vertical axes represents the spectrum of agency from passive individual (in the bottom axes refers pawn) to active autonomous agent (in the top axes refers to queen). In the social democratic society, a profession constitutes area of bottom left-hand quadrant where he or she becomes more altruistic and acts as passive agent in the public sector. On the other hand, in the liberal market, a profession lies on top right-hand one that displays condition of more self preference and autonomous agent. In fact, this theory is too simplistic because there are many kinds of knaves, different type of knight, and complex contribution from queen or pawn.

In relation to pharmacy as profession, the profession of pharmacy may use this concept to reflect its position in the health care system. This evaluation may answer the question regarding definitive roles of pharmacists. Nevertheless, the model is a good reference for the policy maker to calculate the involvement of pharmacists in the community which later implied on the remuneration system for pharmacist.

The Role of Pharmacist in community setting

The role of pharmacist is evolutionary changing from merely the dispenser of tablets and pills towards a professional in medicine. When Helper and Strand introduced the concept of Pharmaceutical Care in 1990 (Helper and Strand 1990), many pharmacists believed that it is the new era of pharmacist professionalism. Under that concept, pharmacist is stipulated to be responsible o the supervision of drug use and encouraged to improve patient's quality of life through assurance on the use of safe and effective medicine.

The concept of Pharmaceutical Care then became a buzz word that familiar for pharmacists particularly for community pharmacists. As the front liners in pharmaceutical services for the society, community pharmacists have the obligation to provide wide range of services.

However, community pharmacy is not only talking about clinical therapy and medicine. Pharmacists in the community are also largely influenced by regulation, economic and social framework (Anderson 2002). By regulation means that pharmacist has to obey "the rules of the game" on the practice, for instance in Indonesia, a pharmacy store must be commanded by at least one pharmacist who in charge for all pharmacy business either clinical or managerial problems. In the economic perspective, a pharmacy is also considered as a retail shop (although most pharmacists protest with the use of "retail" for pharmacy). As a retailer, pharmacist has to gain profit in order to keep the business running. This often implicates to the professional image of pharmacists that assumed for more profit taking than providing nonprofit services. The social framework here relates to the reputation of pharmacist based on the outcome that they did. Public does not recognize the features of profession; they just point out the intrinsic qualities of professional work (e.g. health improvement, increase on knowledge, skill development) that is typical the same for all profession in every circumstances.

What I argue here I called the dynamics of a profession. The professional practice of community pharmacists encompasses a very large number of different tasks. On the one hand he is a professional that acts as altruist helper in the primary care, while on the other hands, he is a professional worker that busy with numbers, management system and financial problems. When he tries to focus on managerial field, then another jobs requires his participation on the counter, as the drug counselor for patient. Pharmacists surely aware that working behind the table is not his common work, he has to meet the patient in order to make a better relationship with patient or maybe another motives such as profit maximizing from selling more medicines. That's why I call this is the dynamic of a profession because personal interests often occur between professional values and organizational demands.

One of distinctive feature of pharmacist as a profession is his responsibilities to predict and overcome drug related problems (DRPs), actual or potential that may be suffered by patients. A study Paulino (Paulino, et al. 2004) indicated that systematic intervention by community pharmacists in discharged patients or their proxies is able to reveal a high number of DRPs which might be related to patient health outcomes. It shows that patient more changes in drug regimens and using more drugs are more likely to suffer DRPs, therefore special attention should be given for these target groups. Readers digest, best selling consumer magazine in the world on 2008 conducted Europe Health Survey to discover the influence of pharmacist across Europe. It is said that "Although the recommendation of a doctor remains the most important influence on consumer's purchase of remedies and drugs, more and more people in every country are relying on their pharmacist for good advice", they concluded that influence of pharmacist has increased by 20% across Europe. Moreover, 80% from total 20.000 respondents said that pharmacist are most trusted person for information about health (Digest 2008).

In a book "Pharmacy Practice" by Kevin Taylor and Geoffrey Harding (Taylor and Harding 2001), explains clearly how community pharmacy practices vary among countries. In Europe, most pharmacists are moving towards pharmaceutical care philosophy, the patient is increasingly becoming the focus of pharmacists' attention. Although pharmacies under financial pressure because some governments want to reduce their health care budgets include tighten the drugs budget, concomitantly pharmacists' role is increasingly important to provide drug information to patients and health care professionals (Mil 2001). In North America, pharmacists are practiced differently in every region. In the USA, pharmacists and physicians are encouraged to follow the drug formularies. Formularies are written with several purposes such as to eliminate inferior, less effective or dangerous items, and also useful instrument for cost containment by prescribing and dispensing drugs that is more cost effective (Serradell and Wertheimer 2001). In the developing countries, the provision and delivery of pharmacy services cannot be separated from political and economic framework in which they operate. There are many features of pharmacy services that are common in developing countries, that may difference significantly to developed countries. Fact shows that most drugs are supplied without prescription, self medication is common practice in the developing countries. People in poor countries are often dealing with inaccessibility of drugs. Pharmacy practice, just like health care services, are bounded by the lack of financial support and that is the reason why pharmacists are difficult to provide comprehensive and high quality services (Smith 2001)

As an example I refer the role of pharmacists in reporting adverse drug reaction (ADR) events. In 2002, WHO conducted international survey for countries who are participating in the WHO Drug Monitoring Program. The study showed that although pharmacists are allowed to report ADR for national health system, only limited number of countries significantly perceived pharmacist contribution. For example in the Netherlands, 40% of the report of ADRs are submitted by pharmacists and their contribution is substantial for pharmacovigillance studies. By contrast, in Indonesia, pharmacists do not participate in the national pharmacovigillance system (Grootheest, et al. 2003). Small contribution of pharmacists in reporting ADRs is a questionable topic because pharmacists are the person who closely related to drug and hold the authorities for drug release in the pharmacy store. This indicates that standard practice of pharmacists are vary among countries. Like in Scandinavian countries, pharmacists role is restricted only in compounding and dispensing of drug, while in Japan, Portugal, the Netherlands and USA, pharmacists may submit bulk of reports and play significant role in reporting ADRs.

Concept of Pharmaceutical Care

As a result of societal changes and internal developments, the pharmacy profession is continuously changing. Like other health care professions, pharmacists has to change systemically to responds societal healthcare needs. The emphasis of current pharmaceutical practice has shifted from the product or substance skills (preparation, purification and dispensing) into more personal attention to the patient problem, particularly on individualization of therapies. It attempts to improve drug therapy outcomes by requiring pharmacists, in cooperation with their patients and other health professionals, to design, implement and monitor patient drug therapy. The current tendency shows that provision of pharmaceutical care is the answer for responding the society.

Helper and Strand (Helper and Strand 1990) defines Pharmaceutical Care is "the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve patient's quality of life. These outcomes are (1) cure of a disease, (2) elimination or reduction of a patient's symptomatology, (3) arresting or slowing of a disease process or (4) preventing a disease or symptomatology".

Furthermore, Helper and Strand wrote that pharmaceutical care is a necessary element of health care and should be integrated with other elements. Pharmaceutical care is designed to give advantages for patient and improving the responsibility of pharmacist to the aspect of patient's quality of care. The mutual beneficial exchange between pharmacist and patient is the fundamental relationship to perform pharmaceutical care.

Nevertheless, some countries have quite different interpretation to the definition of pharmaceutical care. During a symposium in the Netherlands in 2003, European countries regarded pharmaceutical care as "pharmacists being nice to patient". This simplistic definition surely may lead to confusion because just being nice is certainly not enough. Some other tried to clarify pharmaceutical care as "the care of pharmacist around pharmaceuticals for the benefit of the patient", by this definition, is necessary to include pharmacovigillance studies as the part of pharmaceutical care. According to WHO, pharmacovigillance is "the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other possible drug related problem". It seems that there is no uniform across Europe because of countries, language and health system variation.

Apart from the confusion of definition, there also can be differentiation on setting of pharmaceutical care (applied in community or hospital or both) and the goal of it. Some European countries assume that pharmaceutical care goal is optimizing the outcome of drug therapy-nothing more nothing less, while Helper and Strand clearly described that the ultimate goal is to improve patient quality of life not only simple on optimizing a set of drug but also improving clinical, economics and humanistic outcomes.

The Pharmacy Practice Activity Classification

The Pharmacy Practice Activity Classification (PPAC) is a hierarchical categorization of pharmacist activities. It is initiated by the American Pharmacists Association as a standard for pharmaceutical services in the United States. However, as increasing demand on the provision of pharmaceutical care and professional reward for pharmaceutical care services, the PPAC later on becomes broadly accepted as a guideline for pharmacist activities because until now there is no other standard in common language that is comparable to PPAC. The classification on PPAC captures a range of activities from traditional dispensing to direct patient care services. Another important purpose of PPAC is to provide a solid reason to support remuneration system based on professional work.

The Pharmacy Practice Activity Classification

Reproduced from Developing Pharmacy Practice, A Focus on Patient Care (Wiedenmayer, et al. 2006)

The context

The Netherlands

Demographic and Political system

The country of the Netherlands is located in Western Europe. With total population of 16,4 million people who live in 41.528 square kilometers, makes the Netherlands one of the world's most densely populated country with more than 450 inhabitants per square kilometers. Per one thousand live births the infant mortality rate is 5.0. The male and female life expectancy at birth is high. For man it is 76 and for woman 80,7. Apparently, the health of Dutch population diminishes compared to the best EU countries. Per one thousand cases there is a standard death rate of 7.9.

The Netherlands is a constitutional monarchy with a parliamentary system. This means that the government includes not only the ministers and the state secretaries, but also the monarch (currently Queen Beatrix). The monarch is also the head of state. The constitution determines how the powers are divided between the Queen and the other institutions of the State. For example the parliament has certain rights which allow it to check the power of the government. The ministers are accountable to parliament, but the Queen, who has no political accountability, is not. The ministers form a cabinet council as on e of executive bodies. The cabinet council is headed by prime minister who is responsible for the cohesion and coordination of government policy. His position is one of primus inter pares (first among equals) which makes him powerless to make any changes in the cabinet.

The Netherlands is a representative democracy and its parliament (Staten Generaal) is made up of two houses. The Senate (Eerste Kamer) has 75 indirectly elected members, who only have the power of veto in the legislative process. The House of Representatives (Tweede Kamer) has 150 members elected directly by the people. It scrutinizes the government and proposes legislation. Members of both houses serve a four-year term.

The two houses have four rights: the right to set a budget; the right of interpellation; the right to put questions to ministers and state secretaries; and the right of inquiry. The House of Representatives has two further rights: the right of amendment and the right to propose legislation.

Political system in the Netherlands adheres concept of corporatism. Corporatism according to Newton and Van Deth is "a way of organizing public policy making involving the close cooperation of major economic interests within a formal government apparatus that is capable of concerting the main economics group so that they can jointly formulate and implement binding policies". Corporatism is created to minimize conflict, maximize agreement and ensure the implementation of a policy smoothly. In this system, the government has to compromise with the other actor in policy making process. For example in economic system, business interests, trade unions and government have to sit closely together in an institution to maintain the system run effectively for the country.

Corporatism requires a small number of organized authorities that produce wide scope of policies to bind all parties and acts as consultative bodies for government. The Netherlands runs this model since there is no party that has a majority thus a coalition of several parties is necessary to form a cabinet.

Socioeconomics condition

In the Netherlands, as elsewhere, the global economic crisis is taking its toll. In February 2009, Statistics Netherlands confirmed that the Dutch economy has officially been in recession since the second quarter of 2008 and is in worse shape than was previously thought. The downturn in the Dutch economy has been swift. In 2008 the Netherlands Bureau for Economic Policy Analysis (CPB) forecast 1.75% growth in 2009. The contraction that began in April 2008, however, resulted in negative growth over the rest of the year, especially in the housing and the automotive markets, and growth in consumer spending came to a virtual halt in October 2008.

The Dutch economy is expected to shrink by 3.5% in 2009, according to the CPB's February 2008 forecast. In addition, its forecast for 2010 has been revised downwards to a possible contraction of 0.25%. The prospects for unemployment are especially pessimistic. The CPB estimates that unemployment will rise to 5.5% over 2009 and will affect some 8.75% of the workforce by 2010. That translates into 425,000 people out of work in 2009, and 675,000 in 2010.

Health care system and financing of health

A national health status report in 2003 concluded that the majority of the Dutch population enjoys good health status. Life expectancy at a birth has risen to 76 years for male and 80,7 years for female. The major causes of death are cardiovascular disease and cancer. Overall, Dutch mortality is quite low, which is partly caused by traffic accident. Perinatal mortality that indicates important health system indicator is also stagnating to the EU 15 average. However, some increasing risk factors has been a threat for the Dutch population such as, a higher percentage of children born from low economic status, increasing average age of mothers at birth of their children, an increasing percentage of twins and triplets birth and poor life habits like smoking during pregnancy. Health differences in urban-rural area, in high socioeconomic-low socioeconomic status are the challenge for Dutch health care system and have not decreased in the recent years.

The organizational structure of health care system in the Netherlands is rather unique because involving different ministries to steer and supervise the three compartments of the system. What I meant with three compartments is a three parallel compartment of insurance coexist : first compartment is a national health insurance scheme for exceptional medical expenses, second compartment consist of different regulatory regimes, one for compulsory health insurance and another for private health insurance which mostly voluntary, third compartment is voluntary supplementary health insurance (Exter, et al. 2004).

The government appoints three different ministries to govern policies in the health system. The Ministry of Health, Welfare and Sport (Ministerie van Volksgezonheid, Welzijn en Sport, VWS) define policies that ensure the wellbeing of the population and to lead people lives healthy. One of the main objective of VWS is to guarantee access to health care facilities with high quality services. To run this, VWS established social health insurance schemes under the Exceptional Medical Expenses Act (AWBZ) and the Sickness Fund Act (ZFW). Ministry of Social Affairs and Employment (Ministerie van Sociale Zaken en Werkgelenheid, SZW) main tasks are to encourage employment, modern labor relations and an active social security policy. To foster this, SZW collaborates with VWS for health related social security scheme covering sickness benefits and disabled benefits. The Ministry of Finance shares responsibilities with VWS in supervising changes in standard insurance scheme, especially standard insurance contribution.

The Netherlands health care system faces territorial decentralization that is transfer of competencies from the central government to provincial and local governments particularly shown in the care facilities. By territorial decentralization, local government steers care facilities include shift in financing and planning of a care. Due to a scarcity of facilities, care must be rationed, here the local government play its important role to stimulate the number of facilities.

Dutch health care system is largely funded by a system of public and private insurance schemes. This is taken into 88% of the total funding, the rest of fund comes from taxes, out of pocket payment and voluntary supplementary health insurance. The first compartment as I noted above, is mandatorily applied, with few exception, for everyone living in the Netherlands irrespective their nationality, all nonresident employed in the Netherlands and subject to Dutch income tax covered by the act. The second compartment covers people with annual salary below statutory threshold (€ 32.600 in 2004) and all recipients of social security benefits up to age 65 years. The second compartment covers normal necessary care. The third compartment covers the supplementary forms of care that is regarded as less necessary. This is applied to cover the care which is not included in the first or second compartment, therefore the costs are largely covered by the private medical insurance.

Since 2001, the health care expenditure has risen to 9,1%, this in line to EU-15 average level. This number is tripled since 1980. Compared to other EU countries, health care expenditure per Dutch person is about EU-15 average. Spending from the hospitals accounted 25% of total expenditure, while expenditure from nursing homes, home care for elderly and home care institutions constitute 30% of the total expenditure. Spending on health care (hospitals etc) is relatively stable over time, by contrast, the social care has increased over time.

One of major problem that is faced by the Netherlands is longer waiting lists to receive treatment. In 2001, around 150.000 people were in waiting lists and more than 92.000 of them waiting for longer than a month. By the October 2001, the number has increased to 185.000 people. Treatment of orthopaedics, ophthalmology and plastic surgery were contributing to the long waiting lists. Plastic surgery had the longest waiting time with 12 weeks of diagnosis and 23 weeks for treatment. Dutch reported that € 3,2 billion loss per year because of waiting lists. To solve this problem, the government provided extra funding to where waiting lists occurred. As a result, in May 2004, around 95.000 of total 139.000 people in the waiting list, can be treated within four to five weeks. 20% of the people on the waiting lists cannot be treated because capacity problems and 12% refused to be treated because personal or medical reasons.

Family physicians play important role as gatekeeper on the primary care. Gatekeeping principle means that patients do not have free access to specialists or hospital care unless in case of emergency. The impact of this principle is the low referral rate because the vast majority of medical problems can be treated by family physicians. In 2003, the average number of people per family physicians has reached 2300. This makes physician has a great deal of time talking to patients, explaining their problems and discussing various treatments. This results low prescription rate in which prescription given only half of all diagnoses. The secondary and tertiary care is mainly provided by medical specialists in the hospital. About 40% of the population visits medical specialist each year. There were 136 hospitals in 1999 provided various forms of treatments. Hospitals have increased their capacity through mergers and expansion, however, capacity management is still issue concerning to the long waiting lists.

Pharmacy Regulation

Netherlands has approximately 1.700 pharmacists of the 1.900 pharmacies that serve more than 13 million people with average 8.100 per pharmacy (Kengetallen, 2008). More than 90% of the pharmacists are the member of The Professional Organization of Pharmacist, KNMP which stands for The Royal Dutch Association for The Advancement of Pharmacy (Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie). As the Organization of Pharmacist, KNMP enacted Dutch Pharmacy Standards (Nederlandse Apotheek Norm) in 1996 to develop the concept of Pharmaceutical Care, a patient oriented services that weight improvement of patient's quality of life as the major goal. The standards have no external power to bound all pharmacists; it is more like disciplinary and ethical model for pharmacy services. Before a pharmacist is allowed to do pharmacy services, according to Article 14 of the Drug Supply Act, he or she must register first to regional health inspectorate (regionale Inspectie voor de Gezondheidszorg) and fulfilling the requirements such as a pharmacy diploma and statement of the property (Article 2).

Under the Drug Supply Act of 1958 (Wet op de Geneesmiddelenvoorziening) and The Pharmaceutical Practice Decree of 1963 (Besluit Uitoefening Artsenijbereidkunst), pharmacist is the only authorized profession to dispense drug. This monopoly was also strengthened by the regulation of KNMP establishment policy decree (Besluit Vestigingsbeleid KNMP) applied between 1975 and 1978, that defined only member of Pharmacist Organization that was allowed to establish a pharmacy with certain requirement. Because of increased demand from non-member of KNMP that resulted "black establishment' of Pharmacies in 1980, KNMP revised the policy into so-called Guidelines concerning the KNMP advisory establishment policy (Richtlijnen betreffende het vestigingsadviesbeleid KNMP).

The guideline allowed non-member of KNMP to establish a pharmacy under advice from the organization. Until 1998, requirement on the regulation for the establishment of pharmacies generally points pharmacist as the owner of the pharmacies. From 1999 onwards, liberalization has been made to ease non pharmacist to own a pharmacy. Under Article 19 of the Drug Supply Act (Wet op de Geneesmiddelenvoorziening, WOG), each pharmacy should have at least one pharmacist available (Philipsen & Faure, 2002). The pharmacist may hand over his job to assistants. However, pharmacist need to be present for questions or special notes from the assistants, therefore when pharmacist is planning to absence from the pharmacy for several days, he or she should find the replacement for the job. The job then may be carried out by another pharmacist.

In Netherlands, medicines are divided into two categories, WTG and non-WTG. WTG is a medicine that can only be bought in a pharmacy and sold under the Health Care Charges Act (Wet Tarieven Gezondheidszorg), while non WTG is the medicine that is available in outlets other than pharmacies like drug store or even in supermarket. The Netherlands pharmaceutical policy offers incentive for pharmacists to substitute branded name with generic name, therefore generic market is highly competitive as the consequences of the substitution policy. This also result strong relationship between insurers and pharmacies. In this case, Insurers are allowed to enter preferred arrangements with pharmacists. Consequently, the prices paid by insurers can be controlled while the pharmacists are compensated with higher volume of business. (Mossialos and Oliver 2005).

Role of Community Pharmacist

In the Netherlands, Pharmaceutical care is better known as "Pharmaceutical Patient Care". KNMP describes "Pharmaceutical patient care is the provision of care by the pharmacy team, directed towards the individual patient, in relation to pharmacotherapy, with the objective of increasing the quality of life of the patient involved" (Boysen 2004).

A study argued that Dutch patients are protected from drug related problems because usually they visit the same pharmacy and that makes the pharmacy develops automated medication surveillance and high quality counseling (J. F. Mil 2005). Therefore, we may assume that Dutch community pharmacist may reflect pharmaceutical care concept in daily activities, although in a different extent. Community pharmacists are also involved in the reporting of adverse drug reactions (Grootheest, Olsson, Couper, & Van den Berg, 2003), post marketing surveillance of the drugs such as determining potential drug-drug interaction (Grootheest & Van den Berg, 2005, Becker, et al. 2007), patient education (Pronk, Blom, Jonkers, & Bakker, 2002) and even drug utilization studies (Mil, Schulz, & Tromp, 2004).

What is so special from the practice of community pharmacists in Netherlands is that they are involved in a pharmacotherapeutic forum (Farmaco Therapeutisch Overleg, FTO) that involves general practitioners (GP's) and community pharmacists. Currently, there are approximately 800 forums that meet six to eight times in a year to reach agreement on pharmaceutical care in their locality. This forum is implanted in the national structure of the National Association of GPs, the District GP Association and the KNMP. This forum is not exclusively performed by general practitioners and community pharmacists only, but also medical specialists and hospital pharmacists are encouraged to join the forum. In its report, KNMP stated that "the FTO's aim to improve good pharmacotherapy by using the knowledge and expertise of the GP and pharmacist working in the community, sharing information and education concerning new products, and making agreement on the prescription behavior such as discussing the drug choice or the amount of drug/dosages prescribed, discussing prescribing pattern, evaluating effects of the prescribing interventions etc" (Visser 2001).

Since the introduction of the Netherlands Dispensing Chemist Standards in 1996 by the KNMP, guidelines have been formulated with respect to the delivery of patient focused care. In addition, the scientific organization of the professional pharmacist organization (WINAP) declared that pharmaceutical care is the focus of the further professional development. Today, the delivery of pharmaceutical is often included in the contract between pharmacies and health insurance, but the remuneration is very limited (Mil and Schulz 2006).

Although many pharmaceutical products are manufactured by pharmaceutical industries, about 2-3% of prescription or 13.000 medicines per day needs to be compounded by the pharmacists (Buurma, et al. 2003). Compounding occurred almost for dermatologic products and patients of 12 years or younger. In about 33% of the compounding activities are related to patient issue (patient disabilities, repeat prescription etc) and another 10% is concerned to pharmaceutical care issue. However, the frequency will continue to decline due to several issues like changing in the remuneration system, growing pressure on the rationality of compounded medicine and shortage of personnel.

Remuneration system for Pharmacist

In Netherlands, pharmacist fee is determined by the health care authorities. The fee includes all of services delivered by the pharmacist such as drug dispensing, costumer counseling and medication surveillance. In 2007, community pharmacies generated € 874 million for their services. This includes fixed fee for WMG (Wet Marktordening Gezondheidszorg) prescriptions was about € 844 million and the margin on medicines that are not covered by the Health Care Market Regulation Act which about € 30 million (Kengetallen, 2008). For every drug dispensed on the prescription, pharmacist receives € 6,10 per WMG medicine, regardless of the quantity or the price of the drug. The result of this policy is that the tariff for dispending a medicine is same for all pharmacies. The purchase fee, refund paid by the insurers to pharmacies is determined by a reimbursement list so-called taxe of z-index. Taxe is a list of medicine that is registered in Netherlands and published monthly based on the 11 CTG tariff orders.

Pharmacies also receive discount and bonus from the pharmaceutical manufacturers and wholesalers to counterbalance the rising pharmacy practice cost and the reduction of pharmacy budgets. By the end of the 1990s the government fought against discount and bonus received by pharmacies. Since then, pharmacists have been obliged by the government to give some of their refund by a decrease in the reimbursement prices of drugs. This deduction of the reimbursement price is called "clawback". A clawback of 6,82% to a maximum € 15,00 given to justify the difference between official and real selling prices (Philipsen & Faure, 2002).

Another incentive comes from the sale of non WTG and medical devices which in 1998 takes account of 20-30% of profit margin. Pharmacist also gets incentive from the substitution of branded medicines to generic medicines; this is to support the campaign of using generic medicine. However, price differences between generic and branded drug become smaller under the Drug Prices Act and Drug Reimbursement System on the price level. KNMP wrote a list of interchangeable product for each chemical entity that explains the name of the wholesaler, the manufacturer, the number and the registration date. When two drugs on the list are identical, their registration codes will show equal sign. Generic products accounted for 13% of all prescribed medicine in value and 30% in volume (Garattini and Tediosi 2000).

Indonesia

Demographic and Political system

Indonesia is the largest archipelagic nation in the world. It covers more than 17.000 islands that stretches from mainland of southeast Asia to Australia continent. The biggest island is Kalimantan (Borneo) and Papua which is the part of new guinea. With more than 225 million people live in, Indonesia is the fourth most heavily populated country in the world. The population density level is 118 people per square km with Java as the most crowded island in Indonesia. The population is not distributed equally, for example in Jakarta, the capital city of the country, it is inhabited by 13.500 people per square km while in Papua is only inhabited by 6 people per square km. On the conclusion, 69% of the total population lives in Java which only constitutes 7,17% of total square of Indonesia, that means the other parts are only occupied by fewer people. The inequality in population distribution is a major problem for the government which makes more difficult to implement policies for entire nation.

Recent population composition shows that productive ages (15-64) composes the majority of population chart with 65,05%, and people at age group 0-14 with 29,30%. Indonesia is a multiethnic country with diverse culture and tradition that posses more than 300 ethnicities and 700 different dialects. The national language is Bahasa Indonesia

As unitary state in the form of republic, The President is the head of the country and the head of the government. The Indonesian President is the top position in leading and ruling the country, he or she controls the military forces, responsible for domestic and foreign affairs and acted as the chief of executive. To support the Presidential duty, he or she has the right to appoint a council of minister that is chosen by him or herself. Legislative control is undertaken by Majelis Permusyawaratan Rakyat consist of 550 member of the Dewan perwakilan Rakyat or House of Representatives who are elected every five years period as the representation of different political power and multi parties, and Dewan perwakilan Daerah or Regional Representative Council, who are the representation of each provinces. The total number of Majelis Permusyawaratan rakyat is 695 people. Other important organs of state is Supreme Court, Mahkamah agung, that acts as Judicative power, Constitutional court (Mahkamah Konstitusi) to evaluate and end up constitutional dispute, and the State of Audit Board (Badan Pemeriksa Keuangan) to oversee the accountability of public finance.

Administratively, Indonesia has been divided into 33 provinces that consist of 349 districts and 91 municipalities. Therefore to develop the provinces, one of fundamental reform that had been established was the implementation of decentralization legislation with law No. 22/1999, later revised by law No. 32/2004, and the financial balance between central and local government, No. 25/1999 . These laws then transformed Indonesia from the most centralized country in the world became the most decentralized

Socioeconomics condition

Like a roller coaster, Indonesia experiences fluctuation in it economic level. Between 1970 to 1980, the GDP per capita had sharply increased 545% as the result of the booming in oil revenue. However, from 1980 the GDP per capita shrank to 20% and continued by 13% in 1990 to 2000. Indonesia is one of the worst hit country by global economic crisis in the mid 1997. The effect of the crisis was very severe to Indonesia, the real GDP growth slowed down to 0,3% in 1999, while in 1998 the inflation reached 77%. As the consequences, Rupiah, the nation currency, depreciated from 2.600/USD before 1997 to 11.000/USD in 1998 and the peak reached 15.000/USD in mid of 1998. Afterwards, particularly after the relieve of crisis in 2001, the rupiah is maintained on the level 8.000-10.000/USD until now. The economic growth increased accelerated to 5,1% in 2004 to 5,6% in 2005. In spite of slowing global economy in 2007, Indonesia's economic growth increased to 6,3% and considered as the third fastest growing economy in the group of twenty (G20 country) after India and China.

Poverty and unemployment are the classic issue that is faced by developing countries. The high number of poverty will burden the economic level and like domino effect, it will influence other fields especially on health system. Unemployment will tend to erode the individual security and in general affects the national stability, such as labor strike. Unemployment rate in February 2007 was 9,75%, the highest level of unemployment was in Java with 10,39% and the lowest in Bali and Nusa Tenggara with 5,49%. While poverty level increased from 12,85% in 2006 to 15,3% in 2007. There were 3 provinces who had the highest rate of poor population above 30%, Papua (40,78%), West Papua (39,31%) and Maluku (31,14%). All of the poorest provinces are located in eastern Indonesia.

To conclude, inequalities in every field is a major problem for central government including in the socioeconomic condition. The discrepancies between eastern and western part is so high where the western part enjoys more prosperity. The condition in Java and outside Java is also imbalance

Health care system and financing of health

Each sub district in Indonesia has at least one health care centre (PUSKESMAS) headed by a doctor. The health care centers are supported by two or three sub centers that are usually headed by nurses, four wheel drive vehicle or motorboat is provided in each health care centre to serve people in urban and remote rural areas. At the village level as the lowest community level, health care is provided through integrated family health post (POSYANDU), village maternity hut (PONDOK BERSALIN) and village midwife that is under assistance of health care center staff. Goal of establishing health care in village level is to prevent disease event and most important to improve maternal and child health. The existing infrastructure in village level has reached 7.669 health care centers, 21.115 sub health care centers and 243.783 integrated family health posts . At the district level, at least there is one public hospital that is served by at least four specialists. At the higher in the provincial level and national level is equipped with at least 15 specialists. Total public and private hospitals were 1.268 hospitals in 2005.

The health sector in Indonesia fares less favorably than the overall economy as reflected in the health expenditure table. A major constraint is the continued low level of funding to the health sector. In 2001, total spending on health amounted to an estimated 2.6% of GDP in Indonesia compared with 5.5% on average among developing countries worldwide. This translates to about US$ 16 per person, approximately 63% of which originates from individual out-of-pocket expenditures. From the international community, the contribution to health is similarly inadequate. The Government of Indonesia made substantial development progress, with GNP per capita increasing rapidly between 1970 and the early 1990s. Health status also improved remarkably. Whereas a child born in Indonesia in the 1960s could expect to live 46 years, one born in 1996 could expect to live for nearly 65 years. Although difficult to measure, such achievements were due in part to health investments that expanded access to basic services. The total fertility rate, for example, declined from 5.6 in the 1960s to 2.6 children per woman today. This decline was largely attributable to increased contraceptive use. Indonesia invested considerable public funds in health and social services during the 1970s and 1980s. Such investments matched international commitments to expand basic social services, primarily via the public sector, and were largely comprised of infrastructure and equipment for improving access to basic services. For example, the Government nearly doubled the number of public health facilities between 1974 and 1995 to more than 7,000 health centers and 20,000 auxiliary health centers.

The Indonesian government fund their health care systems through a system of taxes. This tax burden is progressive, with lower income quintiles contributing less to the pool of resources. The Ministry of Health and their sub-national departments at the provincial and district level arranges and finances the 'main system' of health service provision under public management. This is in principle accessible for all Indonesian citizens . The decentralization in 2001 has changed the intergovernmental transfer system away from earmarked funding. Before the decentralization, the central transfers were mostly in the form of these earmarked funding. The largest of these transfers was the subsidy from the central government to the autonomous regions. After the decentralization, the central transfers were designed to minimize the vertical and horizontal fiscal imbalances incurred by regional government and to implement the functions stipulated in the decentralization law. These central transfers were then called 'balancing funds'. In Indonesia it is very normal to pay for your health care out of pocket (OOP). That means that when you need health care, you go to a health institution and pay immediately for the care you have received. The Nation Health Account (2007) estimated that nearly 50% of the health spending is OOP. It is difficult to achieve equity in health financing as long as high OOP levels exist. The OOP-payments have a large impact of the health insurance of Indonesia.

The Indonesian government promoted during the 1990s three health insurance schemes. The first one was a social health insurance for private employees (Jamsostek), the second one a voluntary health insurance (private) and the third one was a community health maintenance insurance (Jaminan Pemeliharaan Kesehatan Masyarakat, JPKM). And there is also a social health insurance for civil servants (Askes), which has been offered since 1968. It is necessary to know that only 14% of the Indonesian population is insured. So that means that 86% is not covered by any form of health insurance scheme. Now a few of the several kinds of health insurances of Indonesia is introduced. Because there is a variety of public and private insurance, a fragmented system is the consequence. So that means that the system does not cover all risk groups. Over the years slowly different health insurances evolved for formal sector workers.

The first social health insurance scheme for the civil servants was Askes. There are around 14 million members who are insured in the civil servant compulsory health insurance. Military personnel and all civil servants and pensioner civil servants are mandated to contribute 2% of their basic monthly salary. Regardless of their income or rank, all the members are entitled to comprehensive benefits considered medically necessary. There is a provider network for Askes members. This network consists of public health centers and public hospitals. Most of the time Askes members pay the providers using prospective payments . The Askes insurance was followed by a similar scheme, Jamsostek. This is an insurance for formal private sector employees. Jamsostek is an insurance for those who belongs to a lower income group. This insurance provides four programs namely Employment Injury, Death, Health Insurance and a provident fund type Old Age Benefit. There are just about 3.1 million members who have the Health Insurance of Jamsostek. There is also an insurance for the poor population. In 2005 a new program was started, the program is called Askeskin . Members of Askeskin pay about $ 0,55 (US) (Rp. 5.000) per month as contribution. Totally there are around 60 million members. For the basis health care and health insurance the government allocated Rp. 3.9 trillion. The benefit packages of these insurances are not very different. By example all the insurances which are discussed have a comprehensive package; there are a lot of conditions included. Valid for very insurance, maternity benefits are included. But with Askes and Jamsostek have to pay for a normal delivery. For all the insurance, prevention and health promotion are included. An annual physical check-up is included for Askes, Jamsostek and the private one but for Askeskin it is excluded. Remarkable is that for the insurance Jamsostek, cancer treatments, heart surgery, congenital diseases and renal dialysis is excluded. So those are services which are not covered. However, every insurance has its own limitations. Note that the conditions which are not included for Askeskin are set by government for many years.

Pharmacy Regulation

Pharmacy practice in Indonesia is regulated by the Ministry of Health through presidential decree no. 51/2009. The regulation strictly states that pharmacists are fully responsible on conducting services in the pharmacy store; therefore a minimum one pharmacist must be available on the pharmacy in the daily practice. The practice of pharmacy is also standardized by the ministerial decree no. 1027/2004 that is used as the main guideline to practice in the community level. The decree explains that a pharmacist has to provide at least four consecutive categories in the practice starting from screening of prescription, drug preparation (including compounding, dispensing and patient counseling), promotion and health education and it ended with home care services that are manifested in medication record form.

There are 27 thousands pharmacists in Indonesia that serves almost 250 million people distributed in 10.880 pharmacy stores (Siswadi, 2009). The Indonesian Pharmacist Association (Ikatan Apoteker Indonesia, IAI) assumes that the number of pharmacists exceed the real need of pharmacists. Ideally one pharmacist serves 10 thousand people but the current situation shows reduced number of market scope. In addition, nearly 3500 fresh pharmacists enter the market annually thus makes the competition is more difficult than before. All of Indonesian pharmacists are the member of IAI, while IAI as the other professional organization only owns power to regulate internal organization with limitation role as partnership of government on regulating pharmaceutical field.

The establishment of a pharmacy store is regulated under ministerial decree no. 1032/2002 that every pharmacist is allowed to open a new pharmacy with permission from the minister of health. A new pharmacy has to fulfill special requirements such as in facilities, building, manpower and financial liability. The supervision of the pharmacy is carried out by two organization, the first is ministry of health through local health department that supervise the operational work of pharmacy, and the second is the national agency of drug and food control (Badan Pengawas Obat dan Makanan, BPOM) that controls the post marketing vigilance in the distribution outlets include pharmacy. Sometimes the job of these two organizations overlap each other, this because from the historical view BPOM at the previous was the sub branch of the ministry of health than became independent to perform task on drug monitoring effectively.

Insurance system is not popular in Indonesia so most of patients buy the medicine out of pockets. Unless for the very poor people, government will not reimburse the cost of medicines consume by patients. In daily practice there are two kinds of drug which are OTC (Other the counter) drug that is freely available in pharmacy and common stores and also ethical drug or prescription only medicine which requires doctor prescription that is only sold in pharmacy. To decrease the financial burden of pharmaceutical consumption, government strongly suggests the use of generic medicine under the ministerial decree No. 85/1989.

Role of Community Pharmacist

Pharmacists in Indonesia like the other developing countries are influenced by the political and socioeconomic condition. Pharmacists are mostly dealing with compounding and dispensing of the drugs with a few evidences on providing advance services such as demanded by the pharmaceutical care concept. In Indonesia, pharmacies are freely owned by many people irrespective to pharmacists. However, pharmacists are still be responsible for managing the services.

There are not much studies regarding the role of community pharmacists in Indonesia. Empirical evidences show that normally pharmacists in Indonesia hand over their job to the technicians therefore most of the time pharmacists are not available on the place.

Periodically, pharmacists are asked to fill report of drug adverse reaction which might happen on the pharmacies. This report is arranged by BPOM and distributed to all pharmacists every 4 months. BPOM then will release public announcement if they find the events of ADR. Unfortunately not all pharmacists are willing to take part in the studies that's why ADR's event may be collected from individual report than collective pharmacists.

Remuneration system for Pharmacist

In Indonesia, pharmacists are paid basically from monthly salary dependent where he or she works in, for example pharmacists that works in an individual pharmacy usually earned smaller than who works in chain pharmacy. However, pharmacists that own their pharmacy may gain large amount of money compare to those who are employed by a company. There are great variations on how to remunerate pharmacist in Indonesia and ironically, most of pharmacists are paid lower than the normal rate that is recommended by IAI. Generally, pharmacists in community are paid 1-1,5 millions per month (equal to € 65-100), while IAI recommends that pharmacists salary is minimum € 100 per month.

Another incentive for pharmacists is from the dispensing fees, pharmacy profit and bonuses from pharmaceutical industry. However, pharmacists cannot count on this income because the nominal is varied from time to time and sometimes this incomes is distributed with the other pharmacy team includes for the owner. Professional fee (or consultation fee) is not familiar for pharmacist in Indonesia so very few pharmacists who receive this incentive.

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