Table 3 Illustrative quotes of the findings

Challenges to policy implementation

“When we look at policy changes there are too many hands involved…as you go every layer decisions get diluted, accountability gets diluted, execution gets diluted so there is no strong line for accountability. Who is truly accountable for change of healthcare in Indonesia? Is it the Ministry of health or the police in the region? and you also have very regional influences. You have the region of governance” (P018_FNP). Lack of accountability in the implementation

“We do have policies, standards, regulations on one hand but on the other hand…we see with our eyes that there is no pharmacist (in pharmacy)…There is no one who pushes the policy, facilitates the policy which means that there is a lack of facilitation especially from government to ensure that the policies are running well. They don’t support it so it is up to pharmacy…” (P029_MP). Lack of facilitation from government

“We’re only undertaking CPD because we have no choice, it’s not because we want to improve our competence. It’s just because we have the awareness that (collecting) SKP is a prerequisite to continue practicing pharmacy. That is why CPDs and seminars are being treated like reunions…Whether they (pharmacists) practice is another matter. They say, I get SKP so I can extend my STRA (registration), I need STRA to get my SIPA (license), and no SIPA means no salary. Whether I show up for work is my business with my employer; IAI should mind their own business” (P01_FP). Skeptical to the impact of the policies

“We always look for scapegoats when we do something wrong…The popular excuse when committing violations has been “I can do this because others have done the same and they don’t get punished”. When violations go unpunished, people end up considering these violations as normal” (P02_FP). Lack of enforcement for successful policy implementation

“Many pharmacists from [name of government bodies] work in pharmacy. I ask them to quit but it is difficult to ask people to become good role models in Indonesia…I ask them to be consistent, consistent with their own policies (they created). It is really shameful if individuals from [name of government bodies] should have been present in the pharmacy three times in a week but it turns out he comes only once in every three weeks. It is embarrassing” (P027_FP).

“[name of professional organization] cannot become agents of change because there are many people with various interests in [name of professional organization]. There are people who have interests in obtaining official appointments e.g. becoming a commissioner for a state-owned enterprise, or director for state owned enterprise. Therefore, it is difficult.” (P028_MP). Lack of trust in pharmacy stakeholders

Need for policy changes

“We were challenged by MoH when we had a coordination meeting. They said “If you could show us the evidence of what can pharmacists do when they practice then we can discuss about their fees”. To date, we are unable to show this evidence” (P05_MP).

“We can’t use the word evidence at the moment because we (pharmacists) don’t practice, am I correct? The number of practicing pharmacists is very low…Nowadays, they (pharmacists) only talk about business or sales” (P015_MP). Collection of evidence

“We try to look for role models. For instance, IAI [name of region] covers five branches and I asked each branch to look for a community pharmacy which can be role model. Then we can replicate the success to other pharmacies, one becomes two, three and so on” (P027_FP). Search for pharmacy role model

“There is a wide discrepancy between education and practice because universities are still polyvalent (of knowledge)…Frankly speaking, the education system does not create pharmacists to be pharmacists. The education system is overloaded with too many science courses…there is no practice values within the course” (P015_MP). Changing pharmacy education curricula

“I think they should have collective responsibility but right now they don’t talk each other. So, the universities don’t exactly know where they want to take healthcare to the next stage. The government policy does not have support what comes out and then the IAI also just kind of, I think they are great in showing best practices but not again not execution. I think there is a little bit of within any political maneuvering there are the egos, who should be responsible? which other parties should be responsible for?” (P018_FP). Lack of a shared stakeholder vision

“(we need) policy that makes pharmacists proud of working in pharmacy, policy that supports pharmacy as the first point of contact with patients, policy that makes pharmacy is a setting to listen to patient’s problem related to medication. That’s all. It is a great thing if we have those three policies” (P028_MP). Policy advocating pharmacists

Coping strategies initiated by locals

“we have accreditation system by giving pharmacy star rating from 4 to 1 star…the accreditation evaluates the workforces, facilities, legality for practice, service provision and administrative matters. We give different score for each aspect with service provision is the highest…we do it once in every one or two year and we publish the results regularly…the stars must be displayed in the pharmacy” (P016_MP). Pharmacy star rating model - applied in Yogyakarta

“When a pharmacist wants to open pharmacy and they have difficulty in purchasing, I offer them my stock at a cheap price. I don’t take profit. That is to push pharmacist practice. When there is pharmacist who opens a pharmacy, I endorse colleague to guide the pharmacist from the scratch, help them with how to provide good service and even they are not yet sustainable for procurement, they can buy to another pharmacy” (P05_MP). Peer support and assistance - applied in East Java

“If pharmacist is unable to order medicine such as Imodium (brand name of Loperamide) because the price of one tablet is 6 thousand rupiah (approximately 60 cents)…your pharmacy can buy from me. What important is you have the stock of the medicine. We make a network so we can help other small pharmacies. Other cases, for example your pharmacy can’t sell a medicine. By having network you can distribute it to other pharmacies which may be able to sell it. We can help each other so we can minimize loss due to expired medicines” (P027_FP). Networking and collective approach - applied in Greater Jakarta

“The head of IAI must be strong character person, with vision and knowledge and a resolve to enforce the regulations…It really depends on the leadership, that’s why he should be above any matters involving conflict of interest.” (P025_MP). Leadership influencer and support - applied in Central Sulawesi

“We have a quality assurance division to ensure pharmaceutical services are correctly delivered. We have many tools for supervising and reporting whether services are correctly provided or not…Home care needs to be done once a week, and every week 5 Patient Medication Records (PMR) need to be filled out…we have records of how many hours spent for patient consultations…we learn something new every time, we have an update training every 3 months minimum. Our skills are up to date, the system is good” (P01_FP). System of quality assurance - applied in Chain Pharmacy