| [Aim] Study tools were designed based on summarizing foreign advanced experiences and reviewing domestic and foreign drug policies. Field investigation were carried out in Anhui province so as to understand current implementation situation of essential medicine system in county hospitals and observe the differences of policy effect between those hospitals that execute "zero markup" policy and those not. Influence factors of essential medicine policy implementation effect were analyzed from hospital management, doctors, patients and external supporting policies aspects. Based on the results of theoretical analysis and field survey, policy suggestions were present in order to help essential medicine policy to achieve sustainable effect in Chinese county level hospitals.[Materials and Methods]Research approach and filed survey tools were designed in the combination of literature reviewing, expert consultation, focus group discussion and field preliminary survey.(1) Literature ReviewingSustainability of health policy theory was the mainline that run through the whole research. Implementation effect of essential medicine policy and its influencing factors were compared to the advanced experience of foreign countries. We summed up the domestic problems in the implementation of the policy..(2) Field survey data analysis①36drugs that treat8common disease entities in county hospitals were selected as Survey Drug Catalogue. Ten county hospitals in Hefei, Wuhu and Ma Anshan cities of Anhui province were selected as research sites.②Outcome indicators include availability, affordability and rational drug use.③SPSS16.0was used to complete data statistic analysis. Descriptive analysis was used to describe fundamental status of hospitals, doctors and patients. Proportion or constituent ratio was used to express enumeration data, chi-square test or Fisher exact probability was used to make a comparison, and a=0.05was set as the significant level. Influence factor of rational drug use of doctors was analyzed by multiple linear regressions. [Results](1) General situationTen county hospitals were investigated, and5of them have implemented the "zero markup policy" of essential medicines.5044disease entities prescriptions were selected and counted (including hypertension, diabetes, pelvic inflammatory disease and. children diarrhea), as well as2640medical records (including cerebral infarction, pneumonia in children, gallstone, cesarean section), and5640doctors’prescriptions were also included. A total of578prescribers and1064patients completed the questionnaire.(2) Availability of essential medicinesThe average storage proportion in county hospitals which implemented the "zero markup policy" was85.87%, and the proportion in those not was89.22%. And the difference between the two had statistical significance (P=0.038).(3) Affordability of essential medicinesThe county hospitals which implemented the "zero markup policy" of essential medicines had a proportion of30%medicines unaffordable, and those not had a proportion of37.22%medicines unaffordable.(4) Rational drug use①Institutions’rational use of medicinesThe proportion of the medicines with clearly marked patients got from the hospital pharmacies in the hospitals which implemented the "zero markup policy" was higher than those not (46.6%and37.3%respectively). The proportion of patients who were familiar with the medication doze in the hospitals which implemented the "zero markup policy" was lower than those not (75.0%and78.8%respectively). Compared with the hospitals which haven’t implemented the "zero markup policy", the average treatment time and dispensing time of the patients in hospitals which implemented the policy was longer, the numbers of prescription drugs and the actual numbers of dispensing were also higher.②Doctors’rational use of medicinesCompared the hospitals which implemented the "zero markup policy" with those not, the average drug numbers was higher (2.34and2.3respectively), the proportion of general name used was lower (96.8%and99.1%respectively), the average antibiotics proportion was higher (21.2%and18.26%respectively), and the proportion of essential medicines was higher (38.8%and34.03%respectively) for those four outpatient disease entities.Compared with hospitals which haven’t implemented the "zero markup policy", the antibiotics proportion in hospitals which implemented the policy was higher (21.37%and20.00%respectively), the proportion of injections was higher (87.58%and85.73%respectively), and the proportion of essential medicines was higher (65.5%and57.7%respectively) for those four inpatient disease entities.(5) Patients’ awareness and attitudes towards essential medicinesOf all the1064patients, only159(14.9%) have heard of "essential medicines", and the top three sources of knowledge was medical staff (45.3%), television (39.6%) and the network (27.0%) respectively.19.2%of the patients showed that they were unwilling to use the essential medicines if doctors recommended, and the reason was mainly not trust the therapeutic effectiveness of essential medicines(87.7%), or the quality of essential medicines was difficult to guarantee(26.5%). There was no relationship between the patients’ demographic characteristics such as age, job, education degree, health insurance types and their awareness of essential medicines and willingness to use essential medicines.(6) Influencing factors of rational drug use among doctorsThe drug number of doctor’s prescriptions would influenced by their degree and profession; the proportion of general name used in doctor’s prescriptions would influenced by their degree, profession, educational and training experiences and their attitudes towards essential medicine policy. Doctors’age, degree and profession were the influencing factors of the antibiotics proportion. The proportion of injections used in the prescriptions was affected by doctors’ degree and profession. Furthermore, doctors’degree, profession and pharmaceutical expertise would influence the proportion of essential medicines in the prescriptions.[Conclusions](1) Generally the availability of essential medicine was high in county hospitals. In county hospitals that implemented "zero markup policy", the availability of essential medicine was lower than those not implement the policy.(2) Affordability in hospitals that implement "zero markup policy" was obviously better those not implement the policy.(3) Compared to the hospitals that not implement the "zero markup policy", in hospitals which implement the policy, the drug number was higher, the percentages of drugs prescribed by generic name was lower, the antibiotic, injection and essential drug proportion were higher.(4) Doctor’s age, degree, profession, educational and training experience, professional drug knowledge could affect the rationality of their prescription.(5) The publicity degree of essential medicine policy was inadequate for patients.(6)The government did not carried out stringent regulatory on hospitals and the compensation to hospitals was far enough. County hospitals haven’t established a competitive employment mechanism so there was no incentive for doctors to use essential medicines.[Suggestions](1) Establish a scientific and practicable essential medicine list for couty hospitals Unify the drug selection standards and adhere to the principle of " suitable, economical and effective"; ensure the openness and comprehensiveness of the selection body; take area differences into consideration.(2) Ensure the timely distribution of essential medicine for county hospitals Set up a balanced pricing mechanism and ensure the enthusiasm of medicine manufactures; relize the balance between low price and high quality in the process of centralized bid procurement; manufactures who win the bidding can take the responsibility of distribution so as to cut down intermediate links.(3) County level hospitals change concept and use essential medicine as first choice County level hospitals should change the idea of "drug-maintaining-medicine"; reinforce delicacy management and enhace operating efficiency; draw up measures to promot the preferential use of essential medicine; define the essential medicine allocate ratio and assessment programs for doctors; strengthen the prescription check and surpervision among doctors.(4) Enforce training and standardize prescription pattern among doctors Reinforce education and examination of relevant knowledge on essential medicine among doctors, perfect motivation and restriction mechanism; establish prescription management department and impose restrictions on their prescription pattern; intensify prescription selective inspection and comment; set up a remuneration system that can reflect the labor value of doctors; build a competitive personnel system and an inspirational allocation system.(5) Government should commit to their responsibility in the policy. A new type of financial compensation mechanism should be built. Diversified compensation channel should be formed such as health insurance fund and hospital risk fund compensation, and establish.(6) Optimize the reimbursement policy and bring the role of health insurance departments into play Pay line for essential drugs could be cancelled and in areas where conditions permit the100%reimbursement for hospital medication drugs can be implemented. In county hospital, the DRGs prepaid system for inpatient can be carried out.[Innovation and deficiency](1) InnovationIt’s the first time to introduce health program sustainability theory into the study of essential medicine policy implementation effect in county hospitals both home and aboard. There was no study concerning the corresponding relationship between a doctor’s condition and his or her prescription by now. We integrated surveys on doctors with their prescription records for the first time. The basis for the analysis of essential medicine policy implementation effect from both theoretical and empirical aspects, thus enhanced the credibility of research results, also get core influence factors by comparative analysis.(2) DeficiencyOnly three cities in Anhui province were selected as field test sites, so the results may be not able to reflect the whole status quo in the whole country. So comparisons between different provinces should be made in the following studies. Our study included all the possible influence factors comprehensively from three aspects (policy itself, main policy bodies and external supporting policies). However, thorough analysis on medical insurance and government compensation, two core elements of essential medicine policy, haven’t been done, and this deficiency should be remedied in the future studies. |
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