| Objective:The purpose of this study is to systematically evaluate social insurance related problems in implementing essential medicines policy in China and to study intervention strategy from the perspective of social health insurance. Empirical study which retrospective evaluate the policy effect was carried out in order to measure how essential medicines impact medicine use in primary health centers without adequate intervention from social health insurance. Stakeholder analysis was carried out to study the problems in policy formulation and implementation. On the basis of quantitative and qualitative analysis we propose intervention strategies.Method:Literature review, stakeholder interview, and prescription analysis were used in this study. Literature review was used to identify the existing problems of social health insurance in implementing essential medicines policy. Quasi-experimental design was used to retrospectively evaluate policy impact of essential medicines system without effective social health insurance's intervention. We use this strong design and segmented regression to estimate the change inlevel and trend of medicines use indicators. We use stakeholder interview to describe the position, attitude, power and impact of stakeholders in health-insurance related policy intervention and to study how stakeholders influence policy formulation and implementation.Result and ConclusionMany problems occurred in the essential medicine policy's implementation. The mains issues are the unchanged fee-for-service payment schemes, the unsatisfactory reimbursement rate for essential medicines,unreasonable pricing, and inefficient tendering and procurement. In most areas, social health insurance system does not effectively cover outpatients'cost. Hence, essential medicines'expenditure was not covered by social health insurance schemes. Secondly, social health insurance schemes had not give priority to the reimbursement of essential medicines. Essential medicines are reimbursed at similar rate compared to other medicines. Thirdly, as a payer for medicines cost, social health insurance system had not managing key policy components including medicines selection, pricing, tendering and procurement. At last, social health insurance system as a payer wasunable to control rational medicine use of essential medicines.Without adequate intervention from social health insurance system, the essential medicines policy in Hubei yield mixed policy effect. We use interrupted time series design and segmented regression analysis to study and estimate the policy effect. We retrospectively study the prescription from January 2009 to July 2011. It is estimated that the policy intervention increase the use rate of essential medicines to 92.109%, raised by a policy effect of 36.753%. After the intervention, the average cost per prescription was 31.095 yuan, down by 13.448 yuan had the policy not implemented.However, the positive policy effect had not extended to all indicators. The policy had less effect on the use rate of injection, the use rate of antibiotics, and the average number of medicines per prescription. The change of level and trend of these three indicators were less considerable or statistically insignificant. Other negative policy effect may exist including the increase of outpatient and inpatient service utilization of hospitals, the decreasing role of primary health care facilities in curing disease, and the increasing cost in health care seeking among patients.We found by stakeholder study that 11 stakeholders had not involved in policy formulation process. While non-government sector and international organization had play significant role in policy formulation, major government department including ministry of health, ministry of finance, committee of development and reform, and ministry of human resource and social security had dominant role in policy formulation. The decision making was on joint consensus model which means a policy had to be endorsed by all major government departmentsbefore publication. As different government department had various powers in managing public issues, there are significant obstacles to formulate and implement intervention from social health insurance system. In addition, the vested interest of different government department induces self-seeking behavior among government department. While the social insurance system cares most of sustaining the funds of social health insurance schemes, the ministry of health advocate for maximizing the interest of public health provision system. A share interest among government department was lacking in implementing essential medicines policy.Policy recommendationFirstly, the intervention from health insurance system must be political feasible. Politics strategies for social health insurance authority include (1) strengthen the link to powerful but neutral government department; (2) gain support from national pharmaceutical companies; (3) gain support from mass media; (4) strengthen corporation with research institute on study policy effect; (5) persuade provincial government to increase pilot program; (6) support the existing pilot policy that deemphasize the link between health facilities and health bureaucratic system such as the separation of medicine and health care service and the separation of powers in hospital management; (7) impede policy proposal that only maximize the power and resource of health bureaucratic system. Secondly, a shared value should be established among government department. For the central government, accountability should be introduced in order to push government department in achieving health related goals rather than their own interest. Careful policy evaluation system should be designed by independent professional institute in order to obtain unbiased evidence.Policy evaluation should be carried out by a third party organization.Thirdly, we recommend the health insurance authority establish a new incentive model which reward physicians to protect the health of patients rather than made them rely on government's subsidy. Secondly, we recommend health insuranceusing a new payment schemes for essential medicines to replace the fee-for-service scheme. Our third recommendation would be on patients'health resource utilization control. Patients' medicines reimbursement should be subject to which provider he chooses. Our last recommendation would be on control medicines price and procurement. Social health insurance may intervene in the essential medicines pricing and procurement in order to yield better policy outcome. Innovation and drawbacksThere are two major innovations in the study. The study is the first policy intervention study of China's pharmaceutical policy using interrupted time series design and segmented regression. The study design is a strong alternative to randomized control trial which is rarely possible in health policy research. The use of this method successful addresses most validity threads such as historical influence and materiality. By evaluating a sequence of the outcome variables, the conclusion is reliable.Secondly, the study is the first of its kind which extensively study policy formulation and stakeholder's influence. Using theories of policy processes and stakeholder analysis, we extend the policy analysis from problems in implementation to policy formulation.The limitation of the study is of two folds. Because of certain limitations, this study only analyzed part of the information on the 62000 prescriptions. Other useful information, such as the patient information, diagnosis, treatment, and drug reimbursement had not been analyzed. Therefore, the result of the study is constraint and is unable todescribe detailed policy impact on patients'health outcome. Secondly, the result of the interest groups and their influence on policy formulation and implementation maybe suffer from subjective judgment. |
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