The Status And Effect Study Of The Policy Implementation Of Essential Drug In Chinese City Community Health Institutions

ObjectivesThe study was to analyze the status and effect of the policy implementation of the community essential drug system (EDS) and the rational use of drug (RUD) based on the data of the three-year continuous surveying to the community health service institutions (CHIs) in 36 key contact cities in China during 2007-2009. It was also to sum up the experience and achievements, reveal the challenge and key issues of these policy implementations and put forward the policy recommendations accordingly in order to provide evidence to improve the EDS and strengthen the community health service system.MethodsA survey of all community health centers (CHCs) and community health stations (CHSs) were done in 36 key contact cities which were chosen by the areas, population and social economical level based on the literature review. Totally 2408 CHCs and 5870 CHSs were investigated.2 CHCs and 2 CHSs were randomly selected in every district in every city, and 100 the prescriptions of September for each of these chosen CHCs and CHSs were investigated. Totally 230800 prescriptions were sampled during 3 years.The database was set up by EpiData and the data were analyzed by SAS8.0. Both descriptive analysis and inferring analysis were applied. Chi-square test were used for the rate comparison of the enumeration data and nonparametric test were for the skew-distributed measurement data by a=0.05. The synthetical analysis was done by multiple linear regression analysis, generalized linear regression analysis and clustering analysis etc., and TOPSIS method and RSR method as well.Results1. The present situation of the policy implementation of essential drug system (EDS) in the CHIs The community health service system building has gradually entered into the stage of the connotation construction through the community health service system building in 36 cities in 3 years. The fiscal investment at the different levels has been increased year by year, and the number of the CHIs has been increasing steadily, the rate of the complete construction of CHIs was 90.45%; the setup principle of CHSI was mainly by the government (75.75% of CHCs and 64.73% of CHSs were by the government), meanwhile multi-holders were also encouraged. The difference allocate fund (66.84%) was main for CHCs while the difference allocate fund (38.93%) and self-earning and self-expending (42.64%) were main for CHSs. The rate of first visiting CHI by patient was 33.33% while the rate of CHI implementing of two-way referral system was 95.83%; 36.01% of CHC and 43.9% of CHS carried out the separate management of income and expenditure in two lines; the rates of CHC and CHS designated by health insurance were 95.46%nd 60.82% respectively. The basic medical health service efficiency and utilization rate of CHI were promoting steadily in these three years.The key policy of EDS implementation trended well. (1) The coverage rate of EDS was obviously increasing in three years and it was 62.5% in 2009; the kinds of essential drug list (EML) was decreasing, the average kinds of EML were 490 (289 kinds for western medicine, and 201 kinds for Chinese patent drugs); the clustering analysis of drug allocation showed that the 400-600 kinds of drug were proper in drug allocation for CHC. (2) The rate of CHI implementing central drug purchase, uniform drug allocation and sale by the government was increasing and it was 66.15% in 2009. (3) The rate of CHI implementing the zero difference between the drug purchase and sale was increasing, too, and it was 33.57% for CHC and 55.34% for CHS. The kinds of drug allocation was decreasing,440 kinds were for CHC and 291 kinds for CHS, of which 274 kinds were for CHC and 174 kinds for CHS in implementing the zero difference between the drug purchase and sale, and they were 62.21% and 59.97% of all kinds of drugs for CHC and CHS respectively. (4) There were only 10.29% of CHC and 10.61% of CHS implementing the separate management of medicine and pharmacy.2. The rational use of drug (RUD) of CHIThe RUD of CHI trended well in 3 years, but there was still the irrational use of drug (IUD) phenomenon. The average kinds of drug in a prescription of CHI were 2.4-2.6 for CHC and 2.4-2.5 for CHS, which were obviously higher than the standards of WHO (less than 2 kinds) and other countries. The percentages of antibiotics prescription were 41.3%-45.1% for CHC and 34.9%-45.0% for CHS, which were high than the standard of WHO (less than 30%), and the percentage of encounters on antibiotics with two or more antibiotics prescribed were 10.3%-13.5% for CHC and 10.7%-11.7% for CHS. The percentages of injection prescription were 33.0%-35.4% for CHC and 36.8%-42.1% for CHS, which was higher than the standard of WHO(less than 20%). The percentages of hormone prescription were 7.1%-8.2% for CHC and 6.7%-7.1% for CHS. The cost of the community prescription was increasing in three years. The average cost of community prescription was 62.5 Yuan for CHC and 54.5 Yuan for CHS. It still need be further controlled rationally.The multiple linear regression analysis and generalized linear regression analysis showed that the influential factors for the RUD of CHI included "the location of CHI in the east, middle and west", "the holders and characteristics of CHI", "the implementation of the separate management of income and expenditure in two lines", "the zero difference between drug purchase and sale", "the quality of general practitioners allocation", "the incomes of drug" and "the incomes of health insurance", "the numbers of outpatient and discharge patient", "the number of bed-day" and "the prescription antibiotics and the combined use of antibiotics"3. The effect of the policy implementation of EDS in the CHIsThe study is based on the hypothesis of the EDS implementation can promote the accessibility and rationality of RUD, and the effect of implementation of EDS is evaluated by the evidence-based analysis. (1) The implementation of the EML can normalize the doctor's prescription behavior. The average kinds of drugs in EML were 444 kinds, the clustering analysis showed that there was 38.39% districts were more 500 kinds of drugs in EML, which was hard for the pooling management. (2) The accessibility of basic drugs has been guaranteed by the implementation of central purchase and uniform allocation and sale by the government in the CHI. The income and expenditure of the CHIs which implemented this policy were higher than non-implementation CHIs, the health service supply and drug income have not been influenced, and the prescription drug use was very rational. (3) The burden of drug use was reduced by the implementation of zero difference rate system to change the compensation system and operation system of the CHI. The districts which implement this policy was 74.77% of all investigated districts, thus this policy has been carried out in place. The numbers of the outpatient and discharge patient of the CHI implemented this policy were higher and the bed-day number was lower than non-implementation CHIs; the percentages of fiscal subsidy and health insurance income in total income were higher; the percentage of drug income in outpatient income and the average outpatient cost per visit was higher respectively. The prescription drug use was rational, but the prescription cost was relatively higher. Compare the CHIs which did not implement this policy in 2008 to those which implemented it in 2009, the health service quality and efficiency in the CHIs which implemented this policy was obviously promoted, the percentages of outpatient and inpatient drugs were decreasing, and the rationality of prescription drug use trended well. (4) The policy of the separate management of medicine and pharmacy was still limited in a small scope. Although the structure of drug income and outpatient cost were improved and prescription drug use was more rational in the implemented CHIs, but the visits of the CHIs decreased.The effect of implementation of the EDS relevant policy:(1) The situation of health service supply and utilization were good for the CHIs which implemented the separate management of income and expenditure in two lines, and the percentage of fiscal subsidy were obviously higher than non-implementation CHIs; but the percentages of outpatient drug income and outpatient cost per visit were relatively higher; the prescription drug use was relatively rational, but the cost per prescription was relatively higher. (2) The outpatient visits and inpatient patients were higher for the CHIs designated by the health insurance than those not designated; and the percentage of health insurance income for these CHIs were increasing in three years, and the outpatient cost per visit was decreasing, and the prescription drug use was more rational.4. The comparison of the EDS implementation in the CHIs of the cast, middle and west(1) In the aspect of the system construction, the percentages of the CHIs implementing zero difference rate system were 33.57% for the CHC and 55.34% for the CHS, and the order for the percentages of the CHIs implementing this policy in different areas was:the east> the middle and the west; and the order of the percentages of the CHIs with the subsidy in different policy was:the middle (86.52%)>the east (66.90%)>the west (55.28%). (2) In the aspect of the health service supply, the order of the average daily workload and utilization in outpatient and inpatient of the CHIs implementing this policy in different areas was:the east> the west> the middle. (3) In the aspect of the income and expenditure and outpatient cost, the order of percentage of the financial subsidy in the CHIs implementing zero difference rate system for the drug was:the west (34.95%)> the middle (29.56%)> the east (26.86%); the order of percentage of the health insurance income was:the east (63.85%)> the west (36.83%)> the middle (28.64%); the order of the percentages of the drug income in outpatient income was:the east (75.25%)> the west (61.56%)> the middle (50.21%); the order of the percentages of the outpatient cost per visit was:the east (138.37 Yuan)> the middle (97.08 Yuan)> the west (76.30 Yuan). (4) In the rationality of the prescription drug use, the percentage of the antibiotics and the combined-use antibiotics in the east was obviously lower than those in the middle and the west.(p<0.05); the percentage of the combined-use prescription was obviously higher in the west (14.43%), and the percentage of the injection was obviously higher in the middle (48.47%); the order of the prescription cost in different areas was:the east (71.03 Yuan)>the middle (71.33 Yuan)>the west (55.55 Yuan).The analysis of TOPSIS and the RSR showed that the order of the synthetical effect in the different area:the east> the west and the middle, and the difference for the CHS was large than that for the CHC.Conclusions and recommendationsThe effective connection between the community health service system and the EDS were the win-win combination. The implementation of the EDS can both secure the equity and accessibility of the essential drugs and advance the sustainable and healthy development of the community health service.But the EDS still confronted some urgent unsolved key issues:at the top level design of the EDS, the system need be strengthened, and the content need to be clear and refined; at the level of the policy implementation in the community, the coordination of the EDS need be promoted, and the relevant matching policy for all implementation links need be improved. The EML need be adjusted rationally; the coverage of the central purchase and uniform allocation and sending need be enlarged, and the purchase and allocation system need be standardized; the scope of the zero difference rate system was limited and the corresponding compensation and allocation system need be improved; the relevant matching policy of the implementation of the separate management of medicine and pharmacy need be improved, and the condition for the overall implementation of this policy has not been met; there existed the irrational phenomenon for the community prescription drugs, and the prescription cost need be controlled; the essential drug system in the east, middle and west can not reflect the principles of having stress of their own and guiding by types.At the same time, there existed some key links which affected the implementation of the EDS in the community health service development:the self-earning and self-expending were main for CHIs, and the scope of implementation of the separate management of income and expenditure in two lines was limited in CHIs; there was lack of the systems of first visit of the CHIs and two-way referral; the community medical personnel quality need be strengthened, and the personnel distribution system need be reformed; the compensation system of health insurance to the CHIs need be improved, and the utility of medical insurance need be improved; there was lack of the performance assessment and the encouraging system..Thus the recommendations were as followings:to stick to the leading position of the government, strengthen the top level design, and improve the essential drug system; to stick to the public interest and the benefit of population, and synthetically advance the implementation of the EDS; to improve the matching policy and deepen the synthetical reform of the community system mechanism; to strengthen the connotation construction, and structure the system of long-term effective development of the community EDS.The innovation and limitation of the study(1) The innovation of the study lies in that it is based on the comprehensive survey indicator system and the full and accurate data, and the time span of three-year continuous surveying is just before and after the policy implementation of community EDS and RUD, and the investigated CHIs accounting for approximately 40% of the total number of CHIs in China. It is the first time to do the data collection at this breadth and depth in China, and the conclusions have important reference value for the health policy decision-making.(2) The study is inadequate on the comparability of research results with international similar studies, and it has some limitations on the extrapolation of the research conclusions, and there needs a further qualitative research by in-depth interview.