| Background and Current SituationGoing through 30 years of marketization reform process in China, the economic has been developed rapidly, however, a phenomenon is widespread in the medical field, that "medical treatment is difficult and expensive", and that prominent particularly in rural areas, the existence of this phenomenon has affected the economic and social reform to advancement continually. March in 2009, the State Council executive meeting adopted the To Deepen Medical and Health System, which marks the official launch of a new round of medical reform, the program put forward a sound national basic health system, and to establish a national essential medicines system around the national basic medical care health system, the implementation of essential medicines system has become a hot health policy currently.To line with the implementation of national essential medicines system, series of the supporting policies and regulations were introduced consecutively from national ministries. By the end of 2010, that have been issued involved the selection of essential medicines list, price limits, quality control, and bidding documents, from March 15,2010, the pilot districts and counties began to implement essential medicines system at primary health facilities in Shandong Province.The development of the essential medicine list is a combination of population characteristics and the light of international experience in medicine, the state identified a total of 307 species list, Shandong Province added 216 drugs. There were 27 pilot districts and counties to implement essential medicines system at primary health facilities in rural areas around Shandong Province. The main measures included the sale and use of directory medicines only, the abolition of drug price addition, improved reimbursement through the new rural cooperative scheme, supply channels unchanged.Research Significance and ObjectivesEssential medicine system in Shandong Province have been implemented in the pilot primary health service system, and how well the implementation of the system, can alleviate to some extent from the "medical treatment is difficult and expensive" phenomenon, can balance the relationship between various stakeholders effectively, can meet whole objectives of policy, which requires evaluation of essential medicines system. To explore the effect of essential medicines system implementation in pilot areas, a comprehensive research of essential medicines system implementation is necessary, which is very important in the process of construction of essential medicines system and the overall promotion of sustainable development.There were three main purposes of this study, the first one was to define the policy effects scope of the essential medicines system in theory, and select evaluation methodology of the policy; The other purpose is that through empirical research in the pilot district and county of Shandong Province, in which implementation of essential medicines system, to make the policy effect clearly, and to analyze the status and problems of the essential medicines system; The third is to improve and perfect the essential medicines system, then to promote policy recommendations.Literature Review and Define Policy Effects ScopeSurrounding essential medicines, literature review was composed of three parts, recommendations by WHO, international and domestic research. World Health Organization for the recommendations to the national drugs policy, including the selection of essential medicines, affordability, financing, supply system, drugs control, rational use, drug research, human resources development, monitoring and evaluation, summary of policy was made in the article on brief; international research related to measurement methods of Health Action International (HAI) and International Network for Rational Use Drugs (INRUD); There was seldom systematic study around the new essential medicines system in China, and most of the journal articles were discussion.Health policy belongs to state public policy; the article describes the content of public policy and procedures, Hofferbert's policy evaluation model and the commonly qualitative and quantitative methodologies. Progress of health policy evaluation shows main points to current policy evaluation, considering the trends of essential medicines in rural Shandong Province, the status of the policy determined that qualitative interviews and quantitative analysis of before and after contrast are more appropriate.Following the international research system, the level of policy effects should be determined firstly, they are structure, process and outcome, and then to determine the effect areas by consulting experts' opinion, select the specific indicators in each area and content, at last then to define the policy effects scope, through which the policy implementation and the policy impact of essential medicines system in rural of Shandong Province were shown.Empirical Study DesignThe study used qualitative interviews and quantitative analysis of before and after contrast. The research programs include survey forms design, samples selection, sites implementation and quality control. Based on the different subjects for health facilities and the New Rural Cooperative Medical Scheme, four quantitative questionnaires and one qualitative interviews outline were designed respectively. The typical sampling method was used, Ju County and Laoshan District were selected as the sample areas, and then three township health centers were randomly selected from each sample area, each village clinic was selected respectively, in the health centers each of 100 prescriptions were collected before and after policy, interviews 31 health workers at all levels. For data processing, EXCEL and SPSS software were applied, which all employs quality control strictly. Site survey was implemented during August and September in 2010.ResultsBased on policy effect system, the results are shown according to Laoshan District and Ju County respectively, the seven aspects research result are following below.(1) Equipment of essential medicines. Proportion of equipped essential medicines in health facilities were 64.6% and 62% around Laoshan District and Ju County respectively, proportion of equipped western medicine in list is higher than traditional Chinese medicine, proportion of equipped in the national list is higher than the provincial supplementary list, the main reason of absent essential medicines are that primary health facilities with no corresponding medical items and doctors without habits, some clinical medicines such as pediatric drugs, specialty drugs, homeostatic drugs are needed urgently.(2) Rational use of essential medicines. There are three indicators in article, average number of drugs per encounter, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed, which in turn Ju County the three indicators are reduced, unchanged, unchanged, and Laoshan District followed by increased, increased, unchanged.(3) Price of essential medicines. According to the situation after and before the implementation of the essential medicines system, part of the core essentials medicines price has fallen to zero proportion addition. Individual product prices in Laoshan District are higher than the national limit, all Ju County is lower than the limit, and specifications are different vastly in both areas.(4) Essential medicines supply system. The results come from interviews, which all current supplier firms are regional commercial companies, purchasing frequency variable, uncertain time of payment, and so on.(5) The impact on Health Center. After the implementation of essential medicine system, Ju County Health Center medical income change smoothly, Laoshan District the trend showed a sharp increase; Ju County drug income declined significantly, while the Laoshan District growth significantly; financial compensation is to maintain the normal operation of health facilities necessary conditions.(6) The impact on patients. The number of outpatient and inpatient in Ju County health centers did not change significantly, that average drugs cost of outpatient and inpatient per time decreased significantly; Laoshan District, the number of outpatient and inpatient increase rapidly, average drugs cost of outpatient per time increased slightly.(7) Impact of the New Rural Cooperative Medical Scheme. After the implementation of essential medicine system, the number of out-patient compensated in Ju County change little, while increased in Laoshan District; OOP of patient are reduced in Ju County, Laoshan District remain unchanged; that essential medicine system impact on the Fund is limited, the Fund is running relatively smoothly.At the end of results, policy structure issues of samples were shown.Conclusions and Policy RecommendationsBased on results in empirical research, this part is to discuss policy structure; process and outcome level respectively, corresponding to the selection of essential medicines, compensation to health facilities and drug costs, which focused on drug costs.(1) Policy effects of essential medicines system in Laoshan DistrictAt policy structure level, the current medicines list is unreasonable. Laoshan District did not implement the integrated management of rural health, so essential medicines system is only implemented in township Health Centers, medical care in village health clinics without compensation. Before the implementation of the system, medical needs are restricted, chronic disease spectrum is dominated in the areas.At policy process level, Health Centers use list products since March 15,2010, canceled about 15% of addition drug prices and improve the new rural cooperative scheme compensation. The local governments financial for implementation of essential medicines are a key role.At policy outcome level, medical income and drug revenue of the heath centers grow after implement of essential medicines system. There are signs of medical needs release at the same time, this study suggests that increasing the number of prescription drugs is also a type of medical needs release form. At the same time, outpatient drug cost per times increase slightly. Increased compensation for passengers NCMS, essential medicine system is a limited extent for new rural cooperative funds to run. In addition, the relationship between village clinics and health centers become more competitive after policy implementation.(2) Policy effects of essential medicines system in Ju CountyAt policy structure level, the selection of irrational drugs led to low proportion of primary organizations. Ju County implements integrated management of rural health, rural two primary agencies implement essential medicines system, and residents could be compensated in both agencies. Data show that the medical needs of areas have been released.At policy process level, since May 1,2010, the two health facilities in the country use the national and provincial products and maintain the original supply channels, removal price addition, and to adjust the compensation proportion of new rural cooperative scheme. Province, city and county levels of government financial support to primary health system is the key to essential medicines.At policy outcome level, township health centers medical income remained steady change and significant downward trend in drug income after the policy. Outpatient population change stable, due to the current list narrow hospitalized patients are force d upward; prescription drugs tends to reduce, the number of species is the performance of the rational use of drugs. Both drug costs and OOP reduced significantly. NCMS change little in compensation for passengers. The essential medicines system has a limited impact on running of new rural cooperative fund. The policy strengthen integrated rural health network.On the perspective to improve and implement the policy continuously, the recommendations of the research as follow, the first one should be based on the medical needs of residents and the status of primary health care services, then to establish scientific and standardized selection procedures and selection essential medicines approach, at the right time to adjust and change the List; Second is to further improve health sector compensation mechanism; Third, to achieve the desired goals of control medicines cost, payment methods and medical system reform, the number of drugs and control structure elements are necessary; Last suggestion is to enhance integration of rural health system, which is a an important condition for implementation of essential medicines system effectively.Research Innovation, Defect and ProspectFrom a theoretical and empirical perspective in this paper, it is the first time in domestic to define the policy effects of essential medicines system; and proposed that prescription drugs increased is a form of the medical needs release; and notes a research framework of essential medicines system evaluation. One of the shortcomings is that implementation time of the essential medicines system was shorter, policy effectiveness and impact have not been fully released, some of the research findings need further verification; second, the existing methodology is not able to completely remove the relevant confounding factors. To this end, researchers still need to promote in the light of essential medicine system based on the construction of supporting policies and related systems.
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