| BackgroundIn order to secure residents'essential needs for drugs and decrease their drug cost burden, Chinese Health Ministry and other eight ministries issued the notice of establishing national essential medicine system (EMS) on Aug.18th 2009, the newly essential drug list (EDL) is published as well. The notice sets that thirty percent of the government-run community health services (GCHS) and government-run primary health care institutions (GPHCI) in rural areas should be covered in 2009, including biding and procuring essential drugs publicly on the Internet, delivering essential drugs centralizedly, and using essential drugs only without mark-up in the covering hospitals, and that EMS should be built up preliminarily in 2011.Before the publish of the new healthcare system reform plan, some regions have implemented the zero-slip policy and revenue-expenditure accounting separately policy, in which some issues were released, such as financial subsidies being un-enough, large proportion of drug revenue, low storage and usage rate of essential drugs, low investment by government and inadequate compensation mechanism, etc.After the plan being published, regional reform policies were issued. The EMS was carried out in some provinces as well, which decreased drug price to some extent, benefited the residents and developed the health insurance. But some problems were still unsolved, for example, how to compensate the PHCIs.After the notice, how the local act? How they design related policies and what are the outcomes? Are there any other issue? What are the causes? How to resolve them? Are there any good experiences to learn? All these puzzles are worth studying seriously.In addition, the notice sets that the EMS is implemented in the GCHSs only in the early periods. However, the non-government-run community health services (NCHS) accounts for the majority. Thus, to cover all the PHCIs both in urban and rural areas in 2020, it is necessary to implement the EMS in the NCHSs. How to achieve this goal without enough funding? How those institutions try and what about the outcomes? What policy support is needed? All these queries are also worth investigating.Therefore, it is necessary to investigate the implementation quo in CHSs, monitor their operations, summarize good experiences and shortages, in order to carry out EMS totally and improve it continually, to secure inhabitants'essential medicine needs and let the primary health for all come true.ObjectivesThis study will analyze the effectiveness, issues, difficulties and reasons for them after CHSs implementing EMS, through typical field investigations and analysis of regional design of the EMS, build a compensation model, to measure how much to pay for the CHSs implementing EMS by the government and how much to finance from the community under different mechanisms, and review related literatures to grasp the development level of NCHSs, based on which to propose the necessity, premise and security for them to implement EMS. All these studies will be under the outline of the healthcare system reform plan. The final purposes of these studies are to propose suggestions for the CHSs running the EMS, to give recommendations for the government further improving the system, and to provide a reference for a full swing of the system.Contents and MethodsMethods used in this study including literature analysis, questionnaires, insider interviews, prescription survey, referring to secondary data, and model constructon.The study collected fully and analyzed detailedly the provincial, municipal, district documents appropriate to key contact cities to summarize the main modes of every part of the EMS through searching government websites, search engine-Baidu and Google, mastered the implementation quo of EMS in CHSs, such as the modes, effectiveness, problems, reflecting in the change of outpatients, price of health services and drugs, revenues, rational use of drugs in CHSs, etc., through basic information surveys of the agencies, qualitative interviews with officials from Health Bureau, Health Insurance Funding, Drug Administration, Finance Bureau and other relevant departments, leaders and doctors of CHSs, collection of secondary data and prescription data, established an outpatient demand function of community health service to predict how much is needed to compensate the CHSs for loss because of zero-slip policy and how to finance to balance the health insurance fund under different mechanisms after full coverage by EMS, using data from the National Health Financial Annual Report 2001-2008, China Statistical Yearbook 2010, China Labor Statistical Yearbook 2010, China Total Health Expenditure Report 2009, and analyzed the situation of CHSs and policy environment for their development, proposed the necessity, premises and guarantees for them to execute EMS, through policies and literature analysis combined with interpretation of medical reform theory.ResultsThe study includes four parts. The main results are as follows:The first part analyzed the regional policies, summarized the main modes of every section of the EMS. (1)There are three modes in list management divied by list numbers complemented and where the adding right on:①Two-list mode, represented by Shandong Province, which distinguish urban and rural lists;②Autonomy zoom mode, represented by Guangxi Province, Shenzhen city and Xiamen city, the addition right in which is delegated to the prefecture-level cities;③The conventional mode, adding a single list by provincial health department. (2)There are three modes in bidding divied by the main standard:①"The lower price is the better" mode, used by most provinces;②"Bidding by the quality level" mode, represented by Jiangsu Province;③"Double envelopes" mode, one envelope represents quality, the other one represents price, applied in Anhui Province. (3)Delivering aspects:①"Shanghai Songjiang" mode, in which essential drugs are produced and delivered by only one large pharmaceutical company;②"Beijing Community Medicine delivery" mode, commissioned the secondary distributors to execute by the first distributors;③"Zhejiang Medicine Community" mode, a community made up of a number of enterprises who invested to the joint and shared the responsibility for delivery. (4)Zero-slip compensation aspects, divied by who compensate and compensate what:①"Revenue-expenditure accounted separately" mode, which compensate the gap between revenue and expenditure of all, not only in drugs;②"Government purchasing drug services" Mode;③Compensating the loss from the zero-slip policy by finances;④Compensating the loss from the zero-slip policy by insurance funds;⑤Compensating the loss from the zero-slip policy by finances and insurance funds;⑥Others, such as prescription service fees and raising prices of medical services.The second part introduced three typical models, and analyzed the effectiveness and main problems of the models. (1)Overview:①Tianjin model:one year "537+10%" drug zero-slip sales experience; adjusting 190 species from original directory based on national list, but maintaining the same number; equipping the catalogue on-demand; unity of bidding city-widely, in accordance with the principle that "quality first, supply second, price third"; delivering by a main distributor and a spare when necessary, implementing the two-vote system and forbidding the second bargaining; co-compensating 15% of the total control as the loss from zero-slip sales.②ubei model:2 months transition; adding 118 species; equipping all of the national directory compulsorily and the addition on-demand; unity of bidding province-widely to decide the catalogue, with three lists-one showing on the net directly with price upside down the state guidance price, one hanging on the net with an entry price and the other one bargaining by experts'evaluations; unity of bidding province-widely to determine distributors; procurement traction is on the web platform publicly, but second bargaining organized by the health department of county is allowed; compensating 15% of the purchase price as the loss by the financial sector.③Chongqing Yuzhong model:one year zero-slip sales experience of 730 species; no replenished species, all drugs including herbs being sold without mark-up; equipping species on-demand; unity of bidding of the national list city-widely with 6 specifications of a product and the lowest being purchased preferably, while other drugs being procured voluntarily; essential drug usage to the amount of all should be more than 60%; compensating 15% of the drug cost and 30% of the herbs cost as the loss from zero-slip sales by finances and Urban-Rural Resident Health Insurance (URRHI) funds together in Yuzhong district, while, in other parts of Chongqing doing by pharmaceutical services fee paid by the URRHI, the norm of which is,40% of the drug revenue-expenditure-gap divided by all the PHCIs'attendances city-wide then multiplied by the hospital's attendances; constructing and equipping all the CHSs standardizedly; supervising and controlling the hospitals through an information system. (2)Status analysis:①Usage and equipment of essential drugs are not in full compliance with local regulations in implementing institutions, while institutions un-implementing have used most of the EDL but the usage is low. Reasons including:the national list cannot meet the demand; inappropriate addition list for some regions; competition; long-term drug abuse; profit-divan; some of requirements are unreasonable; oversight.②Irrational drug use is exasiting in some areas. Reasons including:training and publicity for drug use is not in place; difficult to change long-term habits; long-term abuse leading to a vicious circle.③Outpatient rose in most implementing hospitals; rose first then decreased in few hospitals; change less in the un-implementing agencies. Causes are as follows in turn:the EMS reduced the burden on drug cost; drug catalogue cannot meet the needs in some areas; promotions are applied by un-implementing agencies.④Level of charges for one outpatient is down in implementing agencies in Tianjin and Wuhan, while that in Chongqing and un-implementing Yuzhong rose. Causes are below in turn: EDL makes prices of drugs down; Yuzhong compensation mode cannot prevent the mechanism of "drug-maintaining-medicine"; profit-driven nature of the un-implementing agencies continues.⑤Out-patient revenue ups and downs are different among regions and institutions, due to differences among EMS regulations, charge levels, outpatients and responds. (3)Major contradictions:①limited species of EDL between extensive needs; lagged national standards in supply chain between needs to balance the interests among parties;③compensation mechanism in balancing the needs financing enough money to maintain development for CHSs and preventing drug costs rising too fast;④needs for collaboration and interests game among sectors. The third part established an outpatient demand function of community health service, and measured (1)the outpatients and outpatient revenue, with average price of medical services unchanged, average reimbursement ratio increased by certain percentage and average price of drug decreased by some percentage; (2)the outpatients, percentage of average price of medical services needed to improve, and ratio of average reimbursement level needed to ascending by, with the growth rate of outpatient revenue unchanged and drug prices dropped a certain percentage; (3) changes of spending of health insurance funds and how much to fiance under (1) and (2) respectively, changes of outpatient revenue compared to the amount with the original growth rate and how much is indeed needed to compensate under (1), using outpatient data of CHSs, financial data and national economic data.The function is as follow:lnq=-5.4208-0.8104lnp+0.56931nyq is per capita outpatient needs per year of urban residents, p is out-of-pocket, y is per capita disposable income of urban residents. Correlation coefficient R2=0.990, model test p＜＜0.05, coefficient test p＜＜0.05.For (1) mode, if the avarage medical service charge in 2011 is the same as that in 2008, EMS are implemented in all institutions, average price of drugs is dropped 40% and health insurance reimbursement is increased to 70%, the outpatients will increase 120% and outpatient revenue will reach 23.612 billion yuan. The income will not reduce on the revenue growth rate of 2001-2008, but health insurance expenditure will increase 7.765 billion yuan, and the financing level needs to be increased 20 yuan per capita for urban residents. For (2) mode, if EMS be to implement in all institutions in 2011 with patient revenue no less in the growth rate of 2001-2008 (which will be 23.572 billion yuan), the average level of services charges need to increase by 20.95%, meanwhile, the ratio of health insurance reimbursement needs to increase to 66.58% to ensure that residents can afford. Then, compared with 2008, health insurance expenditure will increase 69.32 billion yuan, and the financing level needs to increase 16 yuan per capita for urban residents in 2011.The fourth part summarized the development status of NCHSs, and analysed the necessity, premise and guarantee for them to execute the EMS. (1)Policy environment:①tax-exempt policy under the non-profit orientation;②government subsidies for staff salaries, infrastructure and loss unavailable;③staffing not authorized by personnel department;④pharmaceuticals pricing slip differentially while medical services pricing free;⑤approval for setting institutions, set standards, public health subsidy being the same as the government ones. (2)Development Status:①being less community health service center (CHSC) than government-run ones, while being more community health service station (CHSS) than government-run ones;②being smaller scale and less human resources of CHSCs than that of the government, while the status of CHSS being in the contrary;③NCHSs providing comprehensively primary health care and public health services; quantity of services in NCHSC being less than and quality and efficiency of services being slightly worse than that of the government-run community health service center (GCHSC), while non-government-run community health service station (NCHSS) compared with the government-run community health service station (GCHSS) having their own advantages and disadvantages on certain indicators; providing the public health services selectively;④due to lack of government subsidies, just meetting the balance with a small surplus in finances;⑤patient satisfaction reaching a high level but slightly lower than GCHSs. (3) Necessity analysis:NCHS is an important component of the primary health care system (PHCS), which is the basis to fully realize the equalization of public health and the activator of PHCS. The EMS is consistent with the function of the CHS. What's more, well-designed EMS can attract more patients to CHS to see doctors, reduce the cost of CHS, promote rational drug use and improve the service level. Therefore, it is necessary to implement EMS in NCHS to make urban residents have access to essential medicines equally and enjoy the benefits of EMS. Implementing EMS in NCHS can also promote fair competition between CHSs and lead to a healthy development of CHSs. (4)Premise and guarantee:it is the premise for NCHSs to implement the EMS that adequate funding to ensure their survival; it is the guarantee for NCHSs to implement the EMS that policy environment is favorable and government responsibility is reliable.ConclusionsThis study summarized the main effects, existing problems, and inspiration of typical areas implementing EMS in the CHSs. Also, the study established an out-patient demand function of community health services, provided a basis on which the amount of compensation and level of health insurance funding were calculated in different compensation mechanism, and raised the neccessity implementing EMS in the CHSs. The main conclusions are as follow. (1)Main effects:①Regional plans are issued successively and implemented steadily.②Different modes and mechanisms are appeared in practice.③The drug prices and drug cost burden on patients are reduced.④Outpatients is significantly higher contrast over the same period former in the implementing agencies.⑤ealth behavior is changed, and risk of medication is reduced. (2)Main problems:①The regional plans and supporting files all over the country copy the national blueprint so that the guide role of the local plan are not strong;②Coordination between sectors needs to be strengthened; some complementary measures are not followed up.③National directory cannot meet the needs of urban residents, and the adding directory does not fully take the local actual into account.④The supply chain deserves to be standardized.⑤Compensation mechanism needs to be further improved.⑥Supervision needs to be strengthened.⑦Propaganda is not enough in some areas and the transition period is too short.⑧The EMS promoted for pharmaceutical services only with limited promotion in increasing utilization of medical services in some areas. (3)Inspiration of typical areas:①Transition should be smooth and "one size fits all" should be avoiding.②The EDL should be determined reasonably; hospitals implementing should equip drugs on-demand.③The relationship between the compensation mechanism and drugs amounts should be cut.④Information system should be used to improve efficiency.⑤Other reforms should be implemented to help excute EMS. (4)Through the establishment of demand function of community health services, short-term changes of outpatient revenues of all the institutions in an area can be measured, which determines the amount of compensation and level of health insurance fianacing after implementing EMS. (5)It is necessary to excute EMS in the NCHSs if the policy is well designed. RecommendationsAccording to the problems and inspiration above, recommendations are proposed as follows:(1)Goals detailed and operational plans should be set. (2)The working group should play a true role, and cooperation should be strengthened among departments. (3)Personnel reform and performance evaluation methods should be published as soon as possible. (4)The EDL should be adjusted appropriately in order to be consistent with the fuction of CHSs and meet needs of patients. (5)The supply chain should be regulated to make sure the bidding drugs have excellent quality and favorable price. (6)The EDL should be promoted sequentially; the drugs should be equipped on-demand; the training and health education should be enhanced to promote rational drug use. (7)The amount of compensation for zero-slip should be calculated reasonably to ensure be fully compensated. (8)Health insurance department should actively cooperate to improve the ratio of the reimbursement of essential drugs. (9)The national standards of monitoring and evaluating EMS should be introduced; buildup and development of the third-party assessment agencies should be encouraged (10) Propaganda should be intensified.(11)Laws and regulations should be strengthened and supervision should be reinfored. (12)Investments to CHSs should be optimized to improve their capacity of services.
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