National Essential Medicine Policy Research Articles

The health and health system impacts of China's comprehensive primary health care reforms: a systematic review.

China's comprehensive primary health care (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality health care services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In August 2022, 13 international databases and three Chinese databases were searched for randomised controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group; and assessed impacts on expenditures, utilisation, care quality, and health outcomes. Study quality was assessed using ROBINS-I and results were synthesized narratively. From 49,174 identified records, 42 studies were included - all with quasi-experimental designs, except for one randomised control trial. Nine studies assessed as at low risk of bias. Only five low to moderate quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilisation, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N=15) and financing reforms (N=11) were the most studied policies, whilst policies on primary care provision (i.e., family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilisation (N=17) and improved health outcomes in people with non-communicable diseases (N=8). Evidence on healthcare costs was unclear and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups accrued greater benefits (N=8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilisation, improving some health outcomes, and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance Universal Health Coverage.

Influencing factors of physicians\u2019 prescription behavior in selecting essential medicines: a cross-sectional survey in Chinese county hospitals

BackgroundTo explore the key factors affecting prescription practices of essential medicines in Chinese county hospital. National essential medicine policy (NEMP) plays important roles in health care system, especially in developing countries. As a fundamental component in the Chinese health system reform, NEMP was implemented in primary health care institutions during the first stage of reform. As it is rolled out, priority usage and zero-mark-up policy of essential medicines are to be applied in every government-run healthcare institution. However, the intention and influence factors of physicians on priority selecting essential medicine remains unclear.MethodsBased on the theory of planned behavior, a cross-sectional questionnaire survey was conducted to analyze physicians’ intention, attitude, subjective norms (SNs) and perceived behavioral control (PBC) on prescrictions and their actual behavior on selection of essential medicines.ResultsTwo hundred eighty-two physicians participated in the structural questionnaire interview. The final structural equation model reflected influencing factors affecting physicians’ prescribing behavior (χ2/df = 1.32, GFI = 0.99, IFI = 0.99). Structural equation model analysis showed that attitude, other influencers and institutional environment, and PBC significantly affected behavioral intention. However, the control extent of cognition behavior of physicians prescribing had no significant positive effect on the priority usage of essential medicines.ConclusionInvestigation results demonstrate physicians are unaware of NEMP design and implementation plans. To help enhance rational use of essential medicines we suggest educating physicians on the value of NEMP, and integrating the drug shortage report into the essential medicine (EM) bidding system seamless communication with pharmaceutical manufacturers’ credit information system.

Prices, availability, and affordability of national essential medicines in public primary hospitals: A cross-sectional survey in poverty-stricken rural areas in China.

This study aimed to determine the prices, availability, and affordability of national essential medicines in public primary hospitals in poverty-stricken areas of Anhui province, China. A cross-sectional study was conducted in 143 public primary hospitals in Anhui province, eastern China. Data on access to 44 essential medicines was evaluated using the standardized methodology available in the World Health Organization and Health Action International manual. Median price rates show that 46.51% (21 of 44) of the lowest price generics and 100% of the originator brands were more expensive than the international reference price. The median availability of the 44 medicines was 31.47%, and 65.91% (29 of 44) of the medicines had less than 50% availability. The majority of the medicines were affordable as they would cost less than a day's income in sample areas. Suppliers could respond to 88.27% of the procuring orders raised by the 143 hospitals in the study, but this ranged from 43.96% to 99.86%. There is poor availability and non-ideal response rate of medicine delivery in public primary hospitals in poverty-stricken areas in eastern China. Further implementation of national essential medicine policy needs to focus on improving both availability and distribution efficiency in these areas.

An analysis on rational use and affordability of medicine after the implementation of National Essential Medicines Policy and Zero Mark-up Policy in Hangzhou, China.

BackgroundThe National Essential Medicine Policy and the Zero Mark-up Policy was introduced to improve the rational use and affordability of medicine. This study analyzed the changes of medicine use at different Health Care Institutions in Hangzhou city after the implementation of National Essential Medicine Policy and the Zero Mark-up Policy.MethodsFacility based survey was conducted in 17 Health Care Institutions and 16406 outpatient prescriptions in 2011 and 2013 were collected. Average number of medicines, average number of antibiotics and average expenditure per prescription were analyzed. Comparisons between 2011 and 2013, among different levels of Health Care Institutions and age groups were conducted.ResultsThe average number of medicines per prescription, use of antibiotics, intramuscular (IM) injections and intravenous (IV) injections decreased while the use of hormones increased. No significant change of the average medicine expenditure per prescription was observed. Disparities among different levels of Health Care Institutions and different age groups existed.ConclusionThe problems of poly-pharmacy, overuse of antibiotics, intramuscular (IM) injections and intravenous (IV) injections and hormones still existed, however mitigated after the implementation of The National Essential Medicine Policy and the Zero Mark-up Policy.

Trends analysis for drug utilization in county public hospitals: a sample study of the pilot area of health care reform in China

BackgroundChanges in the national drug policy always have impact on the drug utilization. In the context of China health care reform, what changes had happened in the trend of drug utilization in public hospitals? Has this change met the expectations of policy design? This study was conducted to explore the trend of medicine consumption in county public hospitals before and after health care reform, and to provide real-world evidence to help assess the effectiveness of national drug policy.MethodsA cross-sectional study was performed to investigate the drug utilization trends of 6 county public hospitals in Anhui Province, which is the first pilot area of China health care reform. Data were collected before and after the implementation of the China National Essential Medicine Policy (NEMP) to analyse the drug utilization indicators, such as the drug utilization constituent ratio, the rate of essential medicine usage and the rate of antibiotic consumption.ResultsChemicals are used most frequently and account for 60%~ 70%, followed by oral agents of proprietary Chinese medicine. The results also show increased consumption of Chinese medicine injections (χ2 = 28.428, P < 0.01). The top 3 chemical medicines consumed were anti-infective drugs (12.92%), cardiovascular system drugs (11.61%), and digestive system drugs (8.42%). For Chinese traditional medicine, the top 3 drugs consumed were internal medicine drugs (66.03%), surgical drugs (8.45%), and gynaecological drugs (7.70%). The total sales amounts of drugs covered by medical insurance are at a high level (all above 80%), whereas essential medicines are less than 50% at almost all county-level medical institutions.ConclusionsThis study uncovered the changing tendency of medicine usage under the implementation of the reform. Chinese medicine injections and anti-infective drugs have always been a sustained concern of pharmacovigilance. It is noteworthy that although essential medicines are advocated for as a priority for use in the government-run hospital, the consumption proportion of these medicines is lower than expected.

Evaluating the accessibility of essential medicines in China

Objective: To evaluate the accessibility of essential medicines in China through a new system which integrated the structure, process, and effect of the National Essential Medicine Policy (NEMP).Methods: A structural equation model was built to verify the reliability of the evaluation system. This study utilized the Delphi method to obtain the structure and process index data, and used the WHO/HAI standard method for the effect index data to evaluate the NEMP. Six regions were selected for empirical analysis so that suggestions for optimization could be put forward.Results: The structural equation model consisted of three parts: organization structure, executive process, and effect. The factor loading of the three indicators exceeded 0.5, indicating that this model complied with the preliminary fit criteria. In the organizational structure, rules and regulations and resource investment accounted for a large proportion, indicating that they had a great impact on the effect. As for the executive process, the weight of the seven indicators were similar, and they accounted for a large proportion, indicating that each indicator had a non-negligible impact on the effect. The “p” of all the three hypothesizes was less than .01, especially the “p” of hypothesis 3 was less than .001, indicating that the structure and process of NEMP affected the accessibility of the essential medicines, and three components of the model were positively correlated.Limitations: Some errors may exist in achieving appropriate expert selection because of potential researcher bias in the Delphi approach. The results from only six provinces in China may not be generalized nationwide.Conclusion: The structural indicators and process indicators have a significant impact on outcome indicators, and they also have correlations. That is, the formulation and implementation of the national drug policy and related supporting measures play an important role in improving the accessibility of essential medicines.

Does providing more services increase the primary hospitals' revenue? An assessment of national essential medicine policy based on 2,675 counties in China.

ObjectiveTo understand whether the increased outpatient service provision (OSP) brings in enough additional income (excluding income from essential medicine) for primary hospitals (INCOME) to compensate for reduced costs of medicine.MethodsThe two outcomes, annual OSP and INCOME for the period of 2008–2012, were collected from 34,506 primary hospitals in 2,675 counties in 31 provinces in China by the national surveillance system. The data had a four-level hierarchical structure; time points were nested within primary hospital, hospitals within county, and counties within province. We fitted bivariate five-level random effects regression models to examine correlations between OSP and INCOME in terms of their mean values and dose-response effects of the essential medicine policy (EMP). We adjusted for the effects of time period and selected hospital resources.FindingsThe estimated correlation coefficients between the two outcomes’ mean values were strongly positive among provinces (r = 0.910), moderately positive among counties (r = 0.380), and none among hospitals (r = 0.002) and time (r = 0.007). The correlation between their policy effects was weakly positive among provinces (r = 0.234), but none at the county and hospital levels. However, there were markedly negative correlation coefficients between the mean and policy effects at -0.328 for OSP and -0.541 for INCOME at the hospital level.ConclusionThere was no evidence to suggest an association between the two outcomes in terms of their mean values and dose-response effects of EMP at the hospital level. This indicated that increased OSP did not bring enough additional INCOME. Sustainable mechanisms to compensate primary hospitals are needed.

The Effect of China's National Essential Medicine Policy on Health Expenses: Evidence From a National Study.

To increase use of medical service across the country, the Chinese government has tried to improve equity in health care access and reduce patients’ medical expenses. For this purpose, the National Essential Medicine Policy (NEMP) was introduced in 2009 to mandate the distribution of medicines to health care facilities at a low cost and without profit. This study aims to evaluate the effect of the essential medicine policy on average per-visit expenses for outpatient and inpatient services. The annual national surveillance system data covering all the grassroots-level primary health care facilities (PHFs) in 2675 counties and 31 provinces in China during 2008 to 2012 were used in this study. The 4-level hierarchical random effects models were utilized to deal with possible dose-response effects of the policy and possible variations of such effects at the provincial, county, and facility levels. Our research findings suggest that the NEMP had positive effects in reducing both outpatient and inpatient expenses at grassroots level, and the policy effects tended to be greater as the exposure time increased. This study provides implications on reforming China’s health system and its medicine cost control policies.

Assessing dose–response effects of national essential medicine policy in China: comparison of two methods for handling data with a stepped wedge-like design and hierarchical structure

ObjectivesTo introduce multilevel repeated measures (RM) models and compare them with multilevel difference-in-differences (DID) models in assessing the linear relationship between the length of the policy intervention period and healthcare...

Investigating on the effects of national essential medicine policy on primary care facilities in Hebei province: a case study

Investigating on the effects of national essential medicine policy on primary care facilities in Hebei province: a case study

Access to affordable medicines after health reform: evidence from two cross-sectional surveys in Shaanxi Province, western China.

Limited access to essential medicines is a global problem. Improving availability and affordability of essential medicines is a key objective of the National Essential Medicine Policy (NEMP) in China. In its initial implementation in 2009, the NEMP targeted primary hospitals with policies designed to increase availability of essential medicines and reduce patients' economic burden from purchasing medicines. We assessed medicine availability and price during the early years of the health reform in Shaanxi Province in underdeveloped western China. We undertook two public (hospitals) and private (pharmacy) sector surveys of prices and availability of medicines, in September, 2010 and April, 2012, by a standard methodology developed by WHO and Health Action International. We measured medicine availability in outlets at the time of the surveys and inflation-adjusted median unit prices (MUPs), taking 2010 as the base year. We used general estimating equations to calculate the significance of differences in availability from 2010 to 2012 and the Wilcoxon signed rank test to calculate the significance of differences in adjusted median prices. We collected data from 50 public sector hospitals and 36 private sector retail pharmacies in 2010 and 72 public hospitals and 72 retail pharmacies in 2012. Mean availability of surveyed medicines was low in both the public and private sectors; availability of many essential medicines decreased from 2010 to 2012, particularly in primary hospitals (from 27·4% to 22·3% for lowest priced generics; p<0·0001). The MUPs of originator brands and their generic equivalents decreased significantly from 2010 to 2012 in primary hospitals in comparison with secondary and tertiary hospitals. In the public sector, the median adjusted patient price was significantly lower in 2012 than in 2010 for 16 originator brands (difference -11·7%; p=0·0019) and 29 lowest-priced generics (-5·2%; p=0·0015); the median government procurement price for originator brands also decreased significantly (-10·9%; p=0·0004), whereas the decrease in median procurement price for lowest-priced generics was not significant (-4·9%; p=0·17). In the private sector, the median percentage decrease in price between 2010 and 2012 for 38 lowest-priced generics was 4·7% (IQR 6·3-13·2), compared with 7·9% (4·9-13·9) for 16 originator brands. Although inflation-adjusted medicine prices were numerically lower, there were concerning decreases in availability of lowest-priced generic medicines in both the public and private sectors in 2012 from already low availability in 2010. A long-term, stable, and consistent information system is needed to monitor effects of further implementation of the Chinese Essential Medicine Policy. The National Natural Science Fund (71103141/G0308), the China Medical Board Faculty Development Awards, the Fundamental Research Funds for the Central Universities (2011jdhz62), the Shaanxi Provincial Social Science Fund (10E066), and the Harvard Medical School Pharmaceutical Policy Research Fellowship.

Prescription Pattern and Its Influencing Factors in Chinese County Hospitals: A Retrospective Cross-Sectional Study

ObjectiveThis study aimed to investigate prescription patterns and influencing factors in Chinese county hospitals.MethodsPrescription quality was evaluated by five indicators proposed by WHO/INRUD. A questionnaire for doctors was designed by our research group. All internists, surgeons, obstetricians, gynecologists and pediatricians from 10 county hospitals in Anhui province were asked to fill the questionnaire. Their prescriptions from May 2011 to April 2012 were analyzed.ResultsThree-hundred and thirty-seven doctors completed valid questionnaires, and 5099 prescriptions were analyzed. The average number of drugs per prescription was 3.52±2.31; the average percentage of generic drugs, antibiotic usage, injection drug usage, and drugs prescribed from the national essential drug list were 96.12%, 29.90%, 20.02% and 48.85%, respectively. Differences in final academic degree and specialty led to differences in all of the five prescription quality indicators. The older doctors tended to use more antibiotics. Doctors with more education, more training on rational drug use, and better acquisition of medicine knowledge prescribe a lower percentage of generic drugs. Moreover, the more supportive the doctor’s attitude to national essential medicine policy, the higher the percentage of generic drugs were prescribed. A higher level of medical knowledge was associated with a higher percentage of drugs prescribed from the essential drugs list.ConclusionsPromoting the education of medical knowledge on doctors, reinforcing the publicity of rational drug use to doctors, and initiating the performance evaluation for doctors are effective ways for improving prescription quality in Chinese county hospitals.