基本药物政策实施现状及成效比较研究
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摘要
研究背景
自2009年8月我国正式公布《关于建立国家基本药物制度的实施意见》以来,覆盖政府办基层医疗卫生机构的基本药物体系已逐步建立。这对于保证基本药物的可及性,促进基层综合医疗卫生体制改革具有较大的推动作用。在此背景下,研究进一步提高基本药物可及性、可负担性,改善合理用药水平,提高基本药物制度的惠民性,并实现基层医疗卫生机构的可持续发展就显得尤为重要。
而目前针对基本药物制度的研究宏观层面大都停留在理论方面,缺乏大样本的数据支持,而微观层面大多停留在小样本基础上的实施现状和实施效果的描述性研究。缺乏大样本数据支持基础上对基本药物制度实施现状及实施成效的比较研究,且对基本药物可及性与可负担性影响因素的研究多停留在单因素分析水平上,未对各影响因素的影响程度及相互关系进行探讨。
研究目的
本研究的总体目标是以国家药物政策和基本药物制度理论为基础,以实证研究为手段,从宏观和微观两个层次对国家基本药物制度实施现状及实施成效进行比较研究,分析影响基本药物制度实施效果的关键因素,为基本药物制度的健康可持续发展提供借鉴。
研究方法
本研究资料主要来源于文献复习、自填问卷和26省基本药物监测评价报告。自填问卷法主要用来获取2010年、2011年26省基本药物实施的政策支持环境和政策制定及执行调查结果和同期26省所选522家基层医疗卫生机构调查数据。
资料分析方法主要包括描述性分析和推断性分析,计数资料率的比较采用卡方检验,计量非正态数据采用非参数检验,统计检验水准a=0.05。在此基础上,利用结构方程模型以及TOPSIS法和秩和比(RSR)法等综合评价方法进行综合分析。
主要研究结果及发现
1、基本药物政策和基层综合医改实施成效分析
(1)基本药物政策制定及执行情况。基本药物采购配送机制逐步建立。但招标采购方式有待进一步完善,经济技术标书阶段还存在着如何设置技术评分标准的核心问题,投标阶段难免掺杂人为主观因素,中标企业参差不齐,中标基本药物质量难以保证。商务标书阶段容易出现围标现象,或是参与围标的投标人比较少,就采用低于成本抢标,从而使得基本药物中标价格偏低,影响基本药物生产供应；基本药物配送方式主要是由中标生产企业直接配送和由中标生产企业自行委托配送企业配送两种方式。平均配送到位率为87.66%。个别药品流标现象严重,机构断货、缺货现象严重。26省基本药物集中采购流标率中位数为15.04%,最大流标率为77.04%。
(2)基层综合医改同步推进,但改革力度尚需深入。在实施基本药物制度的基层医疗机构中,大部分机构已经同步实施了人员定编定岗、绩效工资改革、医保补偿调整、一般诊疗费调整等配套措施的改革。同时,通过增加基本药物的补偿比例,进一步降低基层就医的经济负担,切实强化了基层医疗卫生服务体系的公益性建设。但通过调查也发现,在财政补助方面,仍有17.26%的机构财政补助收入较去年同去减少或持平,上级补助收入减少或持平的比例为78%。在制定了新的人事、分配制度的省份,由于缺乏相应监管机制,基层医疗卫生机构的贯彻执行相对薄弱。
2、基层医疗卫生机构基本药物制度实施成效及问题分析
(1)基本药物可及性方面：基本药物制度在26省政府办基层医疗卫生机构实现全覆盖。但基层医疗卫生机构国家基本药物配备率还有待提高(中成药50.87%,西药67.36%),基本药物缺药问题还比较严重(存在缺货的占53.74%)。目录所选的基本药物“用不上”和“不够用”的情况并存。
(2)基本药物可负担性方面：基本药物采购价格与国家发展改革委公布的基层平均采购价格、基本药物零售指导价、去年同期采购价格相比总体呈下降趋势。2011年1-9月基层医疗卫生机构平均处方费用与门诊次均药品费用较去年同期总体呈下降趋势,且2011年开始实施基本药物制度的基层医疗机构,2011年1-9月平均处方费用和门诊次均药品费用较去年同期下降幅度要大。
(3)基层医疗卫生机构合理用药方面：基本药物制度实施以后,基层医疗卫生机构合理用药状况得到持续改善。2010年和2011年分别开始实施基本药物制度的机构,在每百张处方使用二联及以上抗菌药物和激素类药物的处方数及每百名住院病人住院期间使用抗菌药物的人数上,2011年1-9月与去年同期相比下降幅度均较大,且社区卫生服务中心合理用药情况总体好于乡镇卫生院,差别均具有显著性(p<0.000)。但由于用药监管考核机制欠缺,部分基层医疗卫生机构不合理用药现象仍然存在。且由于培训经费不足,基本药物相关培训的深度和宽度大打折扣,一定程度上也不利于合理用药情况的改善。
(4)基层医疗卫生机构的自身发展：基层医疗卫生服务机构可持续发展能力得到增强,基层医疗卫生机构运行呈现“四增三减一改善”趋势,即门急诊人次、服务项目、机构收入、机构人员平均工资增加,药品收入构成、平均处方费用、门急诊药品费用减少,合理用药情况有所改善,基本药物制度的惠民性逐渐显现。但基层卫生人才配置结构不合理、人员素质不高、乡镇卫生院临聘人员问题突出、机构检查与诊疗项目大幅增加,部分机构存在资源过度配置倾向等问题仍然比较严峻,影响了基层医疗卫生机构基本药物制度的健康发展。
3、基本药物可及性与可负担性影响因素分析
(1)基本药物可及性----“是否缺药”的影响因素分析：通过结构方程模型分析,基本药物配备品种数、基本药物采购、配送方式种类数、是否出台基层医疗卫生机构补偿办法是基层医疗卫生机构是否缺药的主要影响因素。经济状况越好的地区,基本药物配备品种数就越多,基本药物缺货状况越轻；出台了基层医疗机构补偿办法的地区,基本药物缺货状况相对较轻；2010年实施基本药物制度的基层医疗卫生机构缺药状况要比2011年开始实施的基层医疗卫生机构严重,这与单因素分析结果一致；针对基本药物的特点分别制定采购、配送政策,实行多种方式相结合的采购配送方式,基本药物缺货状况较轻,而执行单一招标采购、配送政策的机构,缺货状况较严重。
(2)基本药物可负担性——“平均处方费用”的影响因素分析：基层医疗卫生机构收入水平、合理用药水平、是否出台基层医疗卫生机构补偿办法和基本药物配备品种数为影响平均处放费用的主要因素。社会经济状况越好,平均处方费用越高；基本药物制度实施越早的基层机构合理用药水平越高,但其平均处方费用却相对较高；出台基层医疗卫生机构补偿办法有利于降低平均处方费用；机构配备的卫生技术人员越多,职工收入越高,合理用药水平就越高,从而使平均处方费用降低。而机构人力资源配备越强,机构提供的卫生服务量越多,服务水平越高,平均处方费用也就越高；基本药物配备品种数越多,平均处方费用越低。说明基本药物的配备及使用能有效降低平均处方费用。
4、东中西部基层医疗卫生机构基本药物制度实施进展与成效
(1)在机构基本情况方面,从人员编制、每万人口拥有的卫生技术人员数机构业务量、各项收入上看,总体为东部>中部>西部。东中西部均存在护士配置比例不足的问题,但总体西部优于中部,中部优于东部。中部和西部临聘人员问题比较突出,平均实际在职人员数分别高出核定编制数的28.58%和48.28%。实施基本药物制度前后,东中西部基层机构财政补助收入均明显增加。在药品收入上,除中部2011年开始实施基本药物制度的基层医疗卫生机构收入下降幅度较大以外,东西部差别均不明显。
(2)在基本药物制度实施成效方面,从基本药物可及性来看,基本药物配备的品种数总体为东部>中部>西部。而对缺货情况进行分析,则为东中部>西部。说明东中部配备的药品品种数虽然高于西部,但缺货现象仍然比西部严重。从基本药物可负担性来看,平均处方费用总体为东部>中部>西部。从在合理用药来看,总体东部好于中部,中部好于西部。在基本药物相关知识培训方面,东中西部培训力度存在明显差别。总体为东部>中部>西部。从综合分析来看,通过TOPSIS法和秩和比(RSR)综合分析东中西部基本药物制度实施情况,实施成效均为东部>中部>西部,且东部明显好于中西部。
政策建议
1、提高基本药物可及性方面
(1)进一步扩大基本药物的覆盖范围。将基本药物逐步推广到非政府办基层医疗机构中,重点加大村卫生室、社会零售药店中基本药物的销售比重。
(2)适当放宽药品品种范围。建议在国家和省增补目录的基础上,适当放宽基层医疗卫生机构用药品种范围,新增药品品种应该兼顾儿科、精神和肿瘤疾病等专科用药。建议借鉴福建省的相关经验,在确保疗效和合理用药的前提下,在金额和数量的“双控”监管下,按规定在突发事件急诊抢救和上级医院转诊患者就诊时使用一定比例的目录外药品。
(3)提高对基本药物生产配送企业的监督管理。加大对企业特殊基本药物供应能力的考核力度。加强采购配送的监督管理,通过建立健全药物信息监测管理系统,对招标采购和统一配送过程进行全程监管,鼓励企业内部尽快建立起常规性的药品储备机制,重点解决急救药品、价格低廉和市场需求量少的特需药品供应不足的矛盾。在激励措施中,应充分保护此类配送企业的市场利益,提高这些企业对短缺药品储备的积极性。要建立一个应急协调机制,及时对基本药物采购价格进行调整,以免出现因原材料价格上涨而造成药物供应短缺。
(4)建立短缺基本药物应急储备机制。通过市场化运作的方式,通过与大型医药批发经营企业合作的方式,建立国家级或者地区级的药品应急储备中心,动态调整药品储备的品种和数量,提高医药储备专项资金的使用效率,减少资金闲置与浪费现象的出现。
2、提高基本药物可负担性方面
(1)完善基本药物的招标采购工作。建立基本药物优质优价制度,改变现有的“唯低者得”的中标模式。
(2)完善医保支付方式的改革。努力提高基本药物在基层医疗机构内的补偿水平,提高药品的认可度。加快推进各种基本医疗保险信息化建设速度,尽量缩短医保机构与医疗机构费用结算的时间。
(3)尝试免费发放基本药物。在有条件的地区,在合理确定目标人群基础上,政府应该尝试向老年人或困难人群提供免费的基本药物,药品种类集中在高血压、糖尿病等常见病种。
3、改善合理用药方面
(1)科学合理遴选基本药物。建议选择部分常见病和多发病开展系统的循证医学和药品经济学评价。整个评价过程和结果应主动社会公开,接受医疗机构、药品企业和第三方鉴定机构的质疑。
(2)加大基本药物合理使用的培训力度。重点控制抗生素和激素类药品的滥用,并加大对中西部政策倾斜力度。同时,在基本药物制度影响范围不断加大的情况下,要将基本药物的合理使用培训逐渐向二、三级医疗机构推广,缓解目前由于药品品种、剂型、包装的不同所产生的用药差异,从而提高我国整体药品合理用药水平。
4、基层医疗卫生机构综合医改方面
(1)强化政府责任,稳妥推进改革。继续强化政府在推进医改工作方面的主导性,增加对基层医疗机构的直接财政投入力度。加强监督管理与评估机制建设,通过评估和及时反馈实施的成效,发现问题与不足,为制度制定及调整提供实证依据。
(2)增加基层卫生服务项目的绩效考核。以基本医疗卫生服务的数量、质量和群众满意度为核心,逐步建立起更为完善的绩效考核机制。考核结果与机构的财政补偿挂钩。进一步规范基层医疗卫生机构新增检查项目和诊疗项目工作,避免资源过度配置与浪费。
(3)加强基层卫生人才队伍建设。建立人才队伍资源整合机制,特别是加大中西部基层卫生人才队伍建设和东部支援中西部的力度,促进基层人才合理分布。合理设定卫生技术人员编制,着力解决临时聘用人员问题。完善绩效工资制度和考核办法,将人员聘用、岗位管理与服务质量和效果挂钩,建立体现绩效的分配激励和约束机制,逐步建立鼓励引导优秀人才留在基层的长效机制。
Background
Since China formally announced the "Implementation Opinions on the Establishment of National Essential Drug System" in August2009, the essential drug system covering the government-run primary health care institutions has been gradually established. This is to ensure the availability of essential drugs and promote grassroots comprehensive health care reform. In this context, the study further improve access to essential medicines, affordability, improve rational drug levels, improve the public welfare of the basic drug system and to achieve sustainable development of primary health care sector is particularly important.
The current research on the basic drug system in the macro level stays mostly in theory, and lack of data of a large sample, and the research in the micro level has remained mostly based on small sample descriptive study of the status of implementation and effects. The comparative studies to the implement status and effective based on the basic drug system are lacking, and research on the affecting factors on the essential medicines availability and affordability stays level on univariate analysis. The relationships between the factors and the degree of influence are not discussed.
Purposes
Basied on the National drug policies and essential drug system theory, as a means of empirical research, the overall goal of this study is to compare the status and effectiveness of the implementation of national essential drug system from the macro and micro levels, to analyze the key factors in the implementation of National Essential Drug System and provide a reference for the healthy and sustainable development of essential drugs system.
Methods
The data came mainly from literature review, self-administered questionnaires and reports on monitoring and evaluation of essential medicines in the twenty-six provinces. Self-administered questionnaires were mainly used to get data of the policy supporting environment, policy stipulations and results of policy implementation in the twenty-six provinces, as well as the results of survey on522grassroots medical and health facilities selected by the26provinces themselves in2010and2011. Analysis was made on the essential medicines policy environment and the basic status of policy implementation, on the effectiveness of the implementation of the essential medicines system in terms of the availability, affordability and the situation of rational administration of the essential medicines, to sum up experiences and find out the key factors affecting the effectiveness of implementation of the essential medicines system to provide empirical basis for improvement of the construction of the essential medicines system.
Data analysis methods include descriptive analysis and inferential analysis. Comparison between enumeration data rates was made with chi-square test measurement of non-normal data with non-parametric tests, and statistical significance level with α=0.05. On this basis, analysis was made comprehensively with structural equation modeling, TOPSIS and RSR methods.
Main Results and Findings
1、 Implement effectiveness analysis on the essential drug policy and grassroots comprehensive health care reform.
(1) Essential drugs policy formulation and implementation. Mechanisms for procurement and distribution of essential medicines had been gradually established However, the bidding and procurement patterns remained to be further improved. There were still problems concerning how to set evaluation criteria at the stage of economic and technical tender stage, problems of doping of inevitable subjective factors at the tender stage, and problems of uneven development between the enterprises who won the bidding which might be difficult in guarantee of the quality of the essential drugs. At the commercial bid stage, there might appear the phenomenon of bidders ring, or few people to participate in bidding or in the bidding ring, which often resulted in below-cost bids affecting the production and supply of these essential medicines. There were two forms of distribution of the essential medicines:direct distribution and entrusted distribution by the producers who won the bids. The average rate of distribution in place was87.66%. Failed auctions of some individual drugs and short of stock or supply in health institutions were seen seriously. The mean rate of failed auctions during the centralized bidding procurement of the essential medicines in the26provinces was15.04%, the maximum rate was77.04%
(2) The comprehensive integration for the reform at the grassroots health care facilities showed satisfactory progress, but the reform needs further.
In primary health care institutions of implementing the basic drug system, most agencies have implemented simultaneously setting a quota of staff posts, merit pay reform, health insurance compensation adjustment, general clinic fee adjustments and other supporting measures. Also, by increasing the compensation ratio of essential drugs, further reducing the economic burden of grassroots medical treatment, and effectively strengthen the public welfare of the primary health care service system. But there were still17.26%of the facilities got decreased financial subsidies or unchanged sum of subsidies compared to the previous year, with the decreased or unchanged ratio of financial subdidies being78%.Due to the lack of appropriate regulatory mechanisms, in the provinces of formulating new personnel and distribution systems, the implementation of primary health care institutions is relatively weak.
2. The implementation Effectiveness and Issues of the Essential Medicines System at the Grassroots Level Health Care Facilities
(1)In terms of access to essential medicines:All the26provinces had practiced the essential medicines system in the government-run grassroots level health care facilities. Secondly, the rate of supply (Chinese medicine50.87%, Western medicine67.36%) of the national essential medicines in the primary level health care facilities needs to be raised. Shortage of essential medicines was a serious issue in many health facilities (53.74%), which resulted in loss of the patients who need the certain medicines. Selected Essential Drugs List "irrelevant" and "not enough" situation coexist.
(2)Terms of affordability of essential medicines:The purchase price showed a trend of decrease compared with the average purchase price for the grassroots level set by the National Development and Reform Commission, recommended retail price of essential medicines, and the purchase price over the same period last year. However, the bidding and procurement patterns remained to be further improved. The average cost of prescription and drug cost of outpatients January to September in2011have a downward trend over the same period in primary health care institutions. And the downward trend is more pronounced in primary health care institutions beginning to implement the essential drug system.
(3)Primary health care institutions rational use of medicines:After the implementation of the basic drug system, primary health care institutions rational drug situation continued to improve. The rational drug use in Community Health Center is generally better than township hospitals. Differences were statistically significant (p <0.000). However, due to the lack of drug regulatory evaluation mechanism, irrational drug phenomenon still exists in part of primary health care institutions. And due to lack of training funds, the depth and width of training of essential drugs greatly reduced. To some extent, the improving of the rational use of drugs has been affected.
(4)The development of Primary health care institutions:The sustainable development of primary health care services has been enhanced. There presented in the grassroots health care facilities a trend of "four increases, three decreases and one improvement", namely, increase in person-times of outpatient and emergency visits, increase service items, increase in institutional income and increase in average personnel income; decrease in medicine constituted income, decrease in the average cost of prescription and decrease in cost of outpatient and emergency drugs; and, improvement in rational application of drugs. So the benefit of the essential medicines system appeared gradually. But basic health professionals configuration structure is irrational, personnel quality is not high, township hospitals temporary employment issues is outstanding,, there is a tendency to over-provisioning of resources, such as the significant increase in checks and treatment programs. All of them have been affecting the healthy development of the basic drug system in the primary health care institutions.
3、 The influencing factors analysis of availability and affordability of essential medicines
(1)The access to essential medicines----The influencing factors analysis of lack of medicine:By structural equation modeling analysis, better economic conditions, the more of the number of varieties of essential drugs, and the more light of the lack of essential drugs; in the region of developing a grassroots medical institutions remedies, essential drugs out of stock situation is relatively light; The lack of medicine in primary health care institutions beginning to implement the basic drug system in2010is more serious than the institutions beginning to implement the basic drug system in2011. This analysis is consistent with the results of single factor; The lack of medicine in the areas of developing procurement and distribution policy according to the characteristics of essential drugs is lighter than the areas of performing a single tender procurement and distribution policy.
(2)The affordability of essential medicines----The influencing factors analysis of "the average prescription costs": The better the socio-economic situation, the higher the average prescription costs; The earlier the implementation of basic drug system, the higher the rational drug levels, but the average prescription cost is relatively high. Developing a grassroots medical institutions remedies helps to reduce the average prescription costs; more health technicians or the higher the income of workers, the higher the level of rational drug use, so that the average prescription costs reduced. But the higher the quality of human resource, the more volume of services provided by health institutions, the higher the service level and the higher the average prescription costs; The more variety number of essential drugs, the lower the average prescription costs. This shows that reserves and use of essential drugs can effectively reduce the average prescription costs.
4、 The implementation Progress and Effectiveness of the Essential Medicines System in the Eastern, Western and Central Regions of China
(1) In the basic situation of institutional, Viewing from staffing per10,000population, the eastern region was superior to the Central, and the Central superior to the Western. All the Eastern, the Western and the Central regions of China had deficiencies in the proportion of nurses. Relatively speaking, the problem was less serious in the Western than that in the Central, and less serious in the Central than that in the Eastern. In the Central and Western regions, the problem of temporary employment was more prominent, the average number of staff in-service was higher than the actual number of staff, being28.58%and48.28%more than the government authorized strength respectively. Average outpatient visits varied greatly among the three regions, the number of visits in the Eastern region was significantly higher than that in the Central and Western regions, and there was no significant difference between the Central and the Western. Viewing from more admissions, the order was the Eastern, the Central and the Western, and the same to the income. Little changes could be seen in volumes of services after the implementation of the essential medicines system, though the overall volume of services had a little increase compared with the previous years. Funds of government financial subsidies were significantly increased. Medicine-based income had an apparent decline in the primary level health facilities in the Central region since the implementation of the essential medicines system in2011. However, there was no obvious change in the Eastern and Western health facilities.
(2) Judging from more provisions of species of the essential medicines, the order should be the Eastern, the Central and the Western. The problem of shortage of the medicines was more serious in the Eastern and central regions, indicating that though the provision of medicine species was better in the Eastern and Central regions, shortage of the drug store was more serious thatn that in the Western region. On average prescription costs, the order was the Eastern, the Central and the Western. And for the better rational use of drugs, the order was also the Eastern, the Central and the Western. There were obvious differences between the three regions in training on essential medicines-related knowledge. The Eastern region was better than the Central, and the Central better than the Western.
Recommendations for Policy Making
1、 To improve the access to essential medicines
(1)Further expand the coverage of basic drugs. The essential drugs should be gradually extended to non-government-run primary health care institutions, increase the sales proportion of essential drugs in village clinics, community retail pharmacy。
(2)Appropriate to relax the varieties range of drugs. Evidence-based research on decision of the list of the essential medicines should be strengthened. There should be more space for the grassroots level health care facilities to select drug species. Under the premise of ensuring rational use and efficacy of medicines, and under the control of supervision and management on price and quantity, permission should be considered to give the grassroots health care facilities in administration of certain portion of medicines "not" on the list for unexpected events, emergencies, and referral patients.
(3) Strengthen the supervision and management to essential drugs delivery business. Increase the assessment efforts of supply ability of special essential drugs. Strengthen supervision and management of procurement and distribution. Through the establishment of a sound management system for monitoring drug information, to supervise and manage the bidding and uniform distribution so as to improve the rate of essential drugs in primary health care institutions. To build up an emergency coordination mechanism, timely to adjust the procurement prices of essential drugs so as not to appear a shortage of supply of drugs due to rising raw material prices.
(4) Establishing a contingency reserve system to the shortage essential drugs. By the way of the market works, and large pharmaceutical wholesale enterprises cooperation, establishing a national or regional emergency medicine reserve center, dynamically adjusting the type and quantity of drugs reserves, in order to improve the efficiency of medical reserve special funds, to reduce the appearance of the phenomenon of idling and waste of funds.
2、 To improve the affordability of essential medicines
(1) Improving the Bidding and procurement of essential drugs. A price-quality competitive system should be established to change the existing mode of "only bidder with low price" can win.
(2) Improve the Medicare payment reform. To improve the level of compensation of essential drugs in primary health care institutions, improve recognition of drugs. We should accelerate the information construction speed of various basic medical insurances, so as to shorten the time of cost clearing between insurance agencies and medical institutions.
(3)Try the free distribution of essential drugs. In areas where conditions permit, on the basis of determining the reasonable target population, the government should try to provide free basic drugs to the elderly or vulnerable groups. The types of drugs focus on hypertension, diabetes and so on.
3、To improve the rational use of medicines
(1) Scientific and rational selection of essential drugs. To carry out systematic evaluation of evidence-based medicine and pharmaceutical economics on some common and frequently occurring diseases. The process and the results of evaluation should be carried out under the supervision of the public and accept the questioning of medical institutions, pharmaceutical companies and third-party accreditation bodies.
(2)Increase training of rational use of basic medicines. Focusing on the control to the abuse of antibiotics and hormones drugs and increase the Midwest policy support. Meanwhile, under the influence of the basic drug system continuously improves, the training on rational use of essential medicines should be gradually promoted to secondary and tertiary health institutions. Reducing the errors generated by the difference of drug products, formulations, packaging, so as to improve China's overall level of rational use of basic drugs.
4、 Comprehensive health reform in primary health care institutions
(1) The government responsibility should be strengthened, top level program design should be improved, and the health reform should be pushed forward steadily. Integration and cooperation among different sectors and systems should be promoted. Construction of supervision and management system and evaluation mechanism should be enhanced. Experiences and practical methods of implementation of the essential medicines system should be explored. Evaluation should be carried out and feedback of effectiveness should be provided timely to find out obstacles and issues so as to provide basis for establishment and adjustment of the evaluation system.
(2) Increasing performance evaluation of primary health services. We should take the number and quality of basic health services and public satisfaction as the core, and gradually establish a more comprehensive performance assessment mechanism. Financial compensation to institutions links to the assessment results. Further regulate the new inspection program and clinic project in primary health care institutions to avoid over-provisioning and waste of resources.
(3) Long-term development mechanism of the essential medicines system and integrated human resources mechanisms should be built up. Efforts should be made on enhancement of health personnel recruitment in the Central and Western regions, and especially on enhancement of supporting the Central and Western regions by the Eastern region qualified personnel to promote the rational distribution of human resources. Priority should also be given to policy and financial support to the grassroots health care facilities in establishment of mechanism for reasonable training, introduction, selection and use of personnel, and for encouraging the qualified personnel to stay at the grassroots. The employment system should also be reformed with reasonable personnel quotas to solve the problems of temporarily employed staff.
(4)Improve the supervision and management mechanism. Promote the standardization of basic medical services management, strengthen financial supervision, standardize the behavior of income and expenditure, and gradually establish comprehensive performance evaluation mechanism that takes quality and quantity of services as the core and contains professional evaluation, supervision and evaluation of community supervision. Develop and improve the performance pay system and assessment methods, associating the personnel hiring and job management with service quality and effectiveness, establishing performance incentive and restraint mechanisms.
自2009年8月我国正式公布《关于建立国家基本药物制度的实施意见》以来,覆盖政府办基层医疗卫生机构的基本药物体系已逐步建立。这对于保证基本药物的可及性,促进基层综合医疗卫生体制改革具有较大的推动作用。在此背景下,研究进一步提高基本药物可及性、可负担性,改善合理用药水平,提高基本药物制度的惠民性,并实现基层医疗卫生机构的可持续发展就显得尤为重要。
而目前针对基本药物制度的研究宏观层面大都停留在理论方面,缺乏大样本的数据支持,而微观层面大多停留在小样本基础上的实施现状和实施效果的描述性研究。缺乏大样本数据支持基础上对基本药物制度实施现状及实施成效的比较研究,且对基本药物可及性与可负担性影响因素的研究多停留在单因素分析水平上,未对各影响因素的影响程度及相互关系进行探讨。
研究目的
本研究的总体目标是以国家药物政策和基本药物制度理论为基础,以实证研究为手段,从宏观和微观两个层次对国家基本药物制度实施现状及实施成效进行比较研究,分析影响基本药物制度实施效果的关键因素,为基本药物制度的健康可持续发展提供借鉴。
研究方法
本研究资料主要来源于文献复习、自填问卷和26省基本药物监测评价报告。自填问卷法主要用来获取2010年、2011年26省基本药物实施的政策支持环境和政策制定及执行调查结果和同期26省所选522家基层医疗卫生机构调查数据。
资料分析方法主要包括描述性分析和推断性分析,计数资料率的比较采用卡方检验,计量非正态数据采用非参数检验,统计检验水准a=0.05。在此基础上,利用结构方程模型以及TOPSIS法和秩和比(RSR)法等综合评价方法进行综合分析。
主要研究结果及发现
1、基本药物政策和基层综合医改实施成效分析
(1)基本药物政策制定及执行情况。基本药物采购配送机制逐步建立。但招标采购方式有待进一步完善,经济技术标书阶段还存在着如何设置技术评分标准的核心问题,投标阶段难免掺杂人为主观因素,中标企业参差不齐,中标基本药物质量难以保证。商务标书阶段容易出现围标现象,或是参与围标的投标人比较少,就采用低于成本抢标,从而使得基本药物中标价格偏低,影响基本药物生产供应；基本药物配送方式主要是由中标生产企业直接配送和由中标生产企业自行委托配送企业配送两种方式。平均配送到位率为87.66%。个别药品流标现象严重,机构断货、缺货现象严重。26省基本药物集中采购流标率中位数为15.04%,最大流标率为77.04%。
(2)基层综合医改同步推进,但改革力度尚需深入。在实施基本药物制度的基层医疗机构中,大部分机构已经同步实施了人员定编定岗、绩效工资改革、医保补偿调整、一般诊疗费调整等配套措施的改革。同时,通过增加基本药物的补偿比例,进一步降低基层就医的经济负担,切实强化了基层医疗卫生服务体系的公益性建设。但通过调查也发现,在财政补助方面,仍有17.26%的机构财政补助收入较去年同去减少或持平,上级补助收入减少或持平的比例为78%。在制定了新的人事、分配制度的省份,由于缺乏相应监管机制,基层医疗卫生机构的贯彻执行相对薄弱。
2、基层医疗卫生机构基本药物制度实施成效及问题分析
(1)基本药物可及性方面：基本药物制度在26省政府办基层医疗卫生机构实现全覆盖。但基层医疗卫生机构国家基本药物配备率还有待提高(中成药50.87%,西药67.36%),基本药物缺药问题还比较严重(存在缺货的占53.74%)。目录所选的基本药物“用不上”和“不够用”的情况并存。
(2)基本药物可负担性方面：基本药物采购价格与国家发展改革委公布的基层平均采购价格、基本药物零售指导价、去年同期采购价格相比总体呈下降趋势。2011年1-9月基层医疗卫生机构平均处方费用与门诊次均药品费用较去年同期总体呈下降趋势,且2011年开始实施基本药物制度的基层医疗机构,2011年1-9月平均处方费用和门诊次均药品费用较去年同期下降幅度要大。
(3)基层医疗卫生机构合理用药方面：基本药物制度实施以后,基层医疗卫生机构合理用药状况得到持续改善。2010年和2011年分别开始实施基本药物制度的机构,在每百张处方使用二联及以上抗菌药物和激素类药物的处方数及每百名住院病人住院期间使用抗菌药物的人数上,2011年1-9月与去年同期相比下降幅度均较大,且社区卫生服务中心合理用药情况总体好于乡镇卫生院,差别均具有显著性(p<0.000)。但由于用药监管考核机制欠缺,部分基层医疗卫生机构不合理用药现象仍然存在。且由于培训经费不足,基本药物相关培训的深度和宽度大打折扣,一定程度上也不利于合理用药情况的改善。
(4)基层医疗卫生机构的自身发展：基层医疗卫生服务机构可持续发展能力得到增强,基层医疗卫生机构运行呈现“四增三减一改善”趋势,即门急诊人次、服务项目、机构收入、机构人员平均工资增加,药品收入构成、平均处方费用、门急诊药品费用减少,合理用药情况有所改善,基本药物制度的惠民性逐渐显现。但基层卫生人才配置结构不合理、人员素质不高、乡镇卫生院临聘人员问题突出、机构检查与诊疗项目大幅增加,部分机构存在资源过度配置倾向等问题仍然比较严峻,影响了基层医疗卫生机构基本药物制度的健康发展。
3、基本药物可及性与可负担性影响因素分析
(1)基本药物可及性----“是否缺药”的影响因素分析：通过结构方程模型分析,基本药物配备品种数、基本药物采购、配送方式种类数、是否出台基层医疗卫生机构补偿办法是基层医疗卫生机构是否缺药的主要影响因素。经济状况越好的地区,基本药物配备品种数就越多,基本药物缺货状况越轻；出台了基层医疗机构补偿办法的地区,基本药物缺货状况相对较轻；2010年实施基本药物制度的基层医疗卫生机构缺药状况要比2011年开始实施的基层医疗卫生机构严重,这与单因素分析结果一致；针对基本药物的特点分别制定采购、配送政策,实行多种方式相结合的采购配送方式,基本药物缺货状况较轻,而执行单一招标采购、配送政策的机构,缺货状况较严重。
(2)基本药物可负担性——“平均处方费用”的影响因素分析：基层医疗卫生机构收入水平、合理用药水平、是否出台基层医疗卫生机构补偿办法和基本药物配备品种数为影响平均处放费用的主要因素。社会经济状况越好,平均处方费用越高；基本药物制度实施越早的基层机构合理用药水平越高,但其平均处方费用却相对较高；出台基层医疗卫生机构补偿办法有利于降低平均处方费用；机构配备的卫生技术人员越多,职工收入越高,合理用药水平就越高,从而使平均处方费用降低。而机构人力资源配备越强,机构提供的卫生服务量越多,服务水平越高,平均处方费用也就越高；基本药物配备品种数越多,平均处方费用越低。说明基本药物的配备及使用能有效降低平均处方费用。
4、东中西部基层医疗卫生机构基本药物制度实施进展与成效
(1)在机构基本情况方面,从人员编制、每万人口拥有的卫生技术人员数机构业务量、各项收入上看,总体为东部>中部>西部。东中西部均存在护士配置比例不足的问题,但总体西部优于中部,中部优于东部。中部和西部临聘人员问题比较突出,平均实际在职人员数分别高出核定编制数的28.58%和48.28%。实施基本药物制度前后,东中西部基层机构财政补助收入均明显增加。在药品收入上,除中部2011年开始实施基本药物制度的基层医疗卫生机构收入下降幅度较大以外,东西部差别均不明显。
(2)在基本药物制度实施成效方面,从基本药物可及性来看,基本药物配备的品种数总体为东部>中部>西部。而对缺货情况进行分析,则为东中部>西部。说明东中部配备的药品品种数虽然高于西部,但缺货现象仍然比西部严重。从基本药物可负担性来看,平均处方费用总体为东部>中部>西部。从在合理用药来看,总体东部好于中部,中部好于西部。在基本药物相关知识培训方面,东中西部培训力度存在明显差别。总体为东部>中部>西部。从综合分析来看,通过TOPSIS法和秩和比(RSR)综合分析东中西部基本药物制度实施情况,实施成效均为东部>中部>西部,且东部明显好于中西部。
政策建议
1、提高基本药物可及性方面
(1)进一步扩大基本药物的覆盖范围。将基本药物逐步推广到非政府办基层医疗机构中,重点加大村卫生室、社会零售药店中基本药物的销售比重。
(2)适当放宽药品品种范围。建议在国家和省增补目录的基础上,适当放宽基层医疗卫生机构用药品种范围,新增药品品种应该兼顾儿科、精神和肿瘤疾病等专科用药。建议借鉴福建省的相关经验,在确保疗效和合理用药的前提下,在金额和数量的“双控”监管下,按规定在突发事件急诊抢救和上级医院转诊患者就诊时使用一定比例的目录外药品。
(3)提高对基本药物生产配送企业的监督管理。加大对企业特殊基本药物供应能力的考核力度。加强采购配送的监督管理,通过建立健全药物信息监测管理系统,对招标采购和统一配送过程进行全程监管,鼓励企业内部尽快建立起常规性的药品储备机制,重点解决急救药品、价格低廉和市场需求量少的特需药品供应不足的矛盾。在激励措施中,应充分保护此类配送企业的市场利益,提高这些企业对短缺药品储备的积极性。要建立一个应急协调机制,及时对基本药物采购价格进行调整,以免出现因原材料价格上涨而造成药物供应短缺。
(4)建立短缺基本药物应急储备机制。通过市场化运作的方式,通过与大型医药批发经营企业合作的方式,建立国家级或者地区级的药品应急储备中心,动态调整药品储备的品种和数量,提高医药储备专项资金的使用效率,减少资金闲置与浪费现象的出现。
2、提高基本药物可负担性方面
(1)完善基本药物的招标采购工作。建立基本药物优质优价制度,改变现有的“唯低者得”的中标模式。
(2)完善医保支付方式的改革。努力提高基本药物在基层医疗机构内的补偿水平,提高药品的认可度。加快推进各种基本医疗保险信息化建设速度,尽量缩短医保机构与医疗机构费用结算的时间。
(3)尝试免费发放基本药物。在有条件的地区,在合理确定目标人群基础上,政府应该尝试向老年人或困难人群提供免费的基本药物,药品种类集中在高血压、糖尿病等常见病种。
3、改善合理用药方面
(1)科学合理遴选基本药物。建议选择部分常见病和多发病开展系统的循证医学和药品经济学评价。整个评价过程和结果应主动社会公开,接受医疗机构、药品企业和第三方鉴定机构的质疑。
(2)加大基本药物合理使用的培训力度。重点控制抗生素和激素类药品的滥用,并加大对中西部政策倾斜力度。同时,在基本药物制度影响范围不断加大的情况下,要将基本药物的合理使用培训逐渐向二、三级医疗机构推广,缓解目前由于药品品种、剂型、包装的不同所产生的用药差异,从而提高我国整体药品合理用药水平。
4、基层医疗卫生机构综合医改方面
(1)强化政府责任,稳妥推进改革。继续强化政府在推进医改工作方面的主导性,增加对基层医疗机构的直接财政投入力度。加强监督管理与评估机制建设,通过评估和及时反馈实施的成效,发现问题与不足,为制度制定及调整提供实证依据。
(2)增加基层卫生服务项目的绩效考核。以基本医疗卫生服务的数量、质量和群众满意度为核心,逐步建立起更为完善的绩效考核机制。考核结果与机构的财政补偿挂钩。进一步规范基层医疗卫生机构新增检查项目和诊疗项目工作,避免资源过度配置与浪费。
(3)加强基层卫生人才队伍建设。建立人才队伍资源整合机制,特别是加大中西部基层卫生人才队伍建设和东部支援中西部的力度,促进基层人才合理分布。合理设定卫生技术人员编制,着力解决临时聘用人员问题。完善绩效工资制度和考核办法,将人员聘用、岗位管理与服务质量和效果挂钩,建立体现绩效的分配激励和约束机制,逐步建立鼓励引导优秀人才留在基层的长效机制。
Background
Since China formally announced the "Implementation Opinions on the Establishment of National Essential Drug System" in August2009, the essential drug system covering the government-run primary health care institutions has been gradually established. This is to ensure the availability of essential drugs and promote grassroots comprehensive health care reform. In this context, the study further improve access to essential medicines, affordability, improve rational drug levels, improve the public welfare of the basic drug system and to achieve sustainable development of primary health care sector is particularly important.
The current research on the basic drug system in the macro level stays mostly in theory, and lack of data of a large sample, and the research in the micro level has remained mostly based on small sample descriptive study of the status of implementation and effects. The comparative studies to the implement status and effective based on the basic drug system are lacking, and research on the affecting factors on the essential medicines availability and affordability stays level on univariate analysis. The relationships between the factors and the degree of influence are not discussed.
Purposes
Basied on the National drug policies and essential drug system theory, as a means of empirical research, the overall goal of this study is to compare the status and effectiveness of the implementation of national essential drug system from the macro and micro levels, to analyze the key factors in the implementation of National Essential Drug System and provide a reference for the healthy and sustainable development of essential drugs system.
Methods
The data came mainly from literature review, self-administered questionnaires and reports on monitoring and evaluation of essential medicines in the twenty-six provinces. Self-administered questionnaires were mainly used to get data of the policy supporting environment, policy stipulations and results of policy implementation in the twenty-six provinces, as well as the results of survey on522grassroots medical and health facilities selected by the26provinces themselves in2010and2011. Analysis was made on the essential medicines policy environment and the basic status of policy implementation, on the effectiveness of the implementation of the essential medicines system in terms of the availability, affordability and the situation of rational administration of the essential medicines, to sum up experiences and find out the key factors affecting the effectiveness of implementation of the essential medicines system to provide empirical basis for improvement of the construction of the essential medicines system.
Data analysis methods include descriptive analysis and inferential analysis. Comparison between enumeration data rates was made with chi-square test measurement of non-normal data with non-parametric tests, and statistical significance level with α=0.05. On this basis, analysis was made comprehensively with structural equation modeling, TOPSIS and RSR methods.
Main Results and Findings
1、 Implement effectiveness analysis on the essential drug policy and grassroots comprehensive health care reform.
(1) Essential drugs policy formulation and implementation. Mechanisms for procurement and distribution of essential medicines had been gradually established However, the bidding and procurement patterns remained to be further improved. There were still problems concerning how to set evaluation criteria at the stage of economic and technical tender stage, problems of doping of inevitable subjective factors at the tender stage, and problems of uneven development between the enterprises who won the bidding which might be difficult in guarantee of the quality of the essential drugs. At the commercial bid stage, there might appear the phenomenon of bidders ring, or few people to participate in bidding or in the bidding ring, which often resulted in below-cost bids affecting the production and supply of these essential medicines. There were two forms of distribution of the essential medicines:direct distribution and entrusted distribution by the producers who won the bids. The average rate of distribution in place was87.66%. Failed auctions of some individual drugs and short of stock or supply in health institutions were seen seriously. The mean rate of failed auctions during the centralized bidding procurement of the essential medicines in the26provinces was15.04%, the maximum rate was77.04%
(2) The comprehensive integration for the reform at the grassroots health care facilities showed satisfactory progress, but the reform needs further.
In primary health care institutions of implementing the basic drug system, most agencies have implemented simultaneously setting a quota of staff posts, merit pay reform, health insurance compensation adjustment, general clinic fee adjustments and other supporting measures. Also, by increasing the compensation ratio of essential drugs, further reducing the economic burden of grassroots medical treatment, and effectively strengthen the public welfare of the primary health care service system. But there were still17.26%of the facilities got decreased financial subsidies or unchanged sum of subsidies compared to the previous year, with the decreased or unchanged ratio of financial subdidies being78%.Due to the lack of appropriate regulatory mechanisms, in the provinces of formulating new personnel and distribution systems, the implementation of primary health care institutions is relatively weak.
2. The implementation Effectiveness and Issues of the Essential Medicines System at the Grassroots Level Health Care Facilities
(1)In terms of access to essential medicines:All the26provinces had practiced the essential medicines system in the government-run grassroots level health care facilities. Secondly, the rate of supply (Chinese medicine50.87%, Western medicine67.36%) of the national essential medicines in the primary level health care facilities needs to be raised. Shortage of essential medicines was a serious issue in many health facilities (53.74%), which resulted in loss of the patients who need the certain medicines. Selected Essential Drugs List "irrelevant" and "not enough" situation coexist.
(2)Terms of affordability of essential medicines:The purchase price showed a trend of decrease compared with the average purchase price for the grassroots level set by the National Development and Reform Commission, recommended retail price of essential medicines, and the purchase price over the same period last year. However, the bidding and procurement patterns remained to be further improved. The average cost of prescription and drug cost of outpatients January to September in2011have a downward trend over the same period in primary health care institutions. And the downward trend is more pronounced in primary health care institutions beginning to implement the essential drug system.
(3)Primary health care institutions rational use of medicines:After the implementation of the basic drug system, primary health care institutions rational drug situation continued to improve. The rational drug use in Community Health Center is generally better than township hospitals. Differences were statistically significant (p <0.000). However, due to the lack of drug regulatory evaluation mechanism, irrational drug phenomenon still exists in part of primary health care institutions. And due to lack of training funds, the depth and width of training of essential drugs greatly reduced. To some extent, the improving of the rational use of drugs has been affected.
(4)The development of Primary health care institutions:The sustainable development of primary health care services has been enhanced. There presented in the grassroots health care facilities a trend of "four increases, three decreases and one improvement", namely, increase in person-times of outpatient and emergency visits, increase service items, increase in institutional income and increase in average personnel income; decrease in medicine constituted income, decrease in the average cost of prescription and decrease in cost of outpatient and emergency drugs; and, improvement in rational application of drugs. So the benefit of the essential medicines system appeared gradually. But basic health professionals configuration structure is irrational, personnel quality is not high, township hospitals temporary employment issues is outstanding,, there is a tendency to over-provisioning of resources, such as the significant increase in checks and treatment programs. All of them have been affecting the healthy development of the basic drug system in the primary health care institutions.
3、 The influencing factors analysis of availability and affordability of essential medicines
(1)The access to essential medicines----The influencing factors analysis of lack of medicine:By structural equation modeling analysis, better economic conditions, the more of the number of varieties of essential drugs, and the more light of the lack of essential drugs; in the region of developing a grassroots medical institutions remedies, essential drugs out of stock situation is relatively light; The lack of medicine in primary health care institutions beginning to implement the basic drug system in2010is more serious than the institutions beginning to implement the basic drug system in2011. This analysis is consistent with the results of single factor; The lack of medicine in the areas of developing procurement and distribution policy according to the characteristics of essential drugs is lighter than the areas of performing a single tender procurement and distribution policy.
(2)The affordability of essential medicines----The influencing factors analysis of "the average prescription costs": The better the socio-economic situation, the higher the average prescription costs; The earlier the implementation of basic drug system, the higher the rational drug levels, but the average prescription cost is relatively high. Developing a grassroots medical institutions remedies helps to reduce the average prescription costs; more health technicians or the higher the income of workers, the higher the level of rational drug use, so that the average prescription costs reduced. But the higher the quality of human resource, the more volume of services provided by health institutions, the higher the service level and the higher the average prescription costs; The more variety number of essential drugs, the lower the average prescription costs. This shows that reserves and use of essential drugs can effectively reduce the average prescription costs.
4、 The implementation Progress and Effectiveness of the Essential Medicines System in the Eastern, Western and Central Regions of China
(1) In the basic situation of institutional, Viewing from staffing per10,000population, the eastern region was superior to the Central, and the Central superior to the Western. All the Eastern, the Western and the Central regions of China had deficiencies in the proportion of nurses. Relatively speaking, the problem was less serious in the Western than that in the Central, and less serious in the Central than that in the Eastern. In the Central and Western regions, the problem of temporary employment was more prominent, the average number of staff in-service was higher than the actual number of staff, being28.58%and48.28%more than the government authorized strength respectively. Average outpatient visits varied greatly among the three regions, the number of visits in the Eastern region was significantly higher than that in the Central and Western regions, and there was no significant difference between the Central and the Western. Viewing from more admissions, the order was the Eastern, the Central and the Western, and the same to the income. Little changes could be seen in volumes of services after the implementation of the essential medicines system, though the overall volume of services had a little increase compared with the previous years. Funds of government financial subsidies were significantly increased. Medicine-based income had an apparent decline in the primary level health facilities in the Central region since the implementation of the essential medicines system in2011. However, there was no obvious change in the Eastern and Western health facilities.
(2) Judging from more provisions of species of the essential medicines, the order should be the Eastern, the Central and the Western. The problem of shortage of the medicines was more serious in the Eastern and central regions, indicating that though the provision of medicine species was better in the Eastern and Central regions, shortage of the drug store was more serious thatn that in the Western region. On average prescription costs, the order was the Eastern, the Central and the Western. And for the better rational use of drugs, the order was also the Eastern, the Central and the Western. There were obvious differences between the three regions in training on essential medicines-related knowledge. The Eastern region was better than the Central, and the Central better than the Western.
Recommendations for Policy Making
1、 To improve the access to essential medicines
(1)Further expand the coverage of basic drugs. The essential drugs should be gradually extended to non-government-run primary health care institutions, increase the sales proportion of essential drugs in village clinics, community retail pharmacy。
(2)Appropriate to relax the varieties range of drugs. Evidence-based research on decision of the list of the essential medicines should be strengthened. There should be more space for the grassroots level health care facilities to select drug species. Under the premise of ensuring rational use and efficacy of medicines, and under the control of supervision and management on price and quantity, permission should be considered to give the grassroots health care facilities in administration of certain portion of medicines "not" on the list for unexpected events, emergencies, and referral patients.
(3) Strengthen the supervision and management to essential drugs delivery business. Increase the assessment efforts of supply ability of special essential drugs. Strengthen supervision and management of procurement and distribution. Through the establishment of a sound management system for monitoring drug information, to supervise and manage the bidding and uniform distribution so as to improve the rate of essential drugs in primary health care institutions. To build up an emergency coordination mechanism, timely to adjust the procurement prices of essential drugs so as not to appear a shortage of supply of drugs due to rising raw material prices.
(4) Establishing a contingency reserve system to the shortage essential drugs. By the way of the market works, and large pharmaceutical wholesale enterprises cooperation, establishing a national or regional emergency medicine reserve center, dynamically adjusting the type and quantity of drugs reserves, in order to improve the efficiency of medical reserve special funds, to reduce the appearance of the phenomenon of idling and waste of funds.
2、 To improve the affordability of essential medicines
(1) Improving the Bidding and procurement of essential drugs. A price-quality competitive system should be established to change the existing mode of "only bidder with low price" can win.
(2) Improve the Medicare payment reform. To improve the level of compensation of essential drugs in primary health care institutions, improve recognition of drugs. We should accelerate the information construction speed of various basic medical insurances, so as to shorten the time of cost clearing between insurance agencies and medical institutions.
(3)Try the free distribution of essential drugs. In areas where conditions permit, on the basis of determining the reasonable target population, the government should try to provide free basic drugs to the elderly or vulnerable groups. The types of drugs focus on hypertension, diabetes and so on.
3、To improve the rational use of medicines
(1) Scientific and rational selection of essential drugs. To carry out systematic evaluation of evidence-based medicine and pharmaceutical economics on some common and frequently occurring diseases. The process and the results of evaluation should be carried out under the supervision of the public and accept the questioning of medical institutions, pharmaceutical companies and third-party accreditation bodies.
(2)Increase training of rational use of basic medicines. Focusing on the control to the abuse of antibiotics and hormones drugs and increase the Midwest policy support. Meanwhile, under the influence of the basic drug system continuously improves, the training on rational use of essential medicines should be gradually promoted to secondary and tertiary health institutions. Reducing the errors generated by the difference of drug products, formulations, packaging, so as to improve China's overall level of rational use of basic drugs.
4、 Comprehensive health reform in primary health care institutions
(1) The government responsibility should be strengthened, top level program design should be improved, and the health reform should be pushed forward steadily. Integration and cooperation among different sectors and systems should be promoted. Construction of supervision and management system and evaluation mechanism should be enhanced. Experiences and practical methods of implementation of the essential medicines system should be explored. Evaluation should be carried out and feedback of effectiveness should be provided timely to find out obstacles and issues so as to provide basis for establishment and adjustment of the evaluation system.
(2) Increasing performance evaluation of primary health services. We should take the number and quality of basic health services and public satisfaction as the core, and gradually establish a more comprehensive performance assessment mechanism. Financial compensation to institutions links to the assessment results. Further regulate the new inspection program and clinic project in primary health care institutions to avoid over-provisioning and waste of resources.
(3) Long-term development mechanism of the essential medicines system and integrated human resources mechanisms should be built up. Efforts should be made on enhancement of health personnel recruitment in the Central and Western regions, and especially on enhancement of supporting the Central and Western regions by the Eastern region qualified personnel to promote the rational distribution of human resources. Priority should also be given to policy and financial support to the grassroots health care facilities in establishment of mechanism for reasonable training, introduction, selection and use of personnel, and for encouraging the qualified personnel to stay at the grassroots. The employment system should also be reformed with reasonable personnel quotas to solve the problems of temporarily employed staff.
(4)Improve the supervision and management mechanism. Promote the standardization of basic medical services management, strengthen financial supervision, standardize the behavior of income and expenditure, and gradually establish comprehensive performance evaluation mechanism that takes quality and quantity of services as the core and contains professional evaluation, supervision and evaluation of community supervision. Develop and improve the performance pay system and assessment methods, associating the personnel hiring and job management with service quality and effectiveness, establishing performance incentive and restraint mechanisms.
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