我国农村地区基本药物供应保障体系研究
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摘要
研究背景
自20世纪70年代始,WHO基本药物政策为基本药物供应保障体系建设提供了丰富的实践经验,但是基本药物可及性、质量保证和合理用药一直是全球性问题。我国农村地区药品供应历经县或市招标采购、药品供应网和监督网建设,但是基本药物不可及、药品质量隐患和不合理用药等问题一直未得到有效解决。为此,我国自2009年启动基层医疗机构基本药物供应保障体系建设,目标是保证基本药物的可获得、可负担、质量保证和合理用药。安徽省和山东省分别于2009年12月和2010年3月启动该项工作,实行了零差价销售、集中招标采购、政府补助、药品使用等一系列政策,产生了一定效果,也出现了很多非预期结果。
目前基本药物供应保障体系制度安排、协调机制、激励机制、运行结果四个方面研究主要以政策、机构等为研究对象,围绕公共政策理论、WHO调查方法和研究框架来开展。现有研究尚缺少对基本药物供应保障体系基本理论和逻辑框架的剖析、未发现对该体系交易费用的研究,而制度经济学中的交易费用理论以交易为研究对象,可以将上述四个方面的研究整合为一个分析框架,从而提高理论的解释能力。因此,本论文将基于交易费用理论,从人性假设和行为逻辑出发,将基本药物供应保障体系交易关系整合为交易环节、路径、机制,建立解释该体系的制度分析新框架,并且通过交易费用测算进行实证研究,检验和完善分析框架的内在逻辑。
因此本研究提出以下三个研究问题：(1)基本药物供应保障体系预期通过怎样的制度安排达到怎样的政策目标?(2)基本药物供应保障体系实际运行结果是怎样的,和预期的制度设计有什么差距?(3)基本药物供应保障体系的交易费用是如何导致非预期结果出现的?
研究目的
本论文的总目标是通过理论研究和实证分析,探讨我国农村地区基本药物供应保障体系的制度安排是如何通过协调、激励机制改变交易费用,进而影响利益相关者的行为和政策运行结果,最终为该体系形成良好的制度安排提供理论基础和科学依据。具体目标是：构建我国农村地区基本药物供应保障体系制度设计、交易费用和运行结果的分析框架；揭示样本地区基本药物供应保障体系的制度设计特点；分析现行制度设计下基本药物供应保障体系运行结果；模拟测算基本药物供应保障体系交易费用及其结构,探索制度设计与实际运行结果产生差距的原因及路径；提出完善基本药物供应保障体系的政策建议。
研究方法
本研究主要采用二手资料和现场调查数据来验证假设。二手资料主要包括：国家和样本地区基本药物相关政策文件以及研究文献,中国统计年鉴(2011)、山东省统计年鉴(2011)、中国医药统计年报(2009)、山东省基层医疗机构集中采购数据(2011.05.01-10.31)、山东省140县乡镇卫生院业务运行情况数据(2009-2010)等。现场调查采用目的抽样方法在安徽和山东两省收集定量、定性数据,根据经济状况、地域分布、基本药物供应保障体系的制度差异,从安徽省和山东省各抽取3个县,按同样原则前者每县分别抽取2个乡镇卫生院,后者每县抽取3个乡镇卫生院。定量数据主要包括被调查乡镇卫生院财务和业务报表、药品入库单与库存、改革前后基本药物价格调查(安徽和山东省分别随机抽取154、166个样本)、改革前后处方抽查(安徽和山东省分别随机抽取2098、1832张)、患者调查(安徽和山东分别调查72、117人)等。定性数据主要包括焦点小组讨论和关键人物访谈,前者包括3家药品生产企业、7家药品配送企业的讨论；后者包括对两省省卫生厅、省药品集中采购服务中心、县卫生局行政管理人员,乡镇卫生院院长、医生、药剂科主任等关键人物共58人访谈。
本论文分析过程由三部分组成。第一部分是对样本地区基本药物供应保障体系制度安排和制度设计的归纳和总结,资料主要来自政策文件分析、研究性文献、安徽和山东两省和样本县卫生行政管理人员的关键人物访谈。第二部分是分析样本地区基本药物供应保障体系的预期结果和非预期结果,资料来源主要是安徽和山东两省现场调查数据。第三部分是以山东省数据模拟测算和分析基本药物供应保障体系的交易费用,通过定性资料来识别各交易环节中的交易活动及其功能,并根据交易费用理论对交易活动进行归类,形成交易费用测算的初步框架。按此框架,将山东省基层医疗机构集中采购数据、山东省140县乡镇卫生院运行情况数据、中国统计年鉴(2011)和山东省统计年鉴(2011)相关人员年工资收入整合为交易费用测算数据库。然后结合相关访谈、焦点小组讨论分析交易费用对利益相关者行为、运行结果所产生的影响。最终综合制度分析框架、实证分析得出制度安排与政策结果之间的逻辑路径。
主要研究结果
1.基本药物供应保障体系制度安排与制度设计。该体系实质上为政府主导下解决农村药品供应体系购药渠道混乱、药品品种短缺等问题的层级制,其采用的主要方法是分解原体系存在的问题为不同利益相关者的功能。具体制度设计如下：政府通过招标来显示患者的需求；政府通过组织药品生产企业、药品配送企业和乡镇卫生院等来实现供给；同时,政府通过控制激励机制来保证基本药物供应保障体系的个体利益与整体利益的兼容,最终提高大众健康水平。
2.基本药物供应保障体系的预期结果是：(1)可获得性方面：基本药物的品种可获得基本得到解决,主要归因于单一货源承诺、强制配备和使用基本药物的相关政策。招标环节国家基本药物目录安徽和山东两省中标比例分别为89.25%、91.21%,特殊渠道采购的基本药物未进行招标；在配送环节跨市配送企业、市内配送企业较好满足了中标基本药物品种可获得性。(2)可负担性方面：患者负担有所减轻,主要归因于招标环节的最低价中标、供应链的强制使用和零差价政策。招标环节安徽和山东省化学药品和生物制品价格都集中在0-3元区间,构成比分别为66.11%、65.22%采购环节,改革前安徽和山东基本药物平均加成分别为101.89%、50.72%,改革后降为0,采购价格下降幅度均值分别为25.12%、28.85%；使用环节次均处方费用下降,患者反映负担减轻的人员比例较大。(3)质量保证方面：样品留样备案和后续抽验监管措施防止了假劣药的出现。(4)合理用药方面：基本药物的平均使用率和通用名使用率均上升,其余合理用药指标均呈下降趋势,主要归因于基本药物的使用政策。
3.基本药物供应保障体系的非预期结果是：(1)可获得性方面：基本药物的品规、及时可获得性较差。招标环节基本药物每通用名中标品规安徽和山东分别为3.13、2.24,小于政策规定的最大值6,限制了患者的需求；采购环节安徽和山东省国家基本药物中标品规配备率分别为26.49%、39.35%,山东省国家基本药物中标通用名配备率平均为56.43%；基本药物的及时配送还难以达到政策规定的三日到货,跨市配送的供应及时性尤其不好。(2)可负担性方面：中成药、部分化学药品、部分患者负担没有减轻。招标环节,无论是价格绝对数、价格区间、最高价位前十种药品,中成药价格高的构成比均高于化学药品；改革前后采购价格比较,安徽和山东价格上升的基本药物构成比分别为31.17%、26.51%,且上升的幅度大于下降的幅度。(3)质量保证方面：中标基本药物大部分质量层次偏低,存在逆向选择。排名400以后的企业在安徽和山东两省国家基本药物中标比例分别为71.09%、65.10%,品规中标比例分别为60.45%、54.31%；两省最高价前十位药品质量层次偏低,而在山东还出现了最低价前十位质量层次相比高价位高,也即质量层次高的企业易中低价药品,而质量层次偏低企业易中高价药品。(4)合理用药方面：相关指标不稳定、可待改进的空间还很大。
4.制度设计与运行结果之间差距的交易费用解释：由于基本药物供应保障体系多层多任务委托代理关系在制度和技术两个层面的复杂性,这导致制度运行的结果除基本药物的品种可获得性、可负担性降低外其余政策目标更多的是预期之外的。
制度层面的路径主要包括：需求显示路径供需双方主要靠价格协调,但是多层委托代理拉大了患者和供方之间的距离,导致患者需求信息难以传达；供给实现路径由于零差价销售,供需从价格协调变为数量协调,协调手段主要有合同、谈判、企业内管理、机构间沟通等,尤其缺少库存信息,不但影响患者用药需求,也造成积压、浪费、资金过多占用；供方激励路径扭曲了招标环节不同质量层次企业间的竞争关系,产生了逆向选择,并且导致生产企业和配送企业的利益分配和风险分担不利于配送企业,同时外省企业中标增多增加了交易协调的难度、道德风险发生的概率,从而提高了交易费用,使基本药物难以及时配送到乡镇卫生院；需方激励路径政府补助激励不足、新农合政策模糊,导致难以达到合理用药的预期目标。
技术层面的路径主要包括：采购规模的集中程度、市场主体的一体化程度等影响了交易频率、资产专用性,从而影响交易费用,产生了非预期后果；信息化建设中库存信息、交易信息、信息共享、监督信息的完善程度影响了各利益相关者受理性约束的程度、发生机会主义的概率,从而影响了交易费用,产生了非预期后果。
结论和政策建议
我国农村地区基本药物供应保障体系主要组合使用政府、市场和企业等不同协调和激励手段来缓解或控制有限理性、逆向选择和道德风险的危害,最终整合利益相关者目标为体系目标。但是,需求显示路径以价格协调为主、供给实现路径以数量协调为主的方式加大了委托代理的层次、生产企业供应第一责任人制度设计失灵,从而导致招标环节出现了逆向选择、供方和需方行为受到扭曲、正常的市场竞争秩序受到干扰。尤其是政府介入配送关系建立、基本药物日常采购、回款环节增加了问题的复杂程度和药品配送企业、乡镇卫生院的道德风险行为。而在技术方面,信息系统缺少库存信息减少了利益相关者之间的监督,为后续改革日益重要的库存管理埋下了隐患。
为了形成基本药物供应保障体系的良好制度安排,本论文提出以下政策建议：
1.协调机制的政策优化：(1)取消“全国统一市场”的规定,以生产企业的生产和质量保证能力为唯一准则；(2)双信封商务标中的“最低价中标”替代为成本效果价格；(3)3元以下基本药物取消零差价销售；(4)供给实现路径应给予市场以制度创新的空间,政府主要起督导和监管供给行为和质量的作用；(5)“单一货源承诺”改为“供应承包”加强药品生产企业的责任；(6)招标周期应该适当延长以培养供应链的协同能力；(7)在信息化系统设置虚拟库存管理加强参与方的责任和互相监督；(8)优化采购区域和时点形成规模采购。
2.激励机制的优化：(1)通过调整相关政策给药品生产企业、药品配送企业提供更好的制度环境；(2)通过税收减免提高生产和配送企业的收入；(3)通过政府补助、医生绩效工资与患者健康改善挂钩,再辅之以非货币化的激励措施来达到乡镇卫生院合理使用基本药物的目的；(4)通过基本药物报销补偿与总费用报销挂钩、患者教育使患者的需求得到更好的显示。
3.制度分析框架和交易费用测算方法在政策优化中应用的建议：(1)应用制度分析框架诊断基本药物供应保障体系存在的问题；(2)应用交易费用测算方法识别影响体系运行的关键变量。
创新与不足
本研究创新性：
1.目前理论缺少剖析基本药物供应保障体系的基本理论和逻辑框架。本论文基于制度经济学理论,首次建立了对该体系进行剖析的制度分析框架,以期寻找到相应制度安排通过协调和激励机制约束利益相关者行为、控制交易费用、平衡需求和供给,达至体系目标的传导路径。
2.目前尚未发现基本药物供应保障体系交易费用测算研究。本论文基于制度分析框架和交易费用理论,首次研制了适用于基本药物供应保障体系的交易费用测算方法,从机制、路径、交易环节、交易关系、制度类型、控制功能等多角度测算交易费用结构。
3.以不同于传统方法的基本药物供应保障体系交易关系为研究视角,通过制度分析框架和交易费用测算方法来系统分析该体系存在的制度问题、技术问题,为深化基本药物供应保障体系建设提供科学证据。
本研究不足及展望：
1.交易费用测算部分参数根据访谈估计,精确性方面可能有偏差,但是测算结果符合基本药物供应保障体系的运行逻辑。将来可以通过长时期跟踪不同类型的生产、配送企业来获取更为精确的测算参数。
2.交易费用分析主要采用描述性分析,原因主要是基本药物供应保障体系建立时间短,现有数据不适宜采用统计技术来处理。将来可以考虑用结构方程模型验证变量之间的因果关系。另外,也可以采用地理信息系统、区域经济学和社会网络技术测定地理区位、空间、社会资本等因素对交易费用的影响。
Background
Since the1970s, the essential medicine policy of World Health Organization provided the abundant practical experiences for supply security system of essential medicine in the world, but access, quality assurance and rational use of essential medicine have been the global problems. Although the pharmaceutical supply in rural China had been undergone the stage of tender for the county or municipal level and pharmaceutical supply and regulation network for the county level, above-mentioned problems existed for a long time. In2009, Chinese government started the construction of supply security system of essential medicine in the primary health care sector in order to solve these problems and ensure the availability, affordability, quality assurance and rational use of essential medicine. Anhui and Shandong province reformed their supply security system of essential medicine according to the relevant laws in the December2009and the March2010respectively. The main policies include zero-markup sales, bidding and procurment, government grants, pharmaceutical use and etc. These policies produced a certain effectiveness and much more unexpected results.
At present, policy, organization and etc. has been studied on the institutional arrangement, coordination mechanism, incentive mechanism and implementation effectiveness based on the research framework of public policy, WHO survey methodology. The above-mentioned research is still lack of the basic theory and logical framework on the supply security system of essential medicine. Especially the study on transaction cost is not found in the area of pharmaceutical policy. Transaction cost theory of the institutional economics can integrate four kinds of studies into an analytical framework to study transaction relationship. This research path will improve the explanatory power of theoretical framework. Therefore this thesis will combine the transaction relationship into process, path and mechanism to construct new institutional analytical framework in order to explain the unexpected results of supply security system of essential medicine from the human assumptions and behavior logic based on the transaction cost theory. On this basis, transaction cost is measured to obtain empirical evidence to validate the internal logic of the analytical framework.
So this study presented the following three research questions.(1) Which kind of policy objectives is expected to attain through what kind of institutional arrangements?(2) What are the practical results of supply security system of essential medicine? What are the gaps between expected objectives of institution design and practical results in real world?(3) How do transaction costs of supply security system of essential medicine lead to the emergence of unexpected results?
Objectives
The general objective of this thesis is to explore how to generate the unexpected results through institutional arrangement, transaction cost to implementation effectiveness based on the institutional analytical framework and empirical evidence, in order to put forward theoretical basis and scientific evidence on optimizing institutional arrangements of supply security system of essential medicine. The specific aims include:to construct institutional analytical framework of supply security system of essential medicine in rural China; to reveal the characteristics of institutional design of this system; to analyze practical implementation effectiveness of this system; to measure the transaction cost of this system simulatly in order to explore the causes and logic path generated the gap between institutional design and practical implementation; to put forward optimization suggestions on this system.
Methods
This study used secondary data and field survey data to test hypotheses. The secondary data include:policy documents and research literatures on essential medicine policy; China Statistical Yearbook2011; Shandong Statistical Yearbook2011; China Medical Statistical Yearbook2009; centralized procurment data (2011.05.01-10.31) at primary health care sector in Shandong province; business operation data (2009-2010) at township hospitals in Shandong province and etc. The quantitative and qualitative data in the field survey were collected in Anhui and Shandong province. A total of6township hospitals in Anhui province and9township hospitals in Shandong province were selected as the study sites based on purpose sampling according to the economic level, geography distribution and institutional difference of supply security system of essential medicine. The quantitative data includes:financial and business report at the sampling township hospitals; pharmaceutical storage records; price survey of154and166samples before and after essential medicine reform respectively in Anhui province and in Shandong province based on random sampling; prescription survey of2098and1832samples before and after essential medicine reform respectively in Anhui province and in Shandong province based on mechanical sampling;72and117patients survey respectively in Anhui province and in Shandong province. The qualitative data were collected by focus group interview and key informant interview. The focus group interviews were organized for three pharmaceutical manufacturing companies and seven distribution enterprises. The key informant interviews were carried out with58persons, including department of health, provincial pharmaceutical centralized bidding center, and county health department, township hospital in Anhui and Shandong province.
The analytical process of this thesis was consisted with three parts. The first part was to summarize the characteristics of institutional design and institutional arrangement in the sampling sites through the method of policy analysis, literature review and key informant interview. The second part was to analyze the expected effectiveness and unexpected results through the field survey data. The third part was to measure and analyze transaction cost of supply security system of essential medicine based on the quantitative and qualitative data in Shandong province. The measure steps were as follows:to indentify the transaction activity and function in the transaction process through the quantitative data; to construct the preliminary framework of measuring transaction cost of transaction activity according to the transaction cost theory; to consolidate China Statistical Yearbook2011, Shandong Statistical Yearbook2011, centralized procurment data (2011.05.01-10.31) and business operation data (2009-2010) at township hospitals into database for measuring transaction cost; to analyze the institutional effects between the stakeholder's behavior and implementation effectiveness arising from transaction cost; finally to deduce and summarize the logic path between institutional arrangement and implementation effectiveness.
Main results
1. Institutional arrangement and institution design for supply security system of essential medicine was as follows. This system was hierarchical organization led by government in order to solve the problems such as purchasing channel confusion and pharmaceutical shortage. The institutional design planed to decompose the existing problems into different function of different stakeholders. The specific institutional design was as follows:to reveal the demand of patients through the bidding and tender; to realize the supply by organizing the pharmaceutical manufacturing companies, distribution enterprises and township hospitals under the leadership of government; at the same time, to control the incentive mechanism in order to make supply-side and demand-side compatible between individual interests and overall interests; to improve the level of public health ultimately.
2. The expected effectiveness of supply security system of essential medicine was as follow. Firstly, varieties availability of essential medicines had been basically solved mainly due to the policies of single goods source commitment and compulsory equipment and use of essential medicines. In the process of tender, the successful tender rates of national essential medicine list were89.25%,91.21%respectively in Anhui and Shandong province. The essential medicines at special procurement channel did not tender at the process of the current centralized bidding. In the process of distribution, cross-municipal or municipal distribution companies met the variety availability of tendered essential medicines. Secondly patient affordability reduced mainly due to the policy that lowest price would be successful tender and there was zero-markup price and drug use policy at the supply chain of essential medicine. In the process of tender, the price of chemicals and biological was concentrated between￥0and￥3, whose proportion was66.11%、65.22%respectively in Anhui and Shandong province. In the process of procurement, before reform the average markup was101.89%,50.72%respectively in Anhui and Shandong province. After reform of essential medicine policy the markup was reduced to0, the declining extent of procurement price was25.12%,28.85%respectively in Anhui and Shandong province. In the process of clinical use of essential medicine, average prescription costs decreased and larger portion of patients reflected the affordability to be mitigated. Thirdly, sampling records institution before the essential medicines were produced and sampling test institution after the ones were produced ensured quality and prevented the emergence of counterfeit drugs. Finally, the average utilization rate of essential medicine and generic name was rising and the other indicator of rational use was declining mainly due to use policy of essential medicine.
3. The unexpected results of supply security system of essential medicine were as follow. Firstly, there were no better availability on the specification and timely delivery of essential medicine. In the process of tender, the successful tender specification every generic name was3.13,2.24, which was lower than6in essential medicine policy. This impacted the demand of patient. In the process of procurement, the specification equipment rate of successful tendered essential medicine was26.49%,39.35%respectively in Anhui and Shandong province. In Shandong province, the variety equipment rate of successful tender essential medicine was56.43%on average. In the process of distribution, the timely delivery of essential medicine was no better, especially cross-municipal distribution was the worst in all kinds of distribution models. Secondly, the affordability of part of proprietary Chinese medicines, chemical medicines and patients did not reduce. In the process of tender, no matter what absolute price, price range, or what the highest price before the ten drugs, the proportion of proprietary Chinese medicines prices were higher than the chemicals. In the process of procurement, through comparing the purchase price before and after the reform, this thesis found that the proportion of price rising of essential medicines was31.17%,26.51%respectively in Anhui and Shandong province. Furthermore, the extent of price rising was higher than that of price declining. Thirdly, there was adverse selection among the successful tender essential medicine. The proportion of successful tender essential medicine was71.09%,65.10%from manufacturing companies rank after400;60.45%,54.31%from specification respectively in Anhui and Shandong province. The highest price ten essential medicines were produced by the low quality level of the companies in two provinces. At the same time, the quality of the lowest price ten essential medicines were higher than that of the highest price ten essential medicines. Finally, the indicator of drug rational use was unstable and was room for improvement.
4. The explanation for the gap between institution design and unexpected results based on transaction cost theory. Because multi-layer multi-task principal-agent relationship of supply security system of essential medicine had the complexity from institutional impact factor to technological one, only variety availability and affordability improved significantly.
The institutional path was mainly including:Firstly, in the path of demand revealing, supply-side and demand-side mainly coordinated with price mechanism. But multi-layer principal-agent widened the distance from patients to supply-side which led patient demand to be unrevealed. Secondly, in the path of supply realizing, owing to zero-markup policy, the former price coordination mechanism was replaced with quantity coordination. The coordination means mainly included contract, negotiation, management within the enterprise and communication between the manufacturing companies, distribution enterprises and township hospitals. Especially, lack of inventory information had adverse impact on the medication needs of patients, backlog, wasting and improper occupancy of operational funds. Thirdly, in the path of supply-side incentive, the institutional design of tender distorted the competitive relationship between the different quality levels of companies to produce the adverse selection. In addition, the institutional design of tender made the distribution of benefit and risk-sharing between manufacturers and distributors unbeneficial to distribution enterprise. At the same time, the majority of successful tenders from the other provinces increased the difficulty of coordinating transactions and the occurrence probability of moral hazard, which increased transaction cost to make timely delivery of essential medicines to township hospitals difficultly. Finally, in the path of demand-side incentive, the shortage of government grants and the fuzzy of the new rural cooperative policies did not lead to attain the expected goals.
The technological path was as follows. Firstly, the concentration of procurement scale and integration of market stakeholders affected the transaction frequency and asset specificity, thus affected transaction cost to result in unexpected consequence. Secondly, the construction degree of the inventory information, transaction information, information sharing and monitoring information affected the constraint of the bounded rationality and the occurrence probability of opportunism, thus affected transaction cost to result in the unexpected consequence.
Conclusions and Recommendations
The supply security system of essential medicine combined the different coordination and incentive means of government, market and enterprise in order to mitigate the bounded rationality and to control opportunistic behavior of the adverse selection and moral hazard so that the goals of this system would be achieved. But, the price coordination mechanism of demand-revealing path and the quantity coordination mechanism of supply-realizing path widened the layer of principal-agent relationship and led the first responsible person of supply for manufacturing companies to institutional failure. The above-mentioned institutional problems increased the probability of adverse selection, distorted the behavior of supply-side and demand-side, interfered with the normal order of market competition. Especially, the role of government increased the complexity of problem and the probability of moral hazard behavior of distribution enterprise and township hospitals in the process of establishing the contract relationship between the manufacturing companies, distribution enterprises and township hospitals, routine procurement and repayment. In terms of technology, lack of inventory information lessened mutual supervision and planted a hidden danger for the follow-up reform with inventory management more and more importantly.
In order to take shape good institution arrangements for the supply security system of essential medicine, this thesis put forward some suggestions.
1. The recommendations on the policy optimization of coordination mechanism were as follows.(1) To cancel the provision of the united nation market and to make production and quality assurance capabilities of manufacturing companies only as the criterion of successful tender.(2) To replace the criterion of lowest price successful tender in business standard of double envelopment with cost-effective price.(3) To cancel zero-markup sales of essential medinces whose price is lower than￥3.(4) To provide institutional innovation space for market stakeholders and to restrict the role of government only as regulator in the supply-realizing path.(5) To substitute the policy of single goods source commitment for that of supply contract in order to strengthen the responsibility of pharmaceutical manufacturing companies.(6) To extend appropriately the tender cycle in order to cultivate collaborative supply chain.(7) To set up the virtual inventory management to strengthen the responsibility and mutual supervision of the stakeholders in the information management system of essential medicine supply.(8) To optimize region and time to form scale procurement.
2. The recommendations on the policy optimization of incentive mechanism were as follows.(1) To provide the better institutional environment for manufacturing companies and distribution enterprises by adjusting the relevant policy.(2) To increase the net benefit of manufacturing companies and distribution enterprises by tax relief.(3) To establish contact between government grants, pay for performance and health level of patients, complemented by the non-monetary incentives to achieve the purpose of rational use of essential drugs at the township hospitals.(4) To make the demand of patients be revealed much better by patient education and reimbursement incentive of new rural cooperative medical system.
3. The application recommendations to policy optimization using institutional analysis framework and transaction cost measurement method were as follows.(1) To apply the institutional analysis framework for diagnosing the relevant problems of supply security system.(2) To identify the key variables affecting the operation of this system. Innovations and Limitations
The innovations include:
1. Currently there was no basic theory and logical framework to analyze the supply security system of essential medicine. Based on the theory of institutional economics, this thesis constructed the institutional analysis framework in order to explore the logical path from the institutional desingn to the goal of the system that coordinational and incentive mechanism constraints stakeholder behavior, constrols the transaction cost and balances the demand and supply.
2. The current research of essential medicine policy did not carry out the study of transaction cost measurement. This thesis was the first attempt to develop the methodology system to measure the structure of transaction cost from the perspective of mechanism, path, transaction process, transaction relationship, institutional type and control function.
3. This thesis analyzed systematically the institutional and technical problems from the new study perspective of transaction relationship based on the institutional analysis framework and measurement method of transaction cost to put forward scientific evidence for the supply security system of essential medicine.
The limitations include:
1. Some parameters of the transaction cost measurement are estimated based on the focus group and key informant interviews. This can affect accuracy to be deviated. But measurement results meet the implementation logic of supply security system of essential medicine. In the future, the further researches should obtain more accurate estimates on the parameters by tracking different types of pharmaceutical manufacturing companies and distribution enterprises for a long time.
2. Because supply security system has been constructed for a short time, the analytical method of transaction cost data was not suitable to deal with statistical model technology. This thesis mainly deals the above-mentioned data with descriptive analysis. On one hand, the further researches should verify the casual relationship using the structural equation model. On the other hand, the further researches should use geographic information systems, regional economics and social network analysis techniques to help determine geographic location, space, social capital and other factors on the impact of transaction costs.
自20世纪70年代始,WHO基本药物政策为基本药物供应保障体系建设提供了丰富的实践经验,但是基本药物可及性、质量保证和合理用药一直是全球性问题。我国农村地区药品供应历经县或市招标采购、药品供应网和监督网建设,但是基本药物不可及、药品质量隐患和不合理用药等问题一直未得到有效解决。为此,我国自2009年启动基层医疗机构基本药物供应保障体系建设,目标是保证基本药物的可获得、可负担、质量保证和合理用药。安徽省和山东省分别于2009年12月和2010年3月启动该项工作,实行了零差价销售、集中招标采购、政府补助、药品使用等一系列政策,产生了一定效果,也出现了很多非预期结果。
目前基本药物供应保障体系制度安排、协调机制、激励机制、运行结果四个方面研究主要以政策、机构等为研究对象,围绕公共政策理论、WHO调查方法和研究框架来开展。现有研究尚缺少对基本药物供应保障体系基本理论和逻辑框架的剖析、未发现对该体系交易费用的研究,而制度经济学中的交易费用理论以交易为研究对象,可以将上述四个方面的研究整合为一个分析框架,从而提高理论的解释能力。因此,本论文将基于交易费用理论,从人性假设和行为逻辑出发,将基本药物供应保障体系交易关系整合为交易环节、路径、机制,建立解释该体系的制度分析新框架,并且通过交易费用测算进行实证研究,检验和完善分析框架的内在逻辑。
因此本研究提出以下三个研究问题：(1)基本药物供应保障体系预期通过怎样的制度安排达到怎样的政策目标?(2)基本药物供应保障体系实际运行结果是怎样的,和预期的制度设计有什么差距?(3)基本药物供应保障体系的交易费用是如何导致非预期结果出现的?
研究目的
本论文的总目标是通过理论研究和实证分析,探讨我国农村地区基本药物供应保障体系的制度安排是如何通过协调、激励机制改变交易费用,进而影响利益相关者的行为和政策运行结果,最终为该体系形成良好的制度安排提供理论基础和科学依据。具体目标是：构建我国农村地区基本药物供应保障体系制度设计、交易费用和运行结果的分析框架；揭示样本地区基本药物供应保障体系的制度设计特点；分析现行制度设计下基本药物供应保障体系运行结果；模拟测算基本药物供应保障体系交易费用及其结构,探索制度设计与实际运行结果产生差距的原因及路径；提出完善基本药物供应保障体系的政策建议。
研究方法
本研究主要采用二手资料和现场调查数据来验证假设。二手资料主要包括：国家和样本地区基本药物相关政策文件以及研究文献,中国统计年鉴(2011)、山东省统计年鉴(2011)、中国医药统计年报(2009)、山东省基层医疗机构集中采购数据(2011.05.01-10.31)、山东省140县乡镇卫生院业务运行情况数据(2009-2010)等。现场调查采用目的抽样方法在安徽和山东两省收集定量、定性数据,根据经济状况、地域分布、基本药物供应保障体系的制度差异,从安徽省和山东省各抽取3个县,按同样原则前者每县分别抽取2个乡镇卫生院,后者每县抽取3个乡镇卫生院。定量数据主要包括被调查乡镇卫生院财务和业务报表、药品入库单与库存、改革前后基本药物价格调查(安徽和山东省分别随机抽取154、166个样本)、改革前后处方抽查(安徽和山东省分别随机抽取2098、1832张)、患者调查(安徽和山东分别调查72、117人)等。定性数据主要包括焦点小组讨论和关键人物访谈,前者包括3家药品生产企业、7家药品配送企业的讨论；后者包括对两省省卫生厅、省药品集中采购服务中心、县卫生局行政管理人员,乡镇卫生院院长、医生、药剂科主任等关键人物共58人访谈。
本论文分析过程由三部分组成。第一部分是对样本地区基本药物供应保障体系制度安排和制度设计的归纳和总结,资料主要来自政策文件分析、研究性文献、安徽和山东两省和样本县卫生行政管理人员的关键人物访谈。第二部分是分析样本地区基本药物供应保障体系的预期结果和非预期结果,资料来源主要是安徽和山东两省现场调查数据。第三部分是以山东省数据模拟测算和分析基本药物供应保障体系的交易费用,通过定性资料来识别各交易环节中的交易活动及其功能,并根据交易费用理论对交易活动进行归类,形成交易费用测算的初步框架。按此框架,将山东省基层医疗机构集中采购数据、山东省140县乡镇卫生院运行情况数据、中国统计年鉴(2011)和山东省统计年鉴(2011)相关人员年工资收入整合为交易费用测算数据库。然后结合相关访谈、焦点小组讨论分析交易费用对利益相关者行为、运行结果所产生的影响。最终综合制度分析框架、实证分析得出制度安排与政策结果之间的逻辑路径。
主要研究结果
1.基本药物供应保障体系制度安排与制度设计。该体系实质上为政府主导下解决农村药品供应体系购药渠道混乱、药品品种短缺等问题的层级制,其采用的主要方法是分解原体系存在的问题为不同利益相关者的功能。具体制度设计如下：政府通过招标来显示患者的需求；政府通过组织药品生产企业、药品配送企业和乡镇卫生院等来实现供给；同时,政府通过控制激励机制来保证基本药物供应保障体系的个体利益与整体利益的兼容,最终提高大众健康水平。
2.基本药物供应保障体系的预期结果是：(1)可获得性方面：基本药物的品种可获得基本得到解决,主要归因于单一货源承诺、强制配备和使用基本药物的相关政策。招标环节国家基本药物目录安徽和山东两省中标比例分别为89.25%、91.21%,特殊渠道采购的基本药物未进行招标；在配送环节跨市配送企业、市内配送企业较好满足了中标基本药物品种可获得性。(2)可负担性方面：患者负担有所减轻,主要归因于招标环节的最低价中标、供应链的强制使用和零差价政策。招标环节安徽和山东省化学药品和生物制品价格都集中在0-3元区间,构成比分别为66.11%、65.22%采购环节,改革前安徽和山东基本药物平均加成分别为101.89%、50.72%,改革后降为0,采购价格下降幅度均值分别为25.12%、28.85%；使用环节次均处方费用下降,患者反映负担减轻的人员比例较大。(3)质量保证方面：样品留样备案和后续抽验监管措施防止了假劣药的出现。(4)合理用药方面：基本药物的平均使用率和通用名使用率均上升,其余合理用药指标均呈下降趋势,主要归因于基本药物的使用政策。
3.基本药物供应保障体系的非预期结果是：(1)可获得性方面：基本药物的品规、及时可获得性较差。招标环节基本药物每通用名中标品规安徽和山东分别为3.13、2.24,小于政策规定的最大值6,限制了患者的需求；采购环节安徽和山东省国家基本药物中标品规配备率分别为26.49%、39.35%,山东省国家基本药物中标通用名配备率平均为56.43%；基本药物的及时配送还难以达到政策规定的三日到货,跨市配送的供应及时性尤其不好。(2)可负担性方面：中成药、部分化学药品、部分患者负担没有减轻。招标环节,无论是价格绝对数、价格区间、最高价位前十种药品,中成药价格高的构成比均高于化学药品；改革前后采购价格比较,安徽和山东价格上升的基本药物构成比分别为31.17%、26.51%,且上升的幅度大于下降的幅度。(3)质量保证方面：中标基本药物大部分质量层次偏低,存在逆向选择。排名400以后的企业在安徽和山东两省国家基本药物中标比例分别为71.09%、65.10%,品规中标比例分别为60.45%、54.31%；两省最高价前十位药品质量层次偏低,而在山东还出现了最低价前十位质量层次相比高价位高,也即质量层次高的企业易中低价药品,而质量层次偏低企业易中高价药品。(4)合理用药方面：相关指标不稳定、可待改进的空间还很大。
4.制度设计与运行结果之间差距的交易费用解释：由于基本药物供应保障体系多层多任务委托代理关系在制度和技术两个层面的复杂性,这导致制度运行的结果除基本药物的品种可获得性、可负担性降低外其余政策目标更多的是预期之外的。
制度层面的路径主要包括：需求显示路径供需双方主要靠价格协调,但是多层委托代理拉大了患者和供方之间的距离,导致患者需求信息难以传达；供给实现路径由于零差价销售,供需从价格协调变为数量协调,协调手段主要有合同、谈判、企业内管理、机构间沟通等,尤其缺少库存信息,不但影响患者用药需求,也造成积压、浪费、资金过多占用；供方激励路径扭曲了招标环节不同质量层次企业间的竞争关系,产生了逆向选择,并且导致生产企业和配送企业的利益分配和风险分担不利于配送企业,同时外省企业中标增多增加了交易协调的难度、道德风险发生的概率,从而提高了交易费用,使基本药物难以及时配送到乡镇卫生院；需方激励路径政府补助激励不足、新农合政策模糊,导致难以达到合理用药的预期目标。
技术层面的路径主要包括：采购规模的集中程度、市场主体的一体化程度等影响了交易频率、资产专用性,从而影响交易费用,产生了非预期后果；信息化建设中库存信息、交易信息、信息共享、监督信息的完善程度影响了各利益相关者受理性约束的程度、发生机会主义的概率,从而影响了交易费用,产生了非预期后果。
结论和政策建议
我国农村地区基本药物供应保障体系主要组合使用政府、市场和企业等不同协调和激励手段来缓解或控制有限理性、逆向选择和道德风险的危害,最终整合利益相关者目标为体系目标。但是,需求显示路径以价格协调为主、供给实现路径以数量协调为主的方式加大了委托代理的层次、生产企业供应第一责任人制度设计失灵,从而导致招标环节出现了逆向选择、供方和需方行为受到扭曲、正常的市场竞争秩序受到干扰。尤其是政府介入配送关系建立、基本药物日常采购、回款环节增加了问题的复杂程度和药品配送企业、乡镇卫生院的道德风险行为。而在技术方面,信息系统缺少库存信息减少了利益相关者之间的监督,为后续改革日益重要的库存管理埋下了隐患。
为了形成基本药物供应保障体系的良好制度安排,本论文提出以下政策建议：
1.协调机制的政策优化：(1)取消“全国统一市场”的规定,以生产企业的生产和质量保证能力为唯一准则；(2)双信封商务标中的“最低价中标”替代为成本效果价格；(3)3元以下基本药物取消零差价销售；(4)供给实现路径应给予市场以制度创新的空间,政府主要起督导和监管供给行为和质量的作用；(5)“单一货源承诺”改为“供应承包”加强药品生产企业的责任；(6)招标周期应该适当延长以培养供应链的协同能力；(7)在信息化系统设置虚拟库存管理加强参与方的责任和互相监督；(8)优化采购区域和时点形成规模采购。
2.激励机制的优化：(1)通过调整相关政策给药品生产企业、药品配送企业提供更好的制度环境；(2)通过税收减免提高生产和配送企业的收入；(3)通过政府补助、医生绩效工资与患者健康改善挂钩,再辅之以非货币化的激励措施来达到乡镇卫生院合理使用基本药物的目的；(4)通过基本药物报销补偿与总费用报销挂钩、患者教育使患者的需求得到更好的显示。
3.制度分析框架和交易费用测算方法在政策优化中应用的建议：(1)应用制度分析框架诊断基本药物供应保障体系存在的问题；(2)应用交易费用测算方法识别影响体系运行的关键变量。
创新与不足
本研究创新性：
1.目前理论缺少剖析基本药物供应保障体系的基本理论和逻辑框架。本论文基于制度经济学理论,首次建立了对该体系进行剖析的制度分析框架,以期寻找到相应制度安排通过协调和激励机制约束利益相关者行为、控制交易费用、平衡需求和供给,达至体系目标的传导路径。
2.目前尚未发现基本药物供应保障体系交易费用测算研究。本论文基于制度分析框架和交易费用理论,首次研制了适用于基本药物供应保障体系的交易费用测算方法,从机制、路径、交易环节、交易关系、制度类型、控制功能等多角度测算交易费用结构。
3.以不同于传统方法的基本药物供应保障体系交易关系为研究视角,通过制度分析框架和交易费用测算方法来系统分析该体系存在的制度问题、技术问题,为深化基本药物供应保障体系建设提供科学证据。
本研究不足及展望：
1.交易费用测算部分参数根据访谈估计,精确性方面可能有偏差,但是测算结果符合基本药物供应保障体系的运行逻辑。将来可以通过长时期跟踪不同类型的生产、配送企业来获取更为精确的测算参数。
2.交易费用分析主要采用描述性分析,原因主要是基本药物供应保障体系建立时间短,现有数据不适宜采用统计技术来处理。将来可以考虑用结构方程模型验证变量之间的因果关系。另外,也可以采用地理信息系统、区域经济学和社会网络技术测定地理区位、空间、社会资本等因素对交易费用的影响。
Background
Since the1970s, the essential medicine policy of World Health Organization provided the abundant practical experiences for supply security system of essential medicine in the world, but access, quality assurance and rational use of essential medicine have been the global problems. Although the pharmaceutical supply in rural China had been undergone the stage of tender for the county or municipal level and pharmaceutical supply and regulation network for the county level, above-mentioned problems existed for a long time. In2009, Chinese government started the construction of supply security system of essential medicine in the primary health care sector in order to solve these problems and ensure the availability, affordability, quality assurance and rational use of essential medicine. Anhui and Shandong province reformed their supply security system of essential medicine according to the relevant laws in the December2009and the March2010respectively. The main policies include zero-markup sales, bidding and procurment, government grants, pharmaceutical use and etc. These policies produced a certain effectiveness and much more unexpected results.
At present, policy, organization and etc. has been studied on the institutional arrangement, coordination mechanism, incentive mechanism and implementation effectiveness based on the research framework of public policy, WHO survey methodology. The above-mentioned research is still lack of the basic theory and logical framework on the supply security system of essential medicine. Especially the study on transaction cost is not found in the area of pharmaceutical policy. Transaction cost theory of the institutional economics can integrate four kinds of studies into an analytical framework to study transaction relationship. This research path will improve the explanatory power of theoretical framework. Therefore this thesis will combine the transaction relationship into process, path and mechanism to construct new institutional analytical framework in order to explain the unexpected results of supply security system of essential medicine from the human assumptions and behavior logic based on the transaction cost theory. On this basis, transaction cost is measured to obtain empirical evidence to validate the internal logic of the analytical framework.
So this study presented the following three research questions.(1) Which kind of policy objectives is expected to attain through what kind of institutional arrangements?(2) What are the practical results of supply security system of essential medicine? What are the gaps between expected objectives of institution design and practical results in real world?(3) How do transaction costs of supply security system of essential medicine lead to the emergence of unexpected results?
Objectives
The general objective of this thesis is to explore how to generate the unexpected results through institutional arrangement, transaction cost to implementation effectiveness based on the institutional analytical framework and empirical evidence, in order to put forward theoretical basis and scientific evidence on optimizing institutional arrangements of supply security system of essential medicine. The specific aims include:to construct institutional analytical framework of supply security system of essential medicine in rural China; to reveal the characteristics of institutional design of this system; to analyze practical implementation effectiveness of this system; to measure the transaction cost of this system simulatly in order to explore the causes and logic path generated the gap between institutional design and practical implementation; to put forward optimization suggestions on this system.
Methods
This study used secondary data and field survey data to test hypotheses. The secondary data include:policy documents and research literatures on essential medicine policy; China Statistical Yearbook2011; Shandong Statistical Yearbook2011; China Medical Statistical Yearbook2009; centralized procurment data (2011.05.01-10.31) at primary health care sector in Shandong province; business operation data (2009-2010) at township hospitals in Shandong province and etc. The quantitative and qualitative data in the field survey were collected in Anhui and Shandong province. A total of6township hospitals in Anhui province and9township hospitals in Shandong province were selected as the study sites based on purpose sampling according to the economic level, geography distribution and institutional difference of supply security system of essential medicine. The quantitative data includes:financial and business report at the sampling township hospitals; pharmaceutical storage records; price survey of154and166samples before and after essential medicine reform respectively in Anhui province and in Shandong province based on random sampling; prescription survey of2098and1832samples before and after essential medicine reform respectively in Anhui province and in Shandong province based on mechanical sampling;72and117patients survey respectively in Anhui province and in Shandong province. The qualitative data were collected by focus group interview and key informant interview. The focus group interviews were organized for three pharmaceutical manufacturing companies and seven distribution enterprises. The key informant interviews were carried out with58persons, including department of health, provincial pharmaceutical centralized bidding center, and county health department, township hospital in Anhui and Shandong province.
The analytical process of this thesis was consisted with three parts. The first part was to summarize the characteristics of institutional design and institutional arrangement in the sampling sites through the method of policy analysis, literature review and key informant interview. The second part was to analyze the expected effectiveness and unexpected results through the field survey data. The third part was to measure and analyze transaction cost of supply security system of essential medicine based on the quantitative and qualitative data in Shandong province. The measure steps were as follows:to indentify the transaction activity and function in the transaction process through the quantitative data; to construct the preliminary framework of measuring transaction cost of transaction activity according to the transaction cost theory; to consolidate China Statistical Yearbook2011, Shandong Statistical Yearbook2011, centralized procurment data (2011.05.01-10.31) and business operation data (2009-2010) at township hospitals into database for measuring transaction cost; to analyze the institutional effects between the stakeholder's behavior and implementation effectiveness arising from transaction cost; finally to deduce and summarize the logic path between institutional arrangement and implementation effectiveness.
Main results
1. Institutional arrangement and institution design for supply security system of essential medicine was as follows. This system was hierarchical organization led by government in order to solve the problems such as purchasing channel confusion and pharmaceutical shortage. The institutional design planed to decompose the existing problems into different function of different stakeholders. The specific institutional design was as follows:to reveal the demand of patients through the bidding and tender; to realize the supply by organizing the pharmaceutical manufacturing companies, distribution enterprises and township hospitals under the leadership of government; at the same time, to control the incentive mechanism in order to make supply-side and demand-side compatible between individual interests and overall interests; to improve the level of public health ultimately.
2. The expected effectiveness of supply security system of essential medicine was as follow. Firstly, varieties availability of essential medicines had been basically solved mainly due to the policies of single goods source commitment and compulsory equipment and use of essential medicines. In the process of tender, the successful tender rates of national essential medicine list were89.25%,91.21%respectively in Anhui and Shandong province. The essential medicines at special procurement channel did not tender at the process of the current centralized bidding. In the process of distribution, cross-municipal or municipal distribution companies met the variety availability of tendered essential medicines. Secondly patient affordability reduced mainly due to the policy that lowest price would be successful tender and there was zero-markup price and drug use policy at the supply chain of essential medicine. In the process of tender, the price of chemicals and biological was concentrated between￥0and￥3, whose proportion was66.11%、65.22%respectively in Anhui and Shandong province. In the process of procurement, before reform the average markup was101.89%,50.72%respectively in Anhui and Shandong province. After reform of essential medicine policy the markup was reduced to0, the declining extent of procurement price was25.12%,28.85%respectively in Anhui and Shandong province. In the process of clinical use of essential medicine, average prescription costs decreased and larger portion of patients reflected the affordability to be mitigated. Thirdly, sampling records institution before the essential medicines were produced and sampling test institution after the ones were produced ensured quality and prevented the emergence of counterfeit drugs. Finally, the average utilization rate of essential medicine and generic name was rising and the other indicator of rational use was declining mainly due to use policy of essential medicine.
3. The unexpected results of supply security system of essential medicine were as follow. Firstly, there were no better availability on the specification and timely delivery of essential medicine. In the process of tender, the successful tender specification every generic name was3.13,2.24, which was lower than6in essential medicine policy. This impacted the demand of patient. In the process of procurement, the specification equipment rate of successful tendered essential medicine was26.49%,39.35%respectively in Anhui and Shandong province. In Shandong province, the variety equipment rate of successful tender essential medicine was56.43%on average. In the process of distribution, the timely delivery of essential medicine was no better, especially cross-municipal distribution was the worst in all kinds of distribution models. Secondly, the affordability of part of proprietary Chinese medicines, chemical medicines and patients did not reduce. In the process of tender, no matter what absolute price, price range, or what the highest price before the ten drugs, the proportion of proprietary Chinese medicines prices were higher than the chemicals. In the process of procurement, through comparing the purchase price before and after the reform, this thesis found that the proportion of price rising of essential medicines was31.17%,26.51%respectively in Anhui and Shandong province. Furthermore, the extent of price rising was higher than that of price declining. Thirdly, there was adverse selection among the successful tender essential medicine. The proportion of successful tender essential medicine was71.09%,65.10%from manufacturing companies rank after400;60.45%,54.31%from specification respectively in Anhui and Shandong province. The highest price ten essential medicines were produced by the low quality level of the companies in two provinces. At the same time, the quality of the lowest price ten essential medicines were higher than that of the highest price ten essential medicines. Finally, the indicator of drug rational use was unstable and was room for improvement.
4. The explanation for the gap between institution design and unexpected results based on transaction cost theory. Because multi-layer multi-task principal-agent relationship of supply security system of essential medicine had the complexity from institutional impact factor to technological one, only variety availability and affordability improved significantly.
The institutional path was mainly including:Firstly, in the path of demand revealing, supply-side and demand-side mainly coordinated with price mechanism. But multi-layer principal-agent widened the distance from patients to supply-side which led patient demand to be unrevealed. Secondly, in the path of supply realizing, owing to zero-markup policy, the former price coordination mechanism was replaced with quantity coordination. The coordination means mainly included contract, negotiation, management within the enterprise and communication between the manufacturing companies, distribution enterprises and township hospitals. Especially, lack of inventory information had adverse impact on the medication needs of patients, backlog, wasting and improper occupancy of operational funds. Thirdly, in the path of supply-side incentive, the institutional design of tender distorted the competitive relationship between the different quality levels of companies to produce the adverse selection. In addition, the institutional design of tender made the distribution of benefit and risk-sharing between manufacturers and distributors unbeneficial to distribution enterprise. At the same time, the majority of successful tenders from the other provinces increased the difficulty of coordinating transactions and the occurrence probability of moral hazard, which increased transaction cost to make timely delivery of essential medicines to township hospitals difficultly. Finally, in the path of demand-side incentive, the shortage of government grants and the fuzzy of the new rural cooperative policies did not lead to attain the expected goals.
The technological path was as follows. Firstly, the concentration of procurement scale and integration of market stakeholders affected the transaction frequency and asset specificity, thus affected transaction cost to result in unexpected consequence. Secondly, the construction degree of the inventory information, transaction information, information sharing and monitoring information affected the constraint of the bounded rationality and the occurrence probability of opportunism, thus affected transaction cost to result in the unexpected consequence.
Conclusions and Recommendations
The supply security system of essential medicine combined the different coordination and incentive means of government, market and enterprise in order to mitigate the bounded rationality and to control opportunistic behavior of the adverse selection and moral hazard so that the goals of this system would be achieved. But, the price coordination mechanism of demand-revealing path and the quantity coordination mechanism of supply-realizing path widened the layer of principal-agent relationship and led the first responsible person of supply for manufacturing companies to institutional failure. The above-mentioned institutional problems increased the probability of adverse selection, distorted the behavior of supply-side and demand-side, interfered with the normal order of market competition. Especially, the role of government increased the complexity of problem and the probability of moral hazard behavior of distribution enterprise and township hospitals in the process of establishing the contract relationship between the manufacturing companies, distribution enterprises and township hospitals, routine procurement and repayment. In terms of technology, lack of inventory information lessened mutual supervision and planted a hidden danger for the follow-up reform with inventory management more and more importantly.
In order to take shape good institution arrangements for the supply security system of essential medicine, this thesis put forward some suggestions.
1. The recommendations on the policy optimization of coordination mechanism were as follows.(1) To cancel the provision of the united nation market and to make production and quality assurance capabilities of manufacturing companies only as the criterion of successful tender.(2) To replace the criterion of lowest price successful tender in business standard of double envelopment with cost-effective price.(3) To cancel zero-markup sales of essential medinces whose price is lower than￥3.(4) To provide institutional innovation space for market stakeholders and to restrict the role of government only as regulator in the supply-realizing path.(5) To substitute the policy of single goods source commitment for that of supply contract in order to strengthen the responsibility of pharmaceutical manufacturing companies.(6) To extend appropriately the tender cycle in order to cultivate collaborative supply chain.(7) To set up the virtual inventory management to strengthen the responsibility and mutual supervision of the stakeholders in the information management system of essential medicine supply.(8) To optimize region and time to form scale procurement.
2. The recommendations on the policy optimization of incentive mechanism were as follows.(1) To provide the better institutional environment for manufacturing companies and distribution enterprises by adjusting the relevant policy.(2) To increase the net benefit of manufacturing companies and distribution enterprises by tax relief.(3) To establish contact between government grants, pay for performance and health level of patients, complemented by the non-monetary incentives to achieve the purpose of rational use of essential drugs at the township hospitals.(4) To make the demand of patients be revealed much better by patient education and reimbursement incentive of new rural cooperative medical system.
3. The application recommendations to policy optimization using institutional analysis framework and transaction cost measurement method were as follows.(1) To apply the institutional analysis framework for diagnosing the relevant problems of supply security system.(2) To identify the key variables affecting the operation of this system. Innovations and Limitations
The innovations include:
1. Currently there was no basic theory and logical framework to analyze the supply security system of essential medicine. Based on the theory of institutional economics, this thesis constructed the institutional analysis framework in order to explore the logical path from the institutional desingn to the goal of the system that coordinational and incentive mechanism constraints stakeholder behavior, constrols the transaction cost and balances the demand and supply.
2. The current research of essential medicine policy did not carry out the study of transaction cost measurement. This thesis was the first attempt to develop the methodology system to measure the structure of transaction cost from the perspective of mechanism, path, transaction process, transaction relationship, institutional type and control function.
3. This thesis analyzed systematically the institutional and technical problems from the new study perspective of transaction relationship based on the institutional analysis framework and measurement method of transaction cost to put forward scientific evidence for the supply security system of essential medicine.
The limitations include:
1. Some parameters of the transaction cost measurement are estimated based on the focus group and key informant interviews. This can affect accuracy to be deviated. But measurement results meet the implementation logic of supply security system of essential medicine. In the future, the further researches should obtain more accurate estimates on the parameters by tracking different types of pharmaceutical manufacturing companies and distribution enterprises for a long time.
2. Because supply security system has been constructed for a short time, the analytical method of transaction cost data was not suitable to deal with statistical model technology. This thesis mainly deals the above-mentioned data with descriptive analysis. On one hand, the further researches should verify the casual relationship using the structural equation model. On the other hand, the further researches should use geographic information systems, regional economics and social network analysis techniques to help determine geographic location, space, social capital and other factors on the impact of transaction costs.
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