促进社区卫生服务机构基本药物可获得性策略研究
|
摘要
研究目的：
系统总结分析中国在促进社区卫生服务机构基本药物可获得性方面采取的措施以及存在的主要问题，全面了解社区卫生服务机构提供基本药物的配备、使用情况及其影响因素，为完善国家基本药物政策提出建议。
材料与方法：
本研究实证资料主要来源于2007年29个社区卫生服务体系建设重点联系城市基线调查包括193个市辖区随机抽取的2个社区卫生服务中心和2个社区卫生服务站(未设站的城市每个区则抽取4个中心)的机构资料与每机构随机抽取的100张门诊处方。按照不同经济发展水平，2008年在北京、武汉、西安三个城市进行的典型调查：抽取9家社区卫生服务中心及其附属9个社区服务站，对其使用基本药物情况进行处方及机构抽查。以及包括国务院有关部门等人员40人的知情人访谈和20人专家访谈。数据采用Epidata 3．02软件录入，利用Excel2000、SPSS12．0软件进行分析处理。理论分析方法包括利益相关者分析、系统分析、归纳综合等。
研究主要结果：
1．系统阐述中国在提高基本药物可获得性方面采取的主要措施以及存在的主要问题，包括合理遴选、合理使用、可负担价格、药品的提供、贸易全球化和世界贸易组织TRIPS相关政策、可持续的资金投入、供应与管理系统、质量和检测与评价。
2．社区卫生服务机构基本药物可获得性现状测量主要包括社区卫生服务机构药品配备情况：1917所社区卫生服务中心中，平均每个中心配备的药品总数大约为517种，其中西药总数为150种，中成药总数为367种；5212站中平均每站配备药品总数平均298种，其中西药91种，中成药207种。社区卫生服务机构基本药物使用情况：天津市九城区内各社区卫生服务机构使用药品品种范围，目录内139～260种，目录外36～460种。统计使用药品目录内、外的比例情况，全市使用药品品种用药目录内占37．08％、目录外占62．92％，结果显示，目前天津市社区卫生服务机构实际使用的药品远远超出卫生部对全国推荐的社区用药目录范围。根据2007版《WHO基本药物示范目录》统计典型调查的社区卫生服务机构的基本药物使用率、单张处方基本药物平均个数、基本药物处方率、全是基本药物的处方率分别为27．97％、0．59个、43．67％、9．11％，与各自的理想值相差很远。社区卫生服务机构合理用药情况：平均每张处方用药数量为2．51个。静脉注射比例35．11％，激素处方比例．56％，抗生素处方比例为43．58％，二联及以上抗生素处方比例12．30％。高于世界卫生组织调查结果。所有抽查机构处方费用平均值为53．31元。
3．我国社区卫生服务机构基本药物可获得性实践包括制定与实施社区基本用药目录、社区基本药物零差率销售的实践、社区基本药物零差率销售运行保障机制实践、药品统一采购、集中配送制度、医药分开或药房托管等。
4．社区卫生服务机构基本药物可获得性主要影响因素包括社区卫生服务机构设置基本情况、人力资源情况、管理及补偿政策等。其中政府投入比例、机构级别和举办主体不同的社区卫生服务机构的全是基本药物的处方率差异均有显著性意义。未实行收支两条线管理的中心合理用药各项指标均高于实行收支两条线管理的中心。举办主体不同的社区卫生服务机构，平均处方费用之间差异具有显著性意义(P＜0．001)。
5．构建了社区卫生服务机构基本药物可获得性的利益相关者模型、社区卫生服务机构基本药物可获得性影响因素的系统关系模型、社区卫生服务机构基本药物可获得性影响因素的递进关系模型、社区卫生服务机构基本药物可获得性策略模型。
结论与建议：
结论：我国社区卫生服务机构基本药物可获得性较低；我国社区卫生服务机构基本药物可获得性影响因素复杂；我国社区卫生服务机构基本药物可获得性促进策略涉及利益集团较多；我国社区卫生服务机构基本药物可获得性促进策略综合、系统、复杂，需要进一步规划与整合。促进我国基本药物可获得性达到理想状态还任重道远。
建议：合理确定社区卫生服务机构基本药物目录；完善基本药物采购配送制度；建立合理的补偿机制；完善社区卫生服务机构运行机制；加强对社区卫生服务机构用药的监督管理；健全社区卫生服务网络体系；建立完善社区基本药物使用监督评价机制；加强宣传教育，提高群众对基本药物的认识。本研究创新与不足：
本研究创新在于利用WHO促进基本药物可获得性策略框架系统分析我国社区卫生服务机构基本药物促进策略，并构建了相关框架模型；利用利益集团分析方法构建了促进社区卫生服务机构基本药物可获得性策略实施主体框架模型。
研究不足包括社区卫生服务机构基本药物可获得性影响因素太多，分析尚不深入；建立的框架模型尚需进一步完善。
Objective:
To analyze the measures and problems to promote essential medicines' availability in Community Health Service facilities in China, to know the equipping, the use and influencing factors of Community Health Service facilities to provide essential medicines totally and to provide suggestions to consummate national essential medicines policy.
Methods:
Material is obtained through an investigation carried out in 2007 on baseline survey in 29 key communicate cities. The investigation covers 193 districts, of which 2 community health centers and stations are surveyed. In each facility, 100 out-patient prescriptions were collected by random sampling method. Also, we investigated facilities in Xi'an, Wuhan, and Beijing by same method. Prescriptions in 2008 are collected. Interviewing method is used to investigate 40 insiders and 20 experts. Data is recorded by epidata 3.02 and analyzed by SPSS 12.0. In theory analyzing part, interested group analyzing, system analyzing and summarizing are used.
Results:
1.Systmatically describe measures on promoting access to essential medicines, rational use of medicines, affordability, availability and trips of essential medicines, sustainable drug financing, supply management system, quality control and evaluation.
2.Result of Baseline survey: in 1917 community health service centers, an average of 517 medicines were stored, of which 150 is chemical medicines and 367 are traditional Chinese medicines. In 5212 heath stations, an average of 298 medicines is stored, of which 91 is chemical medicines and 207 are Chinese medicines. Drug use situation: In 9 health facilities in Tianjin, 139-260 medicines are within the list, 36-460 are medicines are outside the list. 37.08% medicines used in the city are within the list, 62.92% are outside the list. The result shows that, the range of medicines used in Tianjin far exceed the recommended range set by ministry of health. Referring WHO essential medicines list ver. 07, the value of usage rate of essential medicines, essential medicines in a single prescription, prescription rate of essential medicines, rate of prescription contains only essential medicines are 27.97, 0.59, 43.67, and 9.11 respectively. The values are far below ideal value. In drug use situation, 2.51 drugs are prescribed in a single prescription, 35.11% prescriptions contain intravenous injection, 0.56% contain hormones, 43.58% contain antimicrobials, 12.30% contain more than one type of antimicrobials. The values are higher than recommended value of WHO. The average cost per prescription is 53.31.
3. The practice in prompting access to essential medicines includes using community essential medicines list, non-profit medicines sales of essential medicines, sustainable drug financing, pooled procurement, dispensing mechanism, separation of medical service and medicine sales, and trusteeship of medicines sales department.
4. Influencing factors of access to essential medicines includes configure of health facilities, human resources, management, and reimbursement plan. Investment by government, class of health facilities, and holder of facilities exhibits significant influence. All indicators are more negative in facilities with discrete income and cost management. Difference is statistically significant (P<0.001).
5. Models on interest groups, influencing factors, progressive relations and strategy of access to essential medicines in community health facilities are built.
Conclusions and suggestions:
The access to essential medicines is low. The influencing factors are complicate and twisted. There are many Interest groups posing influences, strategy is too complicated and scattered and needs integrations and plans. There is much work to be done in promoting access to essential medicines. We suggest that essential medicines list should be reviewed and improved; running mechanism of heath facilities should bettered; supervision should be strengthened; accomplished mechanism on use of essential medicines in community should be established; improving advertising and education on essential medicines to increase awareness of essential medicines.
Innovations and limits:
We use WHO frame of strategy on promoting essential medicines to carry out systematical analysis; Models are establish base on the result of analysis; interest group analyzing method is used to establish frame model on execution subject of implementing access to essential medicines strategy. Limits in our study include unsophisticated analyzing; model needs further research and adjustment.
系统总结分析中国在促进社区卫生服务机构基本药物可获得性方面采取的措施以及存在的主要问题，全面了解社区卫生服务机构提供基本药物的配备、使用情况及其影响因素，为完善国家基本药物政策提出建议。
材料与方法：
本研究实证资料主要来源于2007年29个社区卫生服务体系建设重点联系城市基线调查包括193个市辖区随机抽取的2个社区卫生服务中心和2个社区卫生服务站(未设站的城市每个区则抽取4个中心)的机构资料与每机构随机抽取的100张门诊处方。按照不同经济发展水平，2008年在北京、武汉、西安三个城市进行的典型调查：抽取9家社区卫生服务中心及其附属9个社区服务站，对其使用基本药物情况进行处方及机构抽查。以及包括国务院有关部门等人员40人的知情人访谈和20人专家访谈。数据采用Epidata 3．02软件录入，利用Excel2000、SPSS12．0软件进行分析处理。理论分析方法包括利益相关者分析、系统分析、归纳综合等。
研究主要结果：
1．系统阐述中国在提高基本药物可获得性方面采取的主要措施以及存在的主要问题，包括合理遴选、合理使用、可负担价格、药品的提供、贸易全球化和世界贸易组织TRIPS相关政策、可持续的资金投入、供应与管理系统、质量和检测与评价。
2．社区卫生服务机构基本药物可获得性现状测量主要包括社区卫生服务机构药品配备情况：1917所社区卫生服务中心中，平均每个中心配备的药品总数大约为517种，其中西药总数为150种，中成药总数为367种；5212站中平均每站配备药品总数平均298种，其中西药91种，中成药207种。社区卫生服务机构基本药物使用情况：天津市九城区内各社区卫生服务机构使用药品品种范围，目录内139～260种，目录外36～460种。统计使用药品目录内、外的比例情况，全市使用药品品种用药目录内占37．08％、目录外占62．92％，结果显示，目前天津市社区卫生服务机构实际使用的药品远远超出卫生部对全国推荐的社区用药目录范围。根据2007版《WHO基本药物示范目录》统计典型调查的社区卫生服务机构的基本药物使用率、单张处方基本药物平均个数、基本药物处方率、全是基本药物的处方率分别为27．97％、0．59个、43．67％、9．11％，与各自的理想值相差很远。社区卫生服务机构合理用药情况：平均每张处方用药数量为2．51个。静脉注射比例35．11％，激素处方比例．56％，抗生素处方比例为43．58％，二联及以上抗生素处方比例12．30％。高于世界卫生组织调查结果。所有抽查机构处方费用平均值为53．31元。
3．我国社区卫生服务机构基本药物可获得性实践包括制定与实施社区基本用药目录、社区基本药物零差率销售的实践、社区基本药物零差率销售运行保障机制实践、药品统一采购、集中配送制度、医药分开或药房托管等。
4．社区卫生服务机构基本药物可获得性主要影响因素包括社区卫生服务机构设置基本情况、人力资源情况、管理及补偿政策等。其中政府投入比例、机构级别和举办主体不同的社区卫生服务机构的全是基本药物的处方率差异均有显著性意义。未实行收支两条线管理的中心合理用药各项指标均高于实行收支两条线管理的中心。举办主体不同的社区卫生服务机构，平均处方费用之间差异具有显著性意义(P＜0．001)。
5．构建了社区卫生服务机构基本药物可获得性的利益相关者模型、社区卫生服务机构基本药物可获得性影响因素的系统关系模型、社区卫生服务机构基本药物可获得性影响因素的递进关系模型、社区卫生服务机构基本药物可获得性策略模型。
结论与建议：
结论：我国社区卫生服务机构基本药物可获得性较低；我国社区卫生服务机构基本药物可获得性影响因素复杂；我国社区卫生服务机构基本药物可获得性促进策略涉及利益集团较多；我国社区卫生服务机构基本药物可获得性促进策略综合、系统、复杂，需要进一步规划与整合。促进我国基本药物可获得性达到理想状态还任重道远。
建议：合理确定社区卫生服务机构基本药物目录；完善基本药物采购配送制度；建立合理的补偿机制；完善社区卫生服务机构运行机制；加强对社区卫生服务机构用药的监督管理；健全社区卫生服务网络体系；建立完善社区基本药物使用监督评价机制；加强宣传教育，提高群众对基本药物的认识。本研究创新与不足：
本研究创新在于利用WHO促进基本药物可获得性策略框架系统分析我国社区卫生服务机构基本药物促进策略，并构建了相关框架模型；利用利益集团分析方法构建了促进社区卫生服务机构基本药物可获得性策略实施主体框架模型。
研究不足包括社区卫生服务机构基本药物可获得性影响因素太多，分析尚不深入；建立的框架模型尚需进一步完善。
Objective:
To analyze the measures and problems to promote essential medicines' availability in Community Health Service facilities in China, to know the equipping, the use and influencing factors of Community Health Service facilities to provide essential medicines totally and to provide suggestions to consummate national essential medicines policy.
Methods:
Material is obtained through an investigation carried out in 2007 on baseline survey in 29 key communicate cities. The investigation covers 193 districts, of which 2 community health centers and stations are surveyed. In each facility, 100 out-patient prescriptions were collected by random sampling method. Also, we investigated facilities in Xi'an, Wuhan, and Beijing by same method. Prescriptions in 2008 are collected. Interviewing method is used to investigate 40 insiders and 20 experts. Data is recorded by epidata 3.02 and analyzed by SPSS 12.0. In theory analyzing part, interested group analyzing, system analyzing and summarizing are used.
Results:
1.Systmatically describe measures on promoting access to essential medicines, rational use of medicines, affordability, availability and trips of essential medicines, sustainable drug financing, supply management system, quality control and evaluation.
2.Result of Baseline survey: in 1917 community health service centers, an average of 517 medicines were stored, of which 150 is chemical medicines and 367 are traditional Chinese medicines. In 5212 heath stations, an average of 298 medicines is stored, of which 91 is chemical medicines and 207 are Chinese medicines. Drug use situation: In 9 health facilities in Tianjin, 139-260 medicines are within the list, 36-460 are medicines are outside the list. 37.08% medicines used in the city are within the list, 62.92% are outside the list. The result shows that, the range of medicines used in Tianjin far exceed the recommended range set by ministry of health. Referring WHO essential medicines list ver. 07, the value of usage rate of essential medicines, essential medicines in a single prescription, prescription rate of essential medicines, rate of prescription contains only essential medicines are 27.97, 0.59, 43.67, and 9.11 respectively. The values are far below ideal value. In drug use situation, 2.51 drugs are prescribed in a single prescription, 35.11% prescriptions contain intravenous injection, 0.56% contain hormones, 43.58% contain antimicrobials, 12.30% contain more than one type of antimicrobials. The values are higher than recommended value of WHO. The average cost per prescription is 53.31.
3. The practice in prompting access to essential medicines includes using community essential medicines list, non-profit medicines sales of essential medicines, sustainable drug financing, pooled procurement, dispensing mechanism, separation of medical service and medicine sales, and trusteeship of medicines sales department.
4. Influencing factors of access to essential medicines includes configure of health facilities, human resources, management, and reimbursement plan. Investment by government, class of health facilities, and holder of facilities exhibits significant influence. All indicators are more negative in facilities with discrete income and cost management. Difference is statistically significant (P<0.001).
5. Models on interest groups, influencing factors, progressive relations and strategy of access to essential medicines in community health facilities are built.
Conclusions and suggestions:
The access to essential medicines is low. The influencing factors are complicate and twisted. There are many Interest groups posing influences, strategy is too complicated and scattered and needs integrations and plans. There is much work to be done in promoting access to essential medicines. We suggest that essential medicines list should be reviewed and improved; running mechanism of heath facilities should bettered; supervision should be strengthened; accomplished mechanism on use of essential medicines in community should be established; improving advertising and education on essential medicines to increase awareness of essential medicines.
Innovations and limits:
We use WHO frame of strategy on promoting essential medicines to carry out systematical analysis; Models are establish base on the result of analysis; interest group analyzing method is used to establish frame model on execution subject of implementing access to essential medicines strategy. Limits in our study include unsophisticated analyzing; model needs further research and adjustment.
引文
[1]WHO.The selection and use of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no.914).Geneva:World Health Organization,2003.
[2]SCHUNEMANN H,KUNZ R,FALCK-YTTER Y,et al.Procedures and methods of benefit assessments for medicines in Germany:give the child a name[J].Eur J Health Econ,2009.
[3]KISHORE S P,HERBSTMAN B J.Adding a medicine to the WHO model list of essential medicines[J].Clin Pharmacol Ther,2009,85(3):237-9.
[4]CAMERON A,EWEN M,ROSS-DEGNAN D,et al.Medicine prices,availability,and affordability in 36 developing and middle-income countries:a secondary analysis[J].Lancet,2009,373(9659):240-9.
[5]KESSELHEIM A S.Think globally,prescribe locally:how rational pharmaceutical policy in the U.S.can improve global access to essential medicines[J].Am J Law Med,2008,34(2-3):125-39.
[6]AHMAD K.Access denied to essential medicines in developing world[J].Lancet Infect Dis,2002,2(12):711.
[7]HOGERZEIL H,SAMSON M,CASANOVAS J V,et al.Is access to essential medicines part of the fulfillment of the right to health enforceable through the courts?[J].Tropical Medicine & International Health,2007,(12):53.
[8]REIDENBERG M M.World Health Organization program for the selection and use of essential medicines[J].Clin Pharmacol Ther,2007,81(4):603-6.
[9]WHO.How to develop and implement a national drug policy[M].Geneva:World Health Orgnization,2004.
[10]WHO releases global reference guide on 325 essential medicines[J].Bull World Health Organ,2002,80(10):844.
[11]刘保，武瑞雪，叶露．论基本药物的可获得性和可及性障碍[J]．中国药房，2007，18(14)．
[12]刘宝，叶露．基本药物可获得性障碍的原因探讨[J]．中国卫生事业管理，2008，(1)．
[13]NUNN A,FONSECA E D,GRUSKIN S.Changing global essential medicines norms to improve access to AIDS treatment:lessons from Brazil[J].Glob Public Health,2009, 4(2):131-49.
[14]TETTEH E.Providing affordable essential medicines to African households:the missing policies and institutions for price containment[J].Soc Sci Med,2008,66(3):569-81.
[15]MIRZA Z.Thirty years of essential medicines in primary health care[J].East Mediterr Health J,2008,14 Suppl(S74-81.
[16]ZUCKER H,RAGO L.Access to essential medicines for children:the world health organization's global response[J].Clin Pharmacol Ther,2007,82(5):503-5.
[17]ROBERTSON J,HILL S R.The essential medicines list for a global patient population[J].Clin Pharmacol Ther,2007,82(5):498-500.
[18]REIDENBERG M M.Essential medicines for the whole world[J].Clin Pharmacol Ther,2007,82(5):500-3.
[19]中华人民共和国卫生部．中国卫生统计年鉴[M]．北京：中国协和医科大学出版社，2007．
[20]QUICK J D.Essential medicines twenty-five years on:closing the access gap[J].Health Policy and Planning,2003,18(1):1-3.
[21]POGGE T.Montreal Statement on the Human Right to Essential Medicines[J].Camb Q Healthc Ethics,2007,16(1):97-108.
[22]ALBERT M A,FRETHEIM A,MAIGA D.Factors influencing the utilization of research findings by health policy-makers in a developing country:the selection of Mali's essential medicines[J].Health Res Policy Syst,2007,(52.
[23]SEUBA X.A human rights approach to the WHO Model List of Essential Medicines[J].Bull World Health Organ,2006,84(5):405-7; discussion 8-11.
[24]WHO.The selection of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no 615).Geneva:World Health Organization,1977.
[25]LAING R,WANING B,GRAY A,et al.25 years of the WHO essential medicines lists:progress and challenges[J].Lancet,2003,361(9370):1723-9.
[26]MILLOT G.[Access to essential medicines in Africa:a global approach][J].Med Trop (Mars),2006,66(6):558-64.
[27]HOGERZEIL H V,SAMSON M,CASANOVAS J V,et al.Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts?[J].Lancet,2006,368(9532):305-11.
[28]HOGERZEIL H V.Essential medicines and human fights:what can they learn from each other?[J].Bull World Health Organ,2006,84(5):371-5.
[29]中华人民共和国，中国中医药管理局．《制订国家基本药物工作方案》[J]．1996，
[30]叶露，胡善联，MARGARET等．上海市基本药物可负担性实证研究[J]．中国卫生资源，2008，11(4)：195-6．
[31]朱乃庚，，张新平．我国城市社区卫生服务机构基本药物目录研究[J]．中国卫生经济，2007，26(12)．
[32]VUORENKOSKI L.[Would the developed countries need catalogs for essential medicines?][J].Duodecim,2005,121(14):1495-6.
[33]SALEH K,IBRAHIM M I.Are essential medicines in Malaysia accessible,affordable and available?[J].Pharm World Sci,2005,27(6):442-6.
[34]WHO.The selection and ues of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no 950).Geneva:World Health Organization,2008.
[35]CHIRAC P,LAING R.Updating the WHO essential drugs list[J].Lancet,2001,357(9262):1134-7.
[36]WHO.The selection and use of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no 933).Geneva:World Health Organization,2006.
[37]REIDENBERG M M,WALLEY T.The pros and cons of essential medicines for rich countries[J].BMJ,2004,329(7475):1172.
[38]LOGEZ S M,HUTIN Y J,HOLLOWAY K,et al.Could the WHO model list of essential medicines do more for the safe and appropriate use of injections?[J].J Clin Pharmacol,2004,44(10):1106-13.
[39]HOGERZEIL H V.The concept of essential medicines:lessons for rich countries[J].BMJ,2004,329(7475):1169-72.
[40]QUICK J D,HOGERZEIL H V.Ten best readings in...essential medicines[J].Health Policy Plan,2003,18(1):119-21.
[41]QUICK J D,HOGERZEIL H V,VELASQUEZ G,et al.Twenty-five years of essential medicines[J].Bull World Health Organ,2002,80(11):913-4.
[42]KINDERMANS J M,MATTHYS F.Introductory note:The access to Essential Medicines Campaign[J].Trop Med Int Health,2001,6(11):955-6.
[43]WERTHEIMER A I,SANTELLA T M.Innovation and the WHO's essential medicines list:giving credit where credit is due[J].Res Social Adm Pharm,2007,3(1):137-44.
[44]MATOWE L.Access to essential drugs in developing countries:a lost battle?[J].Am J Health Syst Pharm,2004,61 (7):718-21.
[45]CAMPION M D.[Access of developing countries to essential drugs:a process of equity][J].Bull Acad Natl Med,2001,185(7):1255-66; discussion 66-9.
[46]ROJO P.[Access to essential drugs in developing countries][J].Gac Sanit,2001,15(6):540-5.
[47]CHATTOPADHYAY S.Access to essential drugs in poor countries[J].JAMA,1999,282(7):631.
[48]KESSEL E.Access to essential drugs in poor countries[J].JAMA,1999,282(7):630-1;author reply 1.
[49]覃正碧等．国家基本药物制度的现状及其完善对策探讨[J]．中国药房，2008，19(14)：1041-3．
[50]孟锐，李颖．国家基本药物遴选与药物经济学[J]．中国药房，2007，18(35)．
[51]周延安．我国大陆地区药品的可获得性与供需平衡初析[J]．中国医院药学杂志，2007，27(11)．
[52]韩在虹，高明，申红强．国家基本药物制度与基本医疗保险制度的关系[J]．中国药业，2008，17(22)：2-3．
[53]顾昕，余晖，冯立果．基本药物供给保障的制度建设——国际经验的启示[J]．国家行政学院学报，2008，6(22)．
[54]武瑞雪，刘宝，丁敬芳等．基本药物制度实施的国际经验[J]．中国药房，2007，18(17)：1283-5．
[55]田丽娟，于培明．我国不合理用药原因分析及对策探讨[J]．中国药房，2005，16(16)：1204-6．
[56]中共中央国务院关于深化医疗卫生体制改革的建议[R]．中华人民共和国国务院，2003．
[57]孟锐，马昕，逄士萍．国家基本药物制度在我国医疗卫生体制改革中的地位[J]．中国药事，2008，22(12)：1060-4．
[58]许强，刘高伍，程才等．我国医疗机构面对基本药物制度改革趋势与对策[J]．现代医院，2008，8(12)：75-6．
[59]王世玲．卫生部人保部争议医改方案基本药物制度[J]．医院领导决策参考，2008，(22)：7-9．
[60]夏俊杰．中国社区卫生服务：发展与目标[J]．开放导报，2008，6(6)．
[61]熊仁明，余金燕．浅析社区卫生服务的现状及对策[J]．现代医院管理，2008，6(5)：17-8．
[62]李玉堂，游凯．社区卫生服务中慢病防治现状与发展趋势[J]．首都公共卫生，2008，2(5)：214-6．
[63]刘玉玲．社区卫生服务的规范化管理与体会[J]．中国实用医药，2009，4(1)：241-2．
[64]任长乐，毕芳，张春娜等．我国社区卫生服务机构的现状及发展对策[J]．中国卫生质量管理，2008，15(6)：84-6．
[65]周莹，方子．我国社区卫生服务人力资源配置分析[J]．医学与社会，2008，2l(12)：6-8．
1．吴仪副总理在2007年全国城市社区卫生工作会议上的讲话，卫生部网站
2．党的十六届六中全会《关于构建社会主义和谐社会若干重大问题的决定》
3．国务院关于发展城市社区卫生服务的指导意见(国发(2006)10号)，国务院
4．关于公布第一批定点生产的城市社区农村基本用药目录的通知(国食药监市[2006]343号)，国家食品药品监督管理局
5．关于加强城市社区和农村基本用药定点生产、使用和价格管理的通知(国食药监市[2007]308号)，国家食品药品监督管理局
6．关于加强城市社区卫生服务机构医疗服务和药品价格管理意见的通知(发改价格(2006)1305号)，国家发展改革委、卫生部
7．处方管理办法，卫生部令53号
8．唐镜波，李少丽，李大魁等．制定我国国家药物政策的必要性与迫切性[J]．中国药学杂志，2001，(12)
9．李青，曾繁典．wH0国家药物政策的实施现况[J]．药物流行病学杂志，2002，(06)
10．甄伟玲，张新平，陈昊等[J]．国家药物政策的关键元素和评价指标探讨[J]．中国卫生质量管理，2004，(04)
11．孟锐，唐冬蕾，陈凤龙．国家基本药物政策推行与药品获得及合理用药关系的探讨[J]．中国药师，2005，(07)
12．Philwifferl，杜亮，熊鹰等．证据与基本药物：药物目录的筛选、评价和持续[J]．中国循证医学杂志，2003，3(2)：83-88
13．陈冠容，刘忠．2002年世界卫生组织基本药物目录品种[J]．药物流行病学杂志，2003，12(3)：144-153
14．张震巍，沈爱宗．国家《基本医疗保险用药目录》与《基本药物目录》之比较分析[J]．中国卫生事业管理，2004，20(5)：317-318
15．曾颖，杨敏，刘晓琦．我院门诊合理用药国际指标调研及分析[J]．中国医院药学杂志，2006，26(6)：737-739
16．陈莲珍，王青等．合理用药国际指标现场调查[J]．中国药房，2003，14(3)：156-158
17．陈莲珍，王淑洁，王青等．多中心合理用药国际指标对照研究——现场调查[J]．中国医院药学杂志，2003，23(7)：438-440
18．季波，韩丽萍等．3000张门诊处方基本指标及用药情况分析[J]．中国医院药学杂志，2003，23(2)：125-125
19.WHO.WHO Prequalification Program.Program Activities in 2005:2-4 http://mednet3.who.int/prequal/info_general/documents/Prequal_AnnualReport2005 EN.pdf
20.Chaudhury,R.R.,R.Parameswar,U.Gupta,S.Sharma,U.Tekur,and J.S.Bapna,Quality medicines for the poor:experience of the Delhi programme on rational use of drugs.Health Policy Plan,2005.20(2):p.124-36
21.刘佳,钱丽萍,张新平.德里模式与基本药物推广.国外医学·社会医学分册,2003, 20(2): 76-80
22.Abbott TA. Price regulation in the pharmaceutical industry: prescription or placebo? J Health Econ 1995;14(5):471-479
23.Giuliani G, Selke G, Garattini L. The German experience in reference pricing. Health Policy 1998;44:73-85
24.Silvia M. Ess, Sebastian Schneeweiss and Thomas D. Szucs. European Healthcare policies for controlling drugexpenditure. Phamacoeconomics 2003;21(2):89-103
25.Department for International Development. Increasing access to essential medicines in the developing world: UK Government policy and plans [M].2004
26.World Health Organization. Equitable access to essential medicines:a framework for collective action. Essential drug monitor 2004; 4:8-13
27.World Health Organization. Regional strategy for improving access to essential medicines in the Western Pacific Region, 2005 -2010. 2005.
28.http://haiweb.org/medicineprices/
29.Kamaruzaman Saleh and Mohamed I .M. Ib rahim. Are Essential Medicines in Malaysia Accessible, Affordable and Available? Pharmacy World & Science 27:6,442-446
30.Babar ZUD, Ibrahim MIM, Singh H, Bukahri NI, Creese A. (2007) Evaluating Drug Prices, Availability, Affordability, and Price Components: Implications for Access to Drugs in Malaysia. PLoS Med 4(3): e82 doi:10.1371
31.Myhr K. Comparing prices of essential drugs between four countries in East Africa and with international prices. MSF Conference, Nairobi 2000 (http://www.accessmedmsf.org/upload/ReportsandPublications/3920012349208/East%20A frica.pdf)
32.Kotwani, A., M. Ewen, D. Dey, S. Iyer, P.K. Lakshmi, A. Patel, K. Raman, G.L. Singhal, V. Thawani, S. Tripathi, and R. Laing, Prices & availability of common medicines at six sites in India using a standard methodology. Indian J Med Res, 2007. 125(5): p. 645-54
33.Ashcroft RE. Access to essential medicines: a Hobbesian social contract approach. Developing World Bioethics 2005; 5(2): 121-141
[2]SCHUNEMANN H,KUNZ R,FALCK-YTTER Y,et al.Procedures and methods of benefit assessments for medicines in Germany:give the child a name[J].Eur J Health Econ,2009.
[3]KISHORE S P,HERBSTMAN B J.Adding a medicine to the WHO model list of essential medicines[J].Clin Pharmacol Ther,2009,85(3):237-9.
[4]CAMERON A,EWEN M,ROSS-DEGNAN D,et al.Medicine prices,availability,and affordability in 36 developing and middle-income countries:a secondary analysis[J].Lancet,2009,373(9659):240-9.
[5]KESSELHEIM A S.Think globally,prescribe locally:how rational pharmaceutical policy in the U.S.can improve global access to essential medicines[J].Am J Law Med,2008,34(2-3):125-39.
[6]AHMAD K.Access denied to essential medicines in developing world[J].Lancet Infect Dis,2002,2(12):711.
[7]HOGERZEIL H,SAMSON M,CASANOVAS J V,et al.Is access to essential medicines part of the fulfillment of the right to health enforceable through the courts?[J].Tropical Medicine & International Health,2007,(12):53.
[8]REIDENBERG M M.World Health Organization program for the selection and use of essential medicines[J].Clin Pharmacol Ther,2007,81(4):603-6.
[9]WHO.How to develop and implement a national drug policy[M].Geneva:World Health Orgnization,2004.
[10]WHO releases global reference guide on 325 essential medicines[J].Bull World Health Organ,2002,80(10):844.
[11]刘保，武瑞雪，叶露．论基本药物的可获得性和可及性障碍[J]．中国药房，2007，18(14)．
[12]刘宝，叶露．基本药物可获得性障碍的原因探讨[J]．中国卫生事业管理，2008，(1)．
[13]NUNN A,FONSECA E D,GRUSKIN S.Changing global essential medicines norms to improve access to AIDS treatment:lessons from Brazil[J].Glob Public Health,2009, 4(2):131-49.
[14]TETTEH E.Providing affordable essential medicines to African households:the missing policies and institutions for price containment[J].Soc Sci Med,2008,66(3):569-81.
[15]MIRZA Z.Thirty years of essential medicines in primary health care[J].East Mediterr Health J,2008,14 Suppl(S74-81.
[16]ZUCKER H,RAGO L.Access to essential medicines for children:the world health organization's global response[J].Clin Pharmacol Ther,2007,82(5):503-5.
[17]ROBERTSON J,HILL S R.The essential medicines list for a global patient population[J].Clin Pharmacol Ther,2007,82(5):498-500.
[18]REIDENBERG M M.Essential medicines for the whole world[J].Clin Pharmacol Ther,2007,82(5):500-3.
[19]中华人民共和国卫生部．中国卫生统计年鉴[M]．北京：中国协和医科大学出版社，2007．
[20]QUICK J D.Essential medicines twenty-five years on:closing the access gap[J].Health Policy and Planning,2003,18(1):1-3.
[21]POGGE T.Montreal Statement on the Human Right to Essential Medicines[J].Camb Q Healthc Ethics,2007,16(1):97-108.
[22]ALBERT M A,FRETHEIM A,MAIGA D.Factors influencing the utilization of research findings by health policy-makers in a developing country:the selection of Mali's essential medicines[J].Health Res Policy Syst,2007,(52.
[23]SEUBA X.A human rights approach to the WHO Model List of Essential Medicines[J].Bull World Health Organ,2006,84(5):405-7; discussion 8-11.
[24]WHO.The selection of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no 615).Geneva:World Health Organization,1977.
[25]LAING R,WANING B,GRAY A,et al.25 years of the WHO essential medicines lists:progress and challenges[J].Lancet,2003,361(9370):1723-9.
[26]MILLOT G.[Access to essential medicines in Africa:a global approach][J].Med Trop (Mars),2006,66(6):558-64.
[27]HOGERZEIL H V,SAMSON M,CASANOVAS J V,et al.Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts?[J].Lancet,2006,368(9532):305-11.
[28]HOGERZEIL H V.Essential medicines and human fights:what can they learn from each other?[J].Bull World Health Organ,2006,84(5):371-5.
[29]中华人民共和国，中国中医药管理局．《制订国家基本药物工作方案》[J]．1996，
[30]叶露，胡善联，MARGARET等．上海市基本药物可负担性实证研究[J]．中国卫生资源，2008，11(4)：195-6．
[31]朱乃庚，，张新平．我国城市社区卫生服务机构基本药物目录研究[J]．中国卫生经济，2007，26(12)．
[32]VUORENKOSKI L.[Would the developed countries need catalogs for essential medicines?][J].Duodecim,2005,121(14):1495-6.
[33]SALEH K,IBRAHIM M I.Are essential medicines in Malaysia accessible,affordable and available?[J].Pharm World Sci,2005,27(6):442-6.
[34]WHO.The selection and ues of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no 950).Geneva:World Health Organization,2008.
[35]CHIRAC P,LAING R.Updating the WHO essential drugs list[J].Lancet,2001,357(9262):1134-7.
[36]WHO.The selection and use of essential drugs:report of a WHO expert committee.(Tech Rep Ser WHO no 933).Geneva:World Health Organization,2006.
[37]REIDENBERG M M,WALLEY T.The pros and cons of essential medicines for rich countries[J].BMJ,2004,329(7475):1172.
[38]LOGEZ S M,HUTIN Y J,HOLLOWAY K,et al.Could the WHO model list of essential medicines do more for the safe and appropriate use of injections?[J].J Clin Pharmacol,2004,44(10):1106-13.
[39]HOGERZEIL H V.The concept of essential medicines:lessons for rich countries[J].BMJ,2004,329(7475):1169-72.
[40]QUICK J D,HOGERZEIL H V.Ten best readings in...essential medicines[J].Health Policy Plan,2003,18(1):119-21.
[41]QUICK J D,HOGERZEIL H V,VELASQUEZ G,et al.Twenty-five years of essential medicines[J].Bull World Health Organ,2002,80(11):913-4.
[42]KINDERMANS J M,MATTHYS F.Introductory note:The access to Essential Medicines Campaign[J].Trop Med Int Health,2001,6(11):955-6.
[43]WERTHEIMER A I,SANTELLA T M.Innovation and the WHO's essential medicines list:giving credit where credit is due[J].Res Social Adm Pharm,2007,3(1):137-44.
[44]MATOWE L.Access to essential drugs in developing countries:a lost battle?[J].Am J Health Syst Pharm,2004,61 (7):718-21.
[45]CAMPION M D.[Access of developing countries to essential drugs:a process of equity][J].Bull Acad Natl Med,2001,185(7):1255-66; discussion 66-9.
[46]ROJO P.[Access to essential drugs in developing countries][J].Gac Sanit,2001,15(6):540-5.
[47]CHATTOPADHYAY S.Access to essential drugs in poor countries[J].JAMA,1999,282(7):631.
[48]KESSEL E.Access to essential drugs in poor countries[J].JAMA,1999,282(7):630-1;author reply 1.
[49]覃正碧等．国家基本药物制度的现状及其完善对策探讨[J]．中国药房，2008，19(14)：1041-3．
[50]孟锐，李颖．国家基本药物遴选与药物经济学[J]．中国药房，2007，18(35)．
[51]周延安．我国大陆地区药品的可获得性与供需平衡初析[J]．中国医院药学杂志，2007，27(11)．
[52]韩在虹，高明，申红强．国家基本药物制度与基本医疗保险制度的关系[J]．中国药业，2008，17(22)：2-3．
[53]顾昕，余晖，冯立果．基本药物供给保障的制度建设——国际经验的启示[J]．国家行政学院学报，2008，6(22)．
[54]武瑞雪，刘宝，丁敬芳等．基本药物制度实施的国际经验[J]．中国药房，2007，18(17)：1283-5．
[55]田丽娟，于培明．我国不合理用药原因分析及对策探讨[J]．中国药房，2005，16(16)：1204-6．
[56]中共中央国务院关于深化医疗卫生体制改革的建议[R]．中华人民共和国国务院，2003．
[57]孟锐，马昕，逄士萍．国家基本药物制度在我国医疗卫生体制改革中的地位[J]．中国药事，2008，22(12)：1060-4．
[58]许强，刘高伍，程才等．我国医疗机构面对基本药物制度改革趋势与对策[J]．现代医院，2008，8(12)：75-6．
[59]王世玲．卫生部人保部争议医改方案基本药物制度[J]．医院领导决策参考，2008，(22)：7-9．
[60]夏俊杰．中国社区卫生服务：发展与目标[J]．开放导报，2008，6(6)．
[61]熊仁明，余金燕．浅析社区卫生服务的现状及对策[J]．现代医院管理，2008，6(5)：17-8．
[62]李玉堂，游凯．社区卫生服务中慢病防治现状与发展趋势[J]．首都公共卫生，2008，2(5)：214-6．
[63]刘玉玲．社区卫生服务的规范化管理与体会[J]．中国实用医药，2009，4(1)：241-2．
[64]任长乐，毕芳，张春娜等．我国社区卫生服务机构的现状及发展对策[J]．中国卫生质量管理，2008，15(6)：84-6．
[65]周莹，方子．我国社区卫生服务人力资源配置分析[J]．医学与社会，2008，2l(12)：6-8．
1．吴仪副总理在2007年全国城市社区卫生工作会议上的讲话，卫生部网站
2．党的十六届六中全会《关于构建社会主义和谐社会若干重大问题的决定》
3．国务院关于发展城市社区卫生服务的指导意见(国发(2006)10号)，国务院
4．关于公布第一批定点生产的城市社区农村基本用药目录的通知(国食药监市[2006]343号)，国家食品药品监督管理局
5．关于加强城市社区和农村基本用药定点生产、使用和价格管理的通知(国食药监市[2007]308号)，国家食品药品监督管理局
6．关于加强城市社区卫生服务机构医疗服务和药品价格管理意见的通知(发改价格(2006)1305号)，国家发展改革委、卫生部
7．处方管理办法，卫生部令53号
8．唐镜波，李少丽，李大魁等．制定我国国家药物政策的必要性与迫切性[J]．中国药学杂志，2001，(12)
9．李青，曾繁典．wH0国家药物政策的实施现况[J]．药物流行病学杂志，2002，(06)
10．甄伟玲，张新平，陈昊等[J]．国家药物政策的关键元素和评价指标探讨[J]．中国卫生质量管理，2004，(04)
11．孟锐，唐冬蕾，陈凤龙．国家基本药物政策推行与药品获得及合理用药关系的探讨[J]．中国药师，2005，(07)
12．Philwifferl，杜亮，熊鹰等．证据与基本药物：药物目录的筛选、评价和持续[J]．中国循证医学杂志，2003，3(2)：83-88
13．陈冠容，刘忠．2002年世界卫生组织基本药物目录品种[J]．药物流行病学杂志，2003，12(3)：144-153
14．张震巍，沈爱宗．国家《基本医疗保险用药目录》与《基本药物目录》之比较分析[J]．中国卫生事业管理，2004，20(5)：317-318
15．曾颖，杨敏，刘晓琦．我院门诊合理用药国际指标调研及分析[J]．中国医院药学杂志，2006，26(6)：737-739
16．陈莲珍，王青等．合理用药国际指标现场调查[J]．中国药房，2003，14(3)：156-158
17．陈莲珍，王淑洁，王青等．多中心合理用药国际指标对照研究——现场调查[J]．中国医院药学杂志，2003，23(7)：438-440
18．季波，韩丽萍等．3000张门诊处方基本指标及用药情况分析[J]．中国医院药学杂志，2003，23(2)：125-125
19.WHO.WHO Prequalification Program.Program Activities in 2005:2-4 http://mednet3.who.int/prequal/info_general/documents/Prequal_AnnualReport2005 EN.pdf
20.Chaudhury,R.R.,R.Parameswar,U.Gupta,S.Sharma,U.Tekur,and J.S.Bapna,Quality medicines for the poor:experience of the Delhi programme on rational use of drugs.Health Policy Plan,2005.20(2):p.124-36
21.刘佳,钱丽萍,张新平.德里模式与基本药物推广.国外医学·社会医学分册,2003, 20(2): 76-80
22.Abbott TA. Price regulation in the pharmaceutical industry: prescription or placebo? J Health Econ 1995;14(5):471-479
23.Giuliani G, Selke G, Garattini L. The German experience in reference pricing. Health Policy 1998;44:73-85
24.Silvia M. Ess, Sebastian Schneeweiss and Thomas D. Szucs. European Healthcare policies for controlling drugexpenditure. Phamacoeconomics 2003;21(2):89-103
25.Department for International Development. Increasing access to essential medicines in the developing world: UK Government policy and plans [M].2004
26.World Health Organization. Equitable access to essential medicines:a framework for collective action. Essential drug monitor 2004; 4:8-13
27.World Health Organization. Regional strategy for improving access to essential medicines in the Western Pacific Region, 2005 -2010. 2005.
28.http://haiweb.org/medicineprices/
29.Kamaruzaman Saleh and Mohamed I .M. Ib rahim. Are Essential Medicines in Malaysia Accessible, Affordable and Available? Pharmacy World & Science 27:6,442-446
30.Babar ZUD, Ibrahim MIM, Singh H, Bukahri NI, Creese A. (2007) Evaluating Drug Prices, Availability, Affordability, and Price Components: Implications for Access to Drugs in Malaysia. PLoS Med 4(3): e82 doi:10.1371
31.Myhr K. Comparing prices of essential drugs between four countries in East Africa and with international prices. MSF Conference, Nairobi 2000 (http://www.accessmedmsf.org/upload/ReportsandPublications/3920012349208/East%20A frica.pdf)
32.Kotwani, A., M. Ewen, D. Dey, S. Iyer, P.K. Lakshmi, A. Patel, K. Raman, G.L. Singhal, V. Thawani, S. Tripathi, and R. Laing, Prices & availability of common medicines at six sites in India using a standard methodology. Indian J Med Res, 2007. 125(5): p. 645-54
33.Ashcroft RE. Access to essential medicines: a Hobbesian social contract approach. Developing World Bioethics 2005; 5(2): 121-141