摘要
目前,我国卫生保健费用快速上涨,不合理用药现象普遍存在,药品支出在卫生保健总支出中占有相当大的比重,同时卫生工作的公平性和可及性还存在有很大的缺陷,“看病难、看病贵”已经成为影响和谐社会构建的突出问题之一,这极大影响了“人人享有初级卫生保健”这一卫生目标的实现。如何纠正不合理用药行为,减少浪费,控制药品的消费,从根本上抑制药品费用的快速增长,促进卫生资源的公平、合理利用,就需要进行医药卫生体制改革,建立基本药物目录,推行基本药物政策,以提高药物的可获得性,促进卫生工作的公平性和可及性,以有限的资金和资源实现“人人享有初级卫生保健”的目标。
基本药物是WHO于1975年开始向一些国家推荐使用的,旨在使其成员国,特别是发展中国家大部分人口得到基本药物供应,既满足广大人民群众防病治病的需要,又使国家有限的卫生资源得到有效的利用,达到最佳的社会效益和经济效益。社区卫生服务是城市公共卫生和基本医疗服务体系的网底,是医疗卫生服务的第一级提供者,是社区建设的重要组成部分。社区卫生服务是初级卫生保健的载体,发展社区卫生服务是政府实现卫生公平性和可及性的有效途径。发展社区卫生服务,对于实现人人享有初级卫生保健,解决“看病难、看病贵”问题,建设和谐社会具有重大意义。因此,根据基本药物概念的广泛适用性,要求基本药物目录要反映不同级别的卫生保健基础设施的技术和要求,在了解地方疾病谱情况,以及相关遗传、地理、环境等因素后,制订相应基本药物目录。
本研究以基本药物的基本理论为指导,探讨制定《社区卫生服务中心基本药物目录》的必要性,同时在了解社区就诊居民的疾病谱特征和药物可获得性的基础上,借鉴《WHO基本药物标准目录》制定的原则和程序、以《国家基本药物目录》为基础,参照《国家基本医疗保险药品目录》,制定与社区工作相符合的《社区卫生服务中心基本药物目录》。本研究选取山东省济南市的13所社区卫生服务中心进行相关数据的收集,所采用的研究方法主要有:文献复习法、现场调查法、德尔斐(Delphi)法。
本研究主要结果:(1)、社区卫生服务中心总收入以业务收入为主,占58.82%,而业务收入中又以药品收入为主,占60.97%;总支出中以业务支出占主导,而其中药品支出占有较大的比重,为35.46%;(2)、社区卫生服务中心药品种类繁多,西药品种数平均为343.50种,中成药品种数平均为119.50种;(3)、本研究中社区居民的疾病特征与2003年全国卫生服务调查结果基本一致;(4)、基于社区就诊居民疾病特征,借鉴《WHO基本药物标准目录》制定的原则和程序,以《国家基本药物目录》为基础,参照《国家基本医疗保险药品目录》,制定了《社区卫生服务中心基本药物目录》,本目录包含药品共354种,其中化学药物223种,中成药131种。
政策建议:(1)、《社区卫生服务中心基本药物目录》的制定需要充分考虑地区的疾病特征,以及医务人员的素质、财政来源和遗传、地理、环境等因素;(2)、《社区卫生服务中心基本药物目录》在初次制定时应用专家咨询法,但是在以后制定时需要应用药物经济学、循证医学等相关学科的证据支持,因此国家应当大力发展相关学科,注重相关证据数据的收集,以提高基本药物遴选的科学性;(3)、《社区卫生服务中心基本药物目录》的制定只是基础性工作,而基本药物能否发挥其促进合理用药,减少浪费,提高药物的可获得性,促进卫生工作的公平性和可及性,以有限的资源实现“人人享有初级卫生保健”的作用,关键是要看其可行性和可操作性,这就要求全方位推行国家基本药物政策,保证基本药物的生产、供应,加强社区医生的培训,加紧制定与实施临床治疗指南和处方集。
Health care cost rises fast in recent years, among that the drug cost possesses more proportion in total health care expenditure. Simultaneously, there are defects in the fairness and accessibility of health, which impact enormously on the implementation of the objective of "Primary Health Care for All". "Inadequate and overly expensive medical services" has become to be an important issue that influences the establishment of harmonious society. To solve the issue of "Inadequate and overly expensive medical services", retrieve the behavior of irrational utilization of drugs, reduce waste, control drug consumption, fundamentally restrain the fast growth of drug cost, facilitate fair and rational utilization of health resources, we should carry out health care reform, establish Essential Medicine List, and practice essential medicine policy, from which we can improve the fairness and accessibility of health care, and implement the objective of "Primary Health Care for All" with limited fund and health resources.
The concept of essential medicine was proposed by WHO in 1975, which aimed at warranting the provision of essential medicines for most people of the member countries, especially developing countries. Essential medicine can not only satisfy the demand for disease prevention and disease treatment, but also it can facilitate the efficient utilization of limited health resources, from which to achieve optimal social benefit and economic benefit. Community health service is the basis of urban public health and basic medical service system, is the primary provider for medical service, and is an important ingredient of community construction. Community health service is the carrier of primary health care. The development of community health care is a valid approach to implement health care fairness and accessibility. It is significant to develop community health service for the implementation of "Primary Health Care for All", the solution of the issue of "Inadequate and overly expensive medical services", and the establishment of harmonious society. Therefore, according to the extensive applicability of the concept of essential medicine, the Essential Medicine List should reflect the requisition and techniques of infrastructure constructions of health care in different levels. Based on the different spectrum of disease in different locations, and the factors about heredity, geography and environment, we can formulate correspondent Essential Medicine List.
As yet, we haven't found any study on Essential Medicine List for Community Health Service Center. Therefore, we carried out this study. The main objective of this study is to formulate Essential Medicine List for Community Health Service Center, which is based on the concept of essential medicine proposed by WHO, uses the principles and procedures for the formulation of WHO Essential Medicine List, basing on National Essential Medicine List and referencing National Basic Medical Insurance Medicine List, and gets the message of spectrum of disease of inhabitants of Ji'nan, Shandong Province.
Based the guidance of basic principles of essential medicine, the study discussed the essentiality for the formulation of Essential Medicine List for Community Health Service Center thoroughly. Simultaneously, according to the knowledge of the spectrum of disease, we formulated the Essential Medicine List for Community Health Service Center using the principles and procedures of WHO Essential Medicine List, basing on National Essential Medicine List and referencing National Basic Medical Insurance Medicine List. The list was congruous to the practical work of community doctors. 13 community health service centers were chosen in the study to collect data. The methods used in the study are literature review, Delphi, field investigation.
Main findings of the study are: ( i) the main is drug income in professional income(60.97%), which is the main in total income(58.82%), and also the main expenditure is drug expenditure in professional expenditure(35.46%); (ii) there are a great variety of drugs in community health service centers, 343.50 western medicines and 119.50 Chinese traditional medicines are included; (iii) the spectrum of disease of habitants is in accordance with National Community Health Service Investigation in 2003; (iv) based on the spectrum of disease, we formulated the Essential Medicine List for Community Health Service Center referencing WHO Essential Medicine List, National Essential Medicine List and National Basic Medical Insurance Medicine List. The Essential Medicine List for Community Health Service Center contained 354 items, which included 223 Western medicines and 131 Chinese patent medicines.
Recommendations are summarized below according to the study, including: (i) the spectrum of disease, diathesis of medical staff, sources of fund, heredity, geography, environment and so on should be considered in the formulation of Essential Medicine List for Community Health Service Center; (ii) the method used to formulate Essential Medicine List for Community Health Service Center is Delphi method for the first time. However, the Pharmacoeconomic evaluation data, Evidence-based Medicine data and so on should be used to select essential medicines in the future. Therefore, we should pay more attention to the collection of related data, (iii) the formulation of Essential Medicine List for Community Health Service Center is only the first step. Whether or not the essential medicine can facilitate rational utilization of drug, diminish waste, improve the procurability of drugs, facilitate the accessibility and fairness of health care, implement the objective of "Primary Health Care for All" with limited health resources, we should pay attention to the manipuility and feasibility of Essential Medicine List for Community Health Service Center. Then, the practice of National Essential Medicine Policy is needed, which can warrant the manufacture and provision of drugs. Simultaneously, we should strengthen the training of community doctors, formulate and practice clinical guidelines and hospital formularies.
引文
1、龚幼龙.社会医学[M].第一版.北京:人民卫生出版社,2000.
2、郭清.初级卫生保健是构建和谐社会的卫生公平底线[J].中国初级卫生保健,2006,20(1):1-3.
3、郭清.社区卫生服务理论与实践[M].第一版.广州:暨南大学出版社,2000.
4、陈永法,张成绪,邵蓉.建立与完善国家基本药物政策的研究[J].中国药房,2002,13(2):68-72.
5、俞观文.解决看病贵必须标本兼治、综合治理[J].中国制药信息,2006,22(2):1-3.
6、卫生部统计信息中心.中国卫生服务调查研究--第三次国家卫生服务调查分析报告[M].第一版.北京:中国协和医科大学出版社,2004.
7、邵明立.我国药物政策的有关问题[J].江苏药学与临床研究,2005,13(1):1-5.
8、WHO.Action programme on essential drugs.Progress of WHO member states in developing national drug policies and in revising essential drugs lists[R].WHO/DAP,1998:1.
9、The India-WHO programme in essential drugs and the delhi for the promotion of rational use of drugs,http://www.essentialdrugs.org.[2007-11-26]
10、IVAN PRUDENCIO and GIANNI TOGNONI.Essential drugs policy in Bolivia [J].Health Policy and Planning,1987,2(4):301-308.
11、M.C.Chinyere,J.O.Akinde,U.Emmanuel.Improving access to essential drugs for rural communities in Nigeria:the Bamako initiative re-vised[J].Pharmacy World & Science,2006,(28):91-95.
12、Laing R,Waning B,Gray A,et al.25 Years of the WHO Essential Medicines Lists:Progress and Challenges[J].THE LANCET,2003,361(17):1723 - 1729.
13、Highlights-WHO Medicines Strategy:2000-2003,Framework for action in essential drugs and medicines policy[J].Geneva:WHO 29-30 June 1999.
14、World Health Organization.How to develop and implement a national drug policy.Second edition.1988,Geneva.
15、Idanpaan-Heikkila JE.Essential drugs[J].Ann Med,1993,25(1):19.
16、王青,兰奋,李少丽.基本药物的概念及其推广[J].中国药房,2000,11(3):100-102.
17、张新平,李少丽.药物政策学[M].第一版.北京:科学出版社,2003.
18、陈文,叶露,应晓华,等.新医改下的国家基本药物政策[J].中国卫生,2007,(3):87-88.
19、岳彩玲.浅论医院财务分析指标体系[J].会计之友,2006,(07S):95.
20、WHO Model List of Essential Drugs.Reproduced in WHO drug information.Publication in the Technical Report Series in Preparation.1999.
21、 Essential Drugs.WHO Drug Information[C].1999.
22、Couper MR.The selection of essential drugs:A review[J].Chin J Clin Pharmacol,1993,9(1):3.
23、Executive Board WHO.Revised procedures for updating the WHO model list of essential drugs:a summary of proposals and processes JR].EB108/INF.DOC./2.Geneva:World Health Organization,2001.
24、WHO.Technical report series WHO no 914[R].Geneva:World Health Organization,2003.
25、WHO/EDM Department of Essential Drugs and Medicines Policy.Updating and disseminating the WHO Model List of Essential Drugs:the way forward[C].Geneva:World Health Organization,2004.
26、吴景时,王羽竹,颜卿.国家非处方药手册[M].第三版.北京:人民卫生出版社,2001.
27、李德爱,邵友梅,裴晓东.国家基本药物临床手册[M],第三版.北京:化学工业出版社,1999.
28、 WHO.WHO policy perspectives on medicines-the selection of essential medicines [C].Geneva:World Health Organization,2002.
29、中华人民共和国卫生部.卫生部关于印发城市社区卫生服务机构设置原则等三个文件的通知.http://www.moh.gov.cn/newshtml/8011.htm.[2007-11-28]
30、吴秀云,李曼春,马风云.宣武区、东城区社区卫生人力配备研究[J].中国全科医学杂志,2000,3(4):285-286.
31、梁万年,李静,关静,等.全国社区卫生服务现状调查--2000-2002年全国社区 卫生服务中心人力资源现状及地区间比较[J].中国全科医学,2005,8(13):1038-1041.
32、张晓枫,杨珺,高荷蕊,等.全国社区卫生服务现状调查--2000-2002年全国城市社区卫生服务中心财务收入状况分析[J].中国全科医学,2006,9(5):351-353.
33、闫宇翔,李静,杨兴华,等.全国社区卫生服务现状调查--2000-2002年全国社区卫生服务机构总收入分析[J].中国全科医学,2006,9(9):700-702.
34、高荷蕊,王亚东,李春雨,等.全国社区卫生服务现状调查--2000-2002年全国城市社区卫生服务中心财务收支状况分析[J].中国全科医学,2006,9(5):356-358.
35、朱长超.特尔菲法[J].社会科学,1996,(5):69-70.
36、任建华.关于德尔菲技术预测的准确性的研究[J].和田师范专科学校学报:汉文综合版,2005,25(1):142-143.
37、孔越,陈娟.特尔菲法在社区卫生服务利用者满意度指标筛选中的应用[J].中国初级卫生保健,2007,21(5):32-34.
38、中华人民共和国国家中医药管理局.关于征求《社区卫生服务机构基本药物目录(征求意见稿)》意见的函.http://www.satcm.gov.cn/zwgk/yzgl/sqws/20061027/041522.shtml.[2007-12-13]v9、鄢琳,周杰明,井春梅,等.世界卫生组织基本药物示范目录:挑战与发展[J].中国药物警戒,2006,3(5):261-266.
40、WHO's revised drug strategy.Report of the Director General[R].Geneva,WHO,1986.
41、肖爱丽,井春梅,挪琳,等.国家基本药物目录调整原则的探讨[J].药物流行病学杂志,2005,14(5):300-302.
42、石岩,丁长勇.让药物经济学作用于《目录》管理[J].中国社会保障,2006,(8):43-44.