To authors’ knowledge, no scholar has done research on the availability and affordability of essential drugs in Hefei before, and some scholars have discussed the availability and affordability of essential drugs in cities such as Hangzhou, Baoji, and Shanghai.This article aims to ascertain the specific situation of the availability and affordability of essential drugs in Hefei, and to make relevant suggestions to improve the current situation. This article mainly compares key factors such as drug prices, allocation rates, and median price ratios, focusing on the public medical institutions and retail pharmacies [
13].
Before implementing the centralized drug procurement policy, the government has been looking for ways to increase the efficiency of drug distribution and reduce drug delivery time. At present, the expected results have not been achieved [
15]. There are two possible explanations. One possibility is that the purchase of retail pharmacies has reached saturation. Even if there is no relevant policy, the purchase volume of retail pharmacies can only reach one degree. Another explanation may be that the centralized procurement policy has a negative impact on retail pharmacies, and the policy hinders the purchase of medicines [
16].
Allocation analysis of essential drugs in Hefei
Essential drugs are the drugs most closely related to the patients’ lives, and in the ideal state, drug sales institutions should supply to the maximum extent. However, in Hefei, whether in public medical institutions or retail pharmacies, the allocation of essential drug is not satisfactory [
17]. This study found that 50% of essential drugs at public medical institutions and retail pharmacies are quite low, and some medicines are hard to find in the market. The low allocation rate of essential drugs leads to the fact that patients do not enjoyed the benefits of low prices of essential drugs because they choose high-priced equivalent drugs in actual purchase.
The allocation ratio of OBs in retail pharmacies and public medical institutions is not high, and the both allocation ratio is basically the same. In terms of domestic generics, its sales in retail drug stores in Hefei are better than that of public medical institutions. The median allocation rate of essential drug in retail pharmacies is 60.0%, which is significantly higher than 30.0% in public medical institutions.
In China, the essential drug system is in an exploratory stage, and the system itself has not yet reached a perfect stage. Some medicines are expensive and unavailable, not included in the procurement catalogs of public medical institutions and retail pharmacies, resulting in low availability of medicines. In fact, there are alternative medicines, and the indications for the treatment of similar varieties are the same, and some public medical institutions and retail pharmacies purchased the alternative medicines instead of drugs in WHO list, resulting in lower availability of this drugs. The availability of medicines will be improved if factoring in alternative medicines is taken into account. Due to the influence of price factors, after consulting and communicating with patients, doctors and pharmacists may choose low-cost alternative medicines for them, resulting in lower availability of medicines.
Beginning in 2018, in order to stabilize China’s pharmaceutical market, the Chinese government began to implement the “4 + 7 Volume Procurement Policy.” It refers to the state-approved centralized drug procurement at selected cities, covering Beijing, Tianjin, Shanghai, Chongqing, Shenyang, Dalian, Xiamen, Guangzhou, Shenzhen, Chengdu, Xi’an, etc. 11 cities. Such policies have led to a substantial drop in drug prices, for example, the price of therapeutic drug entecavir dispersible tablets fell by 92% with an average decline of more than 50%. In the bidding procurement in 2019, the “4 + 7 Volume Procurement Policy” model is also tracked in areas out of the selected cities. It is generally believed that the prices of essential drugs will continue to fall. After the “4 + 7 Volume Procurement Policy”, there has been a trend to reduce prices, reducing the burden on patients, but the drugs shortage is also increasing. For example, the Chinese government has established a drug shortage monitoring mechanism, and provinces have also published their own drug shortage catalogs.
The purpose of the Chinese government’s “4 + 7 Volume Procurement Policy” is to reduce the drug price and improve the patients’ purchase ability. Successful bidders who pass the conformity assessment of generics will greatly reduce drug prices. The government will give the successful bidders a certain market share, and the coverage of high-quality and low-cost generics will become wider. The pressure on the affordability of drugs will be reduced, and patients will have better drug options. Some pharmaceutical industry associations have applied to suspend the implementation of the policy, fearing that excessive price declines will affect the profitability of pharmaceutical companies, reduce research and development investment, and affect drug innovation. In the long run, patients will lose new treatments, which is not good for them, but the medical insurance department is determined to implement the policy in order to save medical insurance funds. For business risks control, pharmaceutical companies have adopted methods to reduce manufacturing investment and strictly control the scale of drugs production. Due to China’s huge region and the uneven development between provinces, a unified market circulation system has not yet been formed in China. When market fluctuations occur, there may be a decline in the supply of medicines in some regions or within a certain period of time, which reduces the availability of drugs [
18].
Some medicines, such as metformin, amoxicillin, and nifedipine, have large stocks in public medical and retail pharmacies. Due to cheaper generics and market factors, public medical institutions and retail pharmacies will give priority to purchasing generics, such as omeprazole. Its availability is high, and its ratio of the OB and the generics is over 80%. However, most public medical institutions and retail pharmacies have more stocks of generics than stocks of OBs, which may be related to economic factors and policy factors. Pharmaceutical manufacturers may have economic interests with public medical institutions and retail pharmacies, so they will give priority to purchasing generics [
19].
Affordability analysis of essential drugs’ retail prices
The affordability of medicine prices is an important guarantee for the availability of medicines. The affordability of most essential drugs in Hefei is good. Hefei is a relatively underdeveloped region in East China. The per capita income in urban and rural areas is much lower than in economically developed provinces, such as Zhejiang, Jiangsu, etc., and to a certain extent, higher drug expenditures will cause patients to be “poor due to illness” or “back to poverty due to illness” [
20].
By 2018, the Hefei Municipal Government has formulated relevant policies to control drug prices and drug procurement scope. From the survey results, the affordability of public medical institutions is better than that of retail pharmacies. However, the prices of some drugs are still higher than the international standards set by WHO / HAI, and they still need to be improved. Generally, the release and implementation of policies will benefit the availability and affordability of drugs, but the actual situation is not optimistic [
21]. It is recommended that government departments strengthen drug price supervision to make the procurement system more scientific, operate more efficiently, and make the circulation open and transparent.
In the future, due to the influence of national policies, the affordability of drugs in Hefei City will continue to remain at a better level, and low-cost OBs and high-quality generics will enter public medical institutions and retail pharmacies. For patients, it can solve related drug procurement issues [
22].
In the drug affordability survey standards formulated by WHO / HAI, it is defined as the total cost of medicines used to treat a disease with a standard dose of medicines within a certain course of treatment, which is equivalent to the minimum daily salary standard for non-technical personnel in government departments (Or equivalent to the minimum daily wage standard set by the local human resources and social security department). There is a certain deviation from the statistics of Chinese residents’ income. Some residents are individualized or farmed, and cannot be evaluated according to the standards set by WHO / HAI.
This research also has some disadvantages. The first is the time lag of research work. Recently, the Chinese government’s medical insurance drug procurement policy is undergoing a drastic changes, and it can be said that there will be substantial changes every few months. For example, on November 28, 2019, the new national medical insurance catalog has just launched, and the prices of most essential drugs and new medicines have been significantly reduced in order to enter the medical insurance catalog. However, some essential drugs are no longer included in the reimbursement list, and its prices may not be restricted, nor its production may halt due to sales decline. These changes will directly affect the availability and affordability of essential drugs. Second, there may be contingencies in actual investigations. The representativeness of selected hospitals and pharmacies may be biased, and accidental factors are not excluded from the statistical research results, which affect the final research results. Third, the core catalogue developed by WHO / HAI is based on global considerations without considering China’s national conditions. The drastic changes and uncertainties in China’s ongoing national healthcare reform and supporting pharmaceutical procurement reform have also affected the results of this study.