Download Pharmaceutical Price Policies and Practices in China

Candidate Number: 30571
China’s Pharmaceutical Price Policies and Practices
Contents
Abbreviations ........................................................................................................................................3
Abstract .................................................................................................................................................4
1. Introduction ...................................................................................................................................5
2. Methodology .................................................................................................................................8
3. Background ...................................................................................................................................9
3.1. Health System ...................................................................................................................9
3.1.1.
Financing Hospitals and Doctors ..........................................................................9
3.1.2.
Medical Insurance ...............................................................................................10
3.1.3.
Generic Policy ..................................................................................................... 11
3.2. Pharmaceutical Industry and Commerce ........................................................................13
3.2.1.
Pharmaceutical Industry ......................................................................................13
3.2.2.
Pharmaceutical Commerce..................................................................................14
3.2.3.
Medicines Procurement through Central Bidding ...............................................14
3.3. Pharmaceutical Pricing Policies ......................................................................................16
3.4. High Level Forum on Developing NMP to Secure the Essential Medicine System .......18
4. Pricing Surveys ...........................................................................................................................19
4.1. Availability ......................................................................................................................19
4.2. Prices for Core Drugs......................................................................................................20
4.3. Affordability ...................................................................................................................21
4.4. Price Components ...........................................................................................................23
4.5. Comparison with India’s Surveys ...................................................................................24
5. Summary of China’s Medicines Price and Availability Problems ..............................................25
5.1. Complexity and Bureaucratic Structures.........................................................................25
5.2. Lack of Access ................................................................................................................25
5.3. Price and Affordability ....................................................................................................26
5.4. Generic Policy.................................................................................................................27
5.5. Price Components ...........................................................................................................27
5.6. Financing Hospitals ........................................................................................................27
5.7. Drug Use Patterns ...........................................................................................................28
5.8. Conflicts of Interests .......................................................................................................28
5.9. Corruption .......................................................................................................................29
6. Policy Options.............................................................................................................................30
6.1. Selection of Essential Drugs ...........................................................................................30
6.2. Drug Pricing ....................................................................................................................30
6.3. Generic Policy.................................................................................................................31
6.4. Supply and Distribution ..................................................................................................32
6.5. Affordability ...................................................................................................................33
6.6. Rational Reimbursement to Hospitals and to Doctors ....................................................33
6.7. Research ..........................................................................................................................33
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7. Conclusion ..................................................................................................................................34
Annex 1-8 ...........................................................................................................................................35
References...........................................................................................................................................45
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Abbreviations
BMI
CNHEI
Basic Medical Insurance
China National Health Economics Institute
EDL
Essential Drug List
GDP
Gross Domestic Product
GMP
Good Manufacture Practice
HAI
Health Action International
IB
Innovator Branded drugs
IDA
International Dispensary Association
INN
International Non-proprietary Names
IRP
International Reference Price
LPG
Lowest-Priced Generics Equivalent
MOH
Ministry of Health
MHS
Management Science of Health
MOSSL
Ministry of Labour and Social Security
MPR
Median Price Ratio
NDRC
National Development and Reform Commission
NMP
National Medicine Policy
OECD
Organization for Economic Co-operation and Development
R&D
Research and Development
SC
State Council
SFDA
State Food and Drug Administration
SPDC
State Planning and Development Commission (after 2003 became NDRC)
THE
Total Health Expenditure
WHO
World Health Organization
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Abstract
This paper describes China’s complex pharmaceutical sector, covering the overall health
system, the pharmaceutical industry and commerce, and the drug pricing system. I have
tried to collect all current relevant drug-related policies in China and the literature to
evaluate these policies. Also, I have interviewed some key informants in the Chinese
Government and academia. Problems in China’s pharmaceutical sector include lack of
access, irrational reimbursement to hospitals/doctors and consequent irrational drug use
patterns, disorganized supply and distribution systems and conflicts of interest among
different stakeholders. Possible policy options to address these problems include generic
promotion, rational reimbursement of hospitals and doctors, the promotion of regular
supply and distribution systems, reasonable pricing, and encouragement of more
research on all aspects of the pharmaceutical sector.
A comprehensive and balanced National Medicine Policy (NMP), reconciling the varied
interests of the many stakeholders, needs to be established to guide the whole process of
drug production, selection, distribution, consumption and pricing, to promote a
pharmaceutical industry that would ensure access by the Chinese population to essential
medicines that are used rationally.
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1.
Introduction
In 2005, China spent 4.73% of its Gross Domestic Product (GDP) on Total Health
Expenditure (THE) {Ministry of Health (Statistic Information Centre), 2007 #41}.
Drug expenses accounted for 50.5% of medical expenses for out patients and 42.7%
for in patients in 2006 {Ministry of Health (Statistic Information Centre), 2007 #41}.
China spends over 2.26% of GDP on pharmaceuticals which is more than most OECD
countries, as shown in Figure 1.
Figure 1. Pharmaceutical Expenditure/GDP in OECD Countries and China (2005)
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Source: OECD 2007 and MOH, China, 2007
Although medicine retail price indexes have continually decreased since 1995
{National Bureau of Statistics of China, 1995-2006 #31} (See Annex 1), patients still
regard drug prices as unaffordable and their out-of-pocket expenses accounted for
52.21% of THE {China National Health Economics Institute, 2006 #32}.
The pharmaceutical sector in China is very complicated, involving many stakeholders
with different and sometimes contradictory interests. In this paper, I describe the whole
pharmaceutical sector. Although the focus is on pharmaceutical pricing polices, all the
other policies described in the sector impact on prices, including: policies which impact
on access to drugs; reimbursement to hospitals/doctors; and drug use patterns; supply
and distribution systems; and the functions of different stakeholders, etc. No articles
were found which collected all drug policy related documents involving all the
stakeholders to analyse pharmaceutical price issues systematically. Therefore, I present
information on all related policies to show their influence on drug prices. An annotated
bibliography and the text of policy documents and related articles will be produced and
made available on request to WHO. Also, as there is a lack of in-depth surveys on drug
prices, this paper will synthesize existing drug price survey data between China’s
provinces.
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The first part of the paper describes current drug policies and their application. The
second part presents the methodology and the third provides background. The fourth
part compares two medicine pricing surveys in Shandong Province and Shanghai City
on the availability of drugs, drug prices, affordability and price components.
Comparison is also made with surveys done in six Indian states. The fifth part
summarizes China’s medicines price and consequent availability problems, while the
sixth part provides some policy options for Chinese decision-makers to consider. The
paper concludes that a comprehensive NMP should be established to address
pharmaceutical sector issues due to the complexity of the sector.
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2.
Methodology
Drug policy documents were collected from all relevant Government websites,
including SFDA, MOH, NDRC, MOSSL and from individual informants. They were
sorted into the following categories: financing hospitals/doctors, medical insurance,
generic policies, pharmaceutical industry/commerce and pharmaceutical pricing.
Practical evaluations were mainly from VIP-database (a Chinese academic database);
websites with the titles of specific policies as keywords, and other articles were
provided by interviewees and from Pubmed searches.
Interviews were undertaken in Beijing and Shanghai in July 2007. I interviewed key
informants, 12 of whom were from the Chinese Government, who either have been or
are involved in drug price-related policy-making, and 2 were from top academic
institutions, who are all key experts in China doing research on pharmaceutical sector
and also involved in the process of drug policy-making. For each informant, I prepared
a list of questions which depended on their specific roles. See Annex 2. All citations in
this paper are confirmed and authorized by interviewees.
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3.
Background
3.1. Health System
3.1.1. Financing Hospitals and Doctors
China’s health facilities have experienced a transformation from planned management
by Central Government to market-oriented management instigated since China’s
economic reform. The percentage of Government financial support to hospitals
decreased from about 60% at the beginning of the 1980s to 8.2% in 2003 {Ying XH,
2007 #18}. As a result, hospitals regard pharmaceutical sales revenues as their main
financial sources. They accounted for nearly 80% of total drug sales {China National
Health Economics Institute, 2006 #32}. Due to information asymmetry, patients have
no power to control the quality and amount of medical services, and have to rely on
physicians to make decisions on their behalf. So, hospitals and physicians can boost
drug sales. In 2005, hospitals’ margins were over 50 billion Yuan (US$ 6.75 billion),
which accounted for 42% of the procurement price (Zhu CH, 2007, Interview). To
resolve this issue, NDRC {National Development and Reform Commission, 2006 #57}
required retail prices to equal “the procurement price plus margin” with the profit rate
fixed at 15%, while this gives hospitals incentives to procure higher-priced drugs (Li
XF, 2007, Interview).
The irrational salary system for doctors (Lu J, 2007, Interview) and pharmaceutical
companies’ marketing (Wei JG, 2007, Interview) encourages them to prescribe
expensive drugs to obtain higher rebates to compensate for their low salaries. The
monthly salary and allowances of a county hospital doctor are between 1000 and 1500
Yuan ($US125 to $US187.5), while the monthly rebates from prescriptions are
between approximately 3000 and 5000 Yuan (US $375 to US $625) {Liang, 2005
#52}.
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MOH {Ministry of Health, 2000 #56} piloted instituting two-line management in
Anhui Province to separate drug revenues and expenses in medical facilities, and
expenses and revenues from medical services and drug sales. Net drug revenues are
pooled and used to support medical services. An evaluation showed that this policy
had failed to limit the growth in drug expenditure {Wang, 2006 #55}.
Community health services have been encouraged to promote proper distribution of
health resources with more government financial support since the beginning of 2006
{State Council, 2006 #60}.
3.1.2. Medical Insurance
China provides free medicine services to a limited number of individuals, such as
Government officials, most of whom could afford medical expenses (Wu YP, 2007,
Interview). Five years after Zhenjiang Province and Jiujiang City’s pilots in 1993,
the BMI system for urban employees (compulsory), which include employees of
state-owned enterprises, collective-owned enterprises, foreign enterprises and private
enterprises, government offices, institutions, and social groups, was officially
established by the Chinese Government with the premiums paid by both employers
and employees. Also, publication of a national BMI drug list followed {State Council,
1998 #58}. Drugs on the A-list could not be altered, while drugs on the B-list could be
adjusted by the provincial government. The most recent 2004 edition includes 1027
western medicines, far more than the 300 drugs on the WHO Model List of Essential
Medicines {World Health Organisation, 2007 #59}. At the end of 2006, 150.732
million urban employees were covered. Revenues from medical insurance funds were
174.7 billion Yuan (21.84 billion US$) and the expenditure was 127.7 billion Yuan
(15.96 billion US$) in 2006, 24.3% and 18.3% higher respectively than in 2005.
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In 2003, a new rural co-operative medical system was implemented mainly covering
severe diseases. The rural population is expected to participate voluntarily and funds
from individuals, collectives, central and local government. By the end of 2006, 508
million farmers were covered. The Government suggested establishing practical drug
supply, distribution and monitoring systems; promoting drug procurement through
centralized bidding or by county or township health centres on behalf of village clinics;
and encouraging chain enterprises to supply drugs though a centralized supply system
to grassroots-level medical facilities {Ministry of Health, 2003 #14; Ministry of Health,
2006 #13}.
For
drugs
consumed
in
both
urban
communities
and
rural
areas,
Government-designated manufacturers are encouraged to assure the quality of drugs,
print the retail price on even the smallest retail package, and reduce drug costs and
prices by simplifying packaging, and centralizing supply. These drugs’ prices are set
by the Government separately with more flexible mark-ups. Community and rural
medical facilities should give priority to procuring and consuming drugs produced by
designated manufacturers, not through a central bidding system and they should be
procured by medical facilities directly and supplied centrally {State Food and Drug
Administration, 1999 #63}. As a result, drug prices were reduced by 19% in
Dongcheng District (Beijing) compared to hospital prices and the cost per prescription
was reduced by 50%{Liu, 2006 #4}.
3.1.3. Generic Policy
No generic substitution policies exist in China. However, MOH {Ministry of Health
(Statistic Information Centre), 2007 #41} suggested that doctors should prescribe with
INN, patented drug names for new-active compounds, and names of combination
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preparations authorized and published by the SFDA.
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3.2. Pharmaceutical Industry and Commerce
3.2.1. Pharmaceutical Industry
The 2006 production and sales revenues, profits and export delivery values of the
pharmaceutical industry are shown in Table 1. See Annex 3 also.
Table 1. Chinese Pharmaceutical Industry’s Production and Sales Revenues, Profits and
Export Delivery Values and Pharmaceutical Commerce’s Net Sales and Profits in 2006
2006
Compared to 2005
(%)
Pharmaceutical
Total
Medical
and
520/65
+17.53
Industry
Pharmaceutical Product sales
total profits
41.51/8.13
+11.01
Export Delivery Values
67.059/8.38
+25.51
Pharmaceutical
Net Sales
280/35
+16.7
Commerce
Net Profits
68/21
+6.1
revenues
Source: NDRC, 2007
Note: in column 3, figures are first given in billion Yuan and then in billion US$ equivalent.
There are over 4000 pharmaceutical manufacturers in China {Wei JG, 2007 #65}, most
are small scale and produce the same drugs (Wu YP, 2007, Interview). For example,
Compound Sulfamethoxazole are produced by over 1000 manufacturers {Wei JG, 2007
#65}. R&D capacity is very weak and financing for R&D is also low, only accounting
for about 1% of the sales value {Wei JG, 2007 #65}. In 1994, GMP Certification began
in China, but drug production is still not regulated effectively, with no established
regulatory procedures for approving a drug. In 2006, 10386 “new” drugs were approved
for the market by SFDA (Wu YP, 2007, Interview).
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Competition among pharmaceutical manufacturers is based on price, not on quality.
NDRC has reduced drug prices 24 times since 2000. Therefore, manufacturers aim to
produce more “new” drugs, usually branded generics, to increase profits by only
changing the name, formula, or packaging, while effective, “old” drugs were removed
from the market because of their low profit margins. NDRC {National Development
and Reform Commission, 2005 #61} issued “Regulation on Drug Price Differences
Ratio” to verify drug prices for different dosages or weights of selected sample drugs,
and the trend to create “new” drug are expected to be controlled.
3.2.2. Pharmaceutical Commerce
The 2006 net sale values and profits of China’s medical and pharmaceutical industry are
shown in Table 1 {National Development and Reform Commission (Department of
Price), 2007 #29}.
With the intense competition, whether health facilities procure or prescribe a drug is
extremely important for manufacturers, making marketing essential. Therefore,
manufacturers try to decrease production costs and increase marketing costs to ensure
their viability, so adversely affecting drug quality (Wu YP, 2007, Interview). This makes
the drug supply chain another important factor influencing prices. There are usually 6 to
9 links from production to sale in the pharmaceutical sector. The final retail prices
reflect the margins deducted by each link, distributors’ competition, information
asymmetry, the relationship among consecutive links and related policies (Wei JG, 2007,
Interview), which are normally 5 to 10 times higher than actual factory prices {Liang,
2005 #52}. Assuming the retail price of a drug is 100 Yuan, 23 Yuan is given to the
manufacturer, 20 to the the hospital, 10-12 to doctors as rebates and the rest, 45 to 47
Yuan, to the wholesaler {Zuo, 2006 #54}.
3.2.3. Medicines Procurement through Central Bidding
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Drug procurement through centralized bidding has been implemented since 1998. The
savings made from the bidding system compared with Government set prices or market
prices were required to be redistributed rationally between patients and medical
facilities, with the majority transferred to patients {State Council, 2001 #62}.
Communities in Beijing are implementing central bidding procurement {Xin Hua Net,
2007 #25}, centralized supply and cancellation of the previous 15 % mark up rate for
312 common drugs. After implementing central bidding procurement, drug prices in the
first half of 2007 were 21.1% less than in 2006.
In practice, however, some local governments are responsible only for the procurement
of drugs and the contracts signed are usually ambiguous, so the companies which
submit bids have to renegotiate with hospitals after the bidding process to ensure that
hospitals procure their drugs. The bidding procurement system is not well coordinated
and the companies have to take part in several bids per year, wasting financial and
human resources (Zhuang N, 2007, Interview).
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3.3. Pharmaceutical Pricing Policies
Since 2000, new price-setting policies {State Planning and Development Commission,
2000 #21; State Planning and Development Commission, 2000 #22; State Planning and
Development Commission, 2001 #23} have come into effect. Central Government
(SPDC/NDRC) sets maximum retail prices for A-list medicines on the national BMI
drug lists, and for patented innovator and first-class new drugs (i.e. the active ingredient
and its preparation materials extracted from plants, animals or minerals, etc), which
have not previously been on sale in China and for second-class new drugs (i.e. newly
discovered drugs or preparations) {State Food and Drug Administration, 2007 #26}.
Central Government also sets the factory price/landed price of first-class drugs used in
mental health, anesthetics, immunization medicines, and family planning medicines,
leaving retail pharmacies and public hospitals to set their own retail price – which
cannot be higher than the maximum retail price. Provincial governments set prices for
B-list drugs, and the wholesale prices and retail prices of first-class drugs used in mental
health and anesthetics. Since 2000, NDRC has only set the prices of prescription drugs
and provincial price bureaus set OTC medicine prices {State Food and Drug
Administration, 1999 #63}. NDRC {National Development and Reform Commission,
2005 #27} began to set factory prices and maximum retail prices for selected samples of
drugs. Prices are based both on declared costs by manufacturers and calculated as
factory or import prices with duty/taxes and retail distributional profits incorporated
(Annex 4). Manufacturers can apply for special pricing permission for higher prices if
their drugs have greater efficacy and safety or if the treatment cycle and expenses are
much lower than those of other manufacturers producing the same drug. No
international drug price information is currently referred to (Xu WM, 2007, Interview).
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The price of off-patent innovators could be set up to be 35% higher for injections and
30% higher for other formula than generics produced by GMP certified manufacturers.
For patented drugs, manufacturers or distributors can set prices themselves in the year
after they received their import registration license, but after one year, SPDC/NDRC
makes an official assessment of the price. However, all prices not set by Central
Government have to be registered with the Government pricing authority. Drugs with
GMP Certification could be priced up to 40% higher for injections and 30% higher for
other dosage forms than non-GMP certified products.
In practice, the factory price set by manufacturers is usually much higher than the actual
production cost, because the Government pricing authority does not have enough
capacity to check these costs (Wu YP, 2007, Interview). Different prices for the same
drug exist in different areas because of local competition, procurement transparency and
local protection (Xu WM, 2007, Interview).
For medicines with market pricing, the retail price is set based on production costs,
market supply and demand. Wholesalers, retail pharmacies and hospitals can set the
actual selling price but cannot exceed the retail price set by the manufacturer.
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3.4. High Level Forum on Developing NMP to Secure the Essential
Medicine System in China
On 14 June, 2007, a High Level Forum on Developing NMP to Secure the Essential
Medicine System in China was held in Beijing. Some international experts were invited
to suggest policy options as part of China’s health system reform. WHO presented a
strategic framework to achieve reforms in the pharmaceutical sector, including
suggestions on improving affordability, supply, distribution, selection of essential
medicines, regulation and quality assurance, rational use, management, R&D, together
with the relevant implementation procedures {World Health Organisation, 2007 #17}.
Also, WHO background paper {Tang, 2007 #11} for this meeting examined and
described the main problems existing in pharmaceutical sector, critically analyzed the
main socio-economic and institutional factors associated with these key problems and
made recommendations. See Annex 5.
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4.
Pricing Surveys
In 2004 and 2006, WHO/HAI supported two surveys in Shandong Province and
Shanghai City, China {Ye, 2006 #3; Sun, 2005 #2}. The study design of both was based
on the standardized methodology developed by WHO/HAI using a standard list of
medicines, plus additional locally important medicines (supplementary medicines) to
compare the prices and availability of medicines in different sectors and regions in the
provinces {World Health Organisation, 2006 #24}. Sectors surveyed included public
hospital clinics (procurement prices, prices paid by patients and availability) and private
retail pharmacies (prices paid by patients and availability). In Shandong, 39 core and
supplementary medicines were surveyed in 4 areas; in Shanghai 41 core and
supplementary medicines were surveyed in 4 districts (See Annex 6). In the survey,
price data is expressed as MPR, which is the median unit price of the medicine across
the facilities surveyed, divided by the median IRP from MSH {Management Science of
Health, 2003/2005 #10; Management Science of Health, 2005 #67}.
Key findings from these two surveys showed availability of drugs, prices for core
medicines, affordability and price components.
4.1. Availability
In both surveys, availability of medicines surveyed was very poor in the public and
private sectors. This may have been due to the selection of medicines. But even for
life-saving medicines, such as Amoxicillin, Glibenclamide, Omeprazole and Salbutamol
inhaler, the availability ranged from 5% to 90%.
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Table 2. Median of Availability of Medicines in the Public and Private Sectors
Shandong
Shanghai
Public
Private
Public
Private
IB
0.0%
0.0%
13.3%
10.0%
LPG
7.5%
10.0%
33.3%
15.0%
Source: HAI, 2007
Note: “median %” of medicines found in at least 4 facilities; for examples of the top 5 drugs see Annex 7.
4.2. Prices for Core Drugs
MPRs ranged from 0.62 in Shandong for public sector procurement to 9.85 for private
sector innovator products in Shanghai. Comparing patient prices between the public and
private sectors, the MPR was the same or higher in the public sector --- an unusual
situation in which the public sector can charge a price premium.
Table 3. MPRs of Core Medicines
Shandong
Shanghai
Public
IB
LPG
Private
procurement
patient
6.30
4.09
(9)
(6)
0.62
0.93
(15)
(10)
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Public
Private
procurement
patient
7.14 (9)
7.63 (8)
9.83 (9)
9.85 (8)
0.51 (11)
1.44 (10)
1.84
1.43 (9)
(12)
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Source: HAI, 2007
Note: MPRs were reported of medicines found in at least 4 facilities; the number in brackets represents
the number of drugs which were found in the survey; Annex 8 provides the MPRs for some selected
drugs.
Within provinces and sectors, there was considerable price variation for the same
product, e.g. Amoxicillin price varied in Shandong’s private sector from 0.96 to 4.28.
Table 4. Variations of MPR Among Different Areas for Selected Drugs
LPG
Shandong
Public Sector
Aciclovir
1.25-1.59
Beclometasone inhaler
1.89-1.93
Hydrochlorothiazide
Private Sector
Shanghai
0.52-0.77
Ranitidine
0.87
Aciclovir
0.88-1.58
Amoxicillin
0.96-4.28
Beclometasone inhaler
1.83-1.89
Captopril
0.12-0.18
Hydrochlorothiazide
0.33-0.83
Ranitidine
0.39-0.65
0.42-0.96
Source: HAI, 2007
4.3. Affordability
In terms of affordability measured in day’s wages of the lowest paid unskilled
government worker, major differences existed between innovator and generic
equivalents.
For example, in Shanghai, a month’s diabetes treatment with Metformin,
would cost 3.9 day’s wages for the innovator and 0.8 day’s wages for the generic.
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Table 5. Affordability of Treating Sample Conditions in the Public and Private Sectors
Shandong
Shanghai
Public
Private
Private
Median
Day’s
Median
Day’s
Median
Day’s
Median
Day’s
price
wages
price
wages
price
wages
price
wages
(Yuan)
Diabetes:
Public
(Yuan)
IB
144
(Yuan)
10.8
(Yuan)
98.40
3.9
90.90
3.6
LPG
19.16
0.8
IB
203.14
8.1
203.14
8.1
LPG
117.43
4.7
106.28
4.3
Metformin
500mg
per
tab,
3
times daily for 30 days
Hypertension:
Amlodipine
5mg per cap, once
daily for 30 days
Adult resp. infects
IB
Amoxicillin
250mg per
cap,
3
LPG
4.20
0.3
7.98
0.6
22.31
0.9
22.31
0.9
IB
59.4
4.5
54.4
4.1
59.40
2.4
59.40
2.4
0.72
0.1
IB
360.99
14.4
354.64
14.2
LPG
155.00
6.0
150.00
6.0
times daily for 7 Days
Arthritis:
Diclofenac
25mg per cap, twice
LPG
daily for 30 days
Depression
Fluoxetine
20mg per cap, once
daily for 30 days
Asthma:
IB
36.45
2.7
37.50
2.8
35.30
1.4
35.65
1.4
4.75
0.4
22.40
0.9
18.55
0.7
Salbutamol inhaler
0.1mg per dos for 200
LPG
doses
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Peptic ulcer:
IB
Ranitidine
150mg per cap, twice
LPG
8.6
0.6
5.9
0.4
9.00
0.4
8.80
0.4
daily for 30 days
Note: the dosage listed in the first column is based on the Shandong data; however, there are some
variation in Shanghai data, i.e. Metformin, twice a day; Amoxicillin, 500mg per tablet.
4.4. Price Components
In Shandong, cumulative mark-ups (from the manufacturer’s price to the patient price)
were 24-35% in the public sector, and 11-33% in the private sector. In the public sector,
hospital mark-ups were the greatest contributor (hospital mark-ups of up to 26% were
seen). Business tax is applied in the private sector.
Table 6. Medicine Price Composition in the Public and Private Sectors
Only
Generic
Innovator and Generic
Equivalent
Medicine Name
Only Innovator Brand
in China
Amoxicillin
Losec
Omeprazole
Losartan
(Generic)
(Innovator brand)
(Generic)
(Innovator Brand)
12
140.72
48
42.39
12
140.72
48
42.39
10.33%
13.70%
0.58%
6.16%
13.24
160
48.28
45
Hospitals’ Mark-up
14.05%
18.75%
26.14%
17.11%
Hospitals’ Retail Price
15.10
190
60.9
52.7
3%
2%
3%
3%
12.36
143.53
49.44
43.66
Manufacturer’s Selling
Price / Landed Price
(set by manufacturer)
Wholesalers’
Procurement Price
Public Sector
Wholesalers’ Mark-up
to Hospital
Hospitals’ Procurement
Price
Private Sector
Wholesalers’ Mark-up
to Pharmacies
Pharmacies
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Procurement Price
excluding Tax
Regional Tax Paid by
3%
3%
3%
3%
12.73
147.84
50.92
44.97
Pharmacies’ Mark-up
25.69%
22.30
17.83%
4.51%
Retail Price Charged by
16
180.81
60
47
16.1
217
64.7
56.4
Pharmacies
Pharmacies
Procurement Price
including Tax
the Pharmacies
The Maximum Retail
Price Set by
Government
Source: HAI, 2007
4.5. Comparison with India’s Surveys
These surveys reflect similar findings to those done in India {Kotwani, 2007 #28},
using the same methodology. Availability in the public and private sectors was generally
poor, with Shanghai an exception, which may reflect the choice of medicines surveyed.
In terms of price ratios, public sector procurement was generally efficient being less
than IRP, except in Shanghai where price ratios were 44% more than IRP. In India,
public sector procurement price ratios ranged from 0.27 to 0.48 in different states and
private patient prices were substantially higher than public sector patient prices.
Table 6. Comparisons between China and India in terms of Availability of Drugs and
Drug Prices in Both Public and Private Sectors
Shandong
Shanghai
Indian (6 states)
IB
0.0%
13.3%
0
LPG
7.5%
33.3%
0.0%-30.0%
IB
0.0%
10.0%
0.0%-22.9%
Medicine Availability
Public
Procurement
Private
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LPG
10.0%
15.0%
51.0%-95.0%
IB
6.30
7.63
-
LPG
0.62
1.44
0.27-0.48
IB
7.14
9.85
1.74-4.38
LPG
0.51
1.43
1.30-1.84
MPRs for core drugs
Public
Procurement
Private
Source: HAI, 2007; Kotwani, 2007
5.
Summary of China’s Medicines Price and Availability Problems
5.1. Complexity and Bureaucratic Structures
At Central Government level, SFDA, MOSSL, NDRC and MOH are responsible for
different aspects of medicine policies: registration, selection, pricing and procurement
of medicines, and at provincial level, similar devolutions of responsibilities occur. Also,
MOSSL and the Department of Rural Health of MOH are responsible for urban and
rural population separately. Different parties tend to act in their own interests without
mutual monitor, leaving the pharmaceutical market with the problems of a lack of
accurate information and ineffective price regulation (Lu J, 2007, Interview).
Manufacturers, wholesalers, hospitals and pharmacies all play a role in drug distribution,
and each will obtain a profit commensurate with their activity.
5.2. Lack of Access
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Most key informants said that there are enough medicines available to ensure access in
China. However, although there are thousands of pharmaceutical manufacturers, access
to essential medicines as measured in WHO/HAI surveys was not as good as
Government officials expected due to the production structure, procurement, pricing
policies and prescribing habits. According to the surveys, even the availability of
commonly used drugs is very poor.
5.3. Price and Affordability
In-depth research on medicine prices is scarce in China. It would be more appropriate to
compare China’s drug prices with other developing countries, e.g. India, Thailand and
Brazil, and inappropriate to compare with developed countries, such as the USA, UK,
Japan, Germany and Australia, as was done by IMS {National Development and
Reform Commission (Department of Price), 2007 #34}. So, although the results showed
overall drug prices were lower than in these developed countries, and that generally
great price differences exist between branded innovators and generics, it may not reflect
the reality.
The WHO/HAI surveys showed that innovator drugs prices were frequently higher than
MSH IRP. This might be due partly to the over protection of innovator products, for
example by the Drug Pricing Measures, which allow for off-patent innovator prices
higher than domestically produced equivalent generic drugs {State Planning and
Development Commission, 2000 #21}. Also, most drugs with frequent and wide
ranging reductions on the NDRC reduced-price lists were generics, while the reduction
level for innovators was only 5% (Zhu CH, 2007, Interview).
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Although the lowest paid government workers’ incomes have improved rapidly,
out-of-pocket expenses for buying medicines are still high for patients. Medicines are
unaffordable to many of them.
5.4. Generic Policy
In China, generic medicines are usually sold as branded generics {IMS Health, 2007
#66}, which are pharmaceutically identical to the innovator and INN generic (generic
generic), and may be sold at close to the innovator medicine price and actively
marketed.
There are no requirements for generic substitution, or favorable terms for registering
generics and there is no policy to promote the prescription of INN generics in China.
However, in the prescription management strategies issued by MOH {Ministry of
Health (Statistic Information Centre), 2007 #41}, the Government suggested that
doctors should prescribe using the INNs, but this is not a requirement.
5.5. Price Components
Drug prices are calculated based on the costs declared by manufacturers themselves,
and there are insufficient human resources to check their figures, which might cause
some discrepancies. Import duty and tax contribute to the final high prices of imported
drugs as does the regional tax on drug prices in pharmacies. There are too many links in
the drug distribution process. The WHO/HAI surveys, only revealed end user prices but
from other literature, there is evidence that private rebates exist in the whole process,
which benefit wholesalers, retailers and hospitals {Liang Y, 2005 #52}.
5.6. Financing Hospitals
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The Government does not provide adequate funds to support hospitals. The percentage
Government financial input to hospitals at the beginning of the 1980s was about 60%,
while in 2003, it was only 8.2% {Ying XH, 2007 #18}. Increasingly hospitals have to
rely on revenues generated from drug sales, which are considerable as drug expenditure
accounted for nearly a half of total health expenditure in 2006 {Ministry of Health
(Statistic Information Centre), 2007 #41}. Overprescribing of medicines by doctors and
overpaying for medicines by hospitals is common.
5.7. Drug Use Patterns
Total pharmaceutical expenditures are determined not only by drug prices but by
another important element --- the amounts consumed, which is decided by the behaviors
of doctors (Chen V, 2007, Interview). Drug prescription patterns are influenced by the
rebates doctors and hospitals receive from distributors, rather than by patients’ needs.
Branded generics are marketed irrationally. The higher the drug price, the more the
incentives to procure and prescribe it. This is linked to the irrational salary structure for
doctors and the irrational financial reimbursement structure for hospitals {Liang, 2005
#52; Lian, 2004 #51}.
5.8. Conflicts of Interests
Conflicts exist between hospitals’ public service role and their ways of funding in order
to survive, between the ways doctors treat patients and their ways of gaining revenues,
and between wholesalers’ distribution systems and their ways of promoting their
products. All parties are acting in their own interests and frequently what makes sense
personally or institutionally may be contrary to the interests of patients and public
health.
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5.9. Corruption
Rebates exist at every stage of the distribution chain including wholesalers, hospital
directors, hospital pharmaceutical department directors and doctors. Different drug lists
exist at the same time: the EDL, BMI Drug List, New Rural Medical Cooperation Drug
List and Procurement Drug List. Local governments can change the drugs included in
the lists. Inclusion of a drug on the lists can be critical for a manufacturer’s survival and
these factors increase the likelihood of corruption (Lu J, 2007, Interview). Although
China has a Drug Management Law {State Food and Drug Administration, 2001 #47},
stating that manufacturers, wholesalers or medical facilities would be punished if they
receive rebates, enforcement of the law is not rigorous enough in practice (Wu YP, 2007,
Interview).
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6.
Policy Options
Above all, the pharmaceutical sector is very complex, with many players and different
often conflicting interests involved. Therefore, a comprehensive and balanced NMP
should first be developed, followed by adaptions at provincial level, in order to integrate
policies across whole sector, and to guide drug production, distribution and
consumption. This would promote the development of the pharmaceutical industry and
ensure access to essential medicines for most of the population. This NMP should
include the following components.
6.1. Selection of Essential Drugs
Smaller essential drug lists should be established for medicines to treat common
diseases according to evidence-based medicine and cost-effective analysis, which
should favour generic drugs. The drug list should be updated regularly using a
transparent consultative process involving all relevant parties and it should be used as a
basis to develop all reimbursement drug lists, including the medical insurance
reimbursement list. Both the essential drug list and medical insurance reimbursement
drug list should be established jointly by MOSSL, MOH, SFDA and regional health
authorities.
6.2. Drug Pricing
Since there are usually a sufficient number of competing products in China, NDRC
should consider removing price controls on generic drugs to increase competition
among manufacturers (Zhu CH & Zhou Y, 2007, Interview). Free pricing could be
implemented with enough public information provided to ensure price transparency at
all stages of the public sector medicine supply chain, i.e. manufacturers’ selling prices,
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wholesale mark-ups, distribution charges; hospitals’ mark-ups, pharmacies’ mark-ups,
taxes and duties, and other related charges. In the private sector, end user prices need to
be reported in such a way that consumers can make informed choices. Such as in Jordan,
a mobile service allowing citizens to obtain information on medicines (prices,
formulation and dosage) via mobile telephones was implemented {Jordan Food and
Drug Administration, 2006 #64}.
The maximum retail price of drugs on the BMI Reimbursement List should be set by
MOSSL not NDRC (Chen W, 2007, Interview) and the opinions by representatives from
patient groups, other government departments, medical facilities and the pharmaceutical
industry and commerce should be heard (Wei JG, 2007, Interview). Where drug prices
are regulated, the relevant authorities should invest in more human and technical
resources to improve verification of manufacturer-declared production costs and
international reference pricing index should be considered. There seems to be a lack of
sufficient national price information for Government pricing of drugs. This reference
procurement price information could be found in MSH Drug Price Indicator Guide
{Management Science of Health, 2003/2005 #10}, IDA Price Indicator {IDA
Foundation, 2007 #42}, AFRO Essential Medicines Price Indicator {World Health
Organization Regional Office for Africa, 2003 #43}, Generic Pharmaceuticals
Electronic Market Information Tool (eMIT) {National Health Service of United
Kingdom, 2007 #40}, Pharmaceutical Schedule of New Zealand {Pharmaceutical
Management Agency of New Zealand, 2007 #36}, or from the WHO website {World
Health Organisation, 2007 #35}.
6.3. Generic Policy
The SFDA should concentrate on ensuring the quality of medicines in China. Policies to
promote the production of INN generic drugs should be established. Permission given in
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the Drug Registration Management Regulation for generic registration two years prior
to patent expiry is a positive development {State Food and Drug Administration, 1999
#63}. MOSSL should give priority to generic equivalent prescribing and require generic
substitution for reimbursement. A fixed dispensing fee with regressive mark up rates
should be used to create incentives to use lower-price generics, as in the USA
{Department of Health and Mental Hygiene of United States, 2006 #49}. The use of
generics could be promoted by requiring the use of INN for all procurement,
reimbursement, prescribing and dispensing in public facilities. Generic substitution
should be allowed or required even in the private sector. Regulations rather than
suggestions are needed to promote a generic policy.
6.4. Supply and Distribution
The number of small- and medium-sized manufacturers, wholesalers and pharmacies
should be rationalized by tightening the criteria for license applications and renewal.
Taxes and duty for the production and distribution of medicines should be removed
(Zhou Y, 2007, Interview), especially for essential medicines. A policy should be
developed to encourage pharmaceutical manufacturers to export finished generic
medicines, not just pharmaceutical raw materials. A central bidding procurement system
should be further encouraged and the Government should monitor the whole
procurement process including contract, payments and drug delivery details, where
possible, using internet procurement (Li XF, 2007, Interview). Supply chains should be
shortened by reducing the number of irrational distribution levels between
manufacturers and patients. (Wei JG, 2007, Interview). The Government should ensure
the use of WTO/TRIPS flexibilities, such as Sweden’s use of parallel import {Ganslandt,
2004 #39} and compulsory licenses for government use as Thailand has done
{Washington College of Law, 2007 #46}.
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6.5. Affordability
The drugs to treat and prevent chronic diseases should be procured and supplied directly
by the Government to registered patients and the reimbursement rates should be
increased. Health insurance or financial assistance schemes should cover more of the
poor and vulnerable groups, and reimbursement rates should also be increased for these
people to create incentives for them to seek treatments.
6.6. Rational Reimbursement to Hospitals and to Doctors
It is crucial to increase Government input to hospitals. Appropriate mechanisms for
direct government financing hospitals must be developed (Zhu CH & Lu J, 2007,
Interview). Doctors’ salaries should be increased and unethical rebates banned. Standard
treatment protocols should be developed by the Government, not pharmaceutical
companies, using an evidence-based medicines approach (Lu J, 2007, Interview).
Legislation should be strengthened to monitor doctors’ and hospitals’ behavior. For
example, the US Federal Government recovered US$3.89 billion for fraud by drug
manufacturers against Medicaid between 2001 and 30 September, 2006, e.g. TAP
Pharmaceuticals was fined US$875 million for marketing frauds {Schneider A., 2007
#44}.
6.7. Research
Research on implementation of all aspects of pharmaceutical pricing policies should be
actively encouraged. The Government should co-ordinate and direct surveys, including,
as a minimum, those on the availability of drugs, drug prices and price components.
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7.
Conclusion
The problems existing in China’s pharmaceutical sector are complicated, involving the
national health system, the pharmaceutical industry and commerce, and drug pricing. In
China, 2.26% of GDP was spent on pharmaceutical expenses and patient’s out-of-pocket
expenses were almost 50% of total pharmaceutical expenditure. Although there are
thousands of manufacturers in China, many people still lack access even to essential
drugs. This is due to irrational supply and distribution systems, ineffective pricing
regulation, irrational reimbursement to hospitals and doctors (corruption issues involved)
and a lack of promotion of generics. The solution is to establish a comprehensive and
balanced NMP which reconciles the interests of different players in the pharmaceutical
sector and guides the whole process: drug production, distribution, consumption and
pricing. It is critical to for government to regulate industry with patient’s-need- oriented
production, not profit-oriented, and increase financial support to hospitals to break the
present incentive system and increase salaries for doctors to prevent rebates. Also,
improving transparency and providing adequate price and quality information to
empower patients are crucial. These actions are not easy to implement simultaneously,
but as China develops rapidly as a world power and a potential member of OECD, the
national health system must reflect this reality. To do this, China must inevitably
increase Total Health Expenditure while decreasing pharmaceutical expenditure as a
percentage of GDP from the present 2.26% to less than 2%. This can only be done
through major policy changes and the starting point is development of a NMP.
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Annex 1 Medicine Retail Price Index
Price indices compilation is implemented by the department of urban social and
economic survey, national bureau of statistics of China every year. The survey selected
business sites with large scale and wide assortment of drugs in sample small, middle
and large cities or counties which divided by economic regions and rational regional
distribution. There are 226 cities or counties taken the surveys at present. In additional,
the price information were investigated and recorded directly in every site by the
investigators and assistant investigators. Price Index of western medicines was 93.1 for
Shanghai and 96.9 for Shandong in 2004.
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Traditional Chinese and
NI
111.5
108.8
104.4
102.8
101.0
100.2
98.5
96.5
98.4
96.7
97.6
Western Medicines and
UI
111.2
108.4
104.2
102.8
101.3
100.1
97.8
96.2
98.2
96.7
97.7
Health Apparatus and Articles
RI
112.1
109.3
104.6
102.7
100.6
100.4
99.7
97.0
98.8
96.7
97.4
NI
111.6
112.8
108.4
108.1
105.6
104.6
102.3
97.5
104.4
98.4
96.5
UI
111.2
113.1
108.4
108.7
106.3
104.7
101.7
97.1
104.0
98.7
96.6
RI
112.2
112.5
108.4
107.1
104.4
104.5
103.3
98.3
105.2
97.9
96.3
NI
111.0
106.2
101.6
99.1
97.9
97.3
95.8
95.4
94.3
94.5
97.8
UI
110.6
105.3
101.2
98.7
97.9
97.0
95.0
95.1
94.2
94.3
97.8
RI
111.6
107.3
102.1
99.8
97.9
97.7
97.0
96.0
94.4
95.0
97.8
NI
114.9
106.8
103.5
101.0
100.1
99.6
98.8
99.0
100.6
101.9
98.4
UI
114.8
106.7
103.5
100.8
100.0
99.7
98.0
99.2
100.5
102.0
98.6
RI
115.0
107.1
103.6
101.6
100.4
99.5
100.5
98.7
100.7
101.7
98.0
Traditional Chinese Medicinal
Materials and Medicines
Western Medicines
Medical Apparatus and Articles
Notes: the values are on the basis of previous year’s value, which is assumed as 100. RI = Rural Indices;
UI = Urban Indices; NI = National Indices
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Annex 2 Interviews conducted in Beijing and Shanghai between 16 and 25 July
2007
1. Chen Vivian
Director of Healthcare Economics, China Association of Enterprises with Foreign
Investment, R&D-based Pharmaceutical Association Committee
Main topics discussed: the factors impacting pharmaceutical expenditure; protection
of Intellectual Property Rights
2. Chen Wei
Deputy Director of Division of Health Insurance, Department of Health Insurance,
Ministry of Labour and Social Security of China
Main topics discussed: how do they set reimbursement prices and make agreements
with health care providers or hospitals; alternative policies for financing especially
for hospitals; how do they select drugs in positive or negative drug lists;
3. Hu Shanlian
Prof. of Epidemiology and Health Economics, School of Public Health, Fudan
University, Shanghai, China
Main topics discussed: the ways of manufacturers to cope with the reduced drug
prices; comments on the methodology of WHO/HAI surveys
4. Hu Yin
Secretary General of Development Center of Science and Technology of Chinese
Pharmaceutical Association / China Pharmaceutical Database Services
Main topics discussed: the existing national medical economic information network
5. Li Xianfa
Expert in Drug Procurement through Central Bidding
Main topics discussed: evolvement of China’s drug procurement through centralized
bidding, its pros and cons and development trends
6. Lu Jun
Deputy Secretary General of Chinese Medical Doctor Association
Main topics discussed: reasons for high pharmaceutical expenditure in China;
development of Standard Treatment Guidelines; doctors’ salary
7. Wei Jigang
Senior Research Fellow of Industrial Economics Research Department, Development
Research Center, The State Council of P.R.China
Main topics discussed: possibility for general policies to remove tax and duties on
medicine at both national and local levels considering the regressive nature of
medicine taxes; drug supply chain
8. Wu Yongpei
Director of Department of Pharmacy Regulation/National Institue of Hospital
Administration
Main topics discussed: reasons for high pharmaceutical expenditure in China
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9. Xu Weimin
Director of Division 1, Evaluation Center of Drug Pricing, NDRC
Main topics discussed: Criteria, data sources and methods used to price single source
patent protected innovator medicines, multi source existing generic medicines, new
innovator medicines and new generic medicines including those which have just
changed patent status; what the process is; if international reference pricing used
when pricing drugs
10. Ye Lu
Associate Prof. Department of Health Economics, School of Public Health, Fudan
University, Shanghai, China
11. Zhou Yan
Secretary-General of China Pharmaceutical Industry Association
Main topics discussed: reasons for high pharmaceutical expenditure in China; reasons
for increasing production costs; quality of drugs
12. Zhu Changhao
Routine Vice-President of China Association of Pharmaceutical Commerce
Main topics discussed: the process of producing prices including single-source
product, multi-source drugs; if they think price controls have effects on price
reduction of generics with quality assurance as precondition;
13. Zhuang Ning
Department of Planning and Finance, Division of Planning and Price, MOH
Main topics discussed: Are suppliers pre-qualified and how do the procurement
officers monitor the procurement process and the performance of suppliers;
whether international reference prices are considered when awarding tenders; how
they monitor the bidding system
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Annex 3 China’s Medical and Pharmaceutical Industry Sales Revenues, Profits
and Export Delivery Values in 2006
Products
revenues
2006
Pharmaceutical
Raw Materials
Pharmaceutical
Finished
Products
Bio-tech
Products
Chinese
medicine
finished
products
Chinese
Medicine raw
materials
Compared 2006
to 2005
(%)
13.41
41.51/
5.19
14.78
11.51/
1.44
Export
Values
Compared 2006
to 2005
(%)
11.01
29.781/
3.72
2.34
5.889/
0.74
39.06/
4.88
114.01/
14.25
25.50
4.13/
0.52
10.42/
1.30
14.06
19.02/
2.38
29.44
10.37/
1.30
24.58
125.85/
15.73
138.25/
17.28
sales Products sales profits
13.80
2.89
6.778/
0.85
2.964/
0.37
Delivery
Compared
to 2005
(%)
17.16
16.34
30.61
22.6
Note: in columns 2, 4 and 6, figures are first given in billion Yuan and then in US$ equivalent.
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Annex 4 Formula to Calculate Drug Retail Price
The formula to calculate drug retail price of domestic drugs is “retail price=factory
price (inc. tax) *(1+distribution price differences)”;
The formula to calculate drug retail price of imported drugs is “retail price= border
price*(1+distribution price differences)”;
The formula for the factory price of domestic and imported subpackage drug is
“factory price = (manufacture costs + period expenses) / (1-sales profit rate) *
(1+VAT)”;
The formula for the border price of imported drugs is “border price = C.I.F. *
(1+duty rate) * (1+VAT) + border expenses”.
Note: C.I.F.= Cost, Insurance and Freight; VAT=Value-Added Tax
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Annex 5 WHO Background Paper
A background paper {Tang, 2007 #11} for this meeting described and examined the
main problems existing in pharmaceutical registration, production, distribution, use and
administration, and critically analyzed the main socio-economic and institutional factors
associated with these key problems. It was pointed out that the Chinese medicine
registration and pricing systems have not functioned well in pharmaceutical sector
development; the medicine distribution system lacks effective government regulation
and management; the number of pharmacies has increased significantly in recent years
but there is serious concern about their adherence to regulatory standards , particularly
in rural areas; irrational use of medicines, particularly in low level health facilities, has
been increasing, chiefly because of perverse financial incentives. There is also a lack of
co-ordination and communication between various government agencies. It was
suggested that an indicator-based assessment should be followed by more detailed
studies on individual drugs or specific diseases, and the availability/affordability of
essential medicines, especially using time-series analysis. A comprehensive NMP
should be developed. A balanced policy for promoting the development of the
pharmaceutical industry should be drawn up which would also ensure access to
essential medicines for most people. Perverse incentives (hospitals and doctors making
money from selling medicines to maintain the running of their establishments) must be
removed and incentives have to be changed in the alternative provider payment system
to promote rational use of effective treatments.
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Annex 6 The Lists of Core and Supplementary Medicines Surveyed
Core medicines
Shandong
Aciclovir 200mg cap/tab
Amitriptyline 25mg cap/tab
Amoxicillin 250mg cap/tab
Atenolol 50mg cap/tab
Beclometasone 0.05mg/dose inhaler
Captopril 25mg cap/tab
Carbamazepine 200mg cap/tab
Ceftriaxone 1g injection
Ciprofloxacin 500mg cap/tab
Co-trimoxazole 8+40mg/ml suspension
Diazepam 5mg cap/tab
Diclofenac 25mg cap/tab
Fluconazole 200mg cap/tab
Fluoxetine 20mg cap/tab
Glibenclamide 5mg cap/tab
Hydrochlorothiazide 25mg cap/tab
Losartan 50mg cap/tab
Lovastatin 20mg cap/tab
Metformin 500mg cap/tab
Nifedipine Retard 20mg tab
Omeprazole 20mg cap/tab
Phenytoin 100mg cap/tab
Ranitidine 150mg cap/tab
Salbutamol 0.1mg/dose inhaler
Shanghai
Aciclovir 200mg cap/tab
Amitriptyline 25mg cap/tab
Atenolol 50mg cap/tab
Beclometasone 0.05mg/dose inhaler
Captopril 25mg cap/tab
Carbamazepine 200mg cap/tab
Ceftriaxone 1g injection
Diazepam 5mg cap/tab
Diclofenac 25mg cap/tab
Fluoxetine 20mg cap/tab
Glibenclamide 5mg cap/tab
Hydrochlorothiazide 25mg cap/tab
Losartan 50mg cap/tab
Lovastatin 20mg cap/tab
Metformin 500mg cap/tab
Omeprazole 20mg cap/tab
Phenytoin 100mg cap/tab
Ranitidine 150mg cap/tab
Salbutamol 0.1mg/dose inhaler
Supplementary medicines
Shandong
Amlodipine 5mg cap/tab
Shanghai
Albendazole 200mg cap/tab
Alendronate 10mg cap/tab
Amlodipine 5mg cap/tab
Amoxicillin 500mg cap/tab
Anastrozole1mg cap/tab
Atorvastatin 10mg cap/tab
Azathioprine 50mg cap/tab
Azithromycin 500mg cap/tab
Candesartan 4mg cap/tab
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Cefiroxime 250mg cap/tab
Cefradine 0.5g/vial
Ceftazidime 1g/vial
Celecoxib 200mg cap/tab
Cimetidine 0.4g cap/tab
Ciprofloxacin 250mg cap/tab
Clarithromycin 250mg cap/tab
Digoxin 0.25mg cap/tab
Efavirenz 600mg cap/tab
Erythromycin 250mg cap/tab
Esomeprazole 20mg cap/tab
Fluconazole 150mg cap/tab
Ganciclovir 500mg injection
Lisinopril 20mg cap/tab
Gliclazide 80mg cap/tab
Lisinopril 10mg cap/tab
Loratadine 10mg cap/tab
Ketoconazole 200mg cap/tab
Nifedipine 30mg cap/tab
Ofloxacin 200mg cap/tab
Olanzapine 5mg cap/tab
Rifampicin 150mg cap/tab
Rosiglitazone 4mg cap/tab
Simvastatin 20mg cap/tab
Simvastatin 20mg cap/tab
Sodium Chloride 0.9% 500ml
Stavudine 40mg cap/tab
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Annex 7 Top Five Drugs with High Availability in Both Public and Private
Facilities in the Two Provinces Surveyed
Public
facilities
Private
facilities
August 31, 2007
Shandong
1. Diclofenac (45%)
2. amlodipine, diclofenac, omeprazole,
rosiglitazone, simvastatin beclometasone
inhaler (21-50%)
Shanghai
IB
1. Losartan (76.7%)
2. Fluoxetine (63.3%)
3. Beclometasone inhaler
(56.7%)
4. Ceftriaxone injection
(56.7%)
5. Metformin (56.7%)
LPG 1. hydrochlorothiazide (≥ 80%)
1. Omeprazole (90.0%)
2. ceftriaxone inj (≥ 80%)
2. Hydrochlorothiazide
3. captopril (≥ 80%)
(86.7%)
4. amoxicillin (≥ 80%)
3. Phenytoin (80.0%)
5. ranitidine (51-79%)
4. Aciclovir (70.0%)
5. Ranitidine (60.0%)
IB
1. Diclofenac (85%)
1. Omeprazole (85.0%)
2. amlodipine, beclometasone inhaler, 2. Beclometasone inhaler
carbamazepine, celecoxib,
(65.0%)
losartan, omeprazole, rosiglitazone, 3.
Carbamazepine
simvastatin (21-50%)
(60.0%)
4. Metformin (60.0%)
5. Losartan (55.0%)
LPG 1. captopril (≥ 80%)
1. Ranitidine 150mg
2. ranitidine (≥ 80%)
(95.0%)
3. hydrochlorothiazide (≥ 80%)
2. Aciclovir 200mg
4. amoxicillin (≥ 80%)
(75.0%)
5. omeprazole, (≥ 80%)
3. Hydrochlorothiazide
25mg (70.0%)
4. Omeprazole 20mg
(70.0%)
5. Phenytoin 100mg
(60.0%)
43
Candidate Number: 30571
Annex 8 MPRs for some drugs in Shanghai and Shandong
Shandong
Public
facilities
(20)
IB
LPG
Amoxicillin
Beclometasone
Ceftriaxone inj
Clarithromycin
Diclofenac
Fluoxetine
Metformin
Nifedipine
Omeprazole
Salbutamol inh
August 31, 2007
1.52 5.89 0.33
Shanghai
Public
Private
facilities (30) facilities (20)
Private
facilities
(20)
IB
LPG IB
2.69
5.95
0.19
9.83
LPG
IB
LPG
9.87
4.29
0.88
21.64 0.29
-
21.28
4.51
7.74 1.09
69.45 28.94 68.42 28.94
11.85 2.31
7.98
44
4.13
0.51
26.46 6.28
2.72 1.73
26.46 5.83
2.75 1.43
Candidate Number: 30571
References
August 31, 2007
45