The impact of the government health funding on prescribing behaviors in community health institutions in China.

Government health funding (GHF) is a cosmopolitan problem. It is especially conspicuous in China, where drug sales become a main source of medical institutions' incomes due to limited GHF. This is well known as China's "drug maintain medical institutions (DMMIs)" system which results directly in very high use of antibiotics, injections, and corticosteroids. However, few statistical data existed in China on the association between the GHF and the prevalence of inappropriate drug prescribing, despite widespread acknowledgment of its existence.A multistage sampling strategy was employed to select 442,100 prescriptions written between 2007 and 2011 by urban community health (CH) institutions and check the GHF in 36 key cities (districts) across China. This study examined the association between the GHF and the prevalence of inappropriate drug prescribing, which differs somewhat from previous studies.The data suggested that from 2007 to 2011, with the increase of GHF, prescribing behaviors (PB) gradually improved on the whole although doctors still prescribed a few more drugs than the recommendations from World Health Organization (WHO). This study found that there is significant negative association between GHF and main indicators of PB (correlation coefficients more than 0.5).The findings implied that government should further perfect the compensation mechanism to medical institutions for gradually weakening the compensation function of drug sales in medical institutions.

Key Points

From 2007 to 2011, with the increase of GHF, PB gradually improved on the whole although doctors still prescribed a few more drugs than the WHO's recommendations.

There is significant negative association between GHF and main indicators of PB (correlation coefficients more than 0.5).

Government should further perfect the compensation mechanism to medical institutions for gradually weakening the compensation function of drug sales in medical institutions.

This study paves the way for further efforts to understand government's leading role in public health practice.

Introduction

With the rising of the proportion of China national health expenditure in the gross national product (GNP), government's funding is difficult to maintain the medical institutions. In this background, in 1989 the Chinese Ministry of Health, Ministry of Finance, State Administration for Commodity Prices jointly provided a mandate that medical institutions implemented the autonomous funding governs and could be engaged in a variety of paid services.[

Since then there are 3 source of funding support for medical institutions in China: government funding, income from medical services, and drug markup. The government funding allocation depends on its fiscal capacity. Government usually pays attention to economic development while ignoring healthcare. Therefore government funding is very limited for medical institutions. For example, state funding is less than a quarter of the total cost in medical institutions across the country, and the remaining exceeding 3-quarters of the cost stems from medical institutions’ income. Medical services are limited by the price of the Price Bureau. The labor value of medical personnel is underestimated. Therefore medical institutions have to rely on drug markup to maintain the normal operation and personnel salary,[ which results in an increase in household exposure to funding risk and a decline in quality of medical care.[

In 2006, 8 departments of the State Council, including National Development and Reform Commission, etc., jointly issued a regulation “the opinion of further consolidating price order in the drugs and medical service market.” This regulation confirmed that medical institutions could gain respectively 15%, 16%, and 20% of profits from sales of proprietary Chinese medicine, western medicine, and Chinese herbal medicine. Medical institutions encouraged doctors to prescribe more lucrative medicine for obtaining more profits to maintain normal operation. According to the statistics from Chinese Ministry of Health, the proportion of drug “markups” in the hospital income is averagely about 60%, and in a few small- and medium-sized hospitals even reached 70% to 80%. Drug “markups” have become the major source of revenue for healthcare providers, which is well known as drug maintain medical institutions (DMMIs) in China. It results directly in very high use of antibiotics, injections, and corticosteroids.[

China's DMMIs rooted from limited government health funding (GHF).[ According to data released by the Chinese Ministry of Health, in 1990, the proportion of the GHF in the total health expenses was 24.09%; but by 1998, the proportion dropped to 15.6%; it was 17% in 2003 and 29.9% in 2014.

Too little GHF is not only the foundation of DMMIs system, but also the reason of drug abuse, such as very high use of antibiotics, hormone, and injections.[ However, few statistical data existed in China on the association between the GHF and the prevalence of inappropriate drug prescribing, despite widespread acknowledgment of its existence.

This study, sponsored by the Chinese Ministry of Health and intended to fill the data gap, firstly checked the association between GHF and PB by analyzing 442,100 prescriptions written by community doctors in 36 cities of China.

Study data and methods

Ethics statement

The study protocol was approved by the institutional review board of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. All participants read a statement that explained the purpose of the survey and were provided with written consent form before participating in the study.

Prescribing indicators

To design and disseminate effective strategies to improve the way in which drugs are prescribed, the WHO developed a list of rational drug use indicators, which have become widely used to assess PB in medical institutions in most countries in the world.[

Our research team employed four indicators from the WHO's list that could be appraised using data from written prescriptions. These indicators included the average number of drugs prescribed per prescription; the percentage of prescriptions with injections prescribed; the percentage of prescriptions with antibiotics prescribed; and the percentage of prescriptions with 2 or more antibiotics prescribed.[ In view of overwhelming concerns from health officials about inappropriate prescribing of hormones and rising medicine expense, this study incorporated 2 additional indicators: percentage of prescriptions with hormones and average cost per prescription.[

Data collection

The sampling method and sample-size calculation were determined following the methodology recommended by the WHO. First, cities across China were divided into 3 groups: developed eastern cities; least-developed western cities; and “middle” cities between the 2. The cities were further divided into city districts.[ Thirty-six cities were selected using multistage sampling methods based on economic and political characteristics, city size, and the development level of community health (CH) services. Developed eastern cities may contribute more cities than other regions.

To understand GHF and the source of CH special funding in city district, the research team surveyed the health bureau of city district by self-made questionnaire.

Two CH centers and 2 CH stations, which are smaller in scale and serve as satellite outposts of CH centers, were selected randomly in 1 of 220 districts. Outpatient prescriptions written by each selected institution in September of 2007, 2008, 2009, 2010, and 2011 were chosen and coded, and 100 prescriptions were obtained by following a systematic sampling of 1 in every 5 prescriptions. Because of their differences in scale and health resource allocation, CH centers, and CH stations were studied separately.[

Data collection was carried out by designated staff from health bureaus of the participating cities, under the coordination of the Chinese Ministry of Health. The research team convened the designated staff members; trained them to use uniform prescription review forms and processes; supervised the prescription review in the field; and conducted random visits, double-blinded data entry, logical data checks, and agreement tests to ensure the quality of the data.

Data analysis

The data collected by city health officials were submitted to the research team, entered into the database system EpiData 3.0, and analyzed by the statistical analysis software SPSS, version 19.0. Descriptive statistics were used to show the prescribing indicators in the 5 years (2007, 2008, 2009, 2010, and 2011), by institution type (CH centers and stations).

Normality of distribution was determined by QQplots and Shapiro–Wilk test. Because the data were normally distributed, Independent-Samples t test was applied to analyze the differences between institution types. Bivariate test was applied to analyze the correlation between GHF and PB. Statistical significance was accepted when P values were equal to or less than .05.

In order to increase the understanding of the extent of inappropriate prescribing in China, the research team compared its findings with the rational drug use standards recommended by WHO.[

Study results

From 2007 to 2011, the study had been lasted for 5 consecutive years. There were 36 cities involved in China, which covered all provinces (autonomous regions and municipalities directly under the central government) in addition to Hong Kong, Macao, and Taiwan regions. Table 1 shows the quantity of surveyed institutions and prescriptions.

Table 1

Survey object and quantity, 2007–2011.

Table 2 shows the overall situation of GHF in 36 cities. From 2007 to 2011, healthcare funding and the proportion of healthcare funding in the fiscal expenditure increased year by year in the cities district. Healthcare funding growth rate of chain relative ratio was the biggest in 2011. CH special funding increased year by year and amounted to 41.0952 million Chinese yuan in 2011. The proportion of CH special funding in healthcare funding reached the highest (29.71%) in 2009.

Table 2

Health funding in cities district, 2007–2011.

Table 3 presents the overall findings on the 6 prescribing indicators by community institution type and by year. Comparing 3 of the 6 indicators for which the WHO's International Network standards exist, this study confirmed that doctors prescribed many more drugs, more antibiotics, and more injections than the WHO's recommendations in China's CH institutions.[

Table 3

Prescribing indicators for urban CH institutions in China, 2007–2011.

The estimates for the 5 prescribing indicators showed significant decreases over the 5-year period (P < .05). The cost of drugs per prescription, adjusted by the retail price index of medicines, showed a significant decrease between 2007 and 2011, but the decrease is small in magnitude. PB, in terms of both the number of drugs per prescription and the percentage of prescriptions with antibiotics, injections, or hormones, were similar for CH centers and for stations (not significant).

Table 4 shows the impact of the GHF on PB in CH institutions in China. There was significant negative association between GHF and all indicators of PB. Further, most of the absolute value of correlation coefficients are more than 0.5, which shows very close association between GHF and PB. Our data confirmed that, with the increase of GHF, community doctors’ PB gradually improved over the 5-year period.

Table 4

Correlation coefficient between GHF And PB.

Discussion

This study firstly explored the impact of the GHF on PB in nationwide CH institutions, which differs somewhat from previous studies. We find that government appears to have perfected health funding mechanism and increased funding of the healthcare system. The proportion of GHF in the total health expenses gradually raised, which successfully lowered out-of-pocket spending.[

Our analysis suggests that increasing funding of the healthcare system can effectively improve the PB and alleviate DMMIs problem in China. For example, along with formal implementation of the new healthcare reform in 2009, the patients’ feeling and complaint of “too difficult and too expensive to see a doctor,” one of the key public policy issues, still exists. So the Chinese Ministry of Health has rolled out policies that allowed zero markup for drugs on the WHO's essential medicines list, and there is more vigorous supervision of the pharmaceutical market and prescribing behavior (PB). At the same time, the government sharply increased health funding. As a result, PB have been improved since 2009. Key prescribing indicators were statistically significant different respectively between 2007 and 2011 (P < .05). Further, this study showed the significant negative association between health funding and PB (correlation coefficients more than .5).

Our findings were confirmed by those findings in other countries. In the United Kingdom, the evidence suggested that the funding had a marked effect on primary care prescribing volume and cost on some practices who could achieve targets and hence incentive payments.[ A funding scheme can be an important component of a prescribing strategy.[ In the United States, the evidence suggested that the program of federal funding for e-prescribing in the Medicare Improvements for Patients and Providers Act did indeed succeed.[ In the Netherlands, the evidence suggested that independent funding can be a help in changing prescription behavior of general practitioners, and the intervention resulted in a cost-saving of roughly €3000 per general practitioner.[

The government should know the importance of funding of the healthcare system. Reforming the mechanism of DMMIs is actually equal to how to compensate the healthcare system. Few medical institutions have enough funding resources to bear the losses from separation of medical institutions and drug in the current medical system of China. Breaking away from drug profits will bring disaster to medical institutions of China. In fact, the United States, France, and other developed countries can practice the separation of medical institutions and drug because the GHF is enough to maintain medical institutions.[ Studies have showed that each 100 Chinese yuan additional funding of the healthcare system can reduce the social drug costs 660 Chinese yuan, which is one of the main responsibilities of public funding.

To the best of our knowledge, to date, this study is the largest scale study investigating the association between the GHF and the prevalence of inappropriate drug prescribing in China. The large sample size significantly increased statistical power to detect the association between the GHF and the prevalence of inappropriate drug prescribing. However, one limitation that needs to be addressed is the period during which the study was carried out. Moreover, the ecological design of the study is limited in terms of extrapolation. Finally, some information was collected from a self-reported questionnaire and the response bias was therefore unavoidable.

Conclusion

This study provided the first robust nationwide data and analysis on some key prescribing indicators and funding of the healthcare system. It confirmed, for the first time, that the increased GHF had gradually improved PB on the whole although prescribing indicators are more than what is recommended by the WHO and inappropriate prescribing is still widespread in urban CH institutions of China. It is well known in China that the funding is one notable driver of inappropriate prescribing. Presently, a sizable portion of medical institutions’ income comes from the profits from selling prescription drugs due to limited GHF.[ The government should play a leading role in providing basic medical services. Government funding should be mainly responsible for the cost of public health service which was provided equally to urban and rural residents.

It is very important that government should arrange health funding from a systemic perspective.[ Policy makers must further perfect the compensation mechanism to medical institutions for gradually weakening the compensation function of drug sales in medical institutions.[ Government should vigorously implement the separation of medical institutions and drug, and comprehensively cut off the direct interests relationship between the medical institutions, medical personnel, and drug marketing. China must find out a healthy sustainable development mode for medical institutions, which is the key to improve PB and change the situation of DMMIs.[ The result of this study paves the way for further efforts to understand government's leading role in China's ongoing new healthcare reform.

Acknowledgments

The authors thank all study participants who have been involved and contributed to the procedure of data collection.