Hospital pharmacists’ knowledge of and attitudes towards the implementation of the National Essential Medicines System: a questionnaire survey in western China

The past three decades have seen rapid economic growth in China, but no similar improvement in health services [1–3]. There has been sustainable growth in total health expenditure—5.36 % of gross domestic product (GDP) in 2012 [4]. Although the percentage of individual out-of-pocket payments is declining [5], high out-of-pocket payments still place huge financial burdens on many people [6]. To provide affordable, equitable access to high-quality health services for all citizens by 2020, the Chinese government launched a nationwide systematic reform in 2009 [7], one of the key pillars of which is the establishment and implementation of the National Essential Medicines System (NEMS). In order to make NEMS benefit the general population, this policy put great emphasis on medicines accessibility and affordability.

The NEMS is a comprehensive measure covering medicine selection, production, pricing, procurement, prescribing and reimbursement [8]. One of the most remarkable aspects of it is a zero mark-up policy for government-run primary healthcare institutions. This means that medicines included on the National Essential Medicines List (NEML) are sold to patients at cost [9]. As a result, the NEML cannot meet the specific service needs of primary health care institutions [10], such as gynecological medicines and pediatric drugs.

When all primary healthcare institutions had implemented this policy in 2012 [11], the focus shifted to county hospitals. The government has been promoting and expanding the priority use of essential medicines, as well as the proportion available in secondary and tertiary hospitals [12].

There are many literatures concerning the NEMS and a good deal of research has focused on indicators of effect, such as availability [13], affordability [14] and rational drug use [15, 16]. Some studies have also evaluated the effects of NEMS on healthcare workers [17–19], but there are still limits to the information available. For example, most research has focused on primary healthcare institutions, and there is little evidence about secondary/tertiary hospitals [18, 20]. Most studies also focus on doctors [17, 18]. Although their knowledge and attitudes are important to the implementation of NEMS, other medical staff are also closely involved.

By the end of 2014, there were 948,000 medical institutions in China, including 26,000 hospitals, 922,000 grassroots hospitals. All these medical institutions should have pharmacy departments and certain number of pharmaceutical professionals (pharmacists and pharmacy technicians), which generally accounting for 8 % of all professionals [21]. The main responsibility of hospital pharmacy is assuring the medicine quality, guiding rational drug use and making medicines be placed in proper storage conditions. The responsibility of hospital pharmacists is involving many aspects, of which the basic duty is ensuring the quality and supply of medicines and carrying out “patient-centered” clinical work [22]. Hospital pharmacists are in charge of monitoring prescriptions, dispensing medication and providing guidance on the use of medicines. They are therefore directly concerned with selection, procurement, distribution, and use of medicines [23], and play an important role in the implementation of the NEMS. In primary healthcare institutions, operating the zero mark-up policy, pharmacists actively implement the NEMS. Implementing the zero mark-up policy in public secondary and tertiary hospitals will inevitably affect the way in which pharmacists work, as well as their pay, job satisfaction and the drug supply and distribution system. After the launch of this policy, most cities established compensation policies to pay staff a basic salary plus a bonus based on performance. The performance criteria include quality of services and achieved social responsibilities such as controlling cost escalation. It is therefore very important to study the impact of NEMS on primary and higher-level hospital pharmacists.

Internationally, there are corresponding studies on pharmacists’ influences on prescribing [24], rational drug use [25] and opinions on adverse drug reaction reporting [26]. However, there are few studies on hospital pharmacists’ understanding about the NEMS. We therefore conducted a questionnaire survey of pharmacists in tertiary, secondary, and primary healthcare institutions in Shaanxi Province, western China. This aimed to examine their knowledge of and attitudes towards the implementation of the NEMS, and explore their views on problems and how these could be resolved.

Five years after the launch of the healthcare reforms and implementation of the NEMS, some achievements have been made [32, 33]. This study has shown that hospital pharmacists have moderate knowledge of and attitudes towards NEMS. This finding is similar to the studies [18, 19] targeting on doctors and the medical staff in primary hospital. And basically all the respondents learn of the NEMS in their studies. Xu Y et al. [20] found that medical staff had much knowledge of types and therapeutic efficacy of essential medicines. In our study, the hospital pharmacists had a good knowledge of implementation time, zero mark-up policy, supply pattern and reimbursement. However, the majority have no idea of the adjustment time of the NEML. The relevant questionnaire item was an incorrect statement that the NEML is adjusted every 2 years. This may be a result of confusion about action in China and from the World Health Organization (WHO). WHO sets a new essential medicine list at least every 2 years [34], while China operates a system of dynamic management, stipulating that NEML should be adjusted every 3 years in principle [35]. Although zero mark-up policy had in theory been applied in all primary healthcare institutions, there were still some primary pharmacists who did not know about this policy. This suggests that the NEMS had not been promoted effectively. Attitudes towards the implementation of NEMS were generally classified as “moderate”. Surprisingly, only fewer than half of the hospital pharmacists considered the effects of NEMS were satisfactory at present. Identifying the fundamental causes of the dissatisfaction would need more researches. Participants did not agree that their income was affected, but this may be because some were reluctant to provide accurate information, because this is a sensitive topic. This might have introduced a slight error.

Previous study [19] reported that the cognition level is dependent with age, education level, specialty and work experience. Inconsistently, we found that only education level and number of training sessions attended were significantly related to knowledge scores. Pharmacists in public secondary/tertiary hospitals performed better than their counterparts, this can be explained by the fact that someone with a higher education level, or who receives more training, is likely to have a better level of knowledge. Public secondary/tertiary hospitals tended to have more highly educated professionals and training opportunities than primary healthcare institutions. The government could therefore improve pharmacists’ understanding of NEMS by emphasizing the importance of talent introduction and training. More attention should also be paid to primary healthcare institutions where NEMS has been fully implemented.

Pharmacists reported some problems in the implementation of NEMS. The most frequently-reported problem was the supply and distribution system. Similar results have been found in other developing countries [36], and this seems to be a global challenge [37–39]. Problems with timely supply and distribution of essential medicines have serious consequences, such as drug shortages. As a result, some patients with mild conditions have to attend secondary or tertiary hospitals [40], which occupies scarce medical resources and increases patients’ financial burden [32]. Some participants also thought that government funding was insufficient. In fact, the government has regularly increased funding [41], but there may be a cognition gap between the government and pharmacists. Some participants added their own comments. Some questioned the principles of selecting essential medicines. They pointed out that some cheap drugs with general clinical effects were included in the NEML while a number of branded drugs with good clinical effects and high prices were not, which needs urgent improvement.

Access to medicine is the key function of NEMS. The WHO has set out a four-part framework [42] to guide and coordinate collective action on access to essential medicines. This includes rational selection and use, affordable prices, sustainable financing and reliable supply systems. The suggestions included in the questionnaire covered these four areas. The majority of hospital pharmacists suggested that reliable systems and rational selection and use were directly related to their work responsibilities. It is therefore vital to introduce evidence-based selection and pharmacoeconomics into the development of NEML. Some participants suggested other solutions, including raising doctors’ awareness of essential medicines, price management for essential medicines and standardization of the distribution system.

Although there have been some studies of hospital pharmacists, ours is the first to survey a whole province hospital pharmacists’ knowledge of and attitudes towards the NEMS in China. We took advantage of a training program targeting hospital pharmacists across the whole province to conduct the survey. This unique opportunity to select participants has greatly improved the representativeness of the survey; meanwhile, the sampling method may cause a selection bias. This study also has some other limitations, and its results should be interpreted with caution. The survey was conducted only in Shaanxi Province, which may not be typical of the wider situation in China. Nevertheless, we chose Shaanxi Province as sample district because it is broadly representative of the typical health and health system status of the 12 western provinces of China [27], and the total provincial GDP was US$288 billion in 2014, ranking in the middle level in China. It was conducted in a training meeting, so a few participants probably completed the questionnaire in consultation with others. Such behavior would bias the results somewhat. However, our study still provides crucial evidence on hospital pharmacists’ knowledge of and attitudes towards the implementation of NEMS, and the differences between pharmacists in public secondary/tertiary hospitals and in primary healthcare institutions.

Overall, hospital pharmacists in Shaanxi Province showed moderate knowledge and attitude levels about the implementation of NEMS. Compared with those in primary healthcare institutions, pharmacists in public secondary/tertiary hospitals performed better, probably because they were more likely to have a higher level of education and receive more training. There is therefore an urgent need for governments to provide increased opportunities for further education and training for medical institutions, especially primary healthcare institutions. Some problems still exist with the implementation of NEMS, and particularly with the supply and distribution system. Overall, hospital pharmacists deemed reliable systems to be the most important issue to improve the NEMS.

GDP, gross domestic product; NEML, National Essential Medicines List; NEMS, National Essential Medicine System; WHO, World Health Organization