A survey of the availability, prices and affordability of essential medicines in Jiangsu Province, China

Background Field surveys conducted in China before the implementation of the essential medicine policy showed that Chinese individuals faced less access to essential medicines. This paper aims to evaluate the availability, prices and affordability of essential medicines in Jiangsu Province, China after the implementation of the policy in 2009. Methods A cross-sectional survey was conducted in Jiangsu in 2013 using the World Health Organization/Health Action International (WHO/HAI) methodology. Data on the availability and prices of 50 essential medicines were collected from the public and private healthcare sectors. Results The mean availabilities of innovator brands and lowest priced generics (LPGs) were 11.5 % and 100 % in primary healthcare facilities, 36.8 % and 32.6 % in the secondary and tertiary sectors, and 18.7 % and 42.9 % in the private sector, respectively. The median price ratios (MPRs) were 1.26 to 2.05 for generics and 3.76 to 27.22 for innovator brands. Treating ten common diseases with LPGs was generally affordable, whereas treatment with IBs was less affordable. Conclusions The high availability of LPGs at primary healthcare facilities reflects the success of the essential medicine policy, while the low availability in secondary and tertiary levels and in private pharmacies reflects a failure to implement the policy in these levels. The health policy should be fully developed and enforced at the secondary and tertiary levels and in the private sector to ensure equitable access to health services. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1008-8) contains supplementary material, which is available to authorized users.


Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 3,4 China is confronted with less access to essential medicines.
Moreover, the Chinese people have suffered from inaccessible and unaffordable health services for decades.
In addition, government health expenditures accounted for approximately 5% of GDP, with drug expenditures comprising up to 40% of total health expenditures, among the highest proportions in the world.
Objectives 3 State specific objectives, including any prespecified hypotheses 5 This study assesses medicine availability, prices and affordability in Jiangsu by collecting data from five of its cities. Particular attention is paid to the innovator brands (IBs) and lowest-priced generics (LPGs) available in Jiangsu and different types of medicine outlets (public hospitals and private pharmacies).

Study design 4
Present key elements of study design early in the paper 5 We conducted a survey of the availability, prices and affordability of the essential medicines in Jiangsu, China by adopting the standardized WHO/HAI methodology, which was modified as per the requirement of the study done at one province of China. Nanjing is the capital. Five representative cities of this province, rather than six as recommended by the WHO/HAI methodology, were selected as survey areas for data collection: Nanjing, Suzhou, Yangzhou, Suqian, and Yancheng.
Additionally, a localized pilot study was conducted during the training in Nanjing to verify the feasibility and effectiveness of the survey.
Data on the availability and patient prices of medicines at the selected public hospitals and private pharmacies were collected.

Participants 6
Give the eligibility criteria, and the sources and methods of selection of participants 5,6,7 Prior to data collection, a one-week training was held to provide area supervisors, data collectors and data entry personnel with the knowledge and skills required to conduct the medicine availability, prices and affordability survey in an accurate and reliable manner.

Variables 7
Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable 9 The study endpoints focused on three measures: medicine availability, prices and affordability. Availability was defined as the proportion of pharmacies in which the medicines were available at the time of the survey. MPR is the ratio of the median local unit price across facilities divided by the median international reference unit price (IRP).
Affordability was estimated by comparing the total cost of a medicine for a standard course of treatment to the daily wage of the lowest paid unskilled government worker. In this survey, medicine prices from the Drug Prices Guide in 2011 issued by Management Science for Health (MSH) were adopted as the IRPs for core medicines, but because MSH prices were not available for most supplementary medicines, Spanish manufacturers' selling prices were used as their reference prices (supplied by WHO/HAI project member Carmen Peres-Casas).
Affordability was estimated by comparing the total cost of a medicine for a standard course of treatment to the daily wage of the lowest paid unskilled government worker, which was 42.7 CNY per day at the time of the survey.

Bias 9
Describe any efforts to address potential sources of bias 9 All data were entered twice, followed by software verification and validation through "double entry" and "data checker" functions to identify data entry errors. Furthermore, codes, instead of the actual names, were used to identify these public healthcare facilities and retail pharmacies to maintain their anonymity.
Study size 10 Explain how the study size was arrived at 5,6,7 Five representative cities of this province, rather than six as recommended by the WHO/HAI methodology, were selected as survey areas for data collection: Nanjing, Suzhou, Yangzhou, Suqian, and Yancheng. The selected cities are reachable within one day of travel from the capital and provide a large enough sample to represent the province.
The public sector sample therefore contained five public medicine outlets in each of the five cities, yielding 25 public outlets.
The private sector sample was determined by selecting the licensed private pharmacies closest to each of the selected public medicine outlets.
Hence, 50 medicines were finally selected for this survey, including 23 core medicines and 27 supplementary medicines.
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why 9 The availabilities of both types of medicines (IBs and LPGs) in public hospitals and private pharmacies were calculated.
Prices were presented as median price ratios (MPR) in this study. The MPR is the ratio of the median local unit price across facilities divided by the median international reference unit price (IRP). In this survey, medicine prices from the Drug Prices Guide in 2011 issued by Management Science for Health (MSH) were adopted as the IRPs for core medicines, but because MSH prices were not available for most supplementary medicines, Spanish manufacturers' selling prices were used as their reference prices (supplied by WHO/HAI project member Carmen Peres-Casas).
Affordability was estimated by comparing the total cost of a medicine for a standard course of treatment to the daily wage of the lowest paid unskilled government worker, which was 42.7 CNY per day at the time of the survey.
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 9 All data were entered twice, followed by software verification and validation through "double entry" and "data checker" functions to identify data entry errors. The selected cities are reachable within one day of travel from the capital and provide a large enough sample to represent the province.
An additional four public medicine outlets per survey area were then randomly selected from those within a four-hour drive from the main hospital.
(e) Describe any sensitivity analyses NA NA MPRs were only calculated if the medicine was available at a minimum of four facilities.

Participants
In view of the low availability of core medicines, we considered ten priority diseases to measure the affordability of standard treatments. However, the patient prices of IBs were all above the threshold level. The cost of purchasing LPGs at all surveyed was between 0.1 and 0.8 days' wages, which indicated that generic medicines in Jiangsu Province were fairly affordable.
Overall, IB products were less affordable than LPGs in both the public and private sectors. Little difference is found among medicine outlets when comparing the prices of LPGs to their IRPs.
The MPRs of medications on the core list of IBs available in both sectors were generally higher in the public sector than in the private sector.
The data from this survey show that most LPGs for standard treatments are affordable.
A comparative analysis of the affordability of IBs and LPGs indicates that the former are less affordable than the latter. This finding is similar to that in the studies conducted in Hubei and Shaanxi (core list MPRs were 1.05 and 1.84 for the public sector and 0.51 and 1.46 for the private sector in Hubei and Shaanxi, respectively).
In Thailand, analyses revealed that the MPR for IBs was higher in the private sector (11.60) than in the public sector (4.36). This difference in prices might be a reason for the difference in the healthcare policies of Thailand and China.
Generalisabili ty 21 Discuss the generalisability (external validity) of the study results

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Regarding the interpretation of affordability, caution should be exercised when extrapolating the findings to the national level because there may be regional differences in affordability due to differences economic development across the country.