基于交易费用理论的基本药物供应保障模式政策优化研究-以山东省农村地区为例

Objectives: The rural pharmaceutical distribution system in China is related to the complete coverage of national essential medicines. The government has constructed many pharmaceutical distribution models in rural area. This study aims to develop a theoretically sound, robust methodology that measures transaction cost of pharmaceutical distribution system and to examine the impact of these models on performance and transaction cost by comparing institutional arrangements of different pharmaceutical distribution models and identifying determinants for those changes. .Design/methods: Data were collected from Three counties of Shandong Province, an eastern area in China. There are four different pharmaceutical distribution models in sample area. This study collected detailed data regarding transaction costs incurred by activities of pharmaceutical distribution through which those costs were generated and performance which was classified as substantive and relationship outcomes. Substantive outcomes include Channel Effectiveness and Efficiency. Relationship outcomes include Satisfaction and Distributive Equity. Methods included the retrospective review prescription records, interviews with pharmaceutical supply policy makers and distribution participants, focus group discussions and the review of pharmaceutical distribution documents. .Expected Results: Transaction cost will affect the selection of different distribution models, thus lead to different performance and reveal to us the different constraints faced by different pharmaceutical distribution system in Chinese rural area. The Institutional environment, physical environment (geography, population distribution, traffic situation and etc.), institutional arrangements are the major impact factors for transaction cost and performance. The institutional and physical environment determines first choice of pharmaceutical distribution models. Institutional arrangements influence people's motivation, finally affect the coverage of national essential medicines..Conclusions/policy implications: The experiences of pharmaceutical distribution models in Chinese rural area contribute to in-depth understanding relevant policy issues. Different institutional arrangements have different application conditions. So it is important for policy-makers to indentify constraints of institutional environment faced by different distribution models.

交易费用是影响农村基本药物供应保障模式选择的重要因素，模式的选择最终会影响其绩效。对基本药物供应模式、交易费用和绩效的研究，将为其政策优化提供理论和科学依据。本研究采用理论分析和实证研究的方法，进行基本药物供应保障模式、交易费用及其绩效的研究及测算，以揭示供应保障模式选择与交易费用和绩效的内在联系，阐明供应模式选择的影响机制，解决交易费用测算、绩效评价相结合的关键问题。本研究将以交易费用经济学、作业成本法作为测算交易费用和绩效的理论基础，并采取现场调研方法实证分析药品供应模式、交易费用和绩效。现场调查将在山东省三县四种不同基本药物供应保障模式中开展，农村基本药物配送参与单位、参与人员、县卫生局和县药品监督管理人员是主要研究对象。调查将采用机构调查、访谈的方式收集资料。本课题属于首次在国内应用作业成本法、交易费用经济学结合的测算方法，这将有助于丰富农村基本药物供应保障模式的研究。

研究背景.自2009年基本药物制度建立以来，政府与市场的角色不断变换，基本药物供应市场已经形成了村卫生室、零售药店、乡镇卫生院以及县级以上医院四种销售渠道。而新型农村合作医疗保险与城镇居民医疗保险的合并、分级诊疗政策的推广、药品价格政策的连续改革以及中医药政策的渗透，造成这四种渠道的绩效有所不同。所以，本项目的研究问题是：为什么不同基本药物供应渠道绩效差异如此不同？.研究内容.为了回答上述研究问题，首先，我们对山东省3县、9卫生院、18村卫生室、9家药品配送企业和3家药品生产企业进行了机构问卷调查和关键人物访谈，目的是研究基本药物供应保障体系的交易关系和功能；其次，我们对23名药品配送企业配送人员、35名卫生院采购人员、18名村医进行了交易费用问卷调查，目的是测算基本药物供应保障体系的交易费用；最后，我们对18个村902户农村居民进行了家庭入户调查、抽查了9个卫生院7738张处方，目的是研究农村居民基本药物的可获得性、可负担性等绩效情况。.重要结果及关键数据.村卫生室、零售药店是样本地区农村居民购买药品的重要渠道，在所有药品采购渠道中占比分别为43.97%、29.81%，但是村卫生室中非基本药物购药比例约30%，零售药店非基本药物购药比例约43%。基本药物的采购有40%是从网上集中采购渠道以外进行。之所以出现这些问题，主要原因是基本药物政策内部、政策间、政府和市场功能存在不兼容，导致了比较高的交易费用。.科学意义.本研究从供方、需方两个角度研究基本药物供应保障体系的交易费用和绩效，并且关注各种政策间的协同作用，有利于深入剖析基本药物供应保障体系的政策要素、政府和市场间的关系，丰富药品政策评价的理论体系，搭建交易费用理论与基本药物政策研究间的桥梁。因此，本项目的结论对于各省基本药物政策的完善具有应用价值。