Plans for online pharmacies hit a roadblock in China

by MICHAEL WOODHEAD

It was pitched as the great disrupter of the Chinese healthcare system: online sales of prescription drugs would reduce distribution costs, improve efficiency of the supply chain of medicines and be great for consumer choice, convenience and affordability. Unfortunately, despite a lot of official hot air, nothing has actually happened.

In May 2014 the Ministry of Commerce released a draft plan to 'open up' the pharmaceutical market to allow online sales. But since then there has been nothing heard from official sources about when and how online sales of prescription drugs will be permitted. While some of the big players such as Alibaba are positioning themselves to be online pharmaceutical vendors, it is still just talk: selling drug online is still illegal and insiders say the government is now dragging its feet on plan to open up the market. The pressure is coming from vested interests in the pharmaceutical industry and also from the powerful hospital lobby.

According to the Commerce Department, online sales of drugs are growing at a phenomenal rate. They say revenue has increased 50% in the last year and there are now 425 companies competing to sell pharmaceuticals online in a 4 billion yuan market. However, at present only non-prescription drugs can be sold online - that market is worth 200 billion yuan and only 2% of it is online. The much bigger market - the 800 million yuan prescription drug market - is still out of bounds. Analysts predict that up to 30% of drugs sales could move online - so there are huge stakes involved for those who win and lose on online pharmaceuticals.

According to Caixin magazine, plans for online sales of pharmaceutical are being opposed by those who say government-run hospitals will lose one of their main sources of revenue if this goes ahead. The China Pharmaceutical Association warns that prescription drugs must be dispensed under the supervision of a pharmacist to ensure quality of the product and also to ensure that it is going i the right for to the right patient.There is no guarantee that this will happen online, they say. They also point to the fact that online purchases of drugs will not qualify for heath insurance rebates - a crucial factor for most patients, who expect to get some or all of the cost of their medications reimbursed by their health insurance.

Hospital-based pharmacists have also attacked the proposals for having little real-world benefit. They say there is no clear evidence for the benefit of online sales of drugs from a clinical perspective. Are online sales of drugs being promoted to improve patient's health, or just as a trend or a money-making venture, they ask. They have called for a responsible "opening up" policy towards online pharmaceuticals from the government.

In the meantime, it seems China has stalled on the issue of online pharmacies.

Doctors refuse red envelope pledge | Online pharmacies to be allowed | Chinese diabetes patients don't adjust diet

Famous doctor won't sign bribe pledge
One of China's leading doctors has refused to sign the government's anti-bribery pledge against accepting red envelopes, saying it is an ineffective and damaging document. SARS hero Professor Zhong Nanshan said the no red envelopes pledge was not a legally-binding document and its ethical pledges were already contained in the Hippocratic Oath that doctors already swore when they graduated from medical school. He said that if doctors signed the pledge it would be a tacit admission of guilt that all doctors were accepting bribes for preferential treatment, which was not the case. He added that signing the pledge also sent the wrong signal that doctors were to blame for the high costs of medical bills, which he said were actually driven by systemic problems such as the linking of hospital doctors incomes to overservicing and the lack of government funding for government hospitals.

Online pharmacies permitted from 2015
Online sales of prescription medicines in China may begin within months, according to the China Food and Drug Administration. The regulatory agency is expected to announce new policies that will allow  online prescription medicine sales as early as January 2015. Pharmaceutical retailers have said the opening up of online medicine sales will open up a potential 10 billion yuan market for drugs. However, the expected increase in  online pharmacies will have a major impact on bricks and mortar pharmacies, they have warned.

Diabetes patients don't adjust diet
Chinese people with diabetes have little idea how to manage their diet so as to better control their condition, a new study shows. A survey of 100 people with type 1 diabetes by researchers at Peking University People's Hospital found that less than half had ever seen a dietician and few monitored or adjusted their diet to help control their blood glucose levels. The study found that while 64% were aware of carbohydrate counting', only 12% ever used the technique

Medical accidents kill more people than traffic accidents

by Michael Woodhead
In China there are about 8 million unnatural deaths every years and of these about 400,000 are said to be due to medical accidents - often due to unsafe use of medicines. To try and remedy this poor situation, September has been nominated as national medication safety month by the China State Food and Drug Administration.

According to pharmacist Zhang Jichun of the Chinese Pharmaceutical Association, this high rate of accidents and adverse reactions with medications is due to widespread ignorance in the population about appropriate use of medical drugs. A recent survey of more than one million Chinese found that only about one in ten could answer correctly questions about basic drug safe use.

The higher error rate with drug misuse included allergic reactions to antibiotics in babies and infants, misuse of drugs by pregnant women causing birth defects and adverse birth outcomes, accidental drug overdoses, misuse of sleeping tablets causing accidents, using drugs past their shelf life, taking multiple drugs and causing interactions, abuse of weight loss drugs causing cardiac problems and deaths and failing to use cardiac drugs in sufficient doses leading to heart attacks and strokes.

The survey found that there were many problems with the way Chinese people used medications. About 90% bought prescription drugs from pharmacies and self-treated without getting advice or a diagnosis from a doctor. Almost 70% did not read the package insert and a third made major mistakes in dosing while 25% did not take the medicine correctly and failed o get the expected benefit.

 Zhang Jichun said many of the problems with drugs occurred in children and the elderly, who were more susceptible to their effects. A typical and common avoidable serious problem was deafness seen in 300,000 children due to overuse of some classes of antibiotics. This side effect occurred due to parental medication without being aware of the risks.

In the elderly one of the main problems was excessive medication, he added. Many elderly people take several different drugs for various ailments without understanding that they can interact to cause severe side effects, he said. Elderly people also made the mistake of taking western medicines with Chinese traditional medications, and this could also cause problems he said.

To try address this problem the China Pharmaceutical Association has set up a "medication safety expert advice hotline” and invites all Chinese to seek advice before using medications.

Beijing hospitals abolish 'Quick Clinics" in favour of GPs

by Michael Woodhead

Beijing hospitals have angered many patients by abolishing the so called "Convenience Clinics" that provide prescriptions for outpatients.
A legacy of the early 1980s reforms, the Outpatient Prescription clinics have been cancelled because they represent a poor model of care, according to health authorities. Without a proper diagnosis or review, the clinics are little more than glorified drug dealers, say doctors.

Notices went up to say that the Convenience Clinics will be abolished from September 1, with the main reason being that they are at odds with rational use of medicine and pose a risk of medication-related problems, especially for children. Health authorities said drug prescribing had changed enormously since the 1980s, and it was no longer appropriate to offer prescriptions without a review. Prescriptions might now involved multiple drugs and more complex drug treatments with narrow margins of safety, prescribed by different specialists. It was therefore a hazard to have them re-issued without a check on the patient's condition.

If patients with chronic diseases such as hypertension want a simple repeat of their prescription they should make an appointment with the new "general practitioners" rather than waiting a long time to see a specialist. The doctor can then review their condition to see if it has changed and to tailor therapy according to response. There were also cases where the patient did not even attend the "Convenience Clinic", but sent a family member instead. According to the Beijing Daily, hospitals said they wanted their specialist clinics to be reserved for more severe disease, with simpler ailments and repeat prescriptions handled by general practitioners.

Essential medicines for children not available in China

by Michael Woodhead
Essential paediatric medicines such as amoxicillin and salbutamol are often not available in Chinese hospitals or private sector pharmacies, and those that are stocked come with hefty markups, a survey from Shaanxi has found.
When researchers from Xi'an Jiaotong University surveyed a sample of pharmacies and hospital dispensaries to check the availability of 28 common paediatric medicines they found that less than 30% of the drugs on their list were available. The list included basic medicines such as antibiotics, analgesics, antihistamines and vitamins. Drugs that were not available included amoxycillin-clavulanic acid, ibuprofen, morphine and vitamin B6.
Writing in PLOS One, the researchers said this was a concern because when paediatric drugs are not available, doctors   may try adapt adult versions of the drug by using lower doses, which is dangerous. Or if the recommended drug is not available, doctors may substitute a less appropriate drug, they added.
They also found that the paediatric drugs that were available often had huge markup over and above the manufacturers selling price. Amxoycillin, for example, had a manufacturer's price of 6.20 yuan but was sold to the patient for 11 yuan,  a markup of 77%. Salbutamol had a manufacturer's list rice of 13 yuan but sold for 37 yuan to the public. The recommended treatment for chronic asthma,  beclomethasone, cost about 1.6 days’ wages, which made it unaffordable in the public sector hospitals especially as it is needed for ongoing treatment of a chronic condition.
Most of the high markups was due to  public hospital pharmacy profit margins.
The researchers concluded: "We recommend that relevant measures should be taken to enable children to obtain sufficient medicines and effective treatment at affordable prices. The government should adjust the prices of originator brands and lowest-priced generics and improve the efficiency of centralised medicine purchasing systems.
"We recommend urgently that the government should substantially improve public drug procurement and price management, making the procurement system more efficient and the pricing system more scientific, rational and transparent."

Shanghai hospitals' database hacked and records sold to drug companies

translated by Michael Woodhead
A 'mole' hacked into the databases of three major Shanghai hospitals using wireless laptops and extracted drug usage data that was sold to pharmaceutical company representatives, Eastday reports.
The Huangpu court has found two people guilty of fraud after they downloaded drug data from the three hospitals and sold it for 12,000 RMB to drug company contacts. One of the hackers worked in the technical department of one hospital, the other was a pharmacist. The hacker used a laptop computer while sat in a car in the carpark of the hospitals to hack into the wireless network. They were caught in July 2013 when IT staff noticed unauthorised users extracting data, and traced them to the nearby car park, where they were arrested by police. They were fined 5000 RMB and sentenced to one year in jail.
In the past, pharma companies would sometimes pay hospitals for the drug usage data, but this practice has been outlawed. The hackers made contact with drug company representatives and told them they could sell the information each month for 46 different drugs for 250 RMB per item. They emailed the data to the drug company employee, who will be tried separately for corruption.

China's Essential Drug Program: a good idea badly implemented?

Fierce price competiton for basic drug contracts means quality and supply may suffer

 According to a report in the Shandong Health News "the original intention of the national introduction of the basic drug system was very good, but the system has been introduced in too much of a rush, resulting in many problems and loopholes ."
A reporter who investigated the 'grassroots situation' often heard similar opinions voiced.
According to some in the health industries, the lack of oversight means that  the essential drugs program is open to abuse by a few. He said the basic medications tenders are "too cheap" and this attracts low quality bids and deters successful good quality manufacturers.
Due to the vague criteria  not being objective enough, this does not encourage product quality, lead to inter-company fierce price competition. Due to the low prices, many companies that win tenders  are not enthusiastic about drug production, leading to the  frequent often out of stock situation of drugs.
In Yanzhou there are 523 medical institutions that use 300 basic drugs, but some drugs  are simply not able to be purchased, such as Shandong Luoxin Pharmacy cephalexin capsules and Sinopharm compound liquorice tablets.
An industry source said the low prices of essential drugs and high distribution costs means many companies are reluctant to bid for distribution of essential medicines. The lack of supply of products such as such as sodium chloride injection, glucose injection  means companies can not guarantee hospital transfusion services normal supply of stock.
Why is there such a problem?
Part of the blame is on pharmaceutical companies that in order to seize the market,  bid blindly without considering whether the company has sufficient production and distribution capabilities. Also, medicines and other material prices continue to rise, and other factors affecting the cost of drug production, and the cost of management and quality control costs have been increased. With little or no profit, some companies stop the production of essential drugs, resulting in hospitals having no drugs available;
There is also a lack of oversight of supervision of the companies that win tenders. In the tender process for centralized procurement of essential drugs, health authorities should not only take into account the bid price of the company, but should also examine whether there it is qualified to produce the drugs. The authorities also need  to establish a strict regulatory regime after a winning bid, to supervise distribution and usage of essential drugs and to ensure the quality of the medication supplied.
Local protectionism may also affect the distribution of essential drugs, with direct distribution by the provincial pharmaceutical companies or stronger pharmaceutical companies.
Source: China Healthcare

Code of Conduct for health practitioners released by Ministry of Health

Code of practice covers practitioners such as doctors, nurses and pharmacists

by Michael Woodhead
A new national "code of conduct" for medical standards and ethics for medical institutions and health practitioners has been issued and must be "strictly followed", the Ministry of Health has announced.
The code of conduct covers doctors nurses, pharmacists and other health practitioners as well as medical institutions and organisations under the Ministry of Health, the State Food and Drug Administration and the State Administration of Traditional Chinese Medicine.
The ten part code of conduct sets out basic standards such as emphasising adherence to medical ethics and national laws. It defines the role of health practitioners as having a people-oriented practice, adhering to a philosophy of healing the sick, and preventing and curing diseases. Practitioners are also required to be humanitarian, rational, sincere and and act in the spirit of medicine to provide patient-centred health services for the people.
The code also requires practitioners and health organisations to respect the patient's right to informed consent and privacy, safeguard the legitimate rights and interests of the patients and to respect the rights of patients where they may face discrimination because of race, religion, disability or socioeconomic status.
The code of conduct also stipulates the practitioners and health organisations must not seek to take advantage of patients through bribes, soliciting donations or rewards, nor should they engage in profiteering, fraud  or abuse of medical insurance. Practitioners and institutions must also avoid conflicts of interests when providing medical services and products and should advertise and promote their services and products in an ethical way.
It is also required that health practitioners be regularly evaluated to ensure they are maintaining good standards. Practitioners who violate the norms of medical institutions, may be criticised and educated, suspended or dismissed, depending on the seriousness of the infringement. Serious cases of negligence or malpractice may need to be investigated and death with in accordance with the disciplinary rules and case investigation and handling procedures.
The code has been disseminated to all provinces and organisations and will come into effect immediately.
Read more: Ministry of Health