中國將縮減醫藥市場中間環節

A state initiative to reduce intermediaries in China’s pharmaceutical market is expected to more than halve the number of companies in the sector, but experts say the government will struggle to achieve its aim of cutting drug prices and tackling bribery in distribution chains.

中國政府一項縮減醫藥市場中間環節的計劃，有望使該領域的企業數量減少一半以上，但專家們表示，政府將很難實現其壓低藥價、清除分銷鏈條中賄賂行爲的目標。

The vast majority of China’s $110bn annual pharmaceutical sales are to state-run hospitals, which depend on drug and medical equipment sales for most of their revenue. Drug sales are conducted through a byzantine network of some 13,500 distributors, with kickbacks to doctors rife.

中國醫藥行業每年銷售1100億美元產品，其中絕大部分流向公立醫院，這些醫院的收入主要靠賣藥和賣醫療器材。藥品銷售通過一個複雜的網絡進行，這個網絡由大約1.35萬家分銷商組成，給醫生回扣的現象相當普遍。

Regulations limiting the number of invoices between drugmakers and hospitals to a maximum of two will be rolled out nationwide by next year, the State Council said last month. The number of drug distributors is expected to plummet as a result.

中國國務院上月表示，將不晚於明年在全國推開“兩票制”（指藥品從生產企業到流通企業開一次發票，流通企業到醫療機構開一次發票）。預計這將導致藥品分銷商數量大幅減少。

“Reducing the number from more than 10,000 to 2,000-3,000, that is what I have heard from officials,” said Xie Qilin, deputy secretary-general of the Chinese Medical Doctor Association.

中國醫師協會(Chinese Medical Doctor Association)副祕書長謝啓麟表示：“把數量從1萬多家減至2000到3000家，這是我從官員那裏聽到的。”

The “two invoice reform” as it is known is already being tested in 11 provinces, with Fujian in the east reporting a halving of distributors since its adoption in 2012. “The market is not concentrated enough,” Wu Zhen, vice-minister of China’s food and drug administration, said last year, explaining the rational for the policy.

名爲“兩票制”的改革已在11個省份試行，福建省報告稱，自2012年執行規定以來，藥品分銷商已減少了一半。中國國家食品藥品監督管理總局副局長吳湞去年在解釋出臺該政策的理由時表示：“（市場）集中度不夠。”

“The agencies will have to enlarge or die,” said an employee at an overseas medical device manufacturer who asked not to be identified. The sector employs more than 3m people, many of whom will be forced to switch to larger companies or change professions, the Economic Observer newspaper reported.

某海外醫療器械製造商的一名要求不具名的員工表示：“代理商要麼必須擴張，要麼就得關門。”《經濟觀察報》(Economic Observer)報道稱，該行業員工數量超過300萬，其中很多人將被迫轉投較大的公司或改行。

Eric Carlson, a partner at law firm Covington & Burlin, said in a recent report that the crackdown on small distributors would accelerate sector consolidation, “centralising distribution in a handful of pharmaceutical distributors, many of which are state-owned or state-controlled”.

科文頓?柏靈律師事務所(Covington & Burling)合夥人埃裏克?卡爾森(Eric Carlson)在最近一份報告中表示，對小型分銷商的打壓將加快行業整合，“將分銷集中到少數藥品分銷商手中，其中很多是國有或國有控股企業”。

Beneficiaries would include companies such as Sinopharm Group, in which the Chinese government has a majority stake, with Fosun Pharma as a partner.

受益者將包括國藥控股(Sinopharm Group)等公司，中國政府持有國藥控股多數股份，復星醫藥(Fosun Pharma)也是股東之一。

The reform is likely to be more of a challenge for Chinese drugmakers that typically distribute their products indirectly, through local intermediaries. If applied to the medical device market it could benefit overseas companies by reducing the need for complicated supply chains.

對中國藥企來說，此次改革很可能更多是一次挑戰。中國藥企一般通過地方中間商間接分銷其產品。如果這一改革應用於醫療器械市場，可能會使海外藥企受益，因爲它們不再有那麼大的必要去建立複雜的供應鏈。

Ireland-based Medtronic, for instance, was fined $17m by Chinese anti-monopoly authorities last year for price fixing in its multi-layered local distribution system.

例如，總部位於愛爾蘭的美敦力(Medtronic)去年被中國反壟斷部門罰款1700萬美元，原因是該公司在其多層級的地方分銷體系中進行限價。

Other large multinationals tend to have their own sales teams, which employed some 20,000 staff as of 2011, according to Rachel Lee, an industry observer.

其他大型跨國藥企在華往往都擁有自己的銷售團隊，根據行業觀察人士Rachel Lee的數據，自2011年起，這些銷售團隊共僱用了約2萬名員工。

But use of direct sales staff has not prevented bribery. GlaxoSmithKline paid a record ￡297m fine in 2014 after its sales staff were found guilty of corruption, while Bristol-Myers Squibb faced $14m in US penalties over alleged bribery of Chinese hospital officials. Novartis agreed pay $25m last year over similar charges.

但使用直銷人員並沒有防止賄賂行爲的發生。2014年，葛蘭素史克(GlaxoSmithKline)在其銷售人員被判犯有行賄罪後支付了創紀錄的2.97億英鎊罰款。而百時美施貴寶(Bristol-Myers Squibb)因涉嫌賄賂中國醫院官員在美國被罰了1400萬美元。去年，諾華(Novartis)同意就類似的指控支付2500萬美元。

State officials have said the reform is aimed at reducing drug prices. The current drug distribution system is “very inefficient and very costly, and the cost in the end is borne by the patient”, said Franck Le Deu of McKinsey’s healthcare practice. “Provinces and even cities can have a vested interest in having homegrown distributors in their backyard.”

政府官員已表示，此次改革的目的在於降低藥品價格。當前的藥品分銷體系“非常低效、成本很高，這些成本最終都由患者承擔”，麥肯錫(McKinsey)醫療行業實踐部門的樂誠鐸(Franck Le Deu)說，“說到在自己的後院保有本地的分銷商，各省、甚至市可能都在這方面存在既得利益。”

But according to Liu Tingfang, a hospital reform researcher at Tsinghua University, the squeeze on distributors will benefit pharmaceutical companies — which will save on distribution costs — more than patients.

但清華大學研究醫改的劉庭芳研究員表示，壓縮分銷商給藥企帶來的好處（藥企將可節省分銷成本）要多於給患者帶來的好處。

“Prices will not see much impact. Kickbacks will still exist,” he said, with low-paid medical staff at hospitals still expecting a share of sales. “It is necessary to reform doctors’ salaries.”

“藥價不會受到太大影響。回扣將依然存在，”他說，因爲醫院收入不高的醫務人員仍指望從藥品銷售中分一杯羹。“有必要對醫生的工資進行改革。”