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Analysis China’s Health System Reforms: Review of 10 Years of Progress

Rational use of antibiotics in the context of China’s health system reform

BMJ 2019; 365 doi: (Published 21 June 2019) Cite this as: BMJ 2019;365:l4016

China's health system reforms: review of 10 years of progress

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  1. Ping He, assistant professor1,
  2. Qiang Sun, professor2,
  3. Lizheng Shi, professor3,
  4. Qingyue Meng, professor1
  1. 1China Center for Health Development Studies, Peking University, Beijing 100191, China
  2. 2School of Health Care Management, Shandong University, Shandong Jinan 250012, China
  3. 3School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
  1. Correspondence to Ping He phe{at}

Despite improvements in antibiotic use in tertiary hospitals, problems remain in other parts of the health system, say Ping He and colleagues

Key messages

  • Since the 2009 health system reform, China has paid considerable attention to antibiotic control through strengthening national antimicrobial stewardship and establishing the National Essential Medicines System

  • While a national campaign of antimicrobial stewardship was effective in reducing the consumption of antimicrobial agents at tertiary hospitals, the drug policy reform did not improve current problems of antibiotic overuse in primary care and rural settings

  • Improving rational use of antibiotics requires not only cross sector coordination and comprehensive intervention but also participation of multiple stakeholders, particularly active engagement from healthcare providers and patients

China spends a high proportion of its total health expenditure on drugs.1 In 2006, almost half (42.7%) of the total expenditure on health was on medicines.2 It has a serious problem with irrational use of medicines—that is, medically inappropriate or ineffective drug treatment practices.3 The main types of irrational use are polypharmacy, misuse of antibiotics, overuse of injections, failure to prescribe according to standard treatment guidelines, and inappropriate self medication.4 It is estimated that around half of antibiotics are unnecessarily prescribed.5 Overuse and misuse of antibiotics is one of the key contributors to antimicrobial resistance.6

Perverse financial incentives for healthcare facilities and physicians have been widely recognised as the major cause of overprescription of antibiotics.7 In the late 1970s, China’s market oriented economic reform reduced the role of the government in financing healthcare services.8 To compensate for the reduced subsidy, the government officially allowed a 15% or more mark-up on medicines for health facilities.9 Since a bonus system rewarded physicians based on the monetary values of drugs they prescribed, physicians had a strong financial incentive to overprescribe and …

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