Barriers to Stewardship of Medical Antimicrobial Use in China

Antimicrobial resistance (AMR) is a major 21st-century threat to individual and population health. The 2016 Review on Antimicrobial Resistance estimated that by 2050, as many as 10 million people could die each year from AMR. As the problem of AMR worsens, general awareness of it is increasing, with new and updated National Action Plans (NAPs) to address the problem country-by-country continuing to come out. China, which is among the top consumers of antimicrobials worldwide, released its first 5-year NAP in 2016 and renewed its NAP in 2022.

Excessive and inappropriate medical uses of antimicrobials have contributed to the AMR surge. Addressing AMR involves multisectoral, multilevel and multidisciplinary cooperation, but in the end, the implementation of stewardship and other measures designed to help address AMR in humans will inevitably involve people’s behavioral change. A fundamental aspect of AMR governance is whether people take antimicrobials, and which ones they take. With both global and national AMR challenges evolving and with AMR governance efforts ongoing, barriers to securing rational antimicrobial use in China are changing too. The next Chinese NAP will need to be updated with current evidence on emerging barriers and ways to address them.

Research question

Literature shows that in the past, one major barrier to rationalizing people’s antimicrobial use in China was Chinese citizens’ practice of taking antimicrobials over-the-counter, often buying them from informal shops or pharmacies willing to sell drugs without prescriptions. Factors driving such practices included incomplete health insurance coverage that didn’t cover prescribed antimicrobials, and lack of state regulation allowing pharmacies to dispense antimicrobials without prescriptions. Meanwhile some people can easily access drugs by request to clinicians, due to underdeveloped guidelines. More recently, following China’s NAPs, a series of initiatives have been intended to address this phenomenon, including more suitable health insurance coverage, the implementation of a prescription system for the sale of antimicrobials, the reinforcement of antimicrobial supplies, and education for the general public about the rational use of antimicrobial drugs.

Have these initiatives in fact achieved their intended result of changing the public's behavior towards using antimicrobials? The existing literature seems to show that irrational or unauthorized use of antimicrobials in China continues, but in somewhat different forms. If this is the case, what are the new factors influencing irrational antimicrobial use in the population, and how have they changed? Exploring these questions will help us to understand new barriers to rational antimicrobial use in China and to evaluate the previous NAPs’ effectiveness. We hope to inform future NAPs by helping policymakers think about what measures might be needed to address new and emerging barriers to rational antimicrobial use.

Summary of approach

First, we will conduct a rapid review of the academic and grey literature on the Chinese National Action Plan, specifically regarding policies intended to change clinicians’ prescribing behaviors, access to over-the-counter drugs, and patient/public attitudes toward taking antimicrobials. From this review we will gain an understanding of past antimicrobial drug use, especially misuse, in China, and learn about past self-administration by the Chinese public, the reasons for it, and the interventions taken by the state - in particular, what measures the state has taken following the clarification of a national target for reducing inappropriate uses of antimicrobial drugs. Second, using textual analysis, we will describe the characteristics, strengths, and weaknesses of each Chinese NAP (2016 and 2022) by comparing them with each other, with the NAP of the United Kingdom, and with the World Health Organization’s General Action Plan for AMR. Third, we will conduct key informant interviews with patients, members of the public, clinicians, and policymakers in China. We may also conduct social media analysis of publicly available posts on platforms such as Weibo and Zhihu.

Project team

• Principal Investigator: Yali Cong, Peking University School of Health Humanities
• Co-Investigator: Tess Johnson, Ethox Centre, University of Oxford
• Student Investigator: You Zuo, Peking University School of Health Humanities
• Co-Principal Investigator: Maria Merritt, Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health

_{Image credit: Max Zhang}