Antibiotic Stewardship in Retail Pharmacies and the Access-Excess Challenge in China: A Policy Review

Abstract

In China, efforts to restrict excessive antibiotic consumption may prevent sufficient access to these life-saving drugs among the most deprived in society because of the weak primary health care system. This makes antibiotic stewardship in the retail pharmacy sector a particular challenge. We conducted an analysis to examinate policies on antibiotic sales in retail pharmacies in China and how tensions between ‘excess’ and ‘access’ are managed. The analysis was guided by the Walt and Gilson health policy analysis triangle to systematically analyse policies based on the content of policies, contexts, governance processes, and actors. Nine research studies and 25 documents identified from national and international sources were extracted, grouped into categories, and examined within and across records and categories. As of 2020, eight key policies have been introduced in China that focus on two areas: dispending prescribed medicines or antimicrobials with a prescription and having a licensed pharmacist present in the retail pharmacies, with approaches having changed over time. Inappropriate sales of antibiotics are still common in retail pharmacies, which can be linked to the lack of consistency and enforcement of published policies, the profit-driven nature of retail pharmacies, and the displacement of the demand for antibiotics from clinical into less regulated settings.

COVID-19 Pandemic Impacts on Humans Taking Antibiotics in China

“…This coincides with the above-mentioned fact that the residents in the city with more confirmed cases would purchase antibiotics in online pharmacies rather than going to see doctors in the hospitals for treating diseases during the COVID-19 pandemic, which could induce increased immoderate ingestion of antibiotics. 5 , 8 , 27 , 28 Consistently, antibiotic use substantially increased along with the confirmed COVID-19 cases in European regions during the pandemic. 29…”

“…This may be attributed to the temporal and regional differences, as well as the lower LOQs, in this study (0.003–0.138 ng/mL) than in previous studies (0.13–6.63 ng/mL). 31 , 33 , 34 In view of the increased online pharmacy sales of medicines, 5 the common sales of nonprescription antibiotics in pharmacies, 8 , 27 and the relatively weak awareness regarding the rational use of antibiotics for customers 28 during the COVID-19 pandemic, the action of humans taking more antibiotics to cure diseases may have also contributed to the multiple antibiotic exposures. Higher proportions of people were exposed to 3–9 antibiotics (9.5–11.6%) than 0–2 or 10–14 antibiotics (0.603–6.18%).…”

“… 6 Among all medicines in the pharmacy, antibiotics have shown almost the highest average sales. 7 , 8 …”

“…26 However, antibiotics are still dispensed in 83.6% of pharmacies in China without prescriptions, as shown by a nationwide, cross sectional study. 8 , 27 The public awareness of the rational use of antibiotics is relatively weak in China. For example, an investigation in 2019 reported that only 9.7% of pharmacy customers had a good perception of antibiotics.…”

Perspectives on the Ethics of Antibiotic Overuse and on the Implementation of (New) Antibiotics

“…One way to potentially change individual ethical behaviour is through targeted prescriber and general public education campaigns so that doctors and the general public are continuously made aware of the deleterious effect and risk associated with the irrational use of antibiotics to treat unconfirmed bacterial infections [ 11 ]. Ethically speaking, however, one of the possible ethical consequences of such policy implementations may be a reduction in the standard of living of vendors via the profits made by selling antibiotics [ 12 , 13 ]. Another ethical problem is that blocking access to antibiotics may unfairly target lower income groups who cannot afford to pay for a visit to a doctor, or a diagnostic test, on top of the cost of antibiotic treatment.…”