Serve the people or close the sale? Profit-driven overuse of injections and infusions in China's market-based healthcare system

Abstract

Treatment by injection or infusion is widespread in China. Using the common cold as a tracer condition, we explored the reasons for over-prescription of injections and infusions in Guizhou, China. Interviews with prescribers, patients and key informants were supplemented by focus groups. These revealed how historical ideas encourage unnecessary use of percutaneous treatment: faith in the healing power of needles is locally attributed to association with acupuncture. Many patients and some staff believe that injections per se are therapeutic. However, the structure of health service financing and remuneration now reinforces this irrational faith. Market-based reforms have attempted to control costs and increase productivity with an incentive scheme which rewards prescribers financially for over-prescription in general and for use of injections and infusions in particular. Aggressive marketing has displaced oral treatment from health facilities into independent pharmacies, leaving doctors functioning mainly as injection providers. There is a need for a multi-faceted response encompassing education and reform of financial incentives to reduce the use of unnecessary treatment.

Ongoing initiatives to improve prescribing efficiency in China; statins as a case history

“…However, it is likely future demand-side measures will have only limited success unless the current incentives encouraging physicians and hospitals to prescribe and dispense premium priced originators versus lower cost generics are addressed (29,31,33,53). Once these are adequately addressed, potential additional demand-side measures could include greater enforcement of INN prescribing.…”

“…This has resulted in considerable irrational prescribing despite the introduction of measures to decrease this such as essential medicine lists (29,31,33,42,43). An example of irrational prescribing is the continued inappropriate use of injectable drugs including injectable traditional Chinese medicines as well as considerable over prescribing of antibiotics including, as mentioned, the use of expensive versus less expensive antibiotic alternatives (31,32,49,52,53).…”

Exploring the evidence base for national and regional policy interventions to combat resistance

“…The pharmaceutical industry is known in some settings to pressurize both patients and doctors: patients through intense marketing campaigns 76 and doctors through bribery. 69 Well-publicised criminal investigations of irresponsible sales practices of GlaxoSmithKline in China and Poland, for example, demonstrate a policy shift towards the pharmaceutical industry more generally, by national authorities.…”

“…75 Perverse financial incentives that stem from the fee-for-service payment model adopted by state-owned healthcare providers are a primary driver for overprescribing of drugs. 76 As such, the national rural social insurance scheme has inadvertently led to the overprescribing of antibiotics in those who are covered, by lowering financial barriers to accessing healthcare. 77 Subsequent trial modifications within the scheme have demonstrated that changing the payment model from fee-for-service to a capitated budget with pay-for-performance was effective in reducing inappropriate and overprescribing of antibiotics.…”

Initiatives to increase the prescribing of low cost generics; the case of Scotland in the international context

“…generic statins accounted for only 9% to 10 % of total statins in recent years in hospitals in China international context (175). The low use of generics is exacerbated by the need for hospitals to make money from drug procurement for their sustainability and physicians to supplement their income, with this incentive system also stimulating overuse of injections (174,(176)(177)(178) Box 2 -Potential requirements to successfully implement a generic substitution policy (adapted from (118)).…”