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Trop Med Int Health. 2017 Sep;22(9):1166-1174. doi: 10.1111/tmi.12922. Epub 2017 Jul 24.

Impact of China's essential medicines scheme and zero-mark-up policy on antibiotic prescriptions in county hospitals: a mixed methods study.

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Division of Clinical Public Health, and Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Shandong University, Jinan, China.
Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK.
China Global Health Research and Development, Shenzhen, China.
Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China.



To evaluate the impact of the national essential medicines scheme and zero-mark-up policy on antibiotic prescribing behaviour.


In rural Guangxi, a natural experiment compared one county hospital which implemented the policy with a comparison hospital which did not. All outpatient and inpatient records in 2011 and 2014 were extracted from the two hospitals. Primary outcome indicator was antibiotic prescribing rate (APR) among children aged 2-14 presenting in outpatients with a primary diagnosis of upper respiratory tract infection (URTI). We organised independent physician reviews to determine inappropriate prescribing for inpatients. Difference-in-difference analyses based on multivariate regressions were used to compare APR over time after adjusting potential confounders. We conducted 12 in-depth interviews with paediatricians, hospital directors and health officials.


A total of 8219 and 4142 outpatient prescriptions of childhood URTIs were included in the intervention and comparison hospitals, respectively. In 2011, APR was 30% in the intervention and 88% in the comparison hospital. In 2014, the intervention hospital significantly reduced outpatient APR by 21% (95% CI:-23%, -18%), intravenous infusion by 58% (95% CI: -64%, -52%) and prescription cost by 31 USD (95% CI: -35, -28), compared with the controls. We collected 251 inpatient records, but did not find reductions in inappropriate antibiotic use. Interviews revealed that the intervention hospital implemented a thorough antibiotics stewardship programme containing training, peer review of prescriptions and restrictions for overprescribing.


The national essential medicines scheme and zero-mark-up policy, when implemented with an antimicrobial stewardship programme, may be associated with reductions in outpatient antibiotic prescribing and intravenous infusions.


China; Chine; Health Policy; Política sanitaria; antibiotic prescribing; esquema de medicamentos esenciales; essential medicines scheme; mixed methods; méthodes mixtes; métodos mixtos; politique de santé; prescripción de antibióticos; prescription d'antibiotiques; schéma des médicaments essentiels

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