Drug policy in China: pharmaceutical distribution in rural areas

Antibiotic Culture: A History of Antibiotic Use in the Second Half of the 20th and Early 21st Century in the People’s Republic of China

Antimicrobial resistance is now widely regarded as a global public health threat. A growing number of studies suggest that antibiotic resistance is higher in China than in most western countries. Despite the current official regulation prohibiting pharmacies from the unrestricted selling of antibiotics, there is little sign of declining consumer demand. China now ranks as the second largest consumer of antibiotics in the world, after India. Drawing on published historical data, unpublished archival documents, and recently collected oral interviews, this paper provides a historical overview of antibiotic use and abuse in the People’s Republic of China (PRC) from the second half of the 20th century to the present. It demonstrates how the political demand for health improvement, along with the state-sponsored popularization of allopathic medicine, on the one hand, and the lack of access to adequate medical care for the majority of the population, as well as the existing culture of self-medication, on the other hand, are working in tandem to create antibiotic dependency in China. In addition, the privatization and marketization of biomedicine and health care in post-Mao China have helped to build a new and ever-thriving network of production, distribution, and marketing of antibiotics, which has often proven difficult for the authorities to monitor. At the same time, increased purchasing power and easier accessibility created by this new network of production, distribution, and marketing have further contributed to the prevalence of antibiotic overuse in the late 20th and early 21st centuries.

Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province

BACKGROUND

Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example.

METHODS

Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results.

RESULTS

Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs.

CONCLUSIONS

The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.

Pharmaceutical Supply Chain in China: Pricing and Production Decisions with Price-Sensitive and Uncertain Demand

In this paper, we apply game theory to study the price competition between drugstores and hospitals in China’s pharmaceutical supply chain. Motivated by drug shortages and price disparity problems, we build a simplified model with one supplier, one hospital, and one drugstore in which the sellers sell one kind of drug and compete on price. The hospital receives a discount from the government when ordering the drug and both sellers face a price-sensitive and uncertain demand. The existence and uniqueness of a Nash equilibrium are proved and closed-form solutions are found for linear demand cases. We characterize the pricing and ordering decisions of the hospital and drugstore. The analysis shows that high ex-factory price, high price sensitivity, and a small discount are three factors contributing to drug shortages. We consider two special kinds of linear demand to obtain insights into the drug price disparity problem.

The Impact of China's Zero Markup Drug Policy on Hospitalization Expenses for Inpatients in Tertiary Public Hospitals: Evidence Based on Quantile Difference-in-Difference Models

Objectives: The aim of this study was to determine the impact of the Zero Markup drug (ZMD) policy on hospitalization expenses for inpatients in tertiary Chinese hospitals. Methods: Using the administrative data from hospital electronic health records (EHRs) between 2015 and 2017, we implemented the quantile difference-in-differences (QDID) estimators to evaluate the impact of the ZMD policy on hospitalization expenses while controlling for patient-level and hospital-level characteristics. Results: According to the QDID models, the introduction of ZMD policy significantly induced lower drug costs for all inpatients especially at the 50th (-USD 507.84 (SE = USD 90.91), 75th (-USD 844.77 (SE = USD 149.70), and 90th (-USD 1400.00 (SE = USD 209.97)) percentiles of the overall distributions. However, the total hospitalization, diagnostic, treatment, material and services expenses for inpatients were significantly higher for the treated group than the control group. This tendency was more pronounced for inpatients in tertiary hospitals with lower expenses (in the 10th, 25th and 50th percentiles). Conclusion: The implementation of ZMD policy alone may not be enough to change the medical service providers’ profit-driven behavior. The targeted supervision of hospital costs by the Chinese health administration department should be strengthened to avoid unreasonable hospital charges.

A systematic review of pharmaceutical price mark-up practice and its implementation

Pharmaceutical products, apart from being essential for medical treatment, are of high value and heavily regulated to ensure the prices are controlled. This systematic review was conducted to identify pharmaceutical pricing mark-up control measures, specifically in the wholesale and retail sectors. The search method comprised the following databases: PubMed, Science Direct, Springer Link, ProQuest, and EBSCOhost and Google Scholar. The results were filtered systematically from the inception of the aforementioned databases until 23 April 2021. Eligible studies were those focusing on the implementation of pharmaceutical pricing strategies that involve a) mark-ups of medicine, and b) pharmaceutical cost control measures. A total of 13 studies were included in this review: seven covered European countries, four covered Asian countries, one covered the USA and one covered Canada. The main points of discussion in the qualitative synthesis were the implementation of medicine mark-ups, price mark-up regulatory strategies and the outcomes of these regulatory strategies. Our findings suggest that Western countries have a lower mark-up margin, around 4% to 25% of the original purchased price, compared to Asian countries, up to 50%.

Mapping knowledge domains of non-biomedical modalities: A large-scale co-word analysis of literature 1987-2017

This paper presents a systematic mapping of the disparate literature on non-biomedical therapeutic modalities using co-word analysis. Non-biomedical modalities are defined in this paper as therapeutic modalities that exist in separation, but not isolation from, biomedicine. Bibliometric visualisation based on co-word analysis, a method sensitive to the configuration of socio-cognitive networks of knowledge, is employed to create a semantic topography of thirty years' literature from across different disciplines. The proliferation of terminologies to describe non-biomedical modalities from different disciplines raises important issues about the structure of scholarly knowledge about this area, particularly with regards to domains of meaning and conceptual spaces that lay dormant within this discourse. Drawing from a bibliographic dataset of 17,163 peer-reviewed publications written in English between 1987 and 2017 (retrieved on September 31, 2018), this paper presents a rigorous map with which to navigate the highly complex and interdisciplinary literature on non-biomedical knowledge and practices. Arguing that knowledge production about non-biomedical modalities in scholarly literature resembles that of problematic networks of interest, this paper substantiates the separation from biomedicine that contradistinguishes non-biomedical modalities. It does so by analysing the semantic trajectories of the most widely used terminologies in this domain, namely traditional medicine, alternative medicine, herbal medicine, and unclassified drug. Although all equally problematic, these contested terminologies are unlikely to replace one another in any form of paradigmatic shift in the foreseeable future. Their persisting conceptual usefulness is anchored in their own respective clusters of meaning, and researchers wishing to engage in the production of knowledge in this domain should be mindful of the pitfalls associated with their terminology use. Non-biomedical modalities as a term might be better equipped to capture the diversity as well as the historical continuities and discontinuities of therapeutic traditions and practices at the margin of mainstream scientific medicine.

Health Technology Assessment and Its Use in Drug Policies in China

OBJECTIVE

To review drug policies, health technology assessment (HTA), and HTA's use in drug policies in China, to further improve the quality and efficiency of drugs.

METHODS

This study draws on multiple methods. A systematic review of the literature, review of Chinese government documents and statistical handbooks, and authors' experiences in drug policies and HTA in China were combined to achieve the objective.

RESULTS

Of 571 studies identified in the initial search, 14 eligible articles (6 English, 8 Chinese) were finally included. On the Web site of the National Health and Family Planning Commission, the National Development and Reform Commission, and the Ministry of Human Resources and Social Security, we found that HTA or pharmacoeconomics evaluation is mentioned in recent years and its frequency has been increasing; however, there was not one hit about HTA or PE on the Web site of China Food and Drug Administration.

CONCLUSIONS

The decision makers have realized the importance and value of HTA and have tried to integrate HTA into drug policies and regulations. However, the application of HTA findings to drug policymaking is not yet widespread and there are a number of challenges in using HTA in China. Therefore, it is necessary to establish a national HTA commission and develop pharmacoeconomics guidelines to support the use of HTA in decision making. Moreover, the most important steps are to encourage technology innovation, groom more HTA experts, and build reliable databases in China.

Prevalence of hypertension and hypertension control rates among elderly adults during the cold season in rural Northeast China: a cross-sectional study

Objective: The burden of noncommunicable diseases (NCDs) is increasing in China, together with economic development and social changes. The prevalence of risk factors for NCDs, such as overweight/obesity, hypertension, diabetes, and dyslipidemia, is reported to be high even among poor residents of rural areas. We aimed to investigate the prevalence of hypertension among elderly adults in rural Northeast China and the proportion with controlled hypertension among those on antihypertensive medication (hypertension control rate). We also aimed to examine the association of hypertension control with health facilities that provide treatment. Methods: We conducted a community-based cross-sectional study in six rural villages of Northeast China from February to early March, 2012. We interviewed 1593 adults aged 50-69 years and measured their blood pressure. We examined the differences in mean blood pressure between participants who obtained antihypertensive medication from village clinics and those who obtained medication from other sources, using analysis of covariance adjusted for several covariates. Results: The prevalence of hypertension among participants was as high as 63.3%, but the hypertension control rate was only 8.4%. Most villagers (98.1%) were not registered in the chronic disease treatment scheme of the public rural health insurance. The mean systolic blood pressure, adjusted for the covariates, of participants who obtained antihypertensive medication from village clinics was significantly lower than that of participants who obtained medication from township hospitals (by 16.5 mmHg) or from private pharmacies (by 7.3 mmHg). Conclusion: The prevalence of hypertension was high and the hypertension control rate low among elderly villagers during the cold season. As treatment at village clinics, which villagers can access during the cold season seems to be more effective than self-medication or treatment at distant hospitals, improving the quality of treatment in village clinics is urgently needed.

Effects on the medical revenue of comprehensive pricing reform in Chinese urban public hospitals after removing drug markups: case of Nanjing

AIMS

The State Council of China requires that all urban public hospitals must eliminate drug markups by September 2017, and that hospital drugs must be sold at the purchase price. Nanjing-one of the first provincial capital cities to implement the reform-is studied to evaluate the effects of the comprehensive reform on drug prices in public hospitals, and to explore differential compensation plans.

METHODS

Sixteen hospitals were selected, and financial data were collected over the 48-month period before the reform and for 12 months after the reform. An analysis was carried out using a simple linear interrupted time series model.

RESULTS

The average difference ratio of drug surplus fell 13.39% after the reform, and the drug markups were basically eliminated. Revenue from medical services showed a net growth of 28.25%. The overall compensation received from government financial budget and medical service revenue growth was 103.69% for the loss from policy-permitted 15% markup sales, and 116.48% for the net loss. However, there were large differences in compensation levels at different hospitals, ranging from -21.92% to 413.74% by medical services revenue growth, causing the combined rate of both financial and service compensation to vary from 28.87-413.74%, There was a significant positive correlation between the services compensation rate and the proportion of medical service revenue (p < .001), and the compensation rate increased by 8% for every 1% increase in the proportion of services revenue.

DISCUSSION

Nanjing's pricing and compensation reform has basically achieved the policy targets of eliminating the drug markups, promoting the growth of medical services revenue, and adjusting the structure of medical revenue. However, the growth rate of service revenue of hospitals varied significantly from one another.

CONCLUSIONS

Nanjing's reform represents successful pricing and compensation reform in Chinese urban public hospitals. It is recommended that a differentiated and dynamic compensation plan should be established in accordance with the revenue structure of different hospitals.

Distribution of essential medicines to primary care institutions in Hubei of China: effects of centralized procurement arrangements

Background

Poor distribution of essential medicines to primary care institutions has attracted criticism since China adopted provincial centralized regional tendering and procurement systems. This study evaluated the impact of new procurement arrangements that limit the number of distributors at the county level in Hubei province, China.

Methods

Procurement ordering and distribution data were collected from four counties that pioneered a new distribution arrangement (commencing September 2012) compared with six counties that continued the existing arrangement over the period from August 2011 to September 2013. The new arrangement allowed primary care institutions and/or suppliers to select a local distributor from a limited panel (from 3 to 5) of government nominated distributors. Difference-in-differences analyses were performed to assess the impact of the new arrangements on delivery and receipt of essential medicines.

Results

Overall, the new distribution arrangement has not improved distribution of essential medicines to primary care institutions. On the contrary, we found a 7.78–19.85 percentage point (p < 0.01) decrease in distribution rates to rural primary care institutions. Similar results were demonstrated using the indicator of received rates, with a 7.89–19.65 percentage point (p < 0.01) decrease.

Conclusions

Simply limiting the number of distributors does not offer a solution to the poor performance of delivery of essential medicines for primary care institutions, especially those located in rural areas. Procurement arrangements need to consider the special characteristics of rural facilities. In a county, there are more rural primary care institutions than urban ones. On average, rural primary care institutions demand more and are more geographically dispersed compared to their urban counterparts, which may impose increased distribution costs.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2720-3) contains supplementary material, which is available to authorized users.

Balancing Industry and Drug Policy Objectives in the Pharmaceutical Sector: The Case of China

Objectives This article assessed the balance between industry and drug policy objectives in the pharmaceutical sector in China. Methods The articles were mainly identified through databases such as Elsevier, Google Scholar, and SpringerLink, among others. Related articles were mainly separated into three categories: studies on drug policies, studies related to China's new health-care reform policy, and studies concerning patent policies. Results A relatively healthy environment for continuous innovation and drug patent protection in the pharmaceutical industry has been created in China, and the public's drug benefits have also significantly improved. However, the balance between industrial and drug policy objectives in the pharmaceutical sector in China requires additional attention. Discussion and conclusions The results suggest that the government should pay more attention to incentivizing enterprises' innovation, but the current Essential Medicines System in China has limited innovation. Hence, the mechanism for selecting essential medicines should be reformed, and certain appropriate and reasonably innovative medicines should be included. Additionally, medicine coverage, especially the coverage of essential drugs for primary care should be expanded to improve public health benefits. Furthermore, the pharmaceutical industry should be incorporated into the prospective National Drug Policy to achieve a balance between public benefits and pharmaceutical industry development in the future.

Impact of China's Public Hospital Reform on Healthcare Expenditures and Utilization: A Case Study in ZJ Province

Background

High drug costs due to supplier-induced demand (SID) obstruct healthcare accessibility in China. Drug prescriptions can generate markup-related profits, and the low prices of other medical services can lead to labor-force underestimations; therefore, physicians are keen to prescribe drugs rather than services. Thus, in China, a public hospital reform has been instituted to cancel markups and increase service prices.

Methods

A retrospective pre/post-reform study was conducted in ZJ province to assess the impact of the reform on healthcare expenditures and utilization, ultimately to inform policy development and decision-making. The main indicators are healthcare expenditures and utilization.

Results

Post-reform, drug expenditures per visit decreased by 8.2% and 15.36% in outpatient and inpatient care, respectively; service expenditures per visit increased by 23.03% and 27.69% in outpatient and inpatient care, respectively. Drug utilization per visit increased by 5.58% in outpatient care and underwent no significant change in inpatient care. Both were lower than the theoretical drug-utilization level, which may move along the demand curve because of patient-initiated demand (PID); this indicates that SID-promoted drug utilization may decrease. Finally, service utilization per visit increased by 6% in outpatient care and by 13.10% in inpatient care; both were higher than the theoretical level moving along the demand curve, and this indicates that SID-promoted service utilization may increase.

Conclusion

The reform reduces drug-prescription profits by eliminating drug markups; additionally, it compensates for service costs by increasing service prices. Post-reform, the SID of drug prescriptions decreased, which may reduce drug-resource waste. The SID of services increased, with potentially positive and negative effects: accessibility to services may be promoted when physicians provide more services, but the risk of resource waste may also increase. This warrants further research. It is recommended that comprehensive measures that control SID and promote physician enthusiasm be carried out concurrently.

Pharmaceutical pricing: an empirical study of market competition in Chinese hospitals

BACKGROUND

High pharmaceutical prices and over-prescribing of high-priced pharmaceuticals in Chinese hospitals has long been criticized. Although policy makers have tried to address these issues, they have not yet found an effective balance between government regulation and market forces.

OBJECTIVE

Our objective was to explore the impact of market competition on pharmaceutical pricing under Chinese government regulation.

METHODS

Data from 11 public tertiary hospitals in three cities in China from 2002 to 2005 were used to explore the effect of generic and therapeutic competition on prices of antibiotics and cardiovascular products. A quasi-hedonic regression model was employed to estimate the impact of competition. The inputs to our model were specific attributes of the products and manufacturers, with the exception of competition variables.

RESULTS

Our results suggest that pharmaceutical prices are inversely related to the number of generic and therapeutic competitors, but positively related to the number of therapeutic classes. In addition, the product prices of leading local manufacturers are not only significantly lower than those of global manufacturers, but are also lower than their non-leading counterparts when other product attributes are controlled for.

CONCLUSION

Under the highly price-regulated market in China, competition from generic and therapeutic competitors did decrease pharmaceutical prices. Further research is needed to explore whether this competition increases consumer welfare in China's healthcare setting.

Health governance and healthcare reforms in China

This article examines the role of health governance in shaping the outcomes of healthcare reforms in China. The analysis shows that the failure of reforms during the 1980s and 1990s was in part due to inadequate attention to key aspects in health governance, such as strategic interactions among government, providers and users, as well as incentive structures shaping their preferences and behaviour. Although more recent reforms seek to correct these flaws, they are insufficiently targeted at the fundamental governance problems that beset the sector. The article suggests that the Chinese government needs to heighten its efforts to enhance health governance and change the ways providers are paid if it is to succeed in achieving its goal of providing health care to all at affordable cost.

Building institutions for an effective health system: lessons from China's experience with rural health reform

This paper is concerned with the management of health system changes aimed at substantially increasing the access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a 10-year period. It illustrates how the development of reform strategies has been a response both to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts made by the political leadership to manage a transition to a modern economy which provides at least some basic benefits to all. The paper concludes that the key lessons for other countries from China's experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.

Scientific publications in pharmacology and pharmacy journals from Chinese authors in various parts of North Asia: a 10-year survey of the literature

The amount and quality of pharmacology and pharmacy research by authors from China was investigated by comparing published articles from 136 international journals (1998 - 2007) by authors from mainland China, Hong Kong and Taiwan. The number of articles, clinical trials, randomized controlled trials, case reports, impact factors, number of citations and number of articles published in top general medicine journals were compared. The total number of articles increased significantly between 1998 and 2007 (from 324 to 2536 per year). In total, there were 12 021 articles: 7576 from mainland China, 3267 from Taiwan and 1178 from Hong Kong. The accumulated impact factor of the articles from mainland China (16 688.94) was much higher than for those from Taiwan (8726.92) and Hong Kong (3161.22) but, among the three regions, Hong Kong had the highest mean impact factor and the most articles published in top general medicine journals.

Medication storage and self-medication behaviour amongst female students in Malaysia

OBJECTIVES

The aims of this study are to determine the prevalence, attitudes and behaviours of medication storage and self-medication amongst female students at Universiti Sains Malaysia (USM).

METHODS

A cross-sectional survey was conducted and cluster random sampling technique was used for respondent selection. A pre-piloted questionnaire was administered to female respondents so as to collect the data. Data was analyzed using SPSS version 12 and analysis was conducted using descriptive analysis procedures.

RESULTS

Of the 481 participants (mean age; SD was 22.1; 3.3), 93.1% (n=448) students stated that they stored medicine in their rooms, while 70.7% (n=340) stated that they stopped taking a prescribed medicine without consulting a doctor. The prevalence of self-medication was 80.9% (n=389). The most common reasons for self-medication were related to their knowledge of their ailment and its treatment (58.0%), 14.4% thought it saved time and 8.5% mentioned that medication given by provider was not effective. The most common symptoms were otorhinolaryngology problems (22.5%), followed by respiratory disease (19.6%), Gastro Intestinal Tract (GIT) disease (18.1%) and headache/fever (16.8%). Commonly used medicines were analgesics & antipyretics (30.2%), ear, nose & throat drugs (10.8%), vitamins & minerals (10.8%), GIT drugs (8.5%), anti-infections (7.3%) and herbal medicines (3.5%). Prevalence of medicine storage and self-medication practice is high among educated female students in USM.

CONCLUSIONS

There is a need to educate the students to ensure safe practice by increasing their awareness. Strict policies need to be implemented on the unrestricted availability of medicines so as to prevent the wastage of medicines.

Growth of the Asian health-care market: global implications for the pharmaceutical industry

The global economy is being transformed by an explosion of information unleashed by the internet, the digital revolution, communications and increased international mobility. This transformation is manifesting in many ways, including rapid development of countries such as China, commoditization of public services, mobilization of workforces, shifting of market control from suppliers to consumers, interlinked rises in product demand and customer expectations, and problems regulating international business competition. As Asia is home to half of the world's population, and offers both a large relatively low-cost workforce in some countries and a potentially huge retail market, this region could be central to the future of the global economy. Like other industries, the pharmaceutical industry faces a new array of Asia-specific opportunities and challenges. Success in meeting these challenges will go to those pharmaceutical companies that best understand the unique strengths and constraints of Asia's diverse cultures, talents and markets.

Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand--a randomized controlled trial

Private pharmacies are the first line of health care in many communities, commonly selling antibiotics in small doses and prescription-only drugs such as steroids without medical supervision. The aim was to study the effectiveness of a multi-faceted intervention on the dispensing practices of drug sellers in Hanoi and Bangkok. The study was a randomized, controlled trial with 68 Hanoi and 78 Bangkok pharmacies, randomly selected and assigned for intervention and control. Behaviour was assessed by five simulated client visits per pharmacy per dispensing practice, at baseline and a month or more after each intervention. Three three-month interventions were implemented sequentially with four months in between: enforcement of regulations with local inspectors visiting to emphasize the importance of prescription-only medicine legislation; education, performed face-to-face in Hanoi and by a large group in Bangkok; and peer review, voluntary in Bangkok and compulsory in Hanoi. The intervention resulted in significant improvements in Hanoi, reducing the dispensing of illegal steroids (29% vs. 62%) and low dose antibiotics (69% vs. 90%), sustained by means of the peer review (17% vs. 57% steroids and 71% vs. 95% antibiotics), and in fewer dispensers asking no questions and giving no advice (11% vs. 30% steroids and 51% vs. 81% antibiotics). The only significant improvement in Bangkok was the reduction in illegally dispensing steroids (25% vs. 44%) after the regulatory intervention. In Bangkok, fewer of those in the group who volunteered for the peer review asked no questions and gave no advice for low-dose antibiotics requests after the peer review (58% vs. 81%). A multi-component intervention can have a profound effect in changing dispensers' behaviour, but the effect is dependant on the context and the method of implementation. Possible reasons for differences are discussed.

Association between health insurance and antibiotics prescribing in four counties in rural China

A cross-sectional study was carried out at county, township and village health care facilities in four counties in rural China in order to describe and compare the effects of health financing systems on antibiotic prescribing in outpatient care. A total of 1232 outpatients at the health care facilities was selected by multi-stage random sampling and were interviewed over 2 weeks. The results showed that health financing systems appeared to influence antibiotic prescribing in outpatient care, both in terms of frequency and of the types prescribed. The insured group had lower prescribing of antibiotics at township and village health care facilities, and for respiratory tract infections, but had higher prescribing of newer antibiotics at county and village health care facilities, for respiratory tract and g-i infections. Because there was a high patient compliance rate (94.3%) in this study the prescribing of antibiotics (supply side behavior) reflected the use of antibiotics (demand side behavior) to a great extent. Thus the results imply that antibiotics prescribing and using might be biased by the patient's health financing systems and antibiotic prescribing was the result of the interaction between physicians and patients.