Rolf Panel Ely Jin

Case study: antibiotic use in rural China Dr Adrian Ely and Prof Chenggang Jin www.povill.com

Backward mapping: a ' simple ' research methodology ... 1. Start with regulatory perspectives on the problem … … how do regulators shape user practices? Regulatory worlds 2. Start with practices and perspectives of poor users … … how do their concerns diverge from regulatory perspectives? Poor users Antibiotics in China

Pneumonia-Unnecessary care -considerable burden Drug use Unnecessary cost (RMB yuan) 6 (2.60%) Needed 231 101 (43.72%) 124 (53.68%) Total Necessary Unnecessary 0.3 Min 40.52 Median 91.16 SD 540.8 74.12 124 Max Mean N

Median unnecessary cost of antibiotics by social-economic status (RMB Yuan)

Providers’/ regulators’ perspectives
“ medical care service supported by drug sales” – ‘ 以药养医’
Lack of effective supervision and administration.
“ The pharmacies sell drugs without any prescription, or they can write a prescription themselves, and the county FDA can not recognize whether it is true or not” (Director of a county FDA)
“ Doctors are afraid of medical disputes and lawsuits, so preventive antibiotic use becomes common” (a section director in Hubei Health of Bureau)

Patients’ perspectives
Patients use trust as a strategy for sourcing inexpensive, effective drugs, preferring well-established village doctors.
Patients lack knowledge and are open to exploitation:
“ We just accept what the doctors prescribe.” “The more expensive the drug is, the better its effect is.”
(A rural resident in Shandong province)
Widespread belief in a never-ending line of antibiotics:
“ If the disease can not be treated by using a certain type of the antibiotic, then I hypothesize that there is drug resistance and ask the doctor to use another kind of drug antibiotic”
(A rural resident in Shandong province)

Implications/ Closing Questions
Implementation of regulation/ clinical guidelines on the ground is highly variable - capacity gaps are evident, but incentives are also relevant.
Findings re-emphasize the importance of trust/ personal relations in provider behaviour.
Both of these raise important questions for (inter)national regulatory initiatives.

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