The authors also offer theoretical approaches for studying drug regulation, aspects of drug consumption cultures, the socio-political treatment of drugs during various historical periods and ongoing efforts to legislate drug trade, criminalize drug use and manage the drug addict population within national and international contexts. Hong Lu is an Associate Professor in the Department of Criminal Justice at the University of Nevada, Las Vegas, and has written extensively on international and comparative criminology and law.
Terance D. Contents: Preface; The consumption and control of illegal substances; Social conditions and opium in Imperial China pre ; Drug laws and the social context in the Republic era; Narcotics control in the People's Republic of China; Theoretical issues and explanations of China's drug laws; Fighting narcotic drugs in a global context; Appendices; Glossary; Bibliography; Index. See All Customer Reviews. Shop Books. Add to Wishlist. USD Sign in to Purchase Instantly.
Explore Now. Buy As Gift. Overview In the context of global efforts to control the production, distribution and use of narcotic drugs, China's treatment of the problem provides an important means of understanding the social, political, and economic limits of national and international policies to regulate drug practices. Table of Contents Contents: Preface; The consumption and control of illegal substances; Social conditions and opium in Imperial China pre ; Drug laws and the social context in the Republic era; Narcotics control in the People's Republic of China; Theoretical issues and explanations of China's drug laws; Fighting narcotic drugs in a global context; Appendices; Glossary; Bibliography; Index.
A study of prescriptions for outpatients and inpatients from 23 cities and 16 rural primary health care centers between and showed that The same study found that A recent study showed that combination use of antibiotics was found in A large proportion of antibiotics are administered by injection [ 7 ] including at village clinics [ 10 ].
Surveillance data show a growing problem with antimicrobial resistance.
The National Antibacterial Resistance Surveillance Net Mohnarin was founded in by the Ministry of Health to monitor nationwide bacterial resistance. It began in hospitals and has subsequently been extended to hospitals. Its Report showed that the prevalence of antibiotic resistance was much higher in China than in North America and Europe [ 5 ]. Subsequent reports have shown a growing trend in antibiotic resistance. The incidence of MRSA increased from China has taken many measures to address antimicrobial resistance, often in response to global developments.
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Table 1 summarizes measures that have been taken to address the problem of antimicrobial resistance. These interventions have had some success, but antibiotics abuse is still common in China. Although, NHFPC surveillance data showed a fall in the percentages of antibiotics used for both inpatients and outpatients between and , overuse of antibiotics and IV infusions was still a major problem [ 18 ].
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Total drug expenditure from more than surveillance sites nation-wide almost doubled between and Reynolds et al. Li et al. A manager at the NHFPC indicated that China does not yet have a well-organized system to promote the rational use of antibiotics [ 18 ]. Many studies have attempted to understand the implementation of these regulations and strategies. Zhang et al. Jin et al. Gu [ 21 ] argued that the underlying cause of over-prescribing was inappropriate government regulation of prices for health services and medicine.
Liang et al. These publications bring different perspectives for analyzing the influence of regulation on antibiotic use. One way to bring these perspectives together is by viewing antibiotic use as a complex system [ 16 , 23 ], in which many actors at different government levels and in a variety of institutions, including hospitals, pharmacies, manufacturers, insurance agents, and consumers, respond to interventions by adapting their behaviors in ways that have positive and negative effects [ 24 ].
Moreover, some actors function largely outside the health regulatory framework [ 25 ].
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This paper applies the concept of a complex adaptive system CAS to analyze the implementation of regulations and strategies regarding antibiotic use. One important element of a complex adaptive system is the existence of many interacting agents, capable of self-organization and responding to disruptions through interactive behaviors [ 26 , 27 , 28 ]. The interactions between agents are complex and dynamic so it is difficult to control or predict the result of a specific intervention [ 26 , 27 ].
There are feedback loops and interdependencies between parts of the system, and there is often no direct cause and effect relationship [ 29 , 30 ]. In a complex world, strategy is a series of processes for managing change [ 31 ]. There is an increasing recognition of the degree to which health systems exhibit the characteristics of a complex adaptive system [ 26 , 33 ].
This can explain why an insignificant stimulus can sometimes create rapid change at scale and why at other times major interventions result in modest outcomes or unpredicted consequences [ 26 , 30 ]. Health interventions, such as legislative and educational efforts, are inherently complicated to design and evaluate correctly and complex science can provide a useful framework for designing and implementing them [ 34 , 35 ].
A growing body of literature applies the concept of CAS to health systems and their transformation. There have been publications on the design of primary care practice [ 30 , 36 — 38 ], practical solutions in clinical care [ 39 ], designing evaluation programs for health interventions [ 34 , 35 , 39 ], explaining the relationship between management practice and health outcomes in nursing homes [ 40 ] and variation and change in family practices [ 41 ]. These studies frame the interacting parts and agents in the health system in different ways in analyzing how adaptive activities and interactive relationships influence the implementation of policy interventions.
Regulation of antibiotic use has to balance the need to ensure that people have access to appropriate antibiotics, when they need them, whilst preserving the efficacy of these products, as a global public good [ 42 , 43 ]. Overuse of antibiotics results from a combination of inappropriate financial incentives, lack of surveillance information on resistance and the understandings of users and suppliers of these products, amongst other things [ 23 ].
The coordination of different professions and authorities, decentralized organizations with regional groups, and news media are important factors for successfully changing antibiotic use [ 44 ]. A systems approach can help with the identification of drivers and obstacles to effective interventions [ 23 ]. It is important to situate an effort to alter antibiotic use in this context.
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Several studies have contributed to our understanding of this context using the concept of CAS. Bloom et al. They argue that regulatory strategies need to be based on an understanding of local institutions. Xiao et al.
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The authors found that divergent and unpredicted outcomes emerged because of the interaction between agents. They argue that policy development and implementation is the result of the responses of many interacting agents to a dynamic context and the attempts of government to respond to these adaptations. This paper explores the adaptive behavior of different agents, interacting relationships, and the incentives likely to influence the implementation of policies to improve antibiotic use. It views providers and users of antibiotics as key actors in the system and explores the impact of their adaptation to new government regulations.
It focuses on antibiotics for human use rather than for animal husbandry and aquaculture. This paper does not consider related issues, such as environmental spread of antibiotics and antibiotic-resistant bacteria, infection prevention and control, sanitation and hygiene, large-scale migration, bacteria culturing in laboratories, and rapid diagnosis [ 19 ].
This paper explores the implementation of antibiotic regulations in China as a case study that identifies and analyzes factors that explain the limited impact on antibiotic use in a complex context. The data were collected from the following sources: 1 national policy documents about antibiotic use, and related polices in a broader area, 2 published studies in the scientific literature, 3 and other documents.
The key agents are involved in the relationship between supply and demand. The factors that support the health market can set a positive or negative incentive structure. Under the totality of an outside incentive structure and policy intervention, all types of agents will adapt themselves to the environment through interactive behavior and strive to protect their interests, which may be consistent or contradictory to the policy goal.
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Intended or unintended outcomes may appear. Many types of agents, including governments, producers and distributors of pharmaceuticals, hospitals, patients, insurance agents and many informal actors are involved in the system of antibiotic use [ 45 ]. Complex and Fragmented Policy Provision. Government is responsible for making, implementing, and regulating policy.
According to Fang [ 47 ], Chinese health care regulatory institutions include the system of public health administration, the auditing system, the price control regulations, the Food and Drug Administration FDA , the Industry and Commerce Administration ICA system, and other informal regulatory arrangements. In the context of antibiotic use, the public health administration system is responsible for most of the direct regulations and strategies mentioned above; the FDA oversees organizations and individuals who address buying, selling, and prescribing drugs based on Drug Management Law and its Implementation Statute; the Price Control System establishes the prices of health services and drugs at present, the government is exploring ending price regulation of most of medicines and the ICA system has the duty to oversee private health facilities.
Many Providers and Multiple Channels to Users. All types of producers, distributors, health facilities, and retail pharmacies can be seen as antibiotic providers. There are six types of medicine circulation path from medicine providers to patients: 1 producers-distributors-health facilities-patients, 2 producers-distributors-patients, 3 producers- distributors-retailers-patients 4 producers-health facilities-patients, 5 producers-retailers-patients, 6 producers-patients [ 48 ].
Before , most drugs were distributed from producers to wholesalers, then to hospitals or retail pharmacies, and finally to patients. Since the NEMP was implemented in the health system reform, individual health facilities have been forbidden from purchasing essential drugs directly from producers or wholesalers, but they are allowed to purchase through provincial public bidding [ 49 ]. By the end of , there were , drug trading enterprises, including 13, wholesalers, 4, private retail chain enterprises, , chain drugstores and , standalone drugstores [ 50 ].
There were , healthcare facilities in [ 51 ], and their total expenditure accounted for Health facilities have a bilateral monopoly position in the Chinese medicine market, which means they have both a buyer-monopoly position because of powerful purchasing ability, and a seller-monopoly position because of dominating prescription rights [ 21 ]. Drug producers and distributors are not only the main suppliers of antibiotics to health facilities and retail pharmacies, they are also increasingly selling directly to patients through the internet.
Retail pharmacies are becoming important supplier of antibiotics. The proportion of their drug sales in national total drug sales has a steadily rising trend, increasing to Other semi-formal or informal providers, such as village clinics and barefoot doctors, and some illegal private clinics and pharmacies add complexity to the system.
Patients are key actors. Their understandings of the appropriate use of antibiotics strongly influence patterns of use [ 10 ]. Self-medication is common because it allows people to avoid the crowding and high costs of hospitals. Insurance agents can also influence antibiotics use. For example, Fee for service, in which providers are retrospectively reimbursed for each service rendered, can cause over-treatment.