Determinants of non-prescription antibiotic dispensing in Chinese community pharmacies from socio-ecological and health system perspectives.

Although non-prescription antibiotic dispensing (NPAD) has been officially forbidden by the Chinese government since 2004, it is still a common practice throughout the country. In this study, we use China as an example to explore the determinants of NPAD within the framework of its health system from a socio-ecological perspective. A mixed-method combining the simulated client method (SCM) and key informant interviews conducted in Zhejiang, Hubei, and Sichuan provinces was adopted. 73.3% of the SCM interactions engendered NPAD (91.7% through antibiotic requests vs. 55% through consultation) in Chinese community pharmacies; a much higher rate than the global average. At the intrapersonal level, NPAD was found to be driven by profits from selling non-prescription antibiotics and traditional Chinese medicine. At the interpersonal level, NPAD was driven by fierce competition in the community pharmacy market and by customers' unreasonable expectations. At the institutional level, it is easy for community pharmacies to evade the Food and Drug Administration's (FDA) supervision by obtaining unsupervised and fake prescriptions, refusing to give customers sale receipts, and hiding their antibiotic supplies and sale records. At the policy level, the low cost of violating the prescription-only antibiotic sale regulation and poor FDA supervision facilitated NPAD. The Chinese health system has thus failed to establish and regulate a diverse network of pharmacies for patients to fill their prescriptions; few antibiotic prescriptions are transferred from hospitals to community pharmacies. Education campaigns to increase awareness about the risks of self-medication with antibiotics among the general public, recognizable standardize prescriptions for customers to fill their prescriptions in community pharmacies, regulations on Internet and private clinic doctors' antibiotic prescribing behaviors, electronic tracking and tracing system to purchases and sales data of antibiotics and other prescription drugs, increasing cost of violating the prescription-only regulations for antibiotics sales are expected interventions to reduce NPAD.