Ineffective' generic drugs fuel rare public anger in China

Recently, widespread anger has erupted among the Chinese public over the perceived declining efficacy of inexpensive generic drugs used in public hospitals, prompting a rare government response. Doctors argue that the current drug procurement system, which encourages the use of cheap generics over branded drugs, leads pharmaceutical companies to sacrifice patient safety in order to cut costs.

However, according to multiple Chinese state media reports on Sunday, the official response claims that this is more of a "perception" issue than a reality. One report stated that people react differently to medications and that claims of drug ineffectiveness "mainly come from people's anecdotes and subjective feelings." This official response has failed to effectively alleviate public concerns about the quality of medicines in public hospitals and pharmacies. This undoubtedly presents yet another challenge to a healthcare system already under immense pressure due to a rapidly aging population.

The controversy surrounding the use of generic drugs began last December when officials released a list of nearly 200 companies that had won bids to supply drugs to Chinese public hospitals, almost all of which were domestic generic drug manufacturers. The controversy intensified further in January when the head of a department at a Shanghai hospital voiced concerns about the drug procurement system in a widely circulated video interview. Dr. Zheng Minghua listed problems including "antibiotics causing allergies, blood pressure not being lowered, anesthetized patients unable to fall asleep," and laxatives that had no effect.

Dr. Zheng Minghua's words immediately resonated and were distilled into a slogan that has been widely circulated on social media, viewed millions of times over the past month – although much of the discussion on the topic has since been censored on Weibo. Many people have come forward to share their own negative experiences with suspected substandard drugs. One Weibo user wrote: "I had intestinal surgery in 2024 and needed to take laxatives in advance." They stated that the medication they took "had no effect whatsoever," and even after doubling the dose, they had to resort to drinking coffee to help with bowel movements. Concerns about the efficacy of generic drugs have led to distrust and made some unwilling to use them.

One user on Xiaohongshu, a Chinese version of Instagram, said that when a hospital doctor prescribed her generic antibiotics, she immediately went online to buy the "original brand-name drug" because the generic "tasted different." The user warned: "Many people have colds recently. Many of them may have bought this medicine. Hurry up and remind your friends to check the brand before buying." Some popular posts discussing the procurement controversy have been deleted, but it is unclear who removed them. On China's heavily monitored internet, both authorities and users themselves have a strong culture of censorship. In a strongly worded, now-deleted post, prominent podcast host Meng Chang slammed the lack of imported drugs in the public sector: "If this isn't the bottom line, I don't know what is." Public anger has also focused on the difficulty of obtaining imported drugs that they believe are of better quality. Responding to official attempts to reassure people about the quality of generic drugs, one Weibo user wrote: "As long as we are allowed to buy brand-name drugs ourselves, I have no other complaints."

The drug procurement system, launched in 2018 to reduce national spending on medicines, requires local governments to tender for about 70% of the annual drug needs of public hospitals. Pharmaceutical companies then compete to offer the lowest drug prices in order to win these lucrative contracts. This gives an advantage to domestically produced generic drugs, which contain the same active pharmaceutical ingredients as off-patent brand-name drugs, but are typically much cheaper to produce because they do not include high research and development costs. China has become one of the largest players in the global generic drug market, exporting both finished products to foreign consumers and key ingredients to foreign companies. Domestically, thousands of generic drug manufacturers compete to sell their products at competitive prices to capture a share of the expanding domestic market.

In order for generic drugs to qualify for China's procurement process, they must be tested and determined to be sufficiently similar to brand-name drugs. Beijing says the drug procurement system has saved millions of residents more than $50 billion (£40 billion) in its first five years. But the procurement process has also seen some pharmaceutical companies offer drugs at extremely low prices. One project that won a bid last December was for aspirin tablets, priced at less than 1 cent. "Can you eat a pill that costs less than 1 cent?" became a trending topic on Weibo at the time. Zhang Sidi, an associate professor at NYU Langone Health, told the BBC: "The manufacturers who win the bids often set the price so low that they may have difficulty producing high-quality drugs containing the correct ingredients, which may lead to ineffective drugs." She added that while the procurement system is "not designed to limit access to imported brand-name drugs," it may still "affect their accessibility."

Last month, 20 doctors, including Dr. Zheng Minghua, submitted a proposal to Shanghai authorities stating that "there is widespread concern in the industry that excessively low procurement prices are prompting unethical companies to cut corners to reduce costs, thereby affecting the efficacy of drugs." "Doctors are helpless because they have no choice and no channels to escalate feedback." Concerns have also been heightened by a recent article published by Hangzhou doctor Xia Zhimin. In the article, he highlighted what he said was suspicious data from trials of generic drugs on the procurement list – data that was identical to that of brand-name drugs. Dr. Xia implied that this may be evidence of fraud. The National Medical Products Administration responded that his findings were due to "editorial errors." His article has been deleted. In addition, counterfeit and substandard medicines, which have infiltrated the global market for both generic and brand-name drugs and are notoriously difficult to detect, have also fueled concerns about quality. The World Health Organization has described this as a global health problem.

Lu Kewen, an associate professor at the University of South Carolina College of Pharmacy, told the BBC: "To improve affordability, it is essential to introduce cost-effective generic drugs." He added that the procurement process needs "strengthened quality control" and "continuous improvement of drug approval and production standards."

The controversy comes at a time when China's healthcare system is already facing increasing pressure. Rapid population aging means that the country's total healthcare spending has increased nearly 20-fold in the past 20 years, reaching 9 trillion yuan ($1.25 trillion; £1 trillion) in 2023. Across the country, public health insurance funds are becoming increasingly strained. Some provinces have already experienced deficits, and these provinces' local governments, which rely heavily on land sales revenue, are now facing debt problems brought on by the real estate crisis sweeping the Chinese economy. At the same time, the healthcare system is also experiencing a crisis of trust. Since the 2000s, there has been an increase in violent attacks against medical personnel, fueled by anger over scarce resources and declining trust in doctors.

Unlike issues deemed politically sensitive and subject to strict censorship by authorities (such as the persecution of political dissidents or the repression of Uyghurs in Xinjiang), the current controversy surrounding drug procurement has at least been acknowledged by the state as an issue that needs to be addressed. The National Healthcare Security Administration issued a statement on January 19 stating that the authorities "attach great importance" to these safety concerns and will solicit opinions on drug procurement policies. The state media outlet Life Times quoted a public health scholar as saying: "It is undeniable that the national centralized procurement is still in its early stages. The production quality of many pharmaceutical companies is uneven." Other experts quoted in the article called for higher drug evaluation standards.

As authorities attempt to salvage the crumbling image of the procurement system, all the censorship now overshadows a system designed to be a win-win: saving lives and saving money. As one Weibo user put it, the money saved by lowering drug prices is only a "drop in the bucket" of China's national healthcare costs. On the other hand, they wrote, allowing potentially substandard drugs to be widely used is tantamount to "drinking poison to quench thirst."