The current AMR landscape in China and how the healthcare systems and national action plan operate in practice
– by Tao Chen and Yonghong Xiao

The views and opinions expressed in this article are solely those of the original author(s) and do not necessarily represent those of GARDP, their donors and partners, or other collaborators and contributors. GARDP is not responsible for the content of external sites.

The global crisis of antimicrobial resistance (AMR) represents one of the most significant threats to modern public health, and China, given its massive population and vast healthcare network, plays a pivotal role in the global fight. The current landscape of AMR management in China is defined by a sophisticated interplay between an evolving National Action Plan and a robust, rapidly modernizing healthcare delivery system. This synergy is not merely theoretical; it is operationalized through specific legislative frameworks, surveillance networks, and reimbursement policies designed to curb resistance while fostering innovation.

AMR landscape in China: Curbed rising trend

Complementing this extensive healthcare infrastructure is a comprehensive surveillance network that tracks the real-world impact of these policies. Current epidemiological data derived from these systems, indicates a shifting dynamic in the resistance landscape. In recent years, the detection rates of various resistant germs have tended to stabilize, suggesting that the aggressive stewardship measures are beginning to yield results. For instance, data from the Blood Bacterial Resistance Investigation Collaborative System (BRICS) revealed that the detection rate of carbapenem-resistant Acinetobacter baumannii (CRAB) stabilized at approximately 60% between 2018 and 2022, while that of carbapenem-resistant Klebsiella pneumoniae (CRKP) decreased from 20% to 15%.^1,2 Similarly, the China Antimicrobial Resistance Surveillance System (CARSS) reported that CRAB detection rates stabilized at approximately 55%, with CRKP rates remaining at 10% during the 2018–2024 period.³ However, it is important to acknowledge a limitation regarding the granularity of current surveillance. Specific data on AMR prevalence and antimicrobial stewardship (AMS) compliance at the primary care level remain scarce.

However, this stability masks significant heterogeneity across different regions and hospital tiers. Surveillance data reveals that the prevalence of resistant Gram-negative bacteria varies significantly by geography. Furthermore, a distinct disparity exists between hospital levels; provincial hospitals consistently report higher detection rates of critical resistant strains, such as ESBL-producing Escherichia coli, CRAB, and CRKP, compared to prefecture-level hospitals.⁴ This phenomenon is not merely a statistical anomaly but reflects fundamental differences in clinical ecology. Several domestic studies suggest that the elevated resistance rates in provincial (tertiary) hospitals are primarily driven by the concentration of patients with complex case-mixes and severe underlying comorbidities, who often require prolonged hospitalization and broad-spectrum antibiotic therapy.^4,5 Additionally, the higher frequency of invasive procedures in these top-tier centers imposes a greater selection pressure for multidrug-resistant organisms. Variations in infection control standards and prescribing behaviors across different hospital tiers may also contribute to this gradient. This suggests that while the national trend may be stabilizing, the burden of resistance remains heavily concentrated in top-tier medical centers where the most complex cases and invasive procedures occur. Consequently, while the surveillance systems have successfully mapped the battlefield, they also highlight that the “war” against AMR is far from over, requiring continued vigilance and targeted interventions in high-risk medical settings.

National Action Plans: Integrated concept of One Health

The foundation of China’s response lies in the strategic evolution of its National Action Plans. The initial plan, launched in 2016,⁶ established the essential framework for joint prevention and control, focusing on broad goals such as strengthening the Antimicrobial Stewardship (AMS) system. However, recognizing the dynamic nature of microbial threats, China released an updated National Action Plan in 2022.⁷ This second version marks a significant strategic shift from general containment to “prevention first.” It explicitly targets the reduction of infection incidence to lower the demand for antimicrobials in the first place. The 2022-2025 plan is characterized by its quantifiable ambition; it sets rigorous targets, such as achieving an 80% awareness rate regarding the rational use of antimicrobials among the public and ensuring 100% prescription-based sales of antibiotics in pharmacies. Furthermore, it integrates the “One Health” approach by mandating a decrease in resistant microorganisms across both human, animal and environment sectors, acknowledging that AMR is an ecological issue as much as a medical one.

Beyond epidemiological data, infrastructure alone cannot solve AMR; economic incentives must also be aligned. This is where China’s healthcare insurance system acts as a powerful regulatory lever.

In practice, this cross-sectoral integration has seen tangible progress. In the livestock sector, China has enforced a comprehensive ban on the use of antibiotics as growth promoters in feed since 2020,⁸ alongside the “Veterinary Antimicrobial Reduction Action” to curb therapeutic misuse. Concurrently, environmental stewardship is being strengthened through the National Action Plan for Prevention and Control of Water Pollution,⁹ which establishes monitoring networks for antibiotic residues in surface water and sewage. However, challenges remain in standardizing waste disposal from breeding farms and refining real-time environmental surveillance data.

Healthcare systems: Antimicrobial stewardship taking a core role

To translate these high-level strategies into practice, China leverages its immense healthcare infrastructure. By 2024, the country operates over 40,000 hospitals with more than 8 million beds, handling a staggering volume of patient visits, over 83% of which occur in public hospitals. This centralized nature of public healthcare facilitates the enforcement of national mandates. The sheer scale of the workforce, 4.724 million physicians and over 5.63 million registered nurses as of 2023, provides the manpower necessary for implementing AMS (Antimicrobial stewardship) protocols. Crucially, AMS was already set as one of the core regulations in hospital operation, and the system is not limited to tertiary urban centers; approximately 1.1 million physicians are rooted in rural and community grassroots areas. This “core network” is vital for the 2022-2025 Action Plan’s goal of improving surveillance and rational drug use at the primary care level, ensuring that AMR containment is not just a policy in major cities but a practice across the vast countryside.

Healthcare Insurance: Guarantee access and incentive innovation

Beyond epidemiological data, infrastructure alone cannot solve AMR; economic incentives must also be aligned. This is where China’s healthcare insurance system acts as a powerful regulatory lever. China has established the world’s largest basic medical insurance network, covering over 95% of its population. The transition of the National Reimbursement Drug List (NRDL) demonstrates how financial mechanisms are being used to support the AMR agenda. The NRDL structure, updated annually, categorizes drugs to balance accessibility with cost-control.¹⁰ Category A drugs are fully covered, ensuring access to essential treatments, while Category B requires partial patient payment.

The current landscape of AMR management in China is defined by a sophisticated interplay between an evolving National Action Plan and a robust, rapidly modernizing healthcare delivery system.

Most significantly, the system is evolving to support the R&D targets set out in the National Action Plan. The 2022-2025 plan aims to develop 1-3 new antimicrobials and 5-10 new diagnostic technologies. To make this viable, the 2026 NRDL (effective January 1, 2026) introduced Category C, specifically designed for innovative, high-cost treatments. By creating a pathway for commercial health insurance reimbursement for these novel therapies, the state is encouraging the pharmaceutical industry to invest in the “superbugs” that older antibiotics can no longer kill. This creates a sustainable ecosystem where the government controls resistance through strict regulation (Category A and B management) while simultaneously incentivizing the creation of next-generation solutions (Category C).

In practice, the operation of these systems is monitored through rigorous surveillance. The National Action Plan mandates the improvement of monitoring systems for both healthcare and animal sectors. This is supported by the professionalization of the workforce, with targets set for over 80% knowledge accuracy among professionals regarding AMR. The integration of AMR education into primary and secondary school curriculums further suggests a long-term cultural shift, moving beyond immediate clinical interventions to shape a society that understands the value of antibiotics.

References

1. Chen Y, Ji J, Ying C, et al. Blood Bacterial Resistant Investigation Collaborative System (BRICS) Study Group. Blood bacterial resistant investigation collaborative system (BRICS) report: a national surveillance in China from 2014 to 2019. Antimicrob Resist Infect Control. 2022;11(1):17.
2. Ji J, Liu Z, Ying C, et al. (2026) 2024 national bloodstream infection bacterial resistance surveillance (BRICS) report: Gram-negative bacteria. Chin J Clin Infect Dis (Chinese). 19(1): 1-16.
3. China Antimicrobial Resistance Surveillance System. (2026) 2023 and 2024 national bacterial antimicrobial resistance surveillance report. Chin J Infect Control (Chinese), 25(4): 463-488.
4. China Antimicrobial Resistance Surveillance System. (2025) Antimicrobial resistance of bacteria from different grades of hospitals: surveillance report from China Antimicrobial Resistance Surveillance System, 2020-2024. Chin J Infect Control (Chinese), 2025, 24(12): 1717-1734.
5. Pei N, Liu Q, Cheng X, et al. Longitudinal Study of the Drug Resistance in Klebsiella pneumoniae of a Tertiary Hospital, China: Phenotypic Epidemiology Analysis (2013-2018). Infect Drug Resist. 2021;14:613-626.
6. National Health Commission of the People’s Republic of China. (2016) National action plan on controlling bacterial resistance (2016-2020). (Chinese) Accessed 27 August 2026.  
7. National Health Commission of the People’s Republic of China. (2022) National action plan on controlling antimicrobial resistance (2022-2025).  (Chinese) Accessed 27 August 2026. 
8. Ministry of Agriculture and Rural Affairs of the People’s Republic of China. Announcement No. 194 of the Ministry of Agriculture and Rural Affairs of the People’s Republic of China. 2019. (Chinese) Accessed 27 August 2026. 
9. State Council of the People’s Republic of China. (2015) Notice of the State Council on printing and distributing the action plan for prevention and control of water pollution. (Chinese) Accessed 27 August 2026.  
10. National Healthcare Security Administration. (2025) Announcement on the Adjustment Results of the National Medical Insurance Drug Catalog for 2025 (2026 Edition). Gazette of the State Council of the People’s Republic of China. (Chinese)