Global healthcare costs are rising rapidly. Notably, the WHO reported $9 trillion in spending in 2020, accounting for 11% of the world’s GDP, and this trend is expected to continue (1). Drug expenditure has always been a significant component of national and individual medical costs (2). Moreover, drug expenditure accounts for 17% of total health spending in higher-income countries, while in lower-middle-income countries, the proportion can be as high as 70% (3, 4). In response to the growing burden of healthcare costs, governments and health organizations worldwide have implemented various strategies to control healthcare costs, including measures to manage drug expenditure (5–7). Empirical studies also repeatedly highlight the significant effectiveness of bulk purchasing in reducing the costs of pharmaceuticals that are successfully incorporated into procurement contracts (8, 9). Many countries, such as India, Brazil, and Denmark, have successfully implemented centralized drug procurement strategies. As such, they achieve notable reductions in drug prices and significant savings in pharmaceutical costs (10, 11). This global trend is evident in China, where pharmaceutical expenditure reached US$169 billion in 2021. In response to the ongoing challenges of limited healthcare accessibility and medication adherence, China introduced the National Centralized Drug Procurement (NCDP) policy in January 2019. This aims to reduce the price of drugs further, alleviate the medication burden for patients, improve drug availability, and deepen public hospital reform.

The first round of the NCDP policy, also known as the “4 + 7” policy, was so named because 11 cities were selected as pilot cities, including 4 municipalities (Beijing, Tianjin, Shanghai, Chongqing) and 7 sub-provincial cities (Shenyang, Dalian, Xiamen, Guangzhou, Shenzhen, Chengdu, Xi’an). This policy implements “volume-based procurement,” meaning that the tenderer (the government) specifies the procurement volume (60–70% of the medicine consumption of all public medical institutions in pilot cities in the previous year) during the bidding. The bidders (pharmaceutical companies) then quote prices according to the specific volume. Furthermore, the pharmaceutical company with the lowest price for each medicine wins the bid. To ensure that domestically produced generic drugs are therapeutically equivalent to their corresponding brand-name versions in terms of quality, safety, and efficacy, the NCDP policy mandates that all centrally purchased generic drugs pass the Generic Consistency Evaluation (GCE), which requires rigorous bioequivalence testing and pharmaceutical quality standardization (12). In order to be bioequivalent, National Medical Products Administration (NMPA) required that the 90%CI of the geometric mean ratio for main pharmacokinetic parameters, the peak concentration and the area under concentration time curve of the product fall entirely within the range of 80.00–125.00% (13). As of 2024, GCE implementation has enabled 10 rounds of centralized procurement, covering 435 drugs that met these equivalence standards (14). Currently, these drugs cover multiple therapeutic areas, such as medications for chronic diseases like metformin (for diabetes) and amlodipine (for hypertension), antitumor drugs including gefitinib (targeted therapy) and oxaliplatin (a chemotherapeutic agent), and antibiotics like cefdinir and meropenem. The policy has demonstrably reshaped China’s pharmaceutical landscape, yielding significant outcomes across multiple dimensions. Empirical evidence indicated: ① a substantial shift toward generic drugs, with their procurement volume share rising from 60.73 to 77.80%, displacing 17.08% of originator drugs (13); ② improved clinical rational drug use, driven by volume guarantees, performance evaluations promoting quality generics (especially GCE-certified in primary care), and financial disincentives reducing high-cost drug overprescribing (12, 13); ③ reduced patient drug burden, exemplified by a 20.75% decrease in inpatient drug expenditures for conditions like lung cancer (15); and ④ enhanced health insurance efficiency. As of the end of 2021, the policy has saved over 260 billion CNY (approximately US$36.3 billion) (12). NCDP policy has significantly reduced healthcare costs and improved drug accessibility. However, its real-world effectiveness ultimately depends on the active participation and precise execution by frontline healthcare professionals (HCPs), including clinicians (physicians, pharmacists, nurses) directly handling medications and administrators responsible for policy operationalization. In this context, HCPs serve as policy implementers and dynamic interpreters. They are also the main executors of the policy, particularly physicians, who play a key role in generic drug use through their central position as decision-makers for pharmacotherapy (16). The policy’s guiding principles encourage physicians to prioritize centrally procured medicines, limiting their prescription options for non-centrally procured drugs and indirectly affecting patients’ medication adherence. As an integral part of the healthcare system, pharmacists are crucial in promoting the generic drug policy. They collaborate closely with physicians to provide professional advice on generic drug selection, dosage, interactions, and side effects. Additionally, they educate and counsel patients during medication dispensing, thereby enhancing physicians’ acceptance of centrally procured drugs (17). To ensure the effective execution of the policy, relevant departments have introduced implementation opinions and measures to deepen the reform of centralized drug procurement and to establish a national public drug procurement market (18). Therefore, understanding the perceptions and practices of healthcare professionals regarding the NCDP is crucial for optimizing drug usage and ensuring the success of the policy.

Knowledge, attitude, and practice (KAP) surveys serve as an effective instrument for exploring health behaviors and the ways people seek healthcare (19). Previous studies (17, 20) have evaluated the KAP of generic substitution in China among HCPs in different regions. Moreover, researches (21, 22) have shown that the prices of drugs selected in centralized procurement across China are inversely related to economic development. Economically advanced eastern regions, which enjoy more convenient transportation, denser populations, and higher medication demand, are typically more likely to be chosen by enterprises offering lower prices. In contrast, less economically developed areas with lower drug demand are more likely to be selected by higher-priced enterprises. Given that Shaanxi Province, located in northwest China, has a diverse economic profile with both developed and developing regions, assessing the KAP of HCPs in Shaanxi regarding the centralized drug procurement policy is essential.

The current study aimed to assess the KAP of HCPs regarding the NCDP policy in northwestern China. Compared to a previous study (20) conducted in central China, which found that only a small percentage of HCPs had good KAP toward the NCDP policy, our findings indicated that HCPs in Shaanxi have a better KAP level. Notably, this suggests varying levels of comprehension and involvement with the policy among participants.

To begin with, the average knowledge score suggested a moderate awareness among HCPs, indicating a general understanding but potentially lacking in-depth knowledge of the policy’s details. Only about half of the respondents agreed that the clinical efficacy and safety of original and generic drugs are identical. Similarly, many respondents acknowledged unfamiliarity with the identifier for drugs that have passed the GCE. As such, these findings suggested that HCPs have reservations about the quality of generic drugs. Recently, during the Shanghai “Two Sessions,” several medical experts have raised concerns that some centrally procured drugs may pose quality risks (30). The skepticism surrounding generic drugs stems from a lack of trust in the quality evaluation standards of these medications. This was mirrored in the survey findings, which indicated that only slightly over half of the respondents (55.8%) claimed to be aware of or had seen the consistency evaluation mark. Moreover, the substantially lower prices of generic drugs listed in the centralized procurement catalog, compared to their original counterparts, might contribute to this perception, leading some to equate price with quality.

Overall, attitudes toward the NCDP policy were generally positive, with the majority of respondents agreeing on its public benefit, signifying a recognition of the policy’s potential to enhance affordable medication access (31). However, the finding that only a small proportion strongly agreed that the NCDP policy helps to reduce the medical burden on patients indicated that there may be hesitations about the policy’s impact on patient welfare. The main reasons for this hesitation might be doubts about the quality of generic drugs, and some medical staff were also dissatisfied with the therapeutic effects of the centralized procurement of drugs (32). Although the GCE system has demonstrated pharmaceutical equivalence through in vitro pharmaceutical studies (e.g., dissolution profiles, bioavailability of active ingredients), the therapeutic equivalence in clinical practice requires further validation with real-world evidence. It should also be noted that current evaluation criteria primarily focus on critical quality attributes of active pharmaceutical ingredients (17) while potentially overlooking the impact of excipient variations in complex formulations (e.g., sustained-release dosage forms and inhalation preparations). Due to patent protections or trade secret restrictions on proprietary excipient compositions of originator drugs, generic manufacturers face challenges in achieving complete replication (33). Such discrepancies may lead to differences in release kinetics or local absorption efficiency, affecting therapeutic outcomes or safety profiles (34). Furthermore, the existing evaluation framework inadequately addresses systematic assessments of long-term stability, pharmacokinetic characteristics in special populations (e.g., patients with hepatic/renal impairment) (35), and rare adverse reactions. These limitations may contribute to HCPs’ reservations regarding the reliability of consistency-evaluated generic drugs. Our study revealed nuanced differences in attitudes toward the NCDP policy among various occupational groups of HCPs, particularly between pharmacists and physicians, underscoring profession-specific factors that sway policy acceptance. This pattern can be explained by role specialization; pharmacists, as medication supply chain managers, directly observe the impact of NCDP on drug accessibility and cost reduction. Higher education likely enhances their understanding of the policy’s design and long-term benefits. Additionally, workflow integration plays a key role, as pharmacists’ responsibilities in inventory management and shortage reporting align closely with NCDP objectives, fostering a sense of ownership and acceptance.

This finding also suggested that training effectively addresses the knowledge-attitude gap by bridging the critical information deficit physicians face in clinical decision-making, which relies heavily on drug efficacy and safety data, through providing evidence on generic equivalence and quality safeguards. Furthermore, training serves as a behavioral nudge by clarifying the availability of clinical flexibility, such as permitting the use of non-selected drugs under specific conditions, thereby reducing perceived constraints on clinical practice. These divergent patterns carry significant policy implications: pharmacists are well-positioned as NCDP advocates, and utilizing their expertise in supply chain coordination could enhance policy implementation. Meanwhile, physicians require targeted education to address therapeutic concerns, and mandatory training that incorporates real-world evidence, such as post-marketing studies of selected drugs, may bolster trust in the policy.

In terms of practicality, the mean score indicated that there is room for improvement in the implementation of the NCDP policy. The fact that only a minority of HCPs always or often actively follow the update of the NCDP catalog suggested a potential gap in staying informed about policy changes, which is crucial for effective policy implementation. Additionally, the finding that only about half of the HCPs would consider using centrally procured drugs for themselves or their families is disappointing, given the policy’s emphasis on affordability and accessibility. However, as the variety and coverage of these drugs continue to expand, we believe this proportion will gradually increase. Importantly, this result highlighted a significant gap in the consistent adoption of the policy across the board. The rapid frequency of updates in the centralized procurement policy poses difficulties for doctors in keeping track of policy changes in real-time (36). Work experience emerged as a significant factor influencing practice levels, while participation in training demonstrated a strong association with enhanced practice behaviors. These findings underscore the value of hands-on experience in policy implementation and highlight how targeted training can effectively bridge the gap between theoretical knowledge and practical application, thereby optimizing the execution of policy-related tasks.

The concerns of HCPs regarding the NCDP policy reflect the priorities and potential reservations, with the leading issues being guaranteeing medicine quality, strengthening clinical outcomes research, and strengthening monitoring of adverse reactions. These concerns are valid and must be addressed to ensure the successful implementation of the policy. Notably, future research should focus on several key areas. Firstly, high-quality clinical evidence is needed to evaluate the efficacy and safety of centrally procured drugs, especially in real-world settings. This will help to build confidence among HCPs and patients regarding the quality of these medications. Secondly, studies should explore the long-term impacts of the NCDP policy on patient outcomes and healthcare costs, providing a comprehensive assessment of its effectiveness. Thirdly, research should investigate the barriers to policy implementation from the perspectives of HCPs, patients, and policymakers and identify strategies to overcome these challenges. Additionally, the development of robust monitoring systems for adverse drug reactions is crucial to ensure patient safety and enhance the credibility of the policy. Similarly, targeted training is imperative to strengthen HCPs’ policy endorsement and implementation fidelity, with a priority focus on therapeutic effectiveness and safety evaluation. By clarifying bioequivalence certification methodologies (e.g., pharmacokinetic criteria) and quality assurance mechanisms, such education directly addresses the clinical concerns that hinder adherence to drug substitution, thereby turning evidence gaps into actionable competence.

This study benefits from a large, diverse sample across multiple healthcare settings, enhancing its generalizability within similar contexts. The rigorous questionnaire validation and high response rate strengthen this study’s reliability. However, this study also had several limitations. Firstly, the limitations include its cross-sectional design, which precludes causal inferences, and potential selection bias due to convenience and snowball sampling. Secondly, self-reported data may also introduce social desirability bias, particularly in attitude and practice assessments. Thirdly and importantly, the study participants were exclusively drawn from HCPs in public hospitals, excluding those from primary healthcare institutions. Future research should focus on primary healthcare institutions, as they play a vital role in the healthcare system and provide unique insights not captured in the current study. Additionally, the focus on Shaanxi Province—a region with higher GDP and healthcare infrastructure—may limit extrapolation to less-developed areas in China. Also, future studies with larger samples should explore finer subgroup stratifications (e.g., by pharmacy type, institutional context) to uncover additional determinants.

This study investigated healthcare professionals’ KAP regarding China’s NCDP policy in Northwest China. Key findings revealed moderate but suboptimal overall KAP levels, with only 58.4% demonstrating adequate knowledge, 63.2% holding positive attitudes, and 35.2% exhibiting good practices. Pharmacists significantly outperformed physicians across all KAP domains due to their specialized drug management training and policy-aligned roles, while training attendance consistently predicted enhanced KAP across occupational groups. Despite the general acknowledgment of the policy’s public health benefits, concerns about generic drug quality and therapeutic equivalence, particularly regarding clinical efficacy and safety, have persistently emerged as central barriers to its implementation. Significant KAP variations across professions, education levels, and work experience underscore the need for tailored interventions: evidence-based medicine training for physicians to address therapeutic equivalence concerns, drug management protocols for nurses, and targeted educational campaigns reinforcing generic drug quality assurance. To optimize the integration of NCDP policies into healthcare systems, strengthening real-world evidence generation and implementing profession-specific strategies are crucial. Tailored strategies can enhance the effectiveness of NCDP policies and increase their acceptance among healthcare professionals, thereby ensuring the policies’ successful integration.