Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia

Abstract

BackgroundGlobal attention to antimicrobial resistance has increased interest in tackling the widespread inappropriate dispensing of antibiotics by informal, for-profit healthcare providers (HCPs). We provide new evidence on an understudied group of informal HCPs: invisible medicine sellers (IMS) who operate without any marked facility. We investigated factors that influence community decisions on which HCPs to purchase medicines from, focusing on reasons for using IMS, and compared different HCPs’ knowledge of antibiotic use.MethodsWe conducted community focus group discussions (FGDs) in seven purposively selected villages representing high and low informal HCPs use in two peri-urban districts in Phnom Penh, Cambodia. Using information from the FGDs to identify HCPs that sell medicines, we interviewed 35 participants: 21 HCPs (including five IMS) and 14 key informants, including government HCPs and village leaders. We adopted an interpretative approach and conducted a thematic analysis.ResultsCommunity members typically knew of several formal and informal HCPs selling medicines nearby, and IMS were common, as were doctors that sell medicines covertly. Two factors were most salient in influencing the choice of HCP for medicine purchasing. The first was trust in the effectiveness of medicines provided, judged by the speed of symptomatic relief. This pushed HCPs to provide several medicines, including antibiotics, at the first consultation. The second was the convenience offered by IMS and other informal HCPs: supplying medicines when other facilities are closed, accepting delayed payments, providing incomplete courses of medication and selling human antibiotics for animal use.ConclusionThis first study focusing on IMS indicates that it is important, but challenging, for public health agencies to engage with them to reduce inappropriate use of antibiotics. Although public health facilities must fill some gaps that informal HCPs are currently addressing, such as access to medicines at night, reducing demand for unnecessary antibiotics is also critical.

Combating Antimicrobial Resistance in Singapore: A Qualitative Study Exploring the Policy Context, Challenges, Facilitators, and Proposed Strategies

“…In Singapore, vested interests were mentioned among pharmaceutical companies in marketing for higher sales of their antibiotics for their own profits; among private practitioners as they make substantial profits when dispensing antibiotics; and among some veterinarians who prescribed antibiotics even when not clinically needed. Our previous research in other settings (i.e., Pakistan and Cambodia) also suggested several considerations and vested interests around antibiotic use which can hinder the control of AMR in the human and animal health sectors [29,30]. For example, it was reported that among doctors there are monetary incentives to prescribe certain antibiotics as these are often negotiated with pharmaceutical companies.…”

“…Third, the AMR policy context represents a policy arena where certain groups engage in "behaviors" that might conflict with the overall goal of controlling AMR. Vested interests are more noticeable than in other health policy areas since different professional groups coexist in the AMR policy arena and there is substantial profit to be made from selling antibiotics [29,30]. In Singapore, vested interests were mentioned among pharmaceutical companies in marketing for higher sales of their antibiotics for their own profits; among private practitioners as they make substantial profits when dispensing antibiotics; and among some veterinarians who prescribed antibiotics even when not clinically needed.…”

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

“…The implicit and critical assumption behind this strategy is that qualified HCPs will prescribe or dispense antibiotics responsibly and that directing patients towards qualified HCPs, and away from unqualified HCPs, will reduce inappropriate use of antimicrobials [15]. However, when HCP professionalism is lacking, boundaries between qualified HCPs and unqualified providers can be blurred [17,18]; for example, qualified providers may routinely fail to follow treatment guidelines [19] or regulations around prescribing [20], and informal providers may demonstrate more empathy towards patients than qualified HCPs [17,21]. We therefore hypothesise that weaknesses in the professionalism of HCPs-including doctors, pharmacists, and nurses-will have an impact on inappropriate use of antibiotics, and we investigate this in two LMIC, Pakistan and Cambodia.…”

Diarrhoea Management using Over-the-counter Nutraceuticals in Daily practice (DIAMOND): a feasibility RCT on alternative therapy to reduce antibiotic use

“…Despite the limited benefit and potential harm from antibiotic use, acute diarrhoea is commonly treated with antibiotics in low- and middle-income countries (LMICs) [ 4 – 6 ]. Recent audits demonstrate that antibiotics are currently the standard treatment in many places in China [ 5 ]. There is a clear relationship between excessive antibiotic prescribing and antibiotic resistance [ 7 , 8 ], which is a major threat to public health as new antibiotic drug development takes a long time and requires very significant investment [ 9 ].…”