Mapping the Antimicrobial Supply Chain in Bangladesh: A Scoping-Review-Based Ecological Assessment Approach

A standardized method for evaluating antimicrobial supply chains in the context of access and use could be a useful tool in assessing national capacity to implement programs that address antimicrobial resistance. We present both a novel ecological approach comprising mapping and the use of indicators that can be used to characterize national antimicrobial supply chains as well as benchmark countries and, for the first time, a country-level assessment of Bangladesh. Key Messages This framework proposes a novel method for antimicrobial medicines supply chain mapping using 16 indicators with a focus on access and use in the context of antimicrobial resistance containment. Countries, especially low- and middle-income countries, can apply this framework to rapidly assess supply chain gaps and to identify areas for targeted interventions on access and use of antimicrobials. Bangladesh’s antimicrobial supply chain was profiled, identifying strengths in ensuring access to antimicrobials and gaps in use and regulation. Key Implications Policy makers, program managers, and Antimicrobial Resistance Containment One-Health Secretariat committees could use this framework to perform a rapid situational analysis (strength, weakness, opportunities, and threats) of the antimicrobial/antibiotic supply chain for human and veterinary medicines at the national level to identify target areas for intervention. This can include policy interventions via restrictions on licensing of certain antibiotics of critical importance to humans, as Bangladesh is doing with colistin. Through an analysis of the brief market dynamics presented here, program managers can make assessments of supply risks. Regulators could use the mapping to identify geographical regions with high pharmacy densities for more targeted inspections for medicines quality assurance. One-Health Secretariat committees could use professional densities numbers to advocate for more training and capacity building for pharmacists and veterinarians. ABSTRACT Introduction: Maintaining access to antimicrobials while preventing misuse is essential to combating the threat of antimicrobial resistance (AMR). The study objectives are to propose a framework of 16 indicators that can be used at the national level to assess the capacity to ensure access and curtail inappropriate use and to profile the antimicrobial supply chain for Bangladesh. Methods: Using a framework based on a rational construct, we assessed the antimicrobial supply chain of Bangladesh, with a focus on key players and products using a scoping review to obtain and describe information on 16 indicators. With players, we mapped linkages, manufacturers’ production capacity, and ownership, among others, and demand point characteristics—pharmacy and pharmacist density, pharmacy/medicine outlets dispersion, veterinary clinic/hospitals, veterinarians’ density, product quality, and regulation. We assessed product characteristics including listing on the World Health Organization (WHO) Model Essential Medicines List (EML) and WHO Access, Watch, and Reserve (AWaRe) classification of the major (top 10) antibiotics for human use; the proportion of medically important antimicrobials (MIAs) in veterinary use; and pricing. Production capacity and price controls were used to assess access and listing on the WHO EML, AWaRe/MIA classification, and a calculated pharmacy-to-pharmacist ratio to assess use. Results: Bangladesh has a high (98%) local antibiotic production capacity with pricing controls indicating the ability to ensure access. The presence of a high proportion of medicine outlets not under the control of pharmacists (4:1) and the high percentages of WHO Watch (54%) and MIAs (90%) of the major antibiotics are indicators of possible misuse. Discussion: Most of the data used in the framework were publicly available. Bangladesh has the capacity to ensure access but needs to strengthen its ability to regulate the quality of antimicrobials and prevent their inappropriate use through antimicrobial stewardship at the community (medicine outlet) levels to check AMR. There may also be a need for more regulations on licensing of MIAs.