Title: Addressing pharmacy practice in low and middle income settings in an era of antibiotic resistance
Funder: Economic and Social Research Council

Abstract: The five main objectives of this fellowship are to: 1. Publish two additional results papers from my PhD 2. Take forward a practical recommendation from the PhD by engaging with the authoritative global health organisations in the subject area. 3. Undertake advanced training in econometrics to improve my research capabilities. 4. Develop a funding proposal emerging from the PhD investigating how a regulatory framework using hierarchies of drug control may be used to curb the rampant overuse of antibiotics at pharmacies in low and middle-income countries. 5. Successfully apply for promotion to an Assistant Professor position within my current institution.

Lay abstract: During this fellowship, I aim to publish two further research papers. The first will present data on prices of encounters at both chain and independent pharmacies, and the socioeconomic status of customers patronising these two different pharmacy types (no prior research has been published on this area). The second paper will pool quality of care data from both chain and independent pharmacies to provide a complete picture of how childhood diarrhoea is managed at pharmacies in the urban Indian setting. My second objective for the fellowship is to mobilise support at the global level for the creation of pharmacy-specific guidelines for the management of key conditions. This was a specific, practical recommendation from my PhD, which highlighted the lack of such guidelines for childhood diarrhoea. I have already started to develop my contacts with a network of key players in the field of medicine use, and with the International Federation of Pharmacists, and have received considerable support for taking this idea forward. Many of these individuals already serve as policy entrepreneurs within countries, where they are well-networked and respected and thus can help to shape the policy direction of this field. Following further interaction through networking and consultation, I plan to lead on a 'call to action' paper (with the backing of key individuals and organisations), which would state the need for such guidelines, propose what they might cover, and give thought to what the process of producing them would look like. During the course of my PhD I undertook training in quantitative methods, namely statistic courses provided at the LSHTM, in order undertake my analyses. This fellowship would enable me to further improve my quantitative skills through advanced training in econometrics. I believe the UCL 'econometrics for health' course would particularly enhance my skills as an early career researcher. Finally, I propose to use the fellowship to develop a funding proposal in order to investigate how novel regulatory approaches involving hierarchies of drug control may be used in LMICs to curb the overuse of antibiotics. Antibiotic resistance is widely recognised as a leading threat to the public's health, globally. Antibiotic use is a main driver of selection pressure that leads to resistance, yet this class of medicines continue to be amongst the world's most highly purchased. Promoting antibiotic stewardship in the community, encompassing pharmacies, has been identified as a key area for action. Applying an economic analysis lens to the problem of antimicrobial resistance will likely play an important role in the study of this growing problem, shedding light on both supply and demand in these dynamic markets. Further, given the externalities associated with antibiotic misuse, improving both the design and implementation of effective regulation surrounding the provision of antibiotics will be paramount. This line of enquiry was sparked by a result from my PhD: although the illegal sale of (often inappropriate) antibiotics over the counter was widespread, pharmacy staff were found to follow better practice with respect to 'H1 medicines'. These are a category of medicines that were introduced (in India) in 2013 in response to growing concerns over antibiotic resistance. The H1 medicine list is comprised mainly of antibiotics (novel classes and anti-tuberculosis drugs) and medicines on the list are subject to additional regulatory controls. In the case of H1 medicines, pharmacy staff were found to be tightly bound by implicit norms that restrict the use of such medicines. The idea that not all antibiotics are equal is an important one, and the potential of using different levels of drug control for different medicines is yet to be explored. New thinking in regulatory theory, such as risk-based and response regulation, will be used to inform this area of study.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE
Health categories: INFECTION