Access to antibiotics: not a problem in some LMICs
Authors: Giorgia Sulis, Sumanth Gandra
Journal: The Lancet Global Health (2021)

Poor access to antibiotics is estimated to cause substantial morbidity and mortality due to pneumonia and acute febrile illness among children younger than 5 years, with most of these events happening in low-income and middle-income countries (LMICs).1Laxminarayan R Matsoso P Pant S et al.Access to effective antimicrobials: a worldwide challenge.Lancet. 2016; 387: 168-175Summary Full Text Full Text PDF PubMed Scopus (504) Google Scholar However, a study set in eight LMICs showed that children received around 25 antibiotic prescriptions for respiratory tract infection or fever during their first 5 years of life, and most of these prescriptions were deemed inappropriate.2Fink G D'Acremont V Leslie HH Cohen J Antibiotic exposure among children younger than 5 years in low-income and middle-income countries: a cross-sectional study of nationally representative facility-based and household-based surveys.Lancet Infect Dis. 2020; 20: 179-187Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar This conflicting finding calls for better understanding of issues surrounding antibiotic access and use in LMICs, because these countries simultaneously face high burdens of antimicrobial resistance.3O'Neill J Tackling drug-resistant infections globally: final report and recommendations. Review on Antimicrobial Resistance.https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdfDate: 2016Date accessed: February 23, 2021Google Scholar In The Lancet Global Health, Thi Thuy Nga Do and colleagues4Do NTT Vu HTL Nguyen CTK et al.Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach.Lancet Glob Health. 2021; (published online March 10.)https://doi.org/10.1016/S2214-109X(21)00024-3Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar elucidate the complexities of community-based antibiotic use through a combination of individual interviews, focus group discussions, household surveys, and customer exit questionnaires involving both community members and suppliers.4Do NTT Vu HTL Nguyen CTK et al.Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach.Lancet Glob Health. 2021; (published online March 10.)https://doi.org/10.1016/S2214-109X(21)00024-3Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar This mixed-method study was done in seven communities in six LMICs in Asia (Bangladesh, Thailand, and Vietnam) and Africa (Ghana, Mozambique, and South Africa), thus allowing identification of key differences across contexts. A higher density of antibiotic suppliers was observed in the Asian countries than in the African countries, with private providers accounting for more than 90% of mapped suppliers in all three. The proportion of households that reported antibiotic use during the previous month was also much higher in Asian countries (498 [49·4%] of 1009 in Bangladesh, 465 [42·3%] of 1100 in Ghana [Kintampo], 263 [31·1%] of 847 in Ghana [Dodowa], 161 [25·2%] of 639 in Mozambique, 63 [10·2%] of 616 in South Africa, 294 [27·9%] of 1053 in Thailand, and 416 [45·0%] of 925 in Vietnam). It was common for patients to purchase antibiotics without prescription in Ghana (36·1% of purchases), Bangladesh (45·7%), and Vietnam (55·2%), but not in Mozambique (8·0%), Thailand (3·8%), or South Africa (1·2%). The main reasons that participants gave for their choice of antibiotic provider for mild conditions were convenience, trust, costs, and disease severity, and strong enforcement of regulations also affected participant knowledge of purchasing restrictions and whether treatment was sought from private suppliers. Hence, drug stores—which are the easiest, least expensive, and most timely way to obtain antibiotics in many Asian countries—frequently constitute the first point of care for both adults and children. Where drug sellers are less common, and where antibiotic prescriptions are tightly enforced, as is the case in South Africa, or where antibiotics are more costly, as in Mozambique, participants reported a lower consumption of antibiotics than those in other settings, especially for mild conditions that probably do not need antimicrobial treatment. Broad-spectrum antibiotics belonging to the Watch group of the WHO AWaRe classification accounted for more antibiotic sales in Bangladesh and Vietnam as compared with other sites. The study findings provide novel insights into access to antibiotics among mainly rural communities in six LMICs. As Do and colleagues point out, access to medically necessary antibiotics is not a problem across rural and urban or suburban communities in Asia where their study took place. Moreover, the liberal dispensation of Watch-group antibiotics in rural communities in Bangladesh and Vietnam is concerning. Although the generalisability of results beyond the study sites needs to be further explored, these findings bring the adverse outcome estimates attributable to reduced access to antibiotics in LMICs into question.1Laxminarayan R Matsoso P Pant S et al.Access to effective antimicrobials: a worldwide challenge.Lancet. 2016; 387: 168-175Summary Full Text Full Text PDF PubMed Scopus (504) Google Scholar These estimates were based on the assumption that poor access to antibiotics explained all cases of undertreatment with antibiotics for acute febrile illness among children, when in fact a substantial proportion was due to either diagnostic difficulty or diagnostic capacity.1Laxminarayan R Matsoso P Pant S et al.Access to effective antimicrobials: a worldwide challenge.Lancet. 2016; 387: 168-175Summary Full Text Full Text PDF PubMed Scopus (504) Google Scholar However, increased access to antibiotics does not necessarily mean better quality of care.5Bielicki JA Fink G Measuring antibiotic use in children: piecing together the puzzle.Lancet Glob Health. 2020; 8: e742-e743Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Drug sellers are erroneously seen as the best response to people's needs when they might even contribute to poorer outcomes for both the individual (eg, incorrect treatment leading to toxicities and diagnostic delays) and the community (eg, spread of antimicrobial resistance). Additionally, although the problem of counterfeit and substandard medicines was not investigated by Do and colleagues, the prevalence of these products is estimated at approximately 30% in LMICs.6Almuzaini T Choonara I Sammons H Substandard and counterfeit medicines: a systematic review of the literature.BMJ Open. 2013; 3e002923Crossref PubMed Scopus (140) Google Scholar Such poor-quality pharmaceuticals, including a substantial proportion of antibiotics, easily find their way through unauthorised drug stores due to absence of quality control, with serious consequences for the user. The study findings indicate the urgent need for interventions focused on antibiotic dispensing in drug stores for mild conditions. Most research efforts in LMICs to date have been devoted to the evaluation of stewardship programmes in health-care settings.7Wilkinson A Ebata A MacGregor H Interventions to reduce antibiotic prescribing in LMICs: a scoping review of evidence from human and animal health systems.Antibiotics (Basel). 2018; 8: 2Crossref Scopus (39) Google Scholar Drug stores continue to be only marginally affected (if at all) by interventions aimed at promoting rational antibiotic use. Depending on the context, a multi-pronged approach combining education programmes with regular feedback mechanisms and more incisive law enforcement could have a substantial effect on over-the-counter sale of antibiotics. In addition to the drug stores, private health-care providers, including informal providers, contribute to a substantial proportion of antibiotic dispensing in primary care settings in LMICs,8Khare S Purohit M Sharma M et al.Antibiotic prescribing by informal healthcare providers for common illnesses: a repeated cross-sectional study in rural India.Antibiotics (Basel). 2019; 8: 139Crossref PubMed Scopus (11) Google Scholar and interventions aimed at reducing antibiotic dispensation among these groups of providers is much needed as well.7Wilkinson A Ebata A MacGregor H Interventions to reduce antibiotic prescribing in LMICs: a scoping review of evidence from human and animal health systems.Antibiotics (Basel). 2018; 8: 2Crossref Scopus (39) Google Scholar Community-based interventions improving public awareness on the importance of preserving antibiotics will also be crucial. GS is a recipient of the David G Guthrie Fellowship from McGill University, Montreal, Canada. Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approachContextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance. Full-Text PDF Open Access