The role of health markets in managing antibiotic use and addressing antimicrobial resistance
published 20 April 2016
published 20 April 2016
This article first appeared on the Health Systems Global website and has been republished here with kind permission.
‘Unregulated, fragmented, unorganised, patient-centred, for-profit, low-quality, informal and formal’. These are the keywords that describe the busy health markets of Low and Middle Income Countries (LMICs). In the Health Systems Global (HSG) conference at Vancouver, the Private Sector in Health Thematic Working Group brings another angle to the existing narrative of health markets: that of ‘antimicrobial resistance’.
Most people in LMICs acquire their antibiotics in health markets, often from informal providers. Paradoxically however, health markets face the dual challenge of excessive antibiotic use, and also gaps in universal access to antibiotics in the poorest populations.
Antibiotic or antimicrobial resistance is increasingly recognised as one of the major health challenges of our time. Antibiotics play a life-saving role in reducing mortality and morbidity due to communicable diseases like tuberculosis, typhoid, pneumonia and gastroenteritis. For example, penicillin reduced mortality due to pneumonia from 20-40% to 5%. But the overuse of antibiotics in populations can lead to the disease causing bacteria becoming drug resistant over time. Increasing rates of antimicrobial resistance threaten to undo global health gains, and present challenges to medical, agricultural and economic systems.
The statistics are alarming. In a WHO study across multiple sites in India and South Africa, high levels of resistance were found in disease causing E.coli (bacteria that can cause gastroenteritis, urinary tract infections, and neonatal meningitis among other infections) for ampicillin (52.3% – 84.6%), cotrimoxazole (45.5% – 65%), cephalexin (15.9% – 59.7%), gentamycin (6.1%-29.5%), tetracycline (40.9%-77.3%) and ciprofloxacin (1.9%-58.7%). The threat is not limited to LMICs.
Apparently seven percent of gonorrhoea cases in Toronto, Canada, are now untreatable, reflecting a worrying emergence of multi-drug resistant strains of the disease across the world. If that wasn’t bad enough scientists have discovered a mutated bacterial gene which is resistant to a ‘last resort’ antibiotic (colistin) and which can – and has – spread to other strains and species of bacteria.
The discovery raises the prospect of a ‘post-antibiotic era’ where we are susceptible to epidemics of untreatable infections and where modern medical procedures such as surgery or chemotherapy – which rely on antibiotics to treat associated infections – are no longer safe.
The challenge has been compared to climate change. UK Prime Minister, David Cameron, warned of a return to the ‘dark ages of medicine’. President Barack Obama has made drug resistance a priority in the USA’s Global Health Security Agenda. As drug resistant pathogens do not respect national borders, the World Health Assembly adopted the ‘Global Action Plan on Anti-microbial Resistance’ (AMR).
Several LMICs have drafted their own national plans but there is a risk these aspirations will be undermined by gaps between policy statements and the real-world governance of weak health systems and unregulated health markets.
Health markets showcase the ‘good, the bad and the ugly’ of healthcare in many LMICs. An overwhelming share of curative health care, diagnostics and pharmaceutical supplies lies in the private sector. Millions of people rely on private facilities and private providers for healthcare that is reachable and responsive to patients’ needs, but may fall short of clinical correctness.
Drugs including antibiotics are used in plentiful, but may be the wrong ones, or one too many, or used in wrong dosages, or just counterfeit or of poor quality! Health market providers’ irrational and unregulated drug dispensation/prescribing is a major cause of increased antibiotic use by people and communities.
What explains this behaviour and the current state of disorder in health markets? How can we intervene with effective and long lasting changes?
The session will be moderated by Meenakshi Gautham, a private health sector researcher from India, lead of the Private Sector in Health Thematic Working Group’s informal provider sub group, and Research Fellow and IDEAS India Country Coordinator with the London School of Hygiene & Tropical Medicine.
It is co-convened by Meenakshi and Annie Wilkinson, a health systems researcher at the Institute of Development Studies; and chaired by Gerald Bloom, a health economist at the Institute of Development Studies.