Walking the line between antimicrobial access and excess

Antimicrobial resistance, the growing ineffectiveness of antibiotics and anti-microbial drugs, is an increasingly visible topic on the global health agenda. It poses an enormous threat to the global fight against disease, threatening to render ineffective many of the drugs we have used to fight infection since penicillin’s discovery almost a century ago.

Yet, while the world worries about antimicrobial resistance and excess prescription of antibiotics, in many low-income countries, children continue to die from causes that could be easily cured by these remedies. For many, the problem is therefore not the excess prescription of antibiotics or antimicrobial resistance, but the opposite: a lack of access which results in millions of deaths every year.

Simply put, there are many people who need antibiotics and do not get them, and there are many people who use antibiotics but don’t need them. The key point is that in countries with weak health systems, there are many, many more people who lack access to antibiotics than there are people who have a problem with resistance to these drugs.

This week I am visiting Tanzania, a country where community health workers are not permitted to prescribe antibiotics to treat pneumonia. As a result, parents often need to travel long distances to seek assistance from a doctor, potentially delaying diagnosis and treatment of this easily curable disease. This example highlights the importance of guaranteeing access to antibiotics through robust health systems which reach down to the community level. At the same time, in primary health centres in Malawi, health practitioners are encouraged to treat all children experiencing fever with antibiotics, a practice which inevitably results in over prescription, and can cause resistance.

Watch professor Stefan Swartling Peterson explain the access/excess riddle

As we try to do something to address this dual challenge, obviously we must reduce unnecessary, excess use while also increasing access for those who need treatment. What are our options? In Europe we’ve looked very much at controlled distribution and use. We have physicians prescribing, pharmacies selling, et cetera. So why don’t we just simply do that?

Well, for one, in the countries facing the greatest challenges, health systems are weak and most people don’t have the option of seeing a doctor. Even in health centres, the drugs may have run out. So to compensate, there is a strong private sector and many go and buy drugs over-the-counter. So, say some people, why don’t we just close the private pharmacies?

If we closed the pharmacies, we will ultimately reduce access, which may lead to even more deaths. So what are our options? Obviously we need to engage all players in the health system and do a system-wide intervention: to bring incentives for self-regulation, educate consumers, and promote access to effective antibiotics via many channels.

Integrated community case management (ICCM), which aims to extend case management of childhood illness beyond health facilities — bringing lifesaving treatments to more children — is one promising approach not just to improve quality of care, but also to bring about rational use of drugs. Involving health care consumers and providers is key, as is working to create the financial incentives that promote rational drug use.

It is critical to remember that lack of access is a bigger problem than drug resistance in poor countries, and that it takes a system-wide intervention to strengthen the health system. As countries begin writing National Action Plans to curtail antibiotic resistance, we need to defend access at the same time as we tackle excess use. Developing new antibiotics is not enough, just like having a new car does not really help unless you have a road to drive it on. You need a health system to deliver these antibiotics to the people who need them both at the micro level — the individual sick child and patient — and at the national level. With strategies such as ICCM, which leverage the power of frontline health workers, we can achieve a “double impact”, improving quality of care while simultaneously promoting rational use of drugs, ultimately improving health for all.

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Stefan Peterson is currently Chief of Health Section for UNICEF globally, based in New York. He’s a Professor of Global Health at Uppsala University and, prior to that, at the Global Health Division of Karolinska Institute. He has also been visiting professor at Makerere University in Uganda. He has done extensive field work in Tanzania and Uganda and is a co-founder of Medecins Sans Frontieres Sweden.





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