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Bajwa M, Afzal S, Sheikh SA, Saleem Z. Drug Inspector as an antibiotic Steward: challenges and recommendations to implement national action plan of Pakistan on antimicrobial resistance. Expert Rev Anti Infect Ther 2024. [PMID: 38872588 DOI: 10.1080/14787210.2024.2368825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Despite significant measures, low- and middle-income countries (LMICs), including Pakistan, struggle to curtail non-prescription antibiotic sales, enforce regulations, and implement National Action Plan (NAP) against antimicrobial resistance (AMR). NAP Pakistan entails drug inspectors (DIs) to ensure prescription-based sales of antibiotics. This study seeks to understand the perspective of DIs regarding antimicrobial sales without prescription, underlying factors, and policy implementation status. METHODS A qualitative study employing a semi-structured interview guide using in-depth interviews with purposively selected 17 DIs was conducted. Interviews were transcribed verbatim, and data were analyzed following a thematic analysis framework utilizing MAXQDA 2022 software. RESULTS Five main themes emerged after data analysis: (1) drug inspector - the regulator of the antimicrobial armamentarium, (2) the policy context, (3) awareness regarding AMR, (4) barriers to combatting AMR, and (5) the way forward: strategies and recommendations. CONCLUSION A weak regulatory framework, low level of awareness, quackery, vested interests, and socio-economic factors augment inappropriate antibiotic utilization. Opting for better policies and strengthening the DI fraternity as outlined in NAP Pakistan is recommended. Recognizing drug inspectors as effective surveilling units and mobilizing field force against irrational antibiotic utilization is the need of the hour and requires policy reformation.
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Affiliation(s)
- Mishal Bajwa
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Shairyar Afzal
- Department of Pharmacy Practice, Faculty of Pharmacy, Hamdard University, Pakistan
- Department of Pharmacy, DHQ Hospital Jhelum, Jhelum, Pakistan
| | - Sadaf Areej Sheikh
- Department of Pharmacology and Toxicology, University of Veterinary and Animal Sciences, Lahore, Punjab, Pakistan
| | - Zikria Saleem
- Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Punjab, Pakistan
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Noor MN, Rahman-Shepherd A, Siddiqui AR, Aftab W, Shakoor S, Hasan R, Khan M. Socioecological factors linked with pharmaceutical incentive-driven prescribing in Pakistan. BMJ Glob Health 2023; 6:e010853. [PMID: 36731921 PMCID: PMC10175940 DOI: 10.1136/bmjgh-2022-010853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/02/2022] [Indexed: 02/04/2023] Open
Abstract
Pharmaceutical marketing through financial incentivisation to general practitioners (GPs) is a poorly studied health system problem in Pakistan. Pharmaceutical incentivisation is seen to be distorting GPs prescribing behaviour that can compromise the health and well-being of patients. We draw on a conceptual framework outlined in the ecological system theory to identify multiple factors linked with pharmaceutical incentivisation to GPs in Pakistan. We conducted qualitative interviews with 28 policy actors to seek their views on the health system dynamics, how they sustain pharmaceutical incentivisation and their effect on the quality of care. Our analysis revealed four interlinked factors operating at different levels and how they collectively contribute to pharmaceutical incentivisation. In addition to influences such as the increasing family needs and peers' financial success, sometimes GPs may naturally be inclined to maximise incomes by engaging in pharmaceutical incentivisation. On other hand, the pharmaceutical market dynamics that involve that competition underpinned by a profit-maximisation mindset enable pharmaceutical companies to meet GPs' desires/needs in return for prescribing their products. Inadequate monitoring and health regulations may further permit the pharmaceutical industry and GPs to sustain the incentive-driven relationship. Our findings have important implications for potential health reforms such as introducing regulatory controls, and appropriate monitoring and regulation of the private health sector, required to address pharmaceutical incentivisation to GPs.
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Affiliation(s)
- Muhammad Naveed Noor
- Pathology and Laboratory Medicine, Aga Khan University, Karachi, Sindh, Pakistan
- Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Afifah Rahman-Shepherd
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Wafa Aftab
- Community Health Sciences, Aga Khan University, Karachi, Sindh, Pakistan
| | - Sadia Shakoor
- Pathology and Laboratory Medicine, Aga Khan University, Karachi, Sindh, Pakistan
| | - Rumina Hasan
- Pathology and Laboratory Medicine, Aga Khan University, Karachi, Sindh, Pakistan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Mishal Khan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Khan M, Rahman-Shepherd A, Bory S, Chhorn S, Durrance-Bagale A, Hasan R, Heng S, Phou S, Prien C, Probandari A, Saphonn V, Suy S, Wiseman V, Wulandari LPL, Hanefeld J. How conflicts of interest hinder effective regulation of healthcare: an analysis of antimicrobial use regulation in Cambodia, Indonesia and Pakistan. BMJ Glob Health 2022; 7:bmjgh-2022-008596. [PMID: 35589155 PMCID: PMC9121421 DOI: 10.1136/bmjgh-2022-008596] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/20/2022] [Indexed: 11/09/2022] Open
Abstract
Background There has been insufficient attention to a fundamental force shaping healthcare policies—conflicts of interest (COI). We investigated COI, which results in the professional judgement of a policymaker or healthcare provider being compromised by a secondary interest, in relation to antimicrobial use, thereby illuminating challenges to the regulation of medicines use more broadly. Our objectives were to characterise connections between three groups—policymakers, healthcare providers and pharmaceutical companies—that can create COI, and elucidate the impacts of COI on stages of the policy process. Methods Using an interpretive approach, we systematically analysed qualitative data from 136 in-depth interviews and five focus group discussions in three Asian countries with dominant private healthcare sectors: Cambodia, Indonesia and Pakistan. Findings We characterised four types of connections that were pervasive between the three groups: financial, political, social and familial. These connections created strong COI that could impact all stages of the policy process by: preventing issues related to medicines sales from featuring prominently on the agenda; influencing policy formulation towards softer regulatory measures; determining resource availability for, and opposition to, policy implementation; and shaping how accurately the success of contested policies is reported. Interpretation Our multicountry study fills a gap in empirical evidence on how COI can impede effective policies to improve the quality of healthcare. It shows that COI can be pervasive, rather than sporadic, in influencing regulation of medicine use, and highlights that, in addition to financial connections, other types of connections should be examined as important drivers of COI.
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Affiliation(s)
- Mishal Khan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK .,Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan
| | - Afifah Rahman-Shepherd
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Anna Durrance-Bagale
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Rumina Hasan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan
| | | | | | - Chanra Prien
- University of Health Sciences, Phnom Penh, Cambodia
| | | | | | | | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Johanna Hanefeld
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Center for International Health Protection, Robert Koch Institut, Berlin, Germany
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Khan MS, Durrance-Bagale A, Mateus A, Sultana Z, Hasan R, Hanefeld J. What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan. Health Policy Plan 2021; 35:973-982. [PMID: 32743655 DOI: 10.1093/heapol/czaa065] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/25/2022] Open
Abstract
Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.
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Affiliation(s)
- Mishal S Khan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Anna Durrance-Bagale
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Ana Mateus
- Department of Pathobiology and Population Sciences, Royal Veterinary College, London WC1H 9SH, UK
| | - Zia Sultana
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan.,Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Johanna Hanefeld
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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Khan MS, Bory S, Rego S, Suy S, Durrance-Bagale A, Sultana Z, Chhorn S, Phou S, Prien C, Heng S, Hanefeld J, Hasan R, Saphonn V. Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries? HUMAN RESOURCES FOR HEALTH 2020; 18:10. [PMID: 32046723 PMCID: PMC7014603 DOI: 10.1186/s12960-020-0452-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/30/2020] [Indexed: 05/06/2023]
Abstract
BACKGROUND Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. METHODS We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. RESULTS Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. CONCLUSIONS In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.
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Affiliation(s)
- Mishal S Khan
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
- Aga Khan University, Karachi, Pakistan.
| | - Sothavireak Bory
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | - Sonia Rego
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Sovanthida Suy
- Department of Public Health, University of Health Sciences, Phnom Penh, Cambodia
| | - Anna Durrance-Bagale
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | | | | | - Socheata Phou
- Department of Public Health, University of Health Sciences, Phnom Penh, Cambodia
| | - Chanra Prien
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | | | - Johanna Hanefeld
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Rumina Hasan
- Aga Khan University, Karachi, Pakistan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Malik F, Figueras A. Continuous rise in cephalosporin and fluoroquinolone consumption in Pakistan: a 5 year analysis (2014-18). JAC Antimicrob Resist 2019; 1:dlz063. [PMID: 34222937 PMCID: PMC8210202 DOI: 10.1093/jacamr/dlz063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/04/2019] [Accepted: 10/15/2019] [Indexed: 11/22/2022] Open
Abstract
Background Pakistan was third on the list of the highest antibiotic-consuming countries among low- and middle-income countries in 2015. Studies have suggested that areas with higher consumption of antibiotics are likely to have higher antibiotic resistance rates. Objectives With limited surveillance data on consumption and resistance in Pakistan, this study investigated the 5 year trends (April 2014 to March 2019) in consumption of the two highest-sold antibiotic classes, cephalosporins [Anatomical Therapeutic Chemical (ATC) group J01D] and fluoroquinolones (ATC group J01MA). Methods IQVIA Pakistan data (retail) on antibiotic sales presented in units were used. These data were standardized and a DDD was assigned to all formulations, based on WHO’s ATC/DDD index, and the data expressed as DIDs (DDDs per 1000 inhabitants per day). WHO’s AWaRe classification of antimicrobials was used for the analyses, especially of those categorized as ‘Watch’. Results The findings showed a significant increase in consumption trends for ‘Watch’ cephalosporins (61.5%) while the use of ‘Reserve’ cephalosporins doubled during the studied period. In 2018, combined consumption of second- and third-generation cephalosporins (both in the ‘Watch’ group) was nearly five times higher than that of the first-generation cephalosporins. For fluoroquinolones, the total consumption only showed a major increase for ciprofloxacin, with 127 820 more persons per day. The consumption of cephalosporins and fluoroquinolones in Pakistan increased by 1.86 DIDs in just 5 years. Conclusions It is urgent to establish a National Antimicrobial Commission in Pakistan, to critically analyse the pharmaceutical market offerings and implement surveillance systems and antimicrobial stewardship.
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Affiliation(s)
- Farrukh Malik
- Eu2P European Programme in Pharmacovigilance & Pharmacoepidemiology, Université de Bordeaux, Bordeaux, France
| | - Albert Figueras
- Eu2P European Programme in Pharmacovigilance & Pharmacoepidemiology, Université de Bordeaux, Bordeaux, France.,Fundació Institut Català de Farmacologia; Department of Pharmacology, Therapeutics, & Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
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