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Nair M, Engel N, Zeegers MP, Burza S. Perceptions of effective policy interventions and strategies to address antibiotic misuse within primary healthcare in India: A qualitative study. J Infect Prev 2023; 24:113-118. [PMID: 37065277 PMCID: PMC10090571 DOI: 10.1177/17571774231158778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
Objectives Antimicrobial resistance poses a major public health threat. Despite Indian retail sector antibiotic consumption per capita increasing by approximately 22% between 2008 and 2016, empirical studies that examine policy or behavioural interventions addressing antibiotic misuse in primary healthcare are scarce. Our study aimed to assess perceptions of interventions and gaps in policy and practice with respect to outpatient antibiotic misuse in India. Methods We conducted 23 semi-structured, in-depth interviews with a variety of key informants with diverse backgrounds in academia, non-government organisations, policy, advocacy, pharmacy, medicine and others. Data were charted into a framework matrix and analysed using a hybrid, inductive and deductive thematic analysis. Themes were analysed and organised according to the socio-ecological model at various levels ranging from the individual to the enabling environment. Results Key informants largely focused on the importance of adopting a structural perspective to addressing socio-ecological drivers of antibiotic misuse. There was a recognition that educational interventions targeting individual or interpersonal interactions were largely ineffective, and policy interventions should incorporate behavioural nudge interventions, improve the healthcare infrastructure and embrace task shifting to rectify staffing disparities in rural areas. Conclusions Prescription behaviour is perceived to be governed by structural issues of access and limitations in public health infrastructure that create an enabling environment for antibiotic overuse. Interventions should move beyond a clinical and individual focus on behaviour change with respect to antimicrobial resistance and aim for structural alignment between existing disease specific programs and between the informal and formal sector of healthcare delivery in India.
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Affiliation(s)
- Mohit Nair
- Maastricht University, Maastricht, Netherlands
| | - Nora Engel
- Maastricht University, Maastricht, Netherlands
| | | | - Sakib Burza
- London School of Hygiene & Tropical Medicine, London, UK
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2
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3
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Gupta M, Virdi VS, Gupta R. Hurdles in mandatory generic medicine prescription. J Pharmacol Pharmacother 2021. [DOI: 10.4103/jpp.jpp_74_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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4
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Koju P, Rousseau SP, Van der Putten M, Shrestha A, Shrestha R. Advertisement of antibiotics for upper respiratory infections and equity in access to treatment: a cross-sectional study in Nepal. J Pharm Policy Pract 2020; 13:4. [PMID: 32110416 PMCID: PMC7033932 DOI: 10.1186/s40545-020-0202-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 02/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background Pharmaceutical companies actively advertise their branded antibiotics, which influence their sales at community pharmacies. The major proportion of out of pocket health spending is on medicine; and affordability of antibiotics has always been a crucial issue in most developing countries. This study identified promotional activities adopted by pharmaceutical companies in community pharmacies and medicine shops and the affordability of selected antibiotics to clients with lowest wages in Kavrepalanchok district of Nepal. Methods A cross-sectional study was conducted among all community pharmacies and medicine shops (n = 34) in Dhulikhel and Banepa. Available pharmacists / personnel were interviewed, using a structured questionnaire, on the characteristics of the pharmacies, promotional activities, and sales and prices of antibiotics used to treat acute upper respiratory tract infections. This study looked at the association of promotional activities (financial bonus, free samples, and books/brochure/gifts) with the type of antibiotics. Further, affordability was assessed of the most popular antibiotics by comparing the total treatment cost against the lowest wage for unskilled workers in Nepal. Results Financial bonus, free samples, and brochures were the most popular promotional activities. It is also noticed that antibiotics which are top selling were those with a high number of promotional activities. Amoxicillin, azithromycin and amoxicillin+clavulanate had 42, 29 and 17 promotional activities respectively. Irrespective of the prices of antibiotics, almost all of the most popular antibiotics for acute upper respiratory infections were unaffordable for unskilled workers costing them more than a day’s wage. Conclusions Upper respiratory tract antibiotics are widely promoted at community pharmacies. The treatment cost of antibiotics is unaffordable for unskilled workers in Nepal irrespective of the type and unit cost of antibiotics.
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Affiliation(s)
- Pramesh Koju
- 1Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, PO Box 11008, Kathmandu, Nepal
| | | | - Marc Van der Putten
- 3Center of Excellence in Global Health, Faculty of Public Health, Thammasat University, Bangkok, Thailand
| | - Archana Shrestha
- 1Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, PO Box 11008, Kathmandu, Nepal
| | - Rajeev Shrestha
- 1Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, PO Box 11008, Kathmandu, Nepal
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5
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Killeen OJ, Pillai MR, Udayakumar B, Shroff S, Vimalanathan M, Cho J, Newman-Casey PA. Understanding Barriers to Glaucoma Treatment Adherence among Participants in South India. Ophthalmic Epidemiol 2020; 27:200-208. [DOI: 10.1080/09286586.2019.1708121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Olivia J. Killeen
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | | | - Juno Cho
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Paula Anne Newman-Casey
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan, USA
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6
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Kestelyn E, Le Phuong C, Ilo Van Nuil J, Dong Thi HT, Minh Nguyen N, Dinh The T, Chambers M, Simmons CP, Nguyen Trong T, Nguyen The D, Phuong LT, Do Van D, Duc Anh D, Nguyen Van VC, Baker S, Wills B. Expert voices and equal partnerships: establishing Controlled Human Infection Models (CHIMs) in Vietnam. Wellcome Open Res 2019; 4:143. [PMID: 31681857 PMCID: PMC6820821 DOI: 10.12688/wellcomeopenres.15337.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 01/20/2023] Open
Abstract
The number of controlled human infection models (CHIMs) conducted worldwide has increased considerably in recent years, although few have been conducted in low and middle-income countries (LMICs), where infectious diseases have the greatest burden. Recently Oxford University Clinical Research Unit (OUCRU) in Ho Chi Minh City (HCMC) started developing CHIM research proposals motivated by the need to develop a clearer and more grounded understanding of the issues surrounding the conduct of CHIMs in LMICs. To explore initial perceptions and barriers to conducting CHIMs in Vietnam, OUCRU researchers conducted a set of key stakeholder interviews early in 2018 and held a CHIM workshop in HCMC in March 2018. This paper summarizes the discussions from the workshop and outlines a way forward for conducting CHIMs in Vietnam.
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Affiliation(s)
- Evelyne Kestelyn
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Chi Le Phuong
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Jennifer Ilo Van Nuil
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Hoai Tam Dong Thi
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Nguyet Minh Nguyen
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Trung Dinh The
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Mary Chambers
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Cameron P Simmons
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Institute for Vector-Borne Disease, Monash University, Clayton, VIC 3800, Australia
| | | | - Dung Nguyen The
- Department of Infectious Diseases, School of Medicine, Vietnam National University, Ho Chi Minh City, Vietnam
| | | | - Dung Do Van
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Dung Duc Anh
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Vinh Chau Nguyen Van
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Bridget Wills
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam.,Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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7
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Hamill H, Hampshire K, Mariwah S, Amoako-Sakyi D, Kyei A, Castelli M. Managing uncertainty in medicine quality in Ghana: The cognitive and affective basis of trust in a high-risk, low-regulation context. Soc Sci Med 2019; 234:112369. [PMID: 31238286 PMCID: PMC6688066 DOI: 10.1016/j.socscimed.2019.112369] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 11/22/2022]
Abstract
Where regulation is weak, medicine transactions can be characterised by uncertainty over the drug quality and efficacy, with buyers shouldering the greater burden of risk in exchanges that are typically asymmetric. Drawing on in-depth interviews (N = 220) and observations of medicine transactions, plus interviews with regulators (N = 20), we explore how people in Ghana negotiate this uncertainty and come to trust a medicine enough to purchase or ingest it. We identify two mechanisms - attempts to mitigate uncertainty through seeking observable signs of quality and attempts to reduce informational asymmetry - that underpin cognitive assessments of a medicine's trustworthiness. However, these 'cognitive' forms of trust assessment have limited traction where uncertainty is high and trustworthiness remains unknowable, so a third mechanism comes into play: one based on affective relationships within which transactions are socially embedded. Even these, however, cannot eliminate uncertainty, because of the dispersed and under-regulated nature of wider supply chains. In conclusion, we reflect on the need for careful research on actors' practices and decision-making across supply chains to inform more effective policy and regulation.
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Affiliation(s)
- Heather Hamill
- Department of Sociology, Oxford University, 42-43 Park End Street, Oxford, OX1 1JD, UK.
| | - Kate Hampshire
- Department of Anthropology, Durham University, Dawson Building, South Road, Durham, DH1 3LE, UK.
| | - Simon Mariwah
- Department of Geography and Regional Planning, University of Cape Coast, Cape Coast, Ghana.
| | | | - Abigail Kyei
- The Ghana College of Nurses and Midwives, Pentecost University, Accra, Ghana.
| | - Michele Castelli
- Institute of Health and Society, Newcastle University The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
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8
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McDowell A, Engel N, Daftary A. In the eye of the multiple beholders: Qualitative research perspectives on studying and encouraging quality of TB care in India. J Clin Tuberc Other Mycobact Dis 2019; 16:100111. [PMID: 31497654 PMCID: PMC6716552 DOI: 10.1016/j.jctube.2019.100111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
This paper outlines insights qualitative research brings to the study of quality of care. It advocates understanding care as sequential, interpersonal action aimed at improving health and documenting the networks in which care occurs. It assesses the strengths and weakness of contemporary quantitative and qualitative approaches to examining quality of care for tuberculosis (TB) before outlining three qualitative research programs aimed at understanding quality of TB in India. Three case studies focus on the diagnosis level in the cascade of TB care and use qualitative research to examine the clinical use of pharmaceuticals as diagnostics, the development of diagnostic tests, and the role of care providers in the utilization of diagnostic services. They show that 1) care must be understood as part of relationships over time, 2) the presence or absence of technologies does not always imply their expected use in care, 3) physicians' provision of care is often inflected by their perceptions of patient desires, and 4) effective care is not always perfectly aligned with global health priorities. Qualitative methods with a networked perspective on care provide novel findings that can and have been used when developing quality of care improvement interventions for TB.
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Affiliation(s)
- Andrew McDowell
- Department of Anthropology, Tulane University, New Orleans, USA
- CERMES3, Institute National de la Santé et la Recherché Médicale, Paris, France
| | - Nora Engel
- Department of Health, Ethics and Society, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Amrita Daftary
- McGill International TB Centre and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Centre for the AIDS Programme of Research (CAPRISA), University of KwaZulu Natal, Durban, South Africa
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9
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Upadhaya N, Jordans MJD, Gurung D, Pokhrel R, Adhikari RP, Komproe IH. Psychotropic drugs in Nepal: perceptions on use and supply chain management. Global Health 2018; 14:10. [PMID: 29368618 PMCID: PMC5784600 DOI: 10.1186/s12992-018-0322-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/09/2018] [Indexed: 11/10/2022] Open
Abstract
Background Psychotropic drugs play an important role in the treatment of mental, neurological and substance use disorders. Despite the advancement of the use of psycho-pharmaceuticals in the developed countries, the psychotropic drug production and supply chain management in low- and middle- income countries are still poorly developed. This study aims to explore the perceptions of stakeholders involved in all stages of the psychotropic drug supply chain about the need, quality, availability and effectiveness of psychotropic drugs, as well as barriers to their supply chain management. The study was conducted among 65 respondents from the Kathmandu, Chitwan and Pyuthan districts, grouped into four categories: producers, promoters and distributors (N = 22), policy makers and government actors (N = 8), service providers (N = 21) and service users/family members (N = 14). Results The respondents reported that psychotropic drugs, despite having side effects, are 1) needed, 2) available in major regional centers and 3) are effective for treating mental health problems. The stigma associated with mental illness, however, forces patients and family members to hide their use of psychotropic drugs. The study found that the process of psychotropic drug supply chain management is similar to other general drugs, with the exceptions of strict pre-approval process, quantity restriction (for production and import), and mandatory record keeping. Despite these regulatory provisions, respondents believed that the misuse of psychotropic drugs is widespread and companies are providing incentives to prescribers and retailers to retain their brand in the market. Conclusions The production and supply chain management of psychotropic drugs is influenced by the vested interests of pharmaceutical companies, prescribers and pharmacists. In the context of the government of Nepal’s policy of integrating mental health into primary health care and increased consumption of psychotropic drugs in Nepal, there is a need for massive education and awareness as well as strict monitoring and supervision to avoid the misuse of psychotropic drugs. Electronic supplementary material The online version of this article (10.1186/s12992-018-0322-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nawaraj Upadhaya
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.
| | - Mark J D Jordans
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal.,Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dristy Gurung
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | - Ruja Pokhrel
- Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
| | | | - Ivan H Komproe
- Department of Research and Development, HealthNet TPO, Amsterdam, the Netherlands.,Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, the Netherlands
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Das A, Nawal D, Singh MK, Karthick M, Pahwa P, Shah MB, Mahapatra T, Ranjan K, Chaudhuri I. Evaluation of the mobile nurse training (MNT) intervention - a step towards improvement in intrapartum practices in Bihar, India. BMC Pregnancy Childbirth 2017; 17:266. [PMID: 28835213 PMCID: PMC5569501 DOI: 10.1186/s12884-017-1452-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/15/2017] [Indexed: 12/19/2022] Open
Abstract
Background Evidence shows that improving the quality of intrapartum care is critical for maternal survival. However, a significant rise in the proportion of facility-based births over the last decade in India - attributable to a cash transfer program - has not resulted in a corresponding reduction in maternal mortality, thanks, in part, to low-skilled care at facilities. The current study evaluated a mobile knowledge-based intervention aimed at improving quality of care by mentoring in-service staff nurses at public obstetric facilities. Methods An independent evaluation team conducted baseline and post-intervention assessments at every facility using a mix of methods that included training assessments and Direct Observation of Deliveries. The assessment involved passive observation of pregnant women from the time of their admission at the facility and recording the obstetric events and delivery-related practices on a pre-formatted checklist-based tool. Maternal practices were classified into positive and negative ones and scored. Linear regression analysis was used to evaluate the association of MNT intervention with summary scores for positive, negative and overall practice scores. We evaluated retention of intervention effect by comparing the summary scores at baseline, immediately following intervention and 1 year after intervention. Results In both unadjusted and adjusted analyses, the intervention was found to be significantly associated with improvement in positive practice score (Unadjusted: parameter estimate (β) = 16.90; 95% confidence interval (CI) = 15.20, 18.60. Adjusted: β = 13.14; 95% CI = 10.97, 15.32). The intervention was also significantly associated with changes in negative practice score, which was reverse coded to represent positive change (Unadjusted: β = 11.66; 95% CI = 10.06, 13.27. Adjusted: β = 2.99; 95% CI = 1.35, 4.63), and overall practice score (Unadjusted: β = 15.74; 95% CI = 14.39, 17.08; Adjusted: β = 10.89; 95% CI = 9.18, 12.60). One year after the intervention, negative practices continued to improve, albeit at a slower rate; positive labor practices and overall labor practice remained higher than the baseline but with some decline over time. Conclusions Findings suggest that in low resource settings, interventions to strengthen quality of human resources and care through mentoring works to improve intrapartum maternal care. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1452-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aritra Das
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Dipty Nawal
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Manoj Kumar Singh
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Morchan Karthick
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Parika Pahwa
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Malay Bharat Shah
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India. .,Department of Epidemiology, Fielding School of Public Health, University of California - Los Angeles, 650 Charles Young Drive, South. Box 951772, Los Angeles, CA, 90095, USA.
| | - Kunal Ranjan
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
| | - Indrajit Chaudhuri
- CARE India Solutions for Sustainable Development. H No. 14, Patliputra Colony, Patna, Bihar, 800013, India
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Affiliation(s)
- Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - T S Sathyanarayana Rao
- Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
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12
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McDowell A. Mohit's Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan. Med Anthropol Q 2017; 31:332-348. [DOI: 10.1111/maq.12345] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 09/14/2016] [Accepted: 09/20/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew McDowell
- GLOBHEALTH, Centre for Research on Medicine, Science, Health, Mental Health and Society, École des hautes études en sciences sociales/INSERM/CNRS
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13
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Kadam AB, Maigetter K, Jeffery R, Mistry NF, Weiss MG, Pollock AM. Correcting India's Chronic Shortage of Drug Inspectors to Ensure the Production and Distribution of Safe, High-Quality Medicines. Int J Health Policy Manag 2016; 5:535-542. [PMID: 27694680 DOI: 10.15171/ijhpm.2016.44] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 04/16/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Good drug regulation requires an effective system for monitoring and inspection of manufacturing and sales units. In India, despite widespread agreement on this principle, ongoing shortages of drug inspectors have been identified by national committees since 1975. The growth of India's pharmaceutical industry and its large export market makes the problem more acute. METHODS The focus of this study is a case study of Maharashtra, which has 29% of India's manufacturing units and 38% of its medicines exports. India's regulations were reviewed, comparing international, national and state inspection norms with the actual number of inspectors and inspections. Twenty-six key informant interviews were conducted to ascertain the causes of the shortfall. RESULTS In 2009-2010, 55% of the sanctioned posts of drug inspectors in Maharashtra were vacant. This resulted in a shortfall of 83%, based on the Mashelkar Committee's recommendations. Less than a quarter of the required inspections of manufacturing and sales units were undertaken. The Indian Drugs and Cosmetics Act and its Rules and Regulations make no provisions for drug inspectors and workforce planning norms, despite the growth and increasing complexity of India's pharmaceutical industry. CONCLUSION The Maharashtra Food and Drug Administration (FDA) falls short of the Mashelkar Committee's recommended workforce planning norms. Legislation and political and operational support are required to produce needed changes.
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Affiliation(s)
- Abhay B Kadam
- The Foundation for Research in Community Health (FRCH), Pune, India
| | - Karen Maigetter
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Roger Jeffery
- Centre for South Asian Studies, School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | - Nerges F Mistry
- The Foundation for Research in Community Health (FRCH), Pune, India
| | - Mitchell G Weiss
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Allyson M Pollock
- Global Public Health Unit, Queen Mary University of London, London, UK
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Bharara T, Bhalla P, Rawat D, Garg VK, Sardana K, Chakravarti A. Rising trend of antimicrobial resistance among Neisseria gonorrhoeae isolates and the emergence of N. gonorrhoeae isolate with decreased susceptibility to ceftriaxone. Indian J Med Microbiol 2016; 33:39-42. [PMID: 25560000 DOI: 10.4103/0255-0857.148374] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
CONTEXT Gonorrhoea is one of the most common sexually transmitted infections (STI) in developing countries and is a global health problem. AIMS To analyze the trend of antimicrobial susceptibility of Neisseria gonorrhoeae isolates over the years, in a tertiary care hospital of North India. SETTINGS AND DESIGN The study population comprised males with urethritis and females with endocervicitis attending STI clinic of our hospital. MATERIALS AND METHODS In our STI laboratory, all gonococcal isolates are subjected to antimicrobial susceptibility testing by disc diffusion method as per CLSI guidelines. β-Lactamase production is determined by chromogenic cephalosporin test. Minimum Inhibitory Concentration (MIC) for ceftriaxone is determined by E-test. STATISTICAL ANALYSIS USED Data were expressed as percentages. The differences in percentages were tested for statistical significance by using χ2 test and P values were determined. RESULTS The percentage of penicillinase producing N. gonorrhoeae (PPNG) increased from 8% in 1995-96 to 20% in 2004-05 and 88% in 2011-2013. Quinolone-resistant N. gonorrhoeae (QRNG) showed a significant increase from 12% in 1995-96 to 98.3% in 2004-05, while 84% isolates were found to be QRNG by 2011-2013. In January 2013 we detected our first gonococcal isolate with decreased susceptibility to third-generation cephalosporins; Ceftriaxone, Cefixime and Cefpodoxime (MIC for ceftriaxone = 0.19 μg/ml). CONCLUSIONS The results of our study highlighted an alarming increase in the percentage of PPNG and QRNG strains over the years. Emergence of N. gonorrhoeae isolates with decreased susceptibility to third-generation cephalosporins is a cause of concern and thus emphasises the importance of antimicrobial susceptibility testing.
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Affiliation(s)
| | - P Bhalla
- Department of Microbiology, Maulana Azad Medical College, New Delhi, India
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15
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Brhlikova P, Harper I, Subedi M, Bhattarai S, Rawal N, Pollock AM. Aid conditionalities, international Good Manufacturing Practice standards and local production rights: a case study of local production in Nepal. Global Health 2015; 11:25. [PMID: 26072308 PMCID: PMC4470019 DOI: 10.1186/s12992-015-0110-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 06/01/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Local pharmaceutical production has been endorsed by the WHO as a means of addressing health priorities of developing countries. However, local producers of essential medicines must comply with international pharmaceutical standards in order to be eligible to compete in donor tenders. These standards determine production rights for on-patent and off-patent medicines, and guide international procurement of medicines. We reviewed the literature on the impact of Good Manufacturing Practice (GMP) on local production; a gap analysis from the literature review indicated a need for further research. Over sixty interviews were conducted with people involved in the Nepali pharmaceutical production and distribution chain from 2006 to 2009 on the GMP areas of relevance: regulatory capacity, staffing, funding and training, resourcing of GMP, inspectors' interpretation of the rules and compliance. RESULTS Although Nepal producers have increased their overall share of the domestic market, only the public manufacturer, Royal Drugs, focuses on medicines for public health programmes; private producers engage mainly in brand competition for private markets, not essential medicines. Nepali regulators and producers state that implementation of GMP standards is hindered by low regulatory capacity, insufficient training of staff in the industry, financial constraints and lack of investment for upgrading capital. The transition period to mandatory compliance with WHO GMP rules is lengthy. Less than half of private producers had WHO GMP in 2013. Producers are not directly affected by international harmonisation of standards as they do not export medicines and the Nepali regulator does not enforce the WHO standards strictly. Without an international GMP certificate they cannot tender for donor dependent health programmes. CONCLUSIONS In Nepal, local private manufacturers focus mainly on brand competition for private consumption not essential medicines, the government preferentially procures essential medicines from the only public producer while donor funded programmes rely on international manufacturers compliant with international GMP standards. We also found evidence of private hospitals bypassing national medicines approvals process. Policies in support of local pharmaceutical production in developing countries as a source of essential medicines need to examine carefully how GMP regulations impact on regulators, local industry and production of essential medicines in practice.
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Affiliation(s)
- Petra Brhlikova
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK.
| | - Ian Harper
- School of Social and Political Science, University of Edinburgh, 15a George Square, Edinburgh, EH8 9LD, UK.
| | - Madhusudan Subedi
- Patan Academy of Health Sciences, Nepal and Central Department of Sociology and Anthropology, Tribhuvan University, Kathmandu, Nepal.
| | | | - Nabin Rawal
- Central Department of Sociology/Anthropology, Tribhuvan University, Kathmandu, Nepal.
| | - Allyson M Pollock
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK.
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Mirzabagi E, Deepak NN, Koski A, Tripathi V. Uterotonic use during childbirth in Uttar Pradesh: accounts from community members and health providers. Midwifery 2013; 29:902-10. [PMID: 23415370 DOI: 10.1016/j.midw.2012.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 10/14/2012] [Accepted: 11/05/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE this qualitative study aimed to document provider and community practices regarding uterotonic use during labour and delivery in Uttar Pradesh, India, as well as the knowledge, attitudes, and values that underlie such use. METHODS, SETTING, AND PARTICIPANTS a total of 140 in-depth interviews were conducted between May and July 2011 in Agra and Gorakhpur districts, with clinicians, nurses, recently delivered women, mothers-in-law with at least one grandchild, traditional birth attendants, unlicensed village doctors, and pharmacist assistants at chemical shops. FINDINGS interviews reveal that injectable uterotonic use for the purposes of labour augmentation is widespread in both clinical and community settings. However, use of uterotonics for postpartum haemorrhage prevention and treatment appears to be relatively limited and was rarely discussed by respondents. Key beliefs underlying uterotonic use were identified, including high valuation of labour pain, rapid delivery, and biomedical intervention, particularly administration of medicines. Other factors promoting the use of uterotonics for labour augmentation included lack of knowledge about adverse effects, provider beliefs that prolonged labour poses risks to the baby, community perceptions that modern women are less able to have spontaneous delivery, and financial incentives for uterotonic administration. CONCLUSIONS AND IMPLICATIONS major challenges to overcome in minimising uterotonic misuse include entrenched use for labour augmentation in both institutional and community deliveries, perceptions of injectable uterotonics as curative agents symbolic of biomedical care, and the widespread availability of these drugs. The findings demonstrate a need for programmes that reduce inappropriate use of uterotonics, promote appropriate use for postpartum haemorrhage prevention and treatment, and ensure adherence to evidence-based guidelines.
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Affiliation(s)
- Ellie Mirzabagi
- Johns Hopkins Bloomberg School of Public Health, 455 Massachusetts Ave. NW, Washington, DC 20001, USA.
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Sethi S, Golparian D, Bala M, Dorji D, Ibrahim M, Jabeen K, Unemo M. Antimicrobial susceptibility and genetic characteristics of Neisseria gonorrhoeae isolates from India, Pakistan and Bhutan in 2007-2011. BMC Infect Dis 2013; 13:35. [PMID: 23347339 PMCID: PMC3565906 DOI: 10.1186/1471-2334-13-35] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/22/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Knowledge on antimicrobial drug resistance and genetic characteristics of Neisseria gonorrhoeae isolates circulating in India, Pakistan, and Bhutan is sorely lacking. In this paper, we describe the prevalence of antimicrobial resistance and molecular characteristics of N. gonorrhoeae isolates from India, Pakistan, and Bhutan in 2007-2011. METHODS Antimicrobial susceptibility and β-lactamase production were tested for 65 N. gonorrhoeae isolates from India (n=40), Pakistan (n=18) and Bhutan (n=7) using Etest methodology (eight antimicrobials) and nitrocefin solution, respectively. Resistance determinants, i.e. penA, mtrR, porB1b, gyrA, and parC, were sequenced. N. gonorrhoeae multiantigen sequence typing (NG-MAST) was performed for molecular epidemiology. RESULTS The highest resistance level was observed for ciprofloxacin (94%), followed by penicillin G (68%), erythromycin (62%), tetracycline (55%), and azithromycin (7.7%). All the isolates were susceptible to ceftriaxone, cefixime, and spectinomycin. Thirty-four (52%) of the isolates were producing β-lactamase. No penA mosaic alleles or A501-altered alleles of penicillin-binding protein 2 were identified. Forty-nine NG-MAST STs were identified, of which 42 STs have not been previously described worldwide. CONCLUSIONS Based on this study, ceftriaxone, cefixime, and spectinomycin can be used as an empirical first-line therapy for gonorrhoea in India, Pakistan, and Bhutan, whereas ciprofloxacin, penicillin G, tetracycline, erythromycin, and azithromycin should not be. It is imperative to strengthen the laboratory infrastructure in this region, as well as to expand the phenotypic and genetic surveillance of antimicrobial resistance, emergence of new resistance, particularly, to extended-spectrum cephalosporins, and molecular epidemiology.
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Affiliation(s)
- Sunil Sethi
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | - Manju Bala
- WHO GASP SEAR Regional Reference Laboratory, Apex Regional STD Teaching, Training & Research Centre, VMMC & Safdarjang Hospital, New Delhi, India
| | | | - Muhammad Ibrahim
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, SE-701 85, Örebro, Sweden
| | | | - Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, SE-701 85, Örebro, Sweden
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