Dr Gautham: informal health providers key to reducing antibiotic use in rural India

2021-01-25

Dr Meenakshi Gautham is a Research Fellow in Health Systems and Policy at the London School of Hygiene and Tropical Medicine (LSHTM) since 2012. She is currently leading a study to design a One Health Antibiotic Stewardship Intervention in community settings in rural India. In the project she is working with informal health providers and para-vets, the formal public health and veterinary health systems, the pharmaceutical industry and rural communities. Her whole interest in antibiotic use started because of her interest in informal providers. Informal providers are universally available in many low- and middle income-countries but ironically excluded from global and local discussions about Universal Health Coverage.

Tell us more about the project you are working on!

– Our focus is on co-designing a One Health Antibiotic Stewardship intervention. We began with a proper identification of the different stakeholders, who would be affected by any kind of changes in the present patterns of antibiotic use in community settings, and also those who can effect such change.

– The stakeholders are providers, both informal and formal, communities, but will also include the government, regulatory departments and health authorities. Also, pharmaceutical industry stakeholders, not just the corporates, but also those who are involved in the supply chain, the wholesalers, distributors and stockists. Finally, we are to include organizations and groups that are engaged in a more distant way – as champions of antibiotic resistance, like ReAct itself for example.

– We want to include them all in our discussions, because from our work so far, we have realized that this is such a complex problem. There are so many interconnections and inter linkages and mutual dependencies that are creating a whole culture of inappropriate antibiotic use. So, we think that just interacting with all these different stakeholders to co-design an intervention is a project by itself.

You have focused your work on informal health providers and their role in antibiotic use for a long time. What are you finding through your current study in rural India?

– My whole interest in antibiotic use happened because of my interest in informal providers. I began looking at them first, but then realized that it’s a much wider problem of informalities of practices rather than just informal providers.

– When you are trying to change the whole culture of antibiotic use, you have to go beyond focusing on one group. We are working in community settings and this raises so

many other challenges. There are social factors, there are economic factors, our health system’s deficiencies, there are regulatory barriers. So it’s really, really complex. It is not a closed space, but very open ended. So, we have been looking at all the informalities that are going on in that space, irrespective of who is doing it and what their qualifications are and what their legal status is.

Accessing antibiotics in rural India

– What we have found is that people may access their antibiotics from informal providers, but they can also go to pharmacies, where these are available, even in rural areas. They can access antibiotics depending on their payment capacity and they can also get customized packages because informal providers are very responsive to people’s paying capacity. They realize that people may not be able to pay for a full dose or they will choose an antibiotic, which is not hugely expensive. But also not something which is the cheapest, because there are quality issues about the cheapest ones, and that in turn will affect their own reputation.

“So we have found that they use the medium priced ones and tailor them according to the paying capacity of the patient in terms of the dosage, so generally they might dispense for one day or two days. And either ask them to buy the rest from a pharmacy or they would ask them to come back after two days, and if the antibiotic is working, they will continue. Mostly people will not come back. So that leads to incomplete doses.”

Why people reject free medicines from state-run outlets

– When you ask people why they don’t get free medicines which are available in the government Primary Health Centers the feedback we get is about the quality of those drugs. Another important reason is that the nearest Primary Health Centre may be quite far from their village, while the informal provider is a much more accessible neighborhood practitioner.

– There are generics which are being promoted in government facilities, which are much cheaper, but people do not perceive them as being of good quality. So there is a lot of tension over there. People would rather buy a smaller dose from the informal providers, or they would buy from pharmacies than get the government ones.

– Government sponsored studies show that about 10% drugs sold in government facilities are not-of-standard quality compared to 3%, from private pharmacies. So when people are saying they don’t think that drugs from the government are not of good quality, maybe they’re not just imagining things.

How are formal and informal health providers connected in the rural Indian context?

– We find that a lot of the knowledge of informal providers comes from the formal doctors with whom they are connected commercially. Whenever an informal provider is in doubt, he generally consults a formal practitioner and if this is a private practitioner there is also this unspoken understanding that they will refer their patients to them.

– We find a lot of instances of small hospitals in peri-urban and areas on the outskirts of small towns and cities, where new private facilities are being set up. And their real markets are coming now from an emerging rural middle class, and they need informal providers to help them get those patients. So there are a lot of mutually beneficial relationships that are in place between the formal and the informal. And these informal practices are not legal, they’re not ethical, but they are there and they need to be seen as contributing to this kind of a mosaic of informal practices, which constitutes rural health care. In our study, we are calling it a bricolage of informal healthcare.

– So there are a lot of informalities of practice going on irrespective of qualifications and you have the formal  doctors also involved in it. And, the fact is that even formal doctors themselves don’t really have good guidelines about antibiotic use.

What is the role of the pharmaceutical industry in influencing antibiotic use?

– The pharmaceutical industry are doing their own training programmes with informal providers in rural areas. And they are all about drug promotion. They may be presented as disease oriented workshops, but they are actually focusing on promoting new products, new drugs, and how they can be disseminated further into rural areas.

– The pharmaceutical supply chain is really elaborate. In terms of economic benefits, there are discounts at every rung of the chain and the informal provider is at the very bottom of this chain. So, the discounts start from the stockist to the distributor, wholesaler, maybe the retail pharmacist and they are buying from there. So there is a lot of promotion of all kinds of drugs that goes on. Informal providers may get the knowledge from wholesalers also, besides pharmaceutical representatives, who will try to promote certain drugs.

“There are a lot of economic driving forces that are behind antibiotic use and misuse. And a lot of that has to do with informal practices, and the way the whole industry and the private sector is expanding.”

What kind of policies are needed to integrate informal health providers in the health system and improve the quality of work they do?

– There is a kind of a regulatory impasse that exists currently. For an effective and impactful strategy for changing antibiotic use by informal providers what is needed is acceptance that they are going to use drugs, and perhaps some drugs should be allowed. Maybe some WHO’s ‘Access’ category antibiotics should be allowed with proper guidelines and an easy monitoring system in place.

“But right now, the kinds of regulations that we have are very top down ones that allow only formal doctors to use antibiotics or prescription drugs and nobody else. But in practice everybody is using them, and they are easily available across the counter. So how do you reconcile this situation and design a stewardship
programme for community settings?”

– And, you know, this kind of policy impasse is also being influenced by global policies. It’s coming from an obsession with qualifications, and that only qualifications mean quality. In this view anyone who does not have a university qualification is not providing quality care. But there is enough evidence now to show that even providers with qualifications are not delivering standardized clinical care and providing antibiotics
appropriately. Moreover, if you strictly restrict access to essential antibiotics without as a prescription only drugs, where are poor people in rural areas going to access the doctors to write prescriptions for them?

– These issues – of the unintended consequences of prescription only policies and the resulting impasse have not yet entered the policy formulation arena and there is a need to break this impasse. The regulator’s recognize that if they start coming down with very heavy sanctions, on pharmacies or on informal providers, it’s going to adversely affect the whole health system and health outcomes. And of course, it will have political repercussions as well. So they’re not able to prevent antibiotic misuse but the laws obstruct them from finding practical solutions for reducing inappropriate use. This is the impasse! The alternative could be to let certain antibiotics be sold, be available as non-prescription ones with proper guidelines, and the rest could be more strictly regulated. You can’t possibly control the excess without first ensuring access.