Understanding antimicrobial resistance through the lens of antibiotic vulnerabilities in primary health care in rural Malawi

ABSTRACT

The diminishing effectiveness of antimicrobials raises serious concerns for human health. While policy makers grapple to reduce the overuse of antimicrobial medicines to stem the rise of antimicrobial resistance, insufficient attention has been paid to how this applies to low-resource contexts. We provide an in-depth portrayal of antimicrobial prescribing at primary health care level in rural Chikwawa District, Malawi. Ethnographic fieldwork took place over 18 months (2018–2020). We surveyed 22 health facilities in the district, observed 1348 health worker-patient consultations, and carried out 49 in-depth interviews with staff and patients. Care was centred around provision of an antimicrobial. Amid chronic lack of essential medicines and other resources, clinic interactions were tightly scripted, providing patients little time to question or negotiate their treatment. We develop the concept of ‘antibiotic vulnerabilities’ to reveal multiple ways in which provision of antimicrobials in rural Malawi impacts care in conditions of extreme scarcity. Antibiotics are central and essential to primary care. As targets for optimal antimicrobial prescribing take a more central role in global policy, close attention is required of the ramifications for the delivery of care to ensure that efforts to stem resistance do not undermine the goal of improved health for all.

KEYWORDS:

• Antimicrobial resistance
• antibiotic use
• primary health care
• Malawi
• Global South

Acknowledgements

We are grateful to all study participants who took part in this study and to the FIEBRE and DRUM Consortiums. We would like to acknowledge Grace Bongololo (GB) for her support in conducting the interviews and participant observations.

Disclosure statement

No potential conflict of interest was reported by the author(s ).

Additional information

Funding

This study was funded by the Foreign, Commonwealth & Development Office, United Kingdom [FIEBRE Project PO7856] and AMR Cross-Council Initiative through a grant from the Medical Research Council [MR/S004793/1].