Current rates of purchasing of antibiotics without a prescription across sub-Saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance

ABSTRACT

Introduction

Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription.

Areas covered

A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing antibiotics without a prescription). However, considerable variation was seen with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients.

Expert Opinion

ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists’ activities to reduce inappropriate dispensing. Such activities, alongside educating patients and healthcare professionals, should enhance appropriate dispensing of antibiotics and reduce AMR.

KEYWORDS:

• Africa
• antibiotics
• antimicrobial resistance
• antimicrobial stewardship programmes
• AWaRe classification
• community pharmacies
• over-the-counter purchasing
• quality indicators
• utilization patterns

Article highlights

• There is still considerable purchasing of antibiotics without a prescription across Africa, with 100% of community pharmacies in some African countries dispensing antibiotics without a prescription

• However, rates of dispensing vary considerably both within and across countries. It is important to address current high rates typically for self-limiting conditions to reduce AMR, which is a major issue across sub-Saharan Africa (currently the continent with the highest prevalence rate of AMR globally) and an important part of National Action Plan activities to reduce AMR

• High rates of purchasing of antibiotics without a prescription are exacerbated by issues of affordability (cost of medicines and physician costs as well as travel costs to facilities) among the population as well as possible loss of earnings with long waiting times to see a professional in healthcare facilities. Community pharmacists are more convenient

• Educating pharmacists and patients can reduce inappropriate dispensing of antibiotics. The instigation of quality indicators as part of antimicrobial stewardship programmes also helps reduce inappropriate dispensing

• With the publication of the AWaRe book, it is increasingly likely that future quality indicators will be based on its content. Alongside this, there will be an increasing use of information technology and mobile telephones to monitor future antibiotic dispensing patterns against agreed indicators

• The curricula in universities for healthcare professionals will also need to be upgraded to make sure they are fully competent to appropriately counsel patients on the optimal management of their infectious disease/those of their children post qualification, backed up by continuous professional development activities

Declaration of interest

A Cook and C Moore are funded by the Welcome Trust (222051/Z/20/Z) for the ADILA project. E Yeika, SA. Opanga, ZU Mustafa, V Marković-Peković, A Kurdi, BD Anand Paramadhas, E Wesangula, E Hango, N Schellack, S Mudenda, I Hoxha and JC Meyer have either worked for national or regional government agenices or are advisers to them on key issues surrounding AMR including the development and monitoring of NAPs. In addition, S Opanga received a grant from Kenya AIDS Vaccine Institute -Institute of Clinical Research and Institut Merieux for tackling AMR in Kenya and GM Rwegerera also works for Destiny Medical and Research Solutions Proprietary Limited, Gaborone, Botswana. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/14787210.2023.2259106

Additional information

Funding

This paper was not funded.