Informal drug markets and the emerging threat of antibiotic resistance in Bangladesh

Drug retail shops are often the first and only source of healthcare outside home for a majority of patients in developing countries including Bangladesh. Outside the public sector, the retail distribution of drugs presents a totally chaotic situation without any regulatory mechanism. According to the BCDS (Bangladesh Chemist and Druggist Samity), there are about 64,000 licensed pharmacies (of which 14,000 are members of the Samity) and around 70,000 unlicensed drugstores in the country involved in selling drugs ‘over-the-counter’. In reality, there are no ‘prescription-only’ drugs in Bangladesh. Anybody can buy any drug in any amount including antibiotics without prescription from these drugstores.

Most of the salespeople at these drug stores do not have training in dispensing of drugs, not to speak of diagnoses and treatment which they frequently do. According to law, the persons dispensing drugs at the drugstores (community pharmacies) should have at least a short training of twelve weeks duration (Grade C pharmacists) before one can apply for a drug shop (Pharmacy) license. This certificate course is conducted by the Bangladesh Pharmaceutical Society (BPS) in cooperation with the BCDS through 45 tutorial centres. The content, form, and utility of this training remain a matter of grave concern.

As these drugstore salespeople have no other channel of information from the formal sectors open to them, they fall easy prey to the aggressive marketing strategies of the pharmaceutical companies. Irrational use of drugs such as over prescribing, multi-drug prescribing, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems found with these retailers. These shops are also the main channels through which the counterfeit, substandard and expired drugs are marketed.

A number of studies have been on the prescribing behavior of the informal formal sector healthcare providers. In a study comparing UHCs with Urban NGO Clinics under UPHCP project, results revealed the extent of prescribing antibiotics for selected common illnesses e.g., A greater tendency was observed to prescribe antibiotics for fever and common cold/cough than for acute respiratory infection (ARI) (including pneumonia). In all cases, antibiotics were prescribed without any laboratory investigation. 

In another study, besides analgesics, antibiotics were the most frequently reported drug used in fever (around 80%), diarrhoea (around 90%) and childhood pneumonia (around 96%) by the unqualified allopathic providers. The CHWs used antibiotics more frequently while treating children for pneumonia (69%) than when treating fever (30%) or diarrhea (43%). The relatively better practices of the CHWs were reflected in another study of semi-/unqualified allopthc providers where they were found to have used fewer antibiotics for fever (11%), diarrhea (30%) and dysentery (22%) but more for ARI of children (94%). The untrained rural medical practitioners (RMPs), in many instances, prescribed antibiotics on demand from the parents, and in inappropriate doses and duration.

Interestingly, in Bangladesh, physicians rarely follow any protocol for identification of the pathogens and its sensitivity to the drug before antibiotics is prescribed. In a study of prescription pattern of the private practitioners of Dhaka city, antibiotics were prescribed in 70% of the prescriptions (Begum et al. 2012) and in another similar study, antibiotics were prescribed in 72% of the instants.In another population-based study in the rural areas of Dhaka and Rajshahi divisions of Bangladesh during Jul. – Dec. 2012, around 44% physicians prescribed antibiotics in cold and fever before confirmed diagnosis. According to the physicians, patient non-compliance was the main cause of antibiotic resistance in the country (68.8%) and more than 50% patients were found to stop taking the antibiotic as soon as the symptoms disappeared, while only 25.2% patient completed the full course.

 Implications

Due to inappropriate and irrational use of antibiotics by both formal and informal sector healthcare providers, resistance to antimicrobials has reached an enormous proportion which need urgent attention. Bangladesh is currently undergoing double burden of diseases (emerging non-communicable life-style diseases but also, existing communicable diseases) and antibiotic therapy will remain a mainstay of treatment for quite some more time to come. This is especially important as the invention of new antibiotics is not currently keeping pace with the speed of emergence of drug resistance.

Challenges

To address this situation, challenges are manifold. In the short term, it should involve the training and motivation of all types of providers in following protocols for antibiotics use as well as build awareness on the dangers of misuse. To change prescriber behavior, standard treatment guidelines supported by prescription audit was found to be highly effective in Bangladesh. Patient should be made aware about the harmful effects of using antibiotics for trivial illnesses and the necessity of completing the course in appropriate dose and duration. Regulatory authority from the DGDA (Directorate General Drug Administration) should see that antibiotics are not sold without prescription as OTC medicines.

In the long run, preventing the emergence of antimicrobial resistance requires the overhauling of the health systems in the country to make it more accessible and affordable to the poor and the disadvantaged sections of the population, and for pharmaceutical system to be placed under regulatory mechanisms for compliance with GMP and prevent entry of sub-standard medicine or counterfeit medicines in the market. Intensive monitoring is needed for assuring that the code of conduct for marketing pharmaceutical products is strictly followed and proper dispensing of medicines etc. is in place with active and informed participation from the pharmacist community.

Attendants at drug retail outlets should be trained in dispensing through the pharmacy council and drug shops brought under regulatory supervision for preventing sale of antibiotics without prescription. Besides, a surveillance system for monitoring the sensitivity of microbials against common pathogens should be in place to guide the practitioners in using the appropriate antibiotics. Strict enforcement of hospital infection control mechanism will help prevent transmission of resistance strains in the community.