This is a blog which deals with public health problems and prospects of Bangladesh. It contains research reports and articles and documents on relevant issues of Public Health and Health Systems in Bangladesh and blog posts on contemporary health issues of Bangladesh by Syed Masud Ahmed.
Welcome to my Public Health World of Bangladesh!
Welcome! If you are interested about the health and health systems of Bangladesh, its problems and prospects, you have come to the right place! Be informed...
Thursday, 30 October 2014
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
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.
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.
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.
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.
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
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.