Comment
Access to antibiotics: not a problem in some LMICs
Poor access to antibiotics is estimated to cause
substantial morbidity and mortality due to pneumonia
and acute febrile illness among children younger than
5 years, with most of these events happening in low-
income and middle-income countries (LMICs).1 However,
a study set in eight LMICs showed that children received
around 25 antibiotic prescriptions for respiratory tract
infection or fever during their first 5 years of life, and
most of these prescriptions were deemed inappropriate.2
This conflicting finding calls for better understanding of
issues surrounding antibiotic access and use in LMICs,
because these countries simultaneously face high
burdens of antimicrobial resistance.3
In The Lancet Global Health, Thi Thuy Nga Do and
colleagues4 elucidate the complexities of community-
based antibiotic use through a combination of
individual interviews, focus group discussions,
household surveys, and customer exit questionnaires
involving both community members and suppliers.4
This mixed-method study was done in seven com­
munities in six LMICs in Asia (Bangladesh, Thailand,
and Vietnam) and Africa (Ghana, Mozambique,
and South Africa), thus allowing identification of
key differences across contexts. A higher density of
antibiotic suppliers was observed in the Asian countries
than in the African countries, with private providers
accounting for more than 90% of mapped suppliers in
all three. The proportion of households that reported
antibiotic use during the previous month was also
much higher in Asian countries (498 [49·4%] of 1009 in
Bangladesh, 465 [42·3%] of 1100 in Ghana [Kintampo],
263 [31·1%] of 847 in Ghana [Dodowa], 161 [25·2%]
of 639 in Mozambique, 63 [10·2%] of 616 in South
Africa, 294 [27·9%] of 1053 in Thailand, and 416 [45·0%]
of 925 in Vietnam). It was common for patients to
purchase antibiotics without prescription in Ghana
(36·1% of purchases), Bangladesh (45·7%), and Vietnam
(55·2%), but not in Mozambique (8·0%), Thailand
(3·8%), or South Africa (1·2%). The main reasons that
participants gave for their choice of antibiotic provider
for mild conditions were convenience, trust, costs, and
disease severity, and strong enforcement of regulations
also affected participant knowledge of purchasing
restrictions and whether treatment was sought from
private suppliers. Hence, drug stores—which are
www.thelancet.com/lancetgh Vol 9 May 2021 e561
the easiest, least expensive, and most timely way to Published Online
March 10, 2021
obtain antibiotics in many Asian countries—frequently https://doi.org/10.1016/
constitute the first point of care for both adults and S2214-109X(21)00085-1
children. Where drug sellers are less common, and See Articles page e610
where antibiotic prescriptions are tightly enforced, as is
the case in South Africa, or where antibiotics are more
costly, as in Mozambique, participants reported a lower
consumption of antibiotics than those in other settings,
especially for mild conditions that probably do not need
antimicrobial treatment. Broad-spectrum antibiotics
belonging to the Watch group of the WHO AWaRe
classification accounted for more antibiotic sales in
Bangladesh and Vietnam as compared with other sites.
The study findings provide novel insights into access
to antibiotics among mainly rural communities in
six LMICs. As Do and colleagues point out, access to
medically necessary antibiotics is not a problem across
rural and urban or suburban communities in Asia where
their study took place. Moreover, the liberal dispensation
of Watch-group antibiotics in rural communities in
Bangladesh and Vietnam is concerning. Although the
generalisability of results beyond the study sites needs
to be further explored, these findings bring the adverse
outcome estimates attributable to reduced access to
antibiotics in LMICs into question.1 These estimates
were based on the assumption that poor access to
antibiotics explained all cases of undertreatment with
antibiotics for acute febrile illness among children,
when in fact a substantial proportion was due to either
diagnostic difficulty or diagnostic capacity.1 However,
increased access to antibiotics does not necessarily
mean better quality of care.5 Drug sellers are erroneously
seen as the best response to people’s needs when they
might even contribute to poorer outcomes for both the
individual (eg, incorrect treatment leading to toxicities
and diagnostic delays) and the community (eg, spread
of antimicrobial resistance). Additionally, although the
problem of counterfeit and substandard medicines was
not investigated by Do and colleagues, the prevalence
of these products is estimated at approximately
30% in LMICs.6 Such poor-quality pharmaceuticals,
including a substantial proportion of antibiotics, easily
find their way through unauthorised drug stores due to
absence of quality control, with serious consequences
for the user.
 Comment
The study findings indicate the urgent need for
interventions focused on antibiotic dispensing in drug
stores for mild conditions. Most research efforts in
LMICs to date have been devoted to the evaluation of
stewardship programmes in health-care settings.7 Drug
stores continue to be only marginally affected (if at all)
by interventions aimed at promoting rational antibiotic
use. Depending on the context, a multi-pronged
approach combining education programmes with
regular feedback mechanisms and more incisive law
enforcement could have a substantial effect on over-
the-counter sale of antibiotics. In addition to the drug
stores, private health-care providers, including informal
providers, contribute to a substantial proportion
of antibiotic dispensing in primary care settings in
LMICs,8 and interventions aimed at reducing antibiotic
dispensation among these groups of providers is much
needed as well.7 Community-based interventions
improving public awareness on the importance of
preserving antibiotics will also be crucial.
GS is a recipient of the David G Guthrie Fellowship from McGill University,
Montreal, Canada.
Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY-NC-ND 4.0 license.
e562 www.thelancet.com/lancetgh Vol 9 May 2021
Giorgia Sulis, *Sumanth Gandra
gandras@wustl.edu
Department of Epidemiology, Biostatistics and Occupational Health, McGill
University, Montreal, QC, Canada (GS); Department of Medicine, Division of
Infectious Diseases, Washington University in Saint Louis, Saint Louis,
MO 63110, USA (SG)
1 Laxminarayan R, Matsoso P, Pant S, et al. Access to effective antimicrobials:
a worldwide challenge. Lancet 2016; 387: 168–75.
2 Fink G, D’Acremont V, Leslie HH, Cohen J. Antibiotic exposure among
children younger than 5 years in low-income and middle-income countries:
a cross-sectional study of nationally representative facility-based and
household-based surveys. Lancet Infect Dis 2020; 20: 179–87.
3 O’Neill J. Tackling drug-resistant infections globally: final report and
recommendations. Review on Antimicrobial Resistance, 2016. https://amr-
review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf
(accessed Feb 23, 2021).
4 Do NTT, Vu HTL, Nguyen CTK, et al. Community-based antibiotic access
and use in six low-income and middle-income countries: a mixed-method
approach. Lancet Glob Health 2021; published online March 10.
https://doi.org/10.1016/S2214-109X(21)00024-3.
5 Bielicki JA, Fink G. Measuring antibiotic use in children: piecing together
the puzzle. Lancet Glob Health 2020; 8: e742–43.
6 Almuzaini T, Choonara I, Sammons H. Substandard and counterfeit
medicines: a systematic review of the literature. BMJ Open 2013;
3: e002923.
7 Wilkinson A, Ebata A, MacGregor H. Interventions to reduce antibiotic
prescribing in LMICs: a scoping review of evidence from human and animal
health systems. Antibiotics (Basel) 2018; 8: 2.
8 Khare S, Purohit M, Sharma M, et al. Antibiotic prescribing by informal
healthcare providers for common illnesses: a repeated cross-sectional
study in rural India. Antibiotics (Basel) 2019; 8: 139.