Combating drug resistance through better governance of unregulated antimicrobial sellers in Cambodia: addressing stakeholder connections & perceptions

The research proposed here is for a 20-month Foundation grant applying innovative methods to understand, and develop strategies to address unresolved challenges relating to governance of a poorly characterised segment of the health system - unregulated, for-profit drug sellers. We focus on a high priority global health issue, inappropriate dispensing of antimicrobials (AMs), in one of the world's Least Developed Countries: Cambodia. Cambodia serves as an important case study with wider relevance because, like many other countries in the region and those whose health systems have been weakened by conflict, it has experienced a massive growth in unregulated, for-profit healthcare providers.

Our project is a collaboration between the University of Health Sciences in Cambodia and the London School of Hygiene and Tropical Medicine, building upon work initiated in 2014. The team convened is a multidisciplinary group of researchers bringing together experience in health systems research, the Cambodian context and private health sector in Asia. The research will identify the diverse providers that sell AMs, and analyse power relations and networks between unregulated drug sellers (UDS) and local stakeholders that influence policy, in order identify governance approaches for improving AM selling by UDS that are likely to be supported by local policymakers and implemented at scale,

We will address three linked research questions sequentially, producing specific research outputs for each:
1. What are the key "visible" and "invisible" types of outlets selling AMs to engage in interventions to reduce inappropriate use?

To address this research question we will conduct focus group discussions involving a community walk through during which local researchers will be taken to public and private healthcare providers that residents visit for common illnesses in four communes across Phnom Penh, Cambodia. Local researchers will conduct non-participant observations to create a database of healthcare providers including information about whether they are registered or unregistered, and whether they primarily sell medicines or other items.

2. How do the UDS identified link to policy actors including community leaders, commercial drug suppliers and government health officials?

Based on information collected through the initial study, we will select approximately 35 UDS representing the range of actors we identified for in-depth interviews. Through interviews we will investigate people or institutions they are connected to through social or financial networks and generate a list of common stakeholders UDS are connected to.

3. How is policy influenced by UDS's connections to, and ways they are perceived by, policy actors?

We will conduct interviews with the stakeholders identified (we estimate 25) to investigate perceptions of the role that UDS play in providing healthcare, and interviewees will rank alternative governance approaches - banning, regulation, encouragement/subsidy, and purchase of services - while talking through their rationale.

Research undertaken for this Foundation grant will generate: a) understanding of the social and geographical spread of unregulated drug sellers dispensing antimicrobials in urban Cambodia, b) an analysis of stakeholders that are critical to governing unregulated drug sellers and access to antimicrobials in Cambodia, their networks and underlying power relations and c) on this basis, develop a governance intervention to reduce inappropriate access to antimicrobials through unregulated drug sellers. This knowledge and intervention developed will inform a larger research proposal testing the intervention on national scale in Cambodia and provide timely information for policymaking on unregulated drug sellers in other low and middle-income countries that are currently developing health systems strengthening plans under the International Health Regulations.

This Foundation grant addresses the intersection of two 'wicked problems' - antimicrobial resistance and governance of unregulated for-profit healthcare providers. These are challenging to tackle owing to the number and complexity of stakeholders involved who have conflicting interests, as well as the critical role of how the problem is framed in driving responses. Our research will identify the diverse providers that sell antimicrobials in urban Cambodia, and use a political science based social network analysis methodology to investigate power relations and networks between unregulated drug sellers (UDS) and local stakeholders that influence policy. Our analysis will apply the Social Construction Framework for Public Policy to systematically investigate how power relations and social construction reinforce or weaken support for alternative governance measures around antimicrobial selling by UDS, thereby identifying strategies that are likely to be supported by local policy actors and implemented at scale.

Cambodia serves as an important case study with wider relevance because, like many other countries in the region and those whose health systems have been weakened by conflict, it has experienced massive growth in for-profit healthcare providers.

Research will generate: a) understanding of the social and geographical spread of UDS dispensing antimicrobials in urban Cambodia, b) an analysis of stakeholders that are critical to governing UDS and access to antimicrobials, their networks and power relations and c) on this basis, develop a governance intervention to reduce inappropriate access to antimicrobials through UDS. This knowledge and intervention developed will inform a larger research proposal testing the intervention on national scale in Cambodia and provide timely information for policymaking on UDS in other low and middle-income countries that are currently developing health systems strengthening plans under the International Health Regulations.

The ultimate impact of our work will be on populations living in low and middle income countries (LMICs) who will bear the major social and economic consequences of growing antimicrobial resistance (AMR). Inappropriate dispensing of antimicrobial drugs by for-profit healthcare providers in LMICs contributing to AMR is a health systems challenge that is difficult to tackle owing to the number and complexity of stakeholders involved who have conflicting interests, as well as the critical role of how the problem is framed in driving responses. Joint External Evaluations (JEE) to assess country capacity under the International Health Regulations are currently being conducted in all LMICs after which countries are to prepare plans for health systems strengthening in a number of areas including appropriate access to antimicrobials. While improved functioning of the for-profit health sector is a key component of country plans, strategies to improve governance of for-profit healthcare providers in LMICs often do not achieve maximum impact because the local policy and regulatory environment - including perceptions, connections and infrastructure - is poorly understood. Our project will thus provide timely information to maximise impact of research and investments in health systems strengthening by understanding and addressing barriers to uptake of evidence-based approaches for improving governance of for-profit providers; specifically, we focus on unregulated drug sellers (UDS) in Cambodia and our research outputs will impact on:

1. International, regional and national policymakers and funders that are looking to shape LMIC AMR action plans, including the WHO (globally and in the region), the European Union, Public Health England, the Asian Development Bank, the Cambodia Government-Development Partner Coordinating Committee and the Cambodian government's newly formed AMR Working Group.
2. Research funders looking to support evaluations of governance interventions that are aimed at LMIC contexts.
3. Academics with an interest in: health systems based responses to AMR; novel methodologies to study and plan solutions to wicked problems; for-profit or "invisible" healthcare providers; factors influencing policy responses in LMICs.
4. Junior Cambodian and UK researchers through capacity building training and mentorship in applying new health systems methodologies in LMICs.

Research outputs - including scientific papers, conference presentations, a future research questions summary and policy briefs - will be designed to optimise uptake by our end users, and will be disseminate through diverse channels including websites, social media, specific sessions organised at the Prince Mahidol Conference 2018 in Thailand and the Health Systems Research conference 2018 in Liverpool, and publications in targeted at peer reviewed journals.

To maximise impact on the first two groups of beneficiaries, we have devoted considerable attention to arranging an Independent Project Steering Committee of end user representatives. Specific steps taken to optimally engage national policymakers include: conducting a stakeholder mapping exercise to identify platforms for two-way communication about research objectives and findings; planning for our co-I Professor Vonthanak, who, as the Rector of the University of Health Sciences (UHS), is a high level government official, to present to counterparts in the ministries of health, finance, education and law and host seminars at UHS; and early involvement of the local media in building political commitment. Impact on academics will come through new information and testable hypotheses generated as well as advancement of methods to build the nascent discipline of health policy and systems research in LMICs.