Improving Practice in Ugandan drug shops: a holistic approach to regulation

Summary

Drug shops are small retail outlets that sell over the counter, antimalarial and antibiotic medicines. They operate in many countries in Africa and Asia and although they are not part of the formal health system, they sell life-saving treatments to many people in both urban and rural areas. In many countries, however, these shops often sell antibiotics inappropriately, providing too few or too many tablets, combining them in medicinal cocktails and selling them to people who are not suffering from bacterial infections.

Antibiotics are an odd type of medicine, the more we use them then the less useful they become not only to ourselves but also to everyone around us. To protect them and ensure that they are useful for future generations we need to restrict their use. But as the World Health Organisation argues, there has to be a fine balance between restricting the unnecessary use of antibiotics and ensuring that they are available to those that need them. This complex balancing act has led some policy makers to refer to antimicrobial resistance as a super wicked problem.

This research project begins with the recognition that we have to tackle the mis-selling of antibiotics in drug shops around the world while ensuring that the worlds poorest people can still have access to them and that we can only get this balance right if we can regulate medicine sellers more effectively.

Research undertaken by this team and by others working across Africa and Asia shows that one of the reasons that drug shops sell antibiotics in too large or small a quantity and to those who don't need them is because they are poorly regulated. In many countries, regulations are often out of date, impossible to work within and ignored by most people. Regulators are often so poorly paid that they are willing to take bribes from medicine sellers and medicine sellers recognise that it is easier and cheaper to pay the bribes to the regulators than try to work within the official guidelines.

Until recently, we have had few ideas about how to better regulate these markets. What we had tried out had some impact but nothing like the sort of changes that we needed to make to stop antimicrobial resistance making many lifesaving medicines useless. New thinking from the world of anti-corruption has given us exciting new ways to improve regulation and rule abiding behaviour. Building on work in Ugandan drug shops that we started in 2011, this project will build an intervention model, an experiment which can explore which of these new methods will work in Uganda and how they should be best assessed.

Drug shops are small retail outlets that sell over the counter, antimalarial and antibiotic medicines in low- and middle-income countries in Africa and Asia. In many countries, however, these shops are inadequately regulated, and poor practices include inappropriate the sales of antibiotics. In drug shops, simply limiting access to the antibiotics would create a barrier to lifesaving treatment for many of the world's poorest citizens. To be equitable, therefore, interventions in medicine markets must balance efforts to curtail excess use of antibiotics with the population's needs to secure effective access to lifesaving medicines.

This research project will lead to the creation of an affordable, feasible and acceptable intervention that will improve the rational use of antimicrobial medicines by improving the regulation of medicine markets in low- income settings in Africa and Asia. It builds on research among drug shop vendors in Uganda by the research team and seeks to identifying the overlapping social, economic, and professional interests of different (sets of) actors to create novel forms of collective action.

The main intervention trial will be a stepped wedged cluster randomised trial with a process evaluation in 10 districts with collaborative Quality Improvement cycles (with policy makers, regulators, drug shop vendors and community members), subsidized commodities for drug shop vendors and material resources (bicycles, regulation forms) for community members to support regulatory work.

In this project, we will collect qualitative data among drug shop vendors, policy makers, community members and district officials to identify incentives, training needs, and the feasibility of involving members of the community and drug shops and policy makers in holistic regulation.