Marketing and Distribution System Foster Misuse of Antibiotics in the Community: Insights from Drugs Wholesalers in India.

Anita Kotwani,Girdhari Lal Singal,Sumanth Gandra,Arti Bhanot

doi:10.3390/antibiotics11010095

Anita Kotwani, Girdhari Lal Singal + Show 2 more

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https://doi.org/10.3390/antibiotics11010095

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Abstract

Antibiotic misuse is one of the major drivers of antimicrobial resistance (AMR). In India, evidence of antibiotic misuse comes largely from retailers as well as formal and informal healthcare providers (IHCPs). This paper presents the practices and perspectives of drug wholesalers, a critical link between manufacturers and last-mile dispensers. Four experienced wholesalers and an ex-State Drug Controller (ex-SDC) were interviewed in depth, using semi-structured guides in the National Capital Region of Delhi, India, between November 2020 and January 2021. Four main findings were that wholesalers (i) have limited knowledge about wholesale licensing and practice regulations, as well as a limited understanding of AMR; (ii) directly supply and sell antibiotics to IHCPs; (iii) facilitate medical representatives (MRs) of pharmaceutical companies and manufacturers in their strategies to promote antibiotics use in the community; and (iv) blame other stakeholders for unlawful sale and overuse of antibiotics. Some of the potential solutions aimed at wholesalers include having a minimum education qualification for licensing and mandatory Good Distribution Practices certification programs. Decoupling incentives by pharmaceutical companies from sales targets to improve ethical sales practices for MRs and optimize antibiotic use by IHCPs could alleviate wholesalers’ indirect actions in promoting antibiotic misuse.

Highlights

Antibiotic misuse is common in low- and middle-income countries (LMICs) [1,2,3,4], and this practice is one of the major drivers of antimicrobial resistance (AMR)
In-depth interviews were conducted with four wholesalers who are in the business of pharmaceuticals for more than 20 years to explore the practices regarding antibiotics’ sale in the community and their awareness of AMR
This study revealed that wholesalers and small-to-medium-scale manufacturers supply medicines including antibiotics to such informal healthcare providers (IHCPs) without sale bills, which is an illegal practice

Summary

Introduction

Antibiotic misuse is common in low- and middle-income countries (LMICs) [1,2,3,4], and this practice is one of the major drivers of antimicrobial resistance (AMR). Inequalities in healthcare, wide economic disparity, corruption resulting in poor return on taxation, poor hygiene and sanitation systems, easy availability of over-the-counter (OTC) antibiotics, self-medication in the community, preference for broad-spectrum antibiotics, lack of human resources for health, widespread use of antibiotics in animals, and poor regulation and implementation are dominant reasons for antibiotic misuse in LMICs [5,6]. In India, there is an increasing trend in the overuse of antibiotics—especially broad-spectrum and newer antibiotics [7]. Concern has been expressed about irrational prescription practices by physicians and informal healthcare providers (IHCPs) [8,9,10,11]. Drug promotion and marketing tactics by pharmaceutical companies play an important role in driving the OTC sale of antibiotics and indiscriminate prescription practices by physicians and IHCPs [12,13]

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