The Critical Role of Private and Informal Healthcare Providers in Tackling Drug-Resistant Tuberculosis in LMICs
Global focus on antimicrobial resistance (AMR) will return with a second high-level UN meeting in September 2024, supported by a political declaration. Tuberculosis (TB) accounts for a significant proportion of AMR-related deaths and drug resistance is a major driver of the TB burden, drug-resistant TB is largely overlooked in the broader AMR agenda. TB advocates are calling for strong integration of TB in the AMR agenda in the upcoming week, building on the TB political declaration in last year’s UNGA.
Leading up to the AMR event, a series of publications in The Lancet highlighted how the global AMR burden can be significantly reduced by improving water, sanitation, and hygiene (WASH), enhancing infection control, implementing preventive measures in healthcare facilities, and expanding vaccination efforts in low- and middle-income countries (LMICs)(1). Despite the ongoing efforts, progress in tackling AMR is hindered by critical blind spots, which closely resonate with the efforts to End TB. Dr Madhukar Pai highlights these blind spots in his recent The Lancet article “Tackling antimicrobial resistance: recognising the proposed five blind spots can accelerate progress”(2). First, AMR-related diseases in high-income countries receive far greater focus instead of LMICs where the largest burden lies. Second, AMR initiatives and stewardship efforts are mostly in hospitals and tertiary care institutes, despite over 85% of antibiotic use occurring in the community (3). Third, pharmacies and informal providers, often with little to no medical training, are the major dispensers of antibiotics. Although these three blind spots apply broadly to any AMR-related diseases, these are also crucial in addressing and tackling drug-resistant tuberculosis (DR-TB). A cross-sectional study from Bangladesh has shown that 81.32% of patients with predominant TB symptoms sought their first medical consultation with informal healthcare providers leading to longer diagnostic delays compared to those who consulted formal providers initially. Notably, the majority, 68.48%, of the informal healthcare providers were drug sellers (4). Services provided by private and informal healthcare providers are deemed valuable to community members because of their low cost, established trust, easy accessibility, and willingness to dispense small quantities of medications to reduce out-of-pocket costs (5). In LMICs, weak regulations around over-the-counter antibiotic sales make addressing the role of these providers crucial for reducing AMR, particularly drug-resistant TB.
In the upcoming second high-level UN meeting in September 2024, discussions should emphasize building Public-Private Mix systems engaging and equipping private and informal healthcare providers in combating drug-resistant tuberculosis and AMR.
References:
1. Lewnard JA, Charani E, Gleason A, Hsu LY, Khan WA, Karkey A, et al. Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: an evidence review and modelling analysis. Lancet. 2024;403(10442):2439-54.
2. Pai M, Gandra S, Thapa P, Carmona S. Tackling antimicrobial resistance: recognising the proposed five blind spots can accelerate progress. Lancet Microbe. 2024:100968.
3. Duffy E, Ritchie S, Metcalfe S, Van Bakel B, Thomas MG. Antibacterials dispensed in the community comprise 85%-95% of total human antibacterial consumption. J Clin Pharm Ther. 2018;43(1):59-64.
4. Noman MZI, Islam S, Aktar S, Parray AA, Amando DG, Karki J, et al. Healthcare seeking behavior and delays in case of Drug-Resistant Tuberculosis patients in Bangladesh: Findings from a cross-sectional survey. PLOS Glob Public Health. 2024;4(1):e0001903.
5. Suy S, Rego S, Bory S, Chhorn S, Phou S, Prien C, et al. Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia. BMJ Glob Health. 2019;4(5):e001787.