Unregulated prescriptions
Clive and Anandita discuss how healthcare inequities across India provide fertile ground for unregulated medical practice, contributing to growing antimicrobial resistance in rural populations.
How the perilous state of India’s healthcare system is contributing to antimicrobial resistance
Universal health coverage (UHC) champions easy access to health services, whenever needed, and at an affordable cost. Alas! In reality, UHC is a privilege for marginalised communities all over the world, such as those inhabiting the wilderness of Chhattisgarh in central India.
Health inequity prevalent throughout India is magnified in this region for many reasons. One being the perennial conflict between the Indian government and the Maoists—a conflict fueled by a myriad of factors, such as the government’s exploitation of the mineral-dense region. These ongoing clashes have hindered development in the region, including the urgent development of formal health services. As a result, the nearest and only hospital is often tens of miles away. Moreover, due to a history of colonialism and exploitation of these indigenous lands, there is widespread distrust in government facilities—like hospitals—that further dissuade locals from seeking healthcare. Lastly, access is often limited as roads tend to be poorly constructed and transport services are sparse. With the implementation of COVID-19 lockdown measures, these villages have been severed from links to high-quality biomedical healthcare. Working within these communities during the COVID-19 pandemic, we witnessed how the villagers’ wariness in seeking healthcare services was reinforced as misinformation regarding COVID-19 swirled. Such misinformation further deterred them from accessing hospital services and added to the burden of morbidity and mortality in the population.
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Although the issues around health inequity in this region are complex and there is no quick fix, a notable and rectifiable cause of inadequate healthcare is the shortage of formally trained medical professionals. Inequitable distribution of biomedically trained doctors between urban and rural areas means that patients lack formal consultation and advice when they do seek out healthcare. This scenario can be summed up as the inverse care law: the “availability of good medical care tends to vary inversely with the needs of the population served”. In turn, the lack of good medical care creates fertile ground for the growth of informal healthcare services.
“Lack of good medical care creates fertile ground for the growth of informal healthcare services.”
In India, the shortage of doctors has led to the emergence of “self-taught” doctors known as rural medical practitioners (RMPs). Despite their lack of formal qualifications and training, their services are availed by 67% of the people in India requiring healthcare attention. As per reports, 57.3% of those practising allopathic medicine did not have a medical qualification in 2019. RMPs thrive due to the strong relationships cultivated with the population they serve, providing them with emergency care and consultations at home for low fees. These gaps in the formal public healthcare system have even forced the Ministry of Health (MoH) to recognise these practitioners in certain states, deploying them to primary healthcare centres and sub-centres, and training, certifying, and advocating for their involvement. Additionally, and alarmingly, the patronage and incentives of nascent pharmaceutical companies motivate the RMPs to prescribe expensive and unnecessary medications—including antibiotics—to patients. Erroneous prescription of antibiotics raises the risks of antimicrobial resistance (AMR), which is the process in which bacteria become resistant to treatment after repeated misuse of antibiotics, meaning the drug is no longer an effective cure. Although some might argue that unqualified healthcare providers have been saving people’s lives in rural regions, allowing them to distribute medicine without adequate training is arguably a shoddy attempt to seal the cracks in a dysfunctional healthcare system.
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The misuse of antibiotics and subsequent rising levels of AMR demonstrate the harmful side effects of this patchwork system. Antibiotics are included in the Drugs and Cosmetic Rules (1945) in India and are required to be sold by retail only under the prescription of a Registered Medical Practitioner. However, given the hapless state of the healthcare system and the absence of adequate legal regulations, antimicrobials are being sold to consumers whether or not they have a prescription. Members of the general population tend to approach pharmacies and RMPs due to their ease of accessibility, yet they are usually unaware of the drugs being given to them, let alone their side effects. Most often, these drugs are provided in high doses exceeding the therapeutic limit or sometimes in subtherapeutic doses. Additionally, many misconceptions circulate amongst the population celebrating antibiotics as powerful drugs that can bring about quick relief to their ailments. Smaller drug shops are also driven by larger pharmaceutical companies to promote their brands to maximise profits, despite generic drugs being significantly cheaper. Thus, considering the financial component, the cost of superfluous antimicrobial medications dispensed by pharmacies in India is estimated to be between 1.1 and 1.7 billion dollars.
“Given the hapless state of the healthcare system and the absence of adequate legal regulations, antimicrobials are being sold to consumers whether or not they have a prescription.”
The situation in India forms just the tip of the iceberg. AMR is a global threat: it is projected to cause around 10 million deaths globally by the year 2050. However, its burden is disproportionately higher in countries with lower incomes. Weak infrastructure and inadequate preventive measures, widespread corruption, and mismanagement in lower-income countries have led to a high burden of infectious diseases. The provision of clean water, sanitation, and hygiene could break the chain of transmission of infections and would reduce the need for treatment and curb the chance of developing AMR. For instance, reports from four middle-income countries (including India) have shown that with universal access to safe water and sanitation, the use of antibiotics for the treatment of diarrheal diseases would reduce by 60% from the current 500 million courses.
Interventions in the form of global public awareness to educate the general population about antibiotic resistance is vital. India launched the ‘Red Line Campaign’ to restrict the misuse of antibiotics by discouraging self-medication, learning to identify prescription drugs (through a red line printed on the packet), the importance of completing the full course of antibiotics, and so on. This novel initiative needs to be commended. However, the results so far have not been very promising, and the application needs to be further strengthened.
India spent only 3.8% of its GDP on healthcare in 2018. This has led to the vast healthcare inequities and disproportionate allocation of resources, especially in rural areas. In an ideal world, a well populated country like India would be free of RMPs and other forms of quackery. However, the current scenario suggests attempts to eliminate such practices have been futile so far. Instead, the government must make the best use of the RMPs as human resources through formal training and guidelines—such as those for community health workers in India. Detailed guidelines and protocols would outline the roles and responsibilities of RMPs, including diagnosing and treating basic illnesses while stressing the avoidance of handing out antibiotics. Emphasising the immediate referral of complicated cases would decrease the hesitancy of RMPs to refer to higher centres, and official integration of RMPs at the grassroot levels of the healthcare system would abolish their unregulated practices.
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Along with better training of RMPs, expansion, reinvigoration, and implementation of stringent laws aimed to curb imprudent dispensing of over-the-counter antibiotics and other drugs along with strict vigilance is requisite. Pharmacists need to be repeatedly trained, via continuing medical education and workshops, for proper dispensing of antibiotics and how it impacts AMR. Lastly, regulatory bodies should aim at instilling a sense of responsibility within the pharmacists themselves.
AMR is a global issue and is not restricted by international boundaries: we are all so well connected that microbes constantly cross borders with us! Global action is therefore essential to make meaningful progress over the long term.
It is time we do more than just ponder: antibiotic resistance anywhere is a risk everywhere!