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Combating drug resistance through better governance of informal antibiotic sellers in Cambodia

Combating drug resistance through better governance of informal antibiotic sellers in Cambodia

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There is little research on informal health care providers and their role as sellers of antibiotics. We investigated invisible medicine sellers (IMS) in Cambodia, seeking to better understand the health system gaps they fill, features that allow them to become trusted health providers, and their knowledge of antibiotics. This project is funded by a MRC  Joint Health Systems Research Initiative Foundation Grant. 

About this project
AMR and Unregulated Medicine Sellers in Cambodia about 2 columns
AMR and Unregulated Medicine Sellers in Cambodia about
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What were our research questions?

1. Which providers do communities in peri-urban Phnom Penh buy medicines from & what influences their choice of provider?

2. Do people buy antibiotics from unlicensed/invisible drug sellers?

3. What drives irrational use of antibiotics by different healthcare providers?

4. What are policymakers’ views on addressing irrational use of antibiotics by private drug sellers?

What is an invisible medicine seller (IMS)?

Within the private sector, there are formal and informal providers: visible health care providers (HCPs), who provide health services within in a physical space that is signposted and designed for health services, and invisible HCPs, who provide health services without having a marked and specifically designated outlet for this purpose. We define the latter as IMS. 

What is an invisible seller?

Why do they matter?

Dispensing of medicines without establishing clinical need poses a risk to patients- and this inappropriate provision of antibiotics is of major global concern due to the scale of morbidity and mortality that is predicted to be caused by antimicrobial resistance (AMR). 

Thought there are clear laws in Cambodia surrounding the distribution and dispensation of medicines, antibiotics are often readily available and used without a prescription (and are sometimes counterfeit). This is a major challenge in combating AMR in Cambodia- and across the globe. 

Our work mapping all the registered pharmacies and hospitals across the 12 districts of Phnom Penh reveals stark geographical inequalities in the distribution of pharmacies. The peripheral districts have a much lower density of registered pharmacies and hospitals compared with the central districts. For example, only seven registered pharmacies are located in the Por Senchey district despite this area having a population of approximately 185 000 people; each pharmacy in Por Senchey must serve approximately 26 000 people and cover 23 square kilometres. In contrast, the centrally located district of Prampir Meakkakra has 18 registered pharmacies, with one pharmacy every 0.1 square kilometres.

 

Map of registered pharmacies in Phnom Penh
Sen Sok (1), Por Senchey (2), Dangkao (3), Chbar Ampov (4), and inset of central districts, including Prampir Meakkakra

 

Who we are

We are a team of collaborators from the London School of Hygiene & Tropical Medicine, and the University of Health Sciences who share a passion for reducing health inequalities in Cambodia, and across the globe.  We bring together an array of diverse skills and experience, across the fields of public health, health systems, pharmacy, and health policy. 

Profiles

Sonia
Rego

Research Fellow

Dr. Saphonn Vonthanak

Rector (MD, PhD)

Prof. Vonthanak is the first Cambodian to earn a Ph.D. in epidemiology, and is the rector of the University of Health Sciences in Phnom Penh, Cambodia. This project could not have been done without his great support and expertise. 

Dr. Sothavireak Bory

(PharmaD, MSc, PhD)

Sovanthida Suy

( MAppStat, MSc)

Ms. Sovanthida Suy is the head of the Public Health Department at the University of Health Sciences.

Dr. Helena Legido-Quigley

Associate Professor

Prof. Helena Legido-Quigley is an associate professor at the National University of SIngapore's Saw Swee Hock School of Public Health

Johanna
Hanefeld

Associate Professor
Outputs

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.

Conferences and Seminars

We have presented our work at:

 2nd Scientific Conference of University of Health Sciences 
~ 300 national and international researchers, UHS lecturers and students
(27 to 28 February 2019)

Private Sector Interest Group at the London School of Hygiene and Tropical Medicine
(April 2019)

Media Coverage

Our work was recently covered by the Bureau of Investigative Journalism, as part of their antimicrobial resistance coverage. 

Scientific Papers

Scientific Papers
Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia
Sovanthida Suy, Sonia Rego, Sothavireak Bory, Sophea Chhorn, Socheata Phou, Chanra Prien, Sotheara Heng, Shishi Wu, Helena Legido-Quigley, Johanna Hanefeld, Vonthanak Saphonn, Mishal S Khan
2019
BMJ Global Health
Conferences, Seminars, and Workshops
Engagement

On September 23, 2019, we conducted a dissemination event at the University of Health Sciences in Phnom Penh. The half-day event was attended by policymakers, policy actors, and university students. 

The event was opened by Cambodia's Minister of Health, Mam Bun Heng, who spoke on the importance of AMR, and was chaired by Professor Vonthanak Saphonn. After our team shared our results, there was a panel discussion on AMR and Cambodia, where panelists shared their thoughts, then opened the floor up for questions.

 

Panel Discussion participants
UHS and LSHTM Researchers
Innovative Methods
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Following a rapid assessment of community healthcare seeking behaviour across two districts, we conducted Focus Group Discussions (FGDs) with community members from 7 selected villages, led by an experienced bilingual facilitator in Khmer. 

The research team worked with the village leaders to select participants, aiming for an even distribution of age and sex, and these participants were approached by the village leaders. The FGDs were conducted in an open, centrally located space within each village, typically the main community building in a village, or an outdoor wooden platform used for important meetings. After the discussion, every medicine seller mentioned in the discussion was sought.  

We also conducted Interviews with policy makers and policy actors. 

The FGDs and interviews were audio-recorded following consent.

Interview Flowchart
Conducting a focus group in a community
Conducting a focus group in a community
Thinking aloud exercise with policy makers and policy actors
Thinking aloud exercise with policy makers and policy actors