Much of inappropriate use of antibiotics is because of commercial pressures and the nexus it has with professional behaviours. These pressures lead to shaping public demand in favour of inappropriate use and leads to a legitimizing vicious cycle ¹⁰. This report addresses this entire problem as an issue of consumer and provider behaviour and again completely leaves out the political economy considerations which are the main drivers. These are:

• As related to commercial marketing: There is aggressive and often unethical marketing of pharmaceuticals, with inducements and incentives offered to prescribe higher cost antibiotics of the higher two categories. The use of brand names to provide an irrational marketing and pricing advantage and the failure to ensure generic names. Antibiotics are often sold as irrational combinations, often to avoid regulatory price controls or for branding and marketing purposes. Antibiotics are also promoted and used by informal care providers who have no training, and have picked up these practices from the market. And most important, updated unbiased, scientific prescription information on newer antibiotics is not available to prescribing physicians. The relationship of professional associations to such marketing is mixed with many falling preys to the inducements and only few who are able to stand above it.
• As related to quality assurance: It is much easier to ensure quality when it is part of public procurement, it is almost impossible to assure the same in private retail markets. So often sub-standard antibiotics are available in many LMIC markets.

Competitive pressures and health-seeking culture in the private sector:  there are much greater pressures on private providers to prescribe a greater number of antibiotics with greater power, and promising more immediate relief, so as to have a competitive advantage with other providers in the market.

• Patients’ behaviour toward irrational antibiotic use is not solely a result of providers’ low education. Adequate patient education, also indicative of high-quality care, enhances responsive healthcare and is fundamentally a matter of patients’ rights. In the context where, in 18 countries representing approximately 50% of the global population, patients spend 5 minutes or less with their primary care physicians, the issue of patient engagement to build an understanding about the rational use of antibiotics remains a major concern ¹¹. Average consultation time serves as a recognized quality measure and is endorsed by both the WHO and the International Network for the Rational Use of Drugs (INRUD) for enabling the safe and cost-effective utilization of drugs¹². We propose that the strategy should explicitly include average consultation time, as a key systems challenge and as a key metric to assess rational use of antibiotics, as part of the surveillance of antimicrobial consumption to guide patient care and action on antimicrobial resistance.

All these marketing related distortions of ethical and scientific healthcare are not limited to antibiotics, but with antibiotics they contribute in a major way to the misuse of antibiotics. The strategy should therefore call for strong regime of marketing regulation, accompanied by provision of good quality information and proactive promotion of better antibiotic choices. This would have to be part of a better regulatory regime for private sector care in LMICs. Especially in primary health care, but in all levels of health care, one principle of organizing health services must be that clinical decision making is not subject to market pressures. This can be best assured in public provisioning of services or in designing contracts with private providers, which adhere to this principle.

When it comes to stewardship, the first requirement is a significant increase in microbiological capacity- laboratories, professionals, technicians. There is a need to have such capacity even at the district level and to develop technologies that enable this. This is a requirement for surveillance too. It is also important to call for the use of information from microbiology surveillances in a real time basis for local and regional antibiotic stewardship. There is a danger that accelerating the consumption of microbiological and genomic diagnostics for every individual infection episode, would increase costs of care without necessarily improving antibiotic decisions. There is a need for providers to be guided by patterns of antibiotic sensitivity in each region and reducing the necessity for testing. The strategy should therefore call for public provision of microbiological guidance including affordable rate controlled or free testing services to all patients irrespective of choice of provider. It should also call for local availability and use of information from ongoing microbial surveillance.

This commercial basis of the pharmaceutical sector also relates to the current challenges of innovation which is the third strategy proposed in this report. The current innovation and knowledge regime is bad for all essential medicines of public health importance, but when it comes to anti-biotics it is particularly terrible. By definition third and fourth generation antibiotics have to have very restricted use- which means a very limited market size and very high price mark-ups. It is not possible to create an intellectual property regime and a financing model just for newer antibiotics. Public financing of antibiotic research would help, but without control over patents and distribution we will see the same outcome as we saw with Covid vaccines- a huge profit to big pharma with high inequities in access, despite the public finance. A strategy to develop a more effective innovation regime should a) delink the price of innovation and development from the price of marketing the drug- the latter reflecting only manufacturing costs and b) where public financing is involved, mandate a public acquisition of IPRs and mandatory licensing of multiple generic manufacturers to undertake production including where possible public sector manufacture.

In summary though there are many welcome measures in these strategies it is far too incomplete to succeed. In our regions there is a local saying: “like jumping across a well and managing to cross only nine-tenth across it.”  Good try, but you still fall in.