Unregulated sale and overuse of prescription drugs is a common practice in Pakistan. Considering the weak position of our healthcare field, this might not be viewed as such a bad thing. However, this activity is causing the global healthcare sector to find itself in the midst of a dangerous phenomenon known as ‘antimicrobial resistance’ (AMR). AMR involves the process of microorganisms gaining resistance against drugs particularly antibiotics. Given the alarming rate at which AMR is spreading, if allowed to persist, we might be transported back to the era of little or no cure for numerous common diseases. If this sounds a little far-fetched then consider the United Nation’s report which states that AMR will kill more than 10 million people each year by 2050 if it is allowed to spread at its current rate. To put this into perspective, AMR will cause more deaths than cancer.
The increased volume of antibiotics being administered within a population accelerates bacteria acquiring resistance. The equation is relatively straightforward: the more antibiotics we use, the more resistant the bacteria become; and, as a result of this acquired resistance, the effectiveness of the antibiotics diminishes. This could eventually result in the failure to combat common diseases such as pneumonia, tuberculosis and some food borne diseases such as typhoid. The impact of AMR is so strong that it has prompted the World Health Organisation (WHO) to issue a global warning that ‘without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill’.
As far as the framing of healthcare and specifically drugs sale policies is concerned, Pakistan is on par with many developed nations. The Drug Regulatory Authority of Pakistan Act, 2012 outlines extensive measures to implement the law with regards to the regulation of drugs. It could be argued that this is essentially where the problem lies: the law in some cases is just so stringent that it is simply not practical enough to be applied in a developing country such as ours. For example, the law is very clear on the selling of certain drugs only on prescription. However, eliminating all the prescription-only medicines from pharmacies would greatly restrict their access especially in rural areas. A large number of people would be unable to obtain the drug which could give rise to a health endemic. This would create more issues than it will solve. Furthermore, it is not that difficult to imagine it giving rise to another ‘class-divide’ in our society; the ‘well-off’ would be able to ‘arrange’ prescriptions through their contacts leaving the lower classes to bear the brunt.
The National Action Plan, devised in 2017, provides a solid framework for countering antimicrobial resistance. However, taking a pragmatic view of the situation is essential to arriving at a suitable solution. This would mean a realisation that certain stipulations in the law are simply too stringent; their enforcement is just not feasible. Having said that, effective implementation of ‘suitable’ healthcare policies can not only have a profound effect on controlling the spread of disease but also strengthen our healthcare sector.
For example, the presence of a suitably qualified pharmacist in a pharmacy at all times is something that could be enforced. Effective enforcement of this stipulation would help reduce antibiotic consumption especially in rural areas. The underlying principle behind this is that for the majority of the rural population, pharmacies are the first point of information about antibiotics. It is common practice to ‘consult’ the person behind the counter in pharmacies regarding medication; and more often than not that person is not suitably qualified. The presence of a suitably qualified pharmacist would reduce the amount of antibiotics being consumed inappropriately. Moreover, the pharmacist would be able to advise the consumer to complete the full course of the medication.
Effective implementation of public health policies is an essential component of a thriving economy and a prosperous nation. This requires vast administrative and financial resources but the cost of a weak healthcare system is far greater.
Another suitable strategy would be to classify antibiotics according to the urgency with which they need to be regulated. There are some antibiotics that require extremely urgent monitoring. For instance, carbapenems are characterised as antibiotics of ‘last resort’. They are usually given to treat complicated bacterial infections and many multidrug-resistant hospital-acquired bacteria are sensitive only to carbapenems. However, according to a study published in 2014, almost 66% of the bacterial isolates in two of the major cities (Lahore and Islamabad) showed resistance to carbapenems. This figure clearly signifies the need to act promptly to curb the spread of resistance.
These ‘last-resort’ antibiotics could be a good starting point to implement effective monitoring. Since these are almost exclusively used in hospital settings, getting a prescription would not be an issue. Similarly, their usage can also be easily registered. Additionally, given the importance of reducing resistance to these drugs, it would not be difficult to convince doctors and hospitals to consent to the enforced measures. The advantages of taking such measures would be two-fold. Firstly, it would be a step towards introducing a system of prescriptions which can then be gradually extended to more commonly used antibiotics. Secondly, surveillance of the amount of antibiotics being used can be carried out and steps can be taken to prevent overuse.
All the above-mentioned strategies would require a ‘top-down’ approach to be applied. This means that the government would have to adopt a regulatory approach that would involve an administrative body ensuring effective implementation. It is worth pointing out that execution of these measures would not be without its fair share of obstacles. For example, availability of pharmacists might be an issue considering that the majority of them prefer to go into the field of marketing rather than work in pharmacies. Initially, these measures could be enforced in the cities and then worked towards the less developed areas after being fine-tuned. It goes without saying that this would require a sincere and proactive role from the respective provincial health ministries if these steps are to effectively combat the overuse of antibiotics.
A second parallel approach would be a little less conventional but its successful implementation could potentially lead to some excellent results. This approach would comprise of the public itself playing a vital role in confronting the issue. Proper education that seeks to spread awareness of the hazards of antimicrobial resistance would go a long way in improving socio-cultural attitudes. It is pertinent to mention here that if a society is successfully convinced that it needs to act, it would do so with urgency and strength. These ‘intrinsic motivators’ can be far more successful in enabling people to react effectively to a problem than ‘external motivators’ such as monetary incentives.
Effective implementation of public health policies is an essential component of a thriving economy and a prosperous nation. This requires vast administrative and financial resources but the cost of a weak healthcare system is far greater. As the current COVID-19 pandemic has showcased, healthcare is an important pillar of the economy. A high maintenance pillar that supports the entire nation. To sum it up in the words of Cicero; ‘Salus populi suprema lex’– the health of the people is the supreme law.
