In this study we seek to develop a stewardship intervention that addresses two major interrelated challenges that India faces: increasing antimicrobial resistance (AMR) and a pluralistic health system with a large and unregulated informal health sector. AMR is high on India’s policy agenda as it has one of the highest burdens of bacterial infections in the world and is also one of the world’s biggest consumers of antibiotics for human health. One of the major causes of increasing AMR is the excessive use of antibiotics in humans, animals and the environment.
A majority of healthcare providers in rural India, where 68% of the population lives, do not have a formal medical qualification but they fulfil a need for proximate healthcare that the formal health sector has not been able to meet. They are the first contact providers for a variety of illnesses, who frequently and inappropriately treat with antibiotics. Several states in India, including West Bengal, Bihar and Andhra Pradesh are implementing programmes of training and integrating informal providers (IPs) but their use of antibiotics has proven difficult to change. We conducted a study in 2016-17 (funded by HSRI Call 3) in rural West Bengal to understand the social, economic and behavioural drivers of antibiotic use by IPs in order to address the root causes and develop tailored solutions. We found that the key drivers lay beyond IPs’ individual economic needs and knowledge gaps. There was a strong influence of the pharmaceutical industry’s aggressive marketing of antibiotics, and the regulatory and health systems had limited resources and capacity to provide stewardship in this health market. IPs’ integration was opposed by the Indian Medical Association but there were mutually supportive relationships between informal providers and formal doctors (both public and private) as individuals. Community awareness and practices were another driver. We found that IPs also treated animals, typically with the same antibiotics as humans. To contain antimicrobial resistance (AMR), we need to work jointly with these diverse stakeholders to arrive at solutions through deliberations and consensus. In this study we propose to co-design an intervention with multiple stakeholders to serve as an effective model of antibiotic stewardship at this level. AMR also provides an excellent case study for addressing broader issues of strengthening stewardship in the pluralistic health system at this level.
We will start with formative research in two rural locations in district South 24 Parganas in West Bengal (where our previous study was located) to supplement the data that we have collected in our earlier study. During this phase we will explore antibiotic use with animals in more detail, map the pharmaceutical value chains, conduct a stakeholder analysis, map community platforms for behavioural communication and do a small microbiological assessment of local AMR prevalence.
This will be followed by an intervention development phase where we will work with key stakeholders identified through the stakeholder analysis in Phase 1. Using ‘Deliberative Mapping’, a participatory methodology (used with multiple stakeholders) for democratic decision making we will appraise the problem, systematically weigh the pros and cons of the options and identify a future course of actions through consensus. The intervention options that arise from this process will also be further developed during this phase. The final phase will consist of piloting the intervention with a small group of providers, about 15 in each GP. Evaluation will consist of a feasibility analysis of what worked and did not work, any changes in antibiotic use by IPs, and analysis of the actions and reactions of stakeholders in the system to provide systematic learning to support the design of strategies for strengthening stewardship at scale in future, both in India as well as in similar settings in South Asia and Africa.