In the heart of the bustling Nigerian city of Lagos, under the relentless sun, stands a small pharmacy with a faded green sign. It’s a modest place, just a short walk away from my childhood home. As a child, I often wandered inside, not for sweets or toys, but in pursuit of something far more valuable—health.
A few weeks ago, I found myself thousands of miles away from that little pharmacy, seated in the Pennsylvania Convention Centre in Philadelphia, attending the World Antimicrobial Resistance (AMR) Conference. It brought together global health leaders, patient advocates and academics, all dedicated to tackling AMR, which occurs when pathogens—bacteria, viruses, fungi and parasites—develop resistance to the drugs used to treat infections, such as antibiotics. This can make common infections harder—or even impossible—to treat.
The conference was a testament to innovation and collaboration, a global demonstration of synergy and optimism. Yet, as I sat there, a dark cloud of concern hung over my thoughts. An astute Zambian public health doctor, Mirfin Mpundu, spoke on the panel on AMR in Africa. He highlighted the stark challenges posed by lax governmental and pharmaceutical regulations on the distribution and dispensation of over-the-counter antibiotics in African countries.
What he said reflected my experiences in Nigeria, where pharmacies like the one from my childhood were the de facto first point of care for many. Pharmacists assumed the role of physicians, counsellors and dispensers of over-the-counter antibiotics. I remembered how, as a teenager, I’d visit that pharmacy, asking for antibiotics at the first sign of a sniffle, often without a prescription. The pharmacist, a friendly face behind the counter, would oblige since there was no alternative. While this practice might have seemed convenient, it revealed bespoke critical gaps in the health system, where lack of strict regulation and oversight allows antibiotics to be dispensed without proper evaluation, fostering their misuse—and the emergence of antibiotic-resistant infections that are even harder to treat.
As I pondered these memories, a question loomed: How many other people across Africa share a similar narrative, unknowingly fuelling the AMR crisis?
Understanding the global AMR challenge
Overuse and misuse of antimicrobial agents in health care, agriculture, and livestock production are fuelling the growth of AMR. The consequences are profound: prolonged illnesses, increased mortality rates and soaring health-care expenditures.
Over the last two decades, the World Health Organisation (WHO) has repeatedly flagged AMR as a global health priority and one of the leading public health threats of the 21st century. In 2019, estimates for 204 countries and territories, published in the Lancet, revealed that AMR is now a leading cause of death worldwide, higher than HIV/AIDS or malaria, with the worst impacts in low- and middle-income countries. Nearly 1.3 million deaths globally were attributed to antimicrobial-resistant bacterial infections in 2019, with 24 deaths per 100,000 people in Africa attributable to AMR. If unchecked, this number could rise to 10 million global deaths annually by 2050, 4.1 million of them in Africa. [1] Many hundreds of thousands of deaths now occur due to common, previously treatable infections—such as lower respiratory and bloodstream infections—because the bacteria that cause them have become resistant to treatment. Yet the scale of the problem is concealed by patchy surveillance on the continent.
The challenge of antibiotic dispensing and the battle of accessibility
With more antibiotics available in developing countries than ever before, their misuse is facilitated by their availability over the counter, without prescription, and through unregulated supply chains. To tackle this, three challenges must be faced.
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Limited enforcement of regulations: In many countries, the lack of governmental dedication to addressing AMR leads to the absence of effective regulatory frameworks governing the sale and distribution of antibiotics and other antimicrobial drugs. Where such frameworks do exist, there is inadequate enforcement and oversight. Insufficient monitoring and enforcement of pharmaceutical regulations creates a situation where antibiotics are sold without prescriptions, making them easily accessible and enabling their misuse. A 2022 review of AMR records spanning 2016-19 from 14 African countries, including Nigeria, found that up to 34 uncategorised antibiotics not included in the National Essential Medicine Lists were in circulation, highlighting the combined issues of unregulated access and use of antibiotics.
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Supply-chain weaknesses: Primary and tertiary health centres, the cornerstones of healthcare delivery, often have difficulty managing stocks of antibiotics due to weak supply chains. Faced with manufacturing issues, transport problems and an unregulated market, maintaining a consistent and reliable supply of antibiotics becomes a formidable task, which can hinder timely and effective treatment for patients seeking care in these facilities. By contrast, participants in a 2021 study of community-based antibiotic access reported that self-medication was less time-consuming, as well as cheaper and more convenient than accessing medication through healthcare facilities. When drugs were unavailable at such facilities, people could easily acquire them from private pharmacies.
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Pharmacist training: Pharmacists play a critical role in antibiotic dispensing, and they are often the last line of defence against inappropriate antibiotic use. Dispensing involves a range of tasks, such as reviewing, labelling and packaging prescriptions, as well as providing guidance to patients or to caregivers responsible for administering medication. Nevertheless, in numerous low- and middle-income countries, there is a scarcity of pharmacists with the essential knowledge and skills to assess prescriptions, probe symptoms, counsel patients on proper antibiotic use, and identify situations where antibiotics may not be necessary.
Contributing factors
Beyond these structural factors, the improper dispensing of antibiotics is also driven by a complex interplay of personal and cultural considerations.
First, the convenience and immediate relief offered by pharmacies can inadvertently contribute to AMR by promoting the hasty dispensing of antibiotics without proper prescription and oversight. In many instances, pharmacies prioritise profit over patient health, which encourages the sale of antibiotics to consumers without a legitimate medical need or prescription. Patients seeking quick relief from their ailments often pressure pharmacists into providing antibiotics without first obtaining a proper diagnosis or consulting a professional healthcare provider.
Second, deep-seated cultural norms often perpetuate the idea of antibiotics as a panacea, driving patients to demand these drugs for ailments that don’t require them. This can lead to incomplete treatment courses, incorrect dosages, and antibiotics used inappropriately—all of which can drive AMR. Furthermore, the reluctance to seek timely medical care by those who prefer traditional remedies or unregulated sources of treatment delays the prompt administration of antibiotics when they are truly needed.
Finally, the erosion of trust in primary health care as the central source of care intensifies the challenge of AMR in Africa. When individuals lose faith in the healthcare system’s ability to deliver timely and effective care, they are likely to resort to self-diagnosis and irrational use of antibiotics. Rebuilding trust in primary health care as the cornerstone of healthcare delivery is pivotal to curbing AMR and ensuring that antibiotics are used judiciously and responsibly.
Addressing the AMR challenge in Africa and globally
The global threat of AMR has been neglected for far too long. Addressing AMR in Africa must begin with governments acknowledging it as a looming crisis for the continent—and making real, practical commitments to curb it. Using data from the 2021 Global Health Security Index developed by Economist Impact to provide countries with an improved understanding of their existing capacities to prevent, detect and respond to biological threats, including AMR, is an excellent place to start. Without such assessments of capacities, governments may remain unaware of their vulnerability levels, hindering their ability to proactively address and mitigate these pressing global health challenges.
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Building political will:
Building political will demands a concerted effort and a deep commitment to safeguarding public health. Education and advocacy are powerful tools that can shed light on how AMR jeopardises our ability to treat common infections, conduct surgeries and manage chronic diseases effectively. Emphasising the economic and social costs of inaction can galvanise support since AMR threatens not only lives but also national economies and global stability. For instance, a report by the World Bank estimated that by 2050, AMR could result in a reduction of global GDP by 1.1% and push 28.3 million more people into extreme poverty. Communicating these tangible economic repercussions to policymakers can motivate them to prioritise AMR as a critical public health issue. Governments can also implement policies and practices that promote responsible use of antibiotics, such as prescription-only access to reduce the development of antibiotic-resistant bacteria.
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Funding and partnerships:
Public-private partnerships will be crucial in the fight against inappropriate antibiotic use and AMR. The enormous financial, technical and infrastructural gaps in many African countries make it difficult for governments to curb inappropriate antibiotic use and AMR effectively. However, the private sector can provide critical bridge financing, technical expertise and infrastructure. [2] Governments can engage the private sector through public-private partnerships and create a favourable investment climate (eg, removing import barriers that raise the costs of acquiring diagnostic equipment) for private-sector participation in efforts to curb inappropriate antibiotic use and AMR. [3]
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Health systems strengthening:
One of the best opportunities in the short term to mitigate the threat of AMR is to increase investments in healthcare systems and bolster preparedness to combat infectious diseases. This involves enhancing public and veterinary health systems while building surveillance for AMR into them as an integral component. For instance, nations can establish and integrate antimicrobial stewardship (AMS) programmes into existing health-systems-strengthening components such as infection prevention and control protocols, WASH (water, sanitation and hygiene) facilities, adequate diagnostic microbiology services and efficient governance frameworks. [4]
The battle against AMR is daunting, but through collaboration and policy implementation and oversight, we can overcome it. The World AMR Congress made clear that the need to take meaningful action to address AMR is urgent, with AMR mortality estimated to outpace deaths from all cancers in our lifetimes.
As for that modest pharmacy in Lagos, I envision a day when it becomes a place where healthcare advice is coupled with access to a comprehensive healthcare system. A day when pharmacies are not the first and only option but part of a broader healthcare tapestry.
[1] Jonas OB, Irwin A, Berthe Fet al.. Drug-resistant infections: a threat to our economic future (Vol. 2): final report (English). HNP/Agriculture Global Antimicrobial Resistance Initiative Washington, D.C.: World Bank Group. 2017
http://documents.worldbank.org/curated/en/323311493396993758/final-report. [Ref list]
[2] International Finance Corporation (IFC) . The Business of Health in Africa: Partnering with the Private Sector to Improve People’s Lives. 2008 https://documents1.worldbank.org/curated/en/878891468002994639/pdf/441430WP0ENGLI1an10110200801PUBLIC1.pdf [Ref list]
[3] Mason N, Matoso M, Smith W. Private sector and water supply, sanitation and hygiene. 2015. https://cdn.odi.org/media/documents/9930.pdf [Ref list]
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10230568/#dlad062-B88
