BACKGROUND: India—one of the most significant antibiotic users in the world with a high burden of antibiotic resistance—does not have a formal antibiotic surveillance system. No formal studies exist on the sub-national differences in antibiotic use in India except for small hospital or community-based studies. Informed by the WHO Global Action Plan, India developed a national action plan; however only two states have state action plans so far. This suggests that it is important to understand existing antibiotic consumption patterns, sub- national differences and trends over time, and the determinants of antibiotic use so that evidence-informed action plans and programs can be developed in India.
AIM: To understand the changing landscape of antibiotic use in India and contribute to relevant policy and programmatic interventions that can improve the appropriate use of antibiotics in the country. Specific objectives included examining the use of systemic antibiotic consumption at the national level, analyzing geographical and temporal variations across states between 2011 and 2019, and understanding the determinants of antibiotic consumption. Additionally, we examined Kerala as a case study to understand the use and availability of data in designing, implementing, and monitoring the state antibiotic action plan.
METHODOLOGY: First, we conducted a cross-sectional analysis of antibiotic use in 2019 using the WHO Access-Watch-Reserve (AWaRe) and Defined Daily Doses (DDD) matrices at the national level across product type (Fixed-Dose Combinations [FDCs]; and single formulations [SF]), essentiality (listed in the national list of essential medicines [NLEM]; and not listed), and central regulatory approval status (approved and unapproved). Second, we analyzed trends in consumption rates and patterns at the national, state, and groups of states at different levels of health achievements (‘high focus’ [HF]; and ‘non-high focus’ [nHF]) and compared the appropriateness of use between states and state groups. Third, using a cross-sectional, time series (panel) dataset on antibiotic use, per-capita GDP, per-capita government spending on health, girls' tertiary education enrollment ratio, measles vaccination coverage, and lower respiratory tract infection incidence for the period 2011- 2019, we conducted a quasi- experimental fixed-effects analysis to understand the critical determinants of antibiotic use. Finally, we conducted key-informant interviews and document analysis to understand the use of data in policy formulation, implementation, monitoring, and evaluation of the Kerala state action plan.
RESULTS: India's per-capita private-sector antibiotic consumption rate was lower than global rates, but the country has a high consumption rate of broad-spectrum antibiotics, FDCs discouraged by WHO, formulations outside NLEM in FDCs, and unapproved formulations. The overall rate increased from 2011 to 2016 and decreased between 2016 and 2019, registering a net decrease of 3.6%. State consumption rates varied widely— with HF states reporting lower rates. The inappropriate use increased over the years, the share of Access antibiotics decreased (13.1%), and the access-to-watch ratio declined (from 0.59 to 0.49). HF and nHF states showed convergence in the share of the Access and the Access-Watch ratio, while they showed divergence in the use of WHO Discouraged FDCs. The most critical independent determinant of antibiotic use was government spending on health—for every US$12.9 increase in per-capita government spending on health, antibiotic use decreased by 461.4 doses per 1000 population per year after adjusting for other factors. Economic progress (increase in per-capita GDP) and social progress (increase in girls' higher education) were also found to reduce antibiotic use independently. The qualitative case study showed that stakeholders understand and express interest in generating and using data for decision- making, and the action plan document mentions some basic monitoring plans. However, a monitoring and evaluation framework is missing, there is a lack of engagement with the private sector, and there is a lack of understanding among key government policymakers on the importance of using data for surveillance and policy implementation.
CONCLUSION AND IMPLICATIONS: There is significant and increasing inappropriate antibiotic use in India's private sector, accounting for 85-90% of total antibiotic use. Increased government spending on health is critical in reducing private-sector antibiotic use. The dearth of data on public sector use is a significant challenge in understanding the total consumption rate. Developing a monitoring and evaluation system through stakeholder engagement is necessary for Indian States to inform, monitor, and evaluate effective antibiotic action plans. We need global efforts to improve the science and methods to measure antibiotic use. / 2023-08-30T00:00:00Z
| Identifer | oai:union.ndltd.org:bu.edu/oai:open.bu.edu:2144/45083 |
| Date | 30 August 2022 |
| Creators | Fazaludeen Koya, Muhammed Shaffi |
| Contributors | Rockers, Peter C. |
| Source Sets | Boston University |
| Language | en_US |
| Detected Language | English |
| Type | Thesis/Dissertation |
| Rights | Attribution 4.0 International, http://creativecommons.org/licenses/by/4.0/ |
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