A new Comment in The Lancet Global Health. Citation, abstract, extracts and comments from me below. The paper is relevant to HIFA's work on the inforamtion needs of prescribers and users of medicines, and it mentions the Practical Approach to Care Kit which we have previously discussed on HIFA.
CITATION: Mendelson M et al. Facing up to reality: over-the-counter access to antibiotics in low-income and middle-income countries needs a paradigm shift in thinking. Volume 13, Issue 12e2175-e2179 December 2025 Open access.
ABSTRACT
'Almost half of the global population do not have access to universal health coverage and the current shortfall of health-care professionals (including doctors and nurses) is estimated to reach a deficit of 11 million by 2030, disproportionately affecting low-income and middle-income countries (LMICs). Against this backdrop, of the 8 million deaths per year from bacterial sepsis worldwide, over 3 million are from treatable antibiotic-sensitive infections. This number suggests that access to antibiotics under the current model is insufficient. In many LMICs, over-the-counter antibiotic sellers that range from informal drug procurers to small-sized and medium-sized private pharmacies are the primary and most accessible care providers. Yet global health narratives, often shaped by the traditional doctor-led prescribing model, portray them as drivers of misuse rather than recognising them as politically and economically embedded actors that meet unmet health and antibiotic needs. In this Viewpoint, we argue that over-the-counter antibiotic sellers need to be integrated into a solution for antibiotic misuse and overuse, rather than being seen as part of the problem. Furthermore, we provide a framework with which to achieve integration, so that the concept of global health care for all becomes a reality.'
EXTRACTS
'First, investment is needed in training pharmacists (both informal and formal), OTC dispensers, and other stakeholders (such as community health workers, who are a key source of access to health care in many LMICs) to use simple, algorithmic guidelines for a number of common, high-volume primary care infection syndromes where antibiotic use is commonly inappropriate, such as acute respiratory infection and non-bloody diarrhoea... Examples such as South Africa's Practical Approach to Care Kit or WHO and UNICEF's Integrated Management of Childhood Illness could be used as a template to build on.
'Second, access to point-of-care (POC) RDTs should facilitate stewardship. RDTs for malaria are crucial to the management of undifferentiated fever in malaria-endemic countries and have been implemented both in formal health-care settings and community-based programmes that involve community health workers and drug shop vendors...
'The third component of the toolkit would be a targeted number of quality-assured and affordable Access antibiotics, as defined by the WHO Access, Watch, and Reserve (AWaRe) classification...
'Finally, a monitoring and evaluation programme will need to be initiated to ensure algorithm compliance, the correct procurement of quality-assured antibiotics and RDTs (ideally produced locally),37 and compliance with stepped-care practices, including teleconsultations and that patients are referred to the formal health system sectors and providers when their medical condition does not qualify them for OTC antibiotic access...'
COMMENT (NPW): Similar approaches have been discussed previously on HIFA. Theoretically this makes sense, but how to test and implement? Perhaps one could start with a systematic review that looks at the information needs of pharmacists in low-resource settings. This would complement the existing review by HIFA and the University of Nagasaki How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review.https://www.hifa.org/sites/default/files/publications_pdf/BMJGlobalHealt... Indeed, pharmacists are a key component of the primary health workforce and the information needs of all primary health workers need to considered (there is plenty of evidence to show that all PHWs, including doctors, prescribe antibiotics inappropriately: https://www.hifa.org/about-hifa/why-hifa-needed ).
HIFA Steering Group colleagues Joseph Ana and Tracy Eastman have been closely involved with the Practical Approach to Care Kit (which has been implemented beyond South Africa) and may like to share their experience. A paper on PACK notes as its first heading: 'Implementing a training programme in a primary health care system is challenging'. It goes on to say: 'There have been many innovative attempts in low-income and middle-income countries (LMICs) to strengthen primary healthcare since its global adoption in 1978. Some have been successful, like the WHO strategy of Integrated Management of Childhood Illnesses (IMCI) and the Millennium Development Goals 2015. However, many primary care initiatives fail to be implemented beyond pilot phase, and those that are implemented are rarely scaled up and sustained.'
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org