Addressing pharmacy practice in low and middle income settings in an era of antibiotic resistance

在此期间，我打算发表两篇研究论文。第一个将提供连锁药店和独立药店的价格数据，以及光顾这两种不同药店的客户的社会经济地位（之前没有关于这一领域的研究）。第二篇论文将汇集来自连锁药店和独立药店的护理质量数据，以全面了解印度城市药店如何管理儿童腹泻。我的第二个奖学金目标是在全球范围内动员支持，为管理关键条件制定针对药店的指导方针。这是我的博士提出的一个具体而实用的建议，它强调了缺乏儿童腹泻的指导方针。我已经开始与药物使用领域的主要参与者网络以及国际药剂师联合会建立联系，并在推进这一想法方面获得了相当大的支持。其中许多人已经在国内担任政策企业家，他们在国内有很好的关系网，受到尊重，因此可以帮助确定这一领域的政策方向。在通过网络和协商进行进一步互动之后，我计划牵头编写一份“行动呼吁”文件（在关键个人和组织的支持下），这将说明需要这样的指导方针，提出他们可能涵盖的内容，并考虑制作它们的过程会是什么样子。在我的博士学位期间，我接受了定量方法的培训，即LSHTM提供的统计课程，以便进行我的分析。这项奖学金将使我能够通过计量经济学的高级培训进一步提高我的定量技能。我相信伦敦大学学院的“健康计量经济学”课程将特别提高我作为早期职业研究人员的技能。最后，我建议使用奖学金，以研究如何新的监管方法，涉及层次的药物控制可能被用于LMIC遏制抗生素的过度使用的资金建议。抗生素耐药性被广泛认为是全球公众健康的主要威胁。抗生素的使用是导致耐药性的选择压力的主要驱动力，但这类药物仍然是世界上购买量最大的药物之一。在社区（包括药店）促进抗生素管理已被确定为一个关键的行动领域。将经济分析透镜应用于抗菌素耐药性问题可能会在研究这一日益严重的问题中发挥重要作用，从而揭示这些动态市场的供需情况。此外，鉴于与抗生素滥用相关的外部性，改善围绕抗生素供应的有效监管的设计和实施将是至关重要的。这条调查线是由我的博士研究结果引发的：虽然在柜台上非法销售（通常是不适当的）抗生素很普遍，但药房工作人员被发现在“H1药物”方面遵循更好的做法。这是2013年（在印度）引入的一类药物，以应对日益增长的抗生素耐药性问题。H1药品清单主要包括抗生素（新类别和抗结核药物），清单上的药品受到额外的监管控制。就H1药品而言，发现药房工作人员受到限制使用这类药品的隐性规范的严格约束。并非所有抗生素都是平等的，这是一个重要的想法，对不同药物使用不同级别药物管制的潜力尚待探索。监管理论中的新思维，如基于风险的监管和应对监管，将被用来为这一研究领域提供信息。

During this fellowship, I aim to publish two further research papers. The first will present data on prices of encounters at both chain and independent pharmacies, and the socioeconomic status of customers patronising these two different pharmacy types (no prior research has been published on this area). The second paper will pool quality of care data from both chain and independent pharmacies to provide a complete picture of how childhood diarrhoea is managed at pharmacies in the urban Indian setting.My second objective for the fellowship is to mobilise support at the global level for the creation of pharmacy-specific guidelines for the management of key conditions. This was a specific, practical recommendation from my PhD, which highlighted the lack of such guidelines for childhood diarrhoea. I have already started to develop my contacts with a network of key players in the field of medicine use, and with the International Federation of Pharmacists, and have received considerable support for taking this idea forward. Many of these individuals already serve as policy entrepreneurs within countries, where they are well-networked and respected and thus can help to shape the policy direction of this field. Following further interaction through networking and consultation, I plan to lead on a 'call to action' paper (with the backing of key individuals and organisations), which would state the need for such guidelines, propose what they might cover, and give thought to what the process of producing them would look like.During the course of my PhD I undertook training in quantitative methods, namely statistic courses provided at the LSHTM, in order undertake my analyses. This fellowship would enable me to further improve my quantitative skills through advanced training in econometrics. I believe the UCL 'econometrics for health' course would particularly enhance my skills as an early career researcher. Finally, I propose to use the fellowship to develop a funding proposal in order to investigate how novel regulatory approaches involving hierarchies of drug control may be used in LMICs to curb the overuse of antibiotics. Antibiotic resistance is widely recognised as a leading threat to the public's health, globally. Antibiotic use is a main driver of selection pressure that leads to resistance, yet this class of medicines continue to be amongst the world's most highly purchased. Promoting antibiotic stewardship in the community, encompassing pharmacies, has been identified as a key area for action. Applying an economic analysis lens to the problem of antimicrobial resistance will likely play an important role in the study of this growing problem, shedding light on both supply and demand in these dynamic markets. Further, given the externalities associated with antibiotic misuse, improving both the design and implementation of effective regulation surrounding the provision of antibiotics will be paramount.This line of enquiry was sparked by a result from my PhD: although the illegal sale of (often inappropriate) antibiotics over the counter was widespread, pharmacy staff were found to follow better practice withrespect to 'H1 medicines'. These are a category of medicines that were introduced (in India) in 2013 in response to growing concerns over antibiotic resistance. The H1 medicine list is comprised mainly of antibiotics (novel classes and anti-tuberculosis drugs) and medicines on the list are subject to additional regulatory controls. In the case of H1 medicines, pharmacy staff were found to be tightly bound by implicit norms that restrict the use of such medicines. The idea that not all antibiotics are equal is an important one, and the potential of using different levels of drug control for different medicines is yet to be explored. New thinking in regulatory theory, such as risk-based and response regulation, will be used to inform this area of study.