Combating drug resistance through better governance of unregulated antimicrobial sellers in Cambodia: addressing stakeholder connections & perceptions

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The research proposed here is for a 20-month Foundation grant applying innovative methods to understand, and develop strategies to address unresolved challenges relating to governance of a poorly characterised segment of the health system - unregulated, for-profit drug sellers. We focus on a high priority global health issue, inappropriate dispensing of antimicrobials (AMs), in one of the world's Least Developed Countries: Cambodia. Cambodia serves as an important case study with wider relevance because, like many other countries in the region and those whose health systems have been weakened by conflict, it has experienced a massive growth in unregulated, for-profit healthcare providers. Our project is a collaboration between the University of Health Sciences in Cambodia and the London School of Hygiene and Tropical Medicine, building upon work initiated in 2014. The team convened is a multidisciplinary group of researchers bringing together experience in health systems research, the Cambodian context and private health sector in Asia. The research will identify the diverse providers that sell AMs, and analyse power relations and networks between unregulated drug sellers (UDS) and local stakeholders that influence policy, in order identify governance approaches for improving AM selling by UDS that are likely to be supported by local policymakers and implemented at scale, We will address three linked research questions sequentially, producing specific research outputs for each:1. What are the key "visible" and "invisible" types of outlets selling AMs to engage in interventions to reduce inappropriate use?To address this research question we will conduct focus group discussions involving a community walk through during which local researchers will be taken to public and private healthcare providers that residents visit for common illnesses in four communes across Phnom Penh, Cambodia. Local researchers will conduct non-participant observations to create a database of healthcare providers including information about whether they are registered or unregistered, and whether they primarily sell medicines or other items.2. How do the UDS identified link to policy actors including community leaders, commercial drug suppliers and government health officials? Based on information collected through the initial study, we will select approximately 35 UDS representing the range of actors we identified for in-depth interviews. Through interviews we will investigate people or institutions they are connected to through social or financial networks and generate a list of common stakeholders UDS are connected to. 3. How is policy influenced by UDS's connections to, and ways they are perceived by, policy actors?We will conduct interviews with the stakeholders identified (we estimate 25) to investigate perceptions of the role that UDS play in providing healthcare, and interviewees will rank alternative governance approaches - banning, regulation, encouragement/subsidy, and purchase of services - while talking through their rationale.Research undertaken for this Foundation grant will generate: a) understanding of the social and geographical spread of unregulated drug sellers dispensing antimicrobials in urban Cambodia, b) an analysis of stakeholders that are critical to governing unregulated drug sellers and access to antimicrobials in Cambodia, their networks and underlying power relations and c) on this basis, develop a governance intervention to reduce inappropriate access to antimicrobials through unregulated drug sellers. This knowledge and intervention developed will inform a larger research proposal testing the intervention on national scale in Cambodia and provide timely information for policymaking on unregulated drug sellers in other low and middle-income countries that are currently developing health systems strengthening plans under the International Health Regulations.