Addressing conflict of interest driving irrational prescribing of antibiotics in pluralistic health systems: an interventional study in Pakistan

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The study proposed here applies cutting-edge health policy and systems research to address a critical and poorly addressed global health challenge: conflict of interest (COI) hindering improvements in the quality of care delivered by private healthcare providers. We define COI as a situation whereby the impartiality of a healthcare provider's judgment may be influenced by a secondary interest, such as financial gain, leading to a decision that is not in the patient's best interest. There is strong evidence that private doctors seeking to make a profit from patient consultations often experience a COI resulting in prescription of medication or diagnostic tests that are either unnecessary or more costly than available alternatives. We focus on irrational prescribing of antibiotics by private doctors in Pakistan, the sixth most populous country in the world, where more than 80% of people first seek care at private doctors and where antibiotic usage is among the highest in the world. Studies in Pakistan and other low and middle income countries, including our own earlier research, show that private doctors prescribe multiple antibiotics when patients do not need them in order to receive benefits from pharmaceutical companies, or make profits from the medicine sales. Despite the scale and urgency of this issue, which affects millions of people and drives antimicrobial resistance which can spread across the world, there is extremely limited evidence on strategies that are effective in contexts where resources and political support for the enforcement of rules are low. Therefore, training interventions focusing on increasing knowledge and skills to affect voluntary behaviour change in private providers is the most common approach used. However, these interventions have had limited success when irrational prescribing is mainly motivated by profit-generation rather a lack of knowledge; here norms and values associated with professional ethics are critical to address with interventions.Our study has four linked objectives, which together will generate new evidence about the impact of a continuing medical education intervention with specially designed messages to sensitise doctors to professional ethics and COI, as well as critical insights about barriers that need to be overcome in order to facilitate scale-up of this intervention in the local health system. Since influential stakeholders responsible for addressing practices of private doctors may be crossing professional ethics boundaries themselves, often by having multiple income streams without disclosure, our first objective is to understand how COI and professional ethics is conceptualised by influential stakeholders in Pakistan in order to identify potential supporters and opponents of our intervention. We next focus on private doctors, investigating how they decide what is ethically unacceptable and acceptable with respect to getting personal benefits from prescribing antibiotics. Our third objective is to understand how best to present messages that sensitise private doctors to professional ethics and the role of conflict of interest driving irrational prescription of antibiotics in order to design our intervention. Our final objective is to assess the impact of our intervention on the behaviour and attitudes of private doctors with respect to unethical benefits from pharmaceutical companies for prescribing antibiotics.A key strength of the proposed study is that it has been co-designed with Pakistani researchers and policymakers, building on two previous research council funded projects in Pakistan and Cambodia. In addition to producing new evidence to inform ongoing investments in improving quality of care and tackling antimicrobial resistance, our medical education material on COI can be used for research and training in other settings, and the tools developed as part of our innovative health systems research methods will be made available for future studies.