Improving Practice in Ugandan drug shops: a holistic approach to regulation

摘要药店是销售非处方药、抗疟疾和抗生素药物的小型零售商店。它们在非洲和亚洲的许多国家开展业务，虽然它们不是正式卫生系统的一部分，但它们向城市和农村地区的许多人出售挽救生命的治疗方法。然而，在许多国家，这些商店经常不适当地出售抗生素，提供太少或太多的药片，将它们混合在药用鸡尾酒中，然后出售给没有受到细菌感染的人。抗生素是一种奇怪的药物，我们使用得越多，它们不仅对我们自己，而且对我们周围的每个人都变得越不有用。为了保护它们并确保它们对子孙后代有用，我们需要限制它们的使用。但正如世界卫生组织所主张的那样，必须在限制不必要的抗生素使用和确保有需要的人可以获得抗生素之间取得微妙的平衡。这种复杂的平衡行动导致一些政策制定者将抗菌素耐药性称为一个超级邪恶的问题。这项研究项目首先认识到，我们必须解决世界各地药店不当销售抗生素的问题，同时确保世界上最贫穷的人仍然可以获得抗生素，只有我们能够更有效地监管药品销售商，我们才能正确地实现这种平衡。这个团队和其他在非洲和亚洲各地工作的人进行的研究表明，药店向不需要抗生素的人出售或大或小数量的抗生素的原因之一是因为它们监管不善。在许多国家，法规往往过时，不可能在其中发挥作用，而且被大多数人忽视。监管机构的薪酬往往如此之低，以至于他们愿意接受药品销售商的贿赂，而药品销售商认识到，向监管机构行贿比试图在官方指导方针下运作更容易、成本也更低。直到最近，对于如何更好地监管这些市场，我们几乎没有什么想法。我们的尝试产生了一些影响，但完全不像我们需要做出的那种改变，以阻止抗菌素耐药性，使许多救命药物毫无用处。来自反腐败领域的新思维为我们提供了令人振奋的新方法，以改善监管和遵守规则的行为。在我们2011年开始的乌干达药店工作的基础上，这个项目将建立一个干预模型，一个可以探索这些新方法中哪些在乌干达有效以及如何对其进行最佳评估的实验。

Summary Drug shops are small retail outlets that sell over the counter, antimalarial and antibiotic medicines. They operate in many countries in Africa and Asia and although they are not part of the formal health system, they sell life-saving treatments to many people in both urban and rural areas. In many countries, however, these shops often sell antibiotics inappropriately, providing too few or too many tablets, combining them in medicinal cocktails and selling them to people who are not suffering from bacterial infections. Antibiotics are an odd type of medicine, the more we use them then the less useful they become not only to ourselves but also to everyone around us. To protect them and ensure that they are useful for future generations we need to restrict their use. But as the World Health Organisation argues, there has to be a fine balance between restricting the unnecessary use of antibiotics and ensuring that they are available to those that need them. This complex balancing act has led some policy makers to refer to antimicrobial resistance as a super wicked problem. This research project begins with the recognition that we have to tackle the mis-selling of antibiotics in drug shops around the world while ensuring that the worlds poorest people can still have access to them and that we can only get this balance right if we can regulate medicine sellers more effectively. Research undertaken by this team and by others working across Africa and Asia shows that one of the reasons that drug shops sell antibiotics in too large or small a quantity and to those who don't need them is because they are poorly regulated. In many countries, regulations are often out of date, impossible to work within and ignored by most people. Regulators are often so poorly paid that they are willing to take bribes from medicine sellers and medicine sellers recognise that it is easier and cheaper to pay the bribes to the regulators than try to work within the official guidelines. Until recently, we have had few ideas about how to better regulate these markets. What we had tried out had some impact but nothing like the sort of changes that we needed to make to stop antimicrobial resistance making many lifesaving medicines useless. New thinking from the world of anti-corruption has given us exciting new ways to improve regulation and rule abiding behaviour. Building on work in Ugandan drug shops that we started in 2011, this project will build an intervention model, an experiment which can explore which of these new methods will work in Uganda and how they should be best assessed.