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

这里提出的这项研究是为一项为期20个月的基金会资助而进行的，它应用创新的方法来理解和制定策略，以解决与卫生系统中一个特征不佳的部分——不受监管的营利性药品销售商——的治理相关的未解决的挑战。我们重点关注世界上最不发达国家之一柬埔寨的一个高度优先的全球卫生问题，即不适当分配抗菌剂（AMs）。柬埔寨是一个具有更广泛相关性的重要案例研究，因为与该地区许多其他国家以及卫生系统因冲突而被削弱的国家一样，柬埔寨经历了不受监管的营利性医疗保健提供者的大规模增长。我们的项目是柬埔寨卫生科学大学和伦敦卫生与热带医学学院在2014年启动的工作基础上的合作项目。召集的小组是一个多学科研究人员小组，汇集了卫生系统研究、柬埔寨背景和亚洲私营卫生部门的经验。该研究将确定销售AM的不同供应商，并分析不受监管的药品销售商（UDS）与影响政策的当地利益相关者之间的权力关系和网络，以确定改善UDS销售AM的治理方法，这些方法可能得到当地政策制定者的支持并大规模实施。我们将依次解决三个相关的研究问题，为每个问题产生具体的研究成果：1。销售辅助药物的主要“看得见”和“看不见”的销售点有哪些类型可以采取干预措施，以减少不当使用？为了解决这个研究问题，我们将进行焦点小组讨论，其中包括社区漫步，在此期间，当地研究人员将被带到柬埔寨金边四个社区的居民因常见疾病而访问的公共和私人医疗保健提供者。本地研究人员将进行非参与性观察，以建立医疗服务提供者的数据库，包括他们是否注册，以及他们是否主要销售药品或其他物品的信息。UDS如何确定与包括社区领导人、商业药品供应商和政府卫生官员在内的政策行为者的联系？根据通过初步研究收集的信息，我们将选择大约35个UDS代表我们确定的演员范围进行深入访谈。通过访谈，我们将调查通过社会或金融网络与UDS有联系的人员或机构，并生成与UDS有联系的共同利益相关者列表。3. UDS与政策参与者的关系如何影响政策？政策参与者如何看待UDS ？我们将与确定的利益相关者（我们估计有25个）进行访谈，以调查对UDS在提供医疗保健方面发挥作用的看法，受访者将对替代治理方法（禁止、监管、鼓励/补贴和购买服务）进行排名，同时讨论其基本原理。本基金资助的研究将产生：a)了解不受监管的药品销售商在柬埔寨城市配发抗菌素的社会和地理传播情况；b)分析对管理柬埔寨不受监管的药品销售商和获得抗菌素至关重要的利益相关者，他们的网络和潜在的权力关系；c)在此基础上制定治理干预措施，以减少不受监管的药品销售商不适当地获得抗菌素。这些知识和干预措施将为在柬埔寨全国范围内测试干预措施的更大研究提案提供信息，并为目前正在根据《国际卫生条例》制定卫生系统加强计划的其他低收入和中等收入国家的不受管制药品销售商的决策提供及时信息。

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.