What is the PINTAR Study?

PINTAR (Protecting Indonesia from the Threat of Antibiotic Resistance) is a three-year research study which aims to improve the use of antibiotics and ultimately reduce the global spread of antimicrobial resistance (AMR).

Studies show that the vast majority of private drug sellers (PDS) in Indonesia currently dispense oral antibiotics to patients without a prescription and without providing relevant and accurate information on these medicines.

In this study, researchers carefully analyse the way private drug sellers in Indonesia dispense antibiotics and how they interact with their clients. Based on this analysis, a comprehensive intervention will be designed with the aim of improving appropriate antibiotic selling practices by PDS.

The research began in 2018 by a multidisciplinary team from five universities and other institutions across Indonesia, Australia and the United Kingdom.

Why is this research important?

Antimicrobial resistance (AMR) is one of the world’s most pressing public health threats. An estimated 700,000 people die of resistant infections every year globally (1).

The rapid and uncontrolled rise in the use of antibiotics is a major driver of AMR (2, 3). Inappropriate use of antibiotics in humans and animals is further accelerating the AMR process (4). In Indonesia and a number of other countries in the region, most people purchase antibiotics in the private sector and often without a prescription. In fact, most intervention strategies to improve the use of antibiotics in low- and middle-income countries have focused on trained physicians in public hospitals rather than the private sector.

Examples of private drug sellers are pharmacies, drug stores and general stores. While they are often accessible, convenient and reliable sources of affordable medicines (5), they also tend to be poorly regulated and staffed by untrained drug sellers (6).

By understanding the practices and incentives of PDS this research will contribute to the fight against AMR.

What are the aims of the study?

The overall aim of the study is to improve the dispensing of antibiotics by private drug sellers (PDS) in Indonesia. Specific aims are to:

1. Understand the context in which PDS operate, specifically how different economic and social factors influence their antibiotic dispensing practices and the quality of care they give to their clients;
2. Design and evaluate the effect and cost-effectiveness of a multi-faceted intervention to improve appropriate dispensing of antibiotics by PDS;
3. Build capacity in rigorous health systems research.

Where does it take place?

The study happens in Indonesia, the largest country in the Southeast Asia region. With around 260 million people, Indonesia has a major role to play in addressing the inappropriate use of antibiotics and reducing the threat of AMR.

The formative research takes place in two districts in West Java and South Kalimantan Provinces: Bekasi and Tabalong. These sites provide contrasting geographic areas (rural and urban), diversity in type of private drug sellers (community pharmacies, drug stores selling medicines) and socioeconomic status.

The sites for the main evaluation will be identified after the formative research is completed.

The research team is based in multiple institutions around the world, mostly in Indonesia, Australia, and the UK. Visit the Team page for more details.

What are the main research steps?

The research uses a mixture of qualitative and quantitative methods and involves four phases:

1. Gathering evidence on the practices and drivers of antibiotic dispensing by private drug sellers
2. Designing an intervention with relevant stakeholders, based on findings from the formative research (phase 1).
3. Assessing the implementation of the intervention in real-time, with ongoing reporting to stakeholders and continuous improvements over a period of 20 months
4. Developing a plan for expanding the intervention nationally.

What have we found so far?

Please visit the Updates and Findings page for more information.

How will the study outcomes be used?

The PINTAR team is working in partnership with the Indonesian Government to develop strategies to improve antibiotic use in the private sector.

Our findings will be shared with the National Taskforce to support the development of its Action Plan for AMR (the Chair of this Committee, Dr Harry Parathon, is a member of the PINTAR research team).

How does the COVID-19 pandemic influence the study?

The team is working carefully to incorporate best practices and learnings from the pandemic into the design of the PINTAR intervention.

In addition, it has become clear that the COVID-19 pandemic could dangerously aggravate problems related to inappropriate self-medication and lead to an irrational use and hoarding of antimicrobial medicines.

Hence, the research team is working on a sub-study that consists of a national survey of all registered community pharmacies and drug stores in Indonesia. The survey aims to explore the private drug sellers’ understanding of COVID-19 and the medicines and advice given to clients, as well as the actions that could be taken to improve COVID-19 management by PDS.

Read more about the sub-study here.

In summary, this study is important for:

• Informing the development of Indonesia’s National Action Plan for AMR and strengthening public/private partnerships in the health system.
• Avoiding harmful side-effects of unnecessary treatments as well as avoiding the substantial cost burden to patients and the health system associated with purchasing unnecessary antibiotics.

In addition, we expect that the intervention resulting from this research may be later adapted for use in the agricultural sector where private drug sellers are also widespread.

References

1. O’Neil J. Review on antimicrobial resistance. Tackling drug resistant infections globally: final report and recommendations.; 2016.
2. World Health Organization. WHO Global Strategy for Containment of Antimicrobial Resistance.: World Health Organization; 2001.
3. Leung E, Weil DE, Raviglione M, H. N. World health organization world health day antimicrobial resistance technical working group. The WHO policy package to combat antimicrobial resistance. . Bull World Health Organ. 2011;2011(89):390–2.
4. World Health Organisation. Antibiotic resistance. World Health Organisation; 2018.
5. Goodman C, Kachur SP, Abdulla S, Bloland P, Mills A. Drug shop regulation and malaria treatment in Tanzania–why do shops break the rules, and does it matter? Health Policy Plan. 2007;22(6):393-403.
6. Chee G, Michael Borowitz, Barraclough A. Private Sector Health Care in Indonesia. Bethesda, MD: Abt Associates Inc.; 2009.