Antimicrobial resistance (AMR) is one of the world’s most pressing public health threats. Around 700,000 people die of resistant infections every year globally (1, 2). Its onset in one country poses major health security threats regionally and globally since national borders present little barrier to the spread of antibiotic resistant infections.

AMR is driven by the rapid and uncontrolled use of antibiotics resulting in significant morbidity, mortality and costs to health systems and households around the world. In fact, between now and 2050 it is expected to cost the global economy as much as $100 trillion (1, 2).

AMR in Indonesia

According to the WHO, Southeast Asia is at the highest risk globally for the emergence and spread of AMR due to the widespread inappropriate use of antibiotics and weak systems of governance in health and agriculture (3, 4). Cross-border resistance is of growing concern in the region with healthy travellers testing positive for multi-drug-resistant colonisers (5).

In 2011, health ministers in the Southeast Asia region adopted the Jaipur Declaration on AMR, calling for comprehensive action against the irrational use of antibiotics (6). Most recently, the Berlin declaration of the G20 health ministers in May 2017 recognised the increasing threat of AMR and outlined various measures to address it (7). The region’s member states including Indonesia are implementing national action plans to tackle AMR (8).

As the largest country in the region with around 258 million people, Indonesia has a major role to play in addressing the inappropriate use of antibiotics and curtailing the threat of AMR (9-11).

The role of the private sector

The dispensing of antibiotics without a prescription by private drug sellers (PDS) is a key driver of AMR in Indonesia and elsewhere in Southeast Asia. There are approximately 134,520 PDS in Indonesia consisting of both licensed outlets (28,671 community pharmacies and 10,849 drugstores) (12) and unlicensed outlets (5,000 drug stores and 90,000 small stores) (13). Studies show that around 90% of community pharmacies currently sell oral antibiotics without a prescription (9). Despite their prominence in Indonesia’s health system, little is known about the practices of PDS and how to improve governance of this sector. The goal of the PINTAR study is to develop and test strategies to improve antibiotic dispensing by PDS in Indonesia.

References

1. George A. International Security and Antimicrobial Resistance: Why Policy Coherence Matters. Australian Institute of International Affairs [Internet]. 2015. Available from: https://www.internationalaffairs.org.au/australianoutlook/international-security-and-antimicrobial-resistance-why-policy-coherence-matters/.
2. Review on Antimicrobial Resistance. Tackling drug-resistant infections globally: Final report and recommendations. 2016.
3. Chereau F, Opatowski L, Tourdjman M, Vong S. Risk assessment for antibiotic resistance in South East Asia. BMJ (Clinical research ed). 2017;358.
4. Holloway KA, Kotwani A, Batmanabane G, Puri M, Tisocki K. Antibiotic use in South East Asia and policies to promote appropriate use: reports from country situational analyses. BMJ (Clinical research ed). 2017;358.
5. Kennedy K, Collignon P. Colonisation with Escherichia coli resistant to “critically important” antibiotics: a high risk for international travellers. Eur J Clin Microbiol Infect Dis. 2010;29(12):1501-6.
6. World Health Organization Regional Office for South-East Asia. Jaipur declaration on antimicrobial resistance. . 2011.
7. G20 Health Ministers. Berlin Declaration of the G20 Health Ministers: Together Today for a Healthy Tomorrow. Germany2017.
8. Khetrapal P. Speech of the Regional Director. Workshop on National Action Plan on Antimicrobial Resistance for Developing Countries: Focusing on Resistance Emanating from Antibiotic Use in Food Animals. New Delhi, India: 34th session of WHO South-East Asia Advisory Committee on Health Research, World Health Organization.; 2016.
9. Puspitasari HP, Faturrohmah A, Hermansyah A. Do Indonesian community pharmacy workers respond to antibiotics requests appropriately? Trop Med Int Health. 2011;16(7):840-6.
10. Chee G, Borowitz M, Barraclough A. Private Health Care Sector in Indonesia. Bethesda, MD: Abt Associates Inc; 2009.
11. Management Sciences for Health. Managing Access to Medicines and Health Technologies. Arlington, VA: Management Sciences for Health; 2012.
12. Indonesian Ministry of Health. Mapping of Pharmaceutical Facilities 2013 – 2018 (Aplikasi Pemetaan Sarana Kefarmasian 2013-2018) Jakarta2018 [Available from: http://apif.binfar.depkes.go.id/index.php?req=view_services&p=pemetaanIndustriFarmasi.
13. World Bank. Pharmaceuticals : why reform is needed (English). Indonesia health sector review : policy and discussion notes. Washington, DC: World Bank; 2009.