🟠 Moderate Evidence
Informal healthcare providers—including unregulated pharmacists, traditional practitioners, and shop vendors—dispense antibiotics in 18% to 96% of patient encounters across low- and middle-income countries, according to a scoping review published in BMJ Global Health. Yet these providers remain almost entirely absent from antimicrobial resistance (AMR) surveillance systems, creating a blind spot in global efforts to track and control antibiotic overuse.
Key takeaways
- Informal healthcare providers dispense antibiotics in 18%–96% of encounters, with wide variation depending on measurement method
- Limited clinical knowledge, economic incentives, and patient expectations are the primary drivers of inappropriate antibiotic dispensing
- Informal providers are excluded from existing AMR surveillance systems despite handling a substantial share of primary care in LMICs
- Targeted stewardship interventions engaging informal providers are needed to combat rising antibiotic resistance
Study at a Glance
| Source | BMJ Global Health |
| Study type | Scoping review (mixed-methods synthesis) |
| Studies included | 37 studies (9 databases searched) |
| Population | Informal healthcare providers in LMICs |
| Geographic scope | Low- and middle-income countries globally |
Wide variation in informal provider antibiotic dispensing across LMICs
Reported rates by measurement method, based on 31 studies in the scoping review
Source: BMJ Global Health scoping review, 2024 | Georgian Medical Journal News
The surveillance gap: informal providers flying blind
Antimicrobial resistance is projected to cause 10 million deaths annually by 2050 if left unchecked, according to estimates cited in recent WHO fact sheets on antimicrobial resistance. Yet current monitoring systems in LMICs focus almost exclusively on formal healthcare—hospitals, clinics, and registered pharmacies. The BMJ Global Health review, which synthesised 37 studies using Joanna Briggs Institute methodology across nine databases including MEDLINE, EMBASE, and Global Health, found that informal providers—unregulated pharmacists, traditional healers, drug shop attendants, and street vendors—dispense a large but unmeasured volume of antibiotics.
The disparity in reported rates reflects methodological differences: standardised observational studies documented antibiotic dispensing in 18% to 74% of encounters, while provider self-reports ranged from 5% to 96%, and consumer-reported rates spanned 2% to 86%. This variability underscores the difficulty in quantifying informal sector antibiotic use and suggests that current estimates may undercount actual dispensing.
Knowledge gaps and economic drivers fuel inappropriate prescribing
Eight qualitative studies included in the scoping review identified key behavioural and contextual factors shaping informal provider antibiotic dispensing. Limited clinical knowledge and lack of formal training emerged as primary barriers—many informal providers rely on experience-based learning rather than evidence-based guidelines. This is compounded by patient expectations: consumers often demand antibiotics for minor illnesses, and informal providers, lacking authority or training to refuse, comply to retain business.
Economic incentives further distort prescribing patterns. Antibiotics generate higher profit margins than other medicines, creating financial pressure to dispense them widely. Additionally, informal providers perceive consequences of withholding antibiotics—loss of trust, patient dissatisfaction, or adverse outcomes—as personally risky, even when antibiotics are not clinically indicated. Peer influence and advice from pharmaceutical representatives also shape dispensing behaviour, often promoting broader antibiotic use.
Closing the AMR surveillance window requires engagement beyond formal health systems
The review emphasises that informal provider antibiotic dispensing represents a large but unmeasured component of antibiotic use in LMICs. This gap has profound implications for global AMR surveillance and control. Without capturing informal sector data, national and international monitoring systems underestimate true antibiotic consumption, obscure resistance trends, and fail to guide evidence-based stewardship interventions. Current WHO and CDC antimicrobial resistance strategies target qualified practitioners, leaving informal providers—who in many LMICs deliver the majority of primary care—outside stewardship efforts.
Addressing this gap requires a shift in approach. Stewardship strategies must actively engage informal providers through education, regulation, and incentive restructuring. Several LMICs are piloting models—including training programmes for drug shop attendants, price adjustments to reduce antibiotic profit margins, and community-led accountability mechanisms. However, these interventions remain fragmented and under-resourced. A coordinated global effort, supported by WHO’s Antimicrobial Resistance Coordination, is needed to integrate informal providers into surveillance systems and implement culturally appropriate stewardship strategies.
Antibiotic dispensing by informal healthcare providers is widespread and represents a large but unmeasured component of antibiotic use in low- and middle-income countries, creating a critical gap in antimicrobial resistance surveillance.
— BMJ Global Health Scoping Review, 2024
What this means
Frequently asked questions
Why are informal healthcare providers so prevalent in LMICs?
Formal healthcare infrastructure in many LMICs is limited by geography, cost, and availability. Informal providers—pharmacists, traditional healers, and drug shop vendors—are often more accessible and affordable for patients seeking primary care. According to the scoping review, informal providers deliver much of the primary care in these settings, making their practices critical to understanding antibiotic use patterns.
How does informal antibiotic dispensing drive antibiotic resistance?
Inappropriate antibiotic use—dispensing antibiotics for viral infections, incomplete courses, or substandard formulations—accelerates the emergence of resistant bacteria. Because informal providers lack training and oversight, they are more likely to dispense antibiotics without proper diagnosis, dosing, or follow-up, amplifying resistance risk across communities.
What interventions have worked to improve informal provider practices?
Evidence on effective interventions remains limited, though the review identifies promising approaches including brief training programmes on antibiotic stewardship, regulatory frameworks requiring registration and licensing, and price controls to reduce antibiotic profit incentives. However, these remain fragmented and require scaling within integrated national strategies.
The BMJ Global Health scoping review signals a turning point in antimicrobial stewardship: the recognition that ignoring informal healthcare providers amounts to fighting antibiotic resistance with one hand tied. Without comprehensive surveillance and targeted engagement of informal providers, global efforts to control AMR will remain incomplete. The next phase of the global health response must bring informal providers into the fold—through training, regulation, and incentive realignment—to close the surveillance gap and preserve the effectiveness of antibiotics for future generations.
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