Is Antimicrobial Resistance (AMR) relevant if you can’t afford the drugs?


This year’s Global antibiotic awareness week runs from the 14th to the 25th of November. To mark this the Commonwealth Health hub is running an eDiscussion in partnership with the Commonwealth Pharmacists association (CPA) and Public Health England (PHE). This will ask the question ‘Is Antimicrobial Resistance (AMR) relevant if you can’t afford the drugs?’

To join the discussion simply send an email with your contribution to or add your thoughts when signing up to the hub mailing list via the join the hub page

Contributions to the discussion will appear below


Lamin Kamara, Sierra Leone

In addition poverty in developing Countries also contributes to AMR.

People may want to go hospital when they are sick but because of lack of funds at home they are prevented from accessing the hospital, as doctors/clinicians request consultation fees which cannot be afforded by poor people. Because they cannot provide so they will end up buying incomplete doses of antibiotics. This will continue for long and may end up creating resistance.

In our country health education is being done at Health Facilities, through Radio and other Media but yet not all people have access to Radio and some have no time to listen to Radio. From experience some of the patients do not come to hospital/clinic early to listen to health talks instead they come in a hurry to come back home.

So all of these factors add up to the AMR.

Moderator Notes. Dr Stephen Dorey, Commonwealth Secretariat

Our thanks to Lamin Kamara for their contribution.

This contribution is a very valuable reminder that AMR and the factors leading to it cannot be separated from wider day to day issues such as poverty. By tackling these issues, such as strengthening the wider health system and accelerating progress towards Universal Health Coverage (UHC) we can not only address the specific topic of AMR but also achieve wider solutions. If we seek wider solutions then the topic of AMR becomes increasingly relevant to all.

Victoria Rutter, Commonwealth Pharmacists Association 

Dear Latin Kamara, thank you for your valued contribution to this discussion. Your comments emphasise the importance of the role that affordable universal health coverage has in tackling AMR, amongst other wider issues.

Universal health coverage is a priority area for the Commonwealth and we have a vision to see this realised. According to your contribution, Sierra Leone is certainly making an impressive effort in health education, though as you say this is not without its challenges. You have clearly illustrated how the approach to tackling AMR needs to be multifaceted, not least encompassing effective education for the public and affordable and accessible quality healthcare for all.


Dr Oo Popoola, Nigeria

The causes of AMR are multifactorial.

In the developing world, it’s usually a reflection of the dire need to strengthen healthcare at all levels, most especially at the primary care front. Issues of access to care, quality of care, appropriate legislation (and enforcement), with sanctions on erring individuals will go a long way in resolving this crisis.

Health education is a very critical component of healthcare delivery that’s too often overlooked. Massive campaign and enlightenment strategies may be a more strategic approach than the individual approach, as a great number of people have already sought treatment options from the patent medicine store, the local village ‘doctor’, or the hawkers on the street with a ‘one-stop cure’ before even seeking healthcare in the hospital. As such many already have some form of AMR before arriving at the clinic.

 Moderators Note. Victoria Rutter, Commonwealth Pharmacist’s Association (CPA)

Dr Oo Popoola, many thanks for your excellent contribution to this discussion.

As you rightly point out, AMR is one outcome of the lack of effective and well-regulated universal health coverage that needs to be provided by an appropriately skilled and educated workforce. This is a goal that we are all working towards in the Commonwealth.

The massive campaign and enlightenment strategies that you mention would certainly be an important element in education and changing behaviours. World Antibiotic Awareness Week provides is one strategy that is starting the movement across several countries. I would be interested to know what you think a successful campaign might look like?

Education, as you say, needs to go hand in hand with appropriate legislation (and enforcement), which is a big challenge in many countries and needs to be supported from the top levels of government. Would anyone have any views on how best to tackle this in your own countries?


Nwokorie Kelechukwu, Nigeria

Having lived in both the affluent and poor countries, I believe AMR is caused by certain factors like :

In affluent countries
Ingestion of GM foods leading to evolved genetic makeup of the body thereby giving grounds to ineffective treatment of bacterial illnesses and AMR.
In poor countries
Self-medication is easy and unchecked. AMR is found in the young population so easily when compared to the affluent countries.
Antimicrobial Resistance (AMR) is relevant as it denotes the unique underlying physiological problem of the patient so that adequate attention will be given to the research and funding of alternatives.

Moderators Note. Victoria Rutter, Commonwealth Pharmacist’s Association (CPA)

Thanks Nwokorie Kelechukwu, Nigeria for you contribution to the discussion.
I agree with you that in many resource-poor settings, self-medication with antibiotics is easy and contributes significantly to AMR. Healthcare professionals such as pharmacists have a big role to play in promoting the safe and effective use of medicines. This is a challenging task without adequate regulation of medicines and enforcement of legislation in many countries.
In a recent survey to our member organisations throughout the Commonwealth, 92% of countries had legislation to ensure that medicines such as antibiotics were only supplied on prescription. But in a third of these countries this legislation was not enforced.
What steps would we need take to ensure effective ‘gate keeping’ for the antibiotics we do have (bearing in mind that there are not a wealth of new antibiotics in the pipeline)?
The issue of GM food is a controversial in many countries and it is recognised that there are important potential benefits as well as risks associated with this technology. Certain antibiotic resistance genes are used in GM research as marker genes however these have not been shown to cause any significant risk to human health (1). Though important wider concerns exist relating to the involvement of large multinationals in the food chain through the production of GM food, as well as concerns about environmental practices associated with possible uses of GM crops, this is quite different from suggesting a direct threat to human health exists either through AMR or otherwise.

(1) van den Ede G, Aarts H, Buhk H-J, Corthier G, Flint HJ, Hammes W, et al. The relevance of gene transfer for the safety of food and feed derived from genetically modified (GM) plants. Food Chem Toxicol. 2004;42:1127–56.


Nicola Rudall, Pharmacist, UK and Namibia

AMR is relevant even if you can’t afford the drugs because:

  • The patient will still need to be kept away from other patients to prevent spread of the resistant bug, even if they can’t be effectively treated
  • Using the antibiotics you can afford to treat a resistant bug is both a waste of resources, and a potential unnecessary side effect burden for a patient who won’t respond.  It will also increase the risk of further resistance developing.  Likewise, using sub-therapeutic doses of antibiotics that cover the resistant bug, because you can’t afford higher doses (or because you use the expensive drug so rarely you’re unfamiliar with it), will increase the risk of further resistance.
  • With limited resources, you need to make sure you’re using them in the most appropriate way

So yes, it very much does matter.

Moderators Note. Victoria Rutter, Commonwealth Pharmacist’s Association (CPA)

Nicola raises some very pertinent points. In resource-poor settings one could argue that this issue is even more important as these countries cannot always get access to second and third line antibiotics, so the consequences of resistance are potentially much much worse.

On a recent trip to Asia I noticed an advertisement in the medical school for a second/third line antibiotic, stating ‘Get it Right First Time’.  This illustrates the need to tackle the regulation of not just antibiotics themselves, but the marketing rules and the information given to medical professionals and the public must also be addressed.


Dr Kushlani, Jayatilleke, Sri Lanka

I feel antimicrobial resistance is more relevant when the expensive antibiotics are not affordable. If AMR is controlled to such an extent that less expensive antibiotics can be used effectively, more lives would be saved with less cost.

Moderator’s Note. Victoria Rutter, Commonwealth Pharmacy Association (CPA)

Thanks for your comment Dr Jayatilleke. You raise a very important point about the need for good stewardship of antibiotics to ensure that less expensive ones remain effective to save more lives with less cost. Your team presented some very good data on resistance patterns in Sri Lanka at the CMA conference last month. Does anyone have any thoughts about what the biggest challenges are that countries such as Sri Lanka are facing in terms of ensuring antibiotics are used appropriately to prevent resistance?

Background to the discussion topic

AMR is often characterised as an issue primarily faced by the health systems for more affluent countries. After all if a national health budget cannot afford Antibiotics for those who need them then resistance to those drugs is irrelevant. However AMR can also be seen as an important opportunity. It is a good example of a crosscutting issue which touches all parts of a health system from the clinical and laboratory based end of the spectrum through to health promotion and issues of wider health system resourcing and organisation.

Map with permission of Centre for Centre for Disease Dynamics, Economics and Policy

It is also an issue affecting many of the key health problems faced by Commonwealth countries, including those with lower national incomes. It is not just an issue of MRSA and Clostridium Difficile but also of resistance to Anti-Malarials and HIV/AIDs and TB treatments.

As background to this issue the Commonwealth Secretariat in partnership with the UK Department of Health have developed a policy brief looking at antimicrobial resistance and health systems strengthening.

The WHO have also just released the results of a new survey

Clearly the challenges faced by Commonwealth countries differ, however many of the solutions could benefit all if systems wide solutions are sought.

  1. What problems does AMR pose to health in your country?
  2. How are policy makers and health professionals in your country tackling this issue?
  3. How could tackling AMR lead to wider benefits to health systems and public health?
  4. What role do you think the public have in tackling AMR and how is this being encouraged in your countries?

Remember, to join the discussion simply send an email with your contribution to or add your thoughts when signing up to the hub mailing list via the join the hub page

Alongside the eDiscsusion the Commonwealth are also running twitter polls please see below and circulate



In the UK Public Health England are running a campaign to encourage members of the public and health care professionals to become Antibiotic guardians. Even if you are not in the UK you can join more 31, 000 Antibiotic Guardians who have already pledged to do their part to help reduce antibiotic resistance