Treatment protocols are physically present in all countries except DRC, but compliance to protocols varies

Treatment protocols were widely used by prescribers in Sudan. The protocols were seen on every desk and on some of the phones (all those with smartphones) of the prescribers, and were mainly used by prescribers for complicated cases and as study material.

Prescribers of all three departments (ER, PICU and NICU) in the Bissau project were generally aware of treatment protocols and there was a common perception of compliance to protocols among supervisors:

The doctors prescribe antibiotics very correctly, according to the protocols. 90%–95% are prescribing correctly. The only question is the diagnosis – how well the differential diagnosis is made. (MSF Supervisor, Guinea Bissau)

Most doctors in Guinea-Bissau reported that they knew the guidelines and dosages by heart already, so they consulted the protocols only in case of rare conditions. However, language was noted as a potential barrier to the systematic use of protocols in Sudan. Although it was said that some protocols were available in Arabic, only the English copies were seen by the evaluation team. Additionally, while treatment protocols were known to be present in Tawila, Sudan, they were usually not available for routine work by staff and there were contradictions between national and MSF guidelines.

Data from interviews with prescribers, OPD patients, community members and field observations at the HC dispensary suggested that MSF staff in Kabo, CAR complied with the treatment protocols with regard to antibiotic prescriptions. Prescribers at all levels (supervisors and national staff) had sound knowledge of and were aware of the risks of overprescription and ABR.

That being said, however, DRC was a notable exception among all countries because protocols were not present in all facilities. In addition to the lack of copies, compliance and use of the protocols was questionable in DRC. Staff complied with the protocols predominantly in HC Tchonka, but compliance was weakest in the paediatric ward of the Lulingu Hospital. MSF supervisors mentioned some practical issues which may explain inconsistent compliance to the protocols:

Health staff often have problems to identify the proper dosage … although there are protocols and guidelines pinned to the wall … either they forget to check, they do not care, they do not want to accept [treatment] protocols, or they do not understand how to calculate dosages, for example, mg/kg for children. (MSF supervisor, DRC)

Failing health systems are perceived as major drivers of overuse among prescribers

Given the unregulated and uncontrolled dispensation of antibiotics at local pharmacies, prescribers and supervisors in Guinea-Bissau assumed a widespread presence of ABR. This was believed to be linked with the underdeveloped and understaffed primary and secondary healthcare system, which prescribes antibiotics widely, lacks medical supplies, and requests payment from patients to access medical care.

It may be that we have higher resistance against antibiotics than assumed by the protocols, because in the primary health care they use amoxiclav and ceftriaxone a lot…many times, they don’t respond to the ATB that we have in our protocols. We then re-check the diagnosis and go for 2^nd or 3^rd line, but we do not know about the resistance patterns. (MSF supervisor, Guinea-Bissau)

Many interviewees mentioned that some drugs, such as amoxicillin or Amoxicillin-Clavulanate, were compromised due to their widespread prescriptions in the primary health centre (PHC) and uncontrolled use in the communities. Unpaid doctors were largely absent in the PHC and nurses were left to make diagnosis and prescription decisions; often, this contributed to overprescription of antibiotics.

According to supervisors and managers, prescribers followed up closely according to the protocols, but diagnostic accuracy and differential diagnoses were problematic. This was mainly due to limited availability of some laboratory tests. As one prescriber put it:

We are based on the clinical signs. In case if the diagnosis does not work, we don’t have enough laboratory tests such as electrolytes check; echocardiography needs referrals and approval. (MSF prescriber, Guinea-Bissau)

Similarly, in Sudan, a large number of patients came to the OPD, so prescribers and dispensers had limited time with each patient. On average, the OPD medical staff spent approximately 5 min per patient, although the MSF guidelines stipulate that OPD consultations should take around 20 min per patient. In the IPD, the situation was better due to the smaller number of patients.

In the OPD as well as in IPD in Sudan, several register books were filled in parallel, as each prescriber was assigned his/her own register book. Hence, information on previous consultations and treatment could not be easily traced if the patient was other medical staff. This was especially problematic, given the fact that most patients did not know the name of the drugs they were prescribed; as a result, oral history taking would not suffice as a replacement.

Additionally, in Sudan, most patients were seen by medical assistants. Doctors were working mainly in the ER/IPD. Medical assistants mentioned that they felt insecure at times with regards to correct prescriptions.

I use MSF guidelines but sometimes they do not suffice so I need a doctor’s help. (Medical Assistant, Sudan)

In CAR, high workloads, especially at the OPD, resulted in short consultation times and inadequate anamnesis. Prescribers complained that they lacked time and often felt pressure related to the high workload.

Four consultants do 200 patients a day … they cannot give a good and thorough consultation … and there is no time for a proper explanation. (MSF health educator, CAR)

During the observations of consultations in the paediatric and adult OPD in CAR, prescribers reviewed previous treatments, but patients were not asked about a potential allergy to antibiotics. Prescribers did not properly explain antibiotic intake.

Overprescribing antibiotics as a precautionary measure

In some instances, prescribers in Sudan claimed to consciously prescribe either more antibiotics than recommended, or prescribe antibiotics based on certain assumptions. For instance, due to the limited number of follow-up visits (usually only done if the patient was in a bad condition), prescribers found it difficult to adopt a wait-and-see approach. When in doubt, prescribers opted to prescribe antibiotics immediately because they claimed that a follow-up visit, even after assuming proper compliance by patients, might represent a burden for the patient and family in terms of cost, distance, or time.

Some prescribers in Tawila explained that they preferred to err on the side of overprescription rather than underprescription due to the generally low levels of hygiene and nutrition in the area, and hence the possibility of other diseases being present.

The general standard of hygiene both personal and environmental is substandard hence there are a lot of infections and need to use antibiotics. (MSF prescriber, Sudan)

Similarly, in DRC and Bissau, it was observed that medical doctors prescribed more antibiotics than necessary to be ‘on the safe side’. Nurses at the PHCs in Bissau prescribed antibiotics based on their observations of doctors’ prescription habits. If they saw a doctor prescribing an antibiotic to a sick person with a cough and a fever, they would do the same, without knowing that the two cases may be due to different diseases. Furthermore, doctors in the PHCs prescribed without any protocols and were prone to heeding demands from patients, which reportedly contributed to high prescription rates.

Additionally, in DRC, the necessity to use all medications in the stock before they expired seemed to drive prescription practices:

When the expiry date is near, I tell the doctor that he should prescribe more … it is better to give the antibiotics to the patients instead of throwing them away. (Hospital pharmacist, DRC)

Patient demands for antibiotics influenced prescribers in different ways across countries

Prescribers at all levels (doctors and nurses) reported a strong demand for antibiotics and injectable drugs from the population. According to the medical director, 99% of patients typically asked for antibiotic treatment.

Yes, it is often to demand drugs. Sometimes they come without a sick person and request a certain drug. They want antibiotics. (MSF prescriber, Guinea-Bissau)

All prescribers who were interviewed in Guinea-Bissau stated that patient demands or their ethnicity and age group did not influence prescription behaviour, but this information was not triangulated through other methods. However, in Sudan, prescribers reported feeling obliged to give medication in order to build confidence with patients, especially when patients travelled from afar to access health services and had very limited access to ‘modern’ medicine facilities. This behaviour was supposed to maintain patient trust in the prescribers’ knowledge and abilities, as the general societal perception was that proper treatment required a prescription. Prescribers claimed that, in such cases, they mostly prescribed painkillers (paracetamol/diclofenac) or a vitamin supplement, but not antibiotics.

According to prescribers in CAR, marginalised groups (Mbarara, Lithos) or members of the Muslim communities in Kabo (Salamat, Chadian) requested ‘powerful’ medications the most compared with other groups. In the major dispensaries across the CAR project, there were two distinct types of drug sellers: those who were entitled to sell medications without a prescription and those who were not. Many of these sellers even practised home visits. However, interviews with the drug sellers revealed a low level of education (6 months with diploma or interrupted education). These drug sellers adapted to the demand and consumption habits by providing ‘powerful’ medicine (antibiotics and injectable malaria treatments) and by giving injections.

Amoxi is the most used antibiotic in families … they get it from the PDS … on the markets (pharmacies) they mostly do injections … the most given injections are ceftriaxone, penicillin and gentamicin. (MSF health educator, CAR)

Finally, in DRC, prescribers perceived that many community members sought medications according to their previous experiences to avoid costs, lengthy admittance procedures and inefficient diagnoses in the health facilities.

Many come and ask for a certain medication without knowing what disease they have…they (the clients) say: now I came all the way and you only give me paracetamol? They all ask for antibiotics. (Local drug seller, DRC)

All pharmacies who were visited in DRC admitted handing out antibiotics without a prescription. Only one out of three pharmacists who were interviewed had finished his education (as a trained nurse).

Patients want the product (antibiotics) that they have in mind … they do not want a counselling … they say they just come to buy not to get advice. (Local drug seller, DRC)

Barriers to accessing free quality health care

Access to healthcare in Sudan peripheries was deemed to be challenging. In the catchment area, no other provider was offering free healthcare services, which prompted an increased reliance on self-medication from local pharmacies.

If MSF leaves us, we will die because we cannot afford to pay for treatment. (Community member, male, Sudan)

Although some areas were partially served by the mobile clinics, many patients had to travel long distances to access medical care. In addition, even the mobile clinics were cut-off during the rainy season, forcing the population to trek to Tawila on their own to access health service.

Time constraints were another barrier to access MSF health services. Waiting times on busy days could take up to 5 hours because of the huge number of patients and the comparatively limited number of prescribers. Especially during the periods when people were busy with farming, patients tended to avoid going to the HC and either purchased medication from local pharmacies or used medication previously prescribed to them by MSF. Time constraints were also found to be a nagging issue among community members in CAR. The mobile populations (cattle herders) in CAR found it difficult to leave their animals alone for a whole day to seek healthcare. They preferred to visit the pharmacy to receive an injection, which was expected to immediately enable them to return to their herds.

Moreover, the admission procedures in the Kabo project in CAR were particularly problematic and presented a considerable barrier to accessing healthcare. All communities in and around Kabo perceived admission procedures at the HC as unsatisfactory, unfriendly, hostile or discouraging. The complaints mainly referred to the system of triage. Emergencies were treated with priority and patients without fever had to wait the longest and risked being sent home without being seen.

They tell us to come again tomorrow … but the problem is NOW … we don’t come to the HC for no reason. (Community member, CAR)

Furthermore, perceived discrimination functioned as an additional barrier to seeking care in CAR. Most prescribers (MSF national staff) were Christians from Bangui or urban centres. Some groups of patients felt uncomfortable spending a lot of time among members of the other groups. In interviews, some respondents from nomadic groups (Mbarara), remote indigenous populations (Lithos) and resident Muslim populations counted frustrating experiences in the HCs and attributed these to discrimination.

Last time I came they did not admit me … they discriminate me because I am Mbarara … they didn’t even take my temperature and they sent me home … after travelling for 20 km I bought medication at the market … but I would rather get treatment from MSF … this time they treated me. (Patient, CAR)

Delays in the waiting area were often interpreted as discrimination based on ethnic reasons. Women from the ethnic majority (Sara, Banda) and from the local women’s association reported unfriendly admission procedures, which occasionally supported their decision to avoid the HC and look for treatment in the local pharmacies. Poverty and insecurity were reported to be another common reason for avoiding admission and consultation fees in HCs in DRC.

People know that it is risky to go to the “infirmière pirate” (pirate nurses) but they do it out of poverty and because they do not give good treatment in the hospital. (CHW, DRC)

At night, especially when there is insecurity, we go to the pharmacy in the neighborhood instead of the HC. (Community member, male, DRC)

Traditional medicine was usually used when MSF services failed

Reverting to traditional/religious medicine was mainly found among patients with chronic illnesses or mental health issues in Sudan. The scope of traditional treatments used was mainly limited to the use of herbs and/or Mihaya (traditionally water blessed with incantations and readings from the Quran).

These are old people treatments. Nowadays we go to the doctor… most of our old people who knew about these things are dead anyway … we still use Mihaya and similar things for protection of our children. (Community member, female, Sudan)

In CAR, even though MSF prescribers reported frequent cases of patients who consulted traditional healers or relied on homemade remedies before coming to the HC, most community respondents claimed that MSF was seen as the first choice in health-seeking behaviour, with the pharmacy as second choice, and the traditional practitioner only as third or last choice.

When MSF treatment is not effective or when the same treatment is given again people go to see the healer … but most of us go to the HC … people know that the quality is higher. (FGD youth association to combat HIV, CAR)

In DRC, the majority perceived modern medicine as the first choice of treatment, with the exception of singular cases among very precarious and marginalised populations. A common practice included applying a mix of antibiotics to open wounds to accelerate the healing process (ie, crushed chloramphenicol mixed with ampicillin). Such concoctions were also offered in local pharmacies.

In Guinea-Bissau, however, traditional medicine was still the preferred first choice. Respondents perceived traditional healers to be effective for some conditions, but not for others.

High rate of self-medication in communities and explanatory factors

Easy access to antibiotics without prescriptions in local pharmacies exacerbated the problem of self-medication, and many sellers were not trained pharmacists. If the medication was not available at the pharmacy, the drug seller occasionally sold another drug which ‘had the same effect’.

For instance, in Sudan, all medications were available without prescription in local shops. These local pharmacies were run by persons with some level of medical training (nurses/medical assistants) and operated under an MoH license as drug stores. The drugs they provided were purchased from certified drug company agents in Elfashir. Sometimes, customers asked for medicines not by mentioning their categories or names, but either by showing a pill or by describing shape and colour. During an interview with a local shopkeeper, one customer approached him with a pill in an old plastic bag and asked if the same was available for purchase.

Prescribers in CAR suspected that marginalised populations (Mbarara, Lithos) regularly resorted to self-medication (including injectable antibiotics). Community-based discussions from CAR revealed that patients stocked their prescriptions at home (as a reserve) instead of taking the whole treatment because they wanted to avoid the procedures at the admission/triage during their child’s illness.

As for DRC, certain drugs were not available in the hospital/HCs, but they could be found on the private market. These medications were also cheaper than the ones sold in the hospital dispensary. Thus, if a prescriber lacked medication or refused to prescribe an antibiotic, the patient could easily obtain the treatment from a local provider.

High demand for quick relief cures meant that all forms of treatment were not equally accepted by communities

Self-medication may also be driven by a desire for quick relief and easy access to drugs (including antibiotics) in local pharmacies, particularly in CAR and DRC. Respondents stated that they sought products that were perceived as effective and provided quick relief, particularly injectable drugs (among the antibiotics) in local pharmacies.

Community members in DRC often expressed their frustration about children getting sick again only a few weeks after a visit to the health services and being prescribed the same ‘ineffective’ medication again and again.

In the hospital they release patients too early; the disease keeps coming back … when you go to the hospital again the nurse says, 'now you come again' and prescribes the same medication. (community member, female, DRC)

In general, patients preferred intravenous solutions, as stated by community members and healthcare staff. solutions were considered as the most potent form of medication. Injections were slightly less effective, followed by syrups. Pills were perceived as the least potent treatment form. Most prescribers shared historic anecdotes of seeing pills being thrown out by patients near the facility. This was very much the case in Sudan, although there was a reported change in behaviour as the exposure of communities to modern medicine and community health education increased in Tawila.

In addition, intake of pills was often perceived as unpleasant or difficult with regard to taste. It also required sufficient food and clean water. Side effects caused by pills consumption (vomiting, stomach problems, nausea, drowsiness) were repeatedly mentioned as a reason to stop/interrupt treatment.

I am satisfied with pills instead of injections … but here, especially children and elder people do not tolerate pills … they spit or they stop because of side effects and because they don’t have enough food. (Community member, female, CAR)

Treatment with pills was relatively new in the CAR region and associated with the opening of the MSF project; administration of injectable drugs (mostly artemether and quinine but also ATB) was the most common way of treatment. Hence, a considerable part of the population—especially those who were not reached by MSF health educators—still preferred powerful, injectable drugs and rejected oral treatment.

All interviewees (community members, patients, CHWs and prescribers) in DRC confirmed the preference for injectable medications over oral intake. Reasons given for this preference ranged from faster effect, stronger efficiency, better tolerance to psychological effects (infusion means hope and comfort) and feelings of getting ‘a real treatment’ (as compared with the superficial services usually offered in the hospital).

Injectable drugs are more effective … they have immediate effect. (Community member, female, DRC)

Community members associated treatment for some diseases with antibiotic use

Some communities, especially in CAR, clearly associated particular medical conditions such as RTIs with amoxicillin treatment. This was found to be the case among a majority of Kabo residents (not so much for the mobile populations around Kabo). In particular, malaria symptoms such as stomach problems, were expected to be treated with antibiotics.

Similarly, in DRC, malaria was often associated with antibiotic prescriptions. Community members stated that they usually took ACT together with antibiotics, assuming that this is the standard treatment. Furthermore, reports indicated that women who underwent caesarean sections found it necessary to receive antibiotics to cure the wound and requested antibiotics for deliveries. Since they were released soon after birth (2 days), they extended the antibiotic treatment they received in the hospital with additional products purchased in local pharmacies.

Women are unsatisfied when they only get paracetamol after a caesarean … when they have pains, they buy antibiotics in the pharmacy … they ask for what they remember from their last delivery and buy amoxi, gentamicin and Peni V (penicillin). (CHW, DRC)

A repeatedly stated conclusion from community respondents (mothers as well as drug sellers) was that cough, predominantly in children, must be treated with amoxicillin.

I give amoxi to my child when it coughs … when the treatment is over, and it is still coughing I go and buy more amoxi” (Community member, female, DRC).

Incomplete intake of antibiotic treatment and explanatory factors

Patients in CAR indicated that they tended to stop antibiotic treatment after symptoms abated:

There are many women who do not abide to treatment recommendations … they keep parts of the treatment for later when the child gets sick again … or they give it to other children in the family … all that because they want to avoid going through admission in the HC. (Community member, female, CAR)

Similarly, in Sudan, even if patients were given the full course of treatment, some patients stopped the intake when they felt better and then either kept medications for later use or used them as shopping guidance to show to local drug sellers and obtain similar medications in the future.

Some patients, especially mothers, shared their medications with children with similar symptoms.

I always keep some medication in the house. You never know when you will need it and sometimes I can’t get to the clinic, so I keep some of the drugs they prescribe me to use until I can find time to go to the clinic. Sometimes I borrow from my neighbours. (Community member, female, Sudan)

Incomplete intake of antibiotic treatment was also linked to financial factors in other countries. For example, incomplete antibiotic treatment was commonly sold at the local pharmacies in CAR. Most patients in DRC reported that they could not afford to pay for the complete treatment and therefore had to buy antibiotics according to their budget (2–4 pills; only part of the whole prescription). They did not receive the full dose and therefore stopped the treatment before it was completed.

Similarly, when the MSF pharmacy was out of stock of a prescribed medication, some patients in Sudan secured them from the local pharmacies on the market. The majority tended not to buy the full course of medication prescribed because of cost and limited funds. This was particularly true for IDPs who had a very small income that hardly covered the cost of food.

I have to work all day to be able to buy a bowl of sorghum for my family. It costs 35 pounds… if I have to buy medicine for 60, then they will go without food for two days. (Community member, IDP, female, Sudan)

In DRC, the medical system and the private sector supported incomplete treatment by giving out antibiotics in small doses (this was true at the hospital as well as HCs and private clinics/pharmacies). Due to the limited financial capacities of patients and relatively high costs of medications, prescribers tended to only hand out the amount of pills that patients could afford (eg, 4 pills of amoxicillin) instead of the full treatment (eg, 14 pills for 7 days). Patients were told to buy the rest when they had finished the first part or as soon as they could afford to buy more. Frequent shortages of medications in the MoH stocks also contributed to that practice.

There is a problem with some of the MoH prescribers: they prescribe the full treatment, but they only give half of the pills to the patients; the rest they sell in the community. (MSF supervisor, DRC)

Another major reason for incomplete intake of antibiotic treatment was that many patients did not understand the prescriptions which were provided. Most interviewees in CAR claimed to be satisfied with the given explanation by prescribers, but many could not reproduce the message or gave wrong answers with regard to their treatment. In Sudan, most community members described disinterest or even fear of knowing how drugs worked. Some prescribers expressed limited confidence in the ability of patients with limited education to grasp detailed explanations. At the hospital level in DRC, instructions were provided in the paediatric ward, where the atmosphere was noisy and distracting. When questioned afterward, most of the patients did not know what kind of medication was prescribed (ATB or other), whereas others did not understand the pathology.

Besides financial barriers and inadequate information retention, security was also mentioned as a hindering factor for complete intake in DRC:

I know I should take amoxi for seven days … but I had to leave my house in Swiza because of the rebels … I left my pills and my patient book when we had to flee … so I stopped treatment after 5 days. (Community member, female, DRC)

Additionally, language barriers represented a considerable challenge in CAR, especially for Arabic-speaking groups inside the OPD and at the dispensary. Many illiterate patients could neither relate to the symbols on the sachet (sun=morning/ moon=night, and so on) nor to the lines indicating the number of pills that had to be taken.

Trust in prescribers’ judgement and treatment plan

Most respondents expressed a high level of trust in the judgement and prescription decisions of MSF health staff. Many respondents stated that this trust led to stronger compliance:

If you don’t follow the doctor’s orders, you don’t get well. (Community member, female, Sudan)

According to HC staff, people who never went to school or who only visited school for a limited amount of time tended to follow doctors’ orders without doubts due to high trust in modern medicine. Others, with higher education, tended to question the doctor’s decision and occasionally requested different medications than the ones which were prescribed.

Community members in CAR continuously complained that symptoms kept coming back. Interview respondents claimed that prescribers did not change the treatment even if a patient returned several times with the same disease, thereby conveying the impression that prescribers did not question the effectiveness of a treatment.

The consultation is only between 3 and 5 minutes … they don’t check the carnet and they don’t really listen when we tell them about our (health) problems … there are people here who don’t go to the HC because they know they will get the same treatment for a problem that doesn’t go away. (Community member, CAR)

In general, all population groups in CAR perceived MSF as the best healthcare provider (highest quality, most professional and most affordable). However, effectiveness of treatment was questioned all too often, especially in the OPD. Many respondents described receiving medications that had become inefficient and powerless.

They always give the same treatment, we take it but we come back with the same disease … they give us the same treatment again and so on … that’s the treatment we get at the HC. (Community member, CAR)