Out-of-pocket health expenditures and antimicrobial resistance in low- and middle-income countries

BACKGROUND: The decreasing effectiveness of antimicrobial agents is a growing global public health concern. Low- and middle-income countries (LMIC) are vulnerable to the loss of antimicrobial efficacy given their high burden of infectious disease and the cost of treating resistant organisms. METHODS: We analyzed data from the World Health Organization’s Antibacterial Resistance Global Surveillance Report. We investigated the importance of out-of-pocket spending and copayment requirements for public sector medications on the level of bacterial resistance among LMIC, adjusting for environmental factors purported to be predictors of resistance, such as sanitation, animal husbandry and poverty as well as other structural components of the health sector. FINDINGS: Out-of-pocket health expenditures were the only factor demonstrating a statistically significant relationship with antimicrobial resistance. A ten point increase in the percentage of health expenditures that were out-of-pocket was associated with a 3·2 percentage point increase in resistant isolates [95% CI, 1·17 to 5·15, p-value=0·002]. This relationship was driven by countries requiring copayments for medications in the public health sector. Among these countries, moving from the 20(th) to 80(th) percentile of out-of-pocket health expenditures was associated with an increase in resistant bacterial isolates from 17·76 [95%CI 12·54 to 22·97] to 36·27 percentage points [95% CI 31·16 to 41·38]. INTERPRETATION: Out-of-pocket health expenditures were strongly correlated with antimicrobial resistance among LMIC. This relationship was driven by countries that require copayments on medications in the public sector. Our findings suggest cost-sharing of antimicrobials in the public sector may drive demand to the private sector where supply-side incentives to overprescribe are likely heightened and quality assurance less standardized.