title: An analysis of policies for cotrimoxazole, amoxicillin and azithromycin use in Namibia's public sector: Findings and therapeutic implications.
abstract: BACKGROUND
  Despite Namibia's robust medicine use systems and policies, antibiotic use indicators remain suboptimal. Recent medicine use surveys rank cotrimoxazole, amoxicillin and azithromycin (CAA) among the most used medicines. However, there is rising resistance to CAA (55.9%-96.7%). Unfortunately, to date, there have been limited studies evaluating policies to improve antibiotic use in Namibia.
  
  
  OBJECTIVE
  To evaluate public sector pharmaceutical policies and guidelines influencing the therapeutic use of CAA antibiotics in Namibia.
  
  
  METHODS
  Evaluate Namibia's pharmaceutical policies and guidelines for CAA use through quantitative text analysis. The main outcome variables were the existence of antibiotic policies, therapeutic indications per antibiotic and the type/level of healthcare facility allowed to use the antibiotic.
  
  
  RESULTS
  Policies for antibiotic use were limited, with only the draft Namibia Medicines Policy having a statement on antibiotic use. Several essential antibiotics had no therapeutic indications mentioned in the guidelines. Twenty-nine antibiotics were listed for 69 therapeutic indications; CAA (49.3%) antibiotics and ATC J01C/J01D (48%) having the highest indications per antibiotic. For CAA antibiotics, this suggested use was mainly for acute respiratory infections (n=22, 37.2%). Published policies (58.6%-17/29) recommended antibiotics for use at the primary healthcare (PHC) level, with CAA antibiotics recommended mostly for respiratory tract infections and genitourinary infections.
  
  
  CONCLUSIONS
  Policy and guidelines for antibiotic use in Namibia are not comprehensive and are skewed towards PHCs. Existing policies promote the wide use of CAA antibiotics, which may inadvertently result in their inappropriate use enhancing resistance rates. This calls for the development of more comprehensive antibiotic guidelines and essential medicine lists in tandem with local antimicrobial resistance patterns. In addition, educational initiatives among all key stakeholder groups.
authors.affiliation: Department of Pharmacy practice & Policy, School of Pharmacy, University of Namibia, Windhoek, Namibia.
authors.forename: Dan
authors.initials: D
authors.lastname: Kibuule
authors.affiliation: Department of Pharmacy practice & Policy, School of Pharmacy, University of Namibia, Windhoek, Namibia.
authors.forename: Mwangana
authors.initials: M
authors.lastname: Mubita
authors.affiliation: Department of Pharmacy practice & Policy, School of Pharmacy, University of Namibia, Windhoek, Namibia.
authors.forename: Ester
authors.initials: E
authors.lastname: Naikaku
authors.affiliation: Department of Pharmacology and Therapeutics, School of Pharmacy, University of Namibia, Windhoek, Namibia.
authors.forename: Francis
authors.initials: F
authors.lastname: Kalemeera
authors.affiliation: Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.|Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.
authors.forename: Brian B
authors.initials: BB
authors.lastname: Godman
authors.affiliation: Systems for Improved Access to Pharmaceuticals and Services (SIAPS)/Management Sciences for Health (MSH), Windhoek, Namibia.
authors.forename: Evans
authors.initials: E
authors.lastname: Sagwa
mesh_terms: D000658:Amoxicillin / Q000600:supply & distribution; D000900:Anti-Bacterial Agents / Q000600:supply & distribution*; D017963:Azithromycin / Q000600:supply & distribution; D019985:Benchmarking; D003157:Community Pharmacy Services / Q000592:standards*; D004359:Drug Therapy, Combination; D006801:Humans; D009276:Namibia; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D017150:Public Sector; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000600:supply & distribution
chemical_list: D000900:Anti-Bacterial Agents; D000658:Amoxicillin; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D017963:Azithromycin
keywords: Namibia; amoxicillin; antibiotic use; azithromycin; cotrimoxazole; policies