Characterizing Antibiotic Self-Medication in Guatemala

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Characterizing the pharmaceutical nexus of self- medication with antibiotics
in Guatemala
Conference Paper · May 2016
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3 authors:
Brooke Ramay
University of the Valley of Guatemala
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Alejandro Cerón
University of Denver
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Luis Méndez
Universidad Rafael Landivar, Guatemala
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Partie 1 – L'automédication en question p.1
Actes électroniques – Colloque L'automédication en question : un bricolage socialement et territorialement situé
Mise en ligne : juillet 2016

Partie 2 – Automédication et système de santé p.125
Characterizing the pharmaceutical nexus of self-
medication with antibiotics in Guatemala
Brooke Ramay(1), Luis Méndez(2), Alejandro Cerón(3)
1. Universidad del Valle de Guatemala, Department of Pharmaceutical Chemistry,
Center for Health Studies, Centre for Study of Equity and Governance in Health
Systems, Guatemala.
2. Centre for Study of Equity and Governance in Health Systems, Guatemala.
3. University of Denver, Department of Anthropology, Universidad del Valle de
Guatemala, Department of Anthropology and Sociology, Centre for the Study of
Equity and Governance in Health Systems, Guatemala.
Introduction
Self-medication poses several public health-threats to those who choose to take medicine
without a physician’s diagnosis. Some major issues associated with self-medication include
incorrect use which can lead to adverse effects and unnecessary emergency room visits.
These risks are counterbalanced by the possibility that an individual will self-cure quickly.
However, self-medication, specifically with antibiotics, has the additional problem that
infectious disease may be prolonged and local and global antibiotic resistance can increase.
Although not quantified at a global level, the context in which self-medication with
antibiotics occurs has been described in many countries, especially where antibiotics are
sold without a prescription. The social-determinants of self-medication with antibiotics
such as people’s motivations and/or need to self-medicate, the social and political rules
permitting it, and the economic consequences and benefits have not previously been
described in Guatemala, thus our interest in pursuing this topic.
The “pharmaceutical nexus” involves the social, political, economical and ethical
dimensions of providing, obtaining, and using medications (1). When we consider the
pharmaceutical nexus, we analyze and describe the varying levels of health-need and how
various actors attempt to meet those health needs. Heath care providers, patients, and the
pharmaceutical industry all affect health service outcomes and are described based on the
nexus model. It also allows us to analyze how society both facilitates and frowns upon self-
medication with antibiotics. It is within this construct we explore the practice of self-
medication with antibiotics and those who facilitate, and regulate the practice in
Guatemala.
Guatemala’s health care system is structured through a public and a private sector. The
public sector includes the Ministry of Health (MOH) and the Guatemalan Social Security
Institute (IGSS). The MOH is a tax-funded network of hospitals and clinics that does not
charge any fees for services but that is often under-supplied. The IGSS is an employer-
based insurance system that covers 15% of the economically active population. The private
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Partie 2 – Automédication et système de santé p.126
sector includes a wide network of non-governmental organizations, private hospitals and
clinics, and a growing number of pre-paid or insurance based networks that work similarly
to the Health Management Organizations (HMO) from the United States of America.
Private and public health insurance are still uncommon, and more than 50% of the
country’s health expenditure comes from out-of-pocket expenses. Because the system is
fragmented and disarticulated, people navigate between the public and private sectors as
they see fit, but the close to 50% of population living in poverty rely more on the MOH and
private non-for-profit facilities, but it is in this group where the highest proportions of out-
of-pocket expenses have been documented. People with higher purchasing power are the
ones with more access to private services and private health insurance. Patients schedule
appointments to see physicians and the quality of the care may be comparable to most
developed countries. Patients can also call their doctors for phone-call consults, and obtain
medications at private pharmacies with or without a physical prescription, but is often
based on advice given over the phone by the doctor.
Public health care provided by the MOH, and alternatively, health care through IGSS are
often used only if needed and if there is no accessibility or availability to private
alternatives. The public health care system is available free of cost to the entire population
of Guatemala, and this is the health care service that the majority of the population seeks,
leading to a high demand for service by patients with low-purchasing power.
Patients travel long distances (from rural to urban locations and within urban cities) and
wait several hours to be seen by physicians or nurses. Hospitals and pharmacies pertaining
to the MOH, often experience shortages in medical supplies and medications. Problems in
the supply of medications are often publicized in local newspapers and media, and are
attributed to problems in the governments’ budget, corruption and poor health-systems
management.
The Guatemalan Social Security Health System (IGSS) is a service paid for by the
employers of contracted employees. In the social security health care sector, physician
visits and medications are free of cost. Nevertheless seeking service at these institutions
consumes a significant amount of time. The social security hospital has a continual supply
of medications because employers consistently pay into the system. The result is a surplus
in medication supply, which leads to, in some cases, patients selling their medications on
the street. (Medications sold on the street range from anti-hypertensives to anti-diabetics
and antibiotics.) While in the MOH there is a shortage of medications and many patients in
need, there is a surplus of medication in the IGSS accompanied with a high street-value for
selling medications.
Regardless of the differences in cost of health care, and access to health care services,
disparities are made uniform through the direct purchase of medications in private
pharmacies in Guatemala. The private pharmacy represents an environment where
everyone plays by the same rules in accessing medications and perceived access to health
care—so long as one has money to purchase medications, they may obtain remedies to
treat their illness in pharmacies—. Practicing self-medication with antibiotics in
pharmacies overcomes barriers in access to health care, from facilitating treatment
recommended by private-physicians over the phone to providing alternative sources of
medications during periods of MOH shortfalls in care. Private pharmacies are found
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abundantly in Guatemala and have created a niche for over-the-counter sales of
antibiotics. The urban population as a whole has access to pharmacies in which there are
no concrete rules facilitating or prohibiting purchase of medications.
Limitations to accessing health services and medications motivate many Guatemalan
citizens to consider alternatives for obtaining health care. Self-medication has been
demonstrated a viable alternative for treating disease in cases where there are limitations
in health services. In exploring issues in access to medications in the MOH, and antibiotic
self-medication in private pharmacies, we seek to describe the pharmaceutical nexus
surrounding the practice of self-medication with antibiotics in Guatemala.
Summary of methods
Between 2013-2015 we carried out seven studies involving self-medication with antibiotics.
Table 1 summarizes the studies goals, methods and findings. Upon analysis and reflection
of these seven studies, the authors looked for the main lessons learned from them, which
led to the identification of three main themes, which we present in this paper. First, we
have found that there is a high demand for antibiotics that is shaped by benign perceptions
of effects and accessibility to health care.
This demand is homogeneous among those belonging to different socioeconomic status
groups. Second, we have documented a permissive attitude towards the over-the-counter
availability of antibiotics from convenience stores, pharmacies and health care providers
facilitated by a lack of effective regulation of prescription and dispensation. Finally, the
lack of availability of antibiotics in public health facilities together with increased
availability of antibiotics in private pharmacies and convenience stores is facilitated by the
interweaved relationship between the pharmaceutical industry, the legislature, regulatory
agencies and public health care providers. The effects of supply and demand factors,
although important, are highly influenced by political, legal and administrative processes
shaping the pharmaceutical nexus for SMA in Guatemala.
High demand of antibiotics
The results of self-medication with antibiotic studies indicate that first, there is a
high, homogeneous demand for antibiotics across all pharmacies included in these studies
and second, the majority of respondents consciously avoid doctors’ visits when self-
medicating. This is a characteristic previously described in Latin American patients1, and
in Guatemalan studies, where the notion of “entitlement” to a cure when faced with limited
resources leads to unguided decisions regarding treatment options. Self-medication with
antibiotics is one mechanism people use to proactively treat self-diagnosed symptoms.
1 Meredith Gartin, Alexandra A. Brewis, and Norah Anita Schwartz, “Nonprescription Antibiotic
Therapy:,” Medical Anthropology Quarterly 24, no. 1 (March 2010): 85–107, doi:10.1111/j.1548-
1387.2010.01086.x; Elaine L. Larson et al., “Factors Which Influence Latino Community Members to
Self-Prescribe Antibiotics,” Nursing Research 55, no. 2 (April 2006): 94–102; Nancy Vuckovic, “Fast
Relief: Buying Time with Medications,” Medical Anthropology Quarterly 13, no. 1 (March 1999): 51–
68, doi:10.1525/maq.1999.13.1.51; Brooke M Ramay, Paola Lambour, and Alejandro Cerón,
“Comparing Antibiotic Self-Medication in Two Socio-Economic Groups in Guatemala City: A
Descriptive Cross-Sectional Study,” BMC Pharmacology and Toxicology 16, no. 1 (December 2015),
doi:10.1186/s40360-015-0011-3.
Actes électroniques – Colloque L'automédication en question : un bricolage socialement et territorialement situé