Retail Pharmacy Market in Kigali - A game theoretical application on antimicrobial resistance

Abstract: Antimicrobial resistance is an acute global health problem. Sub-Saharan Africa is particularly vulnerable, where antibiotic self-medication is one of the main causes of antimicrobial resistance. Previous research points to the role of pharmacies, where antibiotics are sometimes sold over the counter. Such behavior can be analyzed economically using game theory. This study aimed to analyze and motivate the payoffs which make up the incentives of Rwandan retail pharmacies to sell non-prescribed antibiotics and Rwandan consumers to self-medicate on non-prescribed antibiotics. The aim was fulfilled by first mapping out two hypothetical games on the strategic interaction of pharmacies and healthcare seekers with payoffs based on previous research on AMR in Rwanda. Thereafter, face-to-face semi-structured interviews were conducted with licensed retail pharmacists in Rwanda’s capital city Kigali. Six themes were identified: (1) profit-prioritizing practice (2) expensive prescription (3) strong customer demand (4) retail pharmacy medical advice (5) conflict of interest (6) collaboration problem. These themes were then used to modify the games to better align them with reality. Subsequently, four policies were briefly proposed as ways of altering the payoffs to move the equilibria to the societally optimal ones: (1) enforce an over-the-counter dispensing protocol (2) introduce record-keeping of antibiotic sales (3) decrease the costs of visiting public health institutions (4) execute an awareness campaign for the general public as well as include antimicrobial resistance in retail pharmacists’ continuing professional development. These policies and the illustrative games can be of great use to Rwandan regulators in their implementation of their newly adopted national action plan to combat antimicrobial resistance, as well as to fulfill Sustainable Development Goal three of good health for all.