Mitigating inequitable access to appropriate antibiotics in low- and middle-income countries.

Access to effective medicines (e.g. antibiotics) is a fundamental human right. However, in contrast to high-income countries (HICs), many low- and middle-income countries (LMICs) lack appropriate and effective antibiotics. This is a paradox, and an inequitable scenario, as LMICs can have significantly higher burdens of infectious diseases than HICs and especially require appropriate antibiotics. Inequitable access to appropriate antibiotics results in patients being treated with substandard antibiotics, treatment failure, the emergence of antimicrobial resistance (AMR) and, inevitably, morbidity and mortality. Factors that hinder access to appropriate antibiotics in LMICs include: poor political will, weak health systems, complex bureaucratic protocols, poor implementation of National Action Plans on AMR, inadequate expertise in regulatory science, unfavourable macroeconomic policies and a poor investment climate. Clearly, multisectoral, collaborative approaches are required to effectively mitigate inequitable access to appropriate antibiotics in LMICs. Also, efforts (such as the African Medicines Regulatory Harmonization Initiative and the African Medicines Agency) to streamline bureaucratic processes and improve the registration and entry of appropriate antibiotics into LMICs are required. This review discusses factors responsible for inequitable access to appropriate antibiotics in LMICs, and makes recommendations to mitigate the problem. With rising rates of AMR, a dwindling antibiotic pipeline, and the dangers of a post-antibiotic era, it is clear that the time to act is now, as inequitable access to appropriate antibiotics in LMICs reduces the quality of healthcare, and threatens the achievement of Universal Health Coverage and, ultimately, the Sustainable Development Goals.