Facing up to reality: over-the-counter access to antibiotics in low-income and middle-income countries needs a paradigm shift in thinking

Almost half of the global population do not have access to universal health coverage and the current shortfall of health-care professionals (including doctors and nurses) is estimated to reach a deficit of 11 million by 2030, disproportionately affecting low-income and middle-income countries (LMICs). Against this backdrop, of the 8 million deaths per year from bacterial sepsis worldwide, over 3 million are from treatable antibiotic-sensitive infections. This number suggests that access to antibiotics under the current model is insufficient. In many LMICs, over-the-counter antibiotic sellers that range from informal drug procurers to small-sized and medium-sized private pharmacies are the primary and most accessible care providers. Yet global health narratives, often shaped by the traditional doctor-led prescribing model, portray them as drivers of misuse rather than recognising them as politically and economically embedded actors that meet unmet health and antibiotic needs. In this Viewpoint, we argue that over-the-counter antibiotic sellers need to be integrated into a solution for antibiotic misuse and overuse, rather than being seen as part of the problem. Furthermore, we provide a framework with which to achieve integration, so that the concept of global health care for all becomes a reality.