Stewardship without walls: taming the unregulated antibiotic economy to contain antimicrobial resistance in Ethiopia

Ethiopia’s unregulated private antibiotic economy spans private hospitals, clinics, pharmacies, drug shops and informal vendors. It drives resistance through three forces: intergenerational self-medication (reservoir habit), a satisfaction imperative linking sales to customer retention, and a corner drugstore calculus prioritising immediate access over cheaper but slow public care. Non-prescribed dispensing becomes the norm and selects resistant bacteria. We propose a six-pillar framework: tiered accreditation, point-of-service education, supply chain engagement, mystery client support, technology enabled consultation and operational research. This stewardship without walls is an urgent priority for Ethiopia and similar settings. Arega and Agunie analyze Ethiopia’s unregulated private antibiotic economy and propose a six-pillar framework of stewardship without walls to contain antimicrobial resistance in low-income settings.