Ethiopia Faces Antimicrobial Resistance in an Unregulated Market

In Ethiopia, a large portion of antibiotics is distributed outside official channels. Private hospitals, clinics, pharmacies, small shops, and even street vendors offer these medications without strict oversight. This situation fuels antimicrobial resistance, a phenomenon where bacteria become resistant to treatments, making infections harder to cure.

Three mechanisms explain this dynamic. First, self-medication with antibiotics is a deeply rooted habit in families. Parents pass down the idea that these drugs quickly cure fevers or infections without the need for medical consultation. Second, private vendors and pharmacies are incentivized to satisfy their customers to retain their loyalty. Refusing to sell antibiotics without a prescription could mean losing a customer to a less scrupulous competitor. Finally, patients often choose private outlets to avoid long waits and hidden costs in public facilities, such as lost wages or transportation fees. For a day laborer, a day spent in a public hospital can cost more than buying an antibiotic from a local shop.

The Ethiopian private sector now accounts for between 33% and 48% of healthcare facilities, with over 23,000 private pharmacies and shops. These outlets handle between 54% and 67% of antibiotic transactions in the country. However, healthcare staff remain insufficient: there are only 0.96 doctors and 1.2 nurses per 10,000 inhabitants, well below international standards. This shortage pushes patients toward private solutions, which are often more accessible.

Studies show that selling antibiotics without a prescription is common. In some regions, over 60% of purchases for childhood illnesses are made without a prescription. Street vendors, who sell medications in single doses or small quantities, primarily target the most vulnerable populations: precarious workers, migrants, or those without resources. Even small grocery stores, which are not authorized to sell medications, sometimes offer them, filling a gap in access to care.

The reasons for this situation go beyond a simple lack of regulation. Antibiotics are seen as a quick and effective solution, validated by experience. Vendors, under commercial pressure, prioritize immediate customer satisfaction over compliance with rules. As for patients, they calculate that the total cost of a public visit—time, transportation, uncertainty—is often higher than that of a private purchase, even if it is more expensive.

To combat this phenomenon, a comprehensive approach is needed. Rather than relying solely on sanctions, all private sector actors must be involved. A gradual certification of facilities, tailored to their size and type, could encourage good practices. Simple tools, such as posters explaining when to prescribe or not prescribe antibiotics, help vendors justify their refusals. Wholesalers and distributors can also play a role by reporting suspicious orders, thereby limiting the supply to informal channels.

Technology also offers solutions. Advisory services via SMS or mobile apps allow vendors to obtain quick medical advice. Finally, surprise inspections, conducted in a constructive rather than punitive manner, help assess actual practices and provide targeted training.

Without action in this unregulated sector, efforts to limit antimicrobial resistance in Ethiopia will remain in vain. Patients who are denied antibiotics in a public hospital can easily find them elsewhere. It is therefore essential to transform incentives and behaviors across the entire market, rather than simply suppressing it.

Website References

Scientific Reference

DOI: https://doi.org/10.1038/s41467-026-74671-z

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

Journal: Nature Communications

Publisher: Springer Science and Business Media LLC

Authors: Balew Arega; Asnake Agunie