Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

Abstract

Background: Irrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions.

Method: This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data.

Result: We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well.

Conclusion: The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

Keywords: Complex adaptive systems (CAS); Complexity sciences; Pharmaceutical policy; Rational use of antibiotics.

Fig. 1

Subsystems of antibiotics use in Iran Circle 1 represents agents who make policies, regulate the system and reimburse antibiotics. Circle 2 represents monitoring agents that investigate the implementation of regulations or provide evidence to make policies. Circle 3 points at agents which produce and dispense antibiotics and circle 4 represents agents who contribute to the core function of antibiotic prescription and use

Fig. 2

Main agents’ interactions in antibiotics use in Iran and their contribution to the formation of a networked interaction structure Thick lines represent type-one interactions between agents that are governance-oriented and rule-based. Dots and dashes display type-two interactions, where the heart of antibiotics use lies. Lastly, thin lines illustrate type-three interactions between agents, which are reciprocal