Policy processes and AMR in Pakistan

How do policymaker perceptions of antimicrobial resistance drive behaviour and policies for appropriate antimicrobial use? A case study of Pakistan

Who are we? This piece of research involves an interdisciplinary team of social and animal scientists in both the UK and Pakistan. Dr Johanna Hanefeld, Associate Professor Health Policy and Systems and Head of the Anthropology, Politics and Policy Group at LSHTM, working with co-investigators Dr Mishal Khan (Assistant Professor of Health Policy and Systems Research, LSHTM), Dr Helena Legido-Quigley (Associate Professor National University of Singapore), Dr Ana Mateus (Royal Veterinary College, UK) and Prof Rumina Hasan (Aga Khan University, Pakistan).

In addition, research will benefit from advice and oversight of an academic and an impact advisory panel to ensure maximum impact on policy and future research on AMR. The Centre on Global Health Security at Chatham House in the UK is supporting the research project (www.chathamhouse.org).

What is the aim? The aim of this piece of research is to determine how policymakers’ perceptions of antimicrobial resistance (AMR) drive their behaviour and selection of policy options aimed at appropriate use of antimicrobials, focusing on Pakistan.

Our findings will help identify the specific economic factors, cultural norms, experiences and practices relating to antibiotics that enable the best strategies for action, by providing concrete knowledge and tools for working with policymakers in LMICs as they adapt and adopt national policies for appropriate AM use.

How will we do this? This qualitative piece of work will engage a multidisciplinary team drawn from both human and animal health. We will begin by comprehensively mapping the policy actors involved in developing policy relevant to appropriate use of AM. We will then select actors for in-depth interviews, which will include a ‘thinking aloud’ exercise.


In 2010 the Pakistan government estimated that 45-50% of drugs are fake or sub-standard

What are the key questions?

  • Who are the key policy actors to engage for effective implementation of interventions and policies concerning appropriate antimicrobial use? How are these actors currently, and potentially, connected?
  • How are the selected policy options socially constructed and how do social constructions reinforce or weaken support or opposition for the selected policies?
  • What other motivations, power relations and contextual factors drive the selection of specific policies?
  • How do these differ among different groups of policymakers identified under objective 1 (e.g. animal health versus human health or political affiliation)?
  • Based on analysis of the questions above, how do policies for appropriate use need to be presented and framed to ensure that essential groups of policy actors engage with, and respond to, these effectively?

What is the situation in Pakistan? With a population of around 195 million, Pakistan is possibly the largest country currently without a national policy or guideline on AMR. A key consideration for appropriate use interventions is care provision through the for-profit and informal health sector. This issue is particularly critical in South Asia, where 80% of patients seek care within the poorly regulated private or informal sector. Pakistan provides an ideal case study to investigate this, as 78% of the population pay out-of-pocket and the private sector provides 75% of health services.

Dealing with AMR is complicated by the rising population and urbanisation taking place in Pakistan. On 01 January 2017, the estimated population of Pakistan was 194.9 million, making it the world’s sixth most populous country, sandwiched between Nigeria (seventh) and Brazil (fifth). With a growth rate of 2.1%, the country’s population is continuing to increase at an accelerated pace.

Population density in Pakistan

Population density in Pakistan (image downloaded from reliefweb.int)


Rapid urbanisation has led to Karachi, Pakistan’s financial centre and main port, becoming the seventh largest city in the world, and the third most densely populated city on the planet. Currently 22.1 million people live in urban Karachi, with a population density of 23,400 people per square kilometre. In total, 50% of Pakistanis live in towns of at least 5,000 people.

This 2-minute BBC report from Pakistan explains some of the issues around counterfeit drugs:


Our research recently (31 August 2017) appeared in the major Pakistani newspaper ‘Dawn’, as part of a discussion on multidrug resistance in Pakistan. Click here to read: https://www.dawn.com/news/1355063/multidrug-resistance

What will we produce?

Various documents, including policy briefs for policymakers working on AMR, a research methodology, scientific outputs and publications.

Latest activities

To read more about the project click on this link:


A poster describing the project was presented at a conference in London on 4-5 July 2017: AMR in Pakistan conference poster.

Listen to Mishal discussing the burden of AMR in Pakistan, and this project, here:


Medicines are available in many shops, not just pharmacies


On 1 May 2018 we presented a seminar at LSHTM on the background, methodology and preliminary findings from the project. You can see the slides here: AMR_Seminar_01052018_final_final and watch the presentation here: http://amr.lshtm.ac.uk/2018/01/31/amr-pakistan-cambodia/.

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