Dr Marco J Haenssgen discusses the application of management thinking to solving the growing global problem of antimicrobial resistance.
You may have heard about superbugs, drug-resistant bacteria, or antibiotic and antimicrobial resistance (AMR) – all referring to one of the most pressing health challenges that the world is facing currently. AMR is high on public health agendas, it has attracted several hundreds of millions of pounds of research funding, and it risks to become one of the leading causes of death in the world by claiming an estimated 10 million lives annually by 2050. The World Bank argues that this will have an economic impact similar to the 2008 global financial crisis. Poor countries will be hit hardest, but rich countries are by no means safe because drug resistance is a global problem and drug-resistant bacteria can also be imported from abroad. The UK experienced this very recently, for example.
AMR means that certain types of medicine become less useful. The problem arises when bacteria and other microbes develop a tolerance to antibiotics and other antimicrobial drugs, which happens for example if we keep using antibiotics for the wrong purpose, like to treat flus and colds. At the same time, new medicines to fight superbugs are still far on the horizon, and so diseases like tuberculosis are becoming more difficult to treat or even life threatening.
A part of the response to the superbug crisis therefore involves stimulating the supply of new antimicrobials, and reducing the demand for and unnecessary use of antimicrobial drugs. Typical suggestions to reduce the demand for antibiotics among the general population thereby include reducing infections through improved public health, and to increase public awareness about superbugs. As a social scientist, I would argue that this is unlikely to solve problematic antimicrobial demand and overuse in the general population. The problem is likely to persist even if everyone in the world was aware and educated about AMR because health behaviour is not solely driven by what we know (other determinants include e.g. poverty, lacking access to qualified doctors and nurses, fear, different cultural beliefs, or people’s understanding of what “good care” is).
The supply-and-demand definition of a market for medicine does not help to resolve this problem. The definition is common in neoclassical economists, where markets are defined as an allocation mechanism for products and services. Akin to a “market place,” supply and demand depend on the price of these goods and services. According to this simple model, we could lower demand for antimicrobials by changing people’s preferences, by ensuring that they don’t get sick so often, or by offering them other medicines instead. These suggestions are not insensible, but the focus on a single product or family of products is a barrier to understanding the nature of the demand for antibiotics among the general population, and to find more comprehensive solutions. We can find some impulses for an alternative in strategic management.
Business leaders know that they don’t compete only with comparable products for their customers. An example I have been trained with in management school is a construction firm in the Middle East (let this be our “Customer”). The customer wins a valuable contract by the government to build the next skyscraper, deadlines are tight and stakes are high. The construction firm will therefore have a demand for the best and most reliable construction equipment available (diggers, cranes, and all the other things that get boys excited about). Let a manufacturer of such equipment be our “Supplier 1.” Quite obviously, Supplier 1 competes with other manufacturers of equipment, for example on the basis of product quality, price, or other purchase-related services like quick order fulfilment.
Is Supplier 1 right in considering only the product market for construction equipment? What is it that actually matters to the Customer? Certainly no skyscraper construction can happen without equipment, and so to consider competing manufacturers of the same product is not absurd. But the important consideration for the Customer is to fulfil the construction contract without delay so as to avoid financial penalties by the government. That is why high-quality and breakdown-proof equipment is important, as it helps to limit the risk of delays. Similarly useful would be insurance to cover the penalties for delays, in which case our Customer could make do with cheaper equipment. Supplier 1 is therefore not only in direct competition with other equipment manufacturers, but also with insurance companies, and if the function of avoiding financial penalties for delays can be met by an insurance broker, then suddenly there may no longer be a demand for high-quality and reliable equipment by the Customer. The market does therefore not just comprise products, but more general functions that the customer aims to fulfil, and different types of solutions or technologies can fulfil these functions.
This is the conceptualisation of strategic market segments following Abell (1980), and one line of management teaching suggests that businesses should not only be concerned with competing producers of similar products, but indeed with solutions from other industries that help customers fulfil their needs.
Though it may appear “off the beaten track,” we can apply this definition of strategic markets quite usefully to AMR and the demand of antimicrobial drugs. If we consider the case of people’s antibiotic use, then the conventional supply-and-demand logic can easily trap us in a focus on prices, different types and brands of antibiotics, or perhaps relative prices with other medicines. A strategic market definition draws attention to other aspects: functions (the ultimate goal of taking medicine), technologies (the range of solutions to reach this goal, including medicine), and consumers (different segments of the general population). We could therefore consider:
• What function(s) do antibiotics fulfil when people demand them? For example, some people might just take medicine in the hope to get better quickly, especially if they cannot (afford to) take time off and their family depends on their work.
• What other solutions help people to achieve the same function(s) that antibiotics fulfil? If antibiotics provide peace of mind, then this might not be an intrinsic characteristic of antibiotics, but of receiving some form of pharmaceutical treatment more generally. The same peace of mind could be brought about by labour laws that provide paid sick leave, so people don’t have to worry about their income when they get sick.
• Do these functions matter equally to all consumers? Strategic marketing starts from the premise that consumer groups differ in their needs, and the functions of antibiotics may be distributed unevenly across a population.
If we apply this strategic management definition of a market, then we can broaden our understanding of and response to people’s antibiotic use. For example, while awareness campaigns might change some people’s behaviour, what we think to be superior knowledge or a better solution may not be deemed superior by the population groups whom we serve, so we need to understand their needs and objectives first. The reason for overusing antibiotics might not have been because people did not know what they were taking, but for example because they were desperately trying to keep working and sustain their family.
The strategic market logic thereby permits us to formulate new premises for analysing people’s medicine use. A selection of such premises is exemplified below:
|1. The landscape of healthcare providers is fragmented and obscure.||While access to prescription medicine may be regulated more easily in public healthcare settings, the wide spectrum and number of non-public providers of healthcare (e.g. unregulated pharmacies or grocery stores selling medicine) means that the general population will not automatically be drawn to public healthcare services.|
|2. Preferences and means to access healthcare vary within the population.||Patients may ascribe a higher curative value to private healthcare providers, gaps in public healthcare provision might make private alternatives preferable for logistical reasons, or ethnic minority groups’ experiences with discrimination can bias their treatment-seeking behaviour towards informal local healthcare providers (e.g. local stores) - all of which could increase people’s likelihood to receive antibiotics for their treatment when it is not clinically necessary.|
|3. When navigating these obscure health systems, people share a social space within which they collaborate and compete.||Treatment seeking and access to medicine do not happen in isolation. Help from others can help overcome constraints and shape choices. However, available healthcare resources are often scarce and the competition for them can crowd out already marginalised groups.|
|4. New healthcare solutions that target patient behaviour will always have to compete with existing solutions.||From a strategic market perspective, antibiotic prescription and use, even if they are deemed “inappropriate,” will always be part of a network of solutions to meet various health-related consumer functions. This network constitutes potential competition for new interventions to reduce antibiotic use.|
|5. Social, economic, and technological change can affect treatment-seeking behaviours in unforeseen ways.||Contextual change alters the constraints that people experience when they seek care and access medicine, which can lead to the emergence of new behaviours. Mobile phone diffusion can for instance increase access to healthcare but could also complicate and bias people’s choices towards non-public healthcare providers.|
|6. Solutions for what is deemed “problematic health behaviour” need not be confined to the health sector, but they can plausibly have similarly if not more effective substitutes in other sectors.||In the same way that contextual change can influence healthcare choices and constraints, interventions to improve health behaviour and antibiotic use might focus on changing the composition of contextual constraints. For example, health education about “appropriate antibiotic use” may be informative for the general population but unable to alleviate financial hardship as the underlying driver of adverse behaviours – social protection schemes may be more effective in such a case.|
As a simple frame of mind, the strategic management market definition and this list of premises can be useful to understand people’s demand for antibiotics, but it can also be applied to other health behaviour and interventions beyond AMR. Interdisciplinary approach like this – applying social sciences thinking to global health problems – thereby help us to understand why interventions fall short of expectations, and they can help to stimulate new ideas for action and interventions beyond awareness-raising and education campaigns.
Haenssgen, M. J., Charoenboon, N., Zanello, G., Mayxay, M., Reed-Tsochas, F., Jones, C. O. H., et al. (2018). Antibiotics and activity spaces: protocol of an exploratory study of behaviour, marginalisation, and knowledge diffusion. BMJ Global Health, 3(e000621). doi: 10.1136/bmjgh-2017-000621
Haenssgen, M. J., Charoenboon, N., Althaus, T., Greer, R. C., Intralawan, D., & Lubell, Y. (2018). The social role of C-reactive protein point-of-care testing to guide antibiotic prescription in Northern Thailand. Social Science & Medicine, 202, 1-12. doi: 10.1016/j.socscimed.2018.02.018