Socio-Economic Context and Stakeholder Dynamics in Reducing Inappropriate Use of Antibiotics in Punjab, Pakistan

Abstract

Background: Antimicrobial resistance (AMR) poses a critical global health challenge, particularly in low- and middle-income countries. In Pakistan despite the presence of National Action Plan, the extent to which policies are implemented in practice remains uncertain. This study investigates socio-economic, institutional and stakeholder factors shaping antibiotic use and AMR policies implementation in Punjab, Pakistan. Method: A mixed-method design was employed. A cross-sectional survey of 273 healthcare professionals (47.6% human doctors and 52.4% veterinary doctors) from rural (35.2%) and urban (64.8%) areas assessed sociodemographic factors, AMR training and perception of misuse. Descriptive, bivariate and logistic regression analysis were performed. In parallel, 16 semi structured interviews with medical and veterinary professionals were analyzed thematically to explore policy awareness, challenges and stakeholder dynamics. Results: Overall, 87.6% of respondents agreed that socio-economic status influences inappropriate antibiotic use. Rural respondents (97.9%) were significantly more likely to agree with this statement than urban respondents (81.9%). Younger professionals and those with AMR training also showed higher agreement (<0.05). Qualitative findings revealed recurring themes, including weak enforcement and policies existing only “on paper”, limited access to diagnostics, persistent over the counter sales, patient and farmer pressure to prescribe, and the strong influence of pharmaceutical companies. Conclusion: AMR policies in Punjab remain poorly enforced. Socio economic constraints, weak institutional capacity, and stakeholder interests continue to drive irrational antibiotic use in both human and veterinary sectors. Strengthening stewardship requires inclusive policy making, expanded diagnostic infrastructure and sustained awareness programs. This study provides evidencebased recommendations for policymakers to strengthen AMR governance in LMIC settings