ABACUS: AntiBiotic ACcess and USe


Principal Investigators
Professor Heiman Wertheim, Radboud University Medical Center
Dr Do Thi Thuy Nga 

2016 – 2021 (extension ongoing)

Vietnam, Bangladesh, Thailand, Mozambique, Ghana, South Africa

Project Website

ABACUS phase I (2016-2019) explored antibiotic use and access practices in 6 LMICs and revealed the importance of a context and cultural tailored approach to address responsible antibiotic use in each country. ABACUS phase II (2020-) builds on findings from phase I and aims to investigate the idea of an harmonised physical appearance of antibiotics to facilitate identification from patients and health care professionals.


Community-based antibiotic access and use have received less attention than prescription behaviours in formal healthcare settings. We have little understanding of antibiotic use in the community, which is considered a key driver of antibiotic resistance.

Studies revealed a high prevalence of self-medication: accessibility, affordability, healthcare facility conditions, and health-seeking behaviour were found to be the main determinants of self-medication in studied LMICs.

To fill these research gaps, in ABACUS I, we used a comparative mixed-method approach to compare community-based antibiotic access and use practices across communities in six LMICs in Asia (Bangladesh, Thailand, and Vietnam) and Africa (Mozambique, Ghana, and South Africa) to allow for comparison by national income status and identify supply and demand drivers. Within the existing INDEPTH surveillance network, ABACUS I was powered to identify the contextual complexities and differences between countries with different income levels, policy frameworks, and cultural norms.

Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time-consuming, cheaper, and overall more convenient than accessing them through healthcare facilities.

Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia.

The gained insight into antibiotic practices in different LMICs could inform the design of context-adjusted models for interventions to effectively address the usage of antibiotics and contain antibiotic resistance in these resource-constrained settings.

ABACUS I found common themes reported in previous studies in LMICs but also revealed the diversity and complexity of locally specific sociocultural determinants affecting antibiotic access and usage among studied communities in six Asian and African LMICs.

The identified factors serve as targets for the development of context-tailored interventions to effectively address the misuse of antibiotics and contain antibiotic resistance in LMICs.

In ABACUS II – based on the finding of existing confusion regarding how to identify antibiotics – we build the case for an international system that harmonises the appearance and thus improves the identification of oral solid formulations of antibiotics both for consumers and providers. We will consider the potential negative effects as well.


We have formulated the following key goals:

  1. Assess the potential impact of and obstacles to standardising the physical appearance of commonly used oral antibiotics on formal and informal suppliers as well as consumers in the six ABACUS countries;
  2. Design, with key stakeholders and experts, an approach and prototypes that improve (for both suppliers and consumers) the appropriate identification of oral antibiotics;
  3. Perform a health economics analysis related to the inappropriate identification of oral antibiotics and the potential impact of introducing the standardised designs;
  4. Assess the proportion of substandard and falsified oral antibiotics among three commonly sold antibiotics in four of the six ABCUS countries (Mozambique, Bangladesh, Ghana, and Vietnam).


Nam Vinh Nguyen, Nga Thi Thuy Do, Dung Tien Viet Vu, Rachel C. Greer, Sabine Dittrich, Maida Vandendorpe, Thach Ngoc Pham, Ngan Thi Dieu Ta, Thai Quang Pham Vinh Thanh Khuong, Thuy Thi Bich Le, Lai Tuan Anh, Thai Hung Cao, Tung Son Trinh, Ha Thanh Nguyen, Long Nhat Ngo, Thom Thi Vu, H. Rogier van Doorn, Yoel Lubell, Sonia O. Lewycka
Lancet Reg Health West Pac
October 11, 2022
DOI: 10.1016/j.lanwpc.2022.100611
Nga T T Do, Huong T L Vu, Chuc T K Nguyen, Sureeporn Punpuing, Wasif Ali Khan, Prof Margaret Gyapong, Kwaku Poku Asante, Khatia Munguambe, Prof F Xavier Gómez-Olivé, Prof Johannes John-Langba, Toan K Tran, Malee Sunpuwan, Esperanca Sevene, Hanh H Nguyen, Phuc D Ho, Mohammad Abdul Matin, Sabeena Ahmed, Mohammad Mahbubul Karim, Olga Cambaco, Samuel Afari-Asiedu, Ellen Boamah-Kaali, Martha Ali Abdulai, John Williams, Sabina Asiamah, Georgina Amankwah, Mary Pomaa Agyekum, Fezile Wagner, Proochista Ariana, Betuel Sigauque, Prof Stephen Tollman, H Rogier van Doorn, Prof Osman Sankoh, John Kinsman, Prof Heiman F L Wertheim
Lancet Glob Health
March 10, 2021
DOI: 10.1016/S2214-109X(21)00085-1
Wertheim HFL, Chuc NTK, Punpuing S, Khan WA, Gyapong M, Asante KP, Munguambe K, Gomez-Olive FX, Ariana P, John-Langba J, Sigauque B, Toan TK, Tollman S, Cremers AJH, Do NTT, Nadjm B, van Doorn HR, Kinsman J, Sankoh O
Wellcome Open Res
July 28, 2017
DOI: 10.12688/wellcomeopenres.11985.1.


Heiman Wertheim

Professor Heiman Wertheim

Dodowa Health Research Centre, Ghana

Dodowa Health Research Centre

Dai Hoc Y

Hanoi Medical University


International Centre for Diarrheal Disease Research

Kintampo Health Research Centre

Kintampo Health Research Centre


Mahidol University


Manhica Health Research Centre


MRC-Wits Rural Public Health and Health Transition Research Unit (Agincourt)


Radboud University


Umea University

oxford logo

University of Oxford

University of Witwatersrand

University of Witwatersrand

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