Despite knowing the risks of under-dosing, Jean Marie Mutuyeyezu, a resident of Kigali, says sometimes he has no option but to do so. He recalls many times purchasing half-dose medicine instead of a full dose prescribed by a doctor due to low finances.

Yves Kayitare, a pharmacist in Kigali, says the easy availability of antibiotics in many pharmacies around has also seen people misuse the antibiotics.

Meanwhile, estimates by health officials in Rwanda show that antimicrobial resistance (AMR) is on the rise as one of the major global public health threats.

Based on scientific experiments, researchers concluded that self-medication with and overuse of antibiotics were among the main risk factors for antibiotic resistance.

The latest study published jointly by a team of researchers from Rwanda, Nigeria, UK, and the Netherland in the Pan-African Medical Journal shows that the major reason for self-medication with antibiotics was illnesses not serious enough for consultation.

With the case study on Rwanda, researchers concluded that main reasons for self-medication with antibiotics may be related to the lack of knowledge about the need for rational use of antibiotics.

Beyond limited awareness among the community, some health experts also believe that often, people turn to self-medication as an alternative to the expense of consulting a physician.

Meanwhile, recent research carried out by Rwanda Biomedical Centre, the US Centers for Disease Control and Prevention, and the US Agency for International Development has found evidence of the emergence of artemisinin-resistant malaria in Rwanda.

Lazare Ntirenganya, Rwanda Food and Drug Authority (FDA) Division Manager of Pharmacovigilance and Safety Monitoring, says one of the ways that has been there to combat antimicrobial resistance (AMR) is by use of Community Health Workers (CHWs), who are trained by the government.

He says that apart from being trained, the CHWs are also given malaria test kits, coartem, disinfectants, and mosquito nets that help them in carrying out the entire process.

 "These people are based at the village level where it’s much easier to reach out to them and provide the needed services,” he says.

In each village, there are at least three trained health workers, and today Rwanda maintains a workforce of nearly 45,000 CHWs who provide other services as well, such as maternal check-ins and age-appropriate health assessments.

These workers are globally recognised as a key driver of Rwanda’s early achievement of the Millennium Development Goals.

For instance, Rwanda made significant progress in all the Millennium Development Goals (MDGs), and achieved 7 out of 8 MDGs.

After getting a three-month initial training in malaria programme from Rwanda Biomedical Center, Solange Nyiransabimana, a health community worker (CHW) from Gatsibo District, says this helps them diagnose and administer the right dosage of malaria based on the results.

According to her, they also carry out rapid malaria tests and give treatment to malaria patients from children as young as six months to all ages, and also follow up to ensure patients complete their doses.

Nyiransabimana says they aim at reducing cases of self-medication when it comes to using antibiotics. This has seen people get the right dosage of medicine whenever they are sick with malaria, which is one way of controlling the use of antibiotics.

"Once the person is tested with positive, non-complicated malaria, the patient is given coartem with an appropriate dosage regimen. In cases of complications, we are advised to refer the patient to health centres for further treatment support,” she says.

In addition to this, Nyiransabimana says they also do home visits to find out any health issues and provide solutions depending on the issue and their capacity.

Dr Innocent Hahirwa, the chairperson of National Pharmacy Council, says initiatives such as CHWs have seen people at community levels, which mostly have less knowledge on medication, get diagnosed and get the right medication instead of visiting pharmacists with any symptom related to malaria.

Claude Nshimiyimana, a resident of Gasabo District, says using CHWs in diagnosing and treating malaria has helped because he is able to access a full dose of the medicine which he is given for free. He adds that the money he has can now be directed to other needs instead of medicine.

Nshimiyimana notes that the satisfaction one gets from being properly treated by CHWs forces them to come back again in case of any health problem.

"This is very important as it helps the CHWs keep a record of your illness, which is fundamental as far as administering the right antibiotics is concerned,” he says.

Solange Mutesi, a mother of two from Huye District, says CHWs help her not only with providing drugs but also when it comes to counselling on the proper use of medication, including the right dosage and taking it at the right time, which to her was a challenge before.

Limited awareness

Jeanne Ishimwe, a community health worker from Tumba Sector, Huye District, says despite providing free treatment to the population, there is still low commitment from the population as far as utilising services offered by CHWs is concerned.

There is also unavailability of enough kits for them to use, as well as running out of stock for medicines and diagnostic materials.

This, she says, leads to people turning to pharmacies whenever they experience some symptoms related to malaria.

Jean Bosco Muhire, another community health worker in Gasabo District, says unlike health experts, they still don’t have enough information and knowledge on antimicrobial skill protocols, which at times becomes a limit in terms of providing the right medication after one has been diagnosed with malaria.

Dr Flandrie Habyarimana, a pharmacist, says that although the CHWs initiative helps when it comes to misuse of antibiotics, there is still no environment for culturing medium for other microbial tests at the lower settings.

He notes that the accessibility of some of these drugs in retail pharmacies is still also a challenge because of improper regulation as there is no strict adherence to it.

Joseph Kabatende, the head of FDA, says there is a need to educate people on how to rationally use the medication, noting that prescriptions should be limited as it’s not just a matter of prescribing these strong antibiotics.