Over-the-counter antibiotic access in Somalia: a growing challenge for antimicrobial stewardship

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Dear EditorEasy access to antibiotics without prescription is quietly undermining antimicrobial stewardship (AMS) in Somalia, accelerating antimicrobial resistance (AMR) before effective systems to monitor and contain it are fully established.AMR has become one of the greatest global public health threats, with an estimated 4.95 million deaths linked to bacterial AMR worldwide in 2019 and 1.27 million directly attributable to it.1 Appropriate antibiotic use is fundamental to effective AMS, which the World Health Organization (WHO) recommends to optimize antimicrobial use through appropriate drug choice, dosage, and duration.1 In Somalia, antibiotics are frequently available over the counter without a valid prescription, as pharmacies and informal drug vendors operate with minimal oversight.2 Weak pharmaceutical regulation, limited access to qualified healthcare providers, and widespread self-medication contribute to inappropriate antibiotic use.2,3 Addressing over-the-counter antibiotic access is essential for protecting the effectiveness of existing antibiotics and strengthening Somalia's health system, because antimicrobial stewardship cannot succeed while antibiotics remain easily accessible without adequate regulatory oversight.4 Over-the-counter antibiotic access represents a major public health and AMS challenge in Somalia because widespread selfmedication, inappropriate antibiotic selection, incorrect dosing, and incomplete treatment courses are pervasive.3 Community misconceptions regarding antibiotics are common, with many people not understanding that antibiotics are ineffective against viral infections or the importance of completing a full course of treatment.2 Self-medication prevalence among Somali university students reaches 67%, with antibiotics used in 38% of cases.5 Diagnostic capacity is severely limited, forcing clinicians to rely on empirical treatment that is often inappropriate.4 Weak enforcement of pharmaceutical regulations, informal medicine vendors, and ashortage of trained pharmacists compound these challenges.2,4 Somalia's fragile health system, shaped by over three decades of civil conflict and political instability, together with humanitarian settings and internally displaced populations, creates

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