Non-prescription antibiotic dispensing was routine in Central Gondar outlets
In community drug retail outlets across Central Gondar, Ethiopia, antibiotics were dispensed without a valid prescription in 91 of 120 simulated-client encounters, a rate of 75.8% that leaves little doubt about how often prescription controls fail at the point of sale. The mixed-methods study paired covert standardized visits with interviews, creating a clearer picture of how dispensing behavior unfolds when everyday commercial pressure meets weak oversight.
The simulated clients presented three common scenarios: acute uncomplicated cough or upper respiratory symptoms, non-bloody diarrhea, and mild urinary symptoms. These are exactly the kinds of self-limiting or diagnostically ambiguous complaints in which unnecessary antibiotic use thrives, because symptoms can be mistaken for bacterial infection even when supportive care would be more appropriate. In practice, that uncertainty can be exploited by patients seeking quick relief and by retail settings under pressure to satisfy demand.
A total of 116 antibiotic items were supplied across the 91 encounters in which antibiotics were provided. Amoxicillin accounted for 49 items, or 42.2%, followed by ciprofloxacin at 26 items, or 22.4%, and metronidazole at 14 items, or 12.1%. Those choices matter clinically because broad use of these agents can intensify selective pressure for resistance across respiratory, gastrointestinal, and urinary pathogens, while exposing patients to drugs that may be unnecessary for the presenting syndrome.
Patient assessment happened in only 24 of 120 encounters, or 20.0%. Counseling followed in just 11 of the 91 encounters where antibiotics were supplied, equal to 12.1%. That pattern suggests dispensing often proceeded with minimal screening of symptom severity, no meaningful attempt to distinguish likely viral from bacterial illness, and limited safety communication once a drug was handed over.
Outlet status, staffing, and location tracked with dispensing behavior
The strongest quantitative associations were tied to the structure of the outlet itself. Non-prescription dispensing was more likely in unlicensed outlets, with an adjusted odds ratio of 3.45 in conventional multivariable analysis and 3.32 in the Firth penalized model. Peri-urban location also carried higher odds of dispensing, with adjusted odds ratios of 2.21 and 2.16 in the two models, respectively. The absence of a licensed pharmacist showed a similar direction of effect, with adjusted odds ratios of 2.76 and 2.65.
One covariate showed no evidence of an association in the Firth model, with an adjusted odds ratio of 1.18 and a p value of 0.660. The alignment between the conventional and penalized regression outputs strengthens confidence in the direction of the observed relationships, especially because only 29 outlets were outcome-negative and sparse-data bias was a real concern.
The statistical pattern is clinically important because it points to modifiable system features rather than isolated individual lapses. When a pharmacy outlet is unlicensed, staffed without a licensed pharmacist, and operating in a peri-urban area where demand may be high but oversight uneven, the threshold for dispensing without a prescription appears to drop sharply. In antimicrobial stewardship terms, the outlet environment itself becomes part of the mechanism of inappropriate access.
Commercial pressure and customer expectations shaped the interviews
The qualitative interviews add texture to the numbers. Pharmacy professionals, clinicians, and regulatory officials pointed to regulatory challenges, economic and competitive pressure, and customer expectations for antibiotics as recurrent forces shaping dispensing decisions. Those accounts fit the observed practice: a customer enters with a symptom complaint, a retail outlet faces competition, and an antibiotic becomes the fastest way to meet demand while preserving business.
This is where the biology and the market collide. Unnecessary antibiotic exposure does not only affect the individual encounter; it fuels broader resistance pressure in the community, especially when broad-spectrum agents such as ciprofloxacin are used frequently for nonspecific syndromes. Over time, that pressure narrows future treatment options and can make ordinary infections harder to manage.
The study design is important because it did not rely on self-report alone. Simulated-client methods can reveal routine behavior more reliably than staff questionnaires, particularly in settings where respondents may understate non-prescription dispensing because they know it conflicts with official rules. The addition of interviews then helps explain why the behavior persists despite those rules.
Stewardship gaps are visible at the counter
The evidence points to a dispensing system in which regulation exists on paper, but implementation remains inconsistent at the retail level. Ethiopia classifies antibiotics as prescription-only medicines, yet the observed practice in Central Gondar shows that access without a valid prescription is common enough to be treated as the norm rather than the exception in many outlets.
That gap has immediate implications for antimicrobial stewardship. Training alone will not solve a problem driven by licensing structure, staffing shortages, customer demand, and uneven enforcement. Interventions would need to address the outlet level, the professional workforce, and the local expectations that make antibiotic requests feel routine.
No intervention was tested, and the associations should not be interpreted as causal. Even so, the study offers a direct clinical and regulatory warning: when the retail environment normalizes antibiotic supply for cough, diarrhea, or mild urinary symptoms without proper assessment, stewardship starts to fail before a prescription is ever written. The next step is not abstract policy language but concrete work on oversight, staffing, and access controls in the outlets where these medicines are actually handed over.