Unpacking 'irrational' behaviours: situating the antibiotic selling practices of drug sellers in East Africa

Stewardship of antibiotic medicines will likely play a key role in curtailing the rise of antimicrobial resistance (AMR) globally. In East Africa, drug sellers are a critical group for interventions because they often dispense without prescription and violate regulations designed to facilitate antibiotic stewardship. Currently, measures to tackle regulatory avoidance are often rooted in individuated cognitive-behavioural approaches that label sellers’ actions as ‘irrational’. This study, part of a larger interdisciplinary investigation of AMR drivers in East Africa, conducted in-depth interviews [n = 105] with drug sellers in Kenya, Tanzania and Uganda to explore sellers’ accounts of their own behaviours. Its findings seem contradictory; sellers are aware of regulations and express a desire to comply, yet confirm non-compliance is common. The paper’s contribution is to demonstrate that such behaviour is ‘situationally rational’ when contextualised within a broader socio-material assemblage of unenforced regulation, fierce market competition, relational customer interactions and professional commitment to communities in resource-poor healthcare settings. The paper concludes that an understanding of the structural and relational dynamics driving current behaviours is a necessary precondition for the design of new interventions bringing professional and commercial motivations into closer alignment, something which could make antibiotic stewardship situationally rational for sellers and customers alike.