Producing antibiotic practices from guidelines, clinical assessment and health insurance in Kilimanjaro, Tanzania.

Antibiotics are crucial medications for healthcare delivery. The regulatory frameworks that govern the prescription and consumption of antibiotics vary widely. In Tanzania, over-the-counter sales of antibiotics are illegal, yet widespread. In contrast, prescription of antibiotics in Tanzanian hospitals is constrained through regulatory tools, such as Standard Treatment Guidelines (STG). This paper examines what moves, limits and accelerates antibiotic prescription and use in rural hospitals of the Kilimanjaro region. The study draws on four months of ethnographic fieldwork, including participant observation and semi-structured interviews, between January and July 2022. We demonstrate that antibiotic prescription is influenced by drug availability, resource constraints, and linkages between guidelines and insurance systems. Doctors aim to create paper trails to adhere to the STGs which are closely linked to reimbursements from the National Health Insurance Fund (NHIF), thereby balancing adherence to guidelines with their efforts to make antibiotic treatment work for their patients. Furthermore, resource constraints contribute to use of broad-spectrum antibiotics, such as Ceftriaxone. Through the theoretical frameworks of tinkering and standards in medicine, we argue that tinkering occurs at the individual, institutional and state levels. The STGs are not simply followed or violated but absorbed into broader repertoires of practice shaped by procurement systems, insurance logics, and clinical uncertainty. While concerning from an antimicrobial resistance perspective, it is analytically revealing from an ethnographic perspective, as antibiotic guidelines are reworked in practice rather than simply enacted. The findings of this study can inform policy on the effects of guidelines coupled with health insurance on antibiotic use.