Contextual constraints and dilemmas influencing health providers’ prescription practices in a conflict-affected area: Qualitative insights from Mopti, Mali

Armed conflicts present complex, multidimensional challenges that severely compromise both access to and the quality of healthcare, including the adequate prescription of essential medicines. This study aimed to identify and understand the factors underlying the irrational prescribing of medicine in areas affected by armed conflict in the Mopti region in Mali. An exploratory qualitative study was conducted using a semi-structured interview guide to collect data from 30 participants, including health professionals from three health districts, representatives of the regional health directorate, members of community health associations, and staff from non-governmental organisations (NGOs) working in health sector. Interviews were recorded, transcribed, and subjected to thematic content analysis, using NVIVO 14 (2023 version) to support coding and data retrieval. Study participants reported a range of health system- and patient-related factors contributing to irrational prescribing practices in these conflict-affected areas. Health systems factors included: an imbalance between workload and the availability of qualified staff; limited access to professional training and training resources; poor adherence to prescription guidelines and procedures -often a consequence of contextual constraints; and coercion from armed terrorist groups. Administrative and political challenges were also highlighted, including weak monitoring and supervision mechanisms within the local health system; a lack of oversight by health and regulatory authorities in blockaded areas; the development of an informal pharmaceutical sector to compensate for deficiencies in the formal system; and overprescription of medicines linked to insurance schemes. Patient-related factors included delayed care-seeking linked to regional insecurity and contributing to increased morbidity and worsened health outcomes. Our results show that the multiple contextual factors influencing prescribing of medicines are deeply inter-linked. Efforts to improve the quality of prescribing in conflict zones must recognise that practices often deemed 'irrational' are shaped by complex contextual constraints. A coordinated and comprehensive approach involving all health systems stakeholders is required.