Theme	Explanation	Papers expressing theme
Ineffective regulations	This encompassed comments from several papers about regulations either being absent or poorly enforced. This allowed patients to procure prescription-only medication such as antibiotics without a prescription. Interestingly, several studies argued that rigid enforcement of regulations would cut off the supply of medications to certain communities who found it difficult to get a prescription in the first place	[19–22]
Heterogeneity in healthcare	Many of the study countries had very heterogenous healthcare systems, with patients seeing traditional practitioners, private clinics and government healthcare. This promoted patients passing through multiple different healthcare branches, taking many medications and not having accurate medical records available	[21]
Black market supply	Black market suppliers were reported specifically in 2 papers. These are hard to regulate and increase illicit access to prescription-only medications	[21, 23]
Lack of resistance reporting infrastructure	This was reported in five papers. This encompassed a lack of the culture machines and/or laboratories necessary for the timely reporting of sensitivity results. This made it difficult for clinicians to prescribe appropriate narrow-spectrum antibiotics, relying instead on broad-spectrum ones which are more likely to foster resistance	[27–30]
Bigger clinical concerns	This was reported in three papers. In many cases, issues such as tuberculosis, HIV and tropical diseases formed a much greater concern on wards. This meant that little attention was paid to resistant organisms	[27, 28]
Clinical governance	This was reported in many papers, and encompassed a lack of appropriate stewardship guidelines (or a lack of adherence to them) at the level of individual wards and pharmacies. There were many reasons for this, such as lack of knowledge by clinical staff or fear that prescribing a narrow-spectrum antibiotic would result in a negative career validation. It also involved pharmacies needing to make a profit, and doing so by selling prescription-only medication to patients without appropriate prescriptions	[19, 20, 22, 24–31]
Lack of equipment	This encompassed a lack of resources at the level of wards and departments. In some cases, this resulted in only having access to a small number of antibiotics, causing patients to learn their names and increasing the ease of which they were procured. In other cases it was a lack of ward time to devote to checking culture results and altering prescriptions	[22, 28, 31, 32]
Patient factors	Another wide-reaching theme, this was specific patient behaviours that fostered antimicrobial resistance or hampered efforts for antimicrobial stewardship. Some examples included patients ‘shopping around’ for a healthcare service that would sell them antibiotics regardless of prescription, self-medication, or when patients would learn the dose and name of an antibiotic so they could directly request it from a pharmacist without a prescription	[19, 20, 22–26, 29]