By Gerry Bloom, Sabrina Rasheed, Sehwah Sonkarlay and Wilfred Gwaikolo
There is growing scientific evidence that infections that are resistant to antibiotics are a serious global health challenge. This has stimulated wide agreement on a Global Action Plan for Addressing AMR and many countries have produced National Action Plans. It is important that these action plans take into account the local context. This is especially important in countries with a pluralistic health system in which people seek health care from a wide variety of public and private providers of drugs and medical care. One lesson from the work of the Future Health Systems Consortium is the need to take a systems approach for tackling health challenges in these countries. This blog highlights some priority issues that this kind of approach needs to take into account.
One important way to slow the emergence and spread of bacteria that are resistant to antibiotics is to reduce the exposure of people to infections, where people live and in health facilities. It is important to ensure that human wastes are disposed of safely and that people have access to water to ensure basic hygiene. There are many reasons for governments and communities to give these matters priority and the risk of AMR is a consequence of the failure to do so. In many countries health facilities are an important source of resistant organisms. While people who use the hospitals are especially susceptible to infection, weaknesses in infection control in the hospitals mean that people are exposed to many infectious organisms during their stay. One important way to decrease this problem is to institute rigorous measure to ensure cleanliness and infection control within health facilities.
Almost all countries are committed to increasing access to health services, including antibiotic treatment of common infections. The challenge that governments face is to find ways to both increase access to antibiotics and reduce the risk of AMR. One major problem in many countries with pluralistic health systems is a weakness in the control of quality of the available antibiotics. Often, a big proportion of the medicines are sub-standard or counterfeit. This increases the chances that treatment will fail or that sub-optimal doses are taken, increasing the risk of resistance. In many countries, people buy drugs from informal providers. These may be well-established “village doctors” as in Bangladesh, or “black baggers”, who supply drugs to rural villages in Liberia. These drug suppliers have strong incentives to encourage people to buy large quantities of antibiotics. In many cases, they supply the same antibiotics for use in farm animals. These practices increase the risk of AMR. Strategies for addressing AMR will need to include measures to change the behavior of these providers by providing training in the treatment of infectious diseases, changing incentives that reward high levels of antibiotic supply and regulating their performance.
Many countries have long-standing regulations concerning hospital hygiene and limiting access to antibiotics to doctors, but they have limited capacity to enforce them. An important aspect of a strategy to address AMR will be measures by governments to enforce the most critical regulations. These could include access to basic water and sanitation, enforcement of guidelines for health facility hygiene and the control of access to certain antibiotics. A recent WHO Model List of Essential Medicines differentiates between Key Access products, which should be made widely available, Watch Group products, which should be reserved for specific infections and Reserve Group products of last resort. In countries where a large proportion of the population seek care from informal providers, a strong case could be made for concentrating regulatory effort in limiting their use of the latter two categories of drugs.
The central lesson from FHS is that governments need to establish priorities for action that will need to involve a number of partners, and then employ a learning-by-doing approach for effecting large-scale change.