Identifying and addressing challenges to antimicrobial use surveillance in the human health sector in low- and middle-income countries: experiences and lessons learned from Tanzania and Uganda

Despite these challenges, some solutions are proposed for consideration to build a sustainable structure for AMU surveillance in both countries (Table 1). We apply the Potter and Brough model of systematic capacity building[27] to make recommendations for specific actions across the board, that if implemented could build sustainable systematic capacity for AMU surveillance. Using this approach could also have a “spillover” effect on other AMR containment efforts in both countries and other LMICs.

Apply systematic capacity building targeted towards a whole of approach health systems strengthening for AMU surveillance

To build sustainable AMU surveillance, there is need to apply interventions across all the WHO building blocks of a health system [28]. Human resource needs, governance, service delivery, financing, health information systems and medical products components of the health system that apply to AMU surveillance must be addressed. To achieve this, it is important that a systematic approach to capacity building that addresses key structures, systems, roles, staff and infrastructure, skills and tools [27] is adopted and applied to all the building blocks [29]. The Program is using the USAID Pharmaceutical Systems Framework and the WHO Benchmarks to implement key activities that are aimed at building systematic AMU surveillance capacity in both countries [12, 15, 30].

Use a phased/gradual implementation approach

Our Program’s use of a gradual implementation approach has shown to be successful for similar settings in low resource settings, as recommended in the WHO GLASS manual for early implementation [31]. This approach allows for consideration of local context, national priorities, available resources and has successfully been used by Uganda to build capacity under the GLASS [13]. In Uganda, a starting point could be rejuvenating the appropriate medicines use unit at the Ministry of Health level and following this up by starting AMU surveillance at sentinel surveillance sites as capacity is gradually built (both technical and logistical) at the national level to add more health facilities to the program and later mandate AMU surveillance in representative hospitals in the country. Advanced support could involve digitalization of efforts, linkage or enforcement of legislation and linking data to AMR surveillance. The Program has made contribution to systematic capacity building through implementing priority WHO Benchmark actions for IHR that would lead to an advanced capacity. Examples of WHO Benchmark actions completed with program support include assessment of policies for antibiotic stewardship in both countries, writing of a NAP for AMS and conducting assessment of systems for AMU surveillance in Tanzania and Uganda, respectively.

Strengthen leadership and governance for AMU surveillance at all levels

Strengthening leadership and governance for AMU surveillance is critical for AMR control [32].

At the national level, an AMU surveillance team under the AMS multisectoral TWG should be appointed and facilitated (technical expertise, capacity building, resource allocation) to enable them to understand and support the implementation of the long-term vision for AMR control. These bodies should take a major role in vertical coordination, upstream with the MSC-AMR body and downstream with facilities and communities. The AMS TWG can catalyze funding advocacy, coordination, research, reporting, dissemination, overall coordination, link AMU surveillance to AMR surveillance and laboratory capacity, and facilitate the use of data for decision-making. As part of strengthening leadership, there is an urgent need for approval of national AMU surveillance plans, which clearly define roles and responsibilities and provides a platform for establishment of a governance structure. The TWGs and AMS teams could catalyze the South-to-South Learning. For example, Tanzania conducted their AMU surveillance before Uganda and as part of capacity building for Uganda, a technical exchange was organized between the Program’s teams where the Tanzania team shared their experiences. The Program supports multisectoral TWGs in both countries; for example facilitating data sharing through quarterly meetings in both countries and publication of a newsletter in Uganda [33]. However, as a next step, there is need to support set up of an AMU surveillance working team and institutionalize this team into government structures. At the health facility level, there is need to establish and strengthen AMS teams as part of the drug and therapeutics committee which will provide leadership for AMU surveillance. The Program has worked with country partners to set-up AMS teams in 6 and 13 hospitals in Tanzania and Uganda respectively and supported the teams through training and mentorship.

Strengthen the implementation of policies and regulations on antibiotic prescription and use

Non-prescribed antibiotics are known to increase inappropriate use of antibiotics and increase global use and misuse [34], with the highest non-prescription use found in LMICs, at between 19 and 100% in some cases [35]. Coupled with poor adherence to treatment guidelines in Uganda [17], this practice compounds access to unauthorized parallel markets for antibiotics [36], making AMU surveillance more problematic. Uganda has recently assessed policies and regulations on antibiotic stewardship—a key WHO Benchmark activity, with the activity ongoing in Tanzania. There is a need address the identified gaps in relation to AMU surveillance, strengthen implementation of existing regulations on antibiotic utilization and access, over-the-counter non-prescription access of antibiotics in both countries and control of antibiotic use in the veterinary sector. In Tanzania, the Program supported the development of an AMR NAP and adaptation of the WHO AWaRE categorization. This in turn was integrated into the Tanzania Standard Treatment Guidelines and National Essential Medicine List.

Build stronger data systems with relevant tools in cognizance of the local country context

First, there is need to conduct review of existing HMIS for AMU surveillance and use the findings to inform the development of relevant electronic tools for AMU data collection. The WHO PPS tools should also be digitalized and incorporated into the data collection tools at the health facilities. In Uganda, linking currently available tools on AMU surveillance into existing HMIS tools like the Pharmaceutical Information Portal, Supervision Performance Assessment and Recognition strategy [37] and the District Health Information System- 2 (DHIS-2) should be considered. Similarly, data collection through the DHIS-2 can be strengthened in Tanzania. The WHONET software [38] could be modified to include a module for AMU surveillance in both countries. The WHONET can as well be integrated with the national DHIS2 system. Through integration, challenges of unavailability of data, missing data and poor data quality could be addressed while also creating a system that allows for data sharing at the health facility and the national level. Additionally, consideration could be made for adapting the International Classification of Disease for coding of diagnosis in both countries and other LMICs. Such a system will allow for similar nomenclature of diagnosis, bring clarity on indication of antibiotics, and allow for progress towards a clinical coding surveillance system, which would support systematic surveillance and minimize human resource needs and the costs of surveillance. Lastly, robust systems should be developed to collect data on AMU from the OPDs. In Uganda, the Program has applied the WHO methodology on drug indicator survey to collect data from the OPD [39].

Support knowledge and skills transfer at all levels of the health care system

It is urgent to build a critical mass of experts to support AMU surveillance at both the national and health facility level through training and mentorship programs in both countries. To overcome the observed lack of technical capacity for AMU surveillance among health workers, a competency-based curriculum on AMS incorporating AMU surveillance, with additional educational interventions like continuous medical education, mentorships, and continuous professional development sessions should be developed for in-service health professionals. This would be in line with the WHO framework on health worker training for AMR [40]. Additionally, important components on AMS and AMU surveillance should be introduced in pre-service curriculum and their implementation supported during houseman years or internship training to provide a foundation for long term learning for AMR. The facility technical experts will support the development of contextualized AMU metrics, monitor activity performance, validate methodologies, and guide operational research. Lastly, there is need to develop a culture of AMS at the health facilities. This can be achieved through implementation of quality improvement plans, training, and mentorship. In Tanzania, the Program is implementing quality improvement plans in 6 hospitals. In Uganda, the Program has cumulatively supported 131 facility-based continuous medical education sessions benefiting 2,152 health workers, 2 continuous professional development sessions and 34 onsite mentorship visits.

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