The effect of capacity-building interventions on antimicrobial use practices in Uganda
J.P. Waswa and Marion A. Murungi
Antimicrobial resistance (AMR) is a steadily growing menace, killing 4.95 million people globally in 2019, including 1.27 million from bacterial AMR. The misuse and overuse of antimicrobials, especially antibiotics, accelerates the spread of AMR worldwide, and Uganda is no exception. Seventy years since their discovery, antibiotics continue to save lives and contribute to the survival and advancement of humans and animals. There is need to protect and save antibiotics from the threat of AMR and extend the benefits of their effectiveness.
A big part of antimicrobial stewardship (AMS)―an organizational or systemwide health care strategy to promote appropriate use of antimicrobials by implementing evidence-based interventions―is understanding the use of antibiotics in hospitals and communities. In Uganda, USAID MTaPS undertook supportive efforts for gathering evidence to design and implement AMS interventions at national, health facility, and community levels.
A country prepared to fight back
At the national level, MTaPS supported the Government of Uganda, the One Health technical working committee, and its National AMR Sub-Committee (NAMRSC) in establishing the AMS optimal access and use (ASO)-TWC. The TWC aims to coordinate, catalyze, and monitor AMS activities in the national action plan (NAP) to optimize the access and use of antimicrobial medicines. MTaPS provided logistical support and facilitated communication, coordination, information, and documentation exchange for committee activities. This has enabled the country to effectively implement key benchmark activities from the NAP-AMR and International Health Regulations and improve its scores on the Joint External Evaluation (JEE-2) tool to capacity 3 (developed capacity) for multisectoral coordination, AMR surveillance, and AMS. The JEE-2 measures a country’s capacity to prevent, detect, and rapidly respond to public health threats, including AMR.
Additionally, the MTaPS program has supported the National Drug Authority (NDA) in developing a framework, system, and manual for monitoring the consumption of antimicrobials at the national level. The system and accompanying manual capture the volumes of medicines imported into the country and those manufactured locally, enabling aggregation of data for analysis. These efforts are part of the surveillance of consumption of antimicrobials as stipulated in the global action plan and NAP-AMR. The country can now generate data on antimicrobial consumption to enable policy makers and planners to better understand the priorities for AMS in Uganda and for experts to track the effectiveness of AMS interventions.
No sector left behind
In the animal sector, MTaPS supported the Ministry of Agriculture, Animal Industry, and Fisheries and its stakeholders in updating the national essential veterinary medicines list and developing guidelines for infection prevention and appropriate antimicrobial use in high-production sectors: cattle, goat, sheep, poultry, piggery, and fish farming. The documents were disseminated for use in identified high-production districts in Uganda to increase awareness at farm level, enabling farmers to reduce the overuse and misuse of antibiotics.
Focus on prescribers
MTaPS created centers of excellence (COEs) in six hospitals for AMS, to benchmark AMS best practices and cascade knowledge and skills to other health facilities, especially those at the lower level. Using continuous quality improvement plans, these COEs focus on providing information, skills, and support to prescribers at health facilities as principal initiators of antibiotic use in hospitals. The systemic COE approach helped expand reach to 2,244 health care workers cumulatively—1,036 (46%) male and 1,208 (54%) female—through 90 mentorship visits and 38 health facility education and training activities. As a result, MTaPS noted improved prescriptions for urinary tract infections and upper respiratory tract infections and provided a blueprint for health facilities to improve AMS. Additionally, the COEs remain learning centers for best AMS practices.
What about future prescribers?
MTaPS is committed to leaving no stone unturned. The program supported professional bodies and health institutions in setting up structures for institutionalizing pre-service AMR training in Uganda. This was accomplished by forming and revitalizing AMR interest groups (chapters) in graduate health institutions countrywide, targeting students in medicine, pharmacy, veterinary medicine, nursing, and other health professional courses. Clinical mentors and academic instructors were assigned to provide stewardship for the student AMR interest groups. All these were linked to the National AMR Student Charter, which is under the stewardship of the NAMRSC.
MTaPS also supported the country’s National Council of Higher Education and the health professional councils to develop a pre-service medical curriculum for AMR and health security and to develop an education policy brief. The brief synthesizes existing knowledge and highlights the need to incorporate AMR training into education programs in Uganda and was handed over to the national Ministry of Education and Sports. Institutionalizing AMR training at the pre-service level will help students develop competencies to understand, disseminate, and publicize AMR throughout their practice; promote the appropriate use of antimicrobials through judicious prescription; actively contribute to appropriate diagnosis of infections and surveillance of resistant ones; and emerge as leaders that govern and communicate to all stakeholders about AMR and its containment.
The success of MTaPS’ efforts in Uganda is heavily reliant on the support and collaboration of the Government of Uganda through the various ministries, departments, and agencies. The unwavering commitment and dedication to ensure a conducive and productive environment is enabling MTaPS’ insight, innovation, learning, and knowledge to transfer across countries and sectors to facilitate better understanding of AMS in low- and middle-income settings. Uganda has a stronger foundation for further action in reducing the overuse and misuse of antimicrobial medicines.