One Health approach & focus on health systems strengthening

A One Health approach is advanced to minimize spread of antibiotic resistance that is responsive to low- and middle-income countries needs, and with a strong focus on One Health AMR National Action Plans implementation, health systems strengthening and community engagement.

National Action Plan implementation in LMICs

Why is this important?

After having endorsed a Global Action Plan in 2015, the WHO encouraged its member states to develop their own context-specific National Action Plans on Antimicrobial Resistance (NAPs on AMR) and most countries have already developed such plans. For many countries, National Action Plans are expiring and hence need to be revised and renewed with ways to systematically monitor progress and ensure sustainable efforts.

For most low- and middle-income countries (LMICs), the greatest challenge is the implementation of the National Action Plans. Beyond funding, a major challenge for NAP-implementation in many low- and middle-income countries is:

• human resources
• infrastructure and
• data.

AMR focal points, if present, often have other primary obligations and responsibilities with antibiotic resistance activity being treated as just another added task.

Other resources that are lacking are:

• information systems
• office equipment
• including staff to support them.

Lack of data on the burden of resistance in LMICs

There is a significant lack of data on the burden of resistance in low- and middle-income countries and without a clear picture of the most significant drivers of resistance, prioritization of where to spend scarce resources is difficult. Devising interventions is further complicated by a concurrent overuse and lack of access to antibiotics occurring in low- and middle-income countries.

A One Health approach requires an interdisciplinary collaboration across key stakeholders involved in healthcare delivery, food systems and the environment.

Lack of data on contributing sectors 

Whereas it is well known that antibiotic use in humans is foremost in driving antibiotic resistance following the spread of resistant bacteria between humans, other aspects of this complex problem are not to be neglected. There is widespread inappropriate use of antibiotics in both healthcare delivery and food animal production.

Resistant bacteria can transmit from animal to humans, but to what extent the animal sector is contributing to antibiotic resistance in humans is largely unknown. Up to 80% of antibiotics consumed by humans or animals may be excreted into the waste stream.

Improving water, sanitation and hygiene (WASH) interventions is key, especially in many low- and middle-income countries to prevent infectious diseases that can decrease the use of antibiotics and can reduce the risk for humans to be infected by resistant bacteria.

One health approach in LMICs 

Adapting a One Health approach in low- and middle-income countries has specific challenges. Part of the reason for this is that specific platforms, protocols or mechanisms for collaboration across these sectors are not yet in place.

At national, sub-national and local levels, institutions and personnel often operate in silos with little contact or coordination with each other. For the One Health approach to be effective on the ground, it will require identifying and prioritizing the various opportunities for multi-sectoral collaboration that exist currently.

It will also require developing appropriate interventions, some of which can be piloted prior to wider dissemination.

Education, awareness and behavioral change

Why is this important?

Antibiotic resistance is not only a medical issue, but also a complex political, economic and social challenge issue that requires changing norms and behaviors at different levels of society connected to direct antibiotic use, but also in related areas such as consumer behaviors, vaccines and hygiene practices. The discrepancy between the severity of the problem and the knowledge among the public is a global phenomenon, but given the disproportionate burden of antibiotic resistance in low- and middle-income countries, the situation in these contexts is especially worrying.

The first strategic objective of the Global Action Plan on AMR highlights awareness and understanding among the general public, healthcare professionals, educators, civil society organizations and governments as essential when addressing antibiotic resistance.

Education and awareness-raising

Despite this, investments have been lacking both in UN agencies such as UNESCO, and among other stakeholders engaged in Sustainable Development Goal 4 on inclusive and equitable quality education. Public awareness campaigns should be carefully adapted to local contexts and tailored to target groups promoting messages that help people feel ownership and enable them to make informed decisions concerning their own health and that of their animals. This is particularly important in settings where antibiotics are sold over the counter without a prescription. In the animal sector, education and awareness-raising activities must reach stakeholders as diverse as farmers, veterinarians, the food industry, as well as consumers with tailored and context-specific messages.

Evidence-based interventions 

Regardless of context, in order to translate awareness into new and sustained positive behaviors, there is a need for evidence-based, multicomponent interventions – a family of interconnected actions ranging from regulations and incentives that enable change, communication for behavioral change that includes appropriate channels and tailored messages, as well as interventions based on behavioral insights. Overall, interventions should take a holistic approach and link education and behavioral change on antibiotic use to other aspects of people’s lives.

Identify communities 

Both for reasons of adapting activities to context and for people to feel ownership, a bottom-up approach with consideration of equal rights and gender perspectives of antibiotic resistance is crucial. The Antibiotic Smart Communities project lays an important foundation to this area of ReAct’s work. To identify communities and local institutions that can promote appropriate use of antibiotics and other important aspects of antibiotics is one way to do so. Taking a holistic approach and linking education and behavioral change on antibiotic use to other aspects of people’s lives is another way forward.