News and Opinions  –  2017

From ReAct Africa Conference: summary of key takeaways

2017-10-15

The 3rd RAN Conference held in Machakos Kenya mid September brought together Antimicrobial Champions from 16 countries. Discussions centered around implementation of the National Action Plans on Antimicrobial Resistance, progress made, common challenges faced and possible solutions. In promoting south - south exchanges, colleagues from India, Sweden and the US participated in the conference. The conference takes a roundtable discussion format to encourage participation.

Here is a summary of the key takeaways from the RAN conference on implementation of National Action Plans on AMR. At the end of the summary you can download the full report.

Marc Sprenger, Director, Antimicrobial Resistance Secretariat, WHO, opened the conference.

The keynote speaker, Dr. Marc Sprenger, Head of WHO AMR Secretariat, set the stage by providing the background on antimicrobial resistance (AMR), the toll in Africa, global efforts, progress made and what needs to be done.

Encouraged by the progress made by many African countries who have developed their National Action Plans (NAPs) and some completing the process, the challenging step was going to be seen in implementation. Concerted action and efforts across the human and non-human sectors was going to be key in realizing the goals of the Global Action Plans on AMR. Antimicrobial resistance was not only taking a toll on health but had untoward financial impact at family, country and global level. He pointed out that, while the documented financial impact of antimicrobial resistance is higher in the developed countries, the documented impact on economic loss/productivity was more significant in low- and middle income countries.

The need for global collaboration and continent-based expertise

Sujith Chandy, Head of ReAct Asia Pacific.

In the spirit of south – south cooperation, Dr. Sujith Chandy, Head of ReAct Asia Pacific, shared India’s efforts in addressing antimicrobial resistance through the process and lessons India has learnt. The need for a multi-sectoral approach, local solutions in a global context and the key role of stewardship programs.

Ms. Martha Gyansa-Lutterodt from Ghana and member of the United Nation’s AMR Interagency Coordinating Group, provided the background and charter of the coordinating group and encouraged participants to engage with them by adding their voices and perspectives through submissions. In providing the leadership on antimicrobial resistance they needed ideas and support from everyone. In her closing remarks, Dr. Laetitia Gamhimbare, WHO AFRO Focal Point, thanked ReAct Africa for organizing the conference and she assured participants, that the deliberations and recommendation from the conference will be tabled at future WHO meetings.

An opportunity to take stock

African countries, namely: Mozambique, South Africa, Nigeria, Ghana, Ethiopia, Zimbabwe, Kenya, Malawi, Uganda and Zambia presented their country level experiences on National Action Plan development, followed by a much anticipated update on the implementation efforts. With each individual country, some unique challenges of National Action Plan implementation were expressed, however, the following challenges are notable:

  1. While appreciating the role that non-government actors like civil society organizations, non-governmental organizations and faith based organizations have played in catalyzing action on antimicrobial resistance in many African countries, governments needed to take a leading role in National Action Plan implementation. The National Action Plan is a country document requiring government leadership and resource allocation. In needs to be in the national budgets and planned for.
  2. Lack of financial and human resources was among the immediate challenges towards implementation.
  3. The system of governance in some countries where counties or states have devolved government structures and autonomy was making federal programs and initiatives such as antimicrobial resistance difficulty to implement. Counties and states set their priorities for health and other sectors and may not see antimicrobial resistance as their priority with limited funding to invest in.
  4. Strengthen surveillance systems that are inefficient and/or establish one where it doesn’t exist in order to monitor the quality of medicines on an ongoing basis (as opposed to monitoring the rise of resistant pathogens), which is essential to better understanding the scope and evolution of the issue, as well as to ensure good stewardship of antimicrobials.
  5. Realization of the One Health Approach at country level, with the complexity of laws, policies, priorities maturity of the human and animal sectors that touch on antimicrobial resistance.
  6. Challenges with surveillance frameworks that include infrastructures, coordination, capacities both human and operational.
  7. Access to quality-assured antimicrobials remains a major challenge in most African countries.
  8. The bureaucratic processes of getting the components of National Action Plans approved among the various government institutions and ministries create huge delays in both the development and implementation of National Action Plans.
  9. The lack of human capacity, shortfalls in technical understanding of the pillars of National Action Plans inadequate or non-existent infrastructure, accurate data and facility mapping, identification and engagement of formal and informal stakeholders make surveillance efforts of antimicrobial resistance for an entire country incredibly taxing.
  10. Prioritization and costing of the National Action Plans. Determining what criteria to use in the prioritizing exercise, what would bring more value for money, what will and not be funded with local resources? How will the deficit be funded? These are some questions countries grapple with.
  11. Weak regulatory structures that have contributed to indiscriminate use of antimicrobials especially antibiotics in both the human and animal sectors.
  12. Challenges of implementing IPC, stewardship programs in low resource settings within weak regulatory, low resources both human and material and varying levels of practice.

Tackling NAPs on AMR with an African lens

Group discussions were held to discuss priority gaps, feasible and sustainable solutions and what monitoring and evaluation priorities:

  • antimicrobial stewardship and use,
  • surveillance
  • infection prevention and control and
  • access.

Appropriate antimicrobial use and stewardship

Priority gaps

Feasible and sustainable solutions

Monitoring and Evaluation Indicators

  1. The absence of structures and systems to provide leadership and governance for stewardship programs in both human and animal sectors.
  2. Institutions lacking or not using standard treatment guidelines and protocols as well as inadequate laboratory capacity to guide the development of AMS guidelines in both animal and human health.
  1. Development and implementation of NAPs incorporating appropriate use as well as other strategic elements of the Global Action Plan.
  2. Having an implementation plan that has sanctions and incentives to compel or encourage the use of guidelines and protocols. For instance, accreditation and claims may be tied to institutional stewardship programmes.
  3. There’s need to have a subgroup of national TWGs that will drive the implementation of stewardship components of NAP within the one health framework.
  1. Determine which institutions have stewardship committees and developed/adapted STGs and protocols for use.
  2. Adapting the WHO M&E template currently undergoing consultations.

Access

Priority gaps

Feasible and sustainable solutions

Monitoring and Evaluation Indicators

  1.  Lack of availability and affordability of antimicrobials (AMs).
  2. Fragmented, duplicated and weak registration process in the region.
  1. A pooled purchase of key priority AMs to decrease price and increase affordability and availability.
  2. Collection of data on consumption of AMs to inform pooled purchasing.
  3. Harmonization of regulatory systems for registration of medicines and establishment of a competent registration authority.
  4. Strengthening capacity for enforcement against regulatory systems and increased data sharing between countries to improve enforcement capacity
  1. IPC audits and feedback.
  2. This involves audits on:
  • Financing
  • Hospital-acquired infections
  • Rates of antimicrobial use in animals (recurrent use would imply recurrent infections mainly due to poor IPC).

Infection Prevention and Control

Priority gaps

Feasible and sustainable solutions

Monitoring and Evaluation Indicators

  1. Problems in implementation.
  2. Inadequate financing of IPC activities.
  1. Need to have an IPC focal person at the national level and down to the primary healthcare facilities.
  2. The inclusion of IPC as part of the job description to all healthcare workers and enforce its implementation.
  3. The inclusion of IPC module in the curriculum at all levels of training.
  4. The inclusion of IPC module in appraisal forms in both public and private healthcare providers.
  5. Incentives to those adhering to IPC guidelines.
  6. On financing: Costing of IPC activities and incorporation of the costs in the national budget.
  1. IPC audits and feedback.
  2. This involves audits on:
  • Financing
  • Hospital-acquired infections
  • Rates of antimicrobial use in animals (recurrent use would imply recurrent infections mainly due to poor IPC).

Surveillance

Priority gaps

Feasible and sustainable solutions

Feasible and sustainable solutions

  1. Lack of funding.
  2. Weak laboratory capacity in all sectors.
  3. Lack of standards and their enforcement.
  4. Lack of data management capacity.
  5. Lack of EQA, there are priority organisms.
  6. Lack of research.
  7. Lack of quality management systems.
  8. Lack of policies.
  1. Development of policies and strategy for integrated AMR surveillance.
  2. Development of a national surveillance plan/guidelines.
  3. Clear roles and responsibilities.
  4. Clear coordination, reporting. mechanism and accountability under One Health approach.
  1. Develop harmonised M&E tools for AMR and AMU.

 

 

Addressing antimicrobial resistance and implementing National Action Plans on AMR may require some paradigm shift in thinking, clearly funding was among the top challenges, how about mainstreaming antimicrobial resistance in current funded programs and activities at country level such as SDGs programs. All the countries have programs for HIV, malaria, immunizations and ministry budget lines, how can antimicrobial resistance activities and goals be aligned within these? Development of model IPC or stewardship programs models within low resource settings will need to developed and implemented. Certainly Africa needs its developmental partners to support with National Action Plan implementation as can be seen from the priority listing of gaps.

While some surveillance of some reported diseases occur in most African countries, antimicrobial resistance surveillance is limited or non-existent at all. More investments need to be put into antimicrobial resistance surveillance and antimicrobial use. Efforts should be put into towards a One Health approach of integrating human and animal sector surveillance and strengthening information systems to allow collecting and collation of data to guide policies. Strengthening laboratory systems should include investments into R&D for rapid diagnostic tests for common infections to guide prescribing practices. One of the drivers of irrational prescribing is the lack of diagnostics and culture and sensitivity tests.

Conclusion

Despite a lot of enthusiasm and commitment from champions one thing that was very clear is that implementation of NAPs will not be very easy, sustaining the momentum that has been garnered the last couple of years with other competing priorities at country, regional and global level will challenge the resolve of the Global Action Plan on Antimicrobial Resistance.

Video: Hear the voices of participants from the RAN conference