Tapiwa Kujinga is the Director of the Pan-African Treatment Access Movement (PATAM), a social movement that has taken antimicrobial resistance in Zimbabwe under its wings. He says: "In Zimbabwe civil society is literally involved in every aspect of the response to antimicrobial resistance." Looking back in time, Tapiwa Kujinga notes that when PATAM and involved organizations started working on HIV/AIDS, there was no framework on access to medicines. "We had to work hard in order to get government to come up with a framework. I feel that this is the approach that is required for antimicrobial resistance and for health systems broadly."
In this interview, Tapiwa Kujinga talks about the pros of civil society engagement, the challenges of access and excess, and how PATAM wants to further its engagement.
For how long have you worked with antimicrobial resistance and what motivated you to get involved in the issue?
– I have been working with antimicrobial resistance for 6 years now. I started in 2015 and it was actually through ReAct that Pan African Treatment Access Movement (PATAM) first heard about antimicrobial resistance. We knew nothing about it before. What is still quite interesting is that the moment we heard about antimicrobial resistance, we felt we had to do something about it.
In your opinion, what is the role of civil society organizations in the effort to address antimicrobial resistance?
– The role of civil society is quite multifaceted, the first role is advocacy at all levels. As a civil society organization during the HIV/AIDS era, we were involved in HIV/AIDS advocacy, though it was more on the outside than the inside. With antimicrobial resistance, it is a little bit different as I believe that to be more effective in advocacy, civil society organizations need to be part of the antimicrobial resistance response by working with crucial sectors especially education and awareness – and not only to provide external technical guidance.
– For instance, in Zimbabwe civil society is literally involved in every aspect of the response to antimicrobial resistance. We start right from education and awareness all the way through laboratory surveillance and infection, prevention and control. This is because it is important that we guide and work towards where we feel the response should go, rather than just dictating the response and let somebody else do it. Following this, civil society organizations play a critical role in monitoring that the response is actually going the direction it should be going.
Why is it so important that civil society organizations engage in this effort and what assets do they bring to the table that other stakeholders lack?
– Our advantage as civil society is that we have the ability to get down to grass-root levels that other stakeholders such as government have struggled to reach due to a general distrust from the community. One asset that civil society possesses is goodwill, which makes it easier for people at the community level to believe what is being shared with them.
– Another asset that civil society organizations have is the ability to critically analyze issues through for example, frequently conducting end-term evaluations and objective analysis which hardly happen in government. This is how come civil society organizations are able to hold government accountable on various decisions.
– In addition, civil society organizations are very result-oriented and focused on seeing change. Whereas with government in Zimbabwe for example, the approach is to constantly appear like something is being done to address issues when nothing is actually being done.
What has been your interaction with ReAct Africa?
– Our interaction with ReAct Africa has been very extensive. Initially, ReAct Africa offered us support in hosting a national conference on antimicrobial resistance. This conference was held in July, 2015 and was the first meeting to address antimicrobial resistance in Zimbabwe. ReAct Africa helped us start working on our situational analysis, where we received a lot of technical advice as well as support us with the development of our National Action Plan. Furthermore, we received support from ReAct Africa at our first One Health meeting and the finalization of the National Action Plans.
– We have attended and participated in the annual ReAct Africa Conference and have been linked to some partners through ReAct. In fact, I can actually say that ReAct Africa has been the linchpin and fulcrum in our program. I used to say to my colleague, the late Dr Sekesai Zinyowera, that ReAct Africa has made a difference to our program and if we didn’t have that support, a lot would not have happened.
How do you reason around access to antibiotics and antibiotic resistance?
– Access is another issue which I think we will be addressing for a long time to come. You will find that there are areas where there is an abundant supply of antibiotics and antimicrobials in general. As a result, there is abuse, misuse and overuse. There are now markets here in Zimbabwe where you can walk in and you get antibiotics without a prescription by someone who is not even qualified.
– Contrary, there are also some areas where there are no antibiotics and access is very, very limited. It therefore it becomes a question of access versus excess. In low- and middle-Income countries like ours, you will find that it is very difficult to address this question because there are a lot of dynamics at play. To deal with this, there’s need to address core issues such as inequality and poverty while at the same time there is also need to strictly regulate access in richer communities where antibiotic use tends to be higher.
How can we get antibiotics out to those who need them while at the same time making sure they are not used in the wrong way?
– The issue of regulation is quite important because there are countries that have strictly curtailed access to antibiotics. In Sweden for example, you cannot easily get antibiotics – so in some cases- Zimbabweans in Sweden would sometimes ask for some antibiotics to be brought to them by visiting relatives or friends. Anecdotal data shows that people are not getting any sicker because they are not accessing antibiotics. It is more of a mindset that when one is not feeling well, they feel the need to take an antibiotic. In the end, the placebo effect is at play and the antibiotic becomes the silver bullet for every sickness.
– There is really a need for enhanced regulation to ensure that there is adequate access across the board. This regulation also needs multi-country collaboration because as it stands, it is alleged that a lot of antibiotics are flowing through Zambia to Zimbabwe. Some people say they are coming from the Democratic Republic of Congo where the regulation is not that strong. When such things begin to happen, it becomes very difficult to plug the hole, hence the call for countries to come on board in addressing this issue.
What do you think is the biggest challenge in tackling antibiotic resistance?
– I think the biggest challenge is excessive use and when I say excessive use, I do not spare our formal health systems. It has been found that even some doctors sometimes feel “the more antibiotics, the better”.
– In fact, I helped Dr. Mirfin Mpundu, Director of ReAct Africa and Dr. Philip Mathew, Deputy Director, ReAct Asia Pacific, to do a research on the incentives that doctors get to prescribe particular antibiotics and it was really interesting to find how some doctors could feel pressured to prescribe antibiotics even where they are not needed, all because of the incentives from the manufacturers. In Zimbabwe, you can walk into some pharmacies and get an antibiotic without a prescription. While it is against the law, pharmacists would still give out antibiotics because the person would simply walk to the next pharmacy and be served there. So, we are looking at the system where both the formal and informal sectors are contributing to antibiotic overuse and abuse.
– In regards to animal health in Zimbabwe, access to antibiotics is absolutely unregulated. A study that looked into resistance in human beings found that there was a huge rate of resistance to tetracyclines. Now, we have almost zero tetracycline-based antibiotics for human beings but because tetracyclines are almost routinely prescribed for chickens and once resistance is built, that resistance is transferred to human beings. We now have human beings developing resistance to antibiotics which they are not consuming from their own use but are being consumed through food animals. Another example is colistin which I for example can not get in the pharmacy at all but a farmer could easily have access to it.
What work does PATAM focus on mainly?
– PATAM focuses on treatment, access and advocacy. For instance, we work on HIV treatment advocacy, intellectual property/ access to medicines, COVID-19 and we also work on capacity building.
With your work in HIV/AIDs, are there any notable best practices on access to antiviral treatments that you feel can be applied in regard to issues on access to antibiotics, especially in Africa?
– When we started working on HIV/AIDS, there was no framework on access to medicines. We had to work hard in order to get government to come up with a framework. Today, we do not hear many people talking about HIV/AIDS as compared to 10 years ago. This is all because governments have now built a capacity to address HIV/AIDS. I feel that this is the approach that is required for antimicrobial resistance and for health systems broadly. Health systems are pivot and therefore, strengthening their capacity through a sustainable framework needs to be a priority.
What motivates you in your work as Director for PATAM?
– What motivates me is the ability to make change.
– As PATAM, we made a lot of a difference in the HIV era by working to push governments to action. For instance, in Zambia, we pushed for Prevention of Mother-To-Child Transmission (PMTCT). We were basically saying that PMTCT is one of the easiest things that we could achieve and followed that up by doing quite a lot of work which included surveys. We also worked through paper systems to ensure that the voices of communities would be heard in every President’s Emergency Plan for AIDS Relief (PEPFAR) process. This change has made a lot of a difference as communities can now even access funding for PEPFAR.
– In regards to antimicrobial resistance, we have made a lot of changes here in Zimbabwe. When we started, it was just us and ReAct Africa talking about antimicrobial resistance, but now it’s a big program with many partners. That is a measure of success and motivation because we pushed for antimicrobial resistance for years even when there was no funding. We will not stop here; we are looking for more areas where we can make a difference.
What are you most proud of in regard to what you have accomplished in your role at PATAM so far?
– PATAM is not an ordinary implementing organization, we see ourselves as being trailblazers. We do not look for what has already been proved, but we look for what we know works and nobody has tried it. In our work with HIV/AIDS for example, there were times when people told us that what we were pushing for could not be achieved at all, but it has been achieved today.
– It was the same with antimicrobial resistance, people felt it was not much of a priority because people did not understand what it was. How do you communicate a condition which does not make people sick, one that cannot be seen and cannot even be explained adequately in a local language?. If we were failing to adequately articulate antimicrobial resistance, then people felt it was basically waste of time. But now we have managed to put antimicrobial resistance on the agenda and it is moving forward. What makes me proud, looking at our work history is that we lead and others follow.
Is there something in particular that you hope to accomplish in the future?
– Definitely, for every program that we have, we want to ensure that other partners in civil society are also empowered. For example, before COVID-19 hit, PATAM and other partners including ReAct Africa were pushing for antimicrobial resistance to be embedded in into the programming of every single civil society organization that is working on human health, animal health and the environment.
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