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Policy  –  Examples from the field

Ghana’s national policy

Startled by the dire consequences of antibiotic resistance, the Ministry of Health Ghana was inspired to take action and established the National Platform on Antimicrobial Resistance (NPAR) as the driving institution behind the antimicrobial resistance agenda in Ghana.

By actively engaging in tackling the issue of antimicrobial resistance on a national level, Ghana has been placed on the map as a leader and spokesperson for antimicrobial resistance in the African region. Ghana stands as an example to other low- and middle-income countries on how to use a multi-stakeholder platform to develop a policy only antimicrobial resistance.

In 2010, Martha Gyansa-Lutterodt, the Director of Pharmaceutical Services, Ghana, took part in the working group for the publication ‘The race against drug resistance”. Initial evidence from the report revealed a picture of the emerging antibiotic resistance situation in Ghana. Concerned, she attended a meeting held by ReAct where she learned more about the global situation and emerging threat of resistance. Alarmed by the potential consequences of antibiotic resistance and lack of concerted action, she returned to Ghana, determined to set forth action on the national level. Taking a stand as a champion on antibiotic resistance, she engaged the Ministry of Health in the issue, and harnessed technical and financial support from ReAct. A memorandum of understanding was signed between the two institutions making the start of a multi-year project to address antimicrobial resistance in Ghana.

Policy development process

Over the coming year, several technical exchange visits were held between ReAct and Ghana to iron out the details of the project and gain further national support. ReAct was invited to visit the Ministry of Health to share the work of ReAct and information of what was being done in other countries with regards to antibiotic resistance. Participants highlighted the importance of identifying champions that are interested in taking up the issue of antimicrobial resistance as a key factor to starting a successful initiative. Potential stakeholders to be involved in the project were identified.

Several brainstorming sessions were held on how to address the issue at the national level. A consensus was formed that action was needed on both the civil society and political level. This led to a plan for the development of a national policy on antimicrobial resistance with a sub-project focusing directly on civil society. The Ministry of Health Ghana, with support from Sida, through ReAct, established the National Platform on Antimicrobial Resistance (NPAR) to bring government institutions together with civil society organizations to lead Ghana’s efforts to stop the emergence of antimicrobial resistance.

The platform has representation of key stakeholders with an interest in resistance issues, such as the national agency responsible for development process of pharmaceutical policies in Ghana and the Ghana National Drugs Programme (GNDP) amongst others. A management team steers the efforts with a small group of about 8 people from the Ministry of Health, and led by the Director of Pharmaceutical Services. With input from the wider platform, aims and objectives were set and a budget and work plan were formulated. NPAR’s broad objective is to develop and implement a policy for containment of antibiotic resistance. Attached to this are several specific objectives:

  • Review the Knowledge, Attitudes, Beliefs and Practises (KABP) of health professionals on antibiotic resistance
  • Establish surveillance on antibiotic use and resistance
  • Increase capacity of health professionals and laboratories to deal with antibiotic resistance issues in the health system
  • Link medicine selection to work on antibiotic surveillance
  • Review and enforce the regulations on antibiotics in Ghana
  • Generate data and information for behavioral change communication for rational use of antibiotics
  • Work with CSOs to open up the community to antibiotic resistance issues

Over the coming years, the platform met quarterly to discuss and decide on details of the project, review progress and discuss reports from members on activities relating to antimicrobial resistance. During this period, awareness was raised within the wide stakeholder group, informing both about the issue and ongoing work of the platform. This was key to getting their buy-in which was essential for drafting of the policy and to move it through the parliamentary approval process. Outside of the platform, awareness was raised on the issue through trainings, media engagement and the use of behavior change communication messages for health care professionals and the public.

In order to inform the policy, data was needed on resistance levels, antibiotic consumption, health care-associated infections, the quality of antibiotics, and social-behavioral factors amongst others. This information would be used as a starting point to provide insight to the current situation and inform stakeholders in work to determine the policy areas to be covered, outline options for action in the policy implementation plan, and ensure that the policy fists within the existing health system and is aligned with key existing policies such as the infection control policy, National Medicines Policy and Essential Medicine List policy.  Since limited data existed, the platform prioritized gathering of local evidence and information and after heavy deliberation, decided to carry out a stakeholder analysis , a KAPP study (Knowledge, Attitudes, Practices and Perceptions), and a baseline resistance study (See MEASURE – Examples from the field) and a situational analysis. The studies were conducted by universities that were part of the platform, and the stakeholder analysis and situational analysis was carried out by selected members of the platform.

The management team used the information gathered to develop the basis of a broad policy framework  and an implementation plan. The broad policy perspective covered areas such as Responsible Use of Antimicrobials; Veterinary and Aquaculture; Manufacturing, Supply, distribution, disposal; Regulation and enforcement; National surveillance; Infection prevention and control; Laboratory services; Research and development; and Stakeholder collaboration and Governance of Antimicrobial resistance. It also ensured that there were community education and sociocultural change interventions, which were seen as especially important in the African setting.

The platform reached out to an even wider stakeholder group to present the draft policy and get input and buy-in from participants who had previously not been part of the policy development process. The draft policy was also shared with Directors and other officials of the Ministries of Health, Food & Agriculture, Fisheries & Aquaculture, Education and Environment, Science, Technology & Innovation, the Ghana Health Service and some academic institutions. The Parliamentary Select Committee, and the National Development Planning Commission was also later engaged on the draft policy and implementation plan. Observations on the policy were taken and a final version was drafted.

With the draft policy and implementation plan in hand, the platform wrote a cabinet memo and submitted the documents for approval to the Attorney General’s Department, as is part of the process for the approval of policies in Ghana). Once the Attorney General’s Department is satisfied with the documents presented, they will be forwarded to Cabinet for approval and publication. A policy brief was also developed to inform to policy makers and key stakeholders on the policy.

Key accomplishments

A key output of the NPAR project is the development and submission of the national policy for parliamentary approval. Ghana is one of the very first countries in Africa to achieve this. Equally important is the collection of baseline resistance data, as such information is not regularly collected and necessary to inform both policy and treatment decisions. Also important to recognize as a sign of Ghana’s hard work and emerging expertise on the topic, Martha Gayansa-Lutterodt has become a spokesperson for low- and middle-income countries looking to address the issue. In 2014 and 2015, Martha spoke on behalf of the African Union at the World Health Assembly on antimicrobial Resistance

Throughout project, the platform placed an emphasis on cross learning and sharing of experiences, sending representatives from Ghana to speak about their work to multiple international gatherings, including meetings with Chatam House, at Wilton Park, and with ReAct Africa amongst others. Additionally, some members of the platform participated in some international meetings, workshops, seminars and fora, to share the experience from Ghana, learn from other participants, as well as contribute in the development of resources for combating resistance to antimicrobials.

Challenges

The greatest challenges to achieving the outcomes of the goal were due working within a political process involving multiple stakeholders. In the beginning it was difficult to reach consensus on details of the background studies, resulting in long delays and the need to extend deadlines. Another struggle that is important to note was that apart from the platform, the members of the management team had other full time responsibilities to attend to, and despite interest they often found it difficult to devote the time needed to platform activities. A lessoned that can be learned from this is the importance to ensure support for dedicated staff time for such an undertaking. Funds for staff time, and commitment from the MOH can help to facilitate this.

Lessons learned

One of the main takeaway messages was the importance of identifying champions that are interested in taking up the issue of antimicrobial resistance. Champions like Martha, help to take the issue forward, and engage others for support even when confronted with competing challenges.

Throughout the project, the platform saw first hand the regional, national and global dimensions of antimicrobial resistance and were deeply exposed to various specific challenges in the different sectors affected by the issue. The platform recognized the importance of the policy development process in low and middle-income countries to consider a multi-sectoral approaches in order to arrive at any meaningful policy interventions. For low and middle income countries, they recommend a bottom-up approach to developing a policy on antimicrobial resistance. They add that it is important to note that while the process may appear tedious and slow, it will lead to a policy that is comprehensive and responsive to the specific needs in the local context.

Selected Resources

Resource Description
Antibiotic Policy in Ghana; the way forward (PPT, 11MB) Presentation by Martha Gyansa-Lutterodt, Director Pharmaceutical Services Ghana, given at the ADMER conference in March 2015. The presentation gives an overview of the antibiotic resistance policy development process and highlights ways forward. 
Policy Brief: Antimicrobial Resistance (AMR) (PDF, 1MB) The policy brief provides an overview about the different objectives used by the Ministry of Health Ghana to establish their antimicrobial resistance policy.