“Rise of the superbugs.” “Global crisis.” “Nightmare bacteria.” “Deadly fungus.”
The media has caught on to the dire threat that antimicrobial resistance (AMR) presents, and it has certainly captured the urgency of the situation.
Global health professionals know this crisis has been years in the making and have been acting accordingly. We know, however, that we cannot contain the spread of AMR without strengthening health systems in low- and middle-income countries, which tend to have weaker surveillance systems for drug use and infectious disease management. Our efforts would be futile. It’s time to take stock of where we are and figure out our focus going forward; we have no time to lose.
The global health organization I work for, Management Sciences for Health (MSH), has been strengthening health systems in dozens of countries for almost 50 years, alongside governments, donors, global organizations like the Global Health Security Agenda (GHSA) Consortium and the World Health Organization (WHO) and other nonprofits. Based on results to date, here are four lessons we have learned:
We have laws, but they’re toothless.
Legislation, policies, guidelines, and plans are important, and more than 20 countries have joined the GHSA and developed comprehensive national action plans, guided by WHO, the Food and Agriculture Organization of the United Nations, and the World Organization for Animal Health. Yet having good ideas on paper will not help us solve the AMR problem. Governments and development partners should now focus on implementation and enforcement. Many countries have legal provisions to regulate medicines, such as only selling antimicrobials at licensed outlets and with adequate prescriptions, but these are often not enforced. Two-thirds of antibiotics are sold without prescription in low- and middle-income countries, mostly via the unregulated private sector.
Everyone needs to be at the table, especially the private sector.
This is not just a health sector issue. It involves animals, plants, food and the environment. Antibiotics are routinely added to animal feed to ward off infections and fatten animals more quickly; in fact, current use in livestock is expected to rise by 67 percent by 2030, with some developing countries continuing to use banned substances. It’s not just a government problem, either. Each country needs a coalition that includes civil society organizations, consumer and faith-based groups and private-sector health providers.
Targeted, hyperlocal engagement helps. For example, for the past six years, MSH has engaged pharmacy regulators and shop owners on training and accrediting informal drug sellers so that they are selling genuine, quality products and referring people who need antibiotics for treatment. This program is active in four African countries and in Bangladesh.
Training is not enough. We must promote behavior change.
Maintaining standards of practice is critical for both providers and patients. For example, on average, 61 percent of health workers do not follow recommended hand hygiene practices, including not washing their hands properly. Some may simply lack places to do so; 896 million people worldwide rely on health care facilities that lack water service. Even though health workers may have completed all the required trainings on infection prevention and control, they forget, are too busy, or just don’t understand why it’s important.
We need to break these patterns and make sure good hand hygiene practices and other key proven interventions become ingrained habits. Here, too, we can draw on what we know works, and it might be low-hanging fruit: Patient safety champion and physician Peter Pronovost instituted a simple, low-cost checklist system in 2001 that reduced infections from catheter insertions by 66 percent and continues to save lives.
Another critical example of the need to change behavior is appropriately prescribing antibiotics. Globally, about 50 percent of acute viral upper respiratory infections are inappropriately treated with antibiotics. Incentivizing, and not just educating, health workers is key. Experience with community health worker incentives in Madagascar shows that per diems and performance-based financing, along with supervision and support, result in higher-quality services and reporting.
Accurate, well-used health information is vital.
Pharmaceutical data help managers better manage their supply chain, ensuring the availability and appropriate use of quality medicines. With support from donors and nonprofits, countries are developing tools and processes to collect and analyze this information, including electronic data systems, new laboratory technology, and hospital drug and therapeutics committees to monitor antibiotic use and set standards. Once data are available, they need to be used for better planning and treatment, which involves cultivating a culture of evidence-based decision making.
There are many other takeaways as we continue to rally against this dire threat, but addressing these four issues will go a long way toward making the resources we have go further. We must now apply what we have learned from our hard-earned experience and continue to add to our body of first-hand knowledge going forward. Donors and development partners should incorporate these principles in their work. As we continue the fight against superbugs, it’s not about working harder; it’s about working smarter.