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He S, Shrestha P, Henry AD, Legido-Quigley H. Leveraging collaborative research networks against antimicrobial resistance in Asia. Front Public Health 2023; 11:1191036. [PMID: 38146479 PMCID: PMC10749297 DOI: 10.3389/fpubh.2023.1191036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 11/13/2023] [Indexed: 12/27/2023] Open
Abstract
Background Antimicrobial resistance (AMR) is a global health security threat requiring research collaboration globally and regionally. Despite repeated calls for international research collaboration in Asia, literature analyzing the nature of collaborative AMR research in Asia has been sparse. This study aims to describe the characteristics of the AMR research network in Asia and investigate the factors influencing collaborative tie formation between organizations. Methods We carried out a mixed-methods study by combining social network analysis (SNA) and in-depth interviews. SNA was first conducted on primary data to describe the characteristics of the AMR research network in Asia. Exponential random graph models (ERGMs) were then used to examine the influence of factors such as organization type, country affluence levels, regional proximity and One Health research on collaborative tie formation among organizations. In-depth interviews were conducted with network participants to provide contextual insights to the quantitative data. Results The results reveal that the research network exhibits a core-periphery structure, where a minority of organizations have a significantly higher number of collaborations with others. The most influential organizations in the network are academic institutions from high-income countries within and outside Asia. The ERGM results demonstrate that organizations prefer to collaborate with others of similar organization types, country-based affluence levels and One Health domains of focus, but also with others across different World Health Organization regions. The qualitative analysis identified three main themes: the challenges that impede collaboration, the central role of academic institutions, and the nature of collaborations across One Health domains, giving rise to important empirical milestones in understanding AMR research in Asia. Conclusion We thus recommend leveraging academic institutions as "integrators" to bridge differences, increasing funds channelled towards research capacity building to alleviate structural barriers to collaboration, streamlining collaborative mechanisms to overcome cumbersome administrative hurdles, and increasing efforts to establish trust between all organizations.
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Affiliation(s)
- Shiying He
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Singapore, Singapore
| | - Pami Shrestha
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Singapore, Singapore
| | - Adam Douglas Henry
- School of Government & Public Policy, University of Arizona, Tucson, AZ, United States
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, Singapore, Singapore
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Chua AQ, Verma M, Azupardo K, Lota MM, Hsu LY, Legido-Quigley H. A Qualitative Study on the Policy Process and Development of the National Action Plan on Antimicrobial Resistance in Singapore. Antibiotics (Basel) 2023; 12:1322. [PMID: 37627742 PMCID: PMC10451339 DOI: 10.3390/antibiotics12081322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
The global public health threat of antimicrobial resistance (AMR) has been accelerated by many interrelated factors spanning across One Health-human health, animal health, and the environment. Singapore launched its own National Strategic Action Plan (NSAP) on AMR in November 2017 with the aim of tackling the growing threat of AMR in Singapore through coordinated approaches. However, little is known about the policy process and development of the NSAP in Singapore. In this study, we analysed these aspects using an AMR governance framework. In-depth interviews were conducted with 20 participants across the One Health spectrum. The interviews were transcribed verbatim and analysed thematically. Areas that were well executed included (1) good coordination across various agencies, (2) a dedicated office to coordinate the work on the NSAP, and (3) a high level of governmental support. Areas that were lacking included (1) a lack of participation from certain sectors, (2) insufficient awareness around the AMR issue, (3) constraints in information sharing, and (4) a lack of ideal indicators to track the progress in addressing AMR. Improvements in these areas will provide a more holistic One Health engagement in support of the effective planning and implementation of the NSAP.
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Affiliation(s)
- Alvin Qijia Chua
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore; (M.V.); (L.Y.H.); (H.L.-Q.)
| | - Monica Verma
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore; (M.V.); (L.Y.H.); (H.L.-Q.)
| | - Karen Azupardo
- College of Public Health, University of the Philippines Manila, 625 Pedro Gil St, Ermita, Manila 1000, Philippines; (K.A.); (M.M.L.)
| | - Maria Margarita Lota
- College of Public Health, University of the Philippines Manila, 625 Pedro Gil St, Ermita, Manila 1000, Philippines; (K.A.); (M.M.L.)
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore; (M.V.); (L.Y.H.); (H.L.-Q.)
| | - Helena Legido-Quigley
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore; (M.V.); (L.Y.H.); (H.L.-Q.)
- The George Institute for Global Health UK, Imperial College London, 80 Wood Lane White City, London W12 0BZ, UK
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3
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Allel K, Day L, Hamilton A, Lin L, Furuya-Kanamori L, Moore CE, Van Boeckel T, Laxminarayan R, Yakob L. Global antimicrobial-resistance drivers: an ecological country-level study at the human-animal interface. Lancet Planet Health 2023; 7:e291-e303. [PMID: 37019570 DOI: 10.1016/s2542-5196(23)00026-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 01/20/2023] [Accepted: 02/01/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a pressing, holistic, and multisectoral challenge facing contemporary global health. In this study we assessed the associations between socioeconomic, anthropogenic, and environmental indicators and country-level rates of AMR in humans and food-producing animals. METHODS In this modelling study, we obtained data on Carbapenem-resistant Acinetobacter baumanii and Pseudomonas aeruginosa, third generation cephalosporins-resistant Escherichia coli and Klebsiella pneumoniae, oxacillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium AMR in humans and food-producing animals from publicly available sources, including WHO, World Bank, and Center for Disease Dynamics Economics and Policy. AMR in food-producing animals presented a combined prevalence of AMR exposure in cattle, pigs, and chickens. We used multivariable β regression models to determine the adjusted association between human and food-producing animal AMR rates and an array of ecological country-level indicators. Human AMR rates were classified according to the WHO priority pathogens list and antibiotic-bacterium pairs. FINDINGS Significant associations were identified between animal antimicrobial consumption and AMR in food-producing animals (OR 1·05 [95% CI 1·01-1·10]; p=0·013), and between human antimicrobial consumption and AMR specifically in WHO critical priority (1·06 [1·00-1·12]; p=0·035) and high priority (1·22 [1·09-1·37]; p<0·0001) pathogens. Bidirectional associations were also found: animal antibiotic consumption was positively linked with resistance in critical priority human pathogens (1·07 [1·01-1·13]; p=0·020) and human antibiotic consumption was positively linked with animal AMR (1·05 [1·01-1·09]; p=0·010). Carbapenem-resistant Acinetobacter baumanii, third generation cephalosporins-resistant Escherichia coli, and oxacillin-resistant Staphylococcus aureus all had significant associations with animal antibiotic consumption. Analyses also suggested significant roles of socioeconomics, including governance on AMR rates in humans and animals. INTERPRETATION Reduced rates of antibiotic consumption alone will not be sufficient to combat the rising worldwide prevalence of AMR. Control methods should focus on poverty reduction and aim to prevent AMR transmission across different One Health domains while accounting for domain-specific risk factors. The levelling up of livestock surveillance systems to better match those reporting on human AMR, and, strengthening all surveillance efforts, particularly in low-income and middle-income countries, are pressing priorities. FUNDING None.
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Affiliation(s)
- Kasim Allel
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK; Institute for Global Health, University College London, London, UK.
| | - Lucy Day
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Leesa Lin
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong Special Administrative Region, China; The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Luis Furuya-Kanamori
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Catrin E Moore
- The Centre for Neonatal and Paediatric Infection, Infection and Immunity Institute, St George's, University of London, UK
| | - Thomas Van Boeckel
- Eidgenössische Technische Hochschule, Zurich, Health Geography and Policy Group, Zurich, Switzerland
| | - Ramanan Laxminarayan
- The One Health Trust, Washington DC, USA; The High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
| | - Laith Yakob
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK
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Chan OSK, Wernli D, Liu P, Tun HM, Fukuda K, Lam W, Xiao YH, Zhou X, Grépin KA. Unpacking Multi-Level Governance of Antimicrobial Resistance Policies: the Case of Guangdong, China. Health Policy Plan 2022; 37:1148-1157. [PMID: 35775460 PMCID: PMC9558914 DOI: 10.1093/heapol/czac052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/18/2022] [Accepted: 07/01/2022] [Indexed: 11/14/2022] Open
Abstract
Against the backdrop of universal healthcare coverage and pre-existing policies on antimicrobial use, China has adopted a state-governed, multi-level, top-down policy governance approach around an antimicrobial resistance (AMR) national action plan (NAP). The Plan relies on tightening control over antimicrobial prescription and use in human and animal sectors. At the same time, medical doctors and veterinarians operate in an environment of high rates of infectious diseases, multi-drug resistance and poor livestock husbandry. In exploring the way that policy responsibilities are distributed, this study aims to describe how Guangdong as a province adopts national AMR policies in a tightly controlled public policy system and an economy with high disparity. We draw on an analysis of 225 AMR-relevant Chinese policy documents at the national and sub-national levels. We adopt a multi-level governance perspective and apply a temporal sequence framework to identify and analyse documents. To identify policy detail, we conducted keyword analysis using the Consolidated Framework for Implementation Research (CFIR) on policies that conserve antimicrobials. We also identify pre-existing medical and public policies associated with AMR. Our findings highlight the emphasis and policies around antimicrobial use regulation to address AMR in China.
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Affiliation(s)
- Olivia Sinn Kay Chan
- The University of Hong Kong School of Public Health, 7 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Didier Wernli
- Geneva Transformative Governance Lab, Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Ping Liu
- The University of Hong Kong School of Public Health, 7 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Hein Min Tun
- The University of Hong Kong School of Public Health, 7 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Keiji Fukuda
- The University of Hong Kong School of Public Health, 7 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Wendy Lam
- The University of Hong Kong School of Public Health, 7 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Yung Hong Xiao
- State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, 300013
| | - Xudong Zhou
- School of Medicine, 866 Yuhangtang Road, Zhejiang University, Zhejiang, China
| | - Karen A Grépin
- The University of Hong Kong School of Public Health, 7 Sassoon Road, Pokfulam, Hong Kong SAR, China
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5
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Matthiessen LE, Hald T, Vigre H. System Mapping of Antimicrobial Resistance to Combat a Rising Global Health Crisis. Front Public Health 2022; 10:816943. [PMID: 35784220 PMCID: PMC9249020 DOI: 10.3389/fpubh.2022.816943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Antimicrobial resistance (AMR) decreases the effectiveness of antimicrobials to treat bacterial infections in humans and animals. The increased occurrence of AMR in bacterial population in humans, animals, and the environment requires the measures to combat a rising global health crisis. The aim of this research was to present current knowledge on AMR in a system map and to identify potential explanations of former identified variables significantly associated with AMR. This study applies a systems thinking approach and uses feedback loops to visualize the interconnections between human, animal, and environmental components in a circular AMR system map model. First, a literature review focusing on AMR and socioeconomic factors, wicked problem, and system change was carried out, which was then processed in a system map to conceptualize the present core challenges of AMR via feedback loops. Second, to investigate possible underlying values of the society and those that influence humans' behavior in the present AMR system, an iceberg model was established. Third, leverage points were assessed to estimate which kinds of interventions would have the greatest effect to mitigate AMR in the system. The present AMR system map implies the potential to identify and visualize important risk factors that are direct or indirect drivers of AMR. Our results show that the tool of system mapping, which interconnects animals, humans, and environment in one model, can approach AMR holistically and be used to assess potential powerful entry points for system wide interventions. This study shows that system maps are beneficial as a model to predict the relative effect of different interventions and adapt to rapidly changing environments in a complex world. Systems thinking is considered as a complementing approach to the statistical thinking, and further research is needed to evaluate the use of such tools for the development and monitoring of interventions.
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Khan M, Rahman-Shepherd A, Bory S, Chhorn S, Durrance-Bagale A, Hasan R, Heng S, Phou S, Prien C, Probandari A, Saphonn V, Suy S, Wiseman V, Wulandari LPL, Hanefeld J. How conflicts of interest hinder effective regulation of healthcare: an analysis of antimicrobial use regulation in Cambodia, Indonesia and Pakistan. BMJ Glob Health 2022; 7:bmjgh-2022-008596. [PMID: 35589155 PMCID: PMC9121421 DOI: 10.1136/bmjgh-2022-008596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/20/2022] [Indexed: 11/09/2022] Open
Abstract
Background There has been insufficient attention to a fundamental force shaping healthcare policies—conflicts of interest (COI). We investigated COI, which results in the professional judgement of a policymaker or healthcare provider being compromised by a secondary interest, in relation to antimicrobial use, thereby illuminating challenges to the regulation of medicines use more broadly. Our objectives were to characterise connections between three groups—policymakers, healthcare providers and pharmaceutical companies—that can create COI, and elucidate the impacts of COI on stages of the policy process. Methods Using an interpretive approach, we systematically analysed qualitative data from 136 in-depth interviews and five focus group discussions in three Asian countries with dominant private healthcare sectors: Cambodia, Indonesia and Pakistan. Findings We characterised four types of connections that were pervasive between the three groups: financial, political, social and familial. These connections created strong COI that could impact all stages of the policy process by: preventing issues related to medicines sales from featuring prominently on the agenda; influencing policy formulation towards softer regulatory measures; determining resource availability for, and opposition to, policy implementation; and shaping how accurately the success of contested policies is reported. Interpretation Our multicountry study fills a gap in empirical evidence on how COI can impede effective policies to improve the quality of healthcare. It shows that COI can be pervasive, rather than sporadic, in influencing regulation of medicine use, and highlights that, in addition to financial connections, other types of connections should be examined as important drivers of COI.
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Affiliation(s)
- Mishal Khan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK .,Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan
| | - Afifah Rahman-Shepherd
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Anna Durrance-Bagale
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Rumina Hasan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Department of Pathology and Microbiology, The Aga Khan University, Karachi, Pakistan
| | | | | | - Chanra Prien
- University of Health Sciences, Phnom Penh, Cambodia
| | | | | | | | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.,Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Johanna Hanefeld
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.,Center for International Health Protection, Robert Koch Institut, Berlin, Germany
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7
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Song M, Deng Z, Chan O, Grépin KA. Understanding the Implementation of Antimicrobial Policies: Lessons from the Hong Kong Strategy and Action Plan. Antibiotics (Basel) 2022; 11:antibiotics11050636. [PMID: 35625280 PMCID: PMC9138146 DOI: 10.3390/antibiotics11050636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 01/27/2023] Open
Abstract
In 2017, the Hong Kong Strategy and Action Plan on Antimicrobial Resistance 2017–2022 (HKSAP) was announced with the aim of tackling the growing threat of antimicrobial resistance (AMR) in Hong Kong. However, little is known about how the planned activities have been implemented. In this study, we examine the status of implementation of the HKSAP using the Smith Policy Implementation Process Model. Semi-structured interviews with 17 informants found that important achievements have been made, including launching educational and training activities targeting the public, farmers, and healthcare professionals; upgrading the AMR surveillance system; and strengthening AMR stewardship and infection control. Nevertheless, participants also identified barriers to greater implementation, such as tensions across sectors, ongoing inappropriate drug use and prescription habits, insufficient human and technical resources, as well as a weak accountability framework. Environmental factors such as the COVID-19 pandemic also affected the implementation of HKSAP. Our study indicated that expanding engagement with the public and professionals, creating a collaborative environment for policy implementation, and building a well-functioning monitoring and evaluation system should be areas to focus on in future AMR policies.
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8
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Durrance-Bagale A, Jung AS, Frumence G, Mboera L, Mshana SE, Sindato C, Clark TG, Matee M, Legido-Quigley H. Framing the Drivers of Antimicrobial Resistance in Tanzania. Antibiotics (Basel) 2021; 10:991. [PMID: 34439041 PMCID: PMC8389026 DOI: 10.3390/antibiotics10080991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 11/30/2022] Open
Abstract
Despite global awareness of the key factors surrounding antimicrobial resistance (AMR), designing and implementing policies to address the critical issues around the drivers of AMR remains complex to put into practice. We identified prevalent narratives and framing used by epistemological communities involved in the response to AMR in Tanzania, interrogated how this framing may inform policymaking, and identified interventions that could be tailored to the groups believed responsible for AMR. We interviewed 114 key informants from three districts and analysed transcripts line by line. Our results suggest that many different groups help drive the spread of AMR in Tanzania and need to be involved in any effective response. Human health is currently perceived as driving the response, while other domains lag behind in their efforts. For AMR programmes to be successful, all sectors need to be involved, including civil society groups, community representatives, and those working in communities (e.g., primary care physicians). However, current plans and programmes largely fail to include these viewpoints. The perceived presence of political will in Tanzania is a significant step towards such a response. Any strategies to tackle AMR need to be tailored to the context-specific realities, taking into account constraints, beliefs, and power dynamics within countries.
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Affiliation(s)
- Anna Durrance-Bagale
- London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (A.-S.J.); (T.G.C.); (H.L.-Q.)
| | - Anne-Sophie Jung
- London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (A.-S.J.); (T.G.C.); (H.L.-Q.)
| | - Gasto Frumence
- Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania; (G.F.); (M.M.)
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro 65125, Tanzania; (L.M.); (S.E.M.); (C.S.)
| | - Leonard Mboera
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro 65125, Tanzania; (L.M.); (S.E.M.); (C.S.)
| | - Stephen E. Mshana
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro 65125, Tanzania; (L.M.); (S.E.M.); (C.S.)
- Catholic University of Health and Allied Science, Mwanza 33109, Tanzania
| | - Calvin Sindato
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro 65125, Tanzania; (L.M.); (S.E.M.); (C.S.)
- Tabora Research Centre, National Institute for Medical Research, Tabora 45026, Tanzania
| | - Taane G. Clark
- London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (A.-S.J.); (T.G.C.); (H.L.-Q.)
| | - Mecky Matee
- Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania; (G.F.); (M.M.)
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro 65125, Tanzania; (L.M.); (S.E.M.); (C.S.)
| | - Helena Legido-Quigley
- London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (A.-S.J.); (T.G.C.); (H.L.-Q.)
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9
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Khan MS, Durrance-Bagale A, Mateus A, Sultana Z, Hasan R, Hanefeld J. What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan. Health Policy Plan 2021; 35:973-982. [PMID: 32743655 DOI: 10.1093/heapol/czaa065] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/25/2022] Open
Abstract
Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.
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Affiliation(s)
- Mishal S Khan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Anna Durrance-Bagale
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Ana Mateus
- Department of Pathobiology and Population Sciences, Royal Veterinary College, London WC1H 9SH, UK
| | - Zia Sultana
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan.,Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Johanna Hanefeld
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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10
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Eriksen J, Björkman I, Röing M, Essack SY, Stålsby Lundborg C. Exploring the One Health Perspective in Sweden's Policies for Containing Antibiotic Resistance. Antibiotics (Basel) 2021; 10:antibiotics10050526. [PMID: 34063697 PMCID: PMC8147834 DOI: 10.3390/antibiotics10050526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/01/2021] [Accepted: 05/02/2021] [Indexed: 11/24/2022] Open
Abstract
Antibiotic resistance is considered to be a major threat to global health. The main driver of antibiotic resistance is antibiotic use. Antibiotics are used in humans, animals, and food production and are released into the environment. Therefore, it is imperative to include all relevant sectors in the work to contain antibiotic resistance, i.e., a One Health approach. In this study, we aimed to describe and analyse Sweden’s policies related to containing antibiotic resistance, from a One Health perspective. Twenty-three key policy documents related to containment of antibiotic resistance in Sweden were selected and analysed according to the policy triangle framework. Sweden started early to introduce policies for containing antibiotic resistance from an international perspective. Systematic measures against antibiotic resistance were implemented in the 1980s, strengthened by the creation of Strama in 1995. The policies involve agencies and organisations from human and veterinary medicine, the environment, and food production. All actors have clear responsibilities in the work to contain antibiotic resistance with a focus on international collaboration, research, and innovation. Sweden aims to be a model country in the work to contain antibiotic resistance and has a strategy for achieving this through international cooperation through various fora, such as the EU, the UN system, and OECD.
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Affiliation(s)
- Jaran Eriksen
- Department of Global Public Health—Health Systems and Policy (HSP): Improving the Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden;
- Unit of Infectious Diseases, Venhälsan, Södersjukhuset, 118 83 Stockholm, Sweden
- Correspondence:
| | - Ingeborg Björkman
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Husargatan 3, 751 22 Uppsala, Sweden; (I.B.); (M.R.)
| | - Marta Röing
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Husargatan 3, 751 22 Uppsala, Sweden; (I.B.); (M.R.)
| | - Sabiha Y. Essack
- Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban 4001, South Africa;
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health—Health Systems and Policy (HSP): Improving the Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden;
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The role of external actors in shaping migrant health insurance in Thailand. PLoS One 2020; 15:e0234642. [PMID: 32614845 PMCID: PMC7332068 DOI: 10.1371/journal.pone.0234642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 05/30/2020] [Indexed: 11/19/2022] Open
Abstract
The role of external actors in national health policy in aid-independent countries has received relatively little attention in the literature, despite the fact that influence continues to be exerted once financial support is curtailed as countries graduate from lower income status. Focusing on a specific health policy in an aid-independent country, this qualitative study explores the role of external actors in shaping Thailand’s migrant health insurance. Primary data were collected through in-depth interviews with eighteen key informants from September 2018 to January 2019. The data were analysed using thematic analysis, focusing on three channels of influence, financial resources, technical expertise and inter-sectoral leverage, and their effect on the different stages of the policy process. Given Thailand’s export orientation and the importance of reputational effects, inter-sectoral leverage, mainly through the US TIP Reports and the EU carding decision, emerged as a very powerful channel of influence on priority setting, as it indirectly affected the migrant health insurance through efforts aimed at dealing with problems of human trafficking in the context of labour migration, especially after the 2014 coup d'état. This study helps understand the changed role external actors can play in filling health system gaps in aid-independent countries.
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Khan MS, Bory S, Rego S, Suy S, Durrance-Bagale A, Sultana Z, Chhorn S, Phou S, Prien C, Heng S, Hanefeld J, Hasan R, Saphonn V. Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries? HUMAN RESOURCES FOR HEALTH 2020; 18:10. [PMID: 32046723 PMCID: PMC7014603 DOI: 10.1186/s12960-020-0452-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/30/2020] [Indexed: 05/06/2023]
Abstract
BACKGROUND Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. METHODS We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. RESULTS Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. CONCLUSIONS In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.
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Affiliation(s)
- Mishal S Khan
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
- Aga Khan University, Karachi, Pakistan.
| | - Sothavireak Bory
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | - Sonia Rego
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Sovanthida Suy
- Department of Public Health, University of Health Sciences, Phnom Penh, Cambodia
| | - Anna Durrance-Bagale
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | | | | | - Socheata Phou
- Department of Public Health, University of Health Sciences, Phnom Penh, Cambodia
| | - Chanra Prien
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | | | - Johanna Hanefeld
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom
| | - Rumina Hasan
- Aga Khan University, Karachi, Pakistan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Khan M. Pakistan's children need better protection by the health-care system. Lancet 2020; 395:185. [PMID: 31954455 DOI: 10.1016/s0140-6736(19)33219-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/20/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Mishal Khan
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
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Combating Antimicrobial Resistance in Singapore: A Qualitative Study Exploring the Policy Context, Challenges, Facilitators, and Proposed Strategies. Antibiotics (Basel) 2019; 8:antibiotics8040201. [PMID: 31671826 PMCID: PMC6963657 DOI: 10.3390/antibiotics8040201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 11/16/2022] Open
Abstract
Antimicrobial resistance (AMR) is a global public health threat that warrants urgent attention. However, the multifaceted nature of AMR often complicates the development and implementation of comprehensive policies. In this study, we describe the policy context and explore experts' perspectives on the challenges, facilitators, and strategies for combating AMR in Singapore. We conducted semi-structured interviews with 21 participants. Interviews were transcribed verbatim and were analyzed thematically, adopting an interpretative approach. Participants reported that the Ministry of Health (MOH) has effectively funded AMR control programs and research in all public hospitals. In addition, a preexisting One Health platform, among MOH, Agri-Food & Veterinary Authority (restructured to form the Singapore Food Agency and the Animal & Veterinary Service under NParks in April 2019), National Environment Agency, and Singapore's National Water Agency, was perceived to have facilitated the coordination and formulation of Singapore's AMR strategies. Nonetheless, participants highlighted that the success of AMR strategies is compounded by various challenges such as surveillance in private clinics, resource constraints at community-level health facilities, sub-optimal public awareness, patchy regulation on antimicrobial use in animals, and environmental contamination. This study shows that the process of planning and executing AMR policies is complicated even in a well-resourced country such as Singapore. It has also highlighted the increasing need to address the social, political, cultural, and behavioral aspects influencing AMR. Ultimately, it will be difficult to design policy interventions that cater for the needs of individuals, families, and the community, unless we understand how all these aspects interact and shape the AMR response.
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