Addressing antimicrobial resistance by improving access and quality of care - A review of the literature from East Africa

Universal access to healthcare, including quality medicines, is a fundamental human right but is still out of reach for many in low- and middle-income countries (LMICs). An existing framework capturing variability of access to healthcare in low-resource settings includes the 5 dimensions: availability, accessibility, affordability, adequacy, and acceptability. This framework encompasses key components, including health infrastructure and means to access it as well as service organisation, costs, and factors that influence users’ satisfaction. However, in reality, the effectiveness of accessed healthcare is measured by the likelihood of a positive outcome. We therefore propose an expansion of this framework to include an additional dimension, “aspects of quality,” incorporating quality, which critically influences the ability of the accessed services to generate optimal health outcomes. Within this framework, we explore literature from East Africa likely relevant to a range of LMIC contexts, mainly focusing on the provision of widely used antimicrobials such as antimalarials and antibiotics. We argue that major inadequacies exist across all 6 dimensions of access and quality of drugs and their provision. While the global focus is on curbing excessive antimicrobial use to tackle the antimicrobial resistance (AMR) crisis, major constraints around access shape patients’ health-seeking decisions leading to potentially problematic practices that might exacerbate the AMR problem. We advocate for a holistic approach to tackling these inadequacies, encompassing all dimensions of access and quality of healthcare in order to improve health outcomes while simultaneously counteracting the AMR crisis

A Digital One Health framework to integrate data for public health decision-making

The current implementation of One Health (OH) primarily focuses on multi-sectoral collaboration but often overlooks opportunities to integrate contextual and pathogen-related data into a unified data resource. This lack of integration hampers effective, data-driven decision-making in OH activities. In this perspective, we examine the existing strategies for data sharing and identify gaps and barriers to integration. To overcome these challenges, we propose the Digital OH (DOH) framework for data integration, which consolidates data-sharing principles within five pillars for the OH community of practice: (a) Harmonization of standards to establish trust, (b) Automation of data capture to enhance quality and efficiency, (c) Integration of data at point of capture to limit bureaucracy, (d) Onboard data analysis to articulate utility, and (e) Archiving and governance to safeguard the OH data resource. We discuss an upcoming pilot program as a use case focusing on antimicrobial resistance surveillance to illustrate the application of this framework. Our ambition is to leverage technology to create data as a shared resource using DOH not only to overcome current structural barriers but also to address prevailing ethical and legal concerns. By doing so, we can enhance the efficiency and effectiveness of decision-making processes in the OH community of practice, at a national, regional, and international level

How public health crises expose systemic, day-to-day health inequalities in low- and-middle income countries: an example from East Africa

Background: The current Coronavirus disease pandemic reveals political and structural inequities of the world’s poorest people who have little or no access to health care and yet the largest burdens of poor health. This is in parallel to a more persistent but silent global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania. Methods: We conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences. Results: Three interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals. Conclusion: Entanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in ‘normal’ circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges