Understanding health system linkages: Formative research to develop strategies to support quality improvement in treatment in the private sector
Lead Research Organisation:
London School of Hygiene & Tropical Medicine
Department Name: Infectious and Tropical Diseases
Abstract
Prompt antibiotic therapy for an infected patient can make the difference between cure and death or long-term disability. Unfortunately, all around the world, some infections are becoming resistant to the antibiotic medicines used to treat them. This could lead to a future scenario in which illnesses last longer, deaths increase, and the cost of treatment rises. Under this scenario, the greatest impacts are likely to be felt in low-income countries where infectious diseases are most common and many families lack financial security. Antibiotic resistance is now considered to be one of the biggest threats to global health. The World Health Organization has called for urgent action, research and investment to counter this threat, through the development of new antimicrobial drugs and through more responsible use of existing drugs. In September 2016, global leaders met at the UN General Assembly - only the fourth time in the history of the UN that a health topic was discussed at the General Assembly - to call for concerted action by every national government to limit the development and spread of drug resistance.
Poor prescription practices by health workers, such as overuse of drugs, sale of partial doses, or non-adherence by patients to the full treatment course, all create situations which are conducive to the selection and spread of resistant mutations. Health workers and pharmacists can help tackle resistance by only dispensing antibiotic drugs when they are truly needed; and by prescribing the right drug in the right quantities to treat the illness. Improving the use of antibiotic medicines thus ultimately involves guiding the treatment decisions made by health workers and patients to discourage indiscriminate use. Therefore, if effective intervention strategies are to be developed, better knowledge and understanding of the factors that influence the prescribing practices of health workers will be essential.
The private sector plays an important role in provision of health care in many African countries, with many patients seeking care from private clinics and drug shops, and cannot be overlooked in strategies to control misuse of antibiotics. Neither can treatment practices and standards be addressed by focusing on one sector in isolation. The private sector interacts with, and is shaped by the organisation and performance of the public sector, demand from patients and regulatory controls. Poor practices in one sector can easily undermine or disincentivize behavioural change in another. Yet regulation of the private sector is an acknowledged weakness of the health system in many low income countries.
The proposed research aims to address this challenge. We shall investigate the situations, norms, experiences, and motivations that affect health care practices in private clinics and drug shops in rural Uganda, including the influence of interactions between private providers, government health workers and public health officials, in order to generate improved understandings of how the health system can more effectively control treatment practices, and improve the quality of care that patients receive from private providers.
We intend to use the knowledge and insights gained from this research to develop a comprehensive intervention strategy to improve patient care and combat irresponsible use of antibiotics in private clinics and drug shops in Uganda. This intervention strategy will be tested in future studies. We hope that our findings will also be of value to Ministries of Health and national governments in other low-income countries, and can be used to help inform the development of national plans to counter the threat of antimicrobial resistance.
Poor prescription practices by health workers, such as overuse of drugs, sale of partial doses, or non-adherence by patients to the full treatment course, all create situations which are conducive to the selection and spread of resistant mutations. Health workers and pharmacists can help tackle resistance by only dispensing antibiotic drugs when they are truly needed; and by prescribing the right drug in the right quantities to treat the illness. Improving the use of antibiotic medicines thus ultimately involves guiding the treatment decisions made by health workers and patients to discourage indiscriminate use. Therefore, if effective intervention strategies are to be developed, better knowledge and understanding of the factors that influence the prescribing practices of health workers will be essential.
The private sector plays an important role in provision of health care in many African countries, with many patients seeking care from private clinics and drug shops, and cannot be overlooked in strategies to control misuse of antibiotics. Neither can treatment practices and standards be addressed by focusing on one sector in isolation. The private sector interacts with, and is shaped by the organisation and performance of the public sector, demand from patients and regulatory controls. Poor practices in one sector can easily undermine or disincentivize behavioural change in another. Yet regulation of the private sector is an acknowledged weakness of the health system in many low income countries.
The proposed research aims to address this challenge. We shall investigate the situations, norms, experiences, and motivations that affect health care practices in private clinics and drug shops in rural Uganda, including the influence of interactions between private providers, government health workers and public health officials, in order to generate improved understandings of how the health system can more effectively control treatment practices, and improve the quality of care that patients receive from private providers.
We intend to use the knowledge and insights gained from this research to develop a comprehensive intervention strategy to improve patient care and combat irresponsible use of antibiotics in private clinics and drug shops in Uganda. This intervention strategy will be tested in future studies. We hope that our findings will also be of value to Ministries of Health and national governments in other low-income countries, and can be used to help inform the development of national plans to counter the threat of antimicrobial resistance.
Technical Summary
Qualitative research with a specific focus on antibiotic treatment will be used to shed light on broader processes affecting quality of care in private clinics and drug shops in Uganda. Through improved understandings of how health system factors can be instrumental in shaping treatment practices by small-to-medium sized private providers (SMPPs), the study will generate novel insights on how health system levers could be used more effectively to (i) support and improve quality of care in the private sector, and (ii) promote responsible prescribing and use of antibiotics in Uganda and other low income settings.
The study aims to provide evidence relevant for strategy development in four main areas:
1) Regulation of SMPPs, and improved understandings of the opportunities, challenges, and consequences for the health system.
2) Design of interventions to improve quality of care in SMPPs (provider training/CPD, accreditation, social franchising)
3) Strengthening of linkages between private providers and public health workers, public health officials and regulators to foster partnership, oversight and knowledge exchange
4) Refinement of Uganda's first National Action Plan for Antimicrobial Resistance, and development of specific policies and interventions deriving from the Plan.
This knowledge will be timely for strategic planning by the Ministry to Health to develop its national plan to counter antimicrobial resistance. The study will also identify opportunities to build synergy across sectors, inform current debates on the role of the private sector in healthcare provision in Uganda, and help shape models for future implementation.
The findings will be used to engage with local stakeholders to co-design a comprehensive strategy to promote responsible prescribing and use of antimicrobials, and support quality improvement in health care services in SMPPs in Uganda. Evaluation of this intervention strategy will form the basis of a future grant application.
The study aims to provide evidence relevant for strategy development in four main areas:
1) Regulation of SMPPs, and improved understandings of the opportunities, challenges, and consequences for the health system.
2) Design of interventions to improve quality of care in SMPPs (provider training/CPD, accreditation, social franchising)
3) Strengthening of linkages between private providers and public health workers, public health officials and regulators to foster partnership, oversight and knowledge exchange
4) Refinement of Uganda's first National Action Plan for Antimicrobial Resistance, and development of specific policies and interventions deriving from the Plan.
This knowledge will be timely for strategic planning by the Ministry to Health to develop its national plan to counter antimicrobial resistance. The study will also identify opportunities to build synergy across sectors, inform current debates on the role of the private sector in healthcare provision in Uganda, and help shape models for future implementation.
The findings will be used to engage with local stakeholders to co-design a comprehensive strategy to promote responsible prescribing and use of antimicrobials, and support quality improvement in health care services in SMPPs in Uganda. Evaluation of this intervention strategy will form the basis of a future grant application.
Planned Impact
Antimicrobial resistance is recognized as one of the greatest threats facing global health, with potential to endanger human development across the world. WHO has called for urgent public health action, research and investment to counter this threat. In Sept 2016, global leaders met at the United Nations General Assembly to commit to fighting antimicrobial resistance together - only the fourth time in the history of the UN that a health topic has been discussed at the General Assembly. National authorities, including UK government agencies, are committing significant resources to battling the threat of antimicrobial resistance both at home and abroad. Research on how to contain the emergence and spread of antimicrobial resistance, generating evidence that can be translated into immediate and concrete public health actions, is urgently needed by policy makers and national health authorities.
This study will provide policy-relevant evidence on how health system factors influence and shape antibiotic prescription and use in private health care settings, and how interconnections between private providers and the wider health system affect treatment practices. Specifically, the results will shed light on how health system levers could be used more effectively, thereby helping inform development of workable solutions to reduce misuse of antimicrobials. Results will also provide insights into the role of the private sector in healthcare provision in Uganda and other low-income countries in sub-Saharan Africa, and help shape models for future implementation.
The research findings should be of interest to a wide audience, with potential for both immediate and longer-term public health impact in two ways:
1) Of immediate relevance, from early 2017, Uganda is expected to benefit from a large, sustained investment (to be publicly announced in the later part of January) in surveillance and other control measures to address antimicrobial resistance. Coupled with the development of Uganda's first National Action Plan for Antimicrobial Resistance, prompted by the WHO and currently underway (led by the Ugandan co-PI on this application, Dr A Mbonye), this opportunity both increases the urgency for good-quality evidence on factors that affect antimicrobial use, and enhances the potential benefit of the proposed research by providing a ready space for application of findings. In turn, results from formative research, and subsequent interventions and evaluations in Uganda, will also be valuable for work in other countries with similar health care systems and challenges.
2) The research will expand the limited evidence base on regulatory mechanisms to improve treatment practices amongst private providers. There is as yet a limited body of research on how the private sector can be harnessed to effectively advance public health goals, although there is growing interest amongst researchers, policy makers and donors in developing new models of working with SMPPs (such as franchising systems and accreditation schemes). Improved understanding of the factors which shape and control provider behaviour could be particularly valuable in informing the design of future interventions.
The research has relevance for:
Health service delivery: The most important impact will be to provide evidence to inform the development of intervention strategies to improve prescribing behavior and promote responsible use of antibiotics and other medicines, within a broader context of strategies which seek to expand access to treatment services through use of retail drug shops.
Policy and strategy: The evidence generated will enable policy makers at national, regional and international levels to better evaluate the feasibility, strengths and limitations of different interventions aimed at improving quality of treatment in the private sector. Policy makers will also be able to better assess the role of the private sector in stewardship of antimicrobials
This study will provide policy-relevant evidence on how health system factors influence and shape antibiotic prescription and use in private health care settings, and how interconnections between private providers and the wider health system affect treatment practices. Specifically, the results will shed light on how health system levers could be used more effectively, thereby helping inform development of workable solutions to reduce misuse of antimicrobials. Results will also provide insights into the role of the private sector in healthcare provision in Uganda and other low-income countries in sub-Saharan Africa, and help shape models for future implementation.
The research findings should be of interest to a wide audience, with potential for both immediate and longer-term public health impact in two ways:
1) Of immediate relevance, from early 2017, Uganda is expected to benefit from a large, sustained investment (to be publicly announced in the later part of January) in surveillance and other control measures to address antimicrobial resistance. Coupled with the development of Uganda's first National Action Plan for Antimicrobial Resistance, prompted by the WHO and currently underway (led by the Ugandan co-PI on this application, Dr A Mbonye), this opportunity both increases the urgency for good-quality evidence on factors that affect antimicrobial use, and enhances the potential benefit of the proposed research by providing a ready space for application of findings. In turn, results from formative research, and subsequent interventions and evaluations in Uganda, will also be valuable for work in other countries with similar health care systems and challenges.
2) The research will expand the limited evidence base on regulatory mechanisms to improve treatment practices amongst private providers. There is as yet a limited body of research on how the private sector can be harnessed to effectively advance public health goals, although there is growing interest amongst researchers, policy makers and donors in developing new models of working with SMPPs (such as franchising systems and accreditation schemes). Improved understanding of the factors which shape and control provider behaviour could be particularly valuable in informing the design of future interventions.
The research has relevance for:
Health service delivery: The most important impact will be to provide evidence to inform the development of intervention strategies to improve prescribing behavior and promote responsible use of antibiotics and other medicines, within a broader context of strategies which seek to expand access to treatment services through use of retail drug shops.
Policy and strategy: The evidence generated will enable policy makers at national, regional and international levels to better evaluate the feasibility, strengths and limitations of different interventions aimed at improving quality of treatment in the private sector. Policy makers will also be able to better assess the role of the private sector in stewardship of antimicrobials
Organisations
- London School of Hygiene & Tropical Medicine (Lead Research Organisation)
- University of Glasgow (Collaboration)
- Makerere University (Collaboration)
- Universidad Antonio Nariño (Collaboration)
- Royal Veterinary College (RVC) (Collaboration)
- London School of Hygiene and Tropical Medicine (LSHTM) (Collaboration)
- Makerere University College of Health Sciences (Collaboration)
- West Bengal University of Animal and Fishery Sciences (Collaboration)
- UNIVERSITY OF LEEDS (Collaboration)
Publications
Myers J
(2022)
Crossover-Use of Human Antibiotics in Livestock in Agricultural Communities: A Qualitative Cross-Country Comparison between Uganda, Tanzania and India.
in Antibiotics (Basel, Switzerland)
McCubbin KD
(2021)
Unsafe "crossover-use" of chloramphenicol in Uganda: importance of a One Health approach in antimicrobial resistance policy and regulatory action.
in The Journal of antibiotics
Kielmann K
(2022)
Health systems performance or performing health systems? Anthropological engagement with health systems research.
in Social science & medicine (1982)
Hutchinson E
(2022)
Life in the buffer zone: Social relations and surplus health workers in Uganda's medicines retail sector.
in Social science & medicine (1982)
Hutchinson E
(2023)
Is it possible for drug shops to abide by the formal rules? The structural determinants of community medicine sales in Uganda.
in BMJ global health
Hutchinson E
(2024)
The paradoxical surplus of health workers in Africa: The need for research and policy engagement.
in The International journal of health planning and management
Hutchinson E
(2019)
We Need to Talk About Corruption in Health Systems.
in International journal of health policy and management
Hutchinson E
(2020)
Beyond Talking: We Need Effective Measures to Tackle Systemic Corruption and the Power That Allows It to Persist in Health Systems; A Response to Recent Commentaries.
in International journal of health policy and management
Description | Antibiotic stewardship in agricultural communities in Africa and Asia: A unified One Health strategy to optimise antibiotic use in animals and humans |
Amount | £129,456 (GBP) |
Funding ID | EP/T02500X/1 |
Organisation | Engineering and Physical Sciences Research Council (EPSRC) |
Sector | Public |
Country | United Kingdom |
Start | 05/2020 |
End | 05/2022 |
Description | CGIAR Agriculture for Nutrition and Health research programme (small grants) |
Amount | $4,000 (USD) |
Organisation | CGIAR |
Sector | Charity/Non Profit |
Country | France |
Start | 05/2019 |
End | 09/2019 |
Description | CGIAR Agriculture for Nutrition and Health research programme (small grants) |
Amount | £5,000 (GBP) |
Organisation | CGIAR |
Sector | Charity/Non Profit |
Country | France |
Start | 03/2018 |
End | 08/2018 |
Description | Ensuring access to health care and medicines during COVID-19: critical challenges and feasible policy options for the medicines retail sector |
Amount | £373,551 (GBP) |
Funding ID | MR/V035592/1 |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 11/2020 |
End | 04/2023 |
Description | Improving Practice in Ugandan drug shops: a holistic approach to regulation |
Amount | £136,587 (GBP) |
Funding ID | MR/X503010/1 |
Organisation | Medical Research Council (MRC) |
Sector | Public |
Country | United Kingdom |
Start | 12/2022 |
End | 05/2024 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | London School of Hygiene and Tropical Medicine (LSHTM) |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | Makerere University |
Department | School of Public Health |
Country | Uganda |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | Makerere University College of Health Sciences |
Country | Uganda |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | Royal Veterinary College (RVC) |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | Universidad Antonio Nariño |
Country | Colombia |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | University of Glasgow |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | International network of researchers working on antibiotic stewardship using a One Health approach (Colombia, India, Pakistan, Tanzania, Uganda, UK) |
Organisation | West Bengal University of Animal and Fishery Sciences |
Country | India |
Sector | Academic/University |
PI Contribution | I am co-PI (together with Meenakshi Gautham, LSHTM) for this GCRF Cluster award. The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. The work of the cluster is co-ordinated by myself and my research team at LSHTM. The cluster launched during the COVID-19 pandemic and all international research workshops to date have been virtual. |
Collaborator Contribution | The AgriAMU Cluster, launched in 2020, brings together a set of six GCRF-funded projects examining antibiotic stewardship in agricultural communities in Africa and Asia. Lead researchers from these six projects meet regularly to share findings and insights gained from their work, to make cross-country comparisons, to identify and critically examine common challenges to antibiotic stewardship in animals and humans, and to apply a One Health approach in developing a common framework for addressing these challenges, suited for use in agricultural communities in low-middle income countries. |
Impact | This is a multidisciplinary collaboration including the following disciplines: epidemiology, anthropology, health economics, health systems and policy research, public health, biomedicine and veterinary medicine. Members of the cluster have collaborated on two peer-reviewed articles to date (both accepted for publication in early 2021). Further cross-country collaborative outputs are in process. |
Start Year | 2020 |
Description | Mentor in the Chorus consortium (FCDO funded project) |
Organisation | University of Leeds |
Department | Faculty of Medicine and Health |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | I am a mentor on a CHORUS funded project. |
Collaborator Contribution | I have presented our work on the medicines retail sector to the CHORUS group and will support a project that seeks to understand children's access to care and forms of care seeking in a pluralistic health system in Enugu, Nigeria. |
Impact | No outcomes yet |
Start Year | 2023 |
Description | Research collaboration with researchers in veterinary medicine to compare antibiotic use amongst humans and animals, retail sector supply and regulatory systems for human and veterinary medicines in Uganda |
Organisation | Royal Veterinary College (RVC) |
Department | One Health (Infectious Diseases) |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Supervision of MSc students to support data collection in Uganda, data analysis and interpretation, and preparation of manuscripts for submission to peer-reviewed journals; Ongoing discussions to identify research priorities and funding opportunities arising from these research findings. This collaboration was further strengthened and expanded through the award of the subsequent GCRF grant which culminated in an international workshop hosted in Uganda in March 2022, which brought together researchers working with human and veterinary medicine providers in India, Bangladesh, Tanzania, Brazil, Colombia and Uganda; using a One Health approach to bear on the common issue of antimicrobial stewardship amongst medicine providers in agricultural communities, to share experience, insights and solutions across countries; and a subsequent follow-up international workshop held in London in March 2023 to further develop a One Health antimicrobial stewardship framework. |
Collaborator Contribution | Joint supervision of MSc students to support data analysis and interpretation, and preparation of manuscripts for submission to peer-reviewed journals; Ongoing discussions to identify research priorities and funding opportunities arising from these research findings. Researchers shared their experience, insights and One Health-informed solutions in working to improve antimicrobial stewardship amongst human and veterinary medicine providers in agricultural communities, with researchers working on similar issues from India, Bangladesh, Uganda, Tanzania, Brazil, Colombia. . |
Impact | A poster was presented at launch of CGIAR Agriculture for Nutrition and Health Antimicrobial Resistance (AMR) Hub at the International Livestock Research Institute in Nairbi, Kenya in February 2019. https://www.cgiar.org/news-events/news/launching-today-cgiar-antimicrobial-resistance-hub A number of manuscripts are in preparation. Multidisciplinary - public health epidemiology, veterinary medicine, anthropology, chemistry (drug quality). |
Start Year | 2018 |
Description | Research collaboration with respect to private health care providers in Uganda |
Organisation | Makerere University |
Country | Uganda |
Sector | Academic/University |
PI Contribution | Intellectual input, including expertise in epidemiology, public health research, health system research, health economics, anthropology, intervention trials and research methods This collaboration was expanded through the award of the subsequent GCRF grant in 2020 which culminated in an international workshop hosted in Uganda in March 2022, which brought together researchers working with human and veterinary medicine providers in India, Bangladesh, Tanzania, Brazil, Colombia and Uganda; using a One Health approach to bear on the common issue of antimicrobial stewardship amongst medicine providers in agricultural communities, to share experience, insights and solutions across countries. This was subsequently followed a second international workshop held in London in March 2023 to further develop the One Health antimicrobial stewardship framework created in Uganda. The collaboration has been strengthened further by a series of UKRI grants led by Dr Eleanor Hutchinson from LSHTM and Dr Freddy Kitutu from Makerere University in 2022 and 2023 to conduct further research into the medical retail sector (drug shops, pharmacies and clinics) |
Collaborator Contribution | Intellectual input, including expertise in public health research, health system research, intervention trials and research methods Experience in conducting research in low-income settings New collaborations with researchers with expertise in One Health added in 2018. Makerere University has run a series of webinars and stakeholder workshops to engage Ministry of Health and other national partners in discussing the findings from our research (2020 - 2024) Makerere University organised and hosted an international workshop in March 2022, at which researchers shared their experience, insights and One Health-informed solutions in working to improve antimicrobial stewardship amongst human and veterinary medicine providers in agricultural communities in Uganda, with researchers working on similar issues from India, Bangladesh, Uganda, Tanzania, Brazil, and Colombia. |
Impact | Hansen KS, Clarke SE, Lal S, Magnussen P & Mbonye AK. (2017) Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda. PLoS One; 12(12): e0189758. Bruxvoort KJ, Leurent B, Chandler CI, Ansah EK, Baiden F, et al. (2017) The impact of introducing malaria rapid diagnostic tests on fever case management: a synthesis of ten studies from the ACT consortium. Am J Trop Med Hyg. 97(4): 1170-1179. Hopkins H, Bruxvoort KJ, Cairns ME, Chandler CI, Leurent B, et al. (2017). Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings. BMJ; 356: j1054. Lalani M, Kitutu FE, Clarke SE & Kaur H. (2017) Antimalarial medicine quality field studies and surveys: a systematic review of screening technologies used and reporting of findings. Malaria Journal; 16(1): 197. Buregyeya E, Rutebemberwa E, LaRussa P, Lal S, Clarke SE, Hansen KS, Magnussen P & Mbonye AK. (2017). Comparison of the capacity between public and private health facilities to manage under-five children with febrile illnesses in Uganda. Malaria Journal; 16(1): 183. Mbonye AK, Buregyeya E, Rutebemberwa, E, Clarke SE, Lal S, Hansen KS, Magnussen P & LaRussa P. (2017) Referral of children seeking care at private health facilities in Uganda. Malaria Journal; 16(1): 76. Visser T, Bruxvoort K, Maloney K, Leslie T, Barat LM, et al. (2017) Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review. PLoS One; 12(3): e0173093 Burchett HE, Leurent B, Baiden F, Baltzell K, Björkman A, et al. (2017) Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open; 7(3): e012973 Hutchinson E, Hutchison C, Lal S, Hansen SC, Kayendeke M, Nabirye C, Magnussen P, Clarke SE, Mbonye A, Chandler C. (2017) Introducing rapid diagnostic tests for malaria into the retail sector: What are the unintended consequences? BMJ Global Health, 2: e000067 Mbonye AK, Buregyeya E, Rutebemberwa E, Clarke SE, Lal S, Hansen KS, Magnussen P, LaRussa P. (2016) Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety: a cross-sectional survey in the private sector in Uganda. BMJ Open, 6: e010632. Rutebemberwa E, Buregyeya E, Lal S, Clarke SE, Hansen KS, Magnussen P, LaRussa P & Mbonye AK. (2016) Assessing the potential of rural and urban private facilities in implementing child health interventions in Mukono district, central Uganda-a cross sectional study. BMC Health Services Research, 16:268 Mbonye AK, Buregyeya E, Rutebemberwa E, Clarke SE, Lal S, Hansen KS, Magnussen P & LaRussa P. (2016) Treatment and prevention of malaria in pregnancy in the private health sector in Uganda: implications for patient safety. Malaria J, 15(1):212 Mbonye A, Clarke S, Lal S, Chandler C, Hutchinson E, Hansen KS & Magnussen P. (2015). Introducing rapid diagnostic tests for malaria into registered drug shops in Uganda: lessons learned and policy implications. Malaria Journal 14: 448 Hutchinson E, Chandler C, Clarke SE, Lal S, Magnussen P, Kayendeke M, Nabirye C, Kizito J & Mbonye AK. (2015) "It puts life in us and we feel big": Shifts in the local health care system during the introduction of rapid diagnostic tests for malaria into drug shops in Uganda. Critical Public Health 25 (1): 48-62 Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C & Clarke SE. (2015). A cluster randomised trial introducing rapid diagnostic tests into registered drug shops in Uganda: Impact on appropriate treatment of malaria. PLoS One 10 (7): e0129545 |
Start Year | 2015 |
Description | Blog on regulation of private drug shops |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | "Regulating medicine markets in Uganda: Do developments in anti-corruption research provide a solution?" - a blog written in December 2020 for Health Systems Global (HSG) to highlight issues that influence quality of care in settings where government regulation of the private sector is weak. HSG is a diverse, global membership organization of researchers, decision-makers and implementers who are dedicated to promoting health policy and systems research and knowledge generation; with more than 1,600 members in over 110 countries |
Year(s) Of Engagement Activity | 2020 |
URL | https://healthsystemsglobal.org/news/regulating-medicine-markets-in-uganda-do-developments-in-anti-c... |
Description | Blog on role of drug shops in COVID-19 pandemic response |
Form Of Engagement Activity | Engagement focused website, blog or social media channel |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | "Tackling COVID-19 in Uganda: private medicine outlets at the frontline" - a blog written in April 2020 for Health Systems Global (HSG) to highlight the role of drug shops in responding to the COVID-19 pandemic in low-middle income countries. HSG is a diverse, global membership organization of researchers, decision-makers and implementers who are dedicated to promoting health policy and systems research and knowledge generation; with more than 1,600 members in over 110 countries |
Year(s) Of Engagement Activity | 2020 |
URL | https://healthsystemsglobal.org/news/tacking-covid-19-in-uganda-private-medicine-outlets-at-the-fron... |
Description | Online meetings with the World Health Organization (HRH department) and the International Labour Organization about the work on formally trained health workers working either informally in formal health systems or in informal settings (such as medicine markets in Uganda) |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Other audiences |
Results and Impact | We had a series of meetings with representatives from the International Labour Organization and the World Health Organisation on how to measure and to know about the everyday livelihood strategies of formally trained health workers who are unable to find formal work in the health system. This included discussions about drug shop vendors in Uganda and 'volunteer' health workers in Nigeria. These talks have led to a recognition of the need for more qualitative and quantitative data on these individuals and a need to conceptualise the informal or shadow health system that operates in many countries. |
Year(s) Of Engagement Activity | 2023,2024 |
Description | Presentation at International symposium - Health Systems Global 2020 |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | A presentation in February 2021 on "Rule breaking and rent seeking in drug shops: what space is there for reform?" as part of a panel discussion on "Identifying and addressing conflicts of interest that hinder improvements in quality of private healthcare in low and middle income countries" at the 6th Health Systems Global Symposium "Re-imagining health systems for better health and social justice" - a biannual event attended by health systems researchers, policymakers, funders, implementers, civil society and other stakeholders from relevant national and regional agencies, associations and professional organizations. This year sessions were virtual attracting a large global audience. |
Year(s) Of Engagement Activity | 2021 |
URL | https://hsr2020.healthsystemsresearch.org/ |
Description | Stakeholder workshop with Ministry of Health - February 2022 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | At the request of the Ministry of Health to set up a regular forum to share emerging research findings and strengthen the dialogue and engagement between researchers, public health officials and other stakeholders in the medical retail sector, we held a series of webinars in June/July 2021 and two stakeholder workshops in October 2021 and February 2022. The third workshop, a three-day meeting held on 22-24 February 2022, built upon the issues explored in the earlier meetings, but focussed primarily on the impact of the COVID-19 pandemic on health care delivery, and role of the medical retail sector during moments of health system crisis. The workshop was convened by the Commissioner of Health Services, Ministry of Health, Uganda in collaboration with health systems researchers based at Makerere University, Uganda and London School of Hygiene & Tropical Medicine, UK. Attendees were the same stakeholders as had participated in the 2021meetings, including Ministry of Health officials, drug regulators, professional councils, practitioners and other stakeholders in the retail sector. The aim of the workshop was to present new findings on the impact of the COVID-19 pandemic, national lockdown and travel restrictions in Uganda on access to treatment services in the public and private sectors (government health facilities, private clinics, drug shops and pharmacies); funded under a GECO grant (ref no. MR/V035592/1). Building upon discussions started in the previous meetings, participants then addressed three questions: (1) How can we make more effective use of clinics, pharmacies and drug shops during future pandemics? (2) How can we ensure that they continue to provide access to life-saving commodities during 'shocks' including epidemics and pandemics? and (3) Who should take the lead (which actors and organisations) in developing those changes to ensure continued access to medicines via the MRS during epidemic 'shocks' and other crises in the health system. A number of key recommendations were made, and a formal report is currently being prepared for consideration by the relevant committees within the Ministry of Health. |
Year(s) Of Engagement Activity | 2022 |
Description | Stakeholder workshop with Ministry of Health - October 2021 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | Following an earlier webinar series held during the period of national lockdown in June/July 2021, we were requested by the Ministry of Health to set up a regular forum to share emerging research findings and strengthen the dialogue and engagement between researchers, public health officials, drug regulators, professional councils, practitioners and other stakeholders in the medical retail sector. With the lifting of travel restrictions in late 2021, it was possible to respond to this request and to organise the first of two further in-person workshops, in October 2021. This format was much better suited to participatory group work needed to debate and probe issues, negotiate solutions and advance collaboration between stakeholders with diverse interests, operating in a highly-contested space. This two-day workshop was convened by the Commissioner of Health Services, Ministry of Health, Uganda in collaboration with health systems researchers based at Makerere University, Uganda and London School of Hygiene & Tropical Medicine, UK. The aim of the workshop was to serve as a stimulus for debate on how the medical retail sector in Uganda could be strengthened and improved. The workshop opened by presenting evidence on some of the challenges seen in the medical retail sector in Uganda, including: shortages and surpluses within the health workforce; issues of regulation, corruption, perverse incentives and saturated markets; antimicrobial resistance, crossover-use of antibiotics; substandard medicines; and problems of accessing medicines during the COVID-19 pandemic. Drawing on their own experience, participants were encouraged to identify and rank the main challenges currently facing the medical retail sector in Uganda, and worked together to identify potential solutions to address the two top-priorities. Participants have since reported that the series of policy-oriented research webinars and participatory workshop has led to an increased understanding and appreciation of the role of different stakeholders within the health system, a recognition of mutual interests and common concerns, and resulted in more positive relationships and interactions between regulators and private sector practitioners, than experienced hitherto. It is hoped that this has opened the door and laid the foundation for meaningful policy change going forward. |
Year(s) Of Engagement Activity | 2021 |
Description | Stakeholder workshop with Ministry of Health, Uganda - March 2023 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | A participatory workshop was held on 2-3 March 2023, to discuss "critical challenges and feasible policy options for the Medicines Retail Sector in Uganda". This workshop formed the culminating part of a series of workshops held throughout 2021-23, to build bridges and foster the co-design of interventions with relevant stakeholders from the medical retail sector and national regulators with the aim of strengthening the involvement of private practitioners in public health policy with the ultimate goal of improving treatment practices at point-of-care. Presentations included findings from an international multi-country analysis of crossover-use of antibiotics obtained from human and veterinary medicine retailers in Uganda, Tanzania and India. There was been strong interest in these workshops, with high attendance, and open and frank discussions amongst a diverse set of stakeholders. |
Year(s) Of Engagement Activity | 2023 |
Description | Webinar for the Health Systems Global Technical working group on Action on Accountability and Anti-corruption on 'Unemployed, unpaid health workers in Africa: governance, accountability and the informalization of health systems in Nigeria, Uganda and Sierra Leone |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Other audiences |
Results and Impact | I organised a 1.5 hour webinar that drew together a group of researchers working on unemployed and underemployed health workers in Uganda, Nigeria and Sierra Leone. We had a series of presentations on the work that unemployed health workers undertake and then and question and answer session. The session was tweeted widely and representatives from Universities and the United Nations among others joined the debate. |
Year(s) Of Engagement Activity | 2024 |
URL | https://healthsystemsglobal.org/thematic-groups/action-on-accountability-and-anti-corruption-for-sdg... |
Description | Webinar series with Ministry of Health - June/July 2021 |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | National |
Primary Audience | Policymakers/politicians |
Results and Impact | A series of five half-day webinars were held in June-July 2021 to share and review research findings on the "Medical Retail Sector in Uganda: An overview of current challenges and policy options" with Ministry of Health officials, drug regulators, professional councils, practitioners and other stakeholders in the medical retail sector. Originally this has been planned as a stakeholder consultation workshop, to be held in-person, but due to national lockdown and travel restrictions in Uganda and UK, was shifted online. The meeting was convened by the Commissioner of Health Services, Ministry of Health, Uganda in collaboration with health systems researchers based at Makerere University, Uganda and London School of Hygiene & Tropical Medicine, UK. The aim of the webinar series was to update professionals on policy-relevant research findings and to serve as a stimulus for debate on how the medical retail sector in Uganda could be strengthened and improved. The medical retail sector plays a critical role in access to treatment services in Uganda, for example, serving at the first point of care for over 60% of episodes of fever in children. Evidence presented during the the five seminars included: (ii) the role of the medical retail sector within the Ugandan health system and how that has changed over time; (ii) response to the challenges of antimicrobial resistance (AMR) and COVID-19 to service delivery; (iii) interventions to support antimicrobial stewardship in the retail sector; (iv) policy options to regulate and encourage quality improvement in service provision and (v) vulnerabilities and resilience within the medical retail sector: and what we can learn from COVID-19 pandemic. The webinars were well attended, with over 80 participants online, throughout the series; and generated lively debates at the end of each session. At the end of the webinar series, we were requested by the Ministry of Health to set up a regular forum to share emerging research findings and strengthen the dialogue and engagement between public health officials and researchers. With the lifting of travel restrictions in late 2021, it was possible to respond to this request and to organise two further in-person workshops, in October 2021 and February 2022. This format was much better suited to participatory group work needed to debate and probe issues, negotiate solutions and advance collaboration between stakeholders with diverse interests, operating in a highly-contested space. Participants have since reported that the series of policy-oriented research webinars and participatory workshops led to an increased understanding and appreciation of the role of different stakeholders within the health system, a recognition of mutual interests and common concerns, and resulted in more positive relationships and interactions between regulators and private sector practitioners, than experienced hitherto. It is hoped that this has opened the door and laid the foundation for meaningful policy change going forward. |
Year(s) Of Engagement Activity | 2021 |