Policy analysis of the drivers of antimicrobial resistance within Tanzania's one-health care systems

The causes and impacts of AMR are multi-factorial, not confined to biological, environmental, clinical, or social-economic domains, therefore inter-disciplinary approaches are needed. The proposed project aims to uncover the covert and overt drivers of AMR within Tanzania's health system and the pig production sector using a multi-method and interdisciplinary, "One Health" research approach. First, we will conduct a needs assessment based on a literature and policy document review as well participant observations at key sites in the human and animal health systems. Second, we will conduct a stakeholder analysis which will involve comprehensively mapping out the range of actors involved in policy processes relating to appropriate use of antimicrobials, across the One Health spectrum including formal and informal sector actors. Third, once politically feasible interventions addressing key issues indicated by the needs assessment have been identified we will pilot test an intervention targeted at critical segments within healthcare and/or veterinary systems. Fourth, we will present finding to policymakers and investigate how the new information influences their support or opposition for policy implementation.

The overall expected outcome will be a cost effective, evidence base for policy recommendations, which are relevant in human and animal health systems in Tanzania. By engaging with key policy actors in Tanzania - including the National AMR Coordinating Committee, the technical working groups, the secretariat and the AMR focal point - we will contribute evidence to inform strategies for implementation of the National AMR Action Plan and serve as a model for other resource limited countries. Policy briefs with synthesised evidence on the role of health and veterinary systems in the contribution and persistence of AMR will be a key output. We anticipate that the information generated from this research will be used in strengthening systems for antimicrobial distribution and use.

The causes and impacts of AMR are multi-factorial, and inter-disciplinary approaches are needed. The proposed project aims to uncover the drivers of AMR within Tanzania's health system using a "One Health" research approach. First, we will conduct a needs assessment based on a literature and policy document review as well participant observations at key sites in the human and animal health systems. Second, we will conduct a stakeholder analysis which will involve comprehensively mapping out the range of actors involved in policy processes relating to appropriate use of antimicrobials. Third, once interventions addressing key issues indicated by the needs assessment have been identified we will pilot test an intervention targeted at critical segments within the One Health systems. Fourth, we will present findings to policymakers and investigate how the new information influences their support or opposition for policy implementation.

The overall expected outcome will be a cost effective, evidence base for policy recommendations, which are relevant in human and animal health systems in Tanzania. By engaging with key policy actors in Tanzania, we will contribute evidence to inform strategies for implementation of the National AMR Action Plan, which could serve as a model for other LMIC countries. Further, the proposal aims to build capacity for AMR investigations in Tanzania.

The Global Action Plan on AMR relies on the World Health Organisation (WHO), the Food and Agricultural Organisation (FAO) and World Organisation for Animal Health (OIE) facilitating the preparation of multi-sectoral national AMR action plans. Evidence is needed to inform resource allocation for priority areas as part of Tanzania's newly launched AMR Action Plan (April 2017). This research will impact on strategies for appropriate antimicrobial use currently being developed in Tanzania.

Beneficiaries:
1) International policy organisations that are looking to shape LMIC policy responses to AMR, including the WHO, FAO, OIE
2) National actors involved in AMR policy formation, including the National AMR Coordinating Committee, the technical working groups, the secretariat and the AMR focal point
3) Academics, including policy researchers and those focusing on AMR/One Health approaches

Steps to maximise impact:
1) We are building upon pre-existing partnership between Tanzanian and UK institutions and applying established methods being used in contrasting settings. Thus, findings can be compared with another LMIC and generalisability of findings can be considered;
2) To maintain relevance to end users, there is input during all phases from the high level policy actors focused on global health policy and security, global animal health policy, health policy in Tanzania, and African One Health networks (such as the Southern African Centre for Disease Surveillance);
3) We will adapt academic outputs to present our findings in ways that are most appropriate for policy actors. Key outputs will be short policy briefs, including one targeted towards policy planners and another in the form of How-to-do Notes.
4) Capacity building will lead to outputs that last beyond the life of the project. This will cover researchers and animal and human health professional through the delivery of workshops;.
5) Academic impact - we will add to the small body of literature of policy development in LMICs and on AMR policy responses, producing outputs relevant to researchers interested in novel qualitative methodologies; operationalization of policy design theory in the health field; stakeholder analysis for One Health issues and designing appropriate AM use interventions.
6) Benefits extending beyond the project - stakeholder analysis findings will be presented as tool mapping key actors for planning policy responses to AMR and will be made available on an open source web interface. This will allow it to be adapted for other LMICs, enabling a series of such maps to be developed for different contexts and for policy issues beyond AMR.