Policy analysis of the drivers of antimicrobial resistance within Tanzania's one-health care systems
Lead Research Organisation:
Muhimbili University of Health and Allied Sciences
Department Name: Dept of Microbiology & Immunology
Abstract
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 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.
Technical Summary
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 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.
Planned Impact
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.
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.
Publications
Azabo
(2022)
BMC
Durrance-Bagale A
(2021)
Framing the Drivers of Antimicrobial Resistance in Tanzania.
in Antibiotics (Basel, Switzerland)
Frumence G
(2021)
Policy actors and human and animal health practitioners' perceptions of antimicrobial use and resistance in Tanzania: a qualitative study
in J Glob Antimicrob Resist
Frumence G
(2021)
The Governance and Implementation of the National Action Plan on Antimicrobial Resistance in Tanzania: A Qualitative Study.
in Antibiotics (Basel, Switzerland)
Frumence G
(2021)
The Governance and Implementation of the National Action Plan on Antimicrobial Resistance in Tanzania: A Qualitative Study
in Antibiotics
Frumence G
(2021)
Policy actors and human and animal health practitioners' perceptions of antimicrobial use and resistance in Tanzania: A qualitative study.
in Journal of global antimicrobial resistance
Frumence G
(2021)
Practices and Challenges of Veterinary Paraprofessionals in Regards to Antimicrobial Use and Resistance in Animals in Dar Es Salaam, Tanzania.
in Antibiotics (Basel, Switzerland)
Mshana SE
(2021)
Antimicrobial Use and Resistance in Agriculture and Food Production Systems in Africa: A Systematic Review
in Antibiotics
Sindato C
(2020)
Knowledge, attitudes and practices regarding antimicrobial use and resistance among communities of Ilala, Kilosa and Kibaha districts of Tanzania.
in Antimicrobial resistance and infection control
Sindato C
(2020)
Knowledge, attitudes and practices regarding antimicrobial use and resistance among communities of Ilala, Kilosa and Kibaha districts of Tanzania.
in Antimicrob Resist Infect Control 9, 194 (2020). https://doi.org/10.1186/s13756-020-00862-y
Description | A meeting with the Tanzania National Antimicrobial Surveillance Technical Working Group (TWG) |
Geographic Reach | National |
Policy Influence Type | Contribution to a national consultation/review |
Impact | Objective of the meeting The meeting discussed a newly developed protocol that will be used in human studies for surveillance of multidrug resistance (MDR) urinary tract infection (UTI) pathogens in the community. The protocol has been used to train clinical and lab staff for screening of patients, lab diagnosis and good data sharing system. Discussion and Conclusion • Participants wanted to know why this protocol, and it was clarified that this particular protocol will collect samples from primary health facilities targeting the community UTI infection hence adding value to existing country AMR surveillance. In addition, the protocol will be build the capacity of primary health facilities to participate in national AMR surveillance by establishing sample referral system. This was noted as very important because there is no culture and sensitivity in most of the primary health facilities in the region, therefore, establishing of the sample referral system ensures sustainability of AMR surveillance of primary health facilities. • The participants insisted regarding the training and standardization of laboratory procedures to ensure the data are comparable. It was noted that NPHL will organize the training to review SOPs and reporting system. It was further explained that the NPHL follow the CLSI guidelines that requires the laboratory to test all drugs and report only first line. • The participants raised the issue of stock out of antibiotic discs as big challenges regarding the uniformity of types and number of discs tested in many clinical laboratories. • The impact and outputs of project were considered to be: i) the protocol that can be used in the region to collect community MDR UTI data, ii) build the capacity of primary health facilities to be involved in national AMR surveillance and iii) produce the national AMR data that can be used for patients management and antimicrobial stewardship programme. |
Description | Antimicrobial use and resistance in animals and environment in Africa |
Geographic Reach | Multiple continents/international |
Policy Influence Type | Contribution to a national consultation/review |
URL | https://blogs.biomedcentral.com/on-health/2020/03/10/antimicrobial-use-and-resistance-in-animals-and... |
Description | Capacity building and workforce development for Civil Society Organizations on Antimicrobial Resistance in Africa |
Geographic Reach | Africa |
Policy Influence Type | Influenced training of practitioners or researchers |
Description | Capacity building and workforce development for Civil Society Organizations on Antimicrobial Resistance in Africa |
Geographic Reach | Africa |
Policy Influence Type | Influenced training of practitioners or researchers |
Description | Sensitisation on antimicrobial use (AMU) and antimicrobial resistance in Msimbazi basin in Tanzania |
Geographic Reach | Multiple continents/international |
Policy Influence Type | Contribution to a national consultation/review |
URL | https://www.openaccessgovernment.org/antimicrobial-resistance-amr-a-global-health-concern/99613/ |
Description | Systematic review of antimicrobial resistance, antimicrobial use and existing policies in agriculture/ food production systems in Africa |
Geographic Reach | Africa |
Policy Influence Type | Participation in a guidance/advisory committee |
Impact | We were commissioned by Africa CDC to conduct an extensive literature search to find out barriers for prudent use of antimicrobial agents in agriculture and animal production. Results of this systematic review have been shared among policy makers from all African Union members and was finally adopted after deliberations. At the moment African CDC has commissioned a team of experts to develop policy briefs, based on our review revealed, that will be share throughout the region. |
Description | Clinical application of whole genome sequencing in multidrug resistance tuberculosis patients in Tanzania |
Amount | € 150,000 (EUR) |
Organisation | European Union |
Sector | Public |
Country | European Union (EU) |
Start | 04/2020 |
End | 03/2023 |
Description | Fleming Fund regional CORDS AMR |
Organisation | The East African Integrated Disease Surveillance Network |
Country | Tanzania, United Republic of |
Sector | Public |
PI Contribution | Supported on standardization of data collection (common protocols) for analysis and data sharing for cross-regional comparison |
Collaborator Contribution | None |
Impact | Standardized data collection (common protocols) for analysis and data sharing for cross-regional comparison |
Start Year | 2019 |
Description | Strengthening surveillance, disease intelligence, and health information exchange |
Organisation | Africa Centres For Disease Control And Prevention |
Department | Disease Surveillance Unit |
Country | Ethiopia |
Sector | Charity/Non Profit |
PI Contribution | Implementation of core activities of Africa CDC's strategy to address antimicrobial resistance |
Collaborator Contribution | Networking with other regional stakeholders including REACT Africa, East Central and Southern Africa Health Community (ECSA-HC), Civil Society Organizations in Africa, Regional Coordinating Committees for antimicrobial resistance, World Health Organization, World Animal Health Organization, The African Union Inter-African Bureau for Animal Resources |
Impact | Conducted workshop to develop to increase awareness on issues related to antimicrobial use and antimicrobial resistance (AMR) and Africa CDC AMR framework among Civil Society Organizations in Africa |
Start Year | 2019 |
Description | A workshop |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Professional Practitioners |
Results and Impact | This was a high level advocacy meeting for the legal frameworks on infection prevention and control and biosafety and biosecurity. We organise this meeting in collaboration with Africa Union and Africa CDC. The meeting, which was held in Dar es Salaam between 28 and 29 November, drew participants from members AU member states an advocacy meeting for the IPC Legal Framework with a view of creating awareness of the legal framework to the technical experts and Ministers who will endorse and adopt it during the AU specialized technical Committee meeting scheduled for 1- 5 November 2021. Purpose The legal frameworks will promote safe health care facilities, patient safety and quality universal health coverage; and strengthening the biosafety and biosecurity systems of African Union Member States in order build their capacity to comply with the international requirements and regulations. Improving IPC and BSBS will require political commitment with dedicated budget, strict adherence to protocols for detection and response, provision of adequate supplies and equipment for patient care, adherence to hygiene, sanitation, infectious waste management, and improved building design, including ventilation. Target Participants The workshop will engage about 45 participants; Ministers and Ministerial officials from Member States; Africa CDC representatives and technical partner organizations. Venue White Sands Hotel, in Dar-es-salaam, Tanzania. Dates 28-29 October 2021 |
Year(s) Of Engagement Activity | 2021 |
Description | Community sensitisation |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Public/other audiences |
Results and Impact | This was engagement of about 500 community members and their leaders in Ilala, Kilosa and Kibaha districts of Tanzania. We gave them feed back of what we found in our community survey regarding their knowledge, attitudes and practices (KAP) regarding antimicrobial use (AMU) and resistance (AMR) in human health and animal production. In brief, our survey found moderate level of KAP regarding AMU and AMR in the study districts. The participant's age and level of education were significantly associated with participant's KAP scores. We observed inadequate knowledge, inappropriate attitude, and practices of AMU and AMR, which should be considered as alarming problems that require immediate actions. During these meetings, we stressed on judicious use of antimicrobial agents; including the need for seeking professional advice, observation of withdrawal period, avoiding over the counter purchases of antimicrobials, and stocking of drugs for future use. We are in the process of policy formulation and planning of community-based mitigation measures by involving sector ministries (health, veterinary and agriculture) . At the same time, we have applied for additional funding for training and engagement of these community members through various means e.g. policy briefs, cultural groups, community leaders involvement etc, and prescriber engagement and continuing eduction. Our aim is to develop capacity (based locally accepted and culturally sensitive interventions in these three districts regarding prudent use of AMU that can be rolled to out to other districts. Our involvement of stakeholders from communities to the national level issue to ensure local ownership, relevant and sustainability |
Year(s) Of Engagement Activity | 2020 |
Description | Engagement of paraprofessionals |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | Local |
Primary Audience | Professional Practitioners |
Results and Impact | Para-professionals, either as para-veterinarians or community based animal health workers (CBAHWs), have for some time now been considered one of the most promising means for increasing the provision of animal health services in the rural areas of many developing countries. Key features of para-professionals are their low overhead costs and their willingness to live as part of a rural community. With these characteristics para-professionals are able to provide services to small-scale producers in areas that could not otherwise support a private veterinarian. Although para- professionals cannot fully substitute for veterinarians, these personnel are able to provide a cheap, locally available basic health care service that can lead to quite dramatic improvements in herd health We engaged 43 para-veterinarians from 5 districts of the Dar es Salaam Region, the commercial city of Tanzania. We conducted interviews and focus group discussions, trying to find out their background knowledge, as well as their attitudes and practices in providing community veterinary services. The aim was to perform SWOT analysis that would provide an evidence based information to come up with customized programme with the aim to build an affordable but also viable and self-sustaining basic animal health service delivery system managed by the communities themselves through easily accessed and affordable professional cadre. This can be seen as the initiator of this approach in Tanzania. Moreover, it aimed at encouraging the use of local knowledge on animal health through sharing experiences, for instance documentation and research. |
Year(s) Of Engagement Activity | 2020 |
Description | National AMR Policy/Decision Makers consultative workshop |
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 | We engaged Policy/Decision Markers from the national level. They were from the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Ministry of Livestok and Fisheries (MoLF), Ministry of Natural Resource and Tourism, President Office Regional Administration and Local Government (PORALG), Prime Minister, Vice President (Environment), National Reference and Qauality Assurance laboratory, Food and Agriculture Organization of the United Nations-Tanzania country office, Pharmaceutical section of the MoHCDGEC. During the event, we conducted a stakeholder analysis of the AMR environment to examine the motivations, social constructs, contextual drivers and power relations of policy actors that influence behaviours and decision-making processes in developing policies for AMR, specifically in relation to the appropriate AMU |
Year(s) Of Engagement Activity | 2020 |