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AMS in Uganda

Winnie Nambatya and Peter Babigumira Ahabwe discuss AMS in Uganda.
My name is Winnie Nambatya. I’m a lecturer in clinical pharmacy at Makerere University College of Health Sciences, and I’m here to discuss with my colleague Peter about antimicrobial stewardship in Uganda. My name is Peter Babigumira Ahabwe. I’m a pharmacist with the Infectious Diseases Institute in Uganda, and we support the Ministry of Health with implementation of the AMR programme. So, what does stewardship look like in Uganda? Uganda has been doing stewardship since before it became stewardship. When WHO started their programme on the drug and therapeutics committee, Uganda was one of the adopters.
That was way back in the early 2000s, and as part of the goals of that drug and therapeutics committee, or the medicine and therapeutics committee, as it was adapted in Uganda, was to have rational use of medicines. And in 2009, Uganda released its national guidelines on rational use of medicine. So when stewardship was introduced to the Ministry of Health, very many people were used to the concept of the WHO building blocks, whereby stewardship is more to do with governance and accountability. But the minute you mentioned, we want you to use antibiotics, they went, oh, that’s rational medicine use. So we said yeah, by a different name.
So once we got in to the rational medicine use aspect, many colleagues rapidly understood what it was about, and this time the focus was really antibiotics, not just all drugs. So Uganda was about to start a surveillance task force for AMR because you cannot do AMR without data, and that surveillance task was going to a One Health multisector, multipartner task force that started doing antimicrobial consumption and utilisation surveillance as well. And currently, Uganda is doing that in six sites. Eventually Uganda, with that background data and data from a previous institution analysis that had been done, earlier on, was able to work on and launch its national action plan.
So Uganda currently has a national action plan that established national structures to coordinate AMR. So that’s pretty much how it looks at national level. Then, at the facility level, the management levels are not clinical. Most of the hospital management were oriented on this, and some hospitals have managed to set up stewardship teams, but their functionality is still a work in progress. But my colleague here, Winnie, can go much deeper into the actual real work, the stewardship on the wards with patients impacting new lives, Winnie. So basically, apart from IDI, the Infectious Diseases Institute, coming up with these interventions and antimicrobial stewardship as part of the medicine therapeutics committee, other implementing partners came on board.
For example, commonwealth pharmacists association that has come up with different partnerships and working together with the pharmacists in the hospitals, they’re trying to revamp the emphasis that has actually been dormant for a while. So in most of these antimicrobial stewardship programmes, they encourage pharmacist to be active. Going for ward rounds, monitoring antibiotic usage in collaboration with the other health professionals. But I must say that the concept of antimicrobial stewardship in Uganda is quite new, and people are trying to understand all the principles of a proper antimicrobial stewardship programme. So in Uganda we have the pharmacists, you have the clinicians as the main stakeholders, and you have laboratory technicians. And so I think I would say those are the main stakeholders.
And also maybe to add on the nurses because stewardship programmes studied by IDSA found that stewardship programmes run really well if they’re coupled with infection prevention and control programmes. So by bringing the nurses on board in your trainings and just having them make sure they practise good, efficient, vigilant control, you can limit the spread of hospital-acquired infections. Then there’s also the managers. Because leadership is one of the pillars of stewardship so the hospital administration is a very key stakeholder. Without their buy-in, they don’t necessarily have to commit resources, but at least just giving you permission to go ahead and start the stewardship committee and do research and do audits, that alone is a good starting point.
And as the team starts to show results, usually they may also think of allocating some resources to support the activities of the team. And then, at national level, for some of you might be engaging at that level, it’s similarly like what she said, but if your ministry or department of health has a department responsible for nursing, you may find that infection prevention control and quality improvement activities are anchored there, and that may be a key stakeholder. Clinical services tends to be its own department as well, so you may want to also make sure they are engaged. Pharmacy services is a very key stakeholder in some countries.
Lab services is a very key stakeholder in some countries, and generally making sure that the top management of the ministry of health and the departments of health are fully engaged and in the know of what you’re doing. If you’re engaging at that level, it can really help the programme. And do you think the policy level people are engaged with this in Uganda? Yes, I would say so, that they’re engaged. Because if they were not engaged, we wouldn’t have common platforms at the national level, like the One Health, technical working groups on proper use of antibiotics or antimicrobials in the different hospitals and the different departments or directorates at ministry of health. What do you think, Peter?
I think that the government has really, with the leadership of the minister, who is very passionate about AMR, and the director of general health have really taken up AMR and they launched their national action plan in a huge way. Because agriculture was on board, wildlife, environment. So it’s really a One Health or Health in All, some may call it, approach and it has engaged really the highest levels of the health structures. What do you think are the challenges in implementing antibiotic stewardship in Uganda in hospitals? So, looking at the principles of a proper antimicrobial stewardship programme. Sometimes leadership is not really engaged in the activities of antimicrobial stewardship, and then there’s not proper accountability.
There’s no proper person who is responsible for anything that comes out of the antimicrobial stewardship programme. And some of the hospitals lack expertise. Sometimes, there’s much improper tracking and reporting, and even when the field reports are made, feedback mechanisms or responses from the people getting these reports sometimes is poor. So those are some of the challenges, and people not really understanding what stewardship is. I think Winnie has really reinforced that the pillars of antibiotics stewardship, like leadership, commitment, training, accountability, clinician leadership, pharmacy leadership, they are not just abstract concepts. These are actually recurrent, consistent themes of gaps and challenges, and I really advise anyone who is doing antibiotic stewardship to really reinforce these things.
Like she said, the challenge with leadership is they may give you the go-ahead to work, but if you have a challenge getting some department heads on board, they may not exactly back you up. Or, they may not give you the resources to support small data collection activities or meetings.
I think it needs you to have a heart, and you need to be self-driven. You need to know that you’re a pioneer. You don’t hear stories of pioneers crossing oceans with huge armies, they literally risked their lives to start things. So I think you need to have a pioneering spirit when you’re doing antibiotics stewardship, and you have to be in it for the long haul. You won’t have results in three months or two days. I think another challenge which you already mentioned is data. Many of these hospitals have hospital committees, quality improvement committees, medicine and therapeutics committees, drug and treatment committees, of all kinds. But the thing is, they become like social clubs because there’s no real data to discuss.
So if you do not have labs that are doing diagnostics or pharmacies that are generating stock data or consumption data, then those meetings will die out very quickly. One last message you want to say in this video about what is the future of stewardship in Uganda, or what are the positive things that you think will lead to change, from your experience? So, I could say that future is bright. Because with my experience and moving around in the different hospitals and the different regions of the country, the pharmacists and the rest of the healthcare professionals are really willing to take on antimicrobial stewardship.
So with support from all the implemented partners from the ministry of health, I’m positive there is a future for AMS, and things will change.
I think that the future for AMR, not just in Uganda but in the middle-income countries in general, is that we need to be ready to set up multicentral, multidisciplinary coordinating teams and really take advantage of opportunities like the Fleming fund, country grants, or CDC, or foundations biomerieux, all these partners. But it’s a partnership, that’s the key thing. Because the people you’re finding on the ground, they know the problems, and they know the solutions. They probably lack data or resources or have no registers. So the problem is the concept is new, but it’s solving old problems, and if you really engage with people who understand that context, I’m sure you can come up with meaningful, implementable solutions.
What challenges remain for me? I think we have not yet reached that level of panic globally. People laugh at the statistics that by 2050, 10 million people will be dying every year. So countries are not dedicating their own resources to this, and even different funding mechanisms of taking piecemeal areas. Maybe they focus on risk communication only or surveillance only or research only, and yet, we need a coordinated full mobilised effort. And I think that’s my biggest risk right now, that people still don’t take AMR as seriously as they should.
In this video, Winnie Nambatya (a lecturer in clinical pharmacy) and her colleague Peter Babigumira Ahabwe (a senior program pharmacist), both from Makerere University, Kampala, discuss antimicrobial stewardship in Uganda.

The One Health Common Platform is currently the national program in place to implement AMS, or rational use of medicines (as it is more commonly known in Uganda). Please see the document in the downloads section and read page 10 and 11 for information about the problem of antimicrobial resistance in Uganda and how they plan to reduce the impact.

Some hospitals have managed to set up AMS teams, but their functionality is not yet complete. Pharmacists are being encouraged to go on ward rounds and actively monitor antibiotic use in collaboration with other healthcare professionals.

The current challenges of AMS in Uganda were described in the video:

  • No proper accountability

  • Some hospitals lack expertise

  • Not always enough reports taken

  • General lack of understanding of AMR

  • Lack of data

Winnie Nambatya is positive for the future, however, as ‘everyone is willing’.

The video was recorded during a visit as part of the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) led by Commonwealth Pharmacists Association (CPA) and Tropical Health and Education Trust (THET).

CwPAMS programme is supporting implementation of AMS principles including evidenced based tools and training in Commonwealth African countries. Find out more via the Commonwealth Pharmacy website.

The CPA advances health, promotes well-being and improves education for the benefit of the people of the Commonwealth.

In the comments below please let us know:

  • Are there factors which are similar to AMS in your area?
  • Are there factors which differ to AMS in your area?
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Tackling Antimicrobial Resistance: A Social Science Approach

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