In recent years, Antimicrobial resistance (AMR) has emerged as among the major global threat to public health systems. The misuse and abuse of antimicrobials in agriculture, veterinary and human medicine practices have been described to be the major contributing factors. In clinical settings in Tanzania, the prevalence of multidrug resistant bacteria ranges from 25% to 50% (Mshana et al.,2009, 2013;Moremi et al. 2012; Moyo et al. 2014). More recently about two-thirds of isolates from wounds infections at Muhimbili National Hospital were found to be resistant to at least three classes of antibiotics (Manyahi et al. 2014). Human activities have been shown to contribute to the evolution and spread of AMR in the environment (Pruden et al. 2012). These activities include misuse and overuse of antimicrobials of variable quality and efficacy in humans and animals, improper storage and disposal of antimicrobials and preservatives for food and antibacterial agents in household products. Tackling AMR is quintessentially a One Health issue that requires a holistic and multidisciplinary approach as it has a clear link that intersects with all three domains of human health, animal health, and the wider environment. Further, globalization has brought on an unprecedented increase in cross-border movements of people, animals and food commodities, which precipitates the global spread of resistant organisms. Against this backdrop, this initiative will seek to generate local and international evidence to facilitate policy recommendations and directions within the framework of the One Health approach focused on the mitigation and management of AMR.
Recently, the SACIDS Foundation for One Health has received support from Medical Research Council (UK) to carry out research that will uncover the covert and overt drivers of antimicrobial resistance (AMR) within Tanzania’s public health and animal health system using a triangulation of qualitative methods and interdisciplinary, “One Health” research approach. This research which is being led by Prof. Mecky Matee, Muhimbili University of Health and Allied Sciences, Tanzania and Prof Taane Clark of London School of Hygiene and Tropical Medicinebrings together diverse disciplines to better understand how health systems both shape and are shaped by policies and other social determinants of health in the context of AMR.
This study will be carried out in Tanzania for a period of 24 months and research participants will include policy/decision makers, regulatory authorities, medical and veterinary practitioners, pharmacists, pharmaceutical industries, animal feed industries, farmers, members of the community and drug vendors in Ilala, Kilosa and Kibaha Districts. First, we will conduct a needs assessment to identify the gaps that currently exist in the areas of surveillance, access to, and stewardship of antimicrobials at all levels of 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 (e.g. government (human and animal) bodies, pharmaceutical and livestock production industry, trade department, civil society groups) and their networks. Using the list of policy actors generated by the mapping exercise, we will purposively select policy actors for in-depth interviews which will follow a three-part process: a) capturing existing knowledge and perceptions about AMU and AMR; b) questions about the role of the actor, exploring political, cultural, economic and institutions interests/values related to AMU and AMR; and c) the ranking and ‘thinking aloud’ exercise. Drawing on the Social Construction Framework, qualitative methods will be used by a multidisciplinary research team to identify how motivation, social constructions, power relations and contextual factors shape policy-making behaviours. Third, based on the needs assessment and stakeholders’ analysis, researchers together with key stakeholders will identify and prioritize potential interventions in the healthcare and veterinary health systems that can be tested using appropriate epidemiological designs and incorporating suitable evaluation methods to measure their impact.
Specifically,the planned research will;
- Conduct a needs assessment to identify the gaps that currently exist in the areas of surveillance, access to, and stewardship of antimicrobials at all levels of the human and animal health systems.
- Review existing policies, programmes and structures in place that address antimicrobial use (AMU) and AMR in humans and animals.
- Conduct 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.
- Based on the policy analysis, needs assessment and stakeholder analysis, identify and prioritise potential interventions in the public and animal healthcare sectors that can be tested using appropriate epidemiological designs and incorporating suitable evaluation methods to measure their impact.
- Develop strategies and tools for working with policy makers to effectively implement policies for responsible AMU in human and pig populations.
To achieve the overall goal of the project, atriangulation of qualitative methods (In-depth interviews, discussions with key stakeholders through workshops/forums and review of policy documents) will be adopted to conduct the needs assessment across the public health and animal health sectors of Tanzania. The methodology will involve: mapping of policy actors and their connections (policy networks), by applying a political science based network analysis methodology. We will identify actors from government, human and animal health bodies (national and sub-national), pharmaceutical industry, animal feed industry, trade department and civil society groups through invited advisory committee members. The study will employ a purposive, non-random sampling strategy to draw key informants from each group of actors from the national level, Kilosa, Kibaha and Ilala district. For policy actors, the outputs generated from mapping exercise will be used in the initial stage. For drug vendors, it is assumed that they are largely not licensed, and therefore cannot be obtained exclusively from the list of registered vendors in the study districts. Attempt will be made to consult with authorities to obtain the list of registered drug vendors, if available. Local citizens/community members will be asked for any drug vendor known to them. For all targeted key informants, snow ball and respondent driven sampling (RDS) techniques will be adopted to recruit key informants into the study. Key informants who will be initially invited will serve as seed for subsequent recruitment process, whereby each informant will be asked to name other individuals that they think might be useful sources of information on antimicrobial use and antimicrobial resistance. The snow ball and RDS techniques will be repeated for each group in each of the study district until the point of saturation is reached.
The proposal builds on pre-existing partnership between United Kingdom (UK) and Tanzania institutions, from inception of idea the research proposal has been jointly designed. During implementation smart partnership relationship will be adopted. In design and implementation we have adopted the community of practice approach by which UK and Tanzania investigators interact regularly. This practice of exchanging ideas aims at strengthening Tanzanian institutions in good research practices. The project includes one Tanzania Post-Doc, this will strengthen health system analytical capability in Tanzania. In addition, separately funded post-doc and 1 PhD student working on AMR who will benefit by being part of wide expertise and therefore benefiting from research environment created by this project. This will have impact on the quality of the research of Post-doc and PhD students and be able to publish in high impact Journals and attend in international conferences.
The overall expected outcome will be an evidence based policy relevant in human and animal health systems in Tanzania that could be adoptable by policy makers to minimize AMR problem and serve as model for resource limited countries. Synthesised evidence based information on the role of health and veterinary systems in the contribution and persistence of AMR will be generated. This information will be used in strengthening the systems in relation to antimicrobial distribution and uses using evidence based practices in developing countries. New policy options for optimal intervention strategies based on a One Health approach for effective risk management of AMR will be suggested for implementation taking into account the contextual factors relevant to Tanzania. This will be summarised in a Policy Advisory Briefing document. This project expects to: (i) identify the factors affecting the enforcement of the policy and regulations on management and use of antimicrobials; and (ii) consolidate our knowledge on practices on the use of antimicrobials
Our pathways to impact will be through stakeholders’ engagement, knowledge translations, sensitization and policy dialogues. This will be done at the start and throughout the implementation of the project. A number of stakeholders are expected to adopt, influenced by and benefit from the proposed research. They include government ministries (policy and decision makers) from the health, veterinary, agriculture and environment sectors, non-governmental organizations, private/business sector, and the general public. Government ministries, which will directly benefit from this research are ministries responsible for human health, animal health, agriculture, environment and industries and trade. Under the Ministry of Health, key stakeholders are Directorate of Pharmaceutical services, Directorate of Curative Services, Tanzania Food and Drug Authority, Medical Store Department, Directorate of Quality Assurance and Directorate of Policy and Planning. Others are the National Institute for Medical Research and Tanzania Food and Nutrition Centre. President’s Office, Regional Administration and Local Government, which own most of the public health facilities is also a key stakeholder. In addition, country representative of the World Health Organization and Food and Agriculture Organization will be among the key stakeholders to be involved in the inception, implementation and conclusion of the project.
Within the Ministry of Livestock and Fisheries key actors are from Directorate of Veterinary Services, Tanzania Veterinary Laboratory Agency, Veterinary Council of Tanzania, Tanzania Livestock Research Institute, Livestock Training Agency and Fisheries Education Training Agency. Other key government stakeholders are the One Health Desk of the Prime Minister’s Office, Division of Environment of the Vice President’s Office and Crop Protection department of the Ministry of Agriculture. Non-governmental and faith-based organizations include Pharm Access, Christian Social Services, and Moslem Association of Tanzania (BAKWATA). Private firms including Association of Private Health Facility of Tanzania, Tanzania Farmers Association, Farmer Centre, Bajuta International and Pharmaceutical Society of Tanzania, and Professional Associations such as Medical Association of Tanzania, Tanzania Veterinary Association, Medical Laboratory Scientist Association and Tanzania Paraveterinary Association are also key stakeholders and beneficiaries of this project.
This project is envisaged to have both cultural, economic and health, environment and social impact to the society. The evidences to be generated are likely to influence public policy and practice as well as behavioural change in the general public. The most significant benefit will be improving human health and livestock productivity through better regulations and appropriate use of antimicrobials. The engagement of policy/decision makers will increase awareness on AMU and AMR; enhance interaction among one health actors, and ultimately, improved better use of antimicrobials as well as improved quality of life. On one hand, the policy makers, managers and implementers of AMR strategies and interventions will benefit from adopting the proposed interventions that aims at reducing AMR problems in the community. On the other hand, long term impact of reduction of prevalence of multi-drug resistance, will directly benefit the communities by increasing the effectiveness of antimicrobials through policy design and implementation.
A two-way engagement with publics and stakeholders approach will be adopted to provide continuous feedback that will be used to monitor the achievements of the project. The project will establish an advisory panel with representatives from key actors to provide advices during the implementation. The project plan will be shared with key stakeholders.