Antimicrobial Stewardship Prioritising Quality Access to Healthcare

Julie Babyar ,  RN, MPH, United States of America

Antimicrobial resistance is a global health priority. National and international interventions must account for differences in developing, low and middle income countries. Countries within Asia can reflect this strategy effectively, immediately and to the global health benefit by prioritising quality access to healthcare and workforce development alongside antimicrobial stewardship recommendations.

Antimicrobials, treatments that kill or inhibit the growth of microorganisms, are effective and necessary in medicine. However, organisms and microbes have increasingly begun to resist antimicrobial agents through evolutionary change and mutations. Resistance to antimicrobials creates a difficult path for infectious disease medicine because it becomes harder and harder to treat resistant microbes1. While changes in organisms are natural, misuse and overuse of antimicrobials in humans and animals is believed to be a major accelerator of resistance2. Global and national agendas have been set to address antimicrobial and antibiotic resistance. As these collaborations and strategic plans are set and implemented, it is prudent to hold developing countries equally.

Low and middle income, developing countries in Asia can benefit from a coordinated strategic antimicrobial stewardship response. This response should be accountable to and assisted by global health. Too, this response should center on healthcare operations and medical home responsibility.

Healthcare operations and systems in developing, low and middle income countries are crucial for strategic interventions in antimicrobial stewardship. Current strategic recommendations for antimicrobial resistance include international collaborations, national commitments, rational use of antibiotics, good microbiology practices by providers, infection prevent and control within facilities, judicial antibiotic use in livestock, innovation in new drugs and technology and better methods to counter false medicine3. Strategic responses such as a national antimicrobial resistance policy in India and the inclusion of guidelines available from the Infectious Disease Society of America on antimicrobial stewardship are theoretically impactful. However, ideal operational processes must first be in place for certain strategies to be effective. This makes access to healthcare in developing countries an ideal target as global goals seek more direct, coordinated antimicrobial resistance intervention. Current global recommendations should expand, accounting for operational differences in countries with economic imbalance.

Specifically, developing countries must be in line operationally with all other countries in order for any international guidance to be effective. Many providers in many countries do not hold the same educational or professional background as in developed nations. In instance, one journal reported that many doctors are poorly trained and unlicensed in India4. While full metrics on properly educated practicing medical professionals in India remain varied, echoes of similar concerns are found in literature centered on countries within Asia. Additionally, interns with standard medical education report significant lack of education in antimicrobials. A Bangaldesh study reported that 98 per cent of medical intern respondents would like more antibiotic education.5 To further understand the picture, in low and middle income Asian countries the public often seeks medical care first at the drug store and pharmacy. Often, these first points of contact for healthcare are in pharmacies employing untrained staff6.

It is well documented that prescription practices are less than ideal in many developing countries, too. One recent study found that 71.3 per cent of antimicrobials in India were dispensed without a prescription. However, analysts must be mindful that in low and middle income countries, infections are a major cause of pediatric deaths. Limited access to a physician and thus, a prescription, may mean life or death for those with an infectious disease 7. Access to healthcare must be expanded, through workforce development, structure build out and supply assurance. Strategic plans that incorporate philanthropic, government and World Health Organisation (WHO) guidance must be implemented in sustained fashion.

Another significant difference at the global table is culture and education of the population. The population seeking healthcare is significantly different in low and middle income Asian countries. Alternative and culturally significant healing practices may differ from traditional western medicine. Additionally, education and literacy rates differ in these populations. One study on antibiotic resistance reported a 72 per cent literacy rate within urban and rural areas of a specific Indian district8. Healthcare delivery is a major challenge for uneducated, illiterate populations. Past solutions have included community lay workers to deliver messaging, but even this is resource intensive.

As developing, low and middle income countries continue to sit at the table for antimicrobial stewardship, they must not only have their healthcare operations accounted for, they must have role models. For a pan-Asian collaborative in antimicrobial stewardship, all countries must accurately and wholly commit to the issue. The current climate may indicate degrees of difficulty in this commitment. In China, policies and agreements have been reported to lack enforcement. While this lack of enforcement remains, China continues to use about five times as many antimicrobials as the United States9. In pan-Asian collaborations, action must follow commitment and difficulties must be addressed.

Many operational differences that create barriers in global antimicrobial stewardship can be addressed with healthcare access buildouts. Strengthening health systems is a priority for global health organizations, including the World Health Organization10. Strategies to expand quality healthcare delivery are achievable. Buildouts, health access expansion initiatives and strategies must include a main goal: placing responsibility of the public’s health within medical homes, whether they are government hospitals, philanthropic ventures or private district outpatient facilities.

The responsibility of the public’s health should not be at the door of the drug store, often run by businessmen with no pharmaceutical expertise in the facility7. The responsibility of the public’s health must be in medical home models, interpreted through specific healthcare institutions. These models can provide structure for national health agenda, professional and supply regulation, and public health. These models can also provide the basis for enforcement, of which effective policy agendas are dependent on.

In alternative delivery models where providers are extremely lacking, public health interventions have realized success. In many countries, healthcare is often delivered in the home, with village healthcare workers as the points of contact. As an example, sepsis has been reduced in neonates following home-health models that utilized village workers11. Still, past public health achievements cannot negate the need for medical provider oversight and medical home models, even with home health delivery branches. Accountability and responsibility for the public’s health must be clear and sustained.  

Policies must be designed around these operational differences and must be implemented with enforcement capabilities in mind. As previously mentioned, without access to life-saving antibiotics, many children in these countries do not live. Policies on pharmaceutical regulations would do well to include flexibilities for healthcare access, or be implemented in conjunction with workforce development. Any national or international policy agendas are dependent on functioning healthcare to adequately defend enforcement. Policies are dependent on adequate healthcare, furthering the argument that antimicrobial stewardship is dependent on a primary priority: quality healthcare delivery in all countries. A collaboration of pan-Asian countries can effectively commit to antimicrobial stewardship by prioritising sustained, quality healthcare access.

As developing countries become part of the pharmaceutical market, they should incorporate pharmaceutical and prescription health services research to counter resistance. In instance, a study of Vietnam found that self-medication and poor prescribing practices are common as a result of inadequate healthcare access, and that enforcement of antimicrobial stewardship policies is lacking12. Research such as this details current issues, advocates for future needs and can be utilized for expansion. A recent Malaysian study that found polypharmacy among the elderly to be of great concern13 could be expanded to include antimicrobial-specific analyses, perhaps encompassing multiple nations. Another excellent study incorporates community health workers to use decision support tools for medical and pharmaceutical management of populations in Tibet and India14. This study could be applied and expanded to incorporate antimicrobial use, compliance and provider needs. Funding of pharmaceutical delivery research in Asian nations should accompany sustained commitment of workforce development within the countries studied.

While much of proposed strategic plans in healthcare access, antimicrobial stewardship and workforce development in Asian countries seem unsustainable and not financeable, partnerships can solidify a brighter future. The commitment of pharmaceutical industry to donate regulatory development and pharmaceutical educational workforce development, through assertive global persuasion, should be expected. Global health governing body assistance should be expected. Philanthropic partnerships should be appreciated.

In conclusion, antimicrobial resistance continues to be a global threat. Alarming facts, causes and consequences continue to be at the forefront of antimicrobial stewardship. Countries where antimicrobial misuse and resistant strains are alarming include multiple nations in Asia. Multiple countries in Asia can form dedicated, effective collaborations to address and solve antimicrobial concerns, but these strategies must prioritise quality, effective healthcare access.

The most effective means to antimicrobial resistance lies in foundational basic access to healthcare. Accessible healthcare includes designating responsibility. The responsibility of direct care and ability to enhance antimicrobial stewardship lies within community medical homes, and these medical homes must be a focal point of the future.

References

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2. World Health Organization. Antimicrobial resistance. http://www.who.int/mediacentre/factsheets/fs194/en/. Published 2016.
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8. Chandy SJ, Mathai E, Thomas K, Faruqui AR, Holloway K, Lundborg CS. Antibiotic use and resistance : perceptions and ethical challenges among doctors , pharmacists and the public in Vellore , South India. 2014;X(1):20-27.
9. Ying G-G, He L-Y, Ying AJ, Zhang Q-Q, Liu Y-S, Zhao J-L. China Must Reduce Its Antibiotic Use. Environ Sci Technol. 2017:acs.est.6b06424. doi:10.1021/acs.est.6b06424.
10. World Health Organization. World Health Statistics.; 2016.
11. Bang, A., Bang, R., Baitule, S., Reddy, M., Deshmukh M. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet. 1999;354(9194).
12. Nguyen K Van, Thuy N, Do T, et al. Antibiotic use and resistance in emerging economies : a situation analysis for Viet Nam. 2013.
13. Lim LM, Mcstea M, Chung WW, et al. Prevalence , risk factors and health outcomes associated with polypharmacy among urban community-dwelling older adults in multi- ethnic Malaysia. 2017;69:1-18. doi:10.1371/journal.pone.0173466.
14. Ajay VS, Tian M, Chen H, et al. A cluster-randomized controlled trial to evaluate the effects of a simplified cardiovascular management program in Tibet , China and Haryana , India : study design and rationale. 2014:1-8.

Julie Babyar

Julie Babyar is a healthcare advisor with leading public health and policy expertise. She seeks to design effective healthcare delivery and innovation with global collaboration. She is American, and she resides in the California, USA.

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