Copayment mechanism in selected districts of Uganda: Availability, market share and price of quality assured artemisinin-based combination therapies in private drug outlets.

BACKGROUND: Malaria remains one of the leading causes of morbidity, and mortality in Uganda. A large proportion of malaria symptomatic patients seek healthcare in private sector. However, availability and affordability are major barriers to access to effective treatment. The private sector copayment mechanism in Uganda aims to increase availability and affordability of antimalarial agents. Our study assessed availability, price, and market share of quality assured artemisinin-based combination therapies (QAACTs) in private drug outlets in selected districts during the implementation of copayment mechanism. METHODS: This was a cross-sectional survey of anti-malarial agents in private drug outlets in in selected moderate-to-high (Tororo, and Apac districts) and low (Kabale and Mbarara districts) malaria transmission settings. Following the World Health Organization/Health Action International (WHO/HAI) criteria, an audit of the antimalarial agents was done using a checklist to determine availability, price, and market share of QAACTs. Data were entered in Epi-data and analyzed in STATA ver 14.0 at 95% confidence level. RESULTS: A total of twenty-eight (28) private drug outlets (pharmacies and drug shops) were included in the survey. One in seven (20/144: 95%CI: 9.1, 20.6) of the antimalarial agents in private drug outlets were quality assured artemisinin-based combination therapies (QAACT). Artemether-lumefantrine (AL), 8.9% (11/124) and Artesunate-Amodiaquine (AQ), 7.3% (9/124) were the only QAACTs present in the drug outlets at the time of the survey. The majority, 86.1%% (124/144) of antimalarial agents present in stock in the drug outlets were artemisinin based. The most common, 38.9% (56/144) ACT in the drug outlets was Dihydroartemisinin-Piperaquine (DHP). Most, 69.4% (100/144) of the antimalarial agents were in high malaria transmission settings. The cost of ACT antimalarial agents is high in the country, USD 1.4 (Artemether-Lumefantrine, AL), USD 2.4 (Dihydroartemisinin-Piperaquine, DP), the first line and second-line agents respectively for treatment of uncomplicated malaria in Uganda. There was a statistically significant difference between the dispensing price of 'Green leaf' ACTs (QAACT) and the recommended price (p<0.001). Predictors of availability of QAACT in private drug outlets include pharmacy drug outlet (aPR:0.4; 95%CI: 0.2, 0.9) and dispensing price more than 3000UGX (USD 0.83) (aPR: 0.4, 95%CI: 0.1, 0.51). CONCLUSION: Quality assured artemisinin-based combination therapies (QAACTs) are not common in private drug outlets in selected districts in Uganda. All the drug outlets had at least one ACT antimalarial agent present on the day of the survey. The dispensing price of QAACTs was significantly higher than the recommended markup price. There is need for awareness creation, surveillance, and monitoring of the implementation of Copayment mechanism in the country.

Tackling antimicrobial resistance: developing and implementing antimicrobial stewardship interventions in four African commonwealth countries through a health partnership model.

In recent years, health partnerships have shared infection prevention and control innovations between United Kingdom hospitals and Low-Middle-Income Countries. However, none had focused on antimicrobial stewardship (AMS), a core component of tackling antimicrobial resistance (AMR). This paper documents an effective approach to developing a program to increase AMS capacity in four African countries: Ghana, Tanzania, Uganda, and Zambia as part of the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) program. A systematic approach was applied to assess gaps in AMS interventions and inform the development of the CwPAMS program through deskbased assessments, including National Action Plans on AMR, online focus group meetings, and expert advisory group reviews. Twelve partnerships were selected for the CwPAMS program. AMS support tools were developed based on recommendations from the scoping, including an AMS checklist tool, a healthcare worker knowledge and attitudes questionnaire, and an antimicrobial prescribing app to support clinical decision-making. Training workshops on AMS were developed and delivered to volunteers in Africa and the UK using a train-the-trainer model. The tools and workshops facilitated capacity building for AMS through the generation and strengthening of knowledge, skills, commitment, structures, systems, and leadership among stakeholders in the UK and Africa. The overall average rating assigned to the program following independent evaluation using the Organisation for Economic Cooperation and Development Assistance Committee Evaluation Criteria was very good. The evaluation also highlighted that the majority of the HPs (75%) focused on AMS and/or improved prescribing practice; all HPs have developed and implemented AMS strategies, guidelines, and tools within their hospitals; and NHS staff were able to translate the knowledge and skills they had received early on in the program into clinical practice in response to COVID-19 challenges.

Supply-chain factors and antimicrobial stewardship.

Efficient and secure supply chains are vital for effective health services worldwide. In low- and middle-income countries, the accessibility, affordability and availability of essential medicines, including antimicrobials, remain challenging. Ineffective supply chains often cause antimicrobial shortages, leading to inappropriate use of alternative agents and increasing the risk of antimicrobial resistance. Shortages, coupled with insecure supply chains, also encourage the infiltration of substandard and falsified medicines, leading to suboptimal treatment and further promoting antimicrobial resistance. Addressing antimicrobial supply-chain issues should be considered a key component of antimicrobial stewardship programmes. We have explored the link between medicine supply chains and antimicrobial use in seven focus countries: Kenya, Malawi, Nigeria, Sierra Leone, Uganda, United Republic of Tanzania and Zambia. We explored country medicine supply-system structures, national medicine supply-chain policy documents and global study reports. Our aim was to develop evidence-based strategies to enhance the effectiveness and efficiency of the medicine supply chains in supporting antimicrobial stewardship efforts. Better management of medical supply chains involves rational selection, quantification, forecasting, procurement, storage, distribution, use and stock management of antimicrobials. Important supply-chain considerations include pooled procurement networks to ensure consistent pricing of quality-assured antimicrobials, and improved resource utilization and information exchange among relevant stakeholders. We propose adaptable recommendations for integrating medicine supply chains as an essential part of antimicrobial stewardship programmes, with a call for action at the local, regional and national levels in low- and middle-income countries.

Partout dans le monde, les performances des services de santé dépendent de l'efficacité et de la sécurité des chaînes d'approvisionnement. Mais dans les pays à revenu faible et intermédiaire, l'accessibilité et la disponibilité des médicaments à prix abordable, y compris des antimicrobiens, représentent toujours un défi. L'inefficacité des chaînes d'approvisionnement entraîne souvent des pénuries d'antimicrobiens et, par conséquent, un recours à des alternatives inappropriées et une augmentation du risque de résistance aux antimicrobiens. Ces pénuries, alliées à des chaînes d'approvisionnement peu fiables, favorisent également l'introduction de médicaments falsifiés et de qualité inférieure, altérant l'efficacité du traitement et renforçant encore davantage la résistance aux antimicrobiens. Résoudre les problèmes liés aux chaînes d'approvisionnement en antimicrobiens devrait donc figurer parmi les priorités des programmes de gestion des antimicrobiens. Le présent document s'intéresse au lien entre les chaînes d'approvisionnement en médicaments et l'utilisation d'antimicrobiens dans sept pays cibles: le Kenya, le Malawi, le Nigeria, l'Ouganda, la République-Unie de Tanzanie, la Sierra Leone et la Zambie. Pour chacun de ces pays, nous avons examiné les structures du système d'approvisionnement en médicaments, les documents relatifs à la politique d'approvisionnement national et les rapports d'études globaux. Notre objectif consistait à développer des stratégies fondées sur des données factuelles, afin d'améliorer le fonctionnement et l'efficacité des chaînes d'approvisionnement en médicaments et de contribuer ainsi aux efforts de gestion des antimicrobiens. Une meilleure logistique requiert une certaine rationalité dans la sélection, la quantification, la planification, l'approvisionnement, le stockage, la distribution, l'utilisation et la gestion des stocks d'antimicrobiens. Dans ce contexte, plusieurs éléments sont importants tels que les réseaux d'achats groupés, qui assurent la stabilité des prix pour des antimicrobiens de qualité garantie, ou encore l'optimisation des ressources et l'échange d'informations entre les acteurs concernés. Nous formulons des recommandations ajustables en vue de rendre les chaînes d'approvisionnement en médicaments incontournables dans les programmes de gestion des antimicrobiens, avec un appel à agir à l'échelle locale, régionale et nationale dans les pays à revenu faible et intermédiaire.

Unas cadenas de suministro eficientes y seguras son vitales para la eficacia de los servicios sanitarios en todo el mundo. En los países de ingresos bajos y medios, la accesibilidad, asequibilidad y disponibilidad de los medicamentos esenciales, incluidos los antimicrobianos, sigue siendo un reto. Con frecuencia, las cadenas de suministro ineficaces provocan escasez de antimicrobianos, lo que conlleva un uso inadecuado de agentes alternativos y aumenta el riesgo de resistencia a los antimicrobianos. La escasez, sumada a la inseguridad de las cadenas de suministro, también favorece la infiltración de medicamentos de calidad inferior y adulterados, lo que conduce a un tratamiento subóptimo y fomenta aún más la resistencia a los antimicrobianos. Abordar los problemas de la cadena de suministro de antimicrobianos se debería considerar un componente clave de los programas de administración de antimicrobianos. Hemos explorado la relación entre las cadenas de suministro de medicamentos y el uso de antimicrobianos en siete países seleccionados: Kenia, Malawi, Nigeria, Sierra Leona, Uganda, República Unida de Tanzania y Zambia. Exploramos las estructuras de los sistemas de suministro de medicamentos de los países, los documentos de política nacional sobre la cadena de suministro de medicamentos y los informes de estudios globales. Nuestro objetivo era desarrollar estrategias basadas en evidencias para mejorar la eficacia y la eficiencia de las cadenas de suministro de medicamentos en apoyo de los esfuerzos de administración antimicrobiana. Una mejor gestión de las cadenas de suministro de medicamentos implica la selección racional, la cuantificación, la previsión, la adquisición, el almacenamiento, la distribución, el uso y la gestión de las existencias de antimicrobianos. Entre las consideraciones importantes sobre la cadena de suministro se incluyen las redes de adquisición mancomunada para garantizar precios coherentes de antimicrobianos de calidad garantizada y una mejor utilización de los recursos e intercambio de información entre las partes interesadas pertinentes. Proponemos recomendaciones adaptables para integrar las cadenas de suministro de medicamentos como parte esencial de los programas de administración de antimicrobianos, con una llamada a la acción a nivel local, regional y nacional en los países de ingresos bajos y medios.

Dihydroartemisinin-piperaquine or sulphadoxine-pyrimethamine for the chemoprevention of malaria in children with sickle cell anaemia in eastern and southern Africa (CHEMCHA): a protocol for a multi-centre, two-arm, double-blind, randomised, placebo-controlled superiority trial.

BACKGROUND: An estimated 300,000 babies are born with sickle cell anaemia (SCA) annually. Affected children have chronic ill health and suffer premature death. Febrile illnesses such as malaria commonly precipitate acute crises in children with SCA. Thus, chemoprophylaxis for malaria is an important preventive strategy, but current regimes are either sub-optimally effective (e.g. monthly sulphadoxine-pyrimethamine, SP) or difficult to adhere to (e.g. daily proguanil). We propose dihydroartemisinin-piperaquine (DP) as the agent with the most potential to be used across Africa. METHODS: This will be a randomised, double-blind, parallel-group superiority trial of weekly single-day courses of DP compared to monthly single-day courses of SP in children with SCA. The study will be conducted in eastern (Uganda) and southern (Malawi) Africa using randomisation stratified by body weight and study centre. Participants will be randomised using an allocation of 1:1 to DP or SP. We will investigate the efficacy, safety, acceptability and uptake and cost-effectiveness of malaria chemoprevention with weekly courses of DP vs monthly SP in 548 to 824 children with SCA followed up for 12-18 months. We will also assess toxicity from cumulative DP dosing and the development of resistance. Participant recruitment commenced on 30 April 2021; follow-up is ongoing. DISCUSSION: At the end of this study, findings will be used to inform regional health policy. This manuscript is prepared from protocol version 2.1 dated 1 January 2022. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov, NCT04844099 . Registered on 08 April 2021.

Scoping of pharmacists' health leadership training needs for effective antimicrobial stewardship in Africa.

BACKGROUND: Antimicrobial resistance (AMR) is a global public health concern currently mitigated by antimicrobial stewardship (AMS). Pharmacists are strategically placed to lead AMS actions that contribute to responsible use of antimicrobials; however, this is undermined by an acknowledged health leadership skills deficit. Learning from the UK's Chief Pharmaceutical Officer's Global Health (ChPOGH) Fellowship programme, the Commonwealth Pharmacists Association (CPA) is focused to develop a health leadership training program for pharmacists in eight sub-Saharan African countries. This study thus explores need-based leadership training needs for pharmacists to provide effective AMS and inform the CPA's development of a focused leadership training programme, the 'Commonwealth Partnerships in AMS, Health Leadership Programme' (CwPAMS/LP). METHODS: A mixed methods approach was undertaken. Quantitative data were collected via a survey across 8 sub-Saharan African countries and descriptively analysed. Qualitative data were collected through 5 virtual focus group discussions, held between February and July 2021, involving stakeholder pharmacists from different sectors in the 8 countries and were analysed thematically. Data were triangulated to determine priority areas for the training programme. RESULTS: The quantitative phase produced 484 survey responses. Focus groups had 40 participants from the 8 countries. Data analysis revealed a clear need for a health leadership programme, with 61% of respondents finding previous leadership training programmes highly beneficial or beneficial. A proportion of survey participants (37%) and the focus groups highlighted poor access to leadership training opportunities in their countries. Clinical pharmacy (34%) and health leadership (31%) were ranked as the two highest priority areas for further training of pharmacists. Within these priority areas, strategic thinking (65%), clinical knowledge (57%), coaching and mentoring (51%), and project management (58%) were selected as the most important. CONCLUSIONS: The study highlights the training needs of pharmacists and priority focus areas for health leadership to advance AMS within the African context. Context-specific identification of priority areas supports a needs-based approach to programme development, maximising African pharmacists' contribution to AMS for improved and sustainable patient outcomes. This study recommends incorporating conflict management, behaviour change techniques, and advocacy, amongst others, as areas of focus to train pharmacist leaders to contribute to AMS effectively.

The use of imagery in global health: an analysis of infectious disease documents and a framework to guide practice.

We report an empirical analysis of the use of imagery by the key actors in global health who set policy and strategy, and we provide a comprehensive overview, particularly related to images used in reports on vaccination and antimicrobial resistance. The narrative currently depicted in imagery is one of power imbalances, depicting women and children from low-income and middle-income countries (LMICs) with less dignity, respect, and power than those from high-income countries. The absence of any evidence of consent for using intrusive and out-of-context images, particularly of children in LMICs, is concerning. The framework we have developed provides a platform for global health actors to redefine their intentions and recommission appropriate images that are relevant to the topic, respect the integrity of all individuals depicted, are accompanied by evidence of consent, and are equitable in representation. Adhering to these standards will help to avoid inherent biases that lead to insensitive content and misrepresentation, stigmatisation, and racial stereotyping.

Scoping Review of National Antimicrobial Stewardship Activities in Eight African Countries and Adaptable Recommendations.

Antimicrobial resistance (AMR) is a global health problem threatening safe, effective healthcare delivery in all countries and settings. The ability of microorganisms to become resistant to the effects of antimicrobials is an inevitable evolutionary process. The misuse and overuse of antimicrobial agents have increased the importance of a global focus on antimicrobial stewardship (AMS). This review provides insight into the current AMS landscape and identifies contemporary actors and initiatives related to AMS projects in eight African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia), which form a network of countries participating in the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. We focus on common themes across the eight countries, including the current status of AMR, infection prevention and control, AMR implementation strategies, AMS, antimicrobial surveillance, antimicrobial use, antimicrobial consumption surveillance, a one health approach, digital health, pre-service and in-service AMR and AMS training, access to and supply of medicines, and the impact of COVID-19. Recommendations suitable for adaptation are presented, including the development of a national AMS strategy and incorporation of AMS in pharmacists' and other healthcare professionals' curricula for pre-service and in-service training.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

Gaps and opportunities in sustainable medicines use in resource limited settings: A situational analysis of Uganda.

Resource constraints and widespread poverty among populations undermine disease prevention in low- and middle-income countries (LMICs) and ensure that these countries carry a disproportionate share of the global disease burden. Lack of access to efficacious medicines in LMICs further exacerbates this inequity. Addressing inequitable access to medicines and assuring their sustainable use is critical to the well-being of these populations. Whilst inadequate access to medicines in LMICs has drawn much attention, less is known about the sustainable use of available medicines, particularly to ensure their efficacy and mitigate harm to the population and the environment. Uganda has adopted various measures to ensure sustainable medicines use, including a national medicines policy, essential medicines list, medicines regulation framework and promotion of domestic medicines production. Despite progress, challenges remain to achieving sustainable medicines use in the country, including fragmented access, inappropriate use, poor quality and inappropriate disposal. There is a need to consolidate the globally embraced One Health approach (fostering collaboration between human, animal and environmental health sectors) to addressing these challenges as espoused in the country's One Health strategic plan. Medicines supply chain management in public sector health facilities needs to be strengthened to minimize inventory shortages (stock-outs). A strategy for universal health insurance can minimize economic barriers to medicines access. Enhanced professional and medicines regulation in the private health market needs to be implemented. There are opportunities to build further capacity in Uganda, particularly infrastructure for regulation of its healthcare systems, policy and governance, workforce capacity building, and population action and engagement.

What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course.

BACKGROUND: Whilst antimicrobial stewardship (AMS) is being implemented globally, contextual differences exist. We describe how the use of a massive open online course (MOOC) platform provided an opportunity to gather diverse narratives on AMS from around the world. METHODS: A free 3 week MOOC titled 'Tackling antimicrobial resistance: a social science approach' was launched in November 2019. Learners were asked specific questions about their experiences of AMS via 38 optional free-text prompts dispersed throughout the modules. Content analysis was used to identify key emerging themes from the learners' responses in the first three runs of the MOOC. RESULTS: Between November 2019 and July 2020, 1464 learners enrolled from 114 countries. Overall, 199 individual learners provided a total of 1097 responses to the prompts. The diverse perspectives describe unique challenges present in different contexts including ill-defined roles for pharmacists and nurses in AMS; inadequate governance and policy inconsistencies in surveillance for antibiotic consumption and antimicrobial resistance (AMR) in some countries; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties; and human resource and technological constraints. Patients' knowledge, experiences and perspectives were recognized as a valuable source of information that should be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. CONCLUSIONS: Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician healthcare workers, resource limitations, gaps in knowledge of AMR, and patient engagement and involvement in AMS.

Evaluation of the Clinical Use of Ceftriaxone among In-Patients in Selected Health Facilities in Uganda.

Ceftriaxone has a high propensity for misuse because of its high rate of utilization. In this study, we aimed at assessing the appropriateness of the clinical utilization of ceftriaxone in nine health facilities in Uganda. Using the World Health Organization (WHO) Drug Use Evaluation indicators, we reviewed a systematic sample of 885 patients' treatment records selected over a three (3)-month period. Our results showed that prescriptions were written mostly by medical officers at 53.3% (470/882). Ceftriaxone was prescribed mainly for surgical prophylaxis at 25.3% (154/609), respiratory tract infections at 17% (104/609), and sepsis at 11% (67/609), as well as for non-recommended indications such as malaria at 7% (43/609) and anemia at 8% (49/609). Ceftriaxone was mostly prescribed once daily (92.3%; 817/885), as a 2 g dose (50.1%; 443/885), and for 5 days (41%; 363/885). The average score of inappropriate use of ceftriaxone in the eight indicators was 32.1%. Only 58.3% (516/885) of the ceftriaxone doses prescribed were administered to completion. Complete blood count and culture and sensitivity testing rates were 38.8% (343/885) and 1.13% (10/885), respectively. Over 85.4% (756/885) of the patients improved and were discharged. Factors associated with appropriate ceftriaxone use were gender, pregnancy status, days of hospitalization, health facility level of care, health facility type, and type of prescriber.

An Evaluation of Antibiotic Prescribing Practices in a Rural Refugee Settlement District in Uganda.

Ensuring access to effective antibiotics and rational prescribing of antibiotics are critical in reducing antibiotic resistance. In this study, we evaluated antibiotic prescribing practices in a rural district in Uganda. It was a cross-sectional study that involved a retrospective review of 500 outpatient prescriptions from five health facilities. The prescriptions were systematically sampled. World Health Organization core medicine use prescribing and facility indicators were used. Percentage of encounters with one or more antibiotics prescribed was 23% (10,402/45,160). The mean number of antibiotics per prescription was 1.3 (669/500). About 27% (133/500) of the diagnoses and 42% (155/367) of the prescriptions were noncompliant with the national treatment guidelines. Prescribing antibiotics for nonbacterial infections such as malaria 32% (50/156) and noninfectious conditions such as dysmenorrhea and lumbago 15% (23/156) and nonspecific diagnosis such as respiratory tract infection 40% (59/133) were considered noncompliant with the guidelines. On average, 68% (51/75) of the antibiotics were available on the day of the visit. Inappropriate prescribing practices included excessive use of antibiotics and failure to diagnose and prescribe in compliance with treatment guidelines. There is a need to strengthen antibiotic use in the health facilities through setting up stewardship programs and interventions to promote adherence to national treatment guidelines.