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The hidden side in antibiotics resistance fight

OFTEN RUNS OUT OF ANTIBIOTICS— Chikwawa District Hospital

Adrian Chikumbe

Antibiotics have, like a giant piece of ice exposed to strong rays of the sun, slowly but steadily been losing their sting.

Such diminishing effectiveness has, as anticipated, raised serious concerns among people, with the World Health Organisation (WHO) describing it as one of the top 10 urgent health threats.

Such is the precarious situation people find themselves in that, in the next 35 years, 300 million people are expected to die from issues related to effectiveness, or lack of it, of antibiotics.

The Ministry of Health says Antimicrobial Resistance (AMR) is becoming an issue of concern to the country, attributing the development to self-medicating tendencies among some patients.

It also cites untrained personnel who administer drugs as another factor contributing to AMR.

Spokesperson for the ministry, Adrian Chikumbe, says efforts have been made to reduce the overuse of antimicrobials medicines in order to stem the tide of antimicrobial resistance.

But a recent study by scientists from Malawi Liverpool Wellcome Trust, Liverpool School of Medicine in Malawi and Sheffield Hallam University and Capacity Q, Sheffield, in the United Kingdom has noted that insufficient attention has been paid to how this applies to low-resource contexts.

The team undertook a study in Chikwawa District and one of the scientists, John Mankhomwa says many antibiotics on the Essential Medicines’ list were often out of stock.

“Stock outs left health workers with the challenging choice to either prescribe what they had in stock rather than prescribing according to guidelines,” he says.

The research was aimed at revealing multiple ways in which the provision of antimicrobials in rural Malawi impacts care in conditions of extreme scarcity.

The team, led by Eleanor Macpherson, research associate at Malawi Liverpool Wellcome Trust, spent 18 months in districts studying trends in the provision of care in 22 health facilities.

For 18 months, the study provided an in-depth portrayal of antimicrobial prescribing at primary healthcare level through 1,348 health worker-patient consultations while 49 in-depth interviews with staff and patients were carried out.

Mankhomwa says, while Contrimoxazele is one of the antibiotics frequently used in Malawi followed by LA and Amoxicillin, its availability in Chikwawa is a result of donor programmes.

“However, when other essential medicines are lacking, depending on an extremely limited number of antibiotics in primary care raises questions about resistance patterns and how this may drive AMR,” he says.

Other observations include that there were very short consultation times, with patients given very little time to ask questions or be given diagnosis.

Health workers narrated the complex dilemmas they faced in the absence of drugs they wanted to prescribe to a patient. Some reported asking patients to buy them, but others said they could not prescribe drugs because of the economic burden this placed on the household.

The researchers further learned that there appeared to be an expectation from both patients, and health workers in some cases, that medicines prescribed may not be successful, requiring the patient to return to the clinic.

One of the clinical officers at the Chikwawa District Hospital [Name withheld] told the researchers that “Because the antibiotic is always available … we just give them Bactrim [cotrimoxazole] since it assists various diseases; maybe it would help him as well … we just tell them that they should come again the following day so that we can check on the child.,”

The 2017-22 Malawi Antimicrobial Resistance Strategy acknowledges that the high burden of communicable diseases, particularly the HIV and Aids one, intimates extensive antimicrobial use.

The strategy also puts malaria, lower respiratory tract infections and diarrheal diseases among the top 10 infectious diseases killing people in the country.

While the five-year plan mandates clinical, pharmacy and veterinary practices to eliminate unnecessary dispensing, the scientists say close attention is required on issues such as the ramifications of delivery of care to ensure that efforts to stem resistance do not undermine the goal of improved health for all.

The findings suggest that programmes should be designed not only targeting protection of the vulnerable antibiotics, and patients vulnerable to antibiotic resistance, but also protecting patients from systems that have come to be organised around antibiotics, resulting in case management that leaves patients vulnerable to insufficient care.

“Antibiotics are often portrayed as vulnerable patients are also vulnerable in the face of drug resistance, but moreover, we show that, by tracing out the ways in which antibiotics are deployed in case management in resource constrained settings, patients are also vulnerable to receiving sub-standard care that is provided through an unhelpful antibiotic,” Mankhomwa adds.

Malawi Health Equity Network Executive Director George Jobe says the provision of quality health services must not be compromised, regardless of where people are, to achieve universal health coverage.

“Antibiotics must find their way into rural hospitals. The shortage of that is causing a lot of challenges. We have seen people in rural areas resort to buying these drugs; sometimes they buy drugs that are exposed to the sun and with wrong prescription, hence causing resistance,” he says.

Health rights advocate Maziko Matemba says the issue of antibiotics’ resistance is big and surfaces when the health system is not well funded as people resort to other alternatives.

“The government should raise more awareness on antibiotics resistance and promote the use of medical drugs that are approved by the medicines and poisons authorities,” he says.

These findings point to the need for more funding towards antibiotics’ purchase, as well as the need for consistent provision of a range of essential medicines.

Agnes Kaola from Traditional Authority Kasisi says, with prevailing economic challenges, her family cannot afford to buy medicines.

Kaola hopes that the government will find ways of ensuring that they are able to access quality health services.

“Our only hope is the government. If it cannot provide essential drugs to our hospital, it means that this is the end for us. We hope things will change,” she says.

As indicated by the research, addressing antibiotic vulnerabilities would require a holistic approach that moves beyond restrictions to ensure not only better access to medicines but better care

These will help stakeholders sustain gains in the provision of access to quality health services towards achieving the global goal of universal health coverage by 2030.

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