Engaging Last Mile Animal Healthcare Practitioners to Combat AMR

Brooke's Animal Health Mentoring Framework collaborates with animal health practitioners to help them make better treatment decisions and reduce antimicrobial usage whilst also gathering data from the frontline on the treatment options available at the last-mile. 

Dr Javed Iqbal Gondal. He is the Programme Manager for Brooke Pakistan, a Doctor of Veterianry Medecine and Brooke expert on AMR.

We are trying to reduce usage of antimicrobials and suggest alternatives. Globally 70% of all antimicrobials are used in farm animals. In the LMICs where Brooke works there is rarely access to a well-equipped and qualified veterinarian. Most animals are seen by a paraprofessional, with varying levels of education and access to few treatment options. Consequently, animals receive unnecessary antimicrobials due to poor preventative measures, insufficient knowledge or unavailability of appropriate alternative treatments.  A field survey of 700 clinical cases at government health posts in Ethiopia in 2020 revealed that 100% of animals received an anthelminthic or antibiotic. 87% were treated with one or a combination of only three drugs. AMR is global and needs an inclusive solution, yet much of the data and evidence is collected in urban tertiary care settings. Many livestock are produced in rural settings and the lack of information on antimicrobial usage and lack of awareness in small holder farmers could be contributing significantly to the AMR burden. Our solution works with last mile animal health practitioners to train them to better diagnose problems, make more rational treatment recommendations and advise on preventative measures, all while collecting data on their progress. 

Brooke globally works to strengthen sustainable animal health systems and the data we collect from working with communities and last mile animal health practitioners in the field is crucial in building a picture of the reality for smallholder farmers and subsistence farming.  To improve the quality of healthcare services we work closely with animal health providers and local government animal health bodies. Veterinary training institutions and veterinary regulatory bodies are the other key stakeholders. Through community engagement we seek to understand community priorities and barriers when seeking animal health care services. We also gather feedback from local practitioners on their priorities and barriers to providing animal health services. Their feedback is used to adapt capacity building interventions.  Community involvement is essential for any disease control strategy i.e. when recommending biosecurity measures to control disease spread, encourage all owners in a community to comply. Three key interventions are i) vaccination ii) Biosecurity iii) Vector control. Understanding the barriers can help us to use the data from the Animal Health Mentoring Framework to best advocate for communities’ needs at a national level. Eg in Ethiopia there was no access to suitable pain relief, which was leading to overuse of antimicrobials.  

• The major public good output of our solution are the free to use data dashboards which will collate the data collected on animal health systems, including practitioner skills, animal clinical signs, available treatment options and antimicrobial usage. This data can be used by health services and governments to build evidence for policy changes and other researchers can utilise the data to answer further scientific questions. To increase the breadth and volume of data available in the dashboards a package of training resources and an implementation tool kit will be created so other organisations or governments can use the Animal Health Mentoring Framework. Not only will this data contribute to the central data dashboards but nations and regions will be able to gain insights into their last mile animal health services while simultaneously strengthening the animal health service through local animal health practitioner mentoring and capacity building. 
• Expanding the data collection to new countries and communities presents an unprecedented opportunity to understand the reality of responsible practitioner behaviour and antimicrobial usage in rural primary animal health and help to identify the barriers to reducing the use of antimicrobials in these settings. 

Our solution will make freely accessible data based on animal health services available to animal owning communities within LMICs, especially working equid owning communities who can be very vulnerable and are often invisible to governments. Building an evidence base for the challenges that these communities face in accessing local, responsible and well-resourced animal health services enables organisations to advocate for change and activities that promote animal health systems strengthening which are essential in the fight against AMR. Simultaneous data collection and practitioner capacity building means communities will benefit from better animal health practitioner services immediately which in turn helps to keep their animals healthy, able to provide for them and at reduced need of antimicrobial treatment. This also reduces the need for animal owners to obtain their own medication without guidance from animal health professionals.  

With 75% of new and emerging zoonotic disease coming from animals the near real-time surveillance of geographically tagged animal health data can be used as an early warning system to competent authorities for rapid  biosecurity implementation, and further investigations carried out. AMR and emerging diseases are a risk to every creature on earth, thus a community level early warning system benefits everyone. 

Year one will focus on enhancing existing areas of work to incorporate explicit gathering of data on antimicrobial availability and usage, animal clinical signs and presumptive diagnosis. Work will begin on the training and data tool kit for external use. Digital aspects of data collection, management, visualisation and manipulation will be streamlined, and stress tested, including leveraging patient side data input, geographic information systems and using power BI to generate intuitive, easy to interpret data dashboards.

Year two we will pilot open access data dashboards with key stakeholders within local governments. This will be evaluated to understand how they use and apply the system. We will pilot the training and data AHMF tool kit with a new external organisation. Both will take an iterative approach whereby we slowly increase the pool of external stakeholders engaging with the dashboards and the number of organisations utilising the AHMF tool kit to train in data gathering.  

By end of year three a fully accessible, open access data dashboard will be available externally. We will have engaged research institutions to utilise the data to answer pertinent questions on antimicrobial usage and access in LMIC communities.   

Impact Goal: Develop sustainable animal health systems that promote antimicrobial stewardship.   

Current indicators:  

• Percentage of targeted animal healthcare practitioners able to access essential resources, where essential resources includes access to essential medicines and the kit needed to deliver these safely  

• Percentage improvement in skills of targeted animal healthcare practitioners, this deliberately removes the availability of medicines to focus solely on the capabilities of the practitioner and whether they can make rational diagnosis and treatment choices.  

•  Percentage education in ‘red flags’ e.g when a veterinary mentor steps in to stop an Animal Health Practitioner from causing harm, this includes irrational antimicrobial decision making and poor skills dosing animals.  

• Number of animal health practitioners mentored 

As we pivot the AHMF to collect more antimicrobial usage data, provide open access to AHMF data dashboards and roll out an external AHMF training tool kit it will be necessary to include further measurable indicators e.g   

•  Percentage reduction in irrational antimicrobial usage  

•  Percentage improvement in practitioners providing specific guidance on antimicrobial usage (or not) including withdrawal times.  

• Number of institutions/organisations accessing the data dashboards 

• Number of institutions/organisations using the AHMF tool kit  

• Number of publications citing use of the open access dashboard 

Brooke uses the Animal Health Mentoring Framework (AHMF) extensively in Pakistan and other countries. We are working to demonstrate and share the benefits to relevant veterinary stakeholders such as universities, government livestock departments and veterinary regulators. It is received enthusiastically by stakeholders, but barriers exist within their organisations preventing mass uptake, including limited resources, both financial and human, and competing priorities, especially in government departments where animal health competes for funding with human and environmental health. AMR is a cross cutting issue and addressing this in all three One Health areas is crucial to tackling it effectively. Brooke works to overcome this by demonstrating the advantages of strengthened animal health systems as a public health benefit.   

A barrier to using the AHMF is that sufficient trained mentors are needed to carry out the frontline work with animal health practitioners and communities which is costly and time-consuming. Brooke will overcome this as part of the upscaled project by developing a comprehensive training package including technological solutions that support data collection and reporting. This will improve efficiency through scale and allow organisations to trial the use of the AHMF more easily to gain a solid proof of concept in their own context. 

As an NGO with limited funds, we face the challenge of being able to invest limited amounts in new technology and the constant balance between delivering the programme we have currently and being able to spend the time investing in horizon scanning and trialling new innovations. To date we have focused on making the best internal use of the data generated by the AHMF (Animal Health Mentoring Framework) but we know that we have a unique and valuable approach to data collection focusing on the last mile provision of animal health services. This data could be leveraged by others to better understand the weaknesses, including AMR risk, within animal health systems in LMICs. The Trinity Challenge will provide us with an opportunity to expand the reach of our data sets to those who can make good use of them in the fight against AMR. Furthermore, Trinity Challenge funding will enable us to work on developing a /toolkit so that other organisations can not only use the existing AHMF data but can collect their own too. It will increase credibility and publicise the solution much more widely, facilitating its adoption in the intended LMI countries. We also hope to see it facilitate endorsement from leading relevant organisations such as WOAH. 

As part of our approach to data management is already grounded in Microsoft products, we would like to collaborate with Microsoft to accelerate the generation of open access data dashboards. This is the essential public good that this solution will deliver and therefore there could be opportunities to learn from Zenysis and to integrate our animal health data with human health data.  

We know that the data we collect could be put to broader uses and that with additional expertise there is the opportunity to use our unique relationships with communities we work with to bring about improvements in the lives of animals and people. We need the expertise of health scientists based in institutions that are Trinty partners (University of Cambridge, Imperial, Institute for Health Metrics and Evaluation) to identify opportunities for us to adapt the framework to collect further information and to put these data to better uses.