CARE: Community Approach to Resisting AMR across the Entire Life Cycle

Addressing AMR in Indian settings by taking a holistic life cycle approach. It enhances diagnostics, utilizes advanced technology for data collection and interpretation, and promotes evidence-based decision-making among clinicians and policymakers. It aims to generate insights into AMR and antibiotic usage at the community level, ultimately improving patient health outcomes.

Parag Govil

Manager, Surveillance, Diagnostics and AMR Team, William J. Clinton Foundation

India is characterized by higher prevalence of AMR. Among 0-24 population, It represents the highest DALY for lower-respiratory tract infections and tuberculosis and second highest for enteric infections globally(GBDS, 2019). Higher burden of infectious diseases becomes further threatening due to irrational usage of antibiotics. At primary healthcare levels, India records a disproportionate usage (47%) of WATCH antibiotics and 50% prescriptions for conditions not requiring antibiotic treatment(Sulis, 2020).

The challenges that underscore irrational use of antibiotics are multifold. Lack of diagnostics capacity/availability and standardized protocols leads to data insufficiency for reliable estimations of resistance patterns and limited evidence-based decision-making for antimicrobial stewardship. Incomplete feedback loop for demand to affect supply chain management for antibiotic access.

Ethnographically disadvantaged groups bear the exacerbated brunt of these challenges. Indigenous populations (like Bharia, Baiga, Sahariya tribes in Madhya Pradesh) bear a disproportionate burden of communicable diseases(Roadmap of Tribal Health in Madhya Pradesh, 2021). Nationally, they represent 8.6% of the population and 30% of total malaria cases(Kumar, 2020). Low health literacy and strong beliefs in traditional treatment methods lead to poor health seeking behaviors. Adopting an equity lens, our solution generates data on indigenous populations to positively impact their health outcomes. 

Our solution serves a diverse range of stakeholders, specifically tribal populations, healthcare providers, and policymakers. We will focus on tribal populations seeking care at community-level public health facilities in Madhya Pradesh. These communities face significant public health challenges, including inadequate resources and awareness, leading to a reliance on self-diagnosis and informal care providers. To understand the needs of these populations, we intend to conduct stakeholder consultations and in-depth interviews, also engaging with officials and healthcare workers. These interactions will inform our contextually relevant and culturally sensitive approach, addressing data gaps in tackling antimicrobial resistance (AMR). 

 Our strategy includes strengthening public health institutions at the community level by enhancing capacity in antimicrobial stewardship, improving diagnostic capacities, and promoting evidence-based prescription practices. We will also prioritize education, developing culturally sensitive materials in local languages to facilitate clear understanding and informed decision-making regarding antimicrobial use and healthcare practices.

 By engaging with stakeholders and tailoring our interventions to their needs, we aim to foster community ownership and sustainability, ultimately improving health outcomes for tribal populations in Madhya Pradesh.

Institutionalization: Testing this end-to-end approach to tackling AMR in select districts of Madhya Pradesh allows for generation of a great knowledge bank for adoption of strategies in other districts, states, and similar resource settings globally. To that end, we intend to develop a strategic guiding document in terms of a white paper that will be globally accessible online. This shall act as a catalyst for sustainable scale-up of AMR initiatives in low-resource and community settings.

Documentation: Key insights shall be generated on the relationship between antimicrobial resistance and usage patterns in community settings, influence of demographic factors such as ethnography (given our focus on tribal populations), age and gender on resistance patterns, the interplay and distinction between public and private in antibiotic prescription practices.   We intend to document and publish the key insights thus generated in a peer-reviewed publication for catalyzing further research on AMR, especially in the Indian context.

Dissemination: To affect patient outcomes beyond the remit of our focus facilities, the open-source access to automated and interactive near real-time dashboards on localized antimicrobial resistance patterns and antibiotic policies thus developed may act as job aids for informal/private care providers and pharmaceutical companies. 

In status quo, there exists a significant gap in consideration of AMR in care seeking and delivery behavior in community settings. We have conducted several scoping interviews with government healthcare officials, domain experts and gathered insights from field visits. Key bottlenecks therein highlighted include barriers for target segments of policymakers, clinicians, and the community, especially within vulnerable communities. 

Our model bridges evidence generation with clinical decision making by medical officers. The susceptibility data collected by virtue of strengthening diagnostic availability and establishing standardised protocols will inform the development of hyperlocal resistance patterns using the deployed technological tool. Thus, enabling policymakers with greater and more accurate data visibility for decision-making. At a micro level, the application based CDSS will act as job aid for clinicians in prescription of appropriate antibiotics.

With tribal populations having 38% worse IMR and 48% worse U5 MR as compared to other sections of society, and higher incidence of malaria and tuberculosis and documented lower levels of health care infrastructure (Reference) – they compose a highly vulnerable demographic. At a community-level, our solution aims to positively affecting patient outcomes by facilitating rational antibiotic use, timely and effective treatment, and long-term checks on developing resistance.

The primary objective for the first year of operation is to demonstrate the operational feasibility of the model of increasing access to AST through the hub and spoke model and deploying the tool at the facility level to generate data on antimicrobial dynamics.  We aim to streamline processes for regular generation of such evidence in 5 districts of Madhya Pradesh, distributed between approximately 75 primary health facilities at the community-level and engage with public/private medical officers, pharmacists, microbiologists, and other facility-level staff.

The overarching 3-year vision aims to establish a scalable and sustainable model, successfully tested in multiple districts of Madhya Pradesh (~8 million population). Following which we intend to consult with the state health department leadership, partner organizations, and domain experts for subsequent scale up. The proposed phased scale up strategy would involve development of required protocols and processes for seamless adoption and expansion and enforcement across all 52 districts of the State (~87 million population).

We aim to also leverage this expansion for affecting policies on generation and usage of evidence on AMR at the National level by engaging with nodal governmental agencies. Expanding the adoption of the software solution and the operational model in other geographies. 

A robust monitoring and evaluation framework tracking key performance indicators categorized under the buckets of process, output, outcome and impact would be essential to measure our progress and impact.

Process Indicators: To effectively monitor field activities, regular internal reviews would be structured to track progress along KPIs such as number of facilities connected on the hub and spoke diagnostic network for susceptibility testing, facilities onboarded on the technology tools, trainings of facility staff, and informal/private care providers approached for primary surveys.

Output Indicators: Short-term goals that aid in measuring progress and quality of adoption of the model. Specific indicators for the pillars of diagnostics (sample viability rate, quality control referrals), data (tests recorded on the tool, creation of antibiograms, deployment of real-time automated dashboards), decision-making (clinicians engaged for prescriptive recommendations, state-level reviews), diffusion (training of master trainers, reach of eLearning modules)

Outcome Indicators: Larger objectives that we aim to achieve over the duration of the program timelines such as expansion of diagnostic networks, expanded antibiotic access bucket, changed stock movements of antibiotics, reduction in antibiotic consumption.

Impact Indicators: Long-term impact of sustained interventions on the community in terms of reduced antimicrobial resistance, decline in AMR-associated deaths

Lab Network Expansion: A barrier lies in expanding the hub-and-spoke lab model for extending culture sensitivity testing services to Primary Health Centers and Community Health Centers. We plan to optimize existing resources and leverage current mechanisms, with a minimum requirement being susceptibility testing capacity at district hospitals.

 Human Resource Sufficiency: Ensuring sufficient human resources at focus facilities is another hurdle. Our strategy avoids deploying additional government resources, relying on state-level collaboration and support from field officers. The minimum requirement is a dedicated team of medical officers and identified champions from within the system.

 Capacity for AMR Diagnostics: The scarcity of diagnostic capabilities in the public healthcare system poses another significant barrier. Our strategy involves creating user-friendly job aids and implementing robust capacity-building tools such as Continuous Medical Education, workshops, and e-learning. This approach addresses the imperative for efficient diagnostics, empowering healthcare workers, and closing existing skill gaps. Furthermore, we emphasize the development and deployment of clear guidelines for prudent antimicrobial practices to enhance the effectiveness of our mitigation efforts.

 For overcoming these hurdles, we propose an innovative strategy, leveraging current, fostering strategic collaborations, and employing customized training tools, which is crucial for ensuring a sustainable realization of our objectives.

The gap as identified by the Trinity challenge on the lack of action and visibility at the community-level for AMR containment despite strategic frameworks in terms of action plans, extensive research and some levels of infrastructure, is starkly pertinent in the Indian context. With limited threat perception of AMR due to low literacy and awareness within primary healthcare ecosystems and the community, especially for more vulnerable groups such as indigenous populations, there is an evident need to adopt a human-centric design from an equity lens to engage with one of the key drivers of antimicrobial resistance.

We strongly align with the need to leverage technology and innovation to bridge this gap, particularly to overcome the constraints that come with driving interventions in low-resource settings with systemic gaps. Our solution involves technological tools as an undercurrent to all aspects of our operational model to ensure effectiveness, efficiency, and sustainability.  

Given the strong partner and member network of the Trinity Challenge, we perceive this as an opportunity to forge meaningful collaborations to furthermore improve and expand the scope of our solution. The Challenge will accelerate our drive to test and adopt strategic interventions that utilise evidence for positively impacting communities. 

We intend to leverage the larger Clinton Health Access Initiative network across 35 countries for exploring opportunities for expansion of the solution in other geographies with similar contexts of high disease burden and low resources (such as Nigeria).

For greater penetration within the Indian context, engagement with leading institutes and government agencies (ICMR, NCDC, PHFI, IIPH, AIIMS, NIRTH etc.) would be necessary for understanding contextualization needs and further standardization potential.

The Trinity challenge provides for a unique opportunity to collaborate with global partners and members. Consultations with subject matter experts from research institutes (University of Oxford, Liverpool School of Tropical Medicine, LSHTM, Imperial College London) would help further improve our intervention design and approach. Insights from technology experts from industry leaders like Google will help us improve the underlying technology powering our solution.

Third-party impact evaluation studies involving institutions like IHME would aid in validation of the expected success of the model and adds to the reliability for subsequent scale up. For accelerating and scaling our solution, exploring financial collaborations with donor organizations would also be immensely beneficial.