VISIBILITY: Visualizing “invisible” antimicrobial usage in community

VISIBILITY will generate de novo data on antibiotic sales, distribution, and usage across humans, poultry, livestock and aquaculture. These data will be curated, combined with existing datasets, standardized to develop data analytics models for estimating antimicrobial usage within communities, and strategies for their scaling in India and other LMICs.

Arunima S Mukherjee, who has extensive research and implementation experience in AMR and health information systems in India for over 20 years.

Our project addresses the problem of AMU data invisibility in Indian communities from a OH perspective, which adversely impacts our understanding of usage of antimicrobials, and potential implications for AMR. Enhancing visibility through data and digital innovations is the core focus of VISIBILITY.

Lack of concise AMU data is associated with a multitude of complex and interconnected reasons. There is limited AMU reporting from tertiary public facilities, and there exists no formal mandate of systematic reporting; which constrains AMU reporting channels from communities. Given the limited access to diagnostics facilities, available only in tertiary facilities, data from rural communities is lacking. Since a significant proportion of antimicrobial access is through self-medication and without prescription, data on AMU in communities is even more compromised. Data from veterinary, food and environmental sectors may be available in respective sectors and institutions but are institutionally focused and not contextualized to community settings. Poor regulation and compliance on antimicrobial related transactions further contribute to keeping the invisibility of AMU data across all OH sectors.

VISIBILITY seeks to solve this by adopting innovative methods of data collection, integration and analysis based on modern digital platforms, including both existing and de novo datasets, to enhance AMU visibility.

The solution will target needs of multiple target audiences: i) community members for them to better understand their AMU and access patterns and how they compare with existing guidelines. This approach will strengthen self-awareness and advocacy efforts to mitigate AMR risks; iii) OH researchers in building novel methodologies strategies for compiling, standardizing and analysis of diverse data from different sectors and their integration; iii) veterinary scientists to better understand AMU in animals, and advance research on transmission dynamics between humans and animals; and iv) policy makers to design OH related interventions.

The informational needs of these different target groups will be better understood through the adoption of a participatory co-design process in the development and implementation of the innovation. Teams will be generated in the local communities, representing different target groups, to identify local problems, alternative design pathways, and means for accessing and updating data sources. Smaller groups will cover different components of the solution (described previously), and in each case to gradually take ownership of the process and solution, building their respective capacities to further scale use of the solution. 

Our solution provides public good via four mechanisms, enabling universal and un-encumbered access to all, with freedom to modify and update.

Firstly, the digital solution will be developed on the DHIS2 (see dhis2.org) platform (a leading digital public good for health globally, recognized by WHO and currently used in >100 countries), which is free and open-source. Using a Berkeley open-source license, it can be downloaded and modified as desired with no licensing encumbrances. All applications for compiling, extraction and standardization of data built on DHIS2 platform will be open-source, sustaining free access. DHIS2 provides for open API access, denoting its open integration with other systems.

Secondly, the community AMU estimation data/model and analytical dashboard will also be free and open source, accessible through publicly available free and open login, enabling open access to all, and extendible based on new use cases.

Thirdly, where available, we will exploit existing data in public domain, indicating no restrictions to its use. In some cases, where data is proprietary or generated de novo, we will provide details of how permissions are obtained from owners for further use.

Fourthly, the data and digital solution will be bundled together and released on open public websites.

The proposed solution will generate the following impacts:

• For community members, we will provide processed amalgamated data on their estimated AMU, to raise awareness about impending AMR risks, arising both from human and animal AMU.
• By strengthening awareness and estimates about AMU in OH sector, to enable community members to be more aware of the impact of antimicrobial use in their natural environment, and on mitigating risks.
• A large proportion of our target communities are rural, who tend to be the most marginalized, and worst affected by high AMU.
• Community-based surveillance of AMU and feedback through digital means, will guide members on required corrective actions.
• Results of community estimates will also be transmitted to policy makers, activists and researchers to help expand their respective action networks.  
• State-based AMU estimates developed will be relevant for government policy makers to develop evidence-based, fair and equitable interventions focused particularly on rural and marginalized communities.

(enclosed as attachment: i) list of research publications based on this ongoing research; ii) list of different workshops and seminars presented to the states to initiate feedback and stronger conversations around data)

The solution will be developed on free and open-source platform and tools, guided by a robust development and open sharing philosophy. We will focus primarily on communities and seek to strengthen their informational linkages with public health systems. This community-based AMU data will also be shared continuously with health system at levels of the hospitals and state policy makers, to support their policy interventions to mitigate community AMR risks.

The project to date, and its impacts, have been scaled horizontally and vertically within the public health system. Horizontally, across hospitals and vertically from facilities to state policy makers. By incorporating through VISIBILITY, community focused data extended to OH sectors, we will help develop state-wide estimates of AMU. Methodologies, models, and resources developed under VISIBILITY will be made available to other states and community organizations to aim for national level impacts. This will be a unique impact given the scale and diversity of India, the extent of the AMU problem in the country and the rising state of infectious diseases. 

Project results will be made available to use by other Indian states, through our local partners, such as HISP India, NIPI and Doctors for You.

(partner descriptions given later in application)

Currently, specific mechanisms to monitor and evaluate impact and success in both states. The primary guiding philosophy is that impacts are best based on feedback directly from users on their perceived system effectiveness and added value from data and analytics for strengthening policy and practice interventions. Feedback is currently obtained through different mechanisms.

• Regular phone and digital meetings between the technical team building digital systems and hospital users, to understand emerging analysis needs, and how to better meet them.
• Regular data use workshops with community representative groups where data is analyzed and presented, and improvements needed are noted and acted upon.
• Larger seminars with state level audiences including NGOs, CSOs, researchers and community action groups to present results and obtain feedback.
• Generating quantitative assessments of estimates based on different benchmarks developed and models for their extrapolation to other settings.

While some of these are ongoing, VISIBILITY will expand monitoring mechanisms to obtain feedback on AMU estimates from community members, local health providers and relevant public entities, village level political bodies and local pharmacies. Digital tools such as community surveillance system will be employed. We will employ digital surveys, questionnaires and online feedback forms from citizens, pharmacies and community care providers.

Barriers are twofold. One, the lack of public and institutional awareness regarding AMU and AMR, which constrains uptake of new innovations. In absence of official mandates from government to report AMR statistics, undermines state budgets and accountability. Two, is limited dedicated resources for AMR reporting.  

HISP India’s extensive experience in state has guided developing pragmatic solutions.  For example, addressing state constraints through own funds for small expenses like internet and computer. This provided the space for them to demonstrate benefits of  digitization to build acceptance by administrators. In VISIBILITY we will seek third-party support to subvert funding constraints and create space for similar opportunities.  

Interconnected legal, financial, technical, and cultural barriers, may limit project progress, particularly limited awareness of AMU, entrenched practices of self-medication and OTC antimicrobial transactions. These limit willingness of communities to participate in self-surveillance, and pharmacies resistance to expose their sale and tax records. To incentivize use, we will demonstrate to communities the value of AMU data in mitigating health and out-of-pocket costs. Innovative methods will be used by posing as patients to take advice from pharmacists on drugs for particular illnesses. Such challenges may reduce with government initiatives mandating doctors to write rationale for their prescriptions.

We are excited to apply because of the call’s specific focus on data and analytics focused solutions for engaging with the AMR challenge and other global emergency threats. This is what we believe is that information, or the lack of it, directly impacts on why the AMR challenge is not being adequately addressed in India and many other LMICs. By strengthening the focus on data and digital technologies, we believe many of the current problems can be mitigated. This focus lies directly in our area of expertise and experience, and we have been working on this topic through research and practice for more than 20 years. We believe that this Challenge provides us with tremendous potential to expand our expertise and experience and apply it to one of the most pressing challenge India and other LMICs face. Key barriers related to resources, bringing together of global expertise, and building knowledge of how the data and digital focus can be strengthened, arguably can be addressed through a grant from Trinity Challenge. We believe that the knowledge and expertise built could be applied to other similar domains like environmental AMR and heat-health impacts, where there exists similar invisibility of data.

Organizations we will like to strengthen our collaboration are primarily policy making entities, so as to help enhance the visibility of our solutions and to support their adoption in different state governments. This we believe will provide impetus to building large-scale awareness, and will strengthen national advocacy efforts.

• Research and implementation institutes in - Veterinary, agricultural, fisheries, medical: at national & state level (including ICMR)
• Departments of health at state and national
• Partner and Advisory - FAO, UNEP, WHO, WOAH