�ݺ�ߣ

Editor's Notes

• #3: The increasing use of antimicrobials worldwide has been associated with a global increase in Drug-Resistance Infections, which threatens to return clinical therapies to the pre-antibiotic era. At present, DRIs are estimated to account for 50,000 deaths each year in Europe and the USA alone by 2050 it is estimated that DRIs will account for 10 million • deaths per year worldwide posing an economic and biosecurity threat. (LSHTM Roadmap) The rise of antimicrobial resistance (AMR) poses a threat to our ability to treat common and life-threatening infections on a global scale. Identifying the emergence of AMR requires strengthening of surveillance for AMR, particularly in low and middle-income countries (LMICs) where the burden of infection is higher and health systems are least able to respond.
• #4: In response to this global challenge, DHSC established the fleming Fund. 265million pounds investments on public health systems in 24 countries. Throughout the five years countries, 24 in total will become involved in the programme. Our work is in 3 of these countries, all three in different stages in this process. Focus is on LMICs – situation there is highly dependent on how well the health system in each country functions. Focus is not only on Human Health – instead they are underpinned by a ‘One health approach’ where sectors come together, human health, animal health, agriculture & environment.
• #5: One of the key concepts in the Fleming Fund and also within our work is the idea of an AMR surveillance system that is functioning at global, national, regional and local level. These systems are not really established in LMICs. They are in infancy. Fleming fund is aiming to create these systems. This representation here shows this process and core activities happening in the system. it includes ‘patient’ and activity that is happening in this system by various professionals, such as clinicians and laboratory staff. Laboratories play a big role in this process. However, they are at the margins of the medical profession, usually not much valued and staff there not well recognised. Little is known about how to offer laboratory capacity strengthening in ways that bring about effective change.
• #6: We viewed the laboratory as a key learning setting in the system. Knowledge-intensive workplace A key decision we made in early stages of the project was that we will focus on professionals in the laboratory and we wanted to understand bit more about their roles and what do they do in their everyday work. And how they see themselves fitting into the surveillance system. There’s a mandate by WHO for lab people to comply and establish knowledge on a framework developed by WHO and develop skills on doing tests and generating data and documenting this data. We were looking to unpack characteristics of this environment – what are the prominent work practices related to AMR; who are the people who are working in the labs; what are existing learning practices? How does the use of technology look like? What motivates these professionals? But of course they are not working alone. It’s a system where there are lots of interdependencies, lots of actors, global and local players, donors, complex work practice, and of course as we are talking about LMICs a completely different context.
• #7: Phase 1: Interviews with n=23 ‘experts’ on AMR (in person, online) Members of the Technical Advisory Group of the Fleming Fund / DHSC (n=3) Members of staff at a research institution in a LMIC, leading a capacity programme on AMR (n=2) Members of the Experts Advisory Group of the Management Agency leading the implementation of the Fleming Fund (n=7); Members of staff of the Management Agency; (n=8) and Secondees from the UK DHSC in organisations such as World Health Organisation, World Organisation for Animal Health (OIE) and Food and Agriculture Organisation (FAO) (n=3) Average duration 50min, recorded & transcribed. Experience spanning��multiple countries, including: Vietnam, Malawi, Cambodia, Philippines, Pakistan, Mali, Tanzania, Ghana, Uganda, Nepal, India, Laos, Kenya, Bhutan, New Zealand, Myanmar, Zimbabwe, UK.
• #8: We needed to find practical next steps and here’s what we did ie provide learning events that don’t simply disseminate knowledge but start to support the conditions specified in slides 15-21). In bold are the three most cited. Whilst ‘Foundations in Microbiology’ is a well-established domain in the field. But not the other two: The importance of developing communication, collaboration and advocacy skills across roles in the surveillance system. This category does not look at subject specific skills, such as in the category ‘Foundations in Microbiology’ but it underpins effective surveillance practice because surveillance activity involves numerous processes, interfaces and handoffs across different professional groups with varying levels of educational and professional training, and instances where critical information must be accurately communicated - across professionals, ranks, settings, teams and sectors. Where professionals are not communicating effectively, patient/public health safety is at risk and errors are likely to occur. Experts highlighted the need to bring clinicians and lab professionals together. Data Use & Interpretation for diagnosis - highlights the importance of data flow across local, national and global systems as discussed earlier. This gap in knowledge on how to use data might be due to the fact that AMR surveillance systems are not yet mature in LMICs. It might be because no specific roles have been created to use and interpret data, or because professionals who have this role have not yet acquired specialised skills, do not feel ownership of specific tasks or are not sufficiently supported in the performance of this activity.
• #9: 5.1 Supporting global challenges depends on well-functioning networks Analysis of the interviews with experts identified that the extent to which a global challenge can be reduced in LMICs depends on how well networks of individual organisations operate together with shared values to provide a functioning infrastructure. These networks include government organisations, NGOs, local facilities. The organisations in these networks have to be resourced, the organisations have to work in a joined-up way and there has to be commitment to a common goal from each organisation. �� In most LMICs countries the scale of resourcing in labs varies substantially both trans-nationally, within each country and within sector (animal and human sectors). Typically, labs in rural settings differ from urban areas; the capacity and expertise in AMR reference labs is different from sentinel sites and only a few labs are accredited. A number of systemic issues were identified with day-to-day operation of the labs, including infrastructure problems such as limited power supply, inadequate equipment, insufficient training to use the equipment), derisory quality control and quality assurance. �� The field work identified many examples where organisations were not working in a joined-up way. For example, the procurement process within the public health system in Country A based their choice of reagent based on cost. This means that the reagents selected were low cost. While low cost does not always mean low quality, in this case the reagents not allow for accurate detection of antimicrobial resistance, leading to low data quality. This problem signals a disconnect between the finance ministry and the technical people within each country. This means that systemic issues, such as data = quality, cannot be solved by training lab technicians to carry out state-of-the-art lab testing. Even if technicians know they require high quality reagents, they may not have access to these substances, because the national procurement agency does not support the purchase of these chemicals. Thus, there is an economic value chain that is not taken into consideration, due to a disconnect of the organisations that may be associated with hierarchical relationships (ie the ministry is at a higher level and cannot be questioned by the lab professionals). �� The Fleming Fund work aims to establish AMR networks, which is an on-going, long-term process. The countries visited are all in different stages in this process; some have already established network structures, while others have not. These networks are critical for the flow of good quality data. ��
• #10: AMR surveillance requires readily available, good quality data to be shared within and across networks. Data gathered at a local level – in a hospital or vet lab- has to be aggregated and shared with district and national facilities to inform treatment guidelines. A problem in LMICs is there are currently few systematic ways of collecting and reporting data. There are few standardised procedures and standardisation of reporting systems and data sharing and comparability with other countries is not yet possible. Links between clinical data, samples and clinical outcomes are not usually made, while any data that is available often is generated by externally funded research projects with limited lifespans.
• #11: During the field trips, interviewees drew attention to extensive and often unnecessary use of antimicrobials in human health, animal health and food production processes. It is well known that AMR is driven by an evolutionary response of microbes, but this phenomenon is usually made worse by ingrained professional practice. Each node in the network is likely to have key professions where awareness of AMR could be raised to help change these ingrained practices.
• #12: Almost all the interviewees in our fieldwork reported that lab professionals reported that the tests they carry out are routine and repetitive. The number of types of tests they can carry out and the number of microbes tested for is limited, therefore there was a need to expand the technical expertise needed to perform bacterial susceptibility testing. There was a consensus about the limited opportunities to upskill and engage in professional development. These two problems, repetitive tasks and limited opportunity to develop, were associated with a perceived low value placed in these job roles. These problems were attributed to low retention rates, low salaries and poor motivation of staff, which were all viewed as major barriers in strengthening capacity. Labs are low-resource environments and lab managers and heads of units often cannot commit extra resources to support AMR surveillance and upskill professionals. Entrenched behaviours and ingrained practice amongst members of staff appear to impact the quality of data. This problem is exacerbated by the fact that the public health systems place constraints in making the sort of Human Resources changes that are necessary to improve the system. ��
• #13: During the fieldwork we identified a number of cases where ‘lack of trust’ impeded work. Sometimes trust issues are associated with hierarchical structures within health systems. Frequently clinical staff and laboratory staff do not communicate effectively. Nor do they understand how their work interlinks. This problem leads to a lack of trust that impacts the use of AMR data to guide treatment. Tensions between key groups of professionals is not limited to the clinician-laboratory staff relationship, though this is a major difficulty within the public health part of the network. Laboratories are often run by people without a medical background, which may be perceived as problematic by clinicians. This problem is aggravated by the perception of hierarchy, since lab professionals “cannot exert weight” when giving advice on which antibiotics should be used in the treatment of patients. Clinicians sense responsibility in treating a patient, but often do not trust the lab data. This lack of trust might explain why clinicians follow entrenched prescription practices. �� These findings offer a new perspective on capacity building for global challenges, arguing that professional learning must extend beyond knowledge and skills development, to include reflection on and making adjustments to the work system and network.
• #14: 6.1 In parallel with providing learning opportunities, focus on creating well-functioning workplaces and networks Learning skills and knowledge in itself is not sufficient to tackle AMR. For capacity building to be effective, skills training has to be accompanied by a reflection on and re-organisation of the work environment. This involves examination of current and future roles and work practices and making necessary adjustments to work processes and practices. This could be achieved by designing professional learning events in ways that allow policymakers, senior laboratory professionals and lab professionals to reflect upon and reimagine how work is structured and how new practices (e.g. data use and interpretation) can be built and sustained. �� 6.2 Expand traditional forms of organisation, by supporting work and learning across boundaries To expand beyond traditional ways of working, for example where clinicians and labs are disconnected, there is a need to consider new roles that bridge across sites. New roles can be introduced within the system to act as brokers between various groups (for example a One Health Officer could connect different facilities). �� 6.3 Motivate professionals by offering learning opportunities and valuing career pathways Professional Development programmes should become an on-going provision and embedded within existing structures. However, opportunities to enhance the professional skills should be associated with valuing each profession. Pedagogic leadership development should be a key feature of professional learning programmes, especially for professionals in key training roles. �� 6.4 Encourage trust and openness amongst professionals, by designing learning that supports collaborative work. Collaboration and cooperation across key professional groups can be improved through supporting collaborative working and fostering interdependence across professional groups. Each professional needs to understand how his or her work fits within the system and how it inter-relates to the work of other professionals to ensure people have shared values. �� The paper provided an account of the ways professionals in human, animal and environmental health sectors can expand their capacity to work with antibiotics in ways that reduce antimicrobial resistance. AMR learning needs to focus on the needs and job role of each individual and particular forms of learning should be prioritised towards specific groups. This work points to a broader need to shift in our perspectives on capacity building for global challenges, arguing that professional learning must extend beyond knowledge and skills development, to include reflection on and making adjustments to the work system and networks.
• #15: Collaboration with International Development Office & IET Work with Mott & Department of Health