Addressing antimicrobial resistance by improving access and quality of care—A review of the literature from East Africa

Abstract

Universal access to healthcare, including quality medicines, is a fundamental human right but is still out of reach for many in low- and middle-income countries (LMICs). An existing framework capturing variability of access to healthcare in low-resource settings includes the 5 dimensions: availability, accessibility, affordability, adequacy, and acceptability. This framework encompasses key components, including health infrastructure and means to access it as well as service organisation, costs, and factors that influence users’ satisfaction. However, in reality, the effectiveness of accessed healthcare is measured by the likelihood of a positive outcome. We therefore propose an expansion of this framework to include an additional dimension, “aspects of quality,” incorporating quality, which critically influences the ability of the accessed services to generate optimal health outcomes. Within this framework, we explore literature from East Africa likely relevant to a range of LMIC contexts, mainly focusing on the provision of widely used antimicrobials such as antimalarials and antibiotics. We argue that major inadequacies exist across all 6 dimensions of access and quality of drugs and their provision. While the global focus is on curbing excessive antimicrobial use to tackle the antimicrobial resistance (AMR) crisis, major constraints around access shape patients’ health-seeking decisions leading to potentially problematic practices that might exacerbate the AMR problem. We advocate for a holistic approach to tackling these inadequacies, encompassing all dimensions of access and quality of healthcare in order to improve health outcomes while simultaneously counteracting the AMR crisis.

Viral etiology of lower respiratory tract infections in adults in the pre‐COVID‐19 pandemic era: A cross‐sectional study in a single center experience from Cameroon

“… 8 , 9 , 10 , 11 Many health systems in sub‐Saharan Africa do not have an effective antimicrobial stewardship program because of the lack of a proper diagnostic technical platform. 12 , 13 Selective use of antimicrobials based on proper diagnosis (i.e. evidence of differentiation of bacterial from viral infections) may strengthen antimicrobial stewardship.…”

“…Antibiotics are generally prescribed to patients with respiratory tract infections on a probabilistic basis in most health facilities in sub‐Saharan Africa, and this can lead to antibiotic resistance 8–11 . Many health systems in sub‐Saharan Africa do not have an effective antimicrobial stewardship program because of the lack of a proper diagnostic technical platform 12,13 . Selective use of antimicrobials based on proper diagnosis (i.e.…”

Supply-chain factors and antimicrobial stewardship

“… 30 , 31 Affordability of medicines has also affected decisions on antimicrobial use in Kenya and northern United Republic of Tanzania. 32 Shortages and stock-outs can be prevented by strengthening the supply chain for medicines across all stages, from active pharmaceutical ingredients to finished products, including ensuring robust quality of pharmaceutical ingredients and all raw materials. 33 The fragility of supply chains for medicines was highlighted during the COVID-19 pandemic.…”

“…Studies show that over-the-counter antibiotics may be used as incomplete regimens or to treat non-bacterial illnesses. 32 The problem is exacerbated by shortages and frequent stock-outs of essential medicines, including antimicrobials. Supply-chain security is therefore an important factor in antimicrobial resistance.…”

Quality and safety in the literature: January 2024

“…Emergence and increasing rates of antimicrobial resistance (AMR) pose a substantial threat to the quality and safety of global healthcare. Limited access to and poor quality of care (eg, inadequate adherence to protocols, poor infection control, lack of diagnostics) contribute to escalating resistance 8. It is estimated that in 2019, there were 1.27 million deaths attributable to bacterial AMR, with sub-Saharan Africa bearing the highest burden 9.…”