managing amr- the case of ghana. martha gyansa-lutterod (ghana)

Martha Gyansa-Lutterodt Director Pharmaceutical Services

Ministry of Health Chairperson, Ghana Antimicrobial Resistance Alliance

3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections Networks in Stockholm, Sweden on February

12, 2015

Managing Antimicrobial Resistance: the case of Ghana

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Upper West

Upper East

Northern

Brong Ahafo

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Vol taEastern

WesternCent ral Greater Accra

RegionsAshantiBrong AhafoCentralEasternGreater AccraNorthernUpper EastUpper WestVoltaWestern

Water body# District Capital#Y Regional Capital

Ghana boundary

200 0 200 400 KilometersN

EW

S

Ghana Map

Prepared by Alexander Boakye Marful, July 2005

Ghana

Total Population (2012) 25,366,000

Gross National income per capita (PPP international $, 2012) 1,910

Total expenditure on health per capita (Intl $, 2012) 106

Total expenditure on health as % of GDP (2012) 5.2

Life expectancy at birth m/f (years, 2012) 61/64

Probability of dying between 15 and 60 years m/f (per 1000 population, 2012) 263/227

Ghana Facts and figures

Presenter

Presentation Notes

We have all probably heard about Ghana on other platforms Well known statistics about Ghana

Introduction: the need for AMR interventions

Major causes of mortality

Conditions affected directly by AMR

Conditions Not directly affected by AMR 40% 60%

Presenter

Presentation Notes

40% of the drivers of mortality are from diseases that are treatable/manageable by antimicrobial agents Access to antimicrobial agents is thus critical for health and is life saving for a good proportion of the population The historically and traditional antecedent is that antimicrobial use has been part of the way of life of the people. Would the historical and traditional approach to antimicrobial use be transferred to the products we use today?

Introduction: Access to essential medicines Availability

Availability of medicines >85% for 65 tracer medicines *

Affordability Social health insurance

reimbursing 548 medicines (13.1% antibiotics)

Out of pocket payments Accessibility: Geographical

distribution of medicines outlets Private Pharmacies >80%

urban Licensed chemical sellers

>80% rural Public health facilities, CHPS

Quality SSFFCs and Storage

conditions

*Office of the Chief Pharmacist 2013 data

Ghana Drug Access Problem Ratio

Quality40%

Accessibility20%

Affordability40%

Quality 40%

Accessibility 20%

Affordability 40%

Presenter

Presentation Notes

Overall medicines availability (including antimicrobial agents) is fairly commendable >85% Mechanisms are in place to remove the financial barrier to key antimicrobial agents, but with resistance would affect value for money. Out of pocket payments still exist Licensed chemical sellers who are not allowed by policy stock and dispense antibiotics are the main players in the rural areas, which is not attractive to the private community pharmacies. Thus who fills the access gap to provide access? Policy implementation gap! Antibiotic use in low and middle income countries, as in the case of Ghana, is impacted by systemic and specific challenges that require broad as well as specific solutions

Policy perspective

The National Drug Policy Standard Treatment Guidelines (STGs) & Essential

Medicines Lists (EMLs) with levels of care National Health Insurance Lists (NHIL) Food and Drugs Authority Register, with classification of

medicines Over the Counter medicines, Pharmacy Medicines, Prescription Only

Medicines

Pharmacy council -Major/common human pathogens considered: E. coli, Klebsiella, Salmonella, Pneumococci, Staphylococcus aureus

-Common antibiotics recommended STGs: Amoxicillin, Erythromycin, Ceftriaxone, Tetracycline, Cefuroxime, Gentamicin, Ampicillin, Ciprofloxacin

Presenter

Presentation Notes

Broad framework for medicines management Supportive structures for antibiotic use STG, EML NHIL, FDA-OTC/PM/POM, PC

Policy assessment: sustaining the gains made by positive interventions on trends in RUM

The National Drug Policy recommends routine monitoring of Rational use of medicines (RUM) The WHO core indicators adopted for use in country, includes

one direct indicator for antibiotic use

Office of the Chief Pharmacist, 1999 to 2013

The indicator trend, aligns with investments in DTC training

56.3

40.5 41.4 43.1 36.4

45.2 40.7

37.6

48.7 49.5 42.0 43.6 43.3 41.4 39.9

15.0

25.0

35.0

45.0

55.0

65.0

75.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Percentage of outpatient encounters with an antibiotic prescribed from 1999 to 2013 in Ghana

Ghana AMR initiatives

Presenter

Presentation Notes

In the current context of AMR, should the routine indicator set for monitoring antibiotic use, be expanded? What other data is relevant? What would be the value of the data? The current indicator is very useful. Aligns with investments in RUM training of DTCs in public facilities; and thus is also subject to changes in DTC membership and new recruitments and HR dynamics. How do we sustain the gains and build on. The reality of the linkages between clinical practice and public health is even stronger in our times, Thus we must train health professionals to consider Sustainable broad-based approaches may be more helpful with due cognisance to the aspects requiring specific interventions This is Public sector data….What about the private sector?

Other Challenges in the use of Antibiotics

Use of antibiotics in aquaculture Incentives for the use antibiotics in firm farming ‘Tilapia’ fish farming

Use of antibiotics in animal husbandry Need to strengthen rational use of medicines in veterinary

practice (treatment protocols and standards) Veterinary public health service has been engaged on the Ghana

AMR platform

Nascent surveillance system The Surveillance system is nascent that requires standardization

and quality assurance to feed into global actions

Presenter

Presentation Notes

Tilapia is a delicacy in Ghana, the bigger the better. Antibiotics are being used in this regard. Observing the ‘washout’ periods before the slaughter of animals

The impact of these challenges: The need for efficient stewardship programmes

0.9 0.9 0.9 0.9 1.7 2.6 2.6

5.2 6.1

14.8 24.3

39.1

Deworm DrugFlucloxacillin

MethicillinNivaquine

Co-trimoxazoleAmodiaquineCiprofloxacin

CloxacillinChloroquine

AmoxicillinAmpicillin

ChoramphenicolProportion (%)

Examples of ineffective antibiotics as given by respondents in KABP assessment on CSOs, Non-Health professionals

Medicines users are faced with the implications of AMR on treatment outcomes, cost etc.

Aligns with Resistance to Amp, Chl in Ghana -Ampicillin 76% -Chloramphenicol 75% Newman et al, 2011

Presenter

Presentation Notes

The outplay of all this is that the average medicines user is fully aware that some antimicrobial agents are no longer working, probably based on their-user experience Ampicillin and Chloramphenicol were reported by respondents as ineffective This is supported by Newman et al, 2011, resistance to Ampicillin and Chloramphenicol is 76% and 75% respectively Is the medicine man and his client aware that their actions may have contributed to this phenomenon? -intense community sensitization on the dangers of antibiotic abuse Our interventions must include specific and targeted approaches to some of the challenges we are confronted with

The Beginning of AMR program in Ghana

The role of o ‘The race against Resistance’ - Working Group -Centre for Global

Health Development o The Uppsala Summit on ABR in 2010 o Local institutional leadership in a multi-stakeholder approach

The Ghana Ministry of Health (AMR agenda at May 2014 Health Forum in Ghana)

Multi-stakeholder approach (Ghana AMR stakeholder platform) o Partnerships and synergies

Swedish International Development Agency, ReAct Project-Uppsala University),

World Health Organization (WHO)

What is happening in Ghana-highlights

Baseline assessment Situational analysis, stakeholder analysis, Assessment

of knowledge attitudes beliefs and practices of Health professionals and CSOs in health, baseline assessment of resistance

Policy processes. Ghana AMR policy is ready for parliamentary action

Capacity building CSOs in Health Capacity building programs (under ADMER-project)

African Antibiotic Use conference March 18-20 ,2015 Communication

Papers, Websites, Media

Training of Trainers – CSOs in Health

CSO – Region/location No.

GCNH: IDC - Northern 37

AWI - Western 33

HFFG - Central 29 LAPAG - Greater Accra 25 CSHC - Greater Accra 32 TOTAL 156

Presenter

Presentation Notes

ToT workshop on CSO in health on the responsible use of antibiotics and antibiotic resistance. 156 CSO members have been trained across 4 regions in Ghana where the CSOs are located

Some pre-post test results of CSO training

6 2

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12

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pre post pre post pre post

Central Northern Western

Pre-Post test response to Bacteria and Virus are the same for 3 regions

No No Answer Yes

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30

35

post pre post pre post pre post pre

AccraLapag Central Northern Western

Pre-Post test response to Microbes live in harmony with the environment for 4 CSO

groups

No No answer Yes

Presenter

Presentation Notes

Graph 1: those who responded Yes to bacteria and virus are the same saw a significant change in the post test to the same question. Graph 2: pre-post response to microbes live in harmony with the environment for 4 CSO groups. Majority responded YES it is also significant to note the decrease in numbers for those who answered NO or NO ANSWER in the post test.

Orientation/Sensitization of Key Stakeholders

Over 80 key stakeholders sensitized in western region

About 30 Queen mothers in central

10 municipal health directorate staff

Pharmacist Annual Meeting

AGM of Ward nurses AMR TWG Health Summit

Presenter

Presentation Notes

Queen mothers called for support (technical and financial) and collaboration with the municipal health directorate for more education on responsible use of medicines and antibiotics in their communities

Summary of issues-lessons from Ghana ① The need for broad policy framework

Antimicrobial resistance vrs Antibiotic resistance Key policy areas Community education and Sociocultural change interventions

② Role of Legislative instruments ① Distribution and use

③ Balancing access, excess and equity (inline with distribution of appropriate cadres and level of use)

④ Quality of antimicrobial agents- regulatory mechanisms ⑤ The role of health system issues

Infection Control strategies- Policy review in progress Laboratory capacity and logistics Community actions and participation

Summary of issues-lessons from Ghana

⑥ Need for an expanded monitoring framework RUM indicators (1 indicator for Antibiotic use)

⑦ Alignment and contextualization within existing policies on medicines

Infection control policy National Medicines Policy EML policy

⑧ Linking surveillance data with selection of antibiotics

Reports, Training Manuals, Educational materials

Publications and Papers

3 more manuscripts almost ready

www.ghndp.org/antimicrobialresistance

www.admerproject.org

END Thank you

managing amr- the case of ghana. martha gyansa-lutterod (ghana)

Health & Medicine

ghana total population

tracer medicines

ghana facts

case of ghana

amr conditions

total expenditure

rural public health

storage conditions