Written By Learnmore Edwin Zvada
Almost the entire of rural Africa falls with the low- and middle-income countries (LMICs) bracket. It then follows that this demographic is subject to economic and public health disparities that continue to bedevil marginalized economies. Not least is the scourge of Antimicrobial Resistance (AMR), whose exact extend remains mostly approximate, thus necessitating a robust investment in AMR Surveillance systems and other interventions that can inform on the same.
And the Covid19 pandemic has made things worse, with the gains made in fostering public health access in rural areas of Africa at grave risk. The Economic Commission for Africa(ECA) report on the Covid19 pandemic estimates that close to 27 million Africans, mostly from rural Africa, will be pushed into abject poverty(UNECA, 2020). This simply means that the same people are going to be at risk from public health threats, including AMR.
Antibiotic Knowledge and Use in Rural Africa
Several researches have been conducted to elicit the knowledge of antibiotics amongst rural populations in Africa. Results from the literature review suggest that most people in rural areas have limited understanding of antibiotics. Research conducted in the semi-rural district of Manhiça in Mozambique indicated that many research participants thought that the term ‘antibiotics’ referred to drugs in general (Cambaco et al., 2020).
Notably, most people in rural areas of Africa access antibiotics in public hospitals and clinics. Public health facilities often receive medicine from the government through the relevant ministries and from donations from various stakeholders. Because of the scarcity of antibiotics in public health facilities and lack of microbiological diagnosis, prescribers are often forced to use broad-spectrum antibiotics.
However, excessive use of broad-spectrum antibiotics has been shown to give rise to superbugs resulting in poor therapeutic outcomes. There are cases where the prescribed antibiotic is simply not potent enough against the infectious agent concerned, and this prompts the contagious agent to develop resistance.
It’s a ‘catch 22’ situation for the prescribers because sometimes delaying treatment will result in infection and, in some instances, death. Therefore, there is a need for balance and prudence on the part of the healthcare professionals to ensure optimal empirical antibiotic therapy (Manthous and Amoateng-Adjepong, 2000).
The Economic Burden
The United States of America’s annual healthcare expenditure is an equivalent of about 18% of its Gross Domestic Product(GDP), and close to the federal government provides close to half of the funding(CRFB, 2019). In contrast, Africa spent an average of 5 to 6% of its GDP on healthcare from 2000 to 2015.
As has already been mentioned, the bulk of Africa’s health expenditure is met by donor aid. It means that when donor fund dwindles, African governments are forced to make drastic cuts on the medicine requirements of respective public health institutions, which would already be struggling. Considering that urban centers are residents to most economically productive populations, rural health facilities are often least prioritized and poorly resourced. Resultantly, rural people are left extremely vulnerable to public health threats such as AMR.
On its own, AMR brings a hefty bill bearing in mind that drug-resistant microorganisms or superbugs often require the use of second-and third-line drug regimens, which are costly and difficult to access. The long and short of it is that rural populations are most susceptible to AMR ramifications, and proper measures need to be put in place before it’s too late.
What can be done?
Most rural areas in Africa have no access to clean water, and some still practice open defecation. These factors contribute to the occurrence of infectious diseases, which often require antibiotic therapy, and it has been shown that exposure to antibiotics inherently predisposes one to AMR. NGOs such as the World Vision have initiated Water, Sanitation, and Hygiene (WASH) programs across Africa because it has been found out that poor sanitation, hygiene, and water supply is a massive facilitator of AMR(World Vision, 2020).
Additionally, there is a scarcity of health facilities and personnel in most rural areas. Consequently, there is a severe lack of information on AMU and AMR. People will continue engaging in the misuse of antibiotics without realizing that they are putting their health at risk.
Increasing the number of clinics and hospitals in the long-term plan can be of use in this. Still, the more immediate solution is to train more community health workers who are thoroughly schooled on AMR’s phenomena and what needs to be done to put it under control. In Kenya, the World Vision is working with community health workers to establish WASH clubs in schools where students are trained to participate in peer education.
The 2005 World Health Assembly Resolution regarding AMR resolved that member states would ensure regular monitoring of AMR and AMU in all relevant sectors(WHO, 2009). But statistics on AMU and AMR in rural Africa remain deficient because of skimp resources.
Therefore, responsible authorities must come up with community-based surveillance systems of AMU and AMR. Relevant technical support and funding should be provided, especially during the conception of pilot projects of the same as this will determine the programs’ success in the long haul.
For instance, data on a named antibiotic can be gathered using a defined daily dose (DDD) of the drug prescribed per 100 patients visiting a specified health facility. The data can then be compiled and incorporated into the national surveillance data and, ultimately, the Global Antimicrobial Surveillance System(GLASS). Participation of countries in GLASS is key because this will help implement the Global Action Plan on AMR and influence policymaking on the same.
There has been renewed interest in herbal medicine lately as people are shying away from modern medicine’s adverse effects and the associated high costs of therapy. More research needs to be done in the area of herbal medicine so that we may be certain of its safety, efficacy, and effectiveness.
Most people in rural areas take herbal medicine concomitantly with traditional medicine. This puts them at risk of drug-herb interactions, which may prove detrimental to their health. So, since herbal medicine is the way to go in circumventing antimicrobial/antibiotic use, healthcare professionals and policymakers should ensure that there is standardization in its use and the availing of relevant information to prevent unnecessary harm.
Lastly, perhaps local authorities and national governments, and private players should consider capitalizing on public-private partnerships(PPP) to facilitate the financing of various initiatives that can be put in place in fighting AMR. PPPs have proven to work in countries such as Kenya and Uganda in meeting national requirements of youth reproductive health services thus improving surveillance of national health outcomes (Songwe, 2019). A similar approach can be adopted for antibiotic surveillance systems and related enterprises.
Many works need to be done with regard to education and awareness. Relevant government institutions, healthcare personnel, NGOs, and other stakeholders can visit schools, public gatherings, community health centers and hold seminars and symposia geared at disseminating information on AMU and AMR. Mass media, including radio and television can be put to use in this regard. If this knowledge gap is bridged, people can actively participate in this global fight and offset the prognosticated doom that awaits humanity if the current public health trajectory is maintained.
- Cambaco, O. et al. (2020) ‘Community knowledge and practices regarding antibiotic use in rural Mozambique : where is the starting point for prevention of antibiotic resistance ?’, pp. 1–15.
- CRFB (2016) American Health Care: Health Spending and the Federal Budget | Committee for a Responsible Federal Budget, Committee for a Responsible Federal Budget. Available at: https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget (Accessed: 12 December 2020).
- Manthous, C. A. and Amoateng-Adjepong, Y. (2000) ‘Empiric antibiotic use and resistant microbes: A “Catch-22” for the 21st century’, Chest, 118(1), pp. 9–11. DOI: 10.1378/chest.118.1.9.
- Songwe, V. (2019) Financing Africa’s Healthcare | GBCHealth, GBCHealth. Available at: https://gbchealth.org/financing-africas-healthcare/ (Accessed: 12 December 2020).
- UNECA (2020) ECA Report: COVID-19 in Africa: Protecting Lives and Economies | Africa Renewal, United Nations Africa Renewal . Available at: https://www.un.org/africarenewal/news/coronavirus/eca-report-covid-19-africa-protecting-lives-and-economies (Accessed: 12 December 2020).
- WHO (2009) Community-Based Surveillance of Antimicrobial Use and Resistance in Resource-Constrained Settings. Geneva
- World Vision (2020) Water, Sanitation and Hygiene (WASH) | World Vision International. Available at: https://www.wvi.org/kenya/our-work/water-sanitation-and-hygiene-wash (Accessed: 12 December 2020).