Antimicrobial resistance (AMR) has been causing millions of human fatalities annually and massive losses to global production and incomes. What is AMR? The simplest answer is that AMR is “the ability of microbes to grow in the presence of substances specifically designed to kill them.” How and why has the AMR issue grown massively? We use and hear about antibiotics every other day. Not very long ago and ever since Alexander Fleming discovered penicillin, antibiotics were the most effective treatment for tackling microbial infections. However, the inappropriate use of antimicrobials (including antibiotics) in health care and in raising crops and animals has caused the emergence of multidrug-resistant microorganisms.
Pakistan offers a dismal case study of antibiotics’ over-prescription reinforced by the use of antibiotics where they were probably not needed in the first place. Antibiotic use in Pakistan has increased by 65% over the last 16 years. According to the World Health Organization (WHO), the prevalence of patients receiving at least one antimicrobial agent in clinical/hospital settings in Pakistan is a whopping 75%. In more than half of the possible situations, patients resort to self-medication.
That said, most of the antimicrobial usage (AMU) is in the veterinary and poultry sectors. Pakistan ranks among the top ten livestock producing countries and animals are being provided with antibiotic supplements on a routine basis. In addition, hospital waste, waste-water treatment plants, sewage treatment plants and inappropriate disposal of unused drugs are likely contributing significantly to the environmental burden of antibiotics.
Where does Pakistan stand in acknowledging the damage caused by AMR? The issue has been taken up in Pakistan at the highest levels. To begin with, Pakistan endorsed the AMR Global Action Plan at the 68th session of the World Health Assembly in 2015. Its most notable follow-up was that Pakistan developed an operational AMR National Action Plan (NAP) in 2017. The NAP focuses on critical aspects of AMR, i.e., the surveillance of AMR burden, effective stewardship and prudent use of antibiotics in all sectors with special emphasis on national awareness raising.
The NAP commits to address the issue of AMR through the One Health (OH) approach. What does the OH approach focus on? It aims at simultaneously attaining optimal health for people, animals and the environment. Understandably, under the OH approach, the three primary stakeholders in the federal government include the Ministry of National Health Services Regulation and Coordination (MoNHSR&C), the Ministry of National Food Security and Research (MoNFS&R) and the Ministry of Climate Change (MoCC). The MoNHSR&C is the designated focal point for International Health Regulations (IHR) and AMR in Pakistan with the National Institute of Health (NIH) playing the key part. The MoNFS&R also has a significant and sizeable role in implementing the NAP.
While the recognition of AMR as an issue has been growing, the numbers for Pakistan (as quoted above) tell a different story. The prime question is: What is hindering meaningful steps towards the prudent and restrained use of antibiotics? There is not merely a single responsible factor. However, it appears that a key hindrance is the serious lack of meaningful Multi-sectoral Coordination (MSC) to reduce AMR. Various institutions are working on AMR in different capacities albeit in isolation and sans any systematic mechanisms to share their research and experience. More specifically, human and veterinary health, poultry and agriculture sectors lack collaboration on AMR containment efforts both at federal and provincial levels. At the federal level, for instance, there is limited infrequent need-based interaction between MoNHSR&C, MoNFS&R and MoCC.
Data collection/sharing pertaining to AMR, AMU and antimicrobial consumption offers the best avenue for greater collaboration of human health (HH) and animal health (AH) counterparts and a multi-sectoral stakeholder buy-in. As things stand, the availability of regular and reliable AMR-related data, especially that pertaining to AH, is seriously limited. AMR HH data faces its own quality challenges. It is not uncommon to come across under-reporting issues due to incomplete data of patients as well as lab data of compromised quality.
Some “dormant” national agencies have to play an active role for systemic data collection mechanisms. A good example is the seriously under-performing Drug Regulatory Authority of Pakistan (DRAP) which collects and compiles data related to the import and local production of antibiotics. The DRAP requires an institutional overhaul to develop capacity to analyze and disseminate the collected data for policy purposes. This might also provide an impetus towards better regulation by the DRAP with evidence suggesting that the market is flooded with over-registered, sometime sub-standard antibiotics.
Its downside notwithstanding, the COVID-19 challenge has renewed focus on surveillance systems in Pakistan. The COVID-19 response reflects potential for more strategic focus on IHR implementation in Pakistan. Successful implementation of the AMR NAP will entail prioritizing the OH approach for effective MSC between AH, HH and environment. There is ample evidence that the OH concept is often undermined and underestimated in Pakistan.
The AMR NAP is a comprehensive document that can drive the AMR agenda. But it is time to learn from implementation failures in reducing AMR prevalence. Future efforts must focus on creating a sense of ownership among primary stakeholders at both federal and provincial level. Let us take-off with an AMR advocacy and awareness campaign, not only for health workers, but for the biggest stakeholders – the patients themselves – to highlight the emerging AMR health crisis and its damaging outcomes .
