together4AMR#3 Barriers to and Benefits of a Collaborative Approach to Combat AMR

In this podcast series, global health leaders discuss the benefits and barriers of a collaborative approach to combating antimicrobial resistance (AMR) within communicable disease programs. The main benefit is creating a more sustainable and efficient system for preventing and treating infection. The rise of multi-drug resistant infections poses a threat to disease-specific programs like HIV and TB. However, there are barriers to collaboration, such as the complexity of AMR and territorial concerns from disease-specific programs. Integration, collaboration, and coordination are important, but complete integration may not be possible in larger countries. Advocacy, political commitment, and strategic information sharing are necessary for successful integration. Efficient use of resources and optimizing the health workforce are also important. My name is Anwar Parvez Syed and I welcome you to this series of podcasts together for AMR. In this podcast series, we interviewed five global health leaders who have dedicated their professional careers to combating communicable diseases and antimicrobial resistance. Also they are affiliated with esteemed organizations such as WHO, CDC and World Bank. The views they share in these interviews are personal and based on their extensive work experiences and they do not reflect the official positions of their organizations. This is the third episode of the series and in this episode, we asked our panel members what could be the benefits and barriers to a collaborative approach to antimicrobial resistance within communicable disease programs and here is what they said. I think the main benefit is one should end up with a much more sustainable and efficient system for preventing and treating infection and we urgently need to make progress in antimicrobial resistance and so that would help, I think, accelerate that progress. There's also, of course, the benefits to the disease-specific programs because if we don't get on top of antimicrobial resistance and we get rising multi-drug resistant infections, people with the HIVs and the TBs are going to be particularly susceptible to these infections. So in terms of managing comorbidities for the disease-specific programs is also going to be important. In terms of the barriers, I mean, this is complex. I think people like working in disease-specific programs because the clear focus and the line on delivery and results and undoubtedly working on antimicrobial resistance with the whole spectrum of bugs and drugs is more complex and I think a lot of the disease-specific programs can be a bit territorial. They will be concerned that there will be a dilution of the focus that they've had and a dilution of the money because, of course, dealing with AMR, the market's enormous. So we do need to ensure that in addressing AMR in its entirety in this collaborative way, the necessary focus on the key actions of the disease-specific programs isn't lost and I think that's a subtle balance and, you know, how and where that's done will vary between programs. And I think the other thing is that the disease-specific programs do need to realise that actually the whole mechanisms of resistance are different for bacterial infections. It took me quite a bit of time to realise that when you're thinking about TB, you are talking about resistance to tuberculosis bacillus while it's being treated with the drugs, whereas in AMR, a lot of the problems of resistance are not the index pathogen, if you like, that's being treated. You may have an ulcer on your leg that's being treated with systemic antibiotics, but the resistance may be developing in the microbiome in your gut and so that when you get your neck, you become colonised with a resistant bug that may not even cause you problems at that time, but then, in a later event, it emerges as a resistant strain. So we do need to be aware of the differences as well as the similarities. The Global Fund's strategy is fairly clear on the importance of health security and including AMR, addressing AMR as part of it. And, you know, the Global Fund obviously puts huge amounts of money into lab strengthening and everything else and they've certainly indicated they would welcome a more integrated approach. The challenge now is to get the country offices and the CCMs and everything else to operate in that same way and incorporate AMR appropriately. So I guess there has been resistance, and you're absolutely right that these programmes are more donor-focused. I think the board members of the Global Fund now are increasingly interested, obviously not in funding antibiotics, but in funding strengthening elements. Again, the whole machinery of the Global Fund and the proposal writing and everything else is orientated in one way and turning it around is a bit like turning around the super-tanker, I think. And we certainly need to do much more to achieve that at the country level. Areas are basically that there are disease-specific fundings, there are different programme managers for different diseases, there are earmarked fundings, and they don't want to share their turf, as you call them, that this is my area, I will work in this area only and I will not share my resources of the programme, that is one. But you know, it is a system that we really need to look into it. When we say integration, sometimes integration is taken as in a different way that by integrating I lose my benefits of having a vertical programme because vertical programmes also have their benefits. So when we talk of integration, we should always talk of integration, collaboration, coordination, synergies, not only integration. Our approach should be more of a, I will say, health in all policies of the government. I will give you some examples where we can have stewardship that we want for antimicrobialization. Most important of this is political advocacy and commitment. That is very important. At the national level, there should be country ownership on the nature and extent of the problem and programmatic solutions that are required. So if you have got a high level of political commitment, then it is easy to collaborate and coordinate. But do we really want to integrate everything? Is it possible? And the situation may be different in different countries. In countries which are large, integration of say HIV, TB, Hepatitis, STI may not be possible to large extent because of enormity of the programme. But in smaller countries, they have already shown integration. All their communicable disease programmes are fully integrated. I was WHO representative in Bhutan and this was a very good example of a collaboration of integration of all the programmes. But for bigger countries, there would be some degree of verticality with horizontal bridges in between. We basically require to have advocacy for governance, political commitment and then have three models of integration which can be complete, partial integration. Then also, if we really look into kind when we are talking of integration, we have very different strategic information system. Most of the countries in Southeast Asia region don't have burden of disease of AMR. We only have global data. We don't have the regional data to say there is a prevalence, different antimicrobial resistance to different antibacterials, antifungals. That information is lacking. So, we need to really look into how can we basically integrate our strategic information system. Thereby, we collect and collect information on different diseases and indicators. Then, optimisation of technical resources, training, capacity enhancement can be done which can be implemented in a phased manner. And we need to enable the health workforce to manage these issues in an integrated model. Laboratory services, we have already discussed that we can have multiplex and traditional testing method but focus more on rapid and platform-based. We know that in STIs, most of the countries follow a syndromic management. And we know that syndromic management will be good for coverage of STIs because we have a huge burden of STIs. But ultimately, this will lead to a kind of resistance. We are giving one dose of antibiotic, one dose of ceftric injection, erythromycin, one gram kind of kits that we have. Unless we are able to scale up our testing capacity, net testing, so that we can identify the causative organism, we will not be able to do away with the syndromic management. So, we have to bring in the balance that for preventing antimicrobial resistance, particularly in patients with STIs, of course, that will spread to others also. We really need to increase our testing capacities. Then also, we need to look into issues of procurement, logistics, how can these be combined at multi-disease levels, multi-disease platforms, how can we look into it. So, conflicting objectives of vertical programs need to be addressed to the extent possible. And most countries do not have any specific funding for AMRs. When I was in the regional office, the AMR was a separate unit and EGAS program for gonococcal resistance was with the HIV unit. So, there was hardly any coordination between the two units. But things are changing. Now, under the umbrella of overall AMR unit, all other divisions like HIV division, TB, STIs, they all come together and have one common program. And recently, I think, CRO has developed a regional action plan for AMR also. You know, collaboration is always beneficial in any area, particularly in public health. So, many of our countries in the low-median income country groups, you know, they work on limited resources. You cannot have a person working only on a particular program. It's really an efficiency issue, especially when we have very much constraint in the resource available. We have seen programs where you often work on, for example, tuberculosis control program is a lab technician who is working three in the morning, two or three hours. And after that, there is nothing because his lab tests are linked to morning OPD load, outpatient load. But then, you know, if you really bring in synergy and if you try to optimize his or her availability and try to use his capacity through additional incentives required to use them for other additional lab services, which may be contributed, which may contribute to the antimicrobial programs or maybe other disease control. This is one example that I am seeing. So, there is a lot of efficiency linked to optimize the use of human resources. That's one thing. Second thing is that efficient planning, for example, training program. You know, many times we see, you know, one set of training program happens for a particular program and then after a few weeks, the same person will come and attend for another training program. This leads to a lot of waste of resources and it's ultimately a common resource pool that we are all working on. So, it's important that we plan them properly so that we can channelize our resources in the most efficient way. Then, another major area I think many countries are now focusing on is on pooled procurement. So, pooled procurement is also linked to an efficiency factor because, you know, once you have really a good plan and then plan for procuring laboratory consumables or medicines, it is all linked to the volume. So, if there is a synergy between programs and there are many things that they commonly share, then there is, again, you are bringing in efficiency, saving resources when you bring in this synergy. So, these are some of the examples that I can tell you when it comes to the benefit of collaborative work. The vertical nature of the program, actually, for several years in many of our countries have created a barrier by itself. So, there is always this, you know, my program, my priorities. This sort of attitude, you know, that's really a challenge. So, what happens in that process is that managers of many of our programs are really very highly skilled. They have a lot of expertise in not just the clinical side of managing the program, but also in the managerial and leadership capacities. So, once we have developed, we invest a lot on such share of people, if we are really using them in a very, very vertical fashion, then that's a challenge that we are unable to use their capacity. So, challenge here in many countries is that the funding allocation for many of our programs are strictly built by vertical. So, that's a challenge that which takes away the incentives for collaborative work. So, the problem is that what is my incentive for my collaborative work with another program? So, there should be a space for incentivizing people across programs. For example, lab services versus, say, AMR. So, what is the benefit of lab services when they collaborate with AMR? Or when, as an AMR program manager, what is my benefit or what is my interest in collaborating with lab services? So, the limited understanding or a very narrow approach of some of these people in the leadership position sometimes create this issue that they cannot see beyond their own program. So, the tunnel vision actually creates a challenge in open communication and sitting together and discussing opportunities for collaboration. Once you overcome that challenge, I think that opens up a lot of opportunities for both programs. There are some changes that are seen. For example, as global funds, they are giving some space. Then we have now the pandemic fund, which is really being utilized in many countries and many countries are showing really good interest. There is one health approach, cross-collaboration, which is promoted and which have very specific components, like, for example, labs and strengthening healthcare workforce, capacity building, surveillance. In all these areas, AMR can be part of the whole overall project and the proposals. Globally, there is an understanding or we need to change. We need to change our strategy. And this is also linked to the limited budget space in which major programs are going to run. We see a dip in many countries' contribution to the major programs, global programs. So, I think there is a realization that we have to be more efficient, which means that we have to identify as much areas as possible for collaborative funding and collaborative proposals and projects. If you talk about the benefits, first thing is you will have a holistic response. So, that is like you will address the AMR alongside with other diseases that ensures a comprehensive approach, you know, like for managing a public health challenge. Second thing, you can optimize the resources, lab personnel, you can share the funds and, you know, which will lead on to more cost-effective and cost-efficient thing for implementing public health programs. Then the third thing is behavior change. So, you can coordinate your efforts for promoting rational antibiotic use, like, you know, which we discussed now. And if you talk about barriers, like mainly these programs are silos and these all are fragmented. So, these specific programs, they operate independently usually and despite having lot of HIV-TB coordination and things like that, still there are barriers in a holistic approach of things. But there will be always competing priorities, you know, balancing AMR with other health, their own. That program helps major challenges of implementation. So, that would be a barrier in which one I should focus, like I should focus on antimicrobial resistance or I should focus on just implementing the program for prevention or detection of intensified case finding, like example for TB or 95-95-95 HIV, like which one I should focus. So, again, like competing priorities might be a barrier. Then another barrier, like I could see is, if you tell SEALS tab or if you tell the district authorities, overcoming the initial inertia, right, like we had this problem when in 2010, the HIV-TB collaborative thing for ART centers were implemented. So, lot of initial inertia for, you know, promoting collaboration will be there. So, you have to, you can definitely overcome. So, you have to cross that, like, you know, that would be real barrier. All these programs are centrally funded. So, some are central sector schemes, some are centrally sponsored. But in both the ways, you know, like there is a involvement from the center there and at the highest level advocacy happens and it is agreed upon. I do not think regarding flexibilities within the program will be a problem, you know, like I will do only for this. If you see the health financing currently, there is more of a flexible sort of thing. You can design your priorities like for your state. So, mainly thing is like if you are able to do appropriate advocacy and you, if you are able to convince the policy makers, you will definitely feel the resistance like from the field also. Like what you are telling is this is, this funding is allocated only for this purpose. That is slowly changing, you know, like more of integrated funding. In the coming years, that should not be a problem. You will face initial problems, initial resistance, but if the right kind of advocacy is done for an integrated approach, then I think using the funds for an integrated approach should not be a problem. If you really integrate, you know, you can optimally utilize the resources and this could be a case, you know, why the high level advocacy has to happen and why there should be policy change from the highest level which has to percolate down for communicating to the state and district and field level staff. Because like you will save lot of money which can be used for better, better things like you know, for if you have an integrated approach. So, currently lot of duplication is happening. So, lot of duplication efforts like maybe it could be construction of labs or getting the equipments like for the same purpose and you can use all the human resources also. So, you can optimally utilize all the resources like if policy is there for an integrated approach. And that should happen through national action plan, that should happen through policies, you know, local policies for AMR and IPC and like things like that and you have to bring in regulations, you know, like how to implement that, how to ensure the implementation, all those things. So, it is a high level big task, but if that really happens, you will save lot of money if you have an integrated, synergized, integrated approach. And without that effort like you, it will be very difficult, you know, because the problem is, it is intra-sectoral. See, here we talk about AMR, containment of AMR, inter-sectorally through an old health approach, but are we united within the health system, in human health sector. Intra-sectorally also like we need to do a lot what you are suggesting about synergized effort. So, that would be really helpful like, you know, if you have a policy for having integration and collaboration like among the program, because like I do not think we are working in silos forever, like we will be able to really achieve many of the sustainable development goals. So, you have to have an integrated approach so that, you know, you can have a better system and provide better health for all. We do need a collaborative approach. There is no second thoughts on that. And that is why when we talk about AMR in human health especially, we talk about it not just multi-sectoral, but we also talk about multi-disciplinary. And we can actually add a paradigm in terms of multi-programmatic. We need to have that collaboration to occur because there is lot of cross-learning that can happen and also cross-talk of information that can happen. Right now, if you see the overall sort of collaboration that is happening is at a broader policy level, but not at the implementation level. Because even though the policy level there is convergence, there is a thought of convergence and there is a need for convergence. Action related to convergence or collaboration has been pretty minimal. And the barriers for this is again specifically that every program in itself will have its own vision, mission, objectives, and, you know, trying to reach some targets, outcomes and things like that, which don't get synchronized at a level or just get combined at a level. So each program is looked by multiple people at different level at different places. So there is no one place where all these things are collaboratively or comprehensively looked at. So if we need to move ahead with a collaborative approach, we also have to get the health department or the health ministry also in order. The collaboration that can happen or the sort of benefits that can happen is that there can be a lot of systematic learnings that can move in some of the processes, treatment guidelines, or data systems that can be adopted. And all those things can be combinedly put together and seen, and then probably take overall decisions in terms of health of the people rather than TB health or HIV health or malaria health or any other, you know, disease specific health of the people. We can surely pull these things together, especially if I talk about Indian context. We do see that most of the programs now come under the National Health Mission. And even AMR is a part of the National Health Mission. However, unfortunately, AMR works in silos where HIV, TB, vector-borne diseases, and you know, leprosy, all those things work on various verticals within the NHS. And they don't have a very comprehensive monitoring or review of it at levels where, you know, they can make some decisions. For example, at the district level or at the state level or at the national level, you don't have a combined comprehensive collaborative discussion. So one of the ways to start this collaboration is at least start by sharing data, start by putting data together, and at least provide some information to the policymakers and decision makers for certain actions to be taken. And we can at least start from there is what I think. Funding for communicable diseases programs is very separate. And many times, you know, whatever funding that is coming, whether sufficient or not sufficient, but at least there is funding or financing tied to it. However, when it comes to AMR, it still has to get the financing attached to it or dedicated to it. It's happening slowly, but I don't think it is happening the way we expect it to happen as a program or as a mission to take it up so that we can quickly get everything together. The financing is a huge barrier. But at the same time, I think it is also important that we'll have to think that what are the ways that we can actually integrate things for collaboration. So, you have to make people come together. And what are the ways that we can make people collaborate or come together to work towards a common cause? That still has to be cracked. So, as I said, probably we need to start off with at least data sharing and discussing so that there's some level of interest from the various parties coming together. And there should also be a specific budget for AMR so that if they need to do something else, they can actually improve their surveillance, improve their antibiotic use, and, you know, probably generate policies, do SDGs, do some trainings and things like that. But still, you know, collaboration needs to be, you know, clarified a bit because this is what is general issue because we know what has to be done. We know it has to be a collaborative approach. We know that, you know, collaborative approach will work in this. But we actually don't know how to implement this collaborative approach. What will be this collaborative approach look like? We still have to sort of ease those things out. Just to summarize, a collaborative approach to AMR within communicable disease programs offers several benefits and faces distinct barriers. Benefits include creating sustainable and efficient systems by combining resources such as laboratory personnel, funds, and infrastructure, leading to cost-effective public health interventions. Enhanced disease management becomes possible by integrating HIV and TB programs with AMR initiatives, improving treatment protocols and patient outcomes. Stronger surveillance and data systems facilitated by integrated dashboards enhance the ability to respond to AMR with evidence-based strategies. Improved diagnostics and laboratory services result from pooling resources, reducing inefficiencies, and enhancing diagnostic capacities. Community engagement strategies from disease-specific programs can raise awareness about AMR and promote responsible antibiotic use, leading to significant behavior changes. However, barriers to include programmatic silos that operate independently with dedicated funding and staff, making resource sharing and collaboration challenging. Funding and resource allocation issues arise from earmarked funds for specific diseases and insufficient dedicated AMR funding. The complexity and scope of AMR involving various microbes and drugs complicate integration with disease-specific programs. Leadership and governance challenges require leaders with strategic vision and strong stakeholder coordination. Behavioral and cultural barriers may also hinder collaboration as field staff and authorities resist changes to establish program structures. This is the end of Episode 3. Stay tuned for the next episode in this series, Together for AMR, which will be about the leadership roles at various levels that can significantly promote a collaborative approach to AMR agenda.