One Health Newsletter

One Health Newsletter: Volume 15 Issue 1

Managing Antimicrobial Resistance in Ethiopia: Some Lessons for Other African Countries

Author

Eyoel Abebe Hailegabriel

Introduction

As soon as the concept of One Health in 2017 was considered by the World Health Organization (WHO), the fight against antimicrobial resistance (AMR) was listed as a priority and remains so today, when the agency recognizes the dimension of risk to name it: the silent pandemic. Antimicrobial resistance poses a significant global public health threat, undermining the effectiveness of antimicrobial treatments, and leading to increased morbidity, mortality, and healthcare costs. In African countries, the problem is exacerbated by factors such as inadequate healthcare infrastructure, limited access to quality healthcare, and unregulated antimicrobial usage. Western sub-Saharan Africa is a hotspot for AMR, with high mortality rates linked to AMR.¹ If not tackled effectively, Africa could face over 4.1 million AMR-related deaths annually by 2050.¹

As of 2017, Ethiopia was the only African country with a national action plan to combat AMR.³ According to the WHO, 33 African countries (Figure 1) have subsequently developed action plans to combat AMR.² Implementing national action plans to address AMR in African countries faces numerous challenges, including inadequate technical and financial resources, lack of political commitment, and limited understanding of AMR’s impact on national progress. Additionally, there is a lack of surveillance data, weak inter-sectoral coordination, and limited public health awareness of AMR, as well as a lack of integration into country policies with negative budgetary allocation implications.

Figure 1: African countries developing a National Antimicrobial Resistance Plan. Legend: Red color represents countries with an AMR plan. Source: Adapted from https://www.mapchart.net/index.html, licensed under a Creative Commons Attribution)

This article aims to examine Ethiopia’s policies and strategies for managing AMR and seeks to identify and address the specific gaps, providing valuable lessons for other African countries looking to develop or refine their own AMR policies.

Methods

A comprehensive literature review and policy analysis were conducted to understand the background, prevalence, and impacts of AMR in the country as well as its major drivers. Relevant policy documents were analyzed, such as the Strategy for the Prevention and Containment of Anti-microbial Resistance 2021-2025 and the Ethiopian Standard Treatment Guidelines. This analysis involved evaluating the effectiveness of existing policies and strategies, as well as identifying potential areas of improvement with a focus on the challenges they face in terms of implementation, coordination, and resource allocation.

Results

Findings

Major drivers of AMR in Ethiopia include incorrect and inappropriate use of antimicrobials by healthcare providers and unskilled practitioners, as well as inadequate surveillance. According to a recent study, AMR is causing around 196,000 treatment failures each year in the country, leading to 3,000 child deaths annually.⁴ Empiric antibiotic usage is another contributor to AMR in Ethiopia, where antibiotics are prescribed based on syndromes rather than microbiological data.⁵ Furthermore, the use of antimicrobials in farm animals for prophylaxis and growth promotion is fueling AMR in the country.⁶ Contamination of water sources with drug-resistant bacteria due to human and animal waste is another factor aggravating AMR. Inadequately disinfected drinking water increases the risk of exposure to these drug-resistant pathogens.⁷

A study conducted in Ethiopia found the pathogens causing diverse disease conditions showed 30-85% resistance to key antimicrobial products listed in the Ethiopian Standard Treatment Guidelines (ESTG), while some reached up to 100% among specific drugs such as penicillin, ampicillin, or amoxicillin.⁷ The ESTG, which serves as the principal reference for healthcare providers,⁵ is not updated regularly. As a result, healthcare providers may prescribe drugs that are often ineffective, leading to further resistance. Moreover, patients can readily procure these drugs over the counter, contributing to the improper use of antimicrobials.³ Current policies and strategies tend to focus more on what the government can provide and less on promoting responsible usage of antimicrobials by patients. This approach may not be sufficient to address the full extent of AMR in Ethiopia.

The current policies and strategies include the Strategy for the Prevention and Containment of Anti-microbial Resistance 2021-2025⁸ and the ESTG.⁵ These policies focus on raising awareness, improving education, surveillance, research, infection prevention and control, and antimicrobial stewardship. They aim to provide a comprehensive framework for tackling AMR in Ethiopia through a multi-sectoral approach that involves the collaboration of various stakeholders. The estimated budget for implementation is approximately US$22 million (Table 1).⁸

Objectives	Indicated Budget Allocation
	USD ($)	Percent (%)
1. Improve awareness and understanding of AMR through effective behavior change, communication, education, and training	2,642,355.60	11.8
2. Strengthen knowledge and evidence on antimicrobial use and resistance through surveillance and research	15,034,132.00	67.0
3. Enhance infection prevention and control through effective environmental health, infection prevention and bio-risk management in human animal and plant healthcare	1,526,023.30	6.8
4. Optimize the use of antimicrobials in human, animal, and plant healthcare	2,980,450.00	13.3
5. Strengthen and establish partnerships, alliances, governance, and resource mobilization at all levels	246,580.00	1.1
Total	22,429,540.90	100

Table 1. Summary Indicative Budget for implementation of the Strategy for the Prevention and Containment of Anti-microbial Resistance, 2021-2025. Source: Ethiopian Ministry of Health⁸

Gaps in current policies and strategies

Insufficient antimicrobial stewardship programs and poor patient healthcare-seeking behavior contribute to the dependence on informal sources of antimicrobials outside of the regulatory system. This leads to the widespread misuse and overuse of antimicrobials. Most of the population in Ethiopia does not have insurance coverage, resulting in little motivation to adhere to prescriptions that come at a cost and source antimicrobials from certified facilities. The ESTG does not mention insurance as an essential instrument to promote safe antimicrobial use, therefore policies and strategies are focused on what the government can provide and less on promoting responsible usage of antimicrobials by the people. Common practices such as the purchase of unregulated veterinary antimicrobials in the open market and the unintended use of medicated feed are critical issues in the animal health sector.

The lack of well-defined roles and responsibilities of non-governmental stakeholders (e.g., private sector, civil society organizations, communities) in implementing the policies leads to inadequate engagement and fragmented efforts for suboptimal results. This hinders effective multisector collaboration and coordination needed against AMR with the risk of overlapping efforts and/or inefficient allocation of resources.

The estimated budget for implementing the strategic plan to address AMR in Ethiopia appears to be insufficient, hindering effective implementation for instance, the allocation for awareness and education amounts to only US$2.6 million, which results in two cents per capita, which cannot realistically achieve the plan’s objectives.

Discussion

The promotion of good practices towards antimicrobial use is relevant towards mitigating the spread of AMR. This can be done through deliberate and systematic stakeholder awareness, engagement, and ownership, involving multiple relevant sectors. One way to encourage better healthcare-seeking behavior and responsible antimicrobial use is by expanding health insurance coverage that will help deter the procurement of antimicrobials from uncertified or unregulated sources. Another approach is to provide incentives to farmers for responsible usage, particularly animal husbandry. This can be accomplished by supporting the development of niche markets for responsibly produced animal products from, as an example, farmers who adhere to responsible antimicrobial use practices.

Strengthening governance using a One Health approach involving the Ministry of Health, the Ministry of Agriculture, and other key stakeholders is also another key issue which needs to be addressed. Streamlining coordination mechanisms toward a more decentralized approach can enable ownership and engagement of non-governmental stakeholders by more localized decision-making and tailored interventions for monitoring AMR policies. Complementing education and awareness programs with strict enforcement of prescriptions ensure the safe use of antimicrobials. Enforcement measures could include stricter regulations on prescription-only sales, regular inspections of pharmacies and healthcare facilities, and imposing penalties for non-compliance.

Harnessing the means of implementation through engaging multiple relevant stakeholders including the private sector, international partners, consumers, and financial institutions can help augment and diversify the currently insufficient budget for combating AMR. Mainstreaming activities across all relevant sectors using the One Health approach will allow for better coordination and budgeting within each sector. By integrating AMR-related strategies into various sectors, it becomes easier to allocate resources and implement policies more effectively. Utilizing modern Information and Communication Technology platforms can also improve the reach of stakeholders in an affordable and timely manner. Leveraging technology can facilitate better communication, data sharing, and coordination among stakeholders. Allocating the appropriate budget and employing these strategies can lead to better surveillance capabilities, enabling updates to the ESTG and informing healthcare professionals’ decisions when prescribing effective medications. In the long term, this could help reduce empiric treatment by expanding diagnostic facilities allowing for tailored treatment plans instead of relying solely on syndromic-based prescriptions.

Conclusion

We highlighted gaps in Ethiopia's current AMR policies and strategies, such as insufficient antimicrobial stewardship programs, unclear roles for non-governmental stakeholders, and unrealistic budget allocation. The proposed solutions include the following: (a) promoting responsible antimicrobial use among patients and farmers; (b) strengthening governance through better coordination, collaboration, commitment of various stakeholders, including government, health care providers, the private sector, and the general population, using a One Health approach; and (c) harnessing the means of implementation by mobilizing resources and leveraging technology. It is expected that these measures could lead to better surveillance capabilities, more informed healthcare decisions, and a reduction in the misuse and overuse of antimicrobials.

Ethiopia's experiences can serve as a valuable model for African countries looking to enhance their approach to tackling the AMR challenge to develop effective AMR strategies, and prioritize a multi-sectoral approach guided by the One Health framework. By fostering a culture of collaboration and information sharing, African countries can work together to address the common challenge of such silent AMR pandemics and protect their populations from its impacts.

Acknowledgment

This article was initially prepared for the Seminar for Global Infectious Diseases at Georgetown University. The author is grateful to Dr. Jean Paul Gonzalez for his guidance and support.

References

1. Ohemu GP. Starved of ACTION: a critical look at the antimicrobial resistance action plans of African countries. ACS Infect Dis. 2022;8(8):1377-1380.

2. World Health Organization (WHO). Library of national action plans. https://www.who.int/teams/surveillance-prevention-control-AMR/national-action-plan-monitoring-evaluation/library-of-national-action-plans. Accessed April 17, 2023.

3. Ayukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: causes and control strategies. Antimicrob Resist Infect Control. 2017;6(1):47.

4. Chen HH, Stringer A, Eguale T, Rao GG, Ozawa S. Impact of antibiotic resistance on treatment of pneumococcal disease in Ethiopia: an agent-based modeling simulation. Am J Trop Med Hyg. 2019;101(5):1042-1053.

5. Food, Medicine and Health Care Administration and Control Authority of Ethiopia (FMHACA). Ethiopia: Standard Treatment Guidelines for Health Center. MedBox. https://medbox.org/document/ethiopia-standard-treatment-guidelines-for-health-center#GO. Published 2014. Accessed April 15, 2023.

6. Fujita AW, Werner K, Jacob JT, et al. Antimicrobial resistance through the lens of One Health in Ethiopia: a review of the literature among humans, animals, and the environment. Int J Infect Dis. 2022;119:120-129.

7. Berhe DF, Beyene GT, Seyoum B, et al. Prevalence of antimicrobial resistance and its clinical implications in Ethiopia: a systematic review. Antimicrob Resist Infect Control. 2021;10(1):168. doi:10.1186/s13756-021-00965-0.

8. Ministry of Health, Ethiopia. Antimicrobial resistance prevention and containment strategies plan: The One Health approach, 2021-2025. Addis Ababa: WHO; 2021. https://www.who.int/publications/m/item/Ethiopia-third-one-health-strategic-plan-on-antimicrobial-resistance-prevention-and-containment-2021-2025

 

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