In this interview two pharmacists with significant experience in the field provide insights on pharmacy practice and antimicrobial stewardship in Uganda.
Interviewee: Peter Babigumira Ahabwe B.Pharm. & Winnie Nambatya, M.Pharm.
[Last updated: 30 December 2019]
Antimicrobial resistance has been identified as a global health emergency by the United Nations. It is a problem that we share globally as drug-resistant pathogens multiply and proliferate in and around us. These organisms know no man-made geographical boundaries and in large part are easily transported across the world via infected or colonized human hosts traveling by air, land, or sea.
Given that antimicrobial resistance is a globally shared problem, it is imperative that we attempt to learn from each other’s experiences and collaborate to solve the issues at hand. This is the motivation for this series of interviews, which focuses on the status of antimicrobial stewardship in various countries across the globe.
Recently we were able to connect via Twitter and a few emails with Peter Babigumira Ahabwe and Winnie Nambatya, two pharmacist leaders with infectious diseases expertise who practice in Uganda. They graciously agreed to an interview with us regarding antimicrobial stewardship in Uganda. This article is the result of our correspondence.
1. How did you each get involved in antimicrobial stewardship in Uganda?
PBA: After two years working in the Infectious Disease Institute (IDI) Prevention Care and Treatment Clinic in Mulago, I joined the Global Health Security Project initially working on antimicrobial consumption and use surveillance. My project manager taught me most of the programmatic things while my former supervisor (our pharmacy team lead) provided technical instruction and mentorship as well as sharing manuals, protocols and papers that I read to come up to speed.
Initially I worked very hard, but when my son developed an infection that seemed to be unresponsive to oral cefixime and developed febrile convulsions, I began to take the threat of antimicrobial resistance (AMR) very seriously. I was traumatized by failure of clinical staff to take a sample for culture and sensitivity before ordering a cocktail of gentamicin and ceftriaxone for what started as a flu. Worse still I was shocked when it was suggested we begin on antimalarials after three negative blood tests. The real kicker, was the stock out of paediatric culture bottles at one of the biggest private testing labs. This experience made me realize our challenges span from clinical and lab practice to prescribing to supply chain for diagnostics and general low awareness and lack of resources even in the private sector. Ever since then I have been actively involved in any and all forums and platforms such as Wellcome Trusts call to action, AMR insights ambassadors network, Global Health security ministerial meetings, and most importantly our National One Health and AMR platforms.
WN: During my internship training, I noticed that the majority of the prescriptions I received had at least one drug therapy problem. I reached out to the Pharmaceutical Society of Uganda (PSU) with a proposal to introduce pharmaceutical care in the hospitals. I was also ready to volunteer and provide support to pharmacists and intern pharmacists with skills to identify drug therapy problems. During this endeavor, I travelled to South Africa to have my Masters of Pharmacy (MPharm). After completion of my MPharm, I started work at Makerere University as a clinical pharmacy lecturer. While lecturing, I continued to practice at the neural surgical ward at Mulago National Referral Hospital and it was during this period that I noticed the high rates of antibiotic resistance among most of the post-surgical patients.
I reached out to a colleague Peter Babigumira Ahabwe (PBA) from the IDI who informed me of the programmes they had with regards to antimicrobial resistance. It was from this point that I started collaborating with IDI mainly conducting surveys on antimicrobial surveillance and use, mentorships, and training to pharmacists in the different hospitals. Through this collaboration, I supported with the creation of the medicines therapeutic committee manual. Since PSU leadership was also aware of my passion for the clinical pharmacy profession, the secretary to PSU Mr. Opio Samuel introduced me to the Common Wealth Pharmacists’ Association which was going to support pharmacists in the different referral hospitals with the creation of stewardship progrommes through the Commonwealth Partnerships for antimicrobial stewardship.
2. What is pharmacy practice like in Uganda?
PBA: I think of pharmacy in Uganda, like Caesar, is waiting along the shores the proverbial Rubicon, ready to pass a point of no return. In my opinion, it was traditionally focused on industry and community practice. There was a sense of hesitancy by some to get clinical as well as resistance by other cadres to accept them.
I personally felt unprepared or inadequate to meet the task until I met and was mentored by a fellow African pharmacist who was an associate professor in the US by the age of 35. This bolstered my confidence. She also taught me the basic routine for the deligent hospital Pharmacist. Programatically they mainly did supply chain and Pharmacovigilance. In research some broke through as investigators. The bulk of that work was focused on regulatory affairs, pharmacovigilance, dispensing, and rarely therapeutic drug monitoring. Though I never joined any studies, it was part of my team leads portfolio.
A very small but talented group at Ministry of Health and its specialized agencies the National Drug Authority and National Medical Stores handle government business. Over the past few years their hard work has brought most of the policy-level gains in the field. Some have ventured at politics as well. I think health diplomacy at the national and international level is the final frontier. I look forward to the day a Pharmacist is Minister of Health or WHO Director General.
WN: In order to practice as a pharmacist in Uganda, one has to be registered with the PSU. PSU is the professional body for pharmacists in Uganda, established under the Pharmacy and Drugs Act (PDA) 1970, cap 280 of the constitution of Uganda. After registration with PSU, the majority of pharmacists are practicing in the community pharmacies, the rest of the pharmacists are practicing in academia, non-governmental organizations, public health, industry, National Drug Authority (NDA), or hospitals. In the hospitals, the major role of hospital pharmacists in Uganda is administrative and logistics. However, over the past years, there has been growing interest for pharmacist to be actively involved in direct patient care.
3. What is your perspective on the state of antimicrobial stewardship in Uganda?
PBA: I think it is new but yet not so new. Since the mid-2000’s the Ministry of Health had been promoting rational medicine use, medicines and therapeutics committees, patient safety committees, and continuous quality improvement committees. All these efforts are being harmonized and used as a launch pad for the National and facility programs.
Uganda has completed her One Health National AMR Action plan and the AMR surveillance plan. Uganda also has taken over chairmanship of AMR action package from the United Kingdom under the Global Health Security Agenda.
General National coordination is through AMR subcommittee of the National One Heath platform. The Antimicrobial consumption and use surveillance plan is under development though data is being collected.
Local antimicrobial stewardship is coordinated by pharmacy department appropriate medicine use units. Aspects of IPC are being coordinated by quality improvement, nursing, and clinical services departments. AMR surveillance is coordinated through department of lab services (Uganda National Health Laboratory Service).
WN: In my opinion, antimicrobial stewardship is still a new concept which is yet to be understood. Many of the hospitals had medicines therapeutic committees (MTCs), but there was no structure and guiding principles. Many of these hospitals neither had MTCs with stewardship committees nor surveillance committees to inform the MTC. Currently, IDI and the Common Wealth Pharmacist’s Association are the key players in the establishment of antimicrobial stewardship in the hospitals. The information that will come from the Commonwealth Partnerships for antimicrobial stewardship will inform a lot about the state of the stewardship programmes in Uganda.
4. What role do pharmacists play in antimicrobial stewardship in Uganda?
PBA: I see hospital pharmacists as the secretary of the MTCs as well as stewardship teams. They are also in charge of supply chain management. Increasingly central clinical roles include working with clinicians to ensure rational prescribing as well as with infection preventionists to ensure IPC supplies are available. Pharmacists in Uganda also work with the lab to ensure antibiotics in use are tested for sensitivity as well as identifying products with high resistance and procuring those that work instead. Last but not least, in addition to pharmacy rounds they participate in ward rounds to give guidance on medicine related issues. They are also in charge of monitoring antimicrobial consumption and use.
WN: For the hospitals that are actively collaborating with IDI and the Commonwealth Pharmacist’s Association, the pharmacists have taken the responsibility to validate prescriptions on appropriate use of antimicrobials and they feel proud and comfortable as antibiotic stewards. These pharmacists are in contact with the microbiology laboratories to look at the trends in the resistance patterns as this this later informs the procurement for antimicrobials in the hospitals. On the wards, the pharmacists are constantly interacting with the nurses on the best infection prevention and control practices.
5. Can you discuss your role as pharmacists in getting involved at a governmental and national level in Uganda?
PBA: Because pharmacists tend to have a training in industrial, clinical, community and regulatory issues they serve multiple functions at ministries such as the the Ministry of Health and their departments and agencies (e.g., National Drug Authority, National Medical Stores) and some even in political space as members of parliement.
These roles include both technical, policy and programmatic work such as conducting national consumption and use surveillance, creating policies such as December 2018 Medicines and Therapeutics manual based in identified gaps, and designing programs to combat AMR (based on policy). As mentioned before some work in the political space as members of parliament and presidential advisors advocate to advance these policies.
WN: At the national level we have the One Health Platform and under this, we have the Antimicrobial Resistance Technical Committee. My role as a pharmacist and clinical pharmacy lecturer at National level is to support in the creation of policies and manuals (e.g., the national redistribution manual, medicines therapeutic manual), as well as the training and mentorship of other pharmacists in the government hospitals. At a national level, the other stake holders also share their opinions on what needs to change in the pharmacy curriculum to try and address the challenges faced in patient management.
6. What do you perceive to be the greatest challenge that antimicrobial stewards in Uganda face today?
PBA: I think the biggest challenge is the lack of affordable, easy to use, reliable diagnostics to support clinical decision making. The lack of access to affordable infection prevention supplies complicates this.
WN: The greatest challenge is irrational use of antimicrobials right from the community and the lack of structures to track the patients’ use of antibiotics in the community before they get to the hospitals and also the lack of motivation for the clinicians to change their prescribing behavior. Within the hospitals, there is lack of guidelines on empirical, surgical and medical prophylaxis. In some facilities, the clinical team does not believe the microbiology results because of the poor laboratory structures. The hospital structures do not accommodate enough pharmacists, many of the pharmacists are involved in more administrative work and have no time to dedicate to patient care and appropriate use of antibiotics.
In the private sector, patient satisfaction is the main aim and hence, physicians will use the most potent antibiotic to clear the infection faster as opposed to following the cascade of the antibiotics. Self-medication in the public is also a challenge, hence one of the committees on the one Health plat form is to address public awareness.
7. What is the greatest lesson you have learned from your work in Uganda that you would like to share with the global stewardship community?
PBA: Reflecting on the Porter and Brough model for capacity building, I think the greatest lesson I have learned is that it is quick and easy to do trainings and provide tools, but long lasting change comes from investing in getting the policies, strategies, plans in place which creates an enabling environment for other interventions.
- Recommended reading: Potter C, Brough R. Systematic Capacity Building: A Hierarchy of Needs. Health Policy Plans. 2004; 19(5): 336-345.
WN: The greatest lesson I have learnt is that in order to win the fight for antimicrobial resistance there is a need to build systems for effective workflow. Working as a team and maintaining inter-professional collaborations is key in addressing challenges faced in patient management. The hospital structures need to change and accommodate more pharmacists involved in direct patient care, because supplying medicines that are not going to be used rationally leads to wastage and yet the country does not have enough resources. We also need to work with the One Health concept in mind because, if we for example continue to leave the farmers treating the poultry and animals with antibiotics, it will later come to haunt us.
- Recommended reading: White A, Hughes JM. Critical Importance of a One Health Approach to Antimicrobial Resistance. EcoHealth. 2019; 16: 404-409.
HELPFUL RESOURCES & READINGS
- Infectious Diseases Institute (IDI)
- Pharmaceutical Society of Uganda
- Government of Uganda: Antimicrobial Resistance National Action Plan
- Fujita AW, et al. Antimicrobial Resistance in Uganda and the Urgent Need for Standardized Reporting and a National Surveillance Program. Open Forum Infectious Diseases. 2015; 2 (supplement 1): 1472.
ABOUT THE INTERVIEWEES
Peter Babigumira Ahabwe, B.Pharm.works as a Senior Program Pharmacist at the Infectious Diseases Institute (IDI), Makerere University in Uganda. He serves as an interface between the IDI and the Ministry of Health on projects where science and policy overlap. He contributes to achieving Global Health Security Agenda targets in Uganda. Peter represented IDI on the National AMR Technical Working Committee for Antimicrobial Stewardship and Optimal Use, Logistics and Coordination Subcommittee of the National Task Force, AMR Conference Planning and Scientific Committees and Appropriate Medicines Advisory Group. He has supported the development of national guidelines for antimicrobial stewardship. Peter also coordinates the GPPS data submission in Uganda and gives strategic oversights to the Antimicrobial Resistance (AMR) eLearning and call center at IDI.
Peter intends to revitalize the Medicine and Therapeutics committees of hospitals as an entry point for antimicrobial stewardship interventions. Also, he hopes to measure the burden of inappropriate antibiotic use in public health emergencies and disasters.
You can find him on twitter @Ahabwe_Pharma.
Ms. Winnie Nambatya is a clinical pharmacy lecturer at the College of health Sciences – Makerere University – Uganda for the past three years and maintains a teaching site in Mulago National Referral Hospital. In addition, she is a preceptor for international clinical pharmacy students.
She is working with the pharmaceutical society of Uganda with the aim of assisting both private and government hospitals in setting up systems to support proper pharmaceutical care and pharmacovigilance. Winnie’s research interests are centered around the pharmacist’s role in improving patient outcomes. She is a NURTURE fellow at Makerere University – Kampala, Uganda. Currently she is working with the Common Wealth Pharmacist’s Association under the Common Wealth Partnerships for Antimicrobial stewardship (CwPAMs) project. This project is aimed at exchanging AMS knowledge between the UK institutions and the Ugandan Institutions while having the pharmacists in charge of the decision making.
You can find her on Twitter @WinnieNambatya.
We would like to express our sincere gratitude to Peter and Winnie for their important work and for taking the time out of their very busy schedules to complete this interview and share their insights. We would also like to acknowledge Dr. Diane Ashiru-Oredope (@DrDianeAshiru) for making this interview possible.
Disclosures: The views expressed in this interview represent that of the individuals only and do not necessarily reflect the position or policy of their previous, current, or potential future employers or other organizations in which they serve.
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