Tanzania: A Model for Fighting Superbugs in Resource-Constrained Settings

Imagine that you work for the Ministry of Health in a country with limited resources. You are painfully aware of the growing problem of drug-resistant infections, both locally and globally, and recognize that countries such as yours are at higher risk and carry a greater burden than more wealthy nations. You have a plan to help combat the danger, but you know the problem is not limited solely to the health sector; the actions of those who work with animals, agriculture, and the environment all contribute to the problem.   

That was the dilemma facing Siana Mapunjo in 2018 as she and a group of colleagues at the Tanzania Ministry of Health (MOH) worked to address the problem of antimicrobial resistance (AMR), which is when bacteria, parasites, fungi, and viruses stop responding to treatments that previously were effective against them.  

It is in situations such as this that Management Sciences for Health (MSH) can provide support and technical assistance to countries as they evaluate their options and implement the interventions that will work best for them.  

Over the last five years, a productive partnership has taken shape between the government of Tanzania and the US Agency for International Development’s Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, which is led by MSH. Thanks in part to that partnership, Tanzania is now setting an example for other countries in sub-Saharan Africa and around the world that want to advance the Global Health Security Agenda and contain the threat posed by resistant strains of disease-causing organisms.   

A Global Threat with Local Consequences  

AMR can develop when antibiotics and other medicines are overprescribed or otherwise used inappropriately, and the resulting dangerous microbes can spread when proper infection prevention and control (IPC) measures are not implemented.  

AMR is a serious and growing issue, particularly in low- and middle-income countries (LMIC). While drug-resistant pathogens can affect anyone, anywhere, at any time, LMICs face a relatively greater burden due to a number of factors, including ineffective sanitation and hygiene and limited access to quality medicines and vaccines. LMICs also may lack the resources to provide clinical training on appropriate practices and the laboratory capacity to detect drug-resistant microorganisms.   

Antibiotic-resistant infections directly resulted in the deaths of more than 1.2 million people in 2019, with the highest burden falling on those in resource-constrained settings, according to The Lancet. 

Establishing a Baseline  

As part of MTaPS’ overall goal of strengthening systems for providing patient-centered care and pharmaceutical services in Tanzania, the program supports activities aimed at containing AMR. Such activities include building the capacity of in-country stakeholders to ensure the appropriate use of antimicrobials, strengthening practices promoting IPC, and supporting coordination among the various sectors whose activities can contribute to containing AMR.   

According to Mapunjo, Tanzanian health officials had already done a lot of foundational work by the time MSH arrived on the scene. “When [MSH] first came to Tanzania in 2018, I was the National AMR Focal Person,” Mapunjo says. “By that time, I had a National Action Plan, and I had some areas of interest, especially on antimicrobial stewardship. [MSH] managed to take all the areas I discussed and propose activities to support us.” 

But it would take even more work, along with technical assistance, to make that plan a reality.  

External guidance and regulations, such as those from the World Health Organization (WHO), are key to helping Tanzania and similarly situated countries communicate about the growing threat of AMR and bring stakeholders into the mitigation efforts.   

Among the WHO’s Benchmarks for International Health Regulations is a recommendation that member states establish protocols and databases for monitoring antimicrobial use and consumption to improve their capacity for combating AMR. To that end, MTaPS early in the collaboration supported the government of Tanzania in conducting the country’s first national survey on the consumption of antimicrobials using the standardized WHO methodology. The resulting analysis was the first such study ever to be published out of sub-Saharan Africa.   

Taking that data into account, MTaPS was then able to provide the MOH with the technical support and lessons learned from other countries needed to integrate the WHO’s “Access, Watch, and Reserve” (AWaRe) categorization of antibiotics into the Tanzania’s Standard Treatment Guidelines and National Essential Medicines List. These documents are tools that guide health care providers to choose appropriate treatment options, so incorporating the AWaRe classification into them helps providers prescribe wisely and not worsen the AMR problem.   

Taking Steps Toward Improvement  

A crucial part of addressing AMR is equipping health care workers with the tools and knowledge they need to combat the threat by prescribing the right medicines at the right dosage for the right length of time—a practice known as antimicrobial stewardship. MTaPS supported Tanzania’s efforts to implement antimicrobial stewardship programs in 10 hospitals, disseminating policies and guidelines and strengthening the capacity of health care workers on professional ethics and the appropriate use of antimicrobials.   

Mapunjo says the difference is noticeable when she visits a hospital that has implemented an antimicrobial stewardship program with support from the MTaPS Program. “Where before, lack of awareness around AMR was a problem, now the hospitals have budgets in place, they have committees that meet regularly, and ongoing training for their staff, including an e-learning platform.” While some of these changes, such as educational materials, may be visible to patients, many of them are happening behind the scenes.   

MTaPS also helped develop a training curriculum on antimicrobial stewardship and infection prevention and control; the course is hosted at the Muhimbili University of Health and Allied Sciences. Mapunjo says ongoing training of health care workers is a big part of what will make the work sustainable.     

Bringing the Key Players Together  

Any attempt to combat the growing problem of AMR must take into account that sectors other than human health have a role to play because the more antibiotics that are used, the more resistance is likely to increase. Farm animals are often given antibiotics to help them grow and prevent infections, but any drug-resistant germs that develop from the animal sector’s improper use of pharmaceuticals can easily cross over to humans.  

That is why MTaPS prioritizes helping countries establish national task forces that bring these sectors together and ensure they work in tandem to address AMR. Ideally, these task forces include high-level government officials and other human and animal health stakeholders along with representatives from the agricultural, environmental, and food sectors.  

Tanzania’s Multisectoral Coordinating Committee (MCC) does just that so the different sectors’ responses to AMR are integrated in an approach known as “One Health.” Mapunjo views the formation of this committee as “one of the biggest successes” in Tanzania’s fight against AMR. She says engagement of the MCC is high, and the accountability provided by its regular meetings leads to greater follow-through on action items. Perhaps most importantly, the joint planning of activities by the various sectors creates buy-in.  

“You can’t view intervention as human health alone, so you need it to work together with the other sectors,” she explains. “When we formulated our National Action Plan, we worked especially with the livestock sector. To prepare strategies, you have to start together so that when it comes time for implementation, everyone owns that strategy. You can’t develop a document and then just tell other sectors to go work on it. We are working together but we’re also planning together.”  

Looking to the Future  

Now in its final program year, MTaPS has supported the development of Tanzania’s new National Action Plan (2023–2028) as well as a draft communications plan that will help spread the word about IPC measures to the broader public in a way that encourages behavior change.  

Mapunjo is hopeful that future activities will do even more to involve the private sector and measure the progress that has been made so far. Changing behavior, she says, is probably the biggest challenge.   

She recounted that she once met a mother who was giving an adult dose of medicine to her sick young child. Upon further questioning, Mapunjo discovered that the dispenser had been unaware that the medicine was not for the woman but for her child. That incident crystallized for Mapunjo the need to educate both professionals and the public on the ethics and other issues surrounding the appropriate use of medications. Giving a child a higher dose of an antibiotic than necessary is considered overuse, which is one of the practices that can lead to changes in bacteria that make them resistant to medication.  

Still, Mapunjo is optimistic about the future, thanks to the ongoing education of health care workers and the collaboration that has been built among the various sectors. She says she is grateful to the MTaPS Program for being responsive to the country’s needs. “MTaPS was interested in hearing what we needed,” she says, “and that is why we wanted to work with them.”