Recent Journal Articles by Niranjan Konduri

To delineate the prevalence and factors associated with antimicrobial use across six referral hospitals in Tanzania using WHO point prevalence survey (PPS) methodology to inform hospital-specific antimicrobial stewardship programmes, we conducted a cross-sectional analytical study. We analysed the prevalence of antibiotic use by referral hospital, ward, indication and patient characteristics as the main outcomes. We also described adherence to the Tanzania Standard Treatment Guidelines (STG) and WHO’s AWaRe categorisation of antibiotics. Approximately 62.3% of inpatients were prescribed antibiotics, predominantly from the Access group of antibiotics (ceftriaxone, metronidazole or ampicillin–cloxacillin). Empirical use of antibiotics is common, and the Access group of antibiotics is predominantly prescribed in children less than 2 years and patients admitted to surgical and paediatric wards. Lack of utilisation of antimicrobial susceptibility testing services in these hospitals requires urgent interventions. Routine monitoring of antibiotic use is recommended to be part of antibiotic stewardship programmes in Tanzania.

The objective of this study was to measure antimicrobial consumption in Tanzania. From 2017 to 2019, data on all antimicrobials imported into Tanzania were obtained from the Tanzania Medicines and Medical Devices Authority Data, augmented with purchasing data from the Medical Stores Department and data from local manufacturers. Data were collected and analyzed in accordance with the World Health Organization Anatomical Therapeutic Chemical and defined daily doses (DDD) methodology. The average DDD per 1,000 inhabitants per day (DDD/1,000/D) for all antimicrobials was 80.8 ± 39.35. The DDD/1,000/D declined from 136.41 in 2017 to 54.98 in 2018 and 51.02 in 2019. Doxycycline, amoxicillin, and trimethoprim-sulfamethoxazole were the most frequently consumed antibiotics during these years, accounting for 20.01, 16.75, and 12.42 DDD/1,000/D, respectively. The majority of antimicrobial consumption in Tanzania occurred in the private sector, with the proportion of private-sector antibiotic consumption increasing annually from 2017 to 2019. The private sector use of antimicrobials is significantly increasing and should be carefully monitored in accordance with national policies. Future work is necessary to increase reporting of antimicrobial consumption patterns in sub-Saharan Africa.

Managed entry agreements (MEAs)—a type of formal institutional arrangement between pharmaceutical companies and payers for sharing the risk with respect to the introduction of new pharmaceutical technologies—may expand access to new pharmaceutical technologies for non-communicable diseases. Although common in high-income countries (HICs), there is limited evidence of their use in low- and middle-income countries (LMICs). This article aims to document international experiences of countries implementing MEAs and potential barriers and facilitators for their use in LMICs. We reviewed published literature sources on MEAs over the past 10 years considering peer-reviewed publications and gray literature data. While the use of MEAs in LMICs is very limited, this could be the result of limited empirical evidence on its use and possibly due to the use of a different taxonomy for describing MEAs in these settings. Since there is limited evidence on their use in LMICs, the identified cases of implementation in HICs may serve to inform the interest on MEAs in resource limited settings. Therefore, further research in this field especially in the context of LMICs may be of value for the global community as all countries are embarking into fairer and sustainable Universal Health Coverage.

The objective of this study was to describe the conceptual and implementation approach of selected digital health technologies that were tailored in various resource-constrained countries. Drawing from our multi-year institutional experience in more than 20 high disease-burden countries that aspire to meet the 2030 United Nations Sustainable Development Goal 3, we screened internal project documentation on various digital health tools that provide clarity in the conceptual and implementation approach. Taking into account geographic diversity, we provide a descriptive review of five selected case studies from Bangladesh (Asia), Mali (Francophone Africa), Uganda (East Africa), Mozambique (Lusophone Africa), and Namibia (Southern Africa). A key lesson learned is to harness and build on existing governance structures. The use of data for decision-making at all levels needs to be cultivated and sustained through multi-stakeholder partnerships. The next phase of information management development is to build systems for triangulation of data from patients, commodities, geomapping, and other parameters of the pharmaceutical system. A well-defined research agenda must be developed to determine the effectiveness of the country- and regional-level dashboards as an early warning system to mitigate stock-outs and wastage of medicines and commodities.

Private-sector retail drug outlets are often the first point of contact for common health ailments, including tuberculosis (TB). The objective of this systematic review was to better understand the extent to which the World Health Organization’s (WHO) recommendation on engaging retail drug outlets has been translated into programmatic policy, strategy, and intervention in low- and middle-income countries. The study found that of national strategic plans for TB control from 14 countries with varying TB burdens and a strong private sector, only 2 had explicit statements on the need to engage their national pharmacy professional association. The success rate of referrals from retail drug outlets who visited an approved health facility for TB screening ranged from 48% in Vietnam to 86% in Myanmar. Coverage of retail drug outlets ranged from less than 5 to 9% of the universe of retail drug outlets. For WHO’s End TB Strategy to be successful, scaling up retail drug outlets to increase national coverage, at least in countries with a thriving private sector, will be instrumental in accelerating the early detection and referral of the 3 million missing TB cases. The proposed public-private mix pharmacy model is applicable not only for TB control but also to tackle the antimicrobial resistance crisis in these countries.

We examined how different training modalities have been employed and adapted in 12 countries to meet country-specific needs by a global pharmaceutical systems strengthening program in collaboration with a country’s Ministry of Health and local stakeholders. Case-based learning, practice and feedback, and repetitive interventions such as post-training action plan, supportive supervision and mentoring approaches are effective, evidence-based training techniques. In Ethiopia and Bangladesh, over 94% of respondents indicated that they have improved or developed skills or competencies as a result of the program’s training activities. Supportive supervision structures and mentorship have been institutionalized with appropriate management structures. National authorities have been sensitized to secure funding from domestic resources or from Global Fund grants for post-training follow-up initiatives. The Pharmaceutical Leadership Development Program is an effective, case-based training modality that motivates staff to develop quality-improvement interventions and solve specific challenges. Peer-to-peer learning mechanisms rather than traditional didactic methods was a preferred intervention among high level government officials both within country and between countries.

Ukraine has successfully implemented e-TB Manager nationwide as its mandatory national tuberculosis registry after first introducing it in 2009. Our objective was to perform an end-of-programme evaluation after formal handover of the registry administration to Ukraine's Centre for Disease Control in 2015. Of the 5.9 million transactions over a 4-year period, nine out of 24 oblasts (regions) and Kiev City accounted for 62.5% of all transactions, and corresponded to 59% of Ukraine's tuberculosis burden. There were 437 unique active users in 486 rayons (districts) of Ukraine, demonstrating extensive reach.

Users of e-TB Manager, a web-based eHealth system institutionalized in 10 resource-constrained countries that account for one-third of the world’s tuberculosis (TB) burden, reported that e-TB Manager helped to improve patient care and workplace productivity, and they found it reliable for case management. The users--especially those with more experience in TB programs and those who had used the system for more than two years--were generally satisfied with the system. Responses came from Armenia, Bangladesh, Brazil, Cambodia, Namibia, Nigeria, Indonesia, Ukraine, and Vietnam. The study concluded that younger users and those with less experience in TB programs need more training, and institutional capacity for managing e-TB Manager takes at least five years. The capacity  to manage e-TB Manager has been built in Brazil and Ukraine.