A shrinking window of opportunity

Certain principles of effective quality improvement interventions are universal. Relevant stakeholders must believe that it is worth while to remedy the deficiency in quality, that the benefits of change outweigh the costs, and that change is possible. The threat of antibiotic resistance and its coevolution with particular behaviours of antibiotic use are also universal.1 Unfortunately, the public health agendas of few countries have prioritised the problem of antibiotic resistance. This is especially true in less developed countries, where antibiotics are often overused and misused by formal and informal healthcare providers and by patients, who are often able to obtain antibiotics without a prescription.2 Few policy makers, few members of the general public, and unfortunately too few medical schools and health professionals recognise the urgency and implications of the problem. Instead, pharmaceutical policies often focus on scaling up and ensuring access to drugs, including broad spectrum antibiotics, without considering rational use.

What will really help to create change and foster effective quality interventions to tackle resistant infections in developing countries? Strategies in such countries require changes at the levels of policy, the institution (including healthcare providers), and the individual.3 4 Quality improvement strategies to improve the behaviour of providers and patients do exist in developing countries, but their success depends on government and stakeholder support.

To increase government and stakeholder involvement and accountability, it is important to establish national programmes that publically report rates of antibiotic use and resistance. Although the World Health Organization (WHO), the Pan American Health Organization, and others have promulgated useful recommendations for hospitals and communities around the world to combat antimicrobial resistance, few developing countries have been able to implement these recommendations fully.5 6 When resources are limited, assuring access to drugs tends to overshadow the quality of their utilisation. The international community should partner with developing countries to perform the initial cycles of measurement and to design systems to link the data with information to the public on the effect of the problem on population health, personal health, and the economy. Such measurement should occur across several countries in close proximity to harness “peer pressure” and foster better practices.

Performance measurement and accountability are potent inducers of behavioural and systemic change in organisations. For example, accreditation agencies and funders now require hospitals in the United States to publically report performance and outcome measures, a policy that has triggered an explosion of quality improvement activity in US hospitals. An excellent template for the annual measurement and comparison between countries of consumption of antimicrobials and resistance rates has been developed by the GRACE project in Europe (www.grace-lrti.org/portal/en-GB). Similar utilisation and resistance profiles for developing countries are needed, and efforts are under way to accomplish this in Latin America through a partnership between research institutions, government agencies, and WHO.

Many lessons from quality improvement interventions in health care in wealthier countries can be applied elsewhere. Various frameworks and theories have been found useful for diagnosing contextual factors and developing strategies to change specific policies, organisational practices, and the behaviour of providers and individual consumers.7 For example, education and decision support, when part of a comprehensive effort, have been useful in HIV prevention, tuberculosis management, and tobacco control, as well as in appropriate antibiotic use. The literature also shows that quality improvement initiatives that lack local champions and stakeholder support will face formidable challenges to success.

Strategies that work in one place must be assessed for their applicability to other settings, and programmes must be tailored to countries’ unique circumstances. Formative research into social factors and practices in specific regional and local contexts, such as how the public and professionals make decisions to recommend, procure, and use antibiotics, is indispensable to achieve change.8 For example, we found that most patients (62%) purchasing antibiotics in Mexican pharmacies without a prescription reported acting on the recommendation of a clinician.9 Thus, in Mexico, education campaigns to reduce unnecessary antibiotic use must target doctors as well as the public. Nevertheless, educating the public is crucial, as patients often misuse antibiotics regardless of whether they were bought over the counter or were prescribed.

In developing countries, access to antibiotics without a prescription is commonplace. Here the priority should be to change regulatory policies related to antibiotic procurement and to enforce these policies. This includes creating an infrastructure for surveillance, communication, and effective sanctions. For example, in Chile a mass media campaign preceded enforcement of regulatory measures making antibiotics available by prescription only, resulting in a 35% decrease in antibiotic consumption.10 It may be useful to emphasise the repercussions that are unique to antibiotic use: that in contrast to other drugs the consequences of an individual using antibiotics extend to that person’s family and community. Finally, we also need to use data and the media to challenge the perception that providing access to antibiotics without a prescription somehow helps to compensate for the lower access to doctors in developing countries.

The window of opportunity for combating antibiotic resistance continues to shrink. Much work remains to be done in most countries, but particularly in developing countries. We believe that effective programmes to tackle resistant infections are tenable and within reach of the constrained resources of developing countries. The major barriers are the political and public will to set up the systems that can bring about change. Partnerships among national and international stakeholders will help.