A multi-stakeholder approach towards operationalising antibiotic stewardship in India's pluralistic rural health system.

在本研究中，我们寻求制定一项管理干预措施，以解决印度面临的两个相互关联的主要挑战：抗菌素耐药性（AMR）日益增加，以及拥有庞大且不受监管的非正式卫生部门的多元化卫生系统。抗生素耐药性是印度政策议程上的重要议题，因为印度是世界上细菌感染负担最重的国家之一，也是世界上用于人类健康的抗生素（ABs）的最大消费国之一。抗菌素耐药性增加的主要原因之一是人类、动物和环境中过量使用抗体。在占印度人口68%的农村地区，大多数卫生保健提供者没有正式的医疗资格，但他们满足了正式卫生部门无法满足的就近卫生保健需求。他们是各种疾病的第一接触提供者，他们经常不适当地使用抗体进行治疗。印度的一些邦，包括西孟加拉邦、比哈尔邦和安得拉邦，正在实施培训和整合非正式提供者（IPs）的规划，但评估表明，提供者使用抗生素的情况已被证明难以改变。我们于2016-17年在西孟加拉邦农村进行了一项研究（由HSRI Call 3资助），以了解ip使用抗生素（ABU）的社会、经济和行为驱动因素，以解决根本原因并制定量身定制的解决方案。我们发现，关键驱动因素超出了知识产权的个人经济需求和知识差距。制药业对抗生素的积极营销产生了强大的影响，监管和卫生系统在这一卫生市场中提供管理的资源和能力有限。虽然印度医学协会最初反对专科医生的整合，但目前在个人层面上，非正式提供者和正式医生（公立和私立）之间存在相互支持的关系。IPs从正规医生那里学习，这些医生也被发现开了不恰当的处方。其他驱动因素是社区对不适当使用抗生素的长期危险的认识不足，以及对整个疗程的购买力较低。我们发现大约四分之一的IPs也治疗动物，通常使用与人类相同的抗生素。为了遏制抗菌素耐药性，我们需要与这些不同的利益攸关方共同努力，通过审议和共识达成解决方案。在本研究中，我们建议与多个利益相关者共同设计一种干预措施，作为抗生素管理和卫生系统在这一层面加强的有效模型。我们将在西孟加拉邦南24 Parganas区（我们之前的研究所在地）的两个农村地区进行形成性研究，以补充我们在早期研究中收集的数据。在这一阶段，我们将更详细地探索抗生素在动物中的使用，绘制人类和动物ABU的药品供应和价值链，进行利益相关者分析，绘制社区行为交流平台，并对当地AMR流行情况进行二次数据审查。随后将进入干预发展阶段，在此阶段，我们将与通过使用“审议映射”（一种与多个利益相关者一起用于民主决策的参与式方法）的利益相关者分析确定的关键利益相关者合作。从这一过程中产生的干预方案将进一步发展，并在每个站点大约20个提供者的小组中进行试点。评估将包括对有效和无效措施的可行性分析，IP使用抗生素的任何变化（IP和患者退出访谈），以及在共同设计阶段对利益攸关方的行动和反应的分析，以提供系统的学习，以支持在印度以及南亚和非洲类似环境中未来大规模加强管理的战略设计。

In this study we seek to develop a stewardship intervention that addresses two major interrelated challenges that India faces: increasing antimicrobial resistance (AMR) and a pluralistic health system with a large and unregulated informal health sector. AMR is high on India's policy agenda as it has one of the highest burdens of bacterial infections in the world and is also one of the world's biggest consumers of antibiotics (ABs) for human health. One of the major causes of increasing AMR is the excessive use of ABs in humans, animals and the environment. A majority of healthcare providers in rural India, where 68% of the population lives, do not have a formal medical qualification but they fulfil a need for proximate healthcare that the formal health sector has not been able to fill. They are the first contact providers for a variety of illnesses, who frequently and inappropriately treat with ABs. Some states in India, including West Bengal, Bihar and Andhra Pradesh are implementing programmes of training and integrating informal providers (IPs) but evaluations suggest that providers' use of antibiotics has proven difficult to change. We conducted a study in 2016-17 (funded by HSRI Call 3) in rural West Bengal to understand the social, economic and behavioural drivers of antibiotic use (ABU) by IPs in order to address the root causes and develop tailored solutions. We found that the key drivers lay beyond IPs' individual economic needs and knowledge gaps. There was a strong influence of the pharmaceutical industry's aggressive marketing of antibiotics, and the regulatory and health systems had limited resources and capacity to provide stewardship in this health market. Although IPs' integration had initially been opposed by the Indian Medical Association at present there were mutually supportive relationships between informal providers and formal doctors (both public and private) on an individual level. IPs learned from formal doctors who have also been found to prescribe inappropriately. Other drivers were communities' low awareness about the long term dangers of inappropriate antibiotic use, and low purchasing power for full courses. We found that about a quarter of the IPs also treated animals, typically with the same antibiotics as humans. To contain antimicrobial resistance (AMR), we need to work collectively with these diverse stakeholders to arrive at solutions through deliberations and consensus. In this study we propose to co-design an intervention with multiple stakeholders to serve as an effective model of antibiotic stewardship and health systems strengthening at this level.We will start with formative research in two rural locations in district South 24 Parganas in West Bengal (where our previous study was located) to supplement the data that we have collected in our earlier study. During this phase we will explore antibiotic use with animals in more detail, map the pharmaceutical supply and value chains for human and animal ABU, conduct a stakeholder analysis, map community platforms for behavioural communication and conduct a secondary data review of local AMR prevalence.This will be followed by an intervention development phase where we will work with key stakeholders identified through the stakeholder analysis using 'Deliberative Mapping', a participatory methodology used with multiple stakeholders for democratic decision making. The intervention options that arise from this process will be further developed and piloted with a small group of providers, about 20 in each site. Evaluation will consist of a feasibility analysis of what worked and did not work, any changes in antibiotic use by IPs (IP and patient exit interviews), and analysis of the actions and reactions of stakeholders during the co-design phase to provide systematic learning to support the design of strategies for strengthening stewardship at scale in future, both in India as well as in similar settings in South Asia and Africa.