“Arming half-baked people with weapons!” Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi

Figures & data

Figure 1. Antibiotic drug flows, information sources and desire for information.

Diagram developed through reflective workshops involving researchers from AMIS (Uganda), DRUM (Uganda and Malawi), HATUA (Uganda and Tanzania) and SNAP-AMR (Tanzania).

Table 1. Stakeholders attending workshops across the three countries.

Category	Uganda	Tanzania	Malawi	TOTAL
Human Health	7	7	7	21
Animal Health	8	5	10	23
Total number of participants	15	12	17	44

Table 2. Structure of the human health professions in Uganda, Tanzania and Malawi.

	Uganda	Tanzania	Malawi
Numbers	According to the Ministry of Health [38], there were a total of 66,589 health workers with active licenses in 2020 (1,300 specialist doctors/dentists, 3124 general doctors/dentists, 900 pharmacists 33,420 nurses 14,961 midwives and 12,884 allied health professionals). Overall staffing levels in the public health facilities is at 74%, with the Regional Referral Health facilities having the lowest staffing at 69%.	The number of health care workers increased from 29,063 in 2006/07 to 102,919 in 2019. According to the staffing levels guideline (2014), the number of health workers available is 63,447 and the shortage is 82,007, which is about 56.38%.	In 2016, the Ministry of Health had an estimated 23,188 professional health workers (out of a total of 42,309 positions listed in the MoH staff establishments) working in the public health sector, a 45% vacancy rate. For frontline categories of clinical staff only 17,298 positions were filled of 25,755 positions for both the Christian Health Association of Malawi and the Ministry of Health.
Training	Uganda has a total of 156 registered health training institutions. The institutions offer health related courses, which include a) Medicine and Surgery, Nursing, Public Health, Pharmacy and clinical medicine. Of the 156 health training institutions, 130 belong to the private sector [38].	There are 153 registered training institutions, which offer training programs for health and social welfare workers including:	The Kamuzu University of Health Sciences offers a 5-year program that leads to a Bachelor Medicine and Bachelor of Surgery (MBBS) degree. The College of Medicine runs a 4-year postgraduate program that leads to a Master of Medicine degree in one of the following specialities: Internal Medicine, Paediatrics and Child Health, General Surgery, Anaesthesia and Ophthalmology. The College has since added a degree in Orthopaedics [39].
		(a) Medical Doctor - Five years training + one-year internship.
		(b) Assistant Medical Officer - Clinical officer + two additional years of rotations/coursework
		(c) Clinical Officer -Secondary school + three years of medical training.
		(d) Nurse Midwife -Secondary school + two years of nursing training
		(e) Clinical Assistant/Medical Assistant ± Secondary school + basic triage skills
		(f) Village Health Worker/Medical Attendants Short courses on health education, often no formal schooling.
Structure of professional bodies	The health sector has four professional councils instituted by statutory instruments including:	There are different medical bodies based on profession. These include:	The professional bodies that provide oversight of the private and the public health workers include:
	(a) The Medical and Dental Practitioners Council. Their mandate is to exercise general supervision and disciplinary control over medical and dental practitioners.	(a) Tanzania Nursing and Midwifery Council that regulates and controls Nursing and Midwifery Education and Practice.	(a) Medical Council of Malawi, that regulates doctors, dentists, clinical officers and other paramedical staff excluding nurses. It also issues licenses to all health facilities and regulates training.
	(b) Nurses and Midwives Council that sets and regulates standards of training and practice, registers nurses and midwives and provides professional guidelines for public safety.	(b) The Medical Council of Tanzania, which regulates Medical, Dental and Allied Health practice ensuring high standards, safety and ethical practice through appropriate registration and licensing.	(b) The Nursing Council, that regulates the practice and training of nurses and midwives.
	(c) Allied Health Professional Council whose function is supervising the registration and licensing of Allied Health Professionals and regulating their conduct.	(c) The Pharmacy Council whose mandate is to safeguard and promote the provision of pharmaceutical services to achieve definite therapeutic outcomes for the health and quality of life of clients and promote rational use of medicines.	(c) The Pharmacy, Medicines and Poisons Board, that regulates pharmacy practice and training for pharmacists, pharmaceutical technologists and pharmacy assistants and also regulates pharmacy businesses, including chemists/drug stores, wholesaler/distributors/importers and manufactures.
	(d) The council of the Pharmaceutical Society of Uganda whose mandate is to regulate the practice by pharmacists and their assistants.		(d) The Pharmacy and Medicines Regulatory Authority, that regulates Medicines, allied substances and the exercise of the pharmaceutical profession.

Table 3. Structure of animal health professions in Uganda, Tanzania and Malawi.

	Uganda	Tanzania	Malawi
Numbers	There are about 670 registered veterinarians in Uganda and 1,500 paraprofessionals who offer veterinary care for most livestock keepers and owners of companion animals especially in the rural areas [40] There are 27 veterinary staff employed by the government including 12 Animal Husbandry Officers and 15 Veterinarians (personal communication) There are large numbers of informal paraprofessionals.	There are 1021 registered veterinarians and 4118 veterinary paraprofessionals in Tanzania (Veterinary Council of Tanzania, unpublished report). There are large numbers of informal paraprofessionals.	There are 72 Veterinarians at degree level, and 724 Veterinary paraprofessionals (Assistant Veterinary Officers) at Diploma level [23]. There are large numbers of informal paraprofessionals.
Training	Veterinary field officers/field veterinarians (Public and Private) have a degree in veterinary medicine [31]. Since the 1990s, there has been no formal institution providing paraprofessionals with specific training in veterinary medicine in Uganda. Due to their current unregulated training, paraprofessionals’ knowledge varies greatly: some hold a certificate or a diploma in general agriculture or animal management, while others have only had a few months’ training through an NGO or no relevant training at all [31].	Training of all the levels of animal health professionals in Tanzania ranges from Certificate in Animal Health and Production, Diploma in Animal Health and Production to Bachelor of Veterinary Medicine. According to the Tanzania Veterinary Act of 2003 Veterinary paraprofessionals are certificate or diploma holders in animal health, recognized by the Veterinary Council of Tanzania, and practice at all times under the supervision of a veterinarian or veterinary specialist [41]. In practice, many are not trained or registered. Veterinary paraprofessionals formal training curriculum indicates that minimal information is given on antimicrobial use, usually limited to prescribing a few antibiotics, mainly tetracyclines, and there are no organized post-training seminars/workshops [35].	Veterinarians train at Degree level that takes 5 years of training and Veterinary paraprofessionals (Assistant Veterinary Officers) are at Diploma level that takes 3 years of training (personal communication). Informal paraprofessionals may receive training from NGOs or learn on-the-job.
Structure of professional bodies	Uganda Veterinary Association (UVA) is a legally registered professional association with a membership of more than 987 veterinarians. UVA activities are managed by a team of 10 members. UVA engages in community development programmes, animal welfare, policy advocacy, promotion of professional standards and welfare of its members [42] The Uganda Veterinary Board is the profession regulatory body established by an Act of Parliament (The Veterinary Surgeons Act 1958, Cap 277). It is composed of a team of seven veterinarians appointed by the Minister of Agriculture, Animal Industry and Fisheries with approval of Cabinet. Its major mandate is to ensure that animal health services are offered by qualified, registered and licensed veterinary professionals under their regulatory supervision. (www.ugandavetboard.org)	Tanzanian Veterinary Association originated from the Tanganyika Territory Division of the National Veterinary Medical Association (NVMA) of Great Britain and Ireland. Later on, the National Veterinary Medical Association gave birth to the British Veterinary Association (BVA) and the Association in the then Tanganyika Territory became the Tanganyika Division of the British Veterinary Association. In the 1950s, members of the Tanganyika Division of the British Veterinary Association had to be full members of the British Veterinary Association in the first place. Since the Union of Tanganyika and Zanzibar in1964, the association is known as Tanzania Veterinary Association (TVA) [43].	The Malawi Veterinary Association is an active body and all veterinarians are encouraged to join. It promotes professionalism, ethics and protects the interests of the profession. It has a three-member executive body. The profession is regulated by the Veterinary and Para-Veterinary Practitioners Act which is yet to be operationalized (Personal communication).

Table 4. General information about medicines that expert respondents believed should be shared with end users.

Sector	Type of information deemed suitable for sharing with end users
Human treatment	Directive Instructions:
	● To avoid sharing medicines
	● To avoid stocking medicines
	● To avoid taking medicines left over from previous illness episodes
	● To always seek services of trained health professionals
	● To follow health worker instructions on the dose and duration of treatment
	Specific advice about the given drug
	● Possible side effects
	● Drug interactions
	● Dietary requirements when on medication
	● How to store medicines
	● How to dispose of medicines not taken with in the recommended period
	General Advice about health and drugs:
	● Where to access good quality medicines
	● Who is allowed to sell medicines
	● What to expect from places where healthcare is accessed
	● Questions to ask the person selling you medicines
	● To return to the healthcare provider if there is no improvement
	General warnings
	● Consequences of misusing medicines
	● The danger of antimicrobial resistance
Animal treatment	General information to help determine if an animal is sick and where to seek help
	● Signs and symptoms of diseases
	● Sources of genuine veterinary services
	Directive instructions
	● To consult veterinary professionals when their animals present certain signs and symptoms
	● To only give antibiotics under the supervision of a veterinary professional
	● To avoid using antibiotics for growth promotion
	● To avoid using antibiotics for prevention of diseases
	Information on reducing the need for antibiotics
	● Disease prevention methods
	● Hygiene and biosecurity to minimise the need for antibiotics
	● Encouraging the vaccination of animals
	● Promoting the use of alternatives to antibiotics
	● Promoting good practices at all steps of production and processing of food from animals
	General warnings
	● Consequences of the misuse of medicines (AMR)
	● Antibiotics do not treat everything

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