Interview with Kim Faure, GARP-South Africa

Molly Miller-Petrie: What steps did you take to get the strategy developed and adopted?

Kim Faure: The development and adoption of the AMR strategy has taken about two years, which coincided with a seven year build-up of efforts by many parties, including the Ministry of Health and the South African Antibiotic Stewardship Program (SAASP), on setting and regulating quality care standards, including AMR standards. The GARP-South Africa situation analysis was a big catalyst, too, and my continued work is on behalf of GARP and SAASP. Every year, the Ministry of Health runs a healthcare quality summit. In 2014, the topic for the summit was antimicrobial resistance. The summit outlined the key commitments that all stakeholders would make to manage antimicrobial resistance in South Africa, including investing resources and implementing sound strategies and interventions. The summit was so successful that AMR was then embedded into the work of the pharmacy unit within the Ministry, and the strategy was finalized and published along with the signed commitments document.

MMP: In the South African context, why is it important to have a national strategy for antimicrobial resistance in place?

KF: Interest in developing a national AMR strategy was galvanized by the development of the Ministry of Health’s national standards for quality in health establishments. It was especially important to us to have a strategy in place to guide healthcare managers in the implementation of the standards at the national, regional and facility level, in order to ensure their uptake. It was also hugely beneficial to have GARP, SAASP and other partners working on both the standards and the strategy, guaranteeing that the two were in alignment with each other.

The AMR strategy itself is high level, focusing on collaboration, governance and awareness and education campaigns. A smaller section focuses on facility-level activities, but for the most part the quality standards are the primary intervention at the facility level. Legal regulations ensure the standards are complied with—health facilities must adhere to them and get certified or eventually risk losing public funding. The plan is for all health facilities (private and public) to be inspected and audited by inspectors from the Office of Health Standards Compliance (an independent regulatory body) once every four years. The existence of a national AMR strategy within the Ministry provides a mechanism to ensure that there is national level accountability to taking action on antibiotic resistance.

MMP: What’s next for the national strategy?

KF: Moving forward, we are putting together an implementation plan for the AMR strategy and are focusing on priority activities for the next five years. The implementation plan will hopefully also serve as a useful tool in negotiating budgets and coordinating with other sectors. The design of the plan, in particular for higher-level activities related to national coordination, will be a challenge, in addition to the coordination of responsibilities and budgets among many actors. Other potential challenges to implementation include the lack of an infection control lead within the Ministry, lack of funding for activities, bureaucratic delays to implementation and lack of implementation skills for AMR activities within health facilities.

MMP: What elements do you think were most important in the official adoption of the strategy?

KF: Key to the success of the strategy was the constant dedication and activity of partners from all sectors over a period of years, bringing the issue to the forefront of national dialogues whenever possible and the presence of champions within and outside the Ministry to move the issue forward.

While certain elements of the South African process may be replicated elsewhere, much depends on the national context, presence of champions, and the time and resources available to partners working on this process. We worked to target a wide range of actors, bringing the topic of AMR to the table in each area in which members worked or were involved. Yet the process can be slow and consuming – the formation of the regulatory body for quality of care took more than eight years.

The real tipping point was when clinicians started voicing their interest and concerns on the issue of AMR to the Ministry of Health. For us, the lobbying of clinicians and their messages related to the cost of AMR to the health system were very important. They were saying, “We’re here trying to treat people and it’s only going to get harder and more expensive if we don’t act. Resistance is already a problem and we need to act now, before patients can no longer be treated because we don’t have effective antibiotics.”

Infection control is probably the easiest point of entry for improving the health system. It’s easy to explain what the procedures are and it gets people sensitized to the need for behavior change. Antibiotic stewardship is a step beyond that. Yet here in South Africa, the Ministry lacks a focal person in charge of infection control at the national level, leading to a lack of leadership and a gap in the policy arena. We do, however, have a very keen champion for antimicrobial stewardship (AMS) in the pharmacy unit in the Ministry. We are advocating for the AMS agenda in health facilities through that champion. You have to identify that enthusiastic, effective person and provide them with the support they need to implement – it needs to become their initiative.

In the end, each country will need to find their own way to achieve change, and identify their own constellation of circumstances to facilitate it. While much can be achieved through the dedicated work of volunteers, it is important to have some partners who are employed strictly to work in this area, to create the necessary space and focus to move the process forward.