OASIS: OneHealth Antimicrobial Stewardship for Informal Health Systems

OASIS transforms rural healthcare by enabling informal rural healthcare providers for humans (RHPs) and animals (para-vets) to monitor personal antimicrobial provision data for infections treated, via the Antibiotic Bandhu (friend of antibiotics) app. By  integrating this with regional AMR data, the app will empower providers to adopt responsible  antimicrobial practices.

Meenakshi Gautham, Assistant Professor at the London School of Hygiene and Tropical Medicine, will spearhead a diverse Solution Team spanning disciplines and organizations, to tackle this challenge in rural India.

Nearly half the world’s population resides in rural areas of low and middle-income countries (LMICs), lacking access to formal healthcare sources for antimicrobials, relying instead on informal drug shops/providers (50%-90%), that may dispense these inappropriately, driving antimicrobial resistance (AMR). India, our project location, is the world's largest consumer of antibiotics, with soaring levels of AMR, where only 43% of pneumonia cases could be treated with first-line antimicrobials in 2021.

With nearly 70% of India’s 1.8 billion population being rural, and more than 70% health professionals being urban based, 70%-90% of human healthcare consultations in rural areas, and 30% - 80% for animals, are with informally trained rural healthcare providers (RHPs) and paravets. They lack simple, standardized antimicrobial usage (AMU) guidelines, leading to over- prescriptions (>50% patients), high use of Watch antibiotics (>80% RHPs), improper dosages, and misuse of human antimicrobials in animals. Training programmes without AMU guidance have not changed RHPs' AMU.

Despite being the first line of defense for disease management, national data on RHPs’ and paravets’ AMU and diseases managed is lacking, due to inadequate infrastructure and ambiguous policies that simultaneously outlaw, yet tacitly shield informal providers to supplement inadequate formal health systems. 

Our solution addresses the pressing need for integration of RHPs and paravets with national health systems/registeries and AMR action plans, for improved healthcare quality and antimicrobial stewardship. These providers are integral to rural healthcare, serving about 70% of the country’s 800 million rural population, particularly from low-income households. RHPs (~2 million in India) have diverse non-medical certifications (e.g. in lab technology/pharmacy/integrated medicine/primary-care) and offer biomedical treatments, including antimicrobials, in small clinics for a fee. Para-vets, also known as Prani Bandhus/Mitras/Sevis (~100,000), are government trained for specific animal services like artificial insemination and vaccinations, but also administer antimicrobials beyond their training, when they go house to house delivering essential services.

Despite their pivotal healthcare role, RHPs and para-vets lack methods to document patient data, access to AMU guidelines and information on AMR in their community. We will deploy tailored guidelines (developed previously) on the AB app via iKure's technology platform, and enable data capture, backend analytics and data-informed decision making by providers. In a feasibility study, providers found these guidelines usable and acceptable, were willing to share patient data and sought more local mentorship. Through  user-design  research involving these providers, we will customize the technology to suit their needs.

The OASIS solution tackles a vital AMU data gap in rural India and contributes to several public goods. The Antibiotic Bandhu app will be easily accessible and downloadable by  RHPs, para-vets, and medical/veterinary professionals, as well as patients/farmers and the public, ensuring widespread adoption. To sustain future expansion, we will explore both an open source and a (nominal) subscription-based model. This app will serve as a self-regulatory tool for standardizing AMU among primary providers.

Two, guidelines developed through our project (and deployed on the AB app) can be adapted across India and other similar geographical settings. These include 6 Human health syndromes and 9 Animal health syndromes.

Three, with our local collaborators (NICED and AIIMS, Kalyani), we will share project-generated data with government disease portals, the state health department,  national health mission and AMR National Action Plan Committees for joint reviews and recommendations. We will also link with village communities as part of existing government health programmes (e.g. village health and nutrition days) to generate awareness. Lastly, key project outcomes and findings will be disseminated through peer-reviewed open-source publications and health policy portals to facilitate knowledge exchange, foster continuous dialogue and drive sustainable improvements in AMU within community settings.

Our primary goal is to improve antimicrobial provision for rural populations in India, where infectious diseases like pneumonia and diarrhoea are major contributors to mortality, particularly among children (e.g. 28% of under-5 deaths are due to pneumonia; rural residents are most vulnerable).  Rural Healthcare Providers (RHPs) and Paravets are a crucial pathway to reach these populations, being the first point of contact for many in these communities. The OASIS solution focuses on empowering these providers to make informed decisions regarding AMU.

Our previous research highlights various factors influencing RHPs and paravets' antimicrobial practices, including misconceptions about antimicrobials being a gold-standard therapy for most illnesses, perceived efficacy of human antibiotics in animals, community demands and lack of formal health and veterinary services, inadequate mentorship based on conflicts of interest and pharmaceutical marketing. Rather than promoting outright (and futile) bans on AMU by these providers, our approach emphasizes empowering them with clear guidelines and mentorship. By integrating tailored guidelines, mentorship, and data feedback mechanisms (project activities), our approach targets enhanced AMU among RHPs and para-vets (outputs), ultimately improving disease management and antimicrobial stewardship in rural communities (outcomes). We also anticipate that better-informed decision-making will help providers navigate pharmaceutical pressures more effectively.

In Year 1 we will develop and test the AB app with 100 RHPs and 50 para-vets in two administrative blocks of Nadia district and in Year 2 cover 1075 RHPs and >100 para-vets in these blocks.  In year 3, we aim to cover  Nadia district (~10,000 providers, ~3.7 million rural population), expand to other parts of West Bengal (~50,000 providers, ~25-30 million rural population) and rural areas of Bihar and Andhra Pradesh states (~100,000 providers, ~50 million population). We will explore both open access and a nominal subscription-based model for providers and mentors. For scaling up, we will leverage our institutional alliances with the Indian Institute of Public Health, Hyderabad (Andhra Pradesh), and World Health Partners (Bihar) and in Orissa and Rajasthan  (with AIIMS Bhubaneshwar and Jodhpur), alongside iKURE's operations in 9 states.

Future plans include adapting the OASIS package to other country contexts through existing collaborations in Africa and South/Southeast Asia (e.g. Makerere University, Uganda; Mahidol University, Thailand; ICDDRB, Bangladesh). Furthermore, we plan to include additional infectious and non-infectious diseases in the OASIS package and cover peri-urban pharmacies too, enriching the solution's scope and relevance and facilitating broader adoption and impact across varied settings and disease landscapes.

Our monitoring and evaluation plan encompasses key process and outcome indicators across four key domains, which will be further co-developed with local stakeholders including RHPs’ and para-vets unions/associations:

App: First, we will assess the uptake and usability of the app among RHPs and para-vets, gauging their engagement and interaction patterns to ensure effective utilization.

Data: Second, we will monitor data generated, through comparison with patient exit interviews (at 10% of the provider clinics periodically, and also in the baseline survey) to ensure accuracy and reliability.

Improvements: Third, we will evaluate the utilization of collected data for self-improvement and mentorship purposes, assessing how effectively it informs and guides healthcare practices among providers.

Fourth, we will measure guideline adherence and the proportion of individuals correctly treated in accordance with the established guidelines, and patient care quality.

Data Insights: Finally, we will track the proportion of antimicrobials dispensed across AWARE categories,  drawing links between practitioners’ diagnostic rationales and treatment decisions,  allowing us to analyze patterns of AMU vs AMR, and identifying areas for improvement in antimicrobial stewardship practices.

By systematically evaluating these aspects, we will ensure the effectiveness and efficiency of the OASIS solution, fostering continuous improvement in rural healthcare delivery and AMU.

We anticipate three broad challenges. First, existing regulatory frameworks related to AMR are evolving, especially in LMICs. Binding regulatory instruments (e.g. prescription policies for antibiotic sales) have struggled to address the overuse and misuse of antibiotics  because they deny access and are therefore difficult to enforce.  Through policy entrepreneurship we will showcase how an evidence-based technology-aided solution improves both community-level healthcare and AMU, more than restrictive regulations. Our advocacy will pave the way for acceptance of this solution by regulators, with the mentorship model addressing legal concerns.

Second, for scale up we anticipate language barriers, network challenges in rural areas, and less than 100% availability of smart phones. There may also be a potential lack of interest by healthcare providers fearing financial losses. We will explore offline, multi-linguistic versions for simpler phones, and do a cost analysis of potential financial losses due to reduced AMU versus an increasing footfall of patients who are satisfied with better and lower cost treatments.

Lastly, to manage possible opposition from India’s private sector and medical fraternity we will leverage support from a powerful private sector group  (FICCI) and include reputed professionals on an advisory committee, for co-governance and reimagining regulations.

We are applying to the Trinity AMR Challenge because it aligns perfectly with our proposed Solution. This is just the support that we’ve been waiting for to help us create a digital network of grassroots providers with improved, data driven antimicrobial practices !! This is a ground-breaking and pioneering call as it recognizes the significance of addressing AMR and its complex drivers in community settings, and its underlying structural challenges. Moreover, the call acknowledges the role of informal sources of antibiotics, in humans and animals! 

The funding offered would enable us to concentrate on pivotal issues concerning AMU in informal health systems in community settings, and AMR. Moreover, it would enhance our credibility, and facilitate connections with other innovators in technology spheres. Facilitating connections between applicants and potential mentor organizations holds great promise for transformative collaborations to emerge.  With this support, we can devise even more sophisticated solutions for underserved communities and providers, that expand responsible access to antimicrobials through task shifting solutions, while reducing their excessive and inappropriate use. The SOLVE Challenge represents a fateful and long awaited opportunity for us to amplify our impact and comprehensively address the multifaceted challenges posed by AMR in community settings in LMICs.

We would benefit from collaborations with organisations that specialise in user -design research (Ux-design) that could support our Antibiotic Bandhu app development in creative ways.

We would also benefit from collaborations with:

Google –for ideas on diversifying the app in multiple languages for scale up across India and in other linguistic contexts. Language remains a major barrier for marginalized and semi-literate populations to access internet content.

Microsoft – for refining the technology underlying the app.

Black Sands – to help enhance our communication strategy to promote our work, foster engagement with diverse stakeholders and effectively present our data to meet the needs and interests of diverse groups.

British Society for Antimicrobial Chemotherapy – to help with meaningful AMU and AMR data interpretations to support data informed antimicrobial stewardship practices.

Additionally, iKure would like to seek partnership with the Bill and Melinda Gates Foundation for organizational mentorship, grant funding and peer-to-peer networking.