Studying Antimicrobial Resistance in urban informal settlements through Community-based participatory research (CBPR)

 

Most AMR research has focused mainly on formal healthcare, overlooking the role of the environment. Yet, as cities expand, informal settlements grow, often facing environmental injustices (defined as an inequitable distribution of harms in the human and natural environment) that can worsen AMR. These urban informal settlements (slums) are described as ‘hotspots’ for antimicrobial resistance which is stigmatising. Rather, the marginalised communities face a higher risk of exposure to, and burden of, antimicrobial resistant microbes due to insecure tenure and land rights, poor access to affordable quality healthcare, a lack of formal governance and high exposure to waste, pollution and extreme weather events.

 Our research asks: can informal urban settlements become sites of positive change for AMR? Using community-based, participatory, and arts-driven approaches, we will challenge conventional strategies and explore new pathways across Bangladesh, Kenya, and Nepal. This study brings together diverse disciplines to co-create knowledge on antimicrobial resistance (AMR) within urban informal settlements. It moves beyond the usual framing of formal health systems as “solutions” and informal environments as “problems.”

Primary Health Care (PHC) System Capacity In Bangladesh

 

Primary Health Care is recognized as the foundation of a resilient health system, yet Bangladesh’ PHC continues to face challenges including fragmented service delivery, weak referral systems, underfunded budgets, and shortages of trained health workers. A study was conducted to provide a comprehensive overview of Bangladesh’s Primary Health Care (PHC) system, as part of a regional evidence-gathering initiative of the WHO’s Asia Pacific Observatory on Health Systems and Policies (APO). Besides PHC system capacity, the study also aimed to identify gaps and opportunities, and inform future regional and sub-regional policy and practice. 

The study employed a mixed-methods approach, combining a rapid review of national policies, strategies, guidelines, program reports, and peer-reviewed literature with semi-structured interviews of national experts, government officials, and PHC implementers. Data were triangulated across sources using a standardized domain framework, and ethical approval was obtained from BRAC University’s Institutional Review Board.

Findings reveal that governance of PHC in Bangladesh is anchored in the National Health Policy (2011) and operationalized through the Essential Service Package (ESP, 2016). However, governance remains fragmented across sector programs, with limited integration of pandemic preparedness and climate resilience. Referral coordination is inconsistent, and quality assurance mechanisms, though supported by national policies, are unevenly enforced, particularly in the private sector.

Lab on the paper

 

According to the World Health Organization (WHO), a counterfeit medicine is a pharmaceutical product “which is deliberately and fraudulently mislabeled with respect to identity and/or source”. This definition of counterfeit medicines falls within the broader concept of “substandard medicine” but the two categories should not be confused. The category of substandard medicines includes medicines that may present an unintentionally incorrect package or have an incorrect quantity or ratio of ingredients. The difference with counterfeit medicines is that substandard medicines may not have an intentional attempt but result from inaccurate production due to inadequate resources and structures. Globally 10–15% of the supplied medicines are counterfeit. The prevalence is higher in developing countries in where up to 30–60% of medicines on the market are counterfeit. India is a major supplier of poor quality medicines producing 35–75% and China 20% of fake/counterfeit medicines globally. 

Counterfeit/sub-standard/poor quality medicines are a major cause of therapeutic failure, serious adverse events, deaths, economic burden, medicine resistance, and loss of public confidence in medicines and health services. Many factors contribute to the increased prevalence of substandard and counterfeit medicines, including corruption.  Besides, weak or absent medicine regulatory authority, proliferation of small pharmaceutical companies, complex transactions involving many intermediaries, a lack of good manufacturing practices (GMP) are other reasons in most developing countries. Though the WHO has issued guidelines for combating Counterfeit/sub-standard/or poor-quality medicines, most developing countries are struggling to implement them.

Bangladesh context

In Bangladesh, where out-of-pocket healthcare expenditure is high for medicines, counterfeit/sub-standard/low-quality medicines pose a greater threat to public health. Such medicines range from pain killers to antibiotics to even anti-cancer medication. According to a media report in 2009, 24 children died of acute renal failure after taking adulterated Paracetamol syrups made by a local medicine company.  Diethylene glycol, a chemical used in the dyeing and leather tanning industries, was detected in the syrup. In the same year, government authorities visited 193 pharmaceutical companies, examined their performance levels, and divided them into A, B, C, D, E and F categories. According to their report, companies ranked A-C produced medicines in compliance with the GMP, an international standard for medicine quality control; those ranked D-F did not. 

Skills and need for institution and home-based supplementary health care services in post-pandemic Bangladesh

 

The unprecedented pandemic of COVID-19, a classic ‘low probability, high impact’ event, has shaken both developed and developing countries alike with its adverse health and livelihood consequences. The demand for an appropriately trained and motivated health workforce has been phenomenal during this crisis. As such, the global shortage of health workforce has come to the forefront of discussion, including measures to overcome this for the necessary surge in capacity under resource constraints.

Before the pandemic, Bangladesh was among the 57 countries with critical shortages of health workforces. Its health system is characterised by a “shortage, inappropriate skill-mix and inequitable distribution” of the health workforce. The COVID-19 pandemic has exacerbated this already vulnerable situation. Besides doctors and nurses, the country experienced a critical shortage of medical and nursing aids, medical technologists and technicians, and various categories of health workers who provide physiotherapy, elderly care, disability care, and palliative care, including home-based care. This situation can be considered both a crisis and an opportunity, especially for generating employment for women and facilitating inclusive economic growth.

A study was conducted in late 2020 to explore the types of healthcare services in demand during a pandemic situation, emerging opportunities to provide these services at home and institutions, and the training and accreditation of healthcare workers for specific services. Under the ongoing pandemic situation,  telephone-based interviews were conducted to gather relevant data from the respondents The study  adopted a cross-sectional design and applied a combination of a) rapid review, b) quantitative assessment using a semi-structured questionnaire, and c) qualitative assessment (e.g., key informant interviews (KII)) with the stakeholders) using interview guidelines.