Promoting actionable strategies for gender-equity responsive antimicrobial stewardship in public primary health care in Punjab, Pakistan

National AMR context

Antimicrobial resistance (AMR) poses a critical threat to Pakistan’s primary health care system, which serves as the community’s first point of contact for health services. Recent evidence highlights the lack of antimicrobial stewardship (AMS) practices at the primary healthcare level. Findings from our ongoing work (an ICARS funded cluster randomized trial) indicate that inappropriate antibiotic prescriptions for common infections such as acute upper respiratory tract infections and diarrhoea are ~80% in rural public primary health care facilities. At the facility level, main challenges are limited diagnostic facilities, lack of guidance for empirical prescribing, incomplete drug dispensing, and lack of comprehensive patient counselling. In contrast, main challenges at the community level are unregulated availability of antibiotics at local pharmacies, poor community awareness, limited engagement in care delivery, self-medication, lay-care, and poor care adherence. These existing scenario highlights a systemic challenge of antibiotic misuse, weak regulations, and ineffective stewardship. While Pakistan has launched its second National Action Plan on AMR, urgent, multisectoral action—spanning surveillance, stewardship, and stricter control of antibiotic use—is critical to avert worsening morbidity, mortality, and treatment failures.

Problem

There is increasing evidence that the bulk of current data on AMR does not utilize social and cultural stratifiers (such as gender, education status, socioeconomic background) as segregating factors. There is strong evidence that cultural factors like gender, socioeconomic background, and social norms affects prescription practices and consumption patterns of antimicrobials, both of which are critical in controlling the rise in AMR. However, the ongoing AMS practices do not explicitly utilize a structured gender-equity (GE) approach for ensuring that the relevant considerations are catered for in a contextualized manner. To ensure that the AMS practices are more responsive to the sociocultural dynamics of the communities, there is a need to incorporate GE considerations within ongoing AMS practices for sustainable impact.

Project overview

The project aims to develop, implement, and promote actionable strategies for GE responsive AMS practices at public primary healthcare level by utilizing the guidelines developed by ICARS to integrate gender and equity considerations in antimicrobial resistance research. A context review, using the adapted GE matrix and drawing on both primary and secondary data, captured the sociocultural nuances relevant for AMS at the public primary healthcare level, considering perspectives of both healthcare providers and the community. The review highlighted persistent GE related barriers in access to care and care adherence, including limited mobility, lower health literacy, and restricted decision-making autonomy, as well as structural constraints such as inadequate resources and gender-insensitive service delivery.

Based on these learnings, we synthesized and implemented strategies to improve GE responsiveness in primary healthcare facilities by infrastructure support and fostering GE sensitization (through a tailor–made package) among healthcare staff, institutionalized equitable antibiotic prescribing and dispensing practices, enabled GE responsive AMS monitoring, and facilitated GE sensitive community engagement in care delivery. We will also generate practical evidence, through mixed method research, for adapting and implementing GE responsive AMS practices in other contexts. 

Through this ICARS-supported project, we aim to place gender and equity at the heart of antimicrobial stewardship, ensuring that the primary health care system in Pakistan provides quality care by responding to the realities of the communities it serves.

— Muhammad Amir Khan, Chief Coordinating Professional, ASD, Pakistan

Solutions and outcomes

• Gender-equity responsive care at public primary healthcare facilities 
• Actionable recommendations/strategies for GE responsive AMS 
• Protocols and guidance for GE responsive AMS monitoring 
• Implementation experience of GE responsive AMS in developing country context 
• Practical insights into application of adapted GE matrix 
• Gender-equity sensitization promotion for healthcare staff beyond AMR 

About the Gender and Equity Stream