Ambition versus limitation
The healthcare workforce of the 21st-century transcends boundaries of institution, discipline, and nation.
The education of this workforce, therefore, must help individual practitioners succeed by providing knowledge and understanding of different cultures, languages, systems, and geographies.
This view of the world accords with the results of a prominent global survey in which 75% of CEOs said a skilled, educated, and adaptable, workforce should be a top priority for business and government.
There remain, however, significant challenges to fulfilling this ambition.
Entrenched approaches to education, whether in academia, government, healthcare, or industry, tend to focus on knowledge production linked to patents, publications, conferences, courses (including e-courses) – and less on outcomes like changing practice at the bedside to improve safety and quality of care.
To make matters worse, the lack of experienced and well-trained healthcare workers (HCWs) across many regions has been aggravated by the COVID-19 pandemic.
Plus, the desire and ability to deliver basic continuous education at scale is a huge challenge, particularly in resource-limited settings. HCWs often operate in an environment where time and resources for education are scarce – or just not considered a priority by managers. As such, it can be a challenge to send employees for training because of budget cuts and understaffing.
This, then, is often the context in which antimicrobial stewardship (AMS) education and training is delivered.
Transform the approach
To transform this approach, we must demonstrate how a skills-based education can help staff function in challenging conditions that demand strategic reasoning, insightfulness, effective communication, perseverance, and craftsmanship, to resolve complex problems.
This is where e-learning is already playing an important role. Not only does it help institutions of all sizes save time and money it also provides a continuous source of education that maintains learners’ motivation through a range of interactive mixed media that can be paused and continued later or repeated until the participant has grasped the essentials.
Emerging evidence also suggests e-learning, when combined with face-to-face education (blended learning), leads to participants making faster progress than they would through traditional instructor-based methods alone. In some cases, this is translating into improved behaviours and outcomes.
One of the biggest barriers to combatting AMR is the failure to implement effective interventions. This is particularly true for AMS programmes, regardless of healthcare setting. Inadequate provision is often the result of a fractured relationship between context, available resource, social influence, professional identity, motivation, and behaviour.
AMS education and training underpin the effective implementation of critical interventions (such as the use of new or existing vaccines, antimicrobials, diagnostics, or informatics) – which is why they are routinely identified as core components of AMS checklists at local and national level, and why they are included in the WHO curricula and competency frameworks for HCWs.
In 2018 a global mapping exercise concluded there are many organisations working to develop and share open access educational resources, with governments, hospitals, and professional societies, appearing to lead the way.
However, these programmes were unequally distributed across countries and regions, with many more in North America and Europe, than in Africa or Asia.
Opportunities for action
The survey also identified several opportunities for action: increased engagement with students, improvements to pre-service education, recognition of AMR courses as part of continuing medical education, the need for more context-specific resources, and better platforms for online sharing.
Indeed, an acknowledgement of the latter can be seen in the recent call from Wernli and colleagues for the creation of an open access online learning platform for “One Health” AMR, which would prove useful to a range of stakeholders, including HCWs, public health practitioners, policymakers, industry representatives, and consumer groups.
Several platforms are emerging (see the British Society for Antimicrobial Chemotherapy’s Infection Learning Hub, the work of the Fleming Fund, and WHO’s collection of resource materials), but need further development to embrace global resources, the broader AMR agenda, and multi-functionality.
Proof of this uneven development begs the question: why is there such a gap between intent and action? One reason is that those tasked with the delivery of education and training have not been given adequate funds from the government departments responsible for executing national action plans. Competing priorities for limited resources makes funding of educational activity a low priority.
Instead, it is left to enthusiastic individuals or groups to pursue their own specific training needs and, where appropriate, to share these outputs with others. Those in the private sector may have better opportunities to access industry-sponsored education. While many such activities are well-meant, and governed appropriately to exclude commercial bias, quality of content and delivery is variable.
As such, the bigger question is left hanging: how can all stakeholders in this space collaborate to create, disseminate, monitor, evaluate, and sustain global learning that is context-specific and cost-effective?
A new approach to funding education is essential if we are to move the very latest medico-scientific advances on AMR and AMS into clinical practice.
For example, the money pumped into new infection therapies, surveillance, laboratory capacity, and rapid point of care diagnostics, continues to be substantial. This is exactly how it should be, but I would argue that a portion of these funds should be committed to supporting bespoke HCW and, where appropriate, public-patient education and the innovation of its delivery (for example, through AI, gaming, and virtual classrooms). It stands to reason that if we fail to improve the use of innovations in practice our overall impact will be less effective.
Learning from COVID
The COVID-19 pandemic has shown us how innovative digital technology can be in complementing traditional healthcare delivery, enhancing practice outcomes, and providing a learner-centric and cost-effective method of knowledge exchange.
It has also brought with it unprecedented investment, globally, on many fronts – as tracked by Devex. The analysis of who is prioritising what in the response to COVID-19 is compelling – not least because education ranks as one of the top 10 funded focus areas (see table below).
This approach is consistent with the fact that investment in HCWs, for example in Sub-Saharan Africa, can result in an economic return of up to 10:1— due to increased productivity from a healthier population, potentially reducing the risk of epidemics and the economic impact of increased employment.
Despite this clear return on investment, the funding responses to support the education of HCWs in AMR interventions remains opaque.
This is exemplified by an EU survey (2016) of public investment in AMR research. It found that €1·3 billion had been invested across 19 JPIAMR countries – with 63% of 1,208 projects funded at national level on therapeutics, 15% on transmission, 11% on diagnostics, 4% on interventions, and 3% on environment and surveillance. Education research and implementation were not mentioned.
Last year’s Wellcome Trust report, The Global Response to AMR: Momentum, Success and Critical Gaps, identified seven priority themes and nine enablers. Optimising the use of medicines through behaviour change interventions was identified as a critical gap. However, funding to support the development and delivery of innovative education and behaviour change methods was not prioritised as an enabler.
Instead, funding streams to support well-established enablers continue to be prioritised – with a significant focus on the push for new technologies such as diagnostics, new therapies (antimicrobials and vaccines), surveillance and laboratory capacity, better governance, stronger leadership, and informatics.
Recommendations on policies and funding
All National Action Plans on AMR should mandate the provision of a budget for an education and training plan. This commitment could and should lead to many significant outputs and outcomes, including the development of national/regional training faculties (aided by a network of local faculties) that can support the spread of training, the creation/development of national resources, gateways to other local, regional, national and international open access e-learning resources, tools for evaluation, and the creation of national metrics on education provision at the level of local and national healthcare facilities.
Looking to the UK Government’s Global AMR Innovation Fund, we should either create a new “global fund” or incorporate education into the remit of existing funds, and seek contributions from a range of stakeholders involved in AMR.
Another model to consider adopting would be a more bespoke national or regional approach through public-private partnerships, which have become increasingly responsible for delivering healthcare and education and training, often in LMICs (see the interesting case study in Tanzania on the back of health sector reforms in the 1990s).
There is also the possibility to crowdsource funds for the development of open-access learning resources.
Another option, complementing the approaches above, would be for pharmaceutical companies to set up an education and implementation fund dedicated to HCWs in line with their approach to research into new therapies.
One may, perhaps, naively also argue that a proportion of funding allocated by industry to the marketing of a new technology or therapy could be levied to support education and training through contributions to the sort of global fund referred to above.
Invest now, or pay a much higher price later
Either way, we need a major shift in the current mindset on AMR/AMS education and its delivery – because, as it stands, “it’s left as a low priority, not based on measurement of meaningful impact and left for stretched local healthcare facilities or individuals to do and deliver”.
As Barack Obama said, “Cutting the deficit by gutting our investments in innovation and education is like lightening an overloaded airplane by removing its engine. It may make you feel like you’re flying high at first, but it won’t take long before you feel the impact”.
If we do not invest in traditional and innovative forms of education, our ability to create well-trained HCWs to deliver high-quality care and treatment, with better patient outcomes against AMR, will evaporate – and we will likely pay a far higher price as a consequence.
Professor DILIP NATHWANI; MB, DTM&H, FRCP [Lon.& Edinburgh], FRSE, OBE; AMS Consultant & Emeritus Honorary Professor of Infection, University of Dundee
Dilip Nathwani is a global leader for advocating the pivotal role of the healthcare professionals, their prescribing behaviour and skills – education in the human response to the global pandemic of antimicrobial resistance. His primary interest is human antimicrobial stewardship and implementation. Building innovative high quality open access digital or e-learning knowledge exchange platforms that support the needs of the global workforce, particularly in LMICs, is the premise of his current work. Creating sustainable collaborative learning networks with a range of stakeholders, funded by public- private partnerships and philanthropy, are core to this work. Dilip encourages those interested to join him in this mission.
@DilipNathwani / Royal Society of Edinburgh / University of Dundee
Initial response from BSAC
Dilip has been a great advocate of education and implementation science for most of his working life. He reviews the current issues affecting education in the field of antimicrobial resistance and the use of antimicrobials very comprehensively.