The AMR challenge in Uganda: More than a technical problem

Uganda is experiencing increasing resistance to widely used antibiotics, including amoxicillin, ciprofloxacin, ceftriaxone, gentamicin and cotrimoxazole.[2][3] Surveillance and hospital-based studies show a rising prevalence of multidrug-resistant organisms, particularly extended-spectrum β-lactamase (ESBL)–producing Enterobacterales and methicillin-resistant Staphylococcus aureus (MRSA).[2] 

Drug resistance has also been documented across priority disease programmes. Uganda’s first national tuberculosis (TB) drug-resistance survey reported resistance to any first-line anti-TB drug in 10.3% of new patients and 25.9% of previously treated patients, with multidrug-resistant TB reaching 12.1% among the latter group.[4] In malaria, resistance to chloroquine and later sulfadoxine-pyrimethamine emerged in the 1990s and early 2000s, prompting successive changes in national treatment policy toward artemisinin-based combination therapies.[5] HIV drug resistance has similarly increased over time, particularly to non-nucleoside reverse transcriptase inhibitors, contributing to Uganda’s transition to dolutegravir-based first-line regimens with a higher barrier to resistance.[6][7] 

Together, these trends highlight AMR as a cross-cutting threat requiring coordinated AMS across human health programmes.

For patients, AMR translates into:

• Delayed recovery and treatment failure.
• Prolonged hospital admissions.
• Increased healthcare and household costs.
• Reduced trust in health services.

These outcomes are not driven by clinical factors alone. Patient behaviour and community norms, including self-medication, incomplete adherence to treatment, pressure on clinicians to prescribe antibiotics and sharing of medicines within households, are major contributors to inappropriate antimicrobial use in Uganda.[1][8] Addressing this is therefore essential to effective AMS.

Strong policy commitment, persistent implementation gaps

Uganda has demonstrated strong political commitment to addressing AMR through the National Action Plan on Antimicrobial Resistance II (NAP-AMR II) 2024/25– 2028/29, which aligns with the WHO Global Action Plan on AMR and adopts a One Health approach spanning human, animal and environmental health.[1][8] Key achievements include:

• Establishment of a national AMR Secretariat.
• Adoption of the WHO Access, Watch, and Reserve (AWaRe) antibiotic classification.
• Piloting of AMS committees in selected regional referral hospitals.
• Annual national AMR awareness campaigns.

However, despite these advances, AMS implementation remains uneven. Stewardship activities are largely concentrated in tertiary facilities, diagnostic capacity is limited in many settings, and surveillance systems do not adequately capture community-level antimicrobial use.[8] Critically, patient engagement is not yet systematically embedded within AMS implementation, limiting the reach and sustainability of national efforts.

Why patient engagement is central to AMS

AMS is most effective when patients are not passive recipients of instructions but active partners in care. Patients influence antimicrobial use at every stage: care-seeking behaviour, expectations during clinical encounters, adherence to prescribed treatment and medicine use within households.[1] Meaningful patient-centred AMS ensures that patients are:

• Informed, with clear and accessible information about when antibiotics are needed.
• Empowered, able to ask questions and participate in shared decision-making.
• Engaged, involved in shaping stewardship messages and interventions.
• Partners in accountability, reinforcing appropriate use within families and communities.

Evidence increasingly shows that stewardship interventions incorporating patient education and community engagement achieve more durable behaviour change than provider-only approaches.[9]

The strategic role of patient organisations

Patient organisations occupy a unique position within health systems. Rooted in lived experience and trusted by communities, they can translate complex technical guidance into culturally relevant messages, strengthen trust and support accountability for quality and safety.

UAPO is a national umbrella body representing 18 patient organisations across diverse disease areas. UAPO provides a unified, patient-centred platform that aligns closely with Uganda’s AMR priorities, particularly in:

• Rational medicine use.
• Community awareness and behaviour change.
• Patient safety and quality of care.
• Accountability and transparency in health systems.

UAPO does not replace government leadership or clinical stewardship. Rather, it complements national and facility-based AMS efforts by anchoring stewardship in lived experience and community practice, consistent with WHO guidance on meaningful patient engagement.[10]

Demonstrated patient-led innovation: The CHAIN experience

A compelling example of patient-centred AMS in practice is provided by Community Health and Information Network (CHAIN), a UAPO member organisation. CHAIN has developed an innovative gamification-based approach to antimicrobial stewardship education that targets children as agents of change. Through interactive play, storytelling and peer learning, children are taught:

• When antibiotics are needed—and when they are not.
• The importance of correct dosing and completing treatment.
• Hand hygiene and infection prevention.
• The risks of sharing or misusing medicines.

To date, this approach has reached over 20,000 children in rural and urban communities and has demonstrated measurable improvements in hygiene and medicine safety behaviours (UAPO internal programme data). Children trained through the programme act as AMR champions, influencing parents and caregivers and reinforcing responsible antimicrobial use at household and community levels. This early-life intervention addresses AMR at its behavioural roots and complements facility-based stewardship and regulatory interventions.[8]

UAPO’s positioning to lead a national patient-centred AMS campaign

UAPO is uniquely positioned to lead a national campaign on strengthening AMS through patient engagement by offering:

• National convening power to bring together patients, clinicians, policymakers, regulators, and partners.
• Trusted community reach through established patient networks.
• Strong alignment with national policy, particularly NAP-AMR II.
• Scalable community-based models that complement technical AMS interventions.
• A sustainability focus, embedding stewardship behaviours early and across generations.

Through this role, UAPO can help ensure that AMS is not only implemented, but understood, owned and sustained by the communities it serves, reinforcing national AMR objectives.[8]

Conclusion: From policy to people

Uganda has laid strong foundations for addressing antimicrobial resistance through robust policies and multi-sectoral coordination. However, the next phase of progress depends on translating policy and technical guidance into everyday decisions made by patients and families.

Strengthening antimicrobial stewardship without engaging patients risks short-lived gains. By placing patients at the centre of AMS and by supporting patient organisations, such as UAPO as partners and conveners, Uganda has an opportunity to demonstrate how meaningful patient engagement can accelerate stewardship, protect life-saving medicines and strengthen health system resilience.

Investing in patient-centred AMS is not optional; it is essential.

References

1. World Health Organization. Global action plan on antimicrobial resistance, 2015.
2. Okiror JJ, Aruhomukama D, Kajumbula H. Kateete DP. Trends in antimicrobial resistance from sentinel surveillance sites in Uganda. BMC Infectious Diseases 2024; 24: Article 912.
3. Ndugga P, Mboowa G, Karamagi C, Taremwa IM. Antimicrobial resistance patterns among priority bacterial pathogens in Uganda. BMC Infectious Diseases 2024; 24: Article 930. https://doi.org/10.1186/s12879-024- 09806-y.
4. Lukoye D, Adatu F, Musisi K, et al. Anti-tuberculosis drug resistance among new and previously treated sputum smear-positive tuberculosis patients in Uganda: Results of the first national survey. PLoS ONE, 2023; 8(8): e70763. https://doi.org/10.1371/journal.pone.0070763.
5. Kamya MR, Bakyaita NN, Talisuna AO, et al. Increasing antimalarial drug resistance in Uganda and revision of treatment guidelines. The Lancet 2002; 360(9341): 451–2. https://doi.org/10.1016/S0140-6736(02)09609-7.
6. WHO. HIV drug resistance report 2019. World Health Organization, 2019.
7. Wittkop L, Günthard HF, de Wolf F, et al, WHO HIVResNet. Effect of transmitted drug resistance on virological and immunological response to initial combination antiretroviral therapy for HIV. The Lancet HIV 2021; 8(3): e167–e77. https://doi.org/10.1016/S2352-3018(20)30338-7.
8. Ministry of Health (MoH), Republic of Uganda. National Action Plan on Antimicrobial Resistance II (2024/25–2028/29). Government of Uganda, 2025.
9. WHO. Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries: A WHO practical toolkit. World Health Organization, 2019.
10. WHO. Framework on integrated, people-centred health services. World Health Organization, 2016.

Further reading on the hub:

• Why won’t my doctor give me antibiotics? Ron Daniels explains
• My involvement with the Commonwealth Partnerships for Antimicrobial Stewardship Scheme (CwPAMS) in Zambia
• Top picks: Key resources on antimicrobial resistance

Do you have insights to share around patient safety? We would love to hear from other countries and organisations on the work they are doing. Are you a member of the hub? Why not join our global community today (it’s free and easy to sign up) and submit an article or share a resource? You can also contact the editorial team at content@pslhub.org.

• In 2022-23, more than 84,000 Australians were hospitalised with sepsis – significantly greater than previous estimates of 55,000 cases per year
• One in seven sepsis cases resulted in death
• Over 50% of sepsis readmissions occurred in the first 30 days after discharge
• First Nations people are hospitalised for sepsis at double the rate of non-indigenous Australians
• People with chronic conditions, such as diabetes, kidney disease or cancer face a much greater risk.

There is also encouraging news. The proportion of sepsis-related deaths occurring in emergency departments has declined, suggesting that sepsis pathways and awareness initiatives are starting to have an impact.

But we must do more. Early recognition, timely treatment, and well-coordinated follow-up care are vital to saving lives and reducing long-term impacts.

The importance of patient safety

Patient safety refers to the prevention of errors and adverse effects associated with healthcare delivery. According to the World Health Organization (WHO), millions of patients worldwide suffer from preventable harm due to unsafe care each year. These incidents can range from medication errors to hospital-acquired infections, surgical complications or misdiagnoses. The consequences are profound, affecting patients’ lives, increasing healthcare costs and eroding trust in medical systems.

Ensuring patient safety requires a multifaceted approach that involves healthcare providers, administrators, policymakers and patients themselves. By fostering a culture of safety, we can minimise risks and create an environment where quality care thrives.

Key strategies for improving patient safety and care

To deliver exceptional care while safeguarding patients, healthcare systems must adopt evidence-based practices and innovative solutions. Here are some critical strategies to enhance patient safety:

1. Effective communication

Clear and open communication among healthcare teams is vital. Miscommunication can lead to errors, such as administering the wrong medication or misinterpreting a patient’s condition. Standardised tools like SBAR (Situation, Background, Assessment, Recommendation) can improve handoffs and ensure critical information is shared accurately.

2. Robust training and education

Continuous professional development ensures that healthcare workers stay updated on best practices and emerging technologies. Training programmes should emphasise error prevention, infection control and patient engagement. Empowering staff with knowledge builds confidence and competence in delivering safe care.

3. Leveraging technology

Technology plays a transformative role in patient safety. Electronic Health Records (EHRs) reduce documentation errors, while barcode medication administration systems help verify medications before they reach patients. Additionally, artificial intelligence tools can predict risks, such as sepsis, enabling early interventions.

4. Patient empowerment

Patients are active partners in their care. Encouraging them to ask questions, understand their treatment plans and report concerns fosters shared decision making. Educating patients about their medications and procedures can prevent errors and enhance adherence.

5. Creating a culture of safety

A blame-free environment encourages healthcare workers to report errors or near-misses without fear of retribution. Root Cause Analysis (RCA) and Failure Modes and Effects Analysis (FMEA) can identify systemic issues and drive improvements. Leadership must champion safety as a core value, setting the tone for the entire organisation.

The role of compassion in patient care

While systems and protocols are essential, the human element of care cannot be overlooked. Compassionate care builds trust and promotes healing. Listening to patients, respecting their dignity and addressing their fears create a therapeutic environment. When patients feel valued, they are more likely to engage in their treatment plans and communicate openly, reducing the risk of errors.

Challenges and the path forward

Despite progress, challenges like understaffing, resource constraints and burnout continue to threaten patient safety across the world. Addressing these requires investment in workforce development, equitable resource allocation and mental health support for healthcare workers. Collaboration between governments, healthcare institutions and communities is crucial to overcoming these barriers.

Looking ahead, the integration of data analytics, telemedicine, and patient-reported outcomes will further revolutionise safety and care. By embracing innovation while staying grounded in empathy, we can build a healthcare system that is both safe and compassionate.

A call to action

Patient safety and care are shared responsibilities. As healthcare professionals, we must commit to continuous improvement, learning from mistakes and advocating for our patients. As patients, we should actively participate in our care and hold systems accountable. Together, we can create a future where every patient receives safe, high-quality care.

Let’s work hand in hand to make patient safety not just a goal, but a reality.

Mission

To implement policies, strategies and practices that are based on evidence, patient experience, appropriate system design, healthcare workforce and partnership in order to eliminate all sources of preventable risks and harm to patients and healthcare workers. 

Main dimensions

The main dimensions for the advancement of the patient safety framework, consequently contributing to the improvement of the quality of care across the country are:

1. Adopting policies that will eliminate preventable harm in health care
2. Establishing stable health care systems
3. Safety of clinical processes
4. Involving the patient and their family in the care
5. Education, skills and safety for healthcare workers
6. Information, research and dealing with risks
7. Synergy, partnership and solidarity

For each of these domains, a group of objectives, activities, subjects in charge of the activities, a rough timeline and possible sources of financing have been developed in a period that is synchronized with the National Health Strategy of the Republic of North Macedonia, until 2030. These elements of the national plan are drawn from the existing results of research, accreditation standards related to the safety of patients, other legal regulations, the mission of international consultants conducted in December 2022, medical practice guides, WHO policy recommendations and other documents. 

Considering the context of the current healthcare system and patient safety situation in the Republic of North Macedonia, four core priorities arise from the main dimensions of the National Plan:

• Training of healthcare professionals
• Awareness and patient engagement
• Establishment of the Committee for Patient Safety
• Data infrastructure and IT-based systems to support patient safety interventions

Experts in developed countries have posited that a national hospital occupancy of 85% constitutes a hospital bed shortage (a conservative estimate); these findings show that the US could reach this dangerous threshold as soon as 2032, with some states at much higher risk than others. These scenarios suggest that an increase in the staffed hospital bed supply by 10%, reduction in the hospitalisation rate by 10%, or some combination of the two would offset the aging-associated increase in hospitalizations over the next decade.

The recommendations include action on:

• The individual level – activities on the front line with individuals, local clinical teams, and community services.
• The organisational level –coordinated efforts across organisations and facilities to create supportive environments and ensure effective fall prevention practices.
• The policy level – system changes to support fall prevention efforts.

This report has three distinct sections and offers insights and solutions to reduce falls in the community.

• Part 1 Provides data on the growing problem of falls in NSW, describes the impact on individuals and their loved ones, describes the complexity of falls, and overviews evidence-based interventions
• Part 2 Summarises the insights on falls and actions for fall prevention arising from the April 2023 Roundtable hosted by the Clinical Excellence Commission
• Part 3 Gives examples of local solutions already being undertaken around NSW.

Strategies and action steps for advancing these goals adhere to seven guiding principles:

• Move the health care system toward a mindset of zero tolerance for defects that can result in physical or emotional harm to patients, families, and staff;
• Support approaches to continuous, proactive safety improvement that break down silos and enable all stakeholders to carry out their respective roles;
• Promote a “just culture” by adopting a fair and consistent approach to safety improvement that fosters psychological safety in the health care workforce and holds leadership accountable for breakdowns and shortfalls;
• Advance health equity through the elimination of disparities in safety and quality outcomes on the basis of race, ethnicity, age, disability, sex, gender, language, and economic factors;
• Encourage an approach to health care and safety that maximizes the benefits of co-production, recognizing that patients and families provide expertise essential to person-centered care;
• Reduce low-value administrative burdens; and
• Remove all forms of waste from work, making it easier to do the right thing.

The recent Patient Safety Learning report, 'Mind the implementation gap: The persistence of avoidable harm in the NHS', highlights some important challenges and barriers to patient safety improvement, not only for the NHS in the UK but globally for health systems across the world.

In many countries, including my country, Ethiopia, various investments have been made to improve the safety of healthcare delivery. We have been setting national minimum requirements/standards for health facilities, ethics and competence review systems for health professionals, but we have never had the confidence on the implementation of those standards fully. The implementation gap has become a long standing and consistent challenge in Ethiopia's healthcare system and many other systems.

The Patient Safety Learning report highlights six specific policy areas where there is a gap that acts as a barrier to patient safety improvement:

1. Public inquiries and reviews
2. Healthcare Safety Investigation Branch reports
3. Prevention of Future Deaths reports
4. When patients and families take legal action
5. Patient complaints
6. Incident reports.

Considering my 10 years of experience working in healthcare quality and safety, global health leaders and policy makers at national or international level should consider these areas during planning or executing any patient safety related policies. The COVID-19 pandemic has highlighted the huge challenges of building a learning health system and putting a clear leadership and governance structure for patient safety at national and health facility level. These conditions are clearly aligned with the four underlying thematic areas highlighted in the report:

• Absence of a systemic and joined-up approach to safety.
• Poor systems for sharing learning and acting on that learning.
• Lack of system oversight, monitoring, and evaluation.
• Unclear patient safety leadership.

As a chair of the national Covid case management and facility readiness task force during the first and second wave of Covid pandemic in Ethiopia, one of the most important challenges I faced was lack of data and poor learning systems between Covid treatment centres to understand the patient safety situation in the treatment centres. One day I happened to visit one of the treatment centres with more than 20 ICU beds all occupied with patients. I tried to talk to the nurses and GPs taking care of the patients about their experience of medication error, machine failure or related incidents. None of the professionals had firsthand information and experience of documentation about those incidents. This experience of mine is a common experience and it is clearly aligned with unclear patient safety leadership and lack of system oversight for monitoring and evaluation.

In most low and middle income countries, health workers are facing a lot of challenges due to resource constraints. These problems are amplified in Ethiopia. Working in stressful environments exacerbates safety risks for health workers, including being infected with COVID and contributing to outbreaks in the healthcare facility; having limited access or adherence to personal protective equipment and other infection prevention and control measures; and inducing errors that can potentially harm patients and health workers. For these reasons, addressing health workers safety can be a very good start to address patient safety.

From my experience in the healthcare industry, I believe that creating a culture of safety in the healthcare setting is not easy. In the majority of cases, healthcare workers are positive about ensuring the safety of their patients and other healthcare workers. However, the healthcare workers' efforts must be supported by a policy and political commitment at national and global level to ensure everyone is safe in the healthcare setting. The recent Patient Safety Learning report, 'Mind the implementation gap: The persistence of avoidable harm in the NHS' outlines a very important policy perspective for experts and policy makers to consider.