Antimicrobial resistance (AMR) is an important public health concern shared by developed and developing countries. In developing countries the burden of infectious diseases is greater and exacerbated by limited access to, and availability and affordability of, antimicrobials required to treat infections caused by AMR organisms.
South Africa has faced many challenges over the past two decades, accomplishing profound positive changes in the social structure and government of the nation. This has not yet fully translated into better health for the population, however, particularly the poorest segment. In fact, the population has lost ground since the 1990s in virtually all important health indicators, leaving South Africa with a high burden of infectious disease.
The global problem of antimicrobial resistance is particularly pressing in developing countries, where the infectious disease burden is high and cost constrains the replacement of ineffective antibiotics with newer, more expensive ones. Gastro-intestinal, respiratory, sexually transmitted and hospital-acquired infections are leading causes of disease and death in the developing world; their management is compromised by the appearance and spread of resistance. Actions taken now can slow the spread of resistance without impairing access to antibiotics when they are appropriate. These, as well as extending access where it is currently inadequate, are the ultimate aims of the Global Antibiotic Resistance Partnership (GARP).
This overview of South Africa's demographic profile, economic development and health system provides the context in which to view the situation of antibiotic access and resistance. It presents information on national health policy and governance, infrastructure and human resources. The presence and utilisation of these features within the health system are discussed in relation to access to essential medicines, with a particular focus on antibiotics.
This section examines the regulatory environment and supply chain for antibiotics for both the public and private sectors, followed by a review of what is known about patterns of antibiotic consumption in South Africa. It provides information pertaining to national policy documents and their relationship with drug supply and distribution, the position of antibiotics in therapeutic guidelines and dispensing regulations, and the current status of pharmaceutical management.
South Africa has a high burden of infectious diseases, including a large portion that are of bacterial origin. This section reviews the national burden of disease and levels of antibiotic resistance in common bacterial infections in the human population. The consequences of resistance on clinical outcomes, through either treatment failures or the development of more virulent infections, are largely unknown. The full impact of antibiotic resistance on health in South Africa therefore remains to be assessed.
The critical importance of robust antimicrobial resistance (AMR) surveillance in South Africa cannot be overemphasised. Without knowing what the resistance situation is, it is impossible to develop appropriate antibiotic treatment guidelines and associated essential drug lists (EDLs) and to create and update evidence-based policies both at institutional and national levels.
The antibiotic use and levels of antibiotic resistance found in animal populations in South Africa are reviewed: firstly, the framework for antibiotic management in livestock production; secondly, patterns of consumption by sector and application; and thirdly, what is known about bacterial resistance rates. The bacteria discussed are pathogenic to animals, zoonotic organisms and commensal bacteria.
Antimicrobial resistance (AMR) surveillance activities in South Africa have been described in Part V of this report. Surveillance - knowing the levels of resistance and the trends around the country and in different types of institutions - is essential, but is only useful to the extent that the data influence practice.
Underlying the creation of the Global Antibiotic Resistance Partnership (GARP) as a global alliance was the recognition that antibiotic resistance is a global problem, that some of the tools needed to understand and manage it could be shared globally, but that actions to control it and to ensure access to antibiotics when they are needed must take place at the national level. South Africa is fortunate in having a well-developed cadre of health care professionals already addressing antibiotic use, evident from the wealth of programmes and information included in this report but, even so, resistance is a growing problem. In countries that lack a strong medical system, the challenges are even greater.