PBHL20005 - Global Public Health

Assessment 2: Project Proposal

Combating Antimicrobial Resistance in Dhaka, Bangladesh:

A Community-Based Antibiotic Stewardship and Infection Prevention Intervention

Unit: PBHL20005 Global Public Health

 

Table of Contents

1. Introduction and Background. 3

2. Literature Review.. 4

3. Project Aim and Objectives. 7

4. Intervention Approach and Implementation Plan. 8

5. Expected Outcomes and Impact 11

6. Project Resources. 12

References. 15

 

 

 

1. Introduction and Background

Antimicrobial resistance (AMR) represents one of the most critical global public health threats of the twenty-first century. AMR is listed as a top-ten public health challenges facing humanity around the world, with resistant infections directly responsible for causing approximately 1.27 million deaths globally in 2019 and nearly 4.95 million deaths when associated mortality is taken into account (WHO, 2024). The impact of AMR is disproportionately high in low-and middle-income countries (LMICs) where fragile health systems, fragile sanitation infrastructure and unregulated access to antibiotics, all combine to speed the spread and emergence of AMR.

The case of Bangladesh and especially its capital city Dhaka is a clear case of how all these factors are at play in the South Asian region in driving AMR. Dhaka is one of the world's most populous cities and it has a population of more than 22 million people, of which they are many who reside in informal settlements with limited access is available for clean water, sanitation and formal healthcare. The unregulated OTC sale of antibiotics at community pharmacies (without diagnostic confirmation or prescription) is very well documented as a primary factor of inappropriate antibiotics use in Bangladesh (Al Masud et al. 2024). Last resort antimicrobials are gravely affected by alarming resistance across common pathogens (Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus) in clinical and community contexts in Dhaka (WHO, 2024).

AMR is threatening the realization of the United Nations Sustainable Development Goals (SDGs) globally, especially SDG 3 (Good Health and Well-being), SDG 6 (Clean Water and Sanitation) and SDG 1 (No Poverty) are eroded by AMR, creating unprecedented health expenditures and productivity losses that drive poverty cycles. The environmental dimension of AMR is also mentioned by the United Nations Environment Programme, which point to environmental reservoirs of resistant genes coming from pharmaceutical waste, agricultural run-off, and insufficient wastewater treatment in urban centers where the population is high, such as Dhaka (UNEP, 2025).

Not withstanding these barriers, there have been some signs of impact on antibiotic dispensing behaviour and infection prevention at the community level in similar LMIC settings. This proposal is a practical evidence-based intervention programme to tackle AMR at the community and community pharmacy levels of Dhaka city. The project seeks to not only impact the drug sellers, but also to influence community health workers and households, to minimize inappropriate antibiotic use and improve infection prevention, and to help achieve Bangladesh's National Action Plan on AMR.

2. Literature Review

There is a considerable and evolving evidence base on epidemiology of AMR in Bangladesh and evidence for community-level stewardship interventions. This review collates evidence from four thematic areas: (i) the burden and epidemiology of AMR in Dhaka; (ii) the underlying behaviour drivers of antibiotic misuse in community and pharmacy settings; (iii) evidence of interventions implemented in both pharmacy and community health worker (CHW) settings; and (iv) evidence of the role of infection prevention and control (IPC) and its contribution to the reduction in AMR transmission.

AMR burden and patterns in the city of Dhaka: Constant surveillance going on in tertiary hospitals in Dhaka has indicated high levels of the presence of multidrug resistant (MDR) organisms. WHO AMR surveillance 2024 reports states that Bangladesh is a high-burden nation for MDR TB, ESBL-producing Enterobacteriaceae and CROs (WHO, 2024). These resistant pathogens are seen outside the hospital; in Dhaka with respiratory and gastrointestinal infections being seen among outpatients, mostly children below five years. This is because of the clustering of AMR burden in overcrowded urban slums, where people defecate outside and drinking water is polluted, making it important to have geographically targeted community interventions.

Behavioural Drivers of Antibiotic Misuse: Based on the literature, we can easily conclude that there are three key drivers of inappropriate antibiotic use in Dhaka and they are self-medication, dispensing without prescription by pharmacy drug sellers and over-prescription by informal drug sellers. A study carried out by Islam et al. (2022) was a random selection study of drug sellers in pharmacies in Dhaka, comparing an educational intervention with a control group, for the management of acute respiratory illness; the education was shown to significantly reduce the inappropriate dispensing of drugs. Importantly, the study showed that in addition to patients being increasingly pressured to take the antibiotics from the sellers of drugs, a lack of knowledge by the sellers and their commercial interests in antibiotic sales also played a role in inappropriate dispensing, suggesting that interventions focusing solely on seller's knowledge were inadequate. These findings are reinforced by Ramdas et al. (2025) who highlight the importance of community involvement and social norm change, as key elements of good AMR stewardship in LMICs especially in low-resource contexts where personal health journeys are impacted by suspicion of formal health systems and money gaps in accessing licensed providers.

Pharmacy Based Interventions (PBI) Program: Educational training, along with regulatory reinforcement and peer support programs, has demonstrated effectiveness of intervention in antibiotic stewardship among pharmacy-based interventions in LMICs. Fenech & Gaffiero, (2025) suggest the notion of a multi-level Swiss cheese' model for antibiotic use in the community, where multiple aspects of community pharmacy regulation, public education and healthcare provider learning serve as complementary layers of defense against that misuse. Their framework emphasizes that none of the measures prevents inappropriate use anymore than another; a combination of superposition and reinforcing strategies is necessary to significantly decrease the amount of antibiotics used in a population. The intervention is multi-component and informed by this evidence. Studies in the neighbouring countries of India and Nepal also show the scalability of education programmes for drug sellers in dense urban settings. Improvement in these behaviours observed had been sustainable for up to 12 months after the training, with the caveat that benefit was reinforced by a peer network.

Evidence of Community Health Worker Interventions: Community health workers (CHWs) have been recognized as important intermediaries in the awarenessraisening and changing of their communities' behaviours in areas where formal health care delivery is limited. Household self-medication rates can be deminished when CHWs deliver health education concerning the distinction between viral and bacterial infections, the necessity to complete antibiotic courses, and the proper pathway for seeking care, in similar contexts in South Asia (Hlaing et al. 2022). The government's community clinic network in Bangladesh and Shasthya Seba Karmis (community health workers) offer an existing platform for AMR-related messaging, minimizing the need for implementation efforts and building on trusted community relationships.

Infection Prevention and Control: Poor water, sanitation and hygiene (WASH) conditions in Dhaka's informal settlements exacerbates AMR spread. Resistant gene transfer in the environment in Bangladesh via environmentally persistent contaminated sources of urban water sources is among the highest in the world (Asaduzzaman et al. 2022). Promoting hand washing, storing safe water and improving sanitation are components of AMR stewardship programmes that have been recommended to ascribe greater importance and work synergistically to interrupt the chain of transmission and curb the spread of resistant pathogens in communities (WHO, 2024). There are continued information gaps in the literature on the optimum intensity and length of combined stewardship and IPC interventions in the informal settlement setting in Dhaka, and the sustainability of pharmacy level behaviour change without regulatory interventions. There is a framework to achieve the proposed project to address these gaps.

3. Project Aim and Objectives

Aim

The aim of this project is to minimize inappropriate use of antibiotics at the community level and improve infection prevention in Dhaka, Bangladesh, by developing an integrated intervention in community health worker training, WASH promotion, and stewardship of antibiotics in the pharmacy setting.

Objectives

●      To reduce non-prescription antibiotic dispensing by 40% by November 2006, through training of 80% of all registered drug sellers of the community pharmacies in the two target sub-districts of Dhaka on evidence-based antibiotic dispensing protocols.

●      To reach at least 1500 household members from 6 informal settlement communities in the city of Dhaka with trained CHWs, and observe change in knowledge and self-medication practices in relation to antibiotic drugs at the local community level within 18 months using pre and post surveys.

●      To set-up effective hand hygiene infrastructure and provide WASH knowledge to 90% of the households involved in the project and 100% of all pharmacy outlets in the project area within 12 months as supplementary infection prevention intervention to prevent the transmission of resistant pathogens.

4. Intervention Approach and Implementation Plan

Intervention Framework

This public health programme's intervention framework is multi-component, in alignment with global/ national health guidelines. It functions in tandem with the Global Action Framework on Antimicrobial Resistance of World Health Organization, the Bangladesh National Action Plan on Antimicrobial Resistance. This approach acknowledges that drug resistance emerges out of the combined effect of behavioral, structural and environmental factors in the overcrowded city slums of Dhaka. To meet these challenges optimally, a multi-level and coordinated strategy is needed; also, separate attempts do not adequately address complex situations. The programme therefore organises field activities into three operational areas of community pharmacies, household environments and the physical surroundings.

This initiative is a single intervention aimed at explicitly implementing an action-oriented public health delivery programme as opposed to a theoretical study or systematic review. Each component is underpinned by concrete experiences, with structured timelines, clear population metrics and measurable health outcomes to track progress. In the pharmacy context, the emphasis is on shifting pharmacists' dispensing behaviours via targeted training and peer accountability groups (Mill et al. 2023). At the same time, there are frequent learning visits within the household boundaries to bring about changes in the community's attitude to healthcare seeking and to end self-medication practices that lead to adverse health outcomes. Lastly, environmental domain focusing on routes of pathogen transmission by providing functioning hygiene infrastructure at high user public areas.

The framework brings together these three contexts thus addressing structural and behavioral education simultaneously. This holistic strategy helps interventions that focus on medicine sellers go hand in hand with changes in household behavior. The use of measurable outcomes like mysteries-returned-client rates and survey scores from households helps to hold the project accountable. The scheme sets out clear targets based on the national policy objectives and translates these into measurable health outcomes in vulnerable communities. In the end, this integrates delivery supports, advance community health knowledge and provide a replicable toolset for urban health delivery.

Component 1: Pharmacy Drug Seller Training and Stewardship Programme

The target sub-districts of Mirpur and Mohammadpur in Dhaka will have registered community pharmacies participating in a structured antibiotic stewardship training Course. All the registered drug sellers within the project area will be identified by conducting a baseline mapping exercise. Qualified pharmacists and other public health personnel contracted as part of the project will provide training workshops that each take place during two full days. Students will be informed about the biology of AMR, different viral vs bacterial infection, national antibiotic treatment guidelines, legal requirements according to Bangladesh Drug Control Ordinance related to antibiotic prescription and communication technique to handle demand pressure from patient.

Once trained, a network of engaged pharmacy "peer champions" will be created, to continue with peer support, reinforcement of stewardship norms, and dissemination of new guidance as it is developed. The six-month and twelve-month follow-up training sessions will be refresher training sessions. Objective dispensing behaviour pre and post training will be collected using trained field supervisors visiting the dispensaries as patients to assess dispensing behaviour and serve as mystery clients. Results will be communicated anonymously to drug purveyors in a process of reflective learning feedback.

Component 3: WASH Promotion and Environmental IPC

The Water, Sanitation and Hygiene component focuses on the major environmental contacts for the spread of resistant pathogens in the target informal settlements (Shafique et al. 2024). This systems approach is acknowledging that curbing the spread of antibiotic resistance demands a combination of actions: right medications and right prevention. In addition to the monthly household visits, the community health workers will be available to incorporate the basic handwashing educational sessions into their visits to the homes.

The project's main objective to ensuring structural support for individual changes in behavior will be achieved by installing functional sanitation infrastructure at locations with high foot traffic in the community. Partnerships with the municipality will assure the placement of functional hand washing stations outside schools, clinics and pharmacies. Maintenance of these units will be implemented throughout the project lifespan (18-months) to keep them running for a continued access of clean water and soap.

At the same time, field teams will be working cooperatively with the women's groups in the neighborhood to conduct community hygiene awareness-building activities. The educational events will be focused on real-life home practices such as storage of safe water and sanitary food handling measures (Zavala Nacul & Revoredo-Giha, 2022). The follow-up will be mainly on the Open Defecation theme and how to contribute to stopping environmental contamination in the residential areas where the population is so dense. Breaking the transmission cycle of resistant organisms through the urban ecosystem, by developing infrastructure and engaging in education amongst the community.

Ethical Considerations

Ethical Approval will be obtained from the Bangladesh Medical Research Council (BMRC) before the programme begins. The informed consent in the form of written document will be obtained from all the drug sellers present in the room (Hutchinson et al. 2023). Informed verbal consent will be obtained from the participants in the household survey and they will be told that withdrawing from the survey at any time will not affect their safety. All data picked up will be anonymised, stored securely, accessible only to project research team. The use of an unknown client methodology in assessing pharmacy behaviours is accepted by other behavioural studies and has to be carefully ethically justified and signed off by the BMRC. Project participation in no way will be the basis for withholding care from any member of the community. All community involvement activities will be carried out appropriately considering cultural sensitivity, and women CHWs will be tasked to work with women-headed households.

5. Expected Outcomes and Impact

The major immediate and anticipated outcomes of this project include the reduction in non-prescribed antibiotic dispensing at community pharmacies, raised awareness about AMR health issues through community level and a better hand washing habit of the target communities in Dhaka. In particular, the project expects to reduce inappropriate antibiotic ordering by 40% (as measured by mystery clients) and enhance household KAP scores around antibiotic use by 30% in 12 months, owing to the involvement of WASH stations at all project sites within the target households.

On a systemie level, the project will help to enhance the implementation of the National Action Plan on AMR in Bangladesh by showcasing a replicable, community-based stewardship model that can be extended to other urban sub-districts, and modified to rural contexts. Capacity building of the CHWs on AMR messaging is integral to the longevity of activities related to stewardship beyond the project time (Tumwine et al. 2025).

The project brings direct benefit to SDG 3 (Good Health and Well-being) in terms of global health equity and SDG alignment, by curbing the emergence of resistant infections and ensuring that future generations will have access to drugs which remain effective. Focusing on informal settlements, where the burden of AMR is greatest, and the health system has the greatest capacity to limit access to services, benefits will be felt by the most vulnerable segments of urban populations and this will help achieve SDG 10 (Reduced inequalities). The WASH component is also contributing to SDG 6 (Clean Water and Sanitation). The project not only aims to tackle the health consequences of AMR, but also highlights its impact on social and economic equity, thereby supporting the WHO's concept of a One Health approach.

6. Project Resources

Timeline

Phase	Timeframe	Core Activities and Milestones
Phase 1: Setup	Months 13	Stakeholder engagement, ethical approval, baseline pharmacy mapping, and health worker recruitment.
Phase 2: Launch	Months 49	Drug seller training workshops, household health visits, baseline surveys, and sanitation station installation.
Phase 3: Operation	Months 1015	Full project implementation, peer champion network activation, mid-term surveys, and mystery client evaluations.
Phase 4: Evaluation	Months 1618	Endline data collection, outcome analysis, report writing, and dissemination to national health authorities.

Table 1: Project Implementation Timeline

The project will proceed through four phases: (1) Months 1-3: Stakeholder engagement, ethics approval, baseline mapping of Pharmacies, recruitment and training of CHWs; (2) Months 4-9: Training of drug sellers, start CHW household sessions, baseline KAP surveys, set up WASH stations; (3) Months 10-15: implementation of full programme, activation of peer champion network, 6-month KAP survey, mystery client visits; (4) Months 16-18: endline data collection, analysis, report writing, dissemination to Bangladesh Ministry of Health and Family Welfare.

Budget and Resources

Budget Category	Key Items Included	Allocation (AUD)
Personnel	Project manager, field supervisors, health worker stipends	65,000
Infrastructure	40 handwashing units, procurement, municipal installation	45,000
Training	Materials printing, workshop venue rental, facilitator fees	35,000
Evaluation	Survey tool design, data entry, mystery client operational costs	25,000
Administration	Travel allowances, dissemination meetings, institutional overheads	10,000

Table 2: Budget and Resources

The estimated budget is AUD 180,000 (roughly BDT 1.5 crore) and the funding comes from an agreement with WHO Bangladesh Country Office and AMR programme of the Wellcome Trust. The following key resource needs are identified: the development of training materials, printing of Bangla language flipcharts and leaflets; facilitator fees for pharmacist trainers; CHW stipends and transport allowances; 40 handwashing stations units including procurement and installation; survey tools, data entry and analysis; project coordination staff (one project manager and two field supervisors); and dissemination costs. The project will collaborate with icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh), whose community relationships are already in place in the project communities of Mirpur and Mohammadpur, and who also have existing ethical review infrastructure, which will speed up implementation costs and times.

 

References

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Asaduzzaman, M., Rousham, E., Unicomb, L., Islam, M. R., Amin, M. B., Rahman, M., ... & Islam, M. A. (2022). Spatiotemporal distribution of antimicrobial resistant organisms in different water environments in urban and rural settings of Bangladesh. Science of the Total Environment, 831, 154890. https://www.sciencedirect.com/science/article/pii/S0048969722019830

Fenech, B., & Gaffiero, D. (2025). Barriers and Facilitators to Antimicrobial Stewardship in Antibiotic Prescribing and Dispensing by General Practitioners and Pharmacists in Malta: A Systematic Review. Antibiotics, 14(12), 1181. https://www.mdpi.com/2079-6382/14/12/1181

Hlaing, T., Lat, T. W., & Myint, Z. M. (2022). Prevalence and possible causes of antibiotic self-medication among rural dwellers and volunteer health workers in Nattalin Township, Bago region, Myanmar. Int. J. Community Med. Public Health, 9, 1592. https://www.researchgate.net/profile/Tun-Lat/publication/359493990_Prevalence_and_possible_causes_of_antibiotic_self-medication_among_rural_dwellers_and_volunteer_health_workers_in_Nattalin_Township_Bago_region_Myanmar/links/626ff2d93a23744a725dada6/Prevalence-and-possible-causes-of-antibiotic-self-medication-among-rural-dwellers-and-volunteer-health-workers-in-Nattalin-Township-Bago-region-Myanmar.pdf

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Zavala Nacul, H., & Revoredo-Giha, C. (2022). Food safety and the informal milk supply chain in Kenya. Agriculture & Food Security, 11(1), 8. https://link.springer.com/content/pdf/10.1186/s40066-021-00349-y.pdf