Enhancing infection prevention and control through hand hygiene compliance in six Ugandan hospitals using quality improvement approaches.

Introduction: Hand hygiene (HH) plays a crucial role in mitigating healthcare-associated infections. Improving HH compliance in healthcare facilities in resource-limited settings is urgently needed. Methods: We implemented the World Health Organization (WHO) HH improvement strategy using a continuous quality improvement (CQI) approach targeting improvement in HH compliance by healthcare workers (HCWs). An intervention was implemented in six hospitals using a longitudinal study design between May 2019 and April 2023. We set up and monitored infection prevention and control (IPC) and HH programs using WHO's infection prevention and control assessment framework at the facility level (IPCAF) and hand hygiene self-assessment framework (HHSAF) tools. We implemented HH interventions using CQI techniques while targeting HCW HH knowledge and compliance with the WHO's Five Moments of HH. Results and discussion: By the end of the intervention, IPC and HH capacity improved in all six hospitals, from a median score of 547.0 and 252.5 on IPCAF and HHSAF tools at baseline to an advanced score of 635.0 and 350.0 at endline assessment, respectively. Similarly, HCWs' HH knowledge improved in all hospitals, from a mean score of 45.0% at baseline to 76.0% at endline assessment, most notably among nurses. HH compliance, as assessed using WHO's HH observation tool, at least doubled in all hospitals, rising from 19.9% to 53.8%, with before touching a patient registering the highest (22-fold) improvement. On linear regression analysis, no significant association was observed between HH compliance and IPCAF b = -0.0004 (95% CI -0.093, 0.93) p = 0.990, HHSAF b = 0.009 (95% CI -.0127, 0.145) p = 0.842 and HCW knowledge on HH/IPC b = -0.165 (95% CI 0.815, 0.485) p = 0.519. This is the first documented comprehensive utilization of CQI approaches to implement HH as an entry point for the development of hospital IPC programs, and evaluation of WHO tools and approaches for IPC and HH improvement in Uganda. Conclusion: Implementation of the WHO HH improvement strategy using a CQI approach can lead to remarkable improvement in HH capacity, and HCW compliance and knowledge in hospitals within resource-limited settings.

Addressing gaps in AMR awareness in the public: an evidence-based policy brief to guide school curriculum review in Uganda.

The government of Uganda, through its Ministry of Health, previously adopted curriculum review as a mechanism to respond to public health threats such as HIV/AIDS and include content in primary and secondary schools. This approach contributes to raising public awareness, a key strategy recommended by the World Health Organization to support the global response to the threat of antimicrobial resistance (AMR). This policy brief, developed for policymakers related to school curricula, aims to advocate for and support integration of AMR content in Uganda's primary and secondary level school curricula. The policy brief supports efforts by the multisectoral National AMR Subcommittee to create awareness on this issue as part of its role in facilitating the operationalization of Uganda's National Action Plan on AMR.

Antimicrobial consumption surveillance in Uganda: Results from an analysis of national import data for the human health sector, 2018-2021.

BACKGROUND: The surveillance of antimicrobial consumption (AMC) is critical to developing appropriate antimicrobial stewardship interventions. It is a key component of World Health Organization's (WHO) Global Action Plan on Antimicrobial Resistance and the Uganda Antimicrobial Resistance National Action Plan 2018-2023. Our study's objective was to determine the national consumption of all antimicrobials. METHODS: Data on all imported antimicrobials were retrieved from paper-based records and entered in the web-based National Drug Authority (NDA) management information system from 2021. The import data for the year is a proxy for nationwide consumption because they account for 95% of all medical products. The NDA authorizes all imports to the country regardless of final distribution in the supply chain. The data were analyzed in accordance with WHO Anatomical Therapeutic Chemical codes and defined daily dose (DDD) methodology. We also retrieved consumption data for 2018, 2019, and 2020 that were previously submitted by Uganda to WHO's Global Antimicrobial Resistance and Use Surveillance System. RESULTS: In 2021, the average DDD per 1000 inhabitants was 29.02 for all antimicrobials; 80.7% of antimicrobials consumed were oral. Penicillins (27.6%) were the most consumed antimicrobial class, followed by sulfonamides and trimethoprim (15.5%). Based on WHO's Access, Watch, and Reserve (AWaRe) antibiotic classification, 62.91% of AMC was from the access class, with watch class averaging 14.51% in the period 2018-2021. Watch class AMC spiked in 2021 (34.2%) during COVID-19 pandemic compared to 2020 (24.29%). Azithromycin and ciprofloxacin were the most consumed watch class antimicrobials in 2021. CONCLUSIONS: The relatively high consumption of injectable antimicrobials and year over year increase in watch class AMC requires urgent stewardship interventions. Further work is needed to establish a system for longitudinal AMC surveillance that is well resourced and funded to overcome the challenges of estimation and provide more accurate data on consumption and use patterns.

Optimizing prophylactic antibiotic use among surgery patients in Ethiopian hospitals.

BACKGROUND: Since 2018, the Ethiopian Ministry of Health (MOH) has been working to institutionalize antimicrobial stewardship (AMS) programs across the country. The US Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program supported Ethiopia's multipronged One Health approach to combat AMR. The objective of this paper was to evaluate the effect of a quality improvement intervention to optimize the use of antimicrobials for surgical prophylaxis. METHODS: Basic AMS interventions were introduced in five hospitals from January to May 2023. The AMS committees and multidisciplinary teams working at the surgical wards were trained and provided on-site support to implement surgical antibiotic prophylaxis (SAP) interventions. A before-after comparison was made for 206 medical records at baseline and 213 during the intervention phase. Qualitative data were gathered through discussions during experience-sharing workshops to supplement the quantitative results. RESULT: There were improvements in the presurgery dose of the prophylactic antibiotic and its timing: the doses within the recommended range increased from 11.2 % to 61.0 % (p < 0.001) and the optimal timing increased from 68 % to 82.6 % (p < 0.001). The hospitals also demonstrated some nonsignificant improvement in the duration of prophylactic antibiotic use (from 35 % to 44.6 % [p = 0.106]), with change in practice hampered by practitioners' resistance to early discontinuation for fear of infection due to perceived weaknesses in infection prevention and control practices. Nonavailability of the recommended antibiotic of choice for surgical prophylaxis was another major challenge in addressing all the elements of SAP. The intervention demonstrated a significant antibiotic-related average cost saving, 51.8 Ethiopian birr (∼1 US dollar) per patient (p = 0.028). CONCLUSION: Short-term investments with basic AMS interventions can help to improve SAP use in surgical wards. However, comprehensive success requires complementing AMS interventions with concurrent attention to proper supply chain and infection prevention and control.

What is the appropriate antimicrobial use surveillance tool at the health facility level for Uganda and other low- and middle-income countries?

BACKGROUND: An appropriate antimicrobial use (AMU) surveillance system provides critical data and evidence on which antimicrobial stewardship interventions are based. However, Uganda and most other low- and middle-income countries (LMICs) lack efficient systems for monitoring AMU due to unique health system challenges. METHODS: We reviewed the key tools available for AMU surveillance in health facilities. Based on our implementation experience, we present arguments on the need for country authorities to adapt a customized and standardized tool for national uses. RESULTS: Despite ongoing efforts to set up AMU surveillance programs in Uganda, AMU data remain sparse, with most of the available data collected through antimicrobial stewardship related continuous quality improvement efforts implemented by global AMR control programs. There is variability in the interpretation of available AMU surveillance tools and a need to identify the most appropriate AMU surveillance methodologies and tools for Uganda and other LMICs. Data fields for sex and gender are incorrectly categorized and there is no tool that records pregnancy variable. Based on the past four years of practical implementation experience since the launch of the World Health Organization's Point Prevalence Survey methodology in 2018 for inpatient settings, we believe that the tool should be modified in cognizance of existing capacity and priorities in resource-constrained settings. CONCLUSIONS: The World Health Organization, regional experts, ministry of health authorities, and other stakeholders should urgently review available tools with a view to adopting a customized and standardized facility AMU surveillance methodology suitable for national-level rollout in LMICs.

Development and evaluation of a continuous quality improvement programme for antimicrobial stewardship in six hospitals in Uganda.

BACKGROUND: Appropriate antimicrobial use is essential for antimicrobial stewardship (AMS). Ugandan hospitals are making efforts to improve antibiotic use, but improvements have not been sufficiently documented and evaluated. METHODS: Six Ugandan hospitals implemented AMS interventions between June 2019 and July 2022. We used the WHO AMS toolkit to set-up hospital AMS programmes and implemented interventions using continuous quality improvement (CQI) techniques and targeting conditions commonly associated with antibiotic misuse, that is, urinary tract infections (UTIs), upper respiratory tract infections (URTIs) and surgical antibiotic prophylaxis (SAP). The interventions included training, mentorship and provision of clinical guidelines to support clinical decision-making. Quarterly antibiotic use surveys were conducted. RESULTS: Data were collected for 7037 patients diagnosed with UTIs. There was an increase in the proportion of patients receiving one antibiotic for the treatment of UTI from 48% during the pre-intervention to 73.2%, p<0.01. There was a 19.2% reduction in the number of antimicrobials per patient treated for UTI p<0.01. There was an increase in use of nitrofurantoin, the first-line drug for the management of UTI. There was an increase in the use of Access antibiotics for managing UTIs from 50.4% to 53.8%. The proportion of patients receiving no antimicrobials for URTI increased from 26.3% at pre-intervention compared with 53.4% at intervention phase, p<0.01. There was a 20.7% reduction in the mean number of antimicrobials per patient for URTI from the pre-intervention to the intervention phase, from 0.8 to 0.6, respectively, p<0.001 and reduction in the number of treatment days, p=0.0163. Among patients undergoing surgery, 49.5% (2212) received SAP during the pre-intervention versus 50.5% (2169) during the intervention. CONCLUSIONS: Using CQI approaches to focus on specific causes of inappropriate antibiotic use led to desirable overall reductions in antibiotic use for URTI and UTI.

Moving from assessments to implementation: promising practices for strengthening multisectoral antimicrobial resistance containment capacity.

BACKGROUND: Antimicrobial resistance (AMR) poses a global threat to human, animal, and environmental health. AMR is a technical area in the Global Health Security Agenda initiative which uses the Joint External Evaluation tool to evaluate national AMR containment capacity. This paper describes four promising practices for strengthening national antimicrobial resistance containment capacity based on the experiences of the US Agency for International Development's Medicines, Technologies, and Pharmaceutical Services Program work with 13 countries to implement their national action plans on AMR in the areas of multisectoral coordination, infection prevention and control, and antimicrobial stewardship. METHODS: We use the World Health Organization (WHO) Benchmarks on International Health Regulations Capacities (2019) to guide national, subnational, and facility actions that advance Joint External Evaluation capacity levels from 1 (no capacity) to 5 (sustainable capacity). Our technical approach is based on scoping visits, baseline Joint External Evaluation scores, benchmarks tool guidance, and country resources and priorities. RESULTS: We gleaned four promising practices to achieve AMR containment objectives: (1) implement appropriate actions using the WHO benchmarks tool, which prioritizes actions, making it easier for countries to incrementally increase their Joint External Evaluation capacity from level 1 to 5; (2) integrate AMR into national and global agendas. Ongoing agendas and programs at international, regional, and national levels provide opportunities to mainstream and interlink AMR containment efforts; (3) improve governance through multisectoral coordination on AMR. Strengthening multisectoral bodies' and their technical working groups' governance improved functioning, which led to better engagement with animal/agricultural sectors and a more coordinated COVID-19 pandemic response; and (4) mobilize and diversify funding for AMR containment. Long-term funding from diversified funding streams is vital for advancing and sustaining countries' Joint External Evaluation capacities. CONCLUSIONS: The Global Health Security Agenda work has provided practical support to countries to frame and conduct AMR containment actions in terms of pandemic preparedness and health security. The WHO benchmarks tool that Global Health Security Agenda uses serves as a standardized organizing framework to prioritize capacity-appropriate AMR containment actions and transfer skills to help operationalize national action plans on AMR.

Identifying and addressing challenges to antimicrobial use surveillance in the human health sector in low- and middle-income countries: experiences and lessons learned from Tanzania and Uganda.

BACKGROUND: Antimicrobial resistance (AMR) is a global health security threat and is associated with increased morbidity and mortality. One of the key drivers of AMR is the inappropriate use of antibiotics. A key component of improving antibiotic use is conducting antimicrobial use (AMU) surveillance. METHODS: USAID Medicines Technologies and Pharmaceutical Services Program has supported the implementation of antimicrobial stewardship activities, including setting up systems for AMU surveillance in Tanzania and Uganda. Results from both countries have been previously published. However, additional implementation experience and lessons learned from addressing challenges to AMU surveillance have not been previously published and are the subject of this narrative article. RESULTS: The team identified challenges including poor quality data, low digitalization of tools, and inadequate resources including both financial and human resources. To address these gaps, the Program has supported the use of continuous quality improvement approaches addressing gaps in skills, providing tools, and developing guidelines to fill policy gaps in AMU surveillance. Recommendations to fill these gaps, based on the Potter and Brough systematic capacity building model have been proposed. CONCLUSIONS: Strengthening AMU surveillance through using a capacity-building approach will fill gaps and strengthen efforts for AMR control in both countries.

Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda.

Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization's standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.

Antimicrobial use across six referral hospitals in Tanzania: a point prevalence survey.

OBJECTIVE: To delineate the prevalence and factors associated with antimicrobial use across six referral hospitals in Tanzania using WHO point prevalence survey (PPS) methodology to inform hospital-specific antimicrobial stewardship programmes. DESIGN: Cross-sectional analytical study. SETTING: Six referral hospitals in Tanzania. PARTICIPANTS: Patients irrespective of age and gender (n=948) admitted in the six referral hospital wards before 8:00 hours on each day of the survey were included in December 2019. Using the WHO PPS methodology, data on hospitals, wards, patients, antibiotics, and indications for antibiotics were collected. OUTCOME MEASURES: We analysed the prevalence of antibiotic use by referral hospital, ward, indication and patient characteristics as the main outcomes. We also described adherence to the Tanzania Standard Treatment Guidelines (STG) and WHO's AWaRe categorisation of antibiotics. RESULTS: Approximately 62.3% of inpatients were prescribed antibiotics, predominantly from the Access group of antibiotics (ceftriaxone, metronidazole or ampicillin-cloxacillin). The overall adherence of antibiotic prescriptions to the Tanzania STG was high (84.0%), with the exception of Sekou Toure Regional Referral Hospital (68.0%) and Maweni Regional Referral Hospital (57.8%). The most common indication for antibiotic prescriptions was community-acquired infections (39.8%). Children less than 2 years of age (OR 1.73, 95% CI 1.02 to 2.92, p=0.039); admission to surgical wards (OR 4.90, 95% CI 2.87 to 8.36, p <0.001); and admission to paediatric wards (OR 3.93, 95% CI 2.16 to 7.15, p <0.001) were associated with increased odds of antibiotic use. Only 2 of 591 patients were prescribed antibiotics based on culture and antimicrobial susceptibility testing results. CONCLUSIONS: Empirical use of antibiotics is common, and the Access group of antibiotics is predominantly prescribed in children less than 2 years and patients admitted to surgical and paediatric wards. Lack of utilisation of antimicrobial susceptibility testing services in these hospitals requires urgent interventions. Routine monitoring of antibiotic use is recommended to be part of antibiotic stewardship programmes in Tanzania.

National Consumption of Antimicrobials in Tanzania: 2017-2019.

Objective: Surveillance of antimicrobial consumption is essential to the national action plan for antimicrobial resistance (AMR) as stipulated in the Global Action Plan on AMR and the Tanzanian National Action Plan on AMR. Given the paucity of antimicrobial consumption data in sub-Saharan Africa region, the objective of this study was to measure antimicrobial consumption in Tanzania. Methods: From 2017 to 2019, data on all antimicrobials imported into Tanzania were obtained from the Tanzania Medicines and Medical Devices Authority Data, augmented with purchasing data from the Medical Stores Department and data from local manufacturers. Data were collected and analyzed in accordance with the World Health Organization Anatomical Therapeutic Chemical and defined daily doses (DDD) methodology. Results: The average DDD per 1,000 inhabitants per day (DDD/1,000/D) for all antimicrobials was 80.8 ± 39.35. The DDD/1,000/D declined from 136.41 in 2017 to 54.98 in 2018 and 51.02 in 2019. Doxycycline, amoxicillin, and trimethoprim-sulfamethoxazole were the most frequently consumed antibiotics during these years, accounting for 20.01, 16.75, and 12.42 DDD/1,000/D, respectively. The majority of antimicrobial consumption in Tanzania occurred in the private sector, with the proportion of private-sector antibiotic consumption increasing annually from 2017 to 2019. Based on AWaRe classification >90% of antimicrobial consumption was Access class medications, with Watch and Reserve class medications accounting for <10% and <1%, respectively. Conclusion: The private sector use of antimicrobials is significantly increasing and should be carefully monitored in accordance with national policies. Future work is necessary to increase reporting of antimicrobial consumption patterns in sub-Saharan Africa.

Digital health technologies to support access to medicines and pharmaceutical services in the achievement of sustainable development goals.

OBJECTIVES: The objective of this study was to describe the conceptual and implementation approach of selected digital health technologies that were tailored in various resource-constrained countries. To provide insights from a donor-funded project implementer perspective on the practical aspects based on local context and recommendations on future directions. METHODS: Drawing from our multi-year institutional experience in more than 20 high disease-burden countries that aspire to meet the 2030 United Nations Sustainable Development Goal 3, we screened internal project documentation on various digital health tools that provide clarity in the conceptual and implementation approach. Taking into account geographic diversity, we provide a descriptive review of five selected case studies from Bangladesh (Asia), Mali (Francophone Africa), Uganda (East Africa), Mozambique (Lusophone Africa), and Namibia (Southern Africa). FINDINGS: A key lesson learned is to harness and build on existing governance structures. The use of data for decision-making at all levels needs to be cultivated and sustained through multi-stakeholder partnerships. The next phase of information management development is to build systems for triangulation of data from patients, commodities, geomapping, and other parameters of the pharmaceutical system. A well-defined research agenda must be developed to determine the effectiveness of the country- and regional-level dashboards as an early warning system to mitigate stock-outs and wastage of medicines and commodities. CONCLUSION: The level of engagement with users and stakeholders was resource-intensive and required an iterative process to ensure successful implementation. Ensuring user acceptance, ownership, and a culture of data use for decision-making takes time and effort to build human resource capacity. For future United Nations voluntary national reviews, countries and global stakeholders must establish appropriate measurement frameworks to enable the compilation of disaggregated data on Sustainable Development Goal 3 indicators as a precondition to fully realize the potential of digital health technologies.

User experience analysis of e-TB Manager, a nationwide electronic tuberculosis recording and reporting system in Ukraine.

Ukraine has successfully implemented e-TB Manager nationwide as its mandatory national tuberculosis registry after first introducing it in 2009. Our objective was to perform an end-of-programme evaluation after formal handover of the registry administration to Ukraine's Centre for Disease Control in 2015. We conducted a nationwide, cross-sectional, anonymous, 18-point user experience survey, and stratified the registry's transaction statistics to demonstrate usability. Contrary to initial implementation experience, older users (aged >50 years), often with limited or no computer proficiency prior to using the registry, had significantly better user experience scores for at least six of the 12 measures compared to younger users (aged 18-29 years). Using the registry for >3 years was associated with significantly higher scores for having capacity, adequacy of training received and satisfaction with the registry. Of the 5.9 million transactions over a 4-year period, nine out of 24 oblasts (regions) and Kiev city accounted for 62.5% of all transactions, and corresponded to 59% of Ukraine's tuberculosis burden. There were 437 unique active users in 486 rayons (districts) of Ukraine, demonstrating extensive reach. Our key findings complement the World Health Organization and European Respiratory Society's agenda for action on digital health to help implement the End TB Strategy.

Individual capacity-building approaches in a global pharmaceutical systems strengthening program: a selected review.

BACKGROUND: Medicines use related challenges such as inadequate adherence, high levels of antimicrobial resistance and preventable adverse drug reactions have underscored the need to incorporate pharmaceutical services to help achieve desired treatment outcomes, and protect patients from inappropriate use of medicines. This situation is further constrained by insufficient numbers of pharmaceutical personnel and inappropriate skill mix. Studies have addressed individual capacity building approaches of logistics, supply chain or disease specific interventions but few have documented those involving such pharmacy assistants/professionals, or health workers/professionals charged with improving access and provision of pharmaceutical services. We examined how different training modalities have been employed and adapted to meet country-specific context and needs by a global pharmaceutical systems strengthening program in collaboration with a country's Ministry of Health and local stakeholders. METHODS: Structured, content analysis of training approaches from twelve selected countries and a survey among conveniently selected trainees in Bangladesh and Ethiopia. RESULTS: Case-based learning, practice and feedback, and repetitive interventions such as post-training action plan, supportive supervision and mentoring approaches are effective, evidence-based training techniques. In Ethiopia and Bangladesh, over 94% of respondents indicated that they have improved or developed skills or competencies as a result of the program's training activities. Supportive supervision structures and mentorship have been institutionalized with appropriate management structures. National authorities have been sensitized to secure funding from domestic resources or from the global fund grants for post-training follow-up initiatives. The Pharmaceutical Leadership Development Program is an effective, case-based training modality that motivates staff to develop quality-improvement interventions and solve specific challenges. Peer-to-peer learning mechanisms than traditional didactic methods was a preferred intervention among high level government officials both within country and between countries. CONCLUSION: Interventions must involve local institutions in the design and delivery of content for both pre-service and in-service training as well as web-based methods where feasible. Such efforts would meet the changing demand in the pharmaceutical system, and promote the ownership of the human capacity development interventions. The cost-effective partnership with universities demonstrate that competency based pre-service training will prepare the future pharmaceutical workforce with a critical foundation of knowledge and skills required to meet the growing demand for patient-centered pharmaceutical services in resource-constrained countries.

User experience analysis of an eHealth system for tuberculosis in resource-constrained settings: A nine-country comparison.

BACKGROUND: e-TB Manager, a web-based eHealth system has been successfully institutionalized in 10 resource-constrained countries that account for one-third of the world's tuberculosis (TB) burden, but user experience has never been evaluated. METHODS: A cross-sectional, anonymous survey in eight unique languages based on the targeted countries. e-TB Manager users included nurses, doctors, pharmacists, statisticians/data officers, laboratory professionals/assistants, health workers, and administrators. RESULTS: With an 86.3% completion rate for all required questions, 1,511 completed responses were analyzed. Users had worked in TB programs for a median of five years and had used e-TB Manager for a median of two years. Overall, 60.2% of respondents were female, 65% were clustered in the age groups of 30-39 and 40-49 years old, and nearly half (49%) were using e-TB Manager at the district and sub-district levels of a country's health system. Older respondents aged over 50, regardless of location and with at least 6 or more years of experience in public-sector TB programs, had higher mean satisfaction scores than did their younger counterparts. Overall, those who had used e-TB Manager for more than two years had significantly higher mean scores for the majority of the survey statements than did those who had used e-TB Manager for less than two years. Ukraine had significantly higher mean scores for finding patient information available in e-TB Manager and in its benefit in improving patient care compared to Brazil, Armenia, Nigeria, and Indonesia. Brazil and Ukraine differed significantly from five other countries in that they did not need additional training, thereby demonstrating their institutional capacity after more than five years of using e-TB Manager. CONCLUSION: Although users gave high ratings to e-TB Manager in terms of helping to improve patient care, found it to be reliable, and were generally satisfied, there is need for a combination of refresher training and e-learning methodologies to keep pace with programmatic changes.

Engagement of the private pharmaceutical sector for TB control: rhetoric or reality?

BACKGROUND: Private-sector retail drug outlets are often the first point of contact for common health ailments, including tuberculosis (TB). Systematic reviews on public-private mix (PPM) interventions for TB did not perform in-depth reviews specifically on engaging retail drug outlets and related stakeholders in the pharmaceutical sector. Our objective was to better understand the extent to which the World Health Organization's (WHO) recommendation on engaging retail drug outlets has been translated into programmatic policy, strategy, and intervention in low- and middle-income countries. METHODS: The study included a content analysis of global-level documents from WHO and the Stop TB Partnership in five phases. A country-level content analysis from four data sources was performed. Global-level findings were tabulated based on key messages related to engaging retail drug outlets. Country-level findings were analyzed based on four factors and tabulated. National strategic plans for TB control from 14 countries with varying TB burdens and a strong private sector were reviewed. RESULTS: 33 global-level documents and 77 full-text articles and Union World Lung Health conference abstracts were included for review. Based on experience of engaging retail drug outlets that has emerged since the mid-2000s, in 2011 WHO and the International Pharmaceutical Federation released a joint statement on promoting the engagement of national pharmacy associations in partnership with national TB programs. Only two of 14 countries' national strategic plans had explicit statements on the need to engage their national pharmacy professional association. The success rate of referrals from retail drug outlets who visited an approved health facility for TB screening ranged from 48% in Vietnam to 86% in Myanmar. Coverage of retail drug outlets ranged from less than 5 to 9% of the universe of retail drug outlets. CONCLUSIONS: For WHO's End TB Strategy to be successful, scaling up retail drug outlets to increase national coverage, at least in countries with a thriving private sector, will be instrumental in accelerating the early detection and referral of the 3 million missing TB cases. The proposed PPM pharmacy model is applicable not only for TB control but also to tackle the antimicrobial resistance crisis in these countries.