Assessing antimicrobial resistance inclusion in pre-service pharmacy training curricula of five selected sub-Saharan African universities: challenges and opportunities

Abstract

The World Health Organisation’s Global Action Plan (GAP) on antimicrobial resistance (AMR) emphasises the need for awareness, education, and training of health workers. Globally, there are major gaps in AMR awareness and knowledge among pre-service healthcare professionals. This study evaluated the inclusion of AMR content in pre-service pharmacy curricula across five sub-Saharan African universities.

This study was part of the award winning One Health Pan-African Internship Program 2020–2021, hosted by the Ducit Blue Foundation in collaboration with the African Regional Office of the International Pharmaceutical Students Federation (IPSF AfRO). Five universities were included based on their students’ participation in the internship programme. The pre-service pharmacy curricula of the universities were evaluated against the WHO AMR training competency framework, followed by inductive thematic analysis, using Microsoft Excel.

Results showed limited progress in the inclusion of AMR content in the pre-service curricula. Though some AMR-related topics were present, they were obscured within other subjects. Those topics included were not well aligned with antimicrobial stewardship (AMS) objectives of the AMR Global Action Plan.

There are still major gaps in AMR inclusion in pre-service curricula, which may contribute to the poor AMR outcomes seen in sub-Saharan Africa. Feasibility studies are recommended to assess the costs of designing, upgrading, and implementing new curricula. Training and capacity building for pharmacy lecturers and educators are also needed to update their knowledge on current advances in AMR research. Finally, the integration strategy for implementing the curriculum should include both short-term and long-term plans, with regular monitoring and evaluation to ensure that key AMS goals are embedded at the pre-service level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09015-y.

Introduction

As the world enters the post-COVID era, a silent pandemic emerges – antimicrobial resistance (AMR). It occurs when antimicrobials develop resistance against antimicrobial drugs. It poses a serious threat to the effectiveness of antimicrobials and could return humanity to a pre-antibiotic era, effectively undermining modern medicine [1]. It was listed by the World Health Organisation (WHO) in 2020 as one of the thirteen urgent global health challenges of the next decade [2].

Globally, it was responsible for an estimated 5.85 million deaths in 2021 [3]. If uncontrolled, this number could exceed 10 million deaths by 2050, including about 1.8 million in Africa. The annual economic burden of AMR is projected to reach US$412 billion in additional healthcare costs, and US$443 billion in productivity losses due to reduced workforce participation [4].

Amongst other factors, inappropriate antibiotic prescription and use remain the primary drivers of AMR globally [5–7]. This challenge is particularly severe in developing countries, where antimicrobial stewardship (AMS) programmes are limited and healthcare professionals often lack adequate knowledge of AMS [8, 9]. To address this, the first objective of the WHO Global Action Plan (GAP) on AMR emphasises the need for healthcare professionals to enhance their awareness and understanding of AMR and antibiotics through effective communication, education, and training [10]. Despite this, significant gaps persist in both pre-service and in-service AMR training for healthcare workers [11, 12].

In response, WHO developed a competency framework to guide the education and training of health workers on AMR [13]. This comprehensive framework provides direction for academic institutions, educators, and related stakeholders, equipping health workers with the competencies required to address AMR effectively. It also laid the foundation for the development of more in-depth educational resources and AMR curricula, targeting both pre-service and in-service health education.

Adequately trained healthcare professionals with sound knowledge of antibiotic prescription and stewardship are critical to global AMR containment efforts [14, 15]. Studies have demonstrated improvements in AMR knowledge following the inclusion of AMR-related content in the pre-service training of healthcare professionals [16–18].

Pharmacists play a vital role in safeguarding the effectiveness of antimicrobial medicines. In many sub-Saharan African (SSA) countries, they are often the first point of contact for individuals seeking medicines due to their accessibility and convenience. Pharmacists contribute to AMR control by bridging research gaps in antimicrobial development, engaging in policy formulation, promoting AMS, monitoring AMR trends and antimicrobial use, providing health education to professionals and patients, and leading hospital AMS initiatives [19].

Therefore, the pre-service training and education of undergraduate pharmacy students on AMR control strategies are crucial, as they enhance advocacy and strengthen the future role of pharmacists in AMR containment. Hence, AMR inclusion in this study refers to the presence of topics or content that enhances students’ understanding of AMR and teaches principles of AMS.

Education and training of healthcare professionals on AMR remain key pillars of both the WHO Global Action Plan and the Africa CDC AMR Strategic Framework for the containment of AMR. [10, 20, 21] Notably, the WHO developed a competency training guideline on AMR for health care professions [13]. The guide covers the core competencies required by Day–1 healthcare professionals across four domains.

• Domain 1: Foundations that build awareness of AMR

• Domain 2: Appropriate use of antimicrobial agents

• Domain 3: Infection prevention and control

• Domain 4: Diagnostic stewardship and surveillance

Currently, little is known about the extent to which the pre-service curricula of pharmacy training programmes in Africa align with both the GAP on AMR and the WHO AMR training guideline. Most existing research on pharmacy education in relation to AMR has focused on knowledge, attitudes, and practices surveys; perceptions of curricula; literature reviews; interviews; customised surveys on curriculum content and delivery; and the development of training programmes [22–26].

Recognising this gap, this study examines selected undergraduate pharmacy curricula from SSA to identify AMR-specific content relevant to pre-service training and to highlight gaps in AMR inclusion within the curricula. To the best of our knowledge, this is the first multi-institutional study in Africa to systematically assess undergraduate pharmacy curricula against the WHO Competency Framework for Health Workers’ Education and Training on AMR. The findings from this study will provide valuable insights to stakeholders and policymakers for guiding AMR curriculum development in the pharmacy faculties of universities across SSA.

Methods

Study area

This study focused on the pre-service curricula of five universities in SSA, a region with the highest AMR-attributable mortality globally [27]. The universities included were the University of Nairobi (UoN) in Kenya, the University of Ibadan (UNIBADAN) in Nigeria, the University of Ilorin (UNILORIN) in Nigeria, Kwame Nkrumah University of Science and Technology (KNUST) in Ghana, and the University of Benin (UNIBEN).

Study design

This study was conducted during the 2020–2021 One Health Pan-African Internship Program (OHPAIP), organised by Ducit Blue Foundation (DBF) in collaboration with the African Regional Office of the International Pharmaceutical Students Federation and the African Regional Office (IPSF AfRO). A qualitative approach was employed to analyse the pharmacy curricula of five universities across Nigeria, Kenya and Ghana (Fig. 1). The review focused on identifying what AMR-related topics were taught, when they are taught, and whether the taught courses met the recommended critical competencies required of a Day 1 pharmacist according to the WHO AMR training competency framework [see Appendix 1].

Fig. 1.

Map of Africa showing the sub-Saharan region and selected countries

Selection criteria

Purposive sampling was used to select universities for this study. The inclusion criteria were the participation of pharmacy students – from the Universities – in the OHPAIP. In this study, AMR inclusion refers to the presence of any course in the curricula that has topics or content that enhances students’ understanding of AMR and teaches principles of AMS.

Data collection

The curricula were obtained by interns representing all levels of pharmacy programme. These curricula were sourced from the Faculty of Pharmacy course brochures of their respective universities. The interns reviewed and extracted the AMR-related content from the curricula, using the WHO AMR training competency framework to ensure consistency, minimise individual bias, and validate the findings.

Data analysis

The interns reviewed their curricula and extracted the AMR-related topics and contents into Microsoft Excel version 2019. The AMR-related topics were then assessed against the AMR domains outlined in the WHO AMR training competency framework. For each AMR-related topic, a score of “1” was assigned for “yes” and “0” for “no” to indicate alignment with each competency requirement within the domains (knowledge, skill, and attitude). Descriptive statistical analysis was then employed to calculate the percentage inclusion rates of AMR-related topics for each university, as well as the overall compliance of the curricula with the AMR domains outlined in the WHO AMR training competency framework. The mean score was calculated and interpreted as the percentage inclusion or compliance for each domain [see Appendix 2].

Results

AMR-related courses taught in selected universities

A total of forty-five (45) AMR-related topics were identified across the five (5) universities included in this review. The curriculum of the UoN had the highest number (n = 13) of courses within the AMR domain, followed by UNIBEN (n = 11), UNIBADAN (n = 8), KNUST (n = 7), and UNILORIN (n = 6) in descending order (Fig. 2).

Fig. 2.

AMR-related undergraduate courses in the pharmacy curricula of the selected universities

Only the curriculum of UNIBEN included courses taught in the sixth (6th) year, which may be due to the university’s unique Doctor of Pharmacy (D. Pharm) programme. Table 1 presents the specific AMR-related topics included in undergraduate courses across the pharmacy curricula of the selected universities.

Table 1.

AMR-related Courses in Curricula of the Selected Universities

Year	UNIBEN	UoN	UNILORIN	KNUST	UNIBADAN
2nd	Introduction to Pharmaceutical Microbiology; Practical Pharmaceutical Microbiology	Microbiology (with a special focus on AMR); Biochemistry; Pharmaceutical chemistry	Pharmaceutical microbiology (Chemical Antimicrobial Agents and Disinfections)	Introduction to Microbiology; Pharmaceutical Microbiology II;	Introductory pharmaceutical microbiology
3rd	Pharmaceutical Microbiology; Practical Pharmaceutical microbiology	Pharmaceutics, Clinical Chemistry, Pharmacology; Pathology; Pharmaceutical chemistry.	Nil	Nil	Pharmaceutical microbiology
4th	Pharmaceutical microbiology; Pharmacology; Microbial Chemotherapy & Bacterial Genetics.	Pathology, Pharmaceutical chemistry	Pharmaceutical microbiology; Pharmacology	Medicinal Chemistry II; Chemotherapy of Anti-Effective Agents	Clinical pharmacy; Pharmaceutical microbiology; Pharmacology (chemotherapy);
5th	Clinical pharmacy	Pharmacovigilance; Medication therapy management; Pharmacy leadership & Management	Pharmaceutical microbiology; Pharmacology; Clinical pharmacy	Public Health I & II; Pharmacy practice II.	Medicinal chemistry; Clinical pharmacy; Veterinary pharmacy
6th	Clinical pharmacy; Veterinary pharmacy	Nil	Nil	Nil	Nil

Alignment of the reviewed curricula with the WHO AMR competency framework

The compliance levels of the universities’ curricula to the WHO AMR Competency Framework are presented in Fig. 3.

Fig. 3.

Alignment of the selected universities curricula to WHO AMR Competency Framework

The curricula of the five universities showed notable compliance with domain 1, with inclusion rates of 80% across all institutions. UoN demonstrated very high compliance in domains 2 and 3 (100% each), followed by domains 1 (80%) and 4 (60%). UNIBEN showed varied compliance, with 85.7% in domain 2 and the lowest inclusion in domain 3 (28.55%). For UNIBADAN, inclusion rates were 42.8%, 14.2%, and 20% for domains 2, 3, and 4, respectively. KNUST showed high compliance with domain 2 (92.8%), followed by domains 3 (57.1%) and 4 (40%). Similarly, UNILORIN recorded 85.7% compliance in domain 2 and 60% in domain 4, with the lowest inclusion in domain 3 (28.5%). Overall, UoN had the highest cumulative compliance (85%) with the WHO AMR Competency Framework, followed by KNUST (67.4%), UNILORIN (63.55%), UNIBEN (60.8%), and UNIBADAN (39.2%). The cumulative inclusion rate across all five universities was 62.70% (Fig. 4).

Fig. 4.

Overall inclusion rates of the four domains of the WHO AMR framework across the selected universities

Further analysis of the results indicated that the respective curricula of selected universities in this study did not have any training course that aligned with the “skills” competency arm of the AMR domain, “ability to carry out monitoring of antimicrobial use through PPS”. Also, the review reports show that the skill competency “practicing safe disposal of unused antimicrobials” was not captured in the curricula of all the schools reviewed.

Discussion

The unique position of pharmacists in the health care system makes them the most accessible health care professionals, with a critical role to play in preserving antimicrobials and preventing their resistance. Hence, the need for their pre-service AMR education and training cannot be overemphasised to improve pre- and in-service education and training of the pharmacy workforce in SSA, which has a high burden of AMR deaths.

In this study, we found that the inclusion rate of AMR-related topics in pre-service pharmacy curricula in SSA is moderate. Given the high levels of antimicrobial misuse in the region – particularly through over-the-counter dispensing by pharmacists – this level of inclusion is inadequate. Pharmacists in SSA require a comprehensive understanding of antimicrobial use and the implications of AMR for treatment effectiveness.

Previous studies have similarly shown that universities often fail to cover the full range of AMR-related competencies in pharmacy training. For example, Hamilton et al. (2023) reviewed ten UK undergraduate curricula against national AMS competencies and found that they covered a median of 47 (87%) of the 54 listed competencies, with only 29 (54%) covered by all institutions [28]. Likewise, Suave et al. (2023) assessed ten Canadian undergraduate curricula using a purpose-built questionnaire and reported that 68% of recommended AMS topics were taught [22]. However, non-prescription antimicrobial dispensing is far less common in these regions than in SSA. Overall, our findings highlight the urgent need to review and strengthen pre-service pharmacy curricula in SSA by integrating more AMR-focused content to address the region’s high AMR burden.

Findings from this study also revealed substantial gaps in the level of inclusion across the AMR domains 1 & 2 (awareness and antimicrobial use) of the WHO AMR competency guideline within the curricula. A commonly held view is that certain topics or competencies – particularly those perceived as advanced – should be prioritised and taught in greater depth at the postgraduate level. While this rationale has some merit, it raises several concerns. First, given the significant global public health threat posed by AMR, it is essential that the relevant knowledge, skills, and attitudes are acquired as Day 1 competencies for pharmacists. Secondly, relying on postgraduate training limits the number of graduates who ultimately attain these competencies, as not all pharmacy graduates proceed to further study. Finally, younger learners or pre-service trainees generally adopt new ideas more readily, whereas acquiring such competencies after graduation may be more challenging.

Furthermore, although considerable inclusion rates were recorded for some domains, there is need to strengthen them and ensure existing gaps are addressed. For example, UoN demonstrated high compliance with the WHO AMR competency training guidelines. However, the non-coverage of key competencies such as “promoting AMR drug utilisation” indicates an uneven pattern of compliance. This suggests that AMR is not fully or systematically integrated into the school’s pharmacy curriculum.

Notable similarities were also observed across the pharmacy curricula of some institutions. For example, in UNIBADAN and UNIBEN, most AMR-related topics were taught in the fourth and fifth years under “Clinical Pharmacy”, suggesting that both schools may have developed their curricula from a similar source. In Nigeria, the National Universities Commission (NUC) develops and issues the Core Curriculum and Minimum Academic Standards (CCMAS) for all undergraduate programmes, including pharmacy [29]. Therefore, some level of similarity across Pharmacy curricula in Nigeria would be expected.

However, the substantial differences in overall compliance with the WHO AMR competency framework suggest otherwise. While UNILORIN demonstrated a moderate inclusion rate, UNIBADAN showed a low rate. Possibly because older faculties of pharmacy, such as UNIBADAN (established in 1980), developed their curricula at a time when AMR was not yet recognised as a major threat. In contrast, more recently established faculties of pharmacy, such as that of UNILORIN (established in 2009), may require less modification to align with global best practices in AMR education. This may account for the disparities observed and may also reflect broader differences between older and newer universities in Africa.

Importantly, this gap has already been recognised. In 2022, the NUC announced the completion of a review of the CCMAS to harmonise university curricula across Nigeria and align them with international standards [29]. The revised CCMAS for pharmacy programmes was published in 2023. Under this framework, universities are required to adopt a minimum of 70% of the national template, with the remaining 30% reserved for local adaptation. A similar approach across SSA could help ensure that future pharmacists acquire comparable AMR-related knowledge, skills, and attitudes to address AMR effectively in the region.

It is noteworthy that none of the reviewed curricula included any content related to the fifth pillar of the Global Action Plan (GAP) on AMR – developing the economic case for sustainable investment that takes account of the needs of all countries. This omission is expected, as the curricula were developed around the WHO AMR Competency Framework for Day-1 pharmacists, which only reflected the first four GAP pillars [10]. This emphasises the earlier argument that some topics are reserved for postgraduate training, as the fifth pillar arguably requires advanced knowledge in global health economics, health financing, and systems thinking.

Several studies have made similar observations. Joseph et al. (2017) noted that this pillar primarily concerns health financing and resource mobilisation and hence is not directly aligned with Day-1 pharmacy competencies [30]. Shu et al. (2020) further highlighted that its relevance becomes greater during in-service or postgraduate training, when pharmacists are expected to develop more applied skills and broaden their professional expertise [31]. Nonetheless, there is a need to incorporate elements of this pillar into pre-service pharmacy curricula, as it is important for graduates to understand the economic dimensions and consequences of AMR. Early exposure may help influence students’ attitudes and strengthen their commitment to responsible antimicrobial stewardship.

Some of the perceived challenges to incorporating AMR-related courses into pharmacy curricula in Africa include the potential increase in workload for both staff and students, as well as administrative bottlenecks. In a study conducted in India, limited human resources, insufficient time, restricted interactions, and reduced student motivation during online teaching were identified as major barriers to introducing AMR education into pharmacy programmes [32]. Given the limited funding situation of many universities in SSA, it is not unusual for lecturers to be overstretched, often managing multiple courses simultaneously. Securing the financial resources required for curricular reform also tends to be slow and challenging. However, considering the scale of the threat posed by AMR – one of the most significant global health challenges of the 21st century [2]. The integration of AMR into pre-service pharmacy curricula is essential. Pharmacists play a central role in AMR prevention and control through AMS, antimicrobial access, and surveillance; hence, developing a competent pharmacy workforce in SSA that meets international standards is non-negotiable.

To address these challenges, targeted capacity building for lecturers is critical. Structured AMR training programmes could enhance lecturers’ understanding of the AMR burden in SSA and increase their confidence and willingness to teach AMR-related content at the pre-service level. Additionally, expanding financing options – through government support, grants, or partnerships – would help universities implement the necessary curricular updates without exacerbating existing workload pressures.

Strengthening AMR education in pre-service training requires active engagement of multiple stakeholders. Professional bodies, such as national pharmaceutical societies and regulatory councils, can play a pivotal role by setting competency standards and advocating for AMR integration in curricula. Similarly, student associations can promote awareness and peer-led learning initiatives that reinforce classroom teaching. Collaboration between academia, professional associations, and public health authorities is essential to ensure sustained implementation and alignment with national AMR action plans.

Limitations

This study has several limitations. First, the selection of institutions was based on their participation in an internship programme, which may limit the representativeness of the findings. Since the time of data collection for this study, the Pharmacy curricula of the interns may have been revised or updated, potentially leading to minor variations from our reported findings. Additionally, because the curricula review was conducted by student interns with limited research experience, the findings may be influenced by variability in their interpretation and skill level, introducing a potential source of bias into the results. However, close supervision by the DBF staff helped to mitigate this effect but may not entirely eliminate it. Altogether, the study provides a detailed analysis of AMR-related content and existing gaps within the curricula available as of 2022 and evaluates their compliance with the national AMR action plan.

Conclusion

Through the analysis of curricula conducted in this study, we provide an up-to-date assessment of AMR inclusion in pre-service pharmacy education in SSA, using five universities as case studies. A substantial gap was identified in pre-service training on “diagnostic stewardship and surveillance” and “infection prevention and control” across the reviewed institutions. This finding reflects wider patterns documented in many African universities. These gaps highlight the need for systematic review and standardisation of pharmacy curricula across the continent.

To support this reform, relevant stakeholders should prioritise the development of AMR-focused learning materials, clear learning objectives, and appropriate teaching and assessment approaches. Where resources already exist, mechanisms for networking and knowledge-sharing among universities should be strengthened. Early introduction of AMR – preferably by the second year of training – as a stand-alone course covering AMR and AMS is recommended. Additionally, AMR-related content should be integrated more strongly into clinical practice courses and research training, including encouraging students to undertake final-year projects related to AMR or AMS. These strategies will help ensure that graduates acquire the knowledge, skills and attitudes required for the responsible use of antimicrobials.

Continuous capacity building for lecturers and educators is essential to ensure effective delivery of AMR-related content in line with global best practices. Prior to large-scale integration, feasibility studies should be undertaken by pharmaceutical education bodies and regulatory agencies to determine the financial and operational requirements for curriculum redesign, update, and implementation.

Beyond curriculum development, intellectual and extracurricular activities such as hackathons, seminars, debates and workshops should be introduced to build students’ problem-solving skills and foster innovative thinking around AMR. Annual participation in the World Antibiotic Awareness Week should also be encouraged as an opportunity to strengthen awareness and reinforce classroom learning. Regular SWOT analyses are recommended to assess whether curricula continue to meet their objective of producing pharmacists who uphold key principles of antimicrobial stewardship and contribute meaningfully to curbing AMR.

Finally, we recommend that a multi-stakeholder approach be employed in reforming pharmacy curricula in SSA to strengthen AMR education and awareness. Professional bodies should advocate for the integration of AMR content into national pharmacy training standards and accreditation requirements. Regulatory bodies should provide clear policy directives and enforce compliance to ensure uniform adoption across institutions. Academic institutions should periodically review and update their curricula to reflect emerging AMR priorities and align with global standards. This review should be comprehensive, using a structured method that addresses biases and reflects African AMR priorities. Student associations should also be actively engaged in promoting AMR awareness through peer-led initiatives and advocacy campaigns. Such coordinated action will foster sustained implementation and enhance the preparedness of future pharmacists to address AMR challenges within the One Health framework.

Abbreviations

AMR

Antimicrobial Resistance

AMS

Antimicrobial Stewardship

SSA

Sub–Saharan Africa

WHO

World Health Organization

AU

African Union

GAP

Global Action Plan

NAP

National Action Plan

OH

One Health

Authors’ contributions

TO: conception, design, acquisition, analysis and interpretation of data, drafting, revision; **AOM: ** design, analysis and interpretation of data, drafting, revision; **IS: ** conception, design, acquisition, analysis and interpretation of data; **AZ: ** conception, design **HI: ** design, acquisition, analysis and interpretation of data; **CIO: ** drafting, revison; **CM: ** drafting, revision; **SA: ** analysis and interpretation of data, revision **OM: ** revision; **VI: ** conception, revision; **HB: ** conception, revision; **MH: ** conception, revision; **CV: ** conception, revision;

Funding

No funding was received.

Data availability

Data is provided within the manuscript and supplementary information files.

Declarations

Ethics approval and consent to participate

Not Applicable under national regulations as no personal information/identifiable human data was collected or used in this study.

Consent for publication

Informed consent was secured from all participants, which meets national requirements.

Competing interests

The authors declare no competing interests.