From classrooms to practice: does pre-service training for one health professions provide readiness for antimicrobial stewardship?

Abstract

Background

One Health (OH) professions, specifically doctors, pharmacists and veterinarians, play central roles in antimicrobial stewardship (AMS), serving as the primary gatekeepers of antimicrobial use. Considering that antimicrobial resistance (AMR) is a global health priority, it is essential that these gatekeepers are equipped with the necessary skills for effective AMS at day-one. As part of the Ducit Blue Foundation (DBF) programme, this study assesses the level of day-one competencies for AMS in pre-service curricula across OH professions using the respective global competency frameworks.

Methods

Pre-service training curricula for OH professions in five African countries were compared to their respective World Health Organization (WHO) and World Organisation for Animal Health (WOAH) competency frameworks to determine alignment with specific AMS competencies. Intersectoral comparisons were also conducted to understand variations across OH sectors.

Results

AMS preparedness among OH graduates in Africa was not determined by profession alone, as alignment varied both within and across the OH professions reviewed. The strongest alignment was observed in UniLorin veterinary medicine (77%), UniPort pharmacy (67%), and ABU Zaria medicine (51%), showing that stronger AMS integration is achievable across professional groups. However, lower alignment was also observed across the same professions, including Addis Ababa University medicine (33%), UniLomé pharmacy (39%), and EISMV veterinary medicine (48%). While the AMS components of WHO AMR competency framework emphasises a clinical and research focus, the WOAH competency recommendations extend further by adding OH and public health focus.

Conclusion

These findings suggest that AMS preparedness depends less on professional category and more on how explicitly and consistently AMS competencies are embedded within each curriculum. There is a need to strengthen pre-service AMR education across OH professions in Africa. Regional initiatives such as DBF internship programme that target early-career OH professionals for AMR training are essential for bridging existing gaps in pre-service AMR education in Africa and beyond.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09843-y.

Introduction

Antimicrobial resistance (AMR) is a growing global public health challenge due to high infection rates and limited antimicrobials available to treat them [1]. It arises when microorganisms—bacteria, fungi, viruses and parasites—develop resistance to antimicrobials [2], threatening human, animal and environmental health via the emergence and spread of multidrug-resistant organisms [3]. In 2019, AMR was associated with 4.95 million deaths and directly linked to 1.27 million deaths globally; one in five were children under five [4]. Inappropriate use and gaps in education, regulation and practice are major drivers of AMR [5].

Antimicrobial stewardship (AMS) comprises coordinated measures to optimise antimicrobial use [6]. In many settings, stewardship is often undermined by inadequate training, weak adherence to guidance and practice pressures that encourage misuse [7]. In Sub-Saharan Africa, non-prescribed dispensing in community outlets is a major driver of antibiotic misuse [8]. This has further been complicated by the exit of large pharmaceutical firms such as GlaxoSmithKline and Sanofi in West Africa, by affecting availability of quality antimicrobials [9].

Strengthening AMS is central to preserving treatment effectiveness. One Health (OH) professionals, doctors, pharmacists and veterinarians—are pivotal to achieving this goal. Doctors and pharmacists influence human antimicrobial use through prescribing, dispensing and counselling, while veterinarians promote prudent use in animals, safeguard food safety and reduce zoonotic risk [10, 11]. Ensuring graduates of these professions are stewardship-ready at day-one is therefore critical.

To guide preparation, the World Health Organization (WHO) issued a normative AMR competency framework for health workers [10] and the World Organisation for Animal Health (WOAH) defined day-one graduate competencies for veterinarians [11]. Together, these frameworks specify the knowledge, skills and attitudes expected of new OH graduates and provide benchmarks for aligning pre-service curricula with AMR responsibilities.

Aligning pre-service education with these competencies is a practical route to improved stewardship readiness. However, OH curricula in Africa include limited AMR and stewardship content, leaving graduates under-prepared for societal AMR challenges [12, 13]. To bridge this gap, Ducit Blue Foundation (DBF) targets early-career OH professionals for AMR capacity empowerment. This study forms part of the succession planning within the OH Pan-African AMR Internship/Mentorship Programme. It reflects broader efforts to strengthen policy analysis and evidence translation capacity among early-career public health professionals in Africa. Such capacity building is critical for succession planning in Africa, ensuring that tomorrow’s public health workforce have a good grasp of AMR governance, to support the development of effective NAPs, and ensure that AMS strategies are informed by locally generated evidence.

This study assesses pre-service curricula of OH professions from nine African universities, mapping them against the WHO AMR Competency Framework and WOAH day-one competencies to evaluate stewardship readiness. It also compares and contrasts stewardship recommendations across OH sectors. Findings from this study will identify gaps and inform AMR pre-service training for OH workers in Africa.

WHO competency framework for health workers’ education and training on AMR

This document was developed after adoption of the Global Action Plan on AMR [14]. The WHO coordinated expert consultations between 2016 and 2017, mapped existing AMR education resources, and consolidated evidence and stakeholder input to produce a global competency reference for education and training. The framework was finalised in 2018, and serves to provide normative guidance that enables educators, accreditation and regulatory bodies, and policy-makers to ensure pre-service and in-service programmes equip health workers with competencies needed to combat AMR. Stewardship is explicitly captured in Domain 2: Appropriate use of antimicrobial agents, which defines what doctors and pharmacists must know, do and value to ensure rational antimicrobial use. Table 1 summarises the stewardship competencies for pharmacists and doctors.

Table 1.

AMS competencies derived from international competency frameworks for one health professional training in AMR

WHO Competency Framework – Medicine	WHO Competency Framework – Pharmacy	Revised AMS-relevant indicator from WOAH competency – Veterinary Medicine
Knowledge	Knowledge	Knowledge
1. Diagnosis of disease including the ability to discriminate diseases of different infectious pathology	1. Understand the significance of efficacy data for clinical benefit for each indication (magnitude of benefit estimated in clinical trials).	1. Understand the appropriate use of veterinary drugs, especially antimicrobials, including mechanisms of antimicrobial resistance in pathogens.
2. Indication for antimicrobial therapy, including assessment of severity of infection (sepsis syndrome recognition) to inform urgency for therapy	2. Pharmacokinetics: route of therapy, concept of bioavailability, dosing frequency, therapeutic drug monitoring and clearance.	2. Understand withdrawal times and the risk of drug residues in food-producing animals.
3. Understand that travel, recent hospitalisation or previous microbiology findings of resistant bacteria predispose to resistant pathogen infection	3. Pharmacodynamics: tissue/ organ adverse effects (e.g., abnormal liver function tests, renal toxicity).	3. Understand the link between antimicrobial use in food animals and the development of antimicrobial resistance in pathogens of human importance.
4. Understand common drug interactions between antimicrobials and other therapeutic agents, and between antimicrobials and food. Understand their clinical significance and strategies to avoid interactions	4. Allergy: immediate, non-life threatening, severe adverse drug reactions (e.g., Steven-Johnson Syndrome).	4. Understand the safe use and disposal of veterinary drugs, biologicals, and biological waste to protect the food chain and the environment.
5. Appreciate the risk, benefits and limitations of antimicrobial treatment in the context of patient and setting	Skills	Skills
6. Understand the concept of broad- and narrow-spectrum antibiotics and the importance of avoiding unnecessary use	1. Assess prescriptions in accordance with local policies for antimicrobial use.	1. Use common veterinary products appropriately, including appropriate record keeping, in line with relevant veterinary legislation and professional standards.
7. Understand the use of antimicrobials in special care groups (e.g., paediatrics, pregnancy, renal disease, obesity)	2. Review antimicrobial choice, dose, interval, duration and route of administration.	2. Apply appropriate information on veterinary products, withdrawal times, and antimicrobial resistance when using veterinary medicines in animals.
8. Understand the mechanisms of action of the different antimicrobial drug classes	3. Give advice on dosage form, preparation and administration (especially for special patient cohorts such as children).	3. Communicate technical information on animal health, food safety, disease prevention, and appropriate veterinary product use to public and professional audiences.
9. Understand how to develop a hospital formulary	4. Counsel individuals and populations on the safe and rational use of antimicrobials (including the selection, use, contraindications, storage, drug interactions and side effects).	4. Maintain appropriate records for veterinary product use and participate in disease reporting, surveillance, residue monitoring, and communication of epidemiological information.
10. Understand the basics of antimicrobial product research, development, regulation and marketing	5. Accurately dispense prescribed antimicrobials for major and minor infections	Attitudes
Skill	6. Ensure timely supply of appropriate medicines.	1. Promote appropriate veterinary product use to protect animal health, public health, food safety, and the environment.
1. Select and prescribe antimicrobials in accordance with standard treatment guidelines, considering pathogen, dose, duration and route	7. Ensure appropriate documentation of antimicrobials dispensed including route, time, dose, therapeutic drug monitoring and response for individual patients.	2. Promote disease prevention and control measures, including vaccination, hygiene, early detection, movement control, and other relevant control measures.
2. Recognise the immediate and long-term patient and ecological consequences of inappropriate antimicrobial prescription	Attitude	3. Promote appropriate and legally compliant use of veterinary products, guided by veterinary legislation, ethics, and reliable information sources.
Attitude	1. Promote approaches to increase individual or community knowledge of using antimicrobials appropriately.	4. Recognise the role of veterinarians in One Health, National Veterinary Services, epidemiological networks, disease surveillance, notification, and reporting systems.
1. Promote best practice approaches to prescribing antimicrobials and ensure adherence to guidelines	2. Promote the use of quality assured antimicrobials for patient treatment.
2. Promote capacity to search for reliable sources of unbiased information on best use of antimicrobials	3. Promote AMR drug utilization studies.
3. Beware of market incentives to proliferate antimicrobial prescriptions against guidelines

WHO competencies were presented for medicine and pharmacy, while AMS-relevant veterinary medicine competencies were derived from the WOAH framework. Competencies were grouped under knowledge, skills, and attitudes to support comparison of AMS preparedness across OH pre-service curricula

WOAH recommendations on the competencies of graduating veterinarians (day-one graduates)

This document, produced by WOAH in 2012, incorporates global expert input to address variability in veterinary education and define the minimum competencies required for graduates to contribute effectively to National Veterinary Services. Aligned with the WOAH Performance of Veterinary Services pathway and the OH approach, it establishes Day-one competencies—knowledge, skills, attitudes and aptitudes—necessary for veterinarians in both public and private sectors to promote animal health and welfare, veterinary public health, food safety, and fulfil international obligations. Specific stewardship components are intertwined within some of the competencies (Table 1).

Methods

Study setting

This study was initiated by interns in the 2021–22 cohort of the multi-award-winning OH Pan-African Internship/Mentorship Programme organised by DBF in collaboration with International Federation of Medical Students’ Associations (IFMSA), International Pharmaceutical Students Federation AFRO Chapter (African Regional Office) (IPSF), International Association of Students in Agricultural and Related Sciences (IAAS), International Veterinary Students Association (IVSA), Nigerian Association of Microbiology students (NAMS), and FAO. The programme strengthens young professionals’ competencies in AMR, OH and leadership to tackle misuse, combining structured learning with practical exposure. Their capstone projects formed the basis of this paper.

Study area

Figure 1 shows the countries of selected universities for this study. They were selected based on participation of interns in the DBF programme. They included Interstate School of Veterinary Science and Medicine of Dakar (EISMV) from Senegal; University of Lomé (UniLome) from Togo; Joseph Ki-Zerbo University (JKZU) from Burkina Faso; University of Ilorin (UniLorin) from Nigeria; University of Port Harcourt (UniPort) from Nigeria; Obafemi Awolowo University (OAU) from Nigeria; University of Nigeria Nsukka (UNN) from Nigeria; Ahmadu Bello University (ABU) from Nigeria; and Addis Ababa University (AAU) from Ethiopia.

Fig. 1.

Countries of selected universities. Map of Africa highlighting the countries of selected universities included in the study: Senegal, Burkina Faso, Togo, Nigeria, and Ethiopia

Study design

This paper builds on the earlier AMR curriculum analysis by Omoniyei et al. [13], and focuses specifically on AMS competencies within pre-service curricula of OH professions. A qualitative approach employing textual analysis and curriculum mapping was used to assess alignment of pre-service curricula with WHO and WOAH AMS competencies for day-one graduates. The study spans from November 2021 to February 2022.

Structure of WHO AMR competency framework

The framework is structured into four domains: (1) foundations that build awareness of AMR; (2) appropriate use of antimicrobial agents; (3) infection prevention and control (IPC); and (4) diagnostic stewardship and surveillance. Competencies under each domain are divided into four categories: (1) all health workers; (2) prescribers; (3) non-prescribers, including nurses, pharmacists, and laboratory scientists/technicians; and (4) public health officers/health services managers. Each category is further divided into core competencies, representing essential knowledge, skills, and attitudes, and additional competencies, which are desirable depending on practice setting, available resources, and capacity.

For this study, we assessed both core and additional competencies together to assess comprehensive competencies contained in the curricula but restricted our analysis to Categories 2 (prescribers) and 3 (non-prescribers – pharmacists), as these directly correspond to the professional programmes under review (medicine and pharmacy). Within these categories, we focused on Domain 2: Appropriate use of antimicrobial agents, which captures AMS functions most relevant to the study scope. Other domains and categories were excluded to maintain a clear focus on stewardship-specific competencies and to ensure comparability with the WOAH Day-1 veterinary competencies.

Structure of WOAH day-1 recommendation

The document outlines two competency levels: basic and advanced. Basic competencies represent the minimum requirements for licensure by a Veterinary Statutory Body and include both general and specific competencies relevant to the WOAH mandate. They cover 11 areas: epidemiology; transboundary animal diseases; zoonoses/food-borne diseases; emerging/re-emerging diseases; disease prevention and control programmes; food hygiene; veterinary products; animal welfare; veterinary legislation and ethics; certification procedures; and communication. General competencies comprise foundational veterinary sciences, clinical sciences, and animal production, while specific competencies directly support clinical practice across the same 11 thematic areas.

Advanced competencies define the minimum requirements for veterinarians working within the Veterinary Authority to fulfil its public health mandate, including food safety, hygiene, sanitation, zoonoses and OH. Graduates must demonstrate both basic and advanced competencies before practicing. Advanced competencies span eight areas: veterinary services organisation/management, inspection and certification, contagious disease management, food hygiene, risk analysis, research, the international trade framework, and administration/management.

Stewardship is embedded primarily within the specific competencies—particularly veterinary products, zoonoses, disease prevention and control, food hygiene, veterinary legislation and ethics, and communication–ensuring rational antimicrobial use, infection risk reduction and adherence to regulatory standards. Table 1 shows the stewardship competencies for veterinary medicine.

Data collection

The pre-service curricula were obtained from students of the selected universities who provided official course outlines and curriculum documents. They included two medicine (ABU, AAU), five pharmacy (UniPort, JKZ, UniLome, OAU, UNN) and two veterinary medicine courses (UniLorin, EISMV).

Data analysis and management

Data were managed using Microsoft Excel 2019 and AntConc 4.3.1. WHO explicitly structures competencies into categories – knowledge, skills and attitudes. WOAH recognises these categories but organises competencies into basic general and advanced domains. For uniform analysis, the WOAH competencies were analysed and AMS-relevant indicators were derived from them and categorised into knowledge, skills and attitudes, and AMS components identified. Indicators were classified as knowledge where the WOAH/OIE document used terms such as “understand,” “know,” “explain,” or “describe”; as skills where it used action-oriented terms such as “use,” “utilise,” “participate,” “communicate,” “monitor,” or “report”; and as attitudes where the content implied professional responsibility, ethical conduct, promotion, public-good orientation, or commitment to protecting animal and public health. A detailed mapping of the AMS-relevant veterinary indicators derived from the WOAH/OIE Day-1 competencies, including source sections and rationale for classification, is provided in Supplementary File 1. The pre-service curricula were then mapped against the AMS components of the categories in the stewardship domains of the respective competency frameworks using a five-point traffic light scale, supplemented with grey-scale symbols to enhance visibility for colourblind readers and ensure readability in non-coloured printed formats (Table 2).

Table 2.

Traffic light scoring system used to assess alignment of pre-service curricula with antimicrobial stewardship competencies

Scores ranged from 1 to 5, with higher scores indicating stronger curriculum alignment with AMS competency items. Symbols were used alongside colour labels to improve interpretation without relying on colour alone

Total scores for each curriculum and category (knowledge, skills, and attitudes) were summed and expressed as percentages to indicate overall alignment. Higher alignment scores were interpreted as greater preparedness of day-one graduates.

Results

Medicine

For knowledge competencies, pre-service medicine curricula showed highest alignment with items 8 and 6 (antimicrobial mechanisms of action; broad and narrow-spectrum antibiotics) and weak alignment with items 9 and 10 (hospital formulary development; antimicrobial research, development, regulation and marketing). For skills competencies, alignment was moderate for item 2 (consequences of inappropriate prescription) and weak for item 1 (prescription per standard treatment guidelines). For attitudes competencies, alignment was moderate for item 1 (promoting guideline adherence) and weak for items 2 and 3 (unbiased use research capacity; protecting market-driven over-prescription). Overall, AMS alignment with WHO AMR competency framework was 42% (Table 3). Medicine curricula tended to align better with foundational pharmacology (mechanisms, spectrum concepts) and less with system-level components (formulary development; research and regulation) and prescribing behaviours tied to guidelines. By university, ABU Zaria recorded stronger overall alignment (51%) than AAU (33%) (Fig. 2).

Table 3.

Medicine pre-service AMS alignment

*Key – Lime green (complete alignment); Yellow-green (above average alignment); Amber (average alignment); Dark orange (below average alignment); Firebrick red (no alignment)

Fig. 2.

Medicine pre-service curricula AMS alignment. Comparison of AMS competency alignment scores for medicine pre-service curricula from Ahmadu Bello University Zaria in Nigeria and Addis Ababa University in Ethiopia across overall WHO AMR Competency framework categories; knowledge, skill, and attitude

Pharmacy

For knowledge competencies, pharmacy pre-service curricula showed moderate alignment with items 2 and 3 (pharmacokinetics; pharmacodynamics) and weak alignment with items 1 and 4 (clinical efficacy; allergy). For skills competencies, moderate alignment appeared for items 1, 2, 4 (prescription assessment; antimicrobial review; counselling), while weak alignment was observed for items 3, 5, 6, 7 (dosage advice; accurate dispensing; timely supply; antimicrobial documentation). For attitudes competencies, moderate alignment occurred for items 1 and 4 (awareness; promoting patient understanding), but weak alignment for items 2 and 3 (quality-assured antimicrobial use; AMR drug-utilisation studies). Overall, AMS alignment with WHO framework was 46.9% (Table 4). Pharmacy pre-service curricula aligned more consistently with core pharmacological science and advisory functions, but relatively lower alignment with operational processes (dosage advice, dispensing accuracy, supply timeliness, documentation). By universities, UniPort showed the strongest alignment (67%), while UniLome had the weakest (39%) (Fig. 3).

Table 4.

Pharmacy pre-service AMS alignment

*Key – Lime green (complete alignment); Yellow-green (above average alignment); Amber (average alignment); Dark orange (below average alignment); Firebrick red (no alignment)

Fig. 3.

Pharmacy pre-service curricula AMS alignment. Comparison of AMS competency alignment scores for pharmacy pre-service curricula from Joseph Ki-Zerbo University in Burkina Faso, University of Lomé in Togo, University of Port Harcourt in Nigeria, Obafemi Awolowo University in Nigeria, and University of Nigeria, Nsukka in Nigeria across overall WHO AMR competency framework categories; knowledge, skill, and attitude

Veterinary medicine

For knowledge competencies, veterinary pre-service curricula demonstrated strong alignment with items 1 and 2 (appropriate use; drug safety), moderate alignment with item 3 (One Health), and weak alignment with item 4 (safe disposal and biological waste). For skills competencies, alignment was strong for items 1 and 2 (responsible prescription, dispensing and administration; antimicrobial review), moderate for item 3 (rational use counselling), and weak for item 4 (monitoring, reporting and documentation). For attitudes competencies, alignment was strong for item 1 (responsible use promotion), moderate for item 2 (disease-prevention strategies), and weak for items 3 and 4 (quality-assured antimicrobial use; AMR surveillance advocacy). Overall, AMS alignment with WOAH Day-one competency recommendations was 63% (Table 5). Veterinary pre-service curricula showed consistently higher alignment on clinical competencies, but lower alignment on broader public health competencies. By universities, UniLorin recorded higher alignment (77%) than EISMV (48%) (Fig. 4).

Table 5.

Veterinary medicine pre-service AMS alignment

*Key – Lime green (complete alignment); Yellow-green (above average alignment); Amber (average alignment); Dark orange (below average alignment); Firebrick red (no alignment)

Fig. 4.

Veterinary medicine pre-service curricula AMS alignment. Comparison of AMS competency alignment scores for veterinary medicine pre-service curricula from École Inter-États des Sciences et Médecine Vétérinaires de Dakar in Senegal and University of Ilorin in Nigeria across overall WHO AMR competency framework categories; knowledge, skill, and attitude

Intersectoral comparison: WHO AMR competency framework (medicine/pharmacy) vs. WOAH day-1 competencies (veterinary)

Knowledge

Across competency frameworks, graduates require foundational AMR knowledge with sector-specific emphasis. Medicine focuses on diagnosis, indications, resistance risks and class selection. Pharmacy focuses on drug properties (pharmacokinetics, pharmacodynamics, safety, clinical efficacy). Veterinary medicine focuses on animal health, food safety, residue control and the animal–human AMR interface. Thus, medicine is patient/disease-centred, pharmacy is drug-centred and veterinary animal/public-health-centred. WHO emphasises drug properties/patient safety for pharmacists and clinical decision-making for doctors; WOAH emphasises animal use and public-health implications (Table 6).

Table 6.

Intersectoral comparison of the AMS competencies

Domain	Key focus areas in the WHO framework for Doctors	Key focus areas in the WHO framework for Pharmacists	Key focus areas in the WOAH framework Veterinary Medicine
Knowledge	• Disease diagnosis & differentiation of infectious causes • Indications for antimicrobial therapy & infection severity assessment • Risk factors for resistant infection (travel, hospitalization, past cultures) • Drug interactions (with other drugs/food) & how to avoid them • Risk–benefit limits of antimicrobial use • Broad vs. narrow spectrum use & need to avoid unnecessary treatment • Use of antimicrobials in special groups (pediatric, pregnancy, renal etc.) • Mechanisms of action of antimicrobial classes • How to develop a hospital formulary • Basics of antimicrobial R&D, regulation & marketing	• Significance of efficacy data for each indication • Pharmacokinetics: route, bioavailability, dosing, clearance, TDM • Pharmacodynamics: tissue/organ toxicity (liver, kidney etc.) • Drug allergies & severe reactions	• Understand the appropriate use of veterinary drugs, especially antimicrobials, including mechanisms of antimicrobial resistance in pathogens • Understand withdrawal times and the risk of drug residues in food-producing animals • Understand the link between antimicrobial use in food animals and the development of antimicrobial resistance in pathogens of human importance • Understand the safe use and disposal of veterinary drugs, biologicals, and biological waste to protect the food chain and the environment
Skills	• Select & prescribe antimicrobials per guidelines (pathogen, dose, duration, route) • Recognise clinical & ecological impacts of poor prescribing	• Assess prescriptions against local AMR policies • Review antimicrobial choice, dose, interval, duration, route • Advise on dosage form & administration (incl. children) • Counsel patients/populations on safe rational AMR use • Dispense antimicrobials accurately • Ensure timely supply of medicines • Document route, time, dose, TDM & response	• Use common veterinary products appropriately, including appropriate record keeping, in line with relevant veterinary legislation and professional standards • Apply appropriate information on veterinary products, withdrawal times, and antimicrobial resistance when using veterinary medicines in animals • Communicate technical information on animal health, food safety, disease prevention, and appropriate veterinary product use to public and professional audiences • Maintain appropriate records for veterinary product use and participate in disease reporting, surveillance, residue monitoring, and communication of epidemiological information.
Attitude	• Promote best-practice antimicrobial prescribing & adherence to guidelines • Promote capacity to search for unbiased evidence sources • Acknowledge market pressures that encourage over-prescription	• Promote public awareness on appropriate antimicrobial use • Promote quality-assured antimicrobials • Promote AMR drug-utilization studies • Improve patient understanding of safety, adherence & alerts	• Promote appropriate veterinary product use to protect animal health, public health, food safety, and the environment • Promote disease prevention and control measures, including vaccination, hygiene, early detection, movement control, and other relevant control measures • Promote appropriate and legally compliant use of veterinary products, guided by veterinary legislation, ethics, and reliable information sources • Recognise the role of veterinarians in One Health, National Veterinary Services, epidemiological networks, disease surveillance, notification, and reporting systems

Compares the main AMS competency focus areas across medical, pharmacy, and veterinary medicine training frameworks. The WHO framework was used for doctors and pharmacists, while the WOAH framework was used for veterinary medicine, allowing comparison of profession-specific stewardship roles across knowledge, skills, and attitudes

Skill

All competency frameworks require contributions to antimicrobial decision-making with sector-specific roles. Medical graduates prescribe based on diagnosis, guidelines and patient factors while recognising long-term consequences of inappropriate prescribing. Pharmacy graduates review prescriptions, dispense safely, counsel patients and ensure accurate documentation/dosing. Veterinary graduates prescribe/administer to animals, advise farmers/owners on stewardship/alternatives and monitor residue levels and AMR cases. AMS is shared but applied through clinical decisions (medicine), dispensing/education (pharmacy) and agricultural advisory/prescribing (veterinary) (Table 6).

Attitude

All competency frameworks expect promotion of responsible use, framed differently. Medicine promotes guideline-based prescribing, resists commercial/patient pressure for unnecessary antimicrobials and maintains the ability to source unbiased information. Pharmacy advocates rational use, patient understanding and access to quality-assured medicines. Veterinary promotes responsibility to protect animal/human health, encourages preventive measures (vaccination, biosecurity) and supports AMR reporting within OH systems. Thus, medicine emphasises evidence-based care, pharmacy emphasises medicine quality/patient safety and while veterinary emphasises on One Health/prevention (Table 6).

Discussion

This study assessed AMS alignment of OH pre-service curricula against international frameworks—WHO AMR Competency Framework for medicine and pharmacy, and WOAH Day-1 competencies for veterinary medicine—using pre-service curricula of major universities from Nigeria, Burkina Faso, Senegal, Ethiopia and Togo. These major training institutions provide a regionally grounded view of stewardship preparedness among graduate doctors, pharmacists and veterinarians in Africa.

AMS alignment of the pre-service curricula

Despite uneven coverage across the curricula reviewed, our findings suggest that stronger stewardship integration is achievable across OH professions in Africa. The stronger alignment observed in UniLorin’s veterinary medicine curriculum, UniPort’s pharmacy curriculum, and ABU Zaria’s medicine curriculum shows that OH graduates in Africa can be well prepared for AMS when stewardship competencies are made explicit across knowledge, skills, and attitudes. These higher-aligned programmes provide useful examples of how pre-service curricula can be strengthened to reflect international AMS competency expectations more clearly.

The findings, however, do not suggest a uniform advantage for any one profession. Alignment varied both within and across professional groups, indicating that professional category alone does not explain AMS preparedness. Rather, the key issue is how clearly and consistently AMS competencies are embedded within each university’s curriculum. This is important because doctors and pharmacists have distinct stewardship responsibilities, particularly in prescribing and dispensing, respectively [15]. Where alignment was weaker, the gaps therefore point to clear priorities for curriculum revision. Medical curricula require stronger attention to guideline-based prescribing, resistant-infection risk factors, special populations, drug interactions, formulary development, and antimicrobial product research and regulation. Pharmacy curricula would benefit from greater emphasis on timely medicine supply, antimicrobial documentation, dosage advice, dispensing accuracy, quality-assured antimicrobial use, recognition of severe adverse reactions, and AMR drug-utilisation studies.

Veterinary curricula showed stronger stewardship orientation in several areas, which may reflect the broader medicine-use responsibilities of veterinarians. Unlike doctors and pharmacists, veterinarians often prescribe, dispense, and administer medicines, giving them end-to-end responsibility for antimicrobial use [11]. This stronger focus is appropriate given the high levels of antimicrobial misuse reported in the animal sector [16, 17], and the wider OH accountability of veterinarians across animal, food, environmental, and human health. Even so, veterinary curricula still require targeted strengthening, particularly in safe disposal, residue monitoring, disease reporting, surveillance systems, technical communication, and the veterinarian’s role within OH and National Veterinary Services.

Across the pre-service curricula analysed, Nigerian universities generally demonstrated closer alignment with international competency frameworks than institutions from other countries included in this study. This may partly reflect the higher AMR burden in Nigeria [18, 19]. In 2024, Nigeria recorded an estimated 62,825 AMR-attributable deaths vs. 2,752 in Senegal, 1,478 in Togo and 5,407 in Burkina Faso [20]. Although this higher burden may be partly explained by Nigeria’s larger population, it remains substantial enough to warrant a strong institutional response, reflected in the closer alignment of its pre-service curricula. Also, universities from the other selected countries may place greater emphasis on other AMR domains (e.g., IPC, awareness, diagnostic stewardship) in their pre-service curricula. Nonetheless, universities in Senegal, Burkina Faso, Togo, and Ethiopia should strengthen stewardship components in their pre-service OH curricula to achieve closer alignment with international competency frameworks and better equip day-one graduates for coordinated AMR responses.

It is worth noting that this study analysed documented pre-service curricula, which may not fully reflect the curriculum as delivered or the competencies ultimately acquired by the OH professionals during training. Differences between planned and implemented teaching, as well as variability in learning experiences such as clinical placements and informal instruction during lectures, may influence competence beyond what is specified in official curricula. Therefore, alignment with competency frameworks represents a proxy measure and may not fully capture the true AMS preparedness of graduates. However, it is important that OH pre-service curricula in Africa officially capture adequate AMS components to ensure day-one graduates are formally equipped with necessary skills to support AMR containment in their society.

Overall, these findings support targeted curriculum revision across all three professions to better prepare graduates to fulfil their AMS roles. Higher-aligned curricula should be used as practical examples for improving weaker areas and strengthening AMS preparedness in African OH pre-service training to tackle misuse and overuse which are major AMR drivers in Africa [21].

Intersectoral comparison between WHO and WOAH competency frameworks

Comparison across sectors’ competency frameworks highlights clear differences in how they prepare graduates for antimicrobial responsibility. Both frameworks require graduates to possess strong drug-safety knowledge because all three professions are involved in prescribing, dispensing or administering antimicrobials [11, 15]. However, the orientation of this knowledge differs. The WHO framework emphasises clinical and patient-centred safety, while the WOAH adopts a broader systems-focused approach that extends to animal health, the food chain, public health and One Health. This contrast suggests that veterinary training naturally embeds a wider One Health perspective compared with the more individual patient focus in medicine and pharmacy.

Across the skills category, both frameworks expect graduates to align antimicrobial use with local policies and guidelines, but contexts vary. WHO emphasises diagnosis-driven decision-making in evaluating prescription compliance. WOAH, by contrast, stresses legal compliance in prescribing and the ability to advise livestock keepers, farmers and wider communities on rational use. The comparison underscores the need for context-appropriate stewardship communication, tailored either to individual patients or to agricultural and community groups, and reinforces the importance of aligning practice with local regulations.

Attitudinal expectations also reflect sector-specific priorities. Both frameworks stress responsible antimicrobial use and promotion of quality-assured medicines. However, WHO additionally encourages participation in antimicrobial utilisation research and strengthening patient awareness of safety issues, whereas WOAH places stronger emphasis on prevention-driven attitudes, such as biosecurity, hygiene and vaccination, alongside explicit advocacy for OH. This suggests that human-health education tends to be more research- and patient-oriented, while animal-health education emphasises prevention and cross-sectoral health protection.

Overall, the major distinction between the WHO and WOAH frameworks lies in the breadth of responsibility assigned to each profession. WHO competencies for doctors and pharmacists focus primarily on clinical practice, individual patient management and evidence-based antimicrobial decision-making [10]. WOAH competencies extend beyond clinical care to animal health, food safety, zoonoses and environmental protection [11]. Consequently, while doctors and pharmacists are mainly accountable for individual patient outcomes [22], veterinarians must also safeguard the health of animals, the safety and economic value of animal products and the prevention of zoonotic spillover [23, 24]. This broader mandate helps explain the more comprehensive AMS-related expectations embedded within veterinary curricula.

Conclusion

This study highlights that preparedness for AMS is not determined by professional category alone, but by how clearly and consistently stewardship competencies are embedded in curricula. While veterinary programmes often reflect broader OH responsibilities, medical and pharmacy curricula require targeted strengthening in prescribing, dispensing, and patient safety domains.

The comparison between WHO and WOAH frameworks underscores the sector‑specific breadth of responsibility: human health education focuses on patient‑centred clinical practice, while veterinary education embeds wider systems accountability across animals, food safety, and zoonotic prevention. This reinforces the need for curricula that are context‑appropriate, competency‑based, and aligned with international standards.

Ultimately, strengthening AMS components across all OH pre‑service curricula is essential to equip day‑one graduates with the skills, attitudes, and knowledge required to combat antimicrobial resistance. High‑performing programmes should serve as practical models for curriculum revision, ensuring that Africa’s future OH professionals are prepared to deliver coordinated, evidence‑based stewardship in line with both WHO and WOAH expectations.

Strengthening pre-service education across professions (supported by regional initiatives such as the DBF AMR OH Pan-African Internship programme) is essential to build a pipeline of leaders capable of impactful AMR interventions. This study forms part of succession planning within DBF’s programmes, reflecting broader efforts to strengthen advocacy, policy analysis, evidence translation and leadership capacity among early-career professionals to support effective NAP implementation, including locally informed AMS strategies towards building future public health leaders across Africa.

Limitations

This study has some limitations. The curricula were obtained in 2021–2022, and some universities may have revised their programmes since then. Differences in the structure and wording of the WHO and WOAH competency frameworks may also have introduced inconsistencies during data extraction and comparison. In addition, only nine universities from five African countries were included, selected through convenience sampling of participating interns. Finally, the study analysed documented pre-service curricula, which may not fully reflect delivered teaching, clinical placements, informal instruction, or the competencies ultimately acquired by OH professionals. Alignment with competency frameworks should therefore be interpreted as a proxy measure of AMS preparedness, while still recognising the importance of formally embedding adequate AMS components in African OH curricula to prepare day-one graduates for AMR containment.

Authors’ contributions

ORYA contributed to the conception of the study, coordination of the research, data acquisition, analysis and interpretation of data, and drafting of the manuscript. NCC, BOA, NI, BKB, AM, RAT, SD, CMU, WZR and CYD contributed to data acquisition and interpretation of the study findings. PMI contributed to the design of the study, drafting of the manuscript, and analysis and interpretation of the data. EM contributed to the conception of the study and review of the manuscript. CCO contributed to review of the manuscript. AOM supervised the study, contributed to the design, analysis and interpretation of the data, and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was not required for this study because it involved analysis of pre-service curriculum documents and did not involve human participants or identifiable personal data. The curriculum documents were provided by students from their respective institutions solely for academic research purposes.

Consent for publication

Consent for publication was obtained from all interns, authors, and individuals named in the acknowledgements, in accordance with national requirements.

Competing interests

The authors declare no competing interests.