## 4 Discussion  
Empowering pharmacists in Ghana, Uganda, Tanzania and Zambia to lead AMS activities and rise in awareness of AMR through structured collaboration with UK pharmacists have had a positive impact. Pharmacists within the participating countries have raised the awareness of AMR as well as developed and delivered several AMS interventions, including education and training and conducting PPS. They have locally led AMS interventions through engaging with colleagues, e.g., the cascade of the CwPAMS app, an Antibiotic Guardian pledge-based campaign, WAAW activities and guideline compliance, and they have also engaged with the public, e.g., Boda boda drivers in Tanzania. Using a quality improvement approach, helped in the identification of prescribing barriers, such as low trust in generic medication, fear of treatment failure with first-line antibiotics and lack of awareness of policy. Sociocultural barriers of accessing antibiotic policy using the CwPAMS Antimicrobial Guideline app through mobile phones while taking the patient history for fear of being seen to be using social media were also identified, allowing the pharmacists to work with their prescriber colleagues to address the local barriers to change. Engaging staff over a longer period of time with regular feedback, similar to other studies, incorporating the feedback of surveillance data collected from, e.g., PPS within projects, was shown to lead to positive effects, including the development of new protocols led by clinicians with support from the pharmacists as part of institutions' AMS teams [12; 13]. In addition, pharmacists also led IPC interventions, including Bare Below the Elbow (BBE) campaigns and the large-scale production of alcohol hand rub during the COVID-19 pandemic [14]. Bidirectional learning was also evident particularly during COVID-19 management in the UK, where pharmacists in Zambia trained UK pharmacists to locally produce alcohol hand rub using the WHO hand rub formula. The pharmacists that were part of the CwPAMS projects are now considered core members of their respective AMS committees, providing a sustainable model for AMS within these hospitals. Using a variety of methods and approaches but always focusing on local priorities and being led by local pharmacists will have an impact on patient care, improving infection management and supporting the actions to tackle AMR. Like their colleagues in the UK [4], they now play an important role in leading AMS within their institutions. The collaboration not only highlighted the importance of tackling AMR, but it also raised the profiles of the pharmacists, resulting in their unique skills as pharmacists being recognised within the MDT environment. The skills and experiences gained during the project have given local pharmacists the opportunity to expand their roles. Some pharmacists have taken on a more clinical pharmacy role. Many are now embedded as key members of MDT clinical teams, working with their prescribing colleagues to improve compliance with the antibiotic policy and conduct ward rounds. Pharmacists involved in the projects were also able to link with national committees to support national efforts to tackle AMR through AMS and the surveillance of antimicrobial use, as well as working with external organisations, including universities, to develop modules for pre- and post-service education on AMR. An example is in Tanzania, where the education lead pharmacist and member of the CwPAMS project at KCMC was recently appointed Chair of the NationalTanzania AMS team and has successfully introduced AMS training modules as part of the healthcare school's curriculum within medicine, pharmacy and dentistry. The approach of collaborating via different methods with a focus on education and training and the rollout of a train-the-trainer approach reduced the overall cost and the time pharmacists from the UK required to be in partnership countries. This was a successful approach that could be replicated elsewhere to improve AMS.