## 4 Discussion
Education resources from the CwPAMS project and CPA will make it easier for others to be able to increase the awareness of AMS in other LMIC and replicate the local engagements, finding their own focus for improvements in AMS. While there have been many successes in the projects, these have not been without challenges. In Zambia, funding was a barrier initially to scale up the alcohol hand rub production to other facilities. Barriers with prescriber attitudes, the use of apps due to access to internet data and space app took up on the phones and communication within the multidisciplinary team (MDT) were also identified as issues within the Ghana project. Traditional pharmacy roles need to be challenged in order to allow pharmacists to fulfil their potential within the MDT environment. Ongoing support will be needed to ensure sustainability and continued support from hospital managers. Government support will also be required to sustain the IPC interventions, particularly with the current COVID-19 pandemic. These projects have been very successful at the local level, but AMR awareness and the benefits of AMS are still not widely understood or discussed, and more needs to be done to join up those working locally to teams working within governments to tackle AMR nationally but, also, join up with the effort internationally in order to engage more people in AMR and AMS conversations. Urgency is needed to get the message heard on a larger scale. WHO has recognised AMR as a global health threat, and the barriers need to be overcome in order to respond with a global response to this issue. CPA have made great strides in this aim by both supporting this work and by providing practical advice and resources for pharmacists in LMIC, including the CwPAMS toolkit and checklist ([[https://commonwealthpharmacy.org/cwpams-toolkit/](https://commonwealthpharmacy.org/cwpams-toolkit/)]([https://commonwealthpharmacy.org/cwpams-toolkit/](https://commonwealthpharmacy.org/cwpams-toolkit/)), accessed on 1 November 2020). The newly released CPA continuing the professional development platform, which has an antimicrobial module supporting pharmacists in their efforts to reduce AMR by providing educational and networking opportunities for pharmacists. The CwPAMS toolkit brings together resources and shared experiences from the CwPAMS projects within the framework of the Core Elements for AMS. It also aims to signpost published works or provide CwPAMS project resources to support each component of the Core Elements of AMS. The toolkit may be used by healthcare facilities to identify their own AMS priorities and implement a workplan on the local level. While this is a step in the right direction, more is still needed to spread the AMR message further. One of the strengths of this study is that it adds to the body of evidence on the implementation of AMS interventions/programmes, especially within African countries [15; 16; 17; 18; 19; 20; 21; 22; 23]. A recent systematic review that focused on the extent of the implementation of stewardship programmes in Africa identified only thirteen primary studies: five studies from three countries in East Africa (Tanzania, Kenya and Sudan) and one study from Egypt in North Africa, with no studies identified within West Africa, although the region has the greatest number of countries in Africa [15; 16; 17; 18; 19; 20; 21; 22; 23]. The limitation of some of the data presented is that it includes, in some examples, small sample sizes and preliminary data, due to the fact that these are examples of the pharmacy health partnership model. This makes it difficult to draw conclusions from the data presented; however, it provides an illustration of the progress made within the partnerships. The COVID-19 pandemic had substantial impact on most projects, as it has with much improvement work throughout the world at this time. In particular, the rollout and spread of initiatives and data collection were impacted.