News and Opinions  –  2018

Antibiotic Resistance Coalition, including ReAct, responds to the second round of IACG discussion papers

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The Antibiotic Resistance Coalition (ARC) has again convened to review the second round of papers released by the UN Interagency Coordination Group on Antimicrobial Resistance (IACG). Earlier we shared the key takeaways from the responses on the first set of discussion papers, and here we summarize the main messages of the ARC responses to the second set of three papers.

The main takeaways from the ARC responses are that future governance of AMR needs to stick to the key principles for any governance process, including transparency, safeguarding against conflict of interest, and fairness of representation. In optimizing the use of antibiotics, both issues of underuse and overuse must be addressed. Monitoring for effective stewardship, but not for access to life-saving antibiotics would set back antimicrobial stewardship efforts. Finally, ARC emphasized the important role of civil society in communicating for AMR and driving collecting action. Civil society should be empowered to take on a bigger role.

The last three discussion papers from IACG, open for public consultation.

The second set of discussion papers were on:

4. Future global governance for antimicrobial resistance
5. Reduce unintentional exposure and the need for antimicrobials, and optimize their use.
6. Meeting the challenge of antimicrobial resistance: from communication to collective action.

About fifteen ARC members endorsed one or more of these joint submissions.

Consolidated comments publicly available

Responses from other stakeholders came from the Member States, CSOs, NGOs and other organisations, private actors including industry and individuals. IACG has made all the incoming comments on the papers publicly available. Fewer Member States and organisations responded to this second round of discussion papers compared to the first round. The lack of engagement from Member States is of particular concern in the view of the discussions on future global governance. The incoming responses are mainly from high-income countries and those that are already leading the discussion. There is a critical under-representation and lack of engagement by low- and middle-income countries in these discussions. The process towards agreeing on future governance mechanisms would benefit from a richer debate with different perspectives on the needs and functions for governance.

Future global governance

ReAct and other ARC Members believe that discussions on governance need to emerge from a bottom-up, needs-based analysis to catalyse change rather than being a mere top-down exercise. Whether the process is steered towards a treaty or not, it should not distract or detract from the pace of ongoing efforts to resolve the shortfalls in support of building measures to address AMR. In defining the future governance, the proposals put forward by IACG so far devotes too much attention to structures and too little attention to their functions. IACG should consider the potential functions for global governance first and the strategic levers required for effecting such change second. For example, it is unclear how the proposed governance structure would address the identified barriers to addressing AMR globally, such as gaps in data, misaligned incentives, or variations in national capacity. ARC supports the broadening of governance beyond the Tripartite agencies. It should not remain the province of just the technical agencies steeped in One Health issues. The response stresses the importance of hearing the voices from low- and middle-income countries (LMICs). LMIC and civil society representation should be enlisted more prominently in shaping the model for future AMR global governance. It is unclear how the by IACG proposed governance structure would address the needs and barriers identified in the background paper. The future governance system of AMR needs to stick to the key principles for any governance process, including transparency, safeguards against conflict of interest, prevention of regulatory capture, and fairness of representation. We noted that policy coherence should be ensured across UN and intergovernmental agencies by aligning the normative guidance and efforts of these groups. To address policy incoherence, the global governance approach should be needs-based and Member State driven, rather than fragmented across multiple intergovernmental agencies responding to different ministries. Finally, an effective governance will not happen unless a strong system to monitor for accountability is in place.

Optimize use

On optimize use, we encourage a deeper analysis of the gaps and the opportunities going forward. There are opportunities for stronger cooperation and synergy across sectors and more integrated cross-sectoral approaches to addressing AMR, which would result in greater policy coherence and success. We believe that mainstreaming AMR into the Sustainable Development Goals and current development work is essential. We also support the IACG in taking a tiered approach to stewardship, as country-level action on stewardship should be related to the level of resource in the specific setting. Data collection and sharing on antibiotic use in both human and animal sectors are the foundation for ensuring effective monitoring of progress toward meeting targets, and holding stakeholders accountable. We emphasise that antimicrobial stewardship in healthcare delivery should be seen broadly and include efforts to optimize antibiotic use and prevention and control of human infection. In humans healthcare, both underuse and overuse must be addressed as the lack of access still leads to a higher mortality than excess use does. Monitoring for effective stewardship without drawing attention to the lack of access to life-saving antibiotics would set back antimicrobial stewardship efforts. On the animal use side, the ARC response highlights the need to promote sustainable food production to meet the SDG goal of food security, pointing out that the intensification of industrial farming models which rely on antimicrobial use would continue to drive AMR. The IACG discussion paper did not adequately address key approaches to tackling antibiotic overuse in animals. For example, small-scale farmers should be supported in making the transition to a more sustainable food production approach. Antimicrobial contamination of the environment occurs across the value chain, yet attention to the environmental component is still lacking in the IACG and Tripartite. We therefore propose that UNEP be more involved. Antimicrobial contamination of the environment occurs across the value chain. Targets and standards must be set for all contributors, notably not just pharmaceutical production plants, but also farms, sewage treatment plants and hospitals.

From communication to collective action

For the ‘From communication to collective action’ discussion paper, the ARC response emphasizes the role of civil society as a key partner both in leading communication efforts for AMR and in monitoring their progress. We also point to the importance of securing commitments from Member States and UN agencies to ensure adequate technical and financial resources for awareness, communication, behaviour change and related actions. Sufficient resources are essential to give rise to global social change to tackle AMR. We believe there is value in looking at prior initiatives for different forms of communication – including public health campaigns across developed and developing countries – to learn lessons for the field of AMR. As AMR resonates across sectors and issues like universal health access, WASH, nutrition and sustainable agriculture, supporting its integration more horizontally into existing campaigns could foster more effective communication with limited resources. Setting an effective strategy and priorities for communication and collective action can be aided by the development of global and regional research agendas. ARC and its members see an important role for civil society in communicating AMR, driving collecting action, and leading monitoring for accountability. Civil society can be part of identifying appropriate incentives, implementing strategic interventions, and measuring efforts to build awareness among the public and other key groups to change practice. Therefore, civil society need to be empowered to take on a bigger role. Monitoring for accountability will be an important aspect of effective AMR change. We stressed that the IACG should recommend that AMR is both on the human as the animal side integrated into the SDGs both on the human and the animal side through specific targets and indicators aligned with the goals and targets outlined in the global action plan.