News and Opinions  –  2019

ReAct Interview: UNICEF’s new internal technical guidance paper on AMR

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2019-11-12

22 November, UNICEF will launch its very first internal technical guidance paper on antimicrobial resistance. The paper maps existing activities across the organization that have a direct or indirect impact on antimicrobial resistance - and - identifies areas for future work where Unicef has a comparative advantage.

To learn more about the processes in developing the paper and the reasons why this work was initiated, ReAct interviewed two key persons involved in the process: Stefan Peterson, Chief of Health, UNICEF, and Alexandre Costa, HIV/AIDS Specialist, UNICEF.

Portrait of Stefan Swartling Peterson and Alex Costa, both Unicef.
From left: Stefan Swartling Peterson, Chief of Health, UNICEF, and Alexandre Costa, HIV/AIDS Specialist, UNICEF. Photo: Therese Holm, ReAct and Unicef.

• UNICEF is pioneering an approach to galvanize an institutional response to antimicrobial resistance.

• Antimicrobial resistance is a growing global threat which risks the lives of children. Tackling antimicrobial resistance is a priority for UNICEF and their protection of children’s right to quality health care.

• Antimicrobial resistance, as a global threat, cannot be tackled without comprehensive consideration of children’s health and rights.

Why did UNICEF develop this internal guidance paper on AMR?

Stefan:

– Antimicrobial resistance is among the biggest challenges in global health of this generation. We live in a world where children in resource-limited settings are missing out on essential antibiotics needed to save their lives while at the same time antibiotics are overused in high-income countries and food production. A comprehensive approach to tackling antimicrobial resistance must consider children if we are to control the spread and reduce the impact of this global challenge.

– Internally at UNICEF, a few of us had identified antimicrobial resistance as a growing problem with ramifications across several sectors we work on, but we felt that there wasn’t universal recognition of the scale of the problem.

– Our internal guidance paper seeks to identify our current programmes which already address drug-resistant infections, but also explore new opportunities to do more and ensure our programmes are comprehensive enough to tackle the scale of the challenge.

– Further, we want to be clear on the importance of children’s health and rights as part of the AMR response.

Alex:

– Unicef’s mandate is to protect the rights of children, and this is crucial in the global AMR response. Children are particularly vulnerable as their immune systems are not fully developed and are therefore more susceptible to diseases caused by drug-resistant microbes present in their environment and the people, animals and food to which they are exposed.

– The world’s poorest children, who most commonly have the worst access to health services, face an even greater risk, as poor sanitary conditions, poor hygiene practices and inadequate infection control promote the spread of antimicrobial resistance.

– The technical guidance paper reflects UNICEF’s response to this growing threat and identifies activities with direct and indirect impacts on antimicrobial resistance that will guide the work of the organization on antimicrobial resistance.

UNICEF is one of the first UN organizations to develop internal guidance on antimicrobial resistance

The UNICEF internal technical paper on AMR focuses on three priority areas:

  • Reducing the incidence of infection
  • Promoting access to, and optimal use of, antimicrobial agents
  • Increasing awareness and understanding of AMR

To mitigate impact of antimicrobial resistance on child survival, growth and development

Using this framework, each section in the document identifies how different divisions and sections within UNICEF could strengthen ongoing efforts as well as engage in new efforts to mitigate the impact of antimicrobial resistance on child survival, growth and development.

What are the main antimicrobial resistance related areas UNICEF will focus on to help children across the globe?

Alex:

– There are three key areas and challenges identified in the technical guidance paper which UNICEF will focus on to ensure children are protected and prioritized in the AMR response.

Reducing the incidence of infections: A core principle of the AMR response is the prevention of infections whose treatment could involve the inappropriate use of antimicrobials and the potential spread of drug-resistant pathogens. Thus, we must take steps to reduce infections in children by immunizing every child, ensuring proper nutrition, promoting the rational use of drugs, strengthening health systems, and ensuring clean water and sanitation in communities and health facilities – all areas which UNICEF is already delivering on.

Promoting access to, and optimal use of, antimicrobial drugs: Children have the right to access effective, lifesaving medicines to protect them from dangerous infections. In many resource-limited settings, limited access to health services, and therefore antimicrobials, is responsible for more deaths among children than drug-resistant infections. To protect children in the global AMR response, it is necessary to ensure access to antimicrobials for those who need them, at the same time as preventing the excessive use among those who do not need antimicrobials.

Increasing awareness and understanding of antimicrobial resistance: Improving awareness and understanding of the impact of antimicrobial resistance in children through effective communication, education and training will be necessary to catalyze social engagement and positive behavioral change.

– Antimicrobial resistance is a complex and multifaceted problem that requires a coordinated response across sectors. Therefore, it is paramount that relevant stakeholders recognize their responsibility and engage in measures to mitigate the impact of antimicrobial resistance on human, animal and environmental health. This should be done through a coordinated, multi-sectoral and interdisciplinary One Health approach involving governments, international organizations, donor agencies, private sector, academia, professional organizations and civil society.

Need to develop core skills, capacity and competencies

To engage in new efforts and ensure sustainable work on antimicrobial resistance, it will be necessary to strengthen institutional capacities within UNICEF relevant for antimicrobial resistance. Such as:

  • Developing skills and competencies of teams on antimicrobial resistance.
  • Ensuring minimum level of human resource capacity in key country offices.
  • Investing in the implementation of programmes at scale that can lead to improved policy and programming around antimicrobial resistance.

Unicef’s expertise across various sectors and disciplines relevant for antimicrobial resistance will allow the organization to pursue a multi-sectoral response to antimicrobial resistance on a global scale.

What has been the process in developing the UNICEF technical guidance paper on AMR?

Alex:

– The development of the paper was triggered by awareness of the growing impact of antimicrobial resistance on children by a few staff members and was driven by internal champions who understood the urgency of responding to this global crisis.

–  It was an iterative process of both internal advocacy and information gathering involving numerous colleagues across the organization that led to increased internal awareness of antimicrobial resistance and political will across sectors and at different levels of the organization. Some of the key features of the process included:

  • The establishment of an informal AMR Group made up of representatives from different sectors who kindly volunteered their time and expertise to help support this process.
  • An internal mapping exercise to document existing activities, across different sectors, which had indirect and direct impacts on antimicrobial resistance.
  • Face-to-face interviews with section chiefs offered both an opportunity for deepening our understanding of existing activities as well as for internal advocacy on the importance of our work in this area.
  • Development of a discussion paper and presentations of the mapping exercise and proposed recommendations. This was to gather feedback and drive inclusivity and buy-in from an early stage.
  • A series of sensitization webinars and information sessions for staff across the organization. These webinars were used to raise awareness of the current and future importance of AMR for their work, gather feedback to assist in the development of the guidance paper, and ensure broad support from an early stage.

What were the greatest difficulties in producing the paper?

Alex:

– Three things stood out for me through the process; all challenges which we managed to overcome through creative thinking.

– Firstly, there was a misunderstanding that our goal was to establish a new AMR program. Through information sessions and a lot of internal advocacy, we were able to highlight antimicrobial resistance is not a standalone issue but linked to all our work. It is an issue we are already doing a lot of work on, and we took time to explain to people the importance of the issue for their work and the opportunities to do more to have an even bigger impact for children at risk of antimicrobial resistance .

– Secondly, there was limited awareness and understanding of antimicrobial resistance. In the beginning it was hard to get engagement as people did not see why this issue mattered to them in many cases. Through internal, and often opportunistic advocacy activities, we were able to bring antimicrobial resistance into different conversations and processes to show how this was an important issue for many priority areas. We also used external events such as World Antibiotic Awareness Week to showcase to staff the importance of antimicrobial resistance not only to our work at Unicef but also, on a personal level, to their everyday lives.

– Thirdly, as with many new initiatives, staff capacity and resources meant we could not move forward as quickly as we had planned. Everyone has their own priority areas, which are just as important to the world’s children, so it is always a competition for people’s time and focus on a new area. We had to be clever with the resources we had, making best use of everyone’s time, and asking for people to allocate dedicated time to help in this process.

Stefan:

– Prioritization is a challenge in all global organizations. With a growing number of children caught in conflict, increasing climate chaos, and epidemic outbreaks like Ebola, there are a growing list of global challenges.

– The difficulty in working with a topic like antimicrobial resistance, is that it is a multi-sectoral theme, that is not “owned” by anyone or any team and requires a complex response. It’s everyone’s risk and no one’s responsibility.

– We had to stress in many meetings and presentations how antimicrobial resistance is already affecting our work. The work Alex did on ensuring people heard this message loud and clear really helped ensure people begun to prioritize this issue.

How will the paper be used and spread internally?

Alex:

– We are determined this is not another strategy which just sits somewhere and nobody uses. We have extensive dissemination plans – from events at Unicef Head Quarter in New York to engaging webinars for regional and country offices.

– We are developing an online resource hub to deepen staff’s understanding of UNICEF’s response and engagement across the organization, and ensure everyone can access the information they need on antimicrobial resistance.

– We will continue to identify opportunities for internal advocacy such as when strategies are being developed or when colleagues visit UNICEF Head Quarter to ensure everyone understands the key elements of UNICEF’s response.

Did you mainly request feedback internally or did you also involve external actors?

Stefan:

– We are still at quite an early stage in the development of a full UNICEF approach to antimicrobial resistance. The guidance paper is an important first step in analyzing what UNICEF is doing and what we can do better. It has been built on extensive consultation with colleagues around the world in a range of different roles. We worked with a few external partners, including ReAct, but look forward to exploring collaborations with partners as our approach develops.

How do you think the directions from the new guidance paper will be received? Will it make a difference?

Stefan:

– The response has been very positive. One of the benefits of the extensive internal consultation process involved in the development of the guidance paper was the increase in the level of awareness of antimicrobial resistance across the organization. However, as with any new initiative, capacity of staff and programmes will be an important factor in the success of our new approaches and direct results, like in any new health programming response, will take time to document.

– In any case, we are definitely on a path towards greater integration of antimicrobial resistance across many areas of our work and I am confident of the opportunities to expand our work in the coming years.

Alex:

– Our leadership has been very supportive, particularly as the guidance paper shed light on the impact of antimicrobial resistance on our work.

– Across the organization, the response will likely vary according to the level of awareness of antimicrobial resistance and how its impact has already been felt in the work of UNICEF at the regional and national levels.

– In any case, the paper provides a new framework that can be used to analyze existing work using an AMR lens as well as guide future interventions that can have an impact on antimicrobial resistance.

Looking back, what resources do you wish you had before you started this process?

Alex:

– More people to support the work on antimicrobial resistance. As antimicrobial resistance is a cross cutting issue affecting several thematic areas, more time is needed for consultations, analyses, and sensitization activities. More time to build champions, especially at the country and regional levels, would have helped drive buy-in from the start.

Finally, what are some near-term steps that UNICEF could potentially take?

Alex:

– To begin with, we are certainly going to focus on strengthening the work we are already doing which aligns with the AMR response such as: immunization, nutrition and WASH.

– Importantly, we recognize the need to strengthen institutional capacities relevant for antimicrobial resistance. This includes efforts to develop the skills and competencies across many different teams around antimicrobial resistance and ensuring a minimum level of human resource capacity in key country offices.

– As UNICEF has strong advocacy and behavior change teams in many countries around the world, we will actively look for opportunities which can support governments in how best to communicate around antimicrobial resistance to trigger behavior change.

– In the longer term, UNICEF’s Supply Division is one of the largest procurers of drugs (e.g. penicillin) and diagnostics in the development sector and could act to ensure quality of drugs and stabilize markets where there are shortages of essential antibiotics.

– In addition, we need to ensure we, and other UN organizations, are investing appropriately on the implementation of programmes at scale that can lead to improve policy and programming around antimicrobial resistance.

Stefan:

– One of the most important things to come out of development of the guidance note was the realization that children are not mentioned in external policy documents or conversations around antimicrobial resistance. There will therefore be a crucial role for UNICEF to play in external conversations and policy discussions to ensure children are comprehensively considered as part of the AMR response.

– In particular, we must protect the rights of children by ensuring they have access to life-saving antibiotics when they need them while preserving these same drugs for future generations by preventing the unnecessary and excessive use of these drugs among those who do not need them.

– Communication and advocacy are essential next steps for us.

7 key steps for UNICEF Internal work on AMR guidance note

  1. Developed a discussion paper on what UNICEF is already doing on antimicrobial resistance.
  2. Internal advocacy with key stakeholders (at global, regional and country levels) to increase understanding of why antimicrobial resistance matters for UNICEF.
  3. Created an ‘Elevator Pitch’ of why antimicrobial resistance is a priority issue and used it in informal interactions with a wide range of stakeholders, gathering feedback and developing buy-in.
  4. Formal cross-sectoral presentations with key internal stakeholders to raise awareness of the cross-cutting nature of antimicrobial resistance and need for a coordinated response.
  5. Held sensitization and information gathering webinars with regional and country offices to understand levels of understanding and begin to explore future opportunities.
  6. Further consultations to clarify UNICEF’s internal recommendations and ways forward led to formalization of the discussion paper into a technical guidance note.
  7. Dissemination through various internal channels supported by an internal antimicrobial resistance site.

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