A recently published Antibiotic Resistance Coalition Policy briefing finds World Health Organization Global Action Plan (WHO GAP) on Antimicrobial Resistance (AMR) at crossroads and calls for attention to Comprehensive Review. This briefing is released at a pivotal moment for the WHO to take stock of its progress on the Global Action Plan on AMR. In addition, the many National Action Plans on AMR must be properly financed, but this remains challenging during the global pandemic which has become the forefront of health policy decision-making. Considering this, the briefing identifies eight pillars of action that should be taken to comprehensively address the global solutions to antimicrobial resistance.
Growing out of discussions with the Antibiotic Resistance Coalition, the Antibiotic Resistance Coalition recently published a new briefing “The Global Action Plan on Antimicrobial Resistance at a Crossroads: Insights from the WHO’s Comprehensive Review” that seeks to build on the momentum from the WHO’s Comprehensive Review of the Global Action Plan on AMR (Sep 2021). This briefing is released at a pivotal moment for the World Health Organization to take stock of its progress on the Global Action Plan on Antimicrobial Resistance. In the Tripartite AMR Country Self-Assessment Survey (TrACSS), just 1 in 5 countries had identified any funding for their National Action Plans for Antimicrobial Resistance, and less than half had a budgeted operational plan. These National Action Plans must be properly financed, but this remains challenging during the global pandemic which has become the forefront of health policy decision-making. Considering this, the briefing identifies eight pillars of action that should be taken to comprehensively address the global solutions to AMR.
1. Global Governance Challenges
The global AMR governance structure (primarily the Tripartite—WHO, FAO, OIE) largely neglects other international and UN agencies. While the Interagency Coordination Group (IACG) on AMR recommended the creation of both a One Health Global Leadership Group (GLG) on AMR and Independent Panel on Evidence for Action against AMR, the Comprehensive Review found that the progress on putting into place AMR global governance structures remains slow, with the Independent Panel and Multi-Stakeholder Partnership Platform yet to be operationalized. While the creation of the GLG and the recent addition of UNEP to create the Quadripartite were welcome steps, the AMR governance structure has still not come together in a way that engages the breadth of international agencies that must be enlisted, mobilizes financing required for carrying out its work, nor ensures the necessary accountability to deliver on the Global Action Plan on AMR.
2. Access versus excess in healthcare
Although drug-resistant infections are responsible for an estimated 1,27 million deaths annually, the toll from lack of access to effective antimicrobials for treatable infections exceeds 5.7 million. The Comprehensive Review highlighted civil society concerns that WHO’s division of AMR might play a greater role in advancing antimicrobial access; indeed, missed opportunities include the shortage of liposomal amphotericin-B and the lack of access to benzathine penicillin, the latter of which imperils over 40 million people in need for prophylaxis for rheumatic heart disease.
As the Antibiotic Resistance Coalition has noted, only by addressing access and not just excess use of antimicrobials will there be confidence that the Global Action Plan on AMR is meant to benefit those around the world, including those in low- and middle-income countries.
3. Need for One Health Approach
While the One Health approach taken by the Tripartite has largely focused on human and animal health, according to the Comprehensive Review, concerns have been raised that this approach “excludes important areas, such as plant health, food production, food safety, and the environment.” In fact, in the most recent OIE survey on antimicrobial use in food animals, over a quarter of those responding to the survey (42 out of 160 reporting countries) reported that the use of antimicrobials for growth promotion in food animals was still legally allowed.
The Quadripartite must collaborate to curb antibiotic use, not just in human healthcare delivery, but also in both the environment and food systems.
4. WHO Collaboration with Partners
While antimicrobial resistance requires coordinated efforts, the Comprehensive Review noted that “The important roles of other multi-laterals and UN agencies in responding to AMR are largely overlooked in the GAP AMR and in progress reports… Similarly, there is little systematic progress reporting of the contribution of other sectors including civil society and the private sector.” The proposed structure and governance for a Multi-Stakeholder Partnership, for example, requires consensus to act and makes the private sector—whose financial interests may be at stake—a part of every consensus in the Platform.
A coordinated approach must enlist international agencies and foster meaningful engagement of civil society organizations to strengthen the One Health response to antimicrobial resistance.
5. Beyond the Industry Roadmap to Innovation
The Comprehensive Review highlighted the invaluable role civil society provides in ensuring transparency of governance and monitoring, as well as raising concerns over industry influences on AMR governance. While there have been some positive progress in the area of innovation, such as the development of the AWaRe classification as part of WHO’s Essential Medicines list, initiatives such as the SECURE proposal to expand sustainable access to antimicrobials need to be augmented to ensure that an end-to-end approach is devised to ensure sustainable access not only to newer antimicrobial products, but also to older agents that have limited availability or that suffer from frequent supply chain failures. And most efforts have focused on developing newer antimicrobials, rather than addressing the unmet needs for diagnostics and vaccines, which would reduce the selective pressure on using these drugs.
6. Monitoring for Accountability
In conducting the Comprehensive Review, the evaluation team noted the difficulties in assessing overall progress towards outcomes, as these are not clearly defined. While the need to track progress is recognized, WHO’s failure to track systematically the outcome indicators outlined in the Tripartite Monitoring and Evaluating Framework compound such challenges, and this framework has yet to be operationalized with routine and transparent release of indicator data that could help measure progress against milestones.
For example, among indicators to measure progress towards Sustainable Development Goals (SDGs), there is only one AMR-specific indicator focusing on stewardship. As the Antibiotic Resistance Coalition has previous called for, another AMR-specific indicator to track access to antimicrobials should be included, modifying the methodology of another existing SDG indicator already being tracked.
7. AMR Financing and National Action Plans
With several of the GAP AMR objectives hamstrung by a relative lack of financial and human resources needed to implement and monitor related activities, the Comprehensive Review highlighted how increased awareness of AMR globally has not translated necessarily to increased financial resources. And even though the HWO recently launched a costing and budgeting tool for National Action Plans on AMR, there remains limited information collected to enable tracking such efforts at the country level and the Review notes that “relatively little has been done” by WHO to make the economic case of investment. The Multi-Partner Trust Fund has remained poorly funded, with just under $20 million out of the initial call for $70 million being mobilized.
If we are to make progress on antimicrobial resistance, renewing National Action Plans must come with adequate financing or support.
8. Pandemic Preparedness & Prevention & AMR
The global impact of the COVID-19 pandemic provides several lessons and opportunities from which efforts to address AMR might benefit. For example, the pandemic has reset the pace at which diagnostics, therapeutics, and vaccines are brought to market while also highlighting the importance of being able to scale up diagnostic testing at the point-of-care and using affordable technologies to contain the spread of a pathogen. Negotiations on a pandemic treaty should incorporate effective measures on antimicrobial stewardship, equity and access. There must be sustained advocacy to ensure that AMR is considered as one of the facets of pandemic prevention and control, given the substantial overlap and synergies in the efforts.
The findings of the Comprehensive Review of the WHO GAP on AMR provide a timely account of where WHO has made gains and where it has fallen short on meeting the expectations and implementing the Global Action Plan on AMR. With the COVID-19 pandemic providing an unprecedented opportunity to find synergy and support for emerging diseases, including drug-resistant infections, it is time that awareness is matched by action, that adopting the Global Action Plan on AMR and National Action Plans come with financing, and that progress is met by accountability to measurable milestones.
Launched in May of 2014 at the World Health Assembly, the Antibiotic Resistance Coalition (ARC) is comprised of more than 25 leading civil society organizational members. The policy briefing on “The Global Action Plan on Antimicrobial Resistance at a Crossroads: Insights from the WHO’s Comprehensive Review” was prepared by the ReAct Strategic Policy Program, which serves as the Secretariat of the Antibiotic Resistance Coalition.
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