News and Opinions  –  2024

Key takeaways from LMIC roundtable on global governance on antibiotic resistance

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2024-07-12

On July 2-3 ReAct held a roundtable discussion titled “Improving the future governance of the global response to antibiotic resistance” in Uppsala at the Dag Hammarskjöld Foundation. The discussion was attended by a selected group of experts and representatives from low- and middle-income countries.

Participants of the round table meeting at Dag Hammarskjöld Foundation.
Participants of the round table meeting at Dag Hammarskjöld Foundation. Photo: Therese Holm, ReAct

The meeting, which ran over 1.5 days brought together participants from eight countries from South Asia, Africa and South America with a broad range of expertise and were a mix of antibiotic resistance experts, civil servants, and representatives from civil society and regional and national technical agencies.

The meeting was supported by the Global Challenges Foundation and follows a decade-long tradition of friendly collaboration between ReAct and the Dag Hammarskjöld Foundation to organise convenings of global experts and central actors to discuss core issues such as the SDGs, mobilising financing, the role of the UN and the strengthening of global governance structures to improve the response to antibiotic resistance.

Identifying core gaps in the current global governance structure

Discussions on the first day focused on the capacity of the current global governance regime consisting of the technical agencies in the quadripartite (WHO, FAO, WOAH, UNEP) and other entities (Global Leaders Group, Multi-stakeholder Partnership Platform, Multi-partner Trust Fund) alongside the existing body of action plans, guidance documents and tools to drive and support global and national efforts to manage antibiotic resistance. These discussions identified a number of shortcomings of the current structure, including:

  • A lack of clarity on “who does what“ in the current global governance regime and how they relate to each other. It was noted that often at national level there is limited understanding of what entities such as the Global leaders Group and the Multi-stakeholder Partnership Platform do, and that ministries and countries do not know how they can work with them.
  • Limited accountability on commitments, priorities and actions/lack of action to manage the problem of bacterial resistance development from Member States, the Quadripartite and other entities such as the Global Leaders Group, the Multi-stakeholder Partnership Platform and the Multi-partner Trust Fund. The fact that no accountability framework has been developed for antibiotic resistance, as is seen in other areas and diseases, like for example TB, was highlighted.
  • Limited political understanding of the causes and impact of the problem and  by extension weak high-level buy-in on the need ta take urgent action. A compounding factor is the lack of national and far more context specific data on how the problem impacts across the various sectors, that may be of particular priority in countries.
  • A consequence of the limited high-level political buy-in is that limited financing is made available – both domestically and internationally – which continues to be a real obstacle for implementing national action plans. Increasing domestic funding is particularly difficult when the issue is not yet seen yet as a political priority. Aside from more country-specific data, suggestions such co-financing (a practice used by the Global Fund), catalytic external funding to initiate national action, and analysis of how increasing debt burdens in many LMICs affect investment capacity and domestic health spending, were discussed.
  • While the Quadripartite’s recent investment case has been useful in generating global numbers on cost of inaction, its application at national level is limited.  There is a need for similar national level and country specific analysis to be done as a next step. It was also noted that better analysis of co-benefits of investments, as well as opportunity costs of choosing to invest in one area over another, would be useful.
  • Currently available international financing is seen as fragmented, siloed and uncoordinated. Funders are uncordinated with many investments often going to the same countries. Simultarneously, it is unclear for many countries where international funding for interventions to tackle antibiotic resistance is available.
  • Lack of systems perspective beyond One Health and inadequate cross-sectoral coordination. Antibiotic resistance stretches beyond the scope and mandates of the Quadripartite agencies, but engagements from the broader UN system and other international organisations remains limited. The Quadripartite (WHO, FAO, UNEP and WOAH) bound in collaboration through an MOU, engages however with different ministries in countries. Limited and complicated cross-sectoral collaboration and coordination is also reflected at regional and national level.

Useful lessons from the field of pandemic prevention, preparedness and response

Pandemics, like antibiotic resistance, are a serious health problem with causes and consequences stretching beyond human health. Both are cross-border and cross-sectoral problems with a One Health nature. By extension both clearly require global, coordinated and collective action to be effectively addressed. However, despite the recent devastating experiences of the Covid-19 pandemic, governments failed just a few weeks ago at the WHO in Geneva, to find enough common ground to conclude a global legally binding agreement to prevent, prepare and respond better to future pandemics within the two-year time frame initially set out for the process.

Against this background the meeting participants assessed what lessons could be learned from that process, as well as the UN High-level meeting process last year to negotiate a political declaration on the pandemic prevention, preparedness and response. Reflections on lessons learned included:

  • Momentum and political buy-in is key to get a process of the ground. Antibiotic resistance as an issue does not enjoy this universal political prioritization yet.
  • Process is important! Widespread political alignment on the need to act risk rushing the process whereby important ground-level steps are skipped. Thorough assessment of the merits of the action, what has previously been done in other forums, to what extent the current frameworks are sufficient (and whether a treaty is necessary) as well as clarity on what specifically a global agreement should achieve, should be answered ahead of negotiations. In other more successful international treaties this has been done by creating a specific commission tasked to assess such questions. If these questions are not, (which they were not for the pandemic accord), lack of clarity about the need and what is actually being negotiated will complicate negotiations down the line.
  • Choice of forum matters! Health ministries and health ministers are often not treated as one of the key ministries in government. For issues such as pandemics which exceeds the mandate of the WHO (and for antibiotic resistance – exceeds the mandates of the Quadripartite) it was discussed whether the UN HQ in New York should have a more central role to coordinate the multi-agency response that is required, as well as what the opportunity costs of such a move would mean for the issue. Tackling the perception at the UN in New York that health issues are somehow less of a priority to address should be addressed, in particular for issues where the problem clearly extends beyond the mandate of the WHO.
  • Think creatively on how to address big cross-sector global issues outside of the mainstream! Towards this end the idea of establishing a high-level council to deal with global health threats above all UN agency structures was discussed. It was also noted that global legally binding agreements do not necessarily need to be negotiated within the UN system. As few as 2 countries, while as many as everyone, can create a treaty.

Will the new political declaration address governance shortcomings?

Given the ongoing negotiations at the UN in New York, the roundtable meeting also  took stock of the latest version of the draft political declaration of the High-level Meeting on AMR and assessed to what extent it is able to address the gaps and needs identified. The proposal to establish the ‘Independent Evidence Panel’, as well as the coordination mechanism for international financing add new elements to the global governance structure. While the evidence panel is currently set for more thorough mandate assessment and setup in 2025, the draft declaration does not however mention a broader assessment of mandate, scope, role, financing and importantly – accountability lines – of the remaining governance regime.

More targets and commitments than 2016

The current version contains 9 targets (measurable in varying degrees) as well as 47 commitments. While it can be seen as a positive development from the 2016 declaration, which defines just 7 commitments (of which hardly any has been delivered on), some issues were identified in these discussions including:

  • the lack of detail on HOW these targets and commitments should be achieved
  • the largely varying degree of ambition set out in the current targets
  • missing provisions to ensure not just stocktaking of progress, but also accountability for actions and lack of actions on the targets and commitments

For example, the draft declaration currently says that progress towards the overarching target of 10% mortality reduction in deaths associated with antibiotic resistance by 2030 (from 2019 levels) should be reported on by the UN Secretary General in 2026. However, how this progress can and should be measured is not spelled out. Unless the GRAM study (from which the 2019 base level comes from) is repeated, it is questionable whether it will be possible to report anything meaningful on this target.

The target to have 95% countries report to TRACCS by 2030 or have 60% of countries commit domestic funds to address antibiotic resistance looks ambitious on paper. However, as of 2023, 91% of countries have already reported into TRACCS meaning that the proposed goal aims to raise the bar by 4 percent points over 6 years.

The 60% goal on funds requires 115 countries to have an earmarked budget for NAP implementation. This target can however be achieved, even if none of the countries in the G77 earmarks any domestic financing. As such the highest burden countries could ignore this target entirely, and globally we would still achieve it if all other countries committed domestic financing. This is likelyno not the intention of the target, but points to the importance the qualitative and regular assessment of progress and accountability at political level for how this target is achieved.

Accountability, accountability, accountability!

Discussions also assessed how to strengthen governance structures by clarifying not only the role of the independent panel, but the mandates, roles, tasks and accountability lines of the whole current governance regime. A system where it is not clear to key stakeholders who does what, is not likely to be efficient. The need for establishing a clearer accountability framework to track progress and feed into a political accountability forum to analyze where the response is falling behind was emphasized.

It was also noted that global financing is hard to achieve even when an issue is well understood. For antibiotic resistance the issue of literacy is not even there. In this context it was noted that not everything can be solved by putting money and that country-level exchange of knowledge, ideas, sharing of best practices is insufficient. Towards this end civil society has a key role to play in informing and supporting governments with contextualized action and analysis. Currently, there is no formal forum available for such knowledge exchange to take place, and there is a sense that the countries with good experience managing the problem, do not share their knowledge widely or systematically. As such the Multi-stakeholder Partnership Platform could be considered for such a role in exchanging ideas going forward.

Assessing the pros and cons of a legally binding treaty to manage antibiotic resistance

This part of the meeting assessed the possibilities and limitations of what can be achieved through soft law and hard law, including when each is appropriate. It was noted that the case for hard law (meaning a multilateral internationally binding agreement on antibiotic resistance) increases when cost of non-compliance to soft law measures becomes too high.

It was also noted that often it is not a case of either or, and that soft law language over time indeed can become hard law, in case a decision to proceed into the multilateral treaty lane is taken. As such the specific language of non-binding political declarations that are not legally binding today, may indeed be very important later.

Global treaties do not come about and as such the creation of a conducive environment is crucial. Core elements of creating such an environments include:

  • increasing public awareness: it is important to get people to talk about the treaty – governments, experts but also increase public debate. “You need to make people care about what you want to legislate on”.
  • Government and civil society collaboration: civil society organizations have expertise on issues, and governments have privilege to forge a treaty and stand against states trying to delay the process. The creation of a like-minded group for example has been an effective  way forward in other treaty processes.
  • Urgency and clarity in policy ask: what do we need and when do we need it? Crisis events are not enough to get a mandate.

The way forward short term and long term

Progressing towards a stronger and more effective governance of the global response to antibiotic resistance, the group discussed priority actions in both the short and long term.

In the long-term, it was suggested to prioritize efforts on establishing a small group of like-minded countries and civil-society actors to champion the issue together. Such a group should build on from those already engaged and have focus on ensuring engagement from a number of LMICs.

It was also suggested to initiate work to ensure antibiotic resistance is more centrally placed within the future development framework that will follow Agenda 2030 to correct the past mistake of not including antibiotic resistance in the SDGs from the outset.

For the more immediate, it was also discussed whether LMIC’s concerns and perspectives are sufficiently reflected in the current declaration text, and whether the final declaration text will have the necessary legitimacy and broad buy-in from countries.

The group coalesced around a couple of priorities in the lead up to the UN High-level Meeting in September, as well as the Fourth Global High-level Ministerial Meeting in Saudi Arabia in November under the heading “From declaration to implementation”. These priorities included focus on improving accountability in the political declaration text to ensure clarification of “who does what” in the current global governance regime and the positioning of novel additions such as the the independent evidence panel and the financing coordination mechanism.

There was a clear sentiment in the discussions that accountability cannot be parked with the Quadripartite agencies alone. Governments are the ones formulating targets and commitments in the political declaration. As such it is also governments that are responsible and accountable for achieving what they set out to achieve.

Following this line of thought there was particular support in the group around a suggestion to see a high-level political forum be established where governments would come together annually or biannually across sectors to assess progress based on available data, and identify areas falling behind in the response.

Such a forum for political accountability could align with deliverables from the independent evidence panel, the UN Secretary-General stocktaking in 2026 and biannual progress reports from the Quadripartite agencies that are set out in the political declaration already. And most importantly – it would send a much-needed signal that managing the growing problem of antibiotic resistance and thereby ensuring sustainable access to effective antibiotics now and in the future for everyone everywhere, is finally a firm political priority that countries are actually willing to be held accountable to.

Partner Global Challenges Foundation

This round-table was arranged in partnership with Global Challenges Foundation. The foundation is dedicated to raising awareness of global catastrophic risks and strengthening global governance to address them. Visit Global Challenges Foundation’s website.

Relevant links:

Previous meetings hosted by ReAct and Dag Hammarskjöld Foundation:

Antimicrobial resistance and sustainable development: A planetary threat but a financing orphan

When the Drugs Don’t Work: Antimicrobial Resistance as a Development Problem

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