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Governing antimicrobial resistance: a narrative review of global governance mechanisms.

ABSTRACT: Antimicrobial resistance (AMR), a central health challenge of the twenty first century, poses substantial population health risks, with deaths currently estimated to be around 700,000 per year globally. The international community has signaled its commitment to exploring and implementing effective policy responses to AMR, with a Global Action Plan on AMR approved by the World Health Assembly in 2015. Major governance challenges could thwart collective efforts to address AMR, along with limited knowledge about how to design effective global governance mechanisms. To identify common ground for more coordinated global actions we conducted a narrative review to map dominant ideas and academic debates about AMR governance. We found two categories of global governance mechanisms: binding and non-binding and discuss advantages and drawbacks of each. We suggest that a combination of non-binding and binding governance mechanisms supported by leading antimicrobial use countries and important AMR stakeholders, and informed by One Health principles, may be best suited to tackle AMR.

SUBMITTER: Ruckert A

PROVIDER: S-EPMC7479750 | biostudies-literature | 2020 Sep

REPOSITORIES: biostudies-literature

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Governing antimicrobial resistance: a narrative review of global governance mechanisms.

Ruckert Arne A Ruckert Arne A Fafard Patrick P Hindmarch Suzanne S Morris Andrew A Packer Corinne C Patrick David D Weese Scott S Wilson Kumanan K Wong Alex A Labonté Ronald R

Journal of public health policy 20201201 4

Antimicrobial resistance (AMR), a central health challenge of the twenty first century, poses substantial population health risks, with deaths currently estimated to be around 700,000 per year globally. The international community has signaled its commitment to exploring and implementing effective policy responses to AMR, with a Global Action Plan on AMR approved by the World Health Assembly in 2015. Major governance challenges could thwart collective efforts to address AMR, along with limited k ...[more]

PMID: 32908184

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Project description:BACKGROUND:Antimicrobial resistance (AMR) is a growing problem worldwide in need of global coordinated action. With the endorsement of the Global Action Plan (GAP) on AMR in 2015, the 194 member states of the World Health Organization committed to integrating the five objectives and corresponding actions of the GAP into national action plans (NAPs) on AMR. The article analyzes patterns of alignment between existing NAPs and the GAP, bringing to the fore new methodologies for exploring the relationship between globally driven health policies and activities at the national level, taking income, geography and governance factors into account. METHODS:The article investigates the global governance of AMR. Concretely, two proxies are devised to measure vertical and horizontal alignment between the GAP and existing NAPs: (i) a syntactic indicator measuring the degree of verbatim overlap between the GAP and the NAPs; and (ii) a content indicator measuring the extent to which the objectives and corresponding actions outlined in the GAP are addressed in the NAPs. Vertical alignment is measured by the extent to which each NAP overlaps with the GAP. Horizontal alignment is explored by measuring the degree to which NAPs overlap with other NAPs across regions and income groups. In addition, NAP implementation is explored using the Global Database for Antimicrobial Resistance Country Self-Assessment. FINDINGS:We find strong evidence of vertical alignment, particularly among low-income countries and lower-middle-income countries but weaker evidence of horizontal alignment within regions. In general, we find the NAPs in our sample to be mostly aligned with the GAP's five overarching objectives while only moderately aligned with the recommended corresponding actions. Furthermore, we see several cases of what can be termed 'isomorphic mimicry', characterized by strong alignment in the policies outlined but much lower levels of alignment in terms of actual implemented policies. CONCLUSION:To strengthen the alignment of national AMR policies, we recommend global governance initiatives based on individualized responsibilities some of which should be legally binding. Our study provides limited evidence of horizontal alignment within regions, which implies that regional governance institutions (e.g., WHO regional offices) should primarily act as mediators between global and local demands to strengthen a global governance regime that minimizes policy fragmentation and mimicry behavior across member states.

Project description:All infections are potentially curable as long as the etiological agents are susceptible to antimicrobials. The increased rate at which antimicrobials are becoming ineffective is a global health risk of increasing concern that threatens withdrawal of beneficial antimicrobials for disease control. The increased demand for food of animal origin, in particular eggs, meat and milk has led to intensification and commercial production systems where excessive use and misuse of antimicrobials may prevail. Antimicrobials, handled and used by farmers and animal attendants with no formal education, may be predisposed to incorrect dosages, misuse, incorrect applications and non-adherence to withdrawal periods. This study was conducted to assess the regulatory roles and governance of antimicrobials, establish the pattern and extent of their use, evaluate the antimicrobial residues and resistance in the food animals and crop agriculture value chains, and relate these findings to existing strategies in place for combating the emergence of antimicrobial resistance in Tanzania. A multimethod approach (desk review, field study and interviews) was used. Relevant establishments were also visited. High levels of resistance to penicillin G, chloramphenicol, streptomycin and oxytetracycline have been reported, especially for Actinobacter pyogenes, Staphylococcus hyicus, Staphylococcus intermedius and Staphylococcus aureus from dairy cattle with mastitis and in humans. Similar trends were found in poultry where eggs and meat are contaminated with Escherichia coli strains resistant to amoxicillin + clavulanate, sulphamethoxazole and neomycin. An increasing trend of emerging multidrug resistant E. coli, Klebsiella pneumoniae, Staphylococcus aureus and Salmonella was also found in food animals. An increase in methicillin resistant Staphlococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL) in the livestock sector in Tanzania have been reported. The pathogens isolated in animals were resistant to ampicillin, augmentin, gentamicin, co-trimoxazole, tetracycline, amoxicillin, streptomycin, nalidixic acid, azithromycin, chloramphenicol, tylosin, erythromycin, cefuroxime, norfloxacin and ciprofloxacin. An increased usage of antimicrobials for prophylaxis, and therapeutics against pathogens and for growth promotion in livestock, aquaculture and crop production were observed. A One Health strategic approach is advocated to combat antimicrobial resistance (AMR) in the food and agriculture sectors in Tanzania. Practical recommendations include (a) legislation review and implementation; (b) antimicrobial use (AMU), AMR and antimicrobial residue (AR) awareness and advocacy among stakeholders along the value chain; (c) strengthening of surveillance and monitoring programs for AMU, AMR and AR; (d) enhanced development and use of rapid and innovative diagnostic tests and the promotion of biosecurity principles; and (e) good husbandry practices. The utilization of this information to improve public health policies and reduce the burden of AMR will be beneficial.

Project description:ObjectivesTo determine how important governmental, social, and economic factors are in driving antibiotic resistance compared to the factors usually considered the main driving factors-antibiotic usage and levels of economic development.DesignA retrospective multivariate analysis of the variation of antibiotic resistance in Europe in terms of human antibiotic usage, private health care expenditure, tertiary education, the level of economic advancement (per capita GDP), and quality of governance (corruption). The model was estimated using a panel data set involving 7 common human bloodstream isolates and covering 28 European countries for the period 1998-2010.ResultsOnly 28% of the total variation in antibiotic resistance among countries is attributable to variation in antibiotic usage. If time effects are included the explanatory power increases to 33%. However when the control of corruption indicator is included as an additional variable, 63% of the total variation in antibiotic resistance is now explained by the regression. The complete multivariate regression only accomplishes an additional 7% in terms of goodness of fit, indicating that corruption is the main socioeconomic factor that explains antibiotic resistance. The income level of a country appeared to have no effect on resistance rates in the multivariate analysis. The estimated impact of corruption was statistically significant (p< 0.01). The coefficient indicates that an improvement of one unit in the corruption indicator is associated with a reduction in antibiotic resistance by approximately 0.7 units. The estimated coefficient of private health expenditure showed that one unit reduction is associated with a 0.2 unit decrease in antibiotic resistance.ConclusionsThese findings support the hypothesis that poor governance and corruption contributes to levels of antibiotic resistance and correlate better than antibiotic usage volumes with resistance rates. We conclude that addressing corruption and improving governance will lead to a reduction in antibiotic resistance.

Project description:ObjectivesDespite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR.DesignSemistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach.SettingTwo metropolitan tertiary-referral hospitals in Australia.ParticipantsTwenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented.ResultsThematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of 'political' priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem 'solving' rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis.ConclusionThere are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.

Dataset Information

Governing antimicrobial resistance: a narrative review of global governance mechanisms.

Publications

Governing antimicrobial resistance: a narrative review of global governance mechanisms.

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