Allocation of adequate resources and community engagement key to NAP implementation
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In 2015 recognizing the growing problem of antimicrobial resistance the World Health Organization endorsed a Global Action Plan on AMR. The five objectives that the Global Action Plan aimed for were improving awareness and understanding of antimicrobial resistance, strengthening surveillance and research, reducing the incidence of infection, optimizing the use of antimicrobial medicines in human and animal health and ensuring sustainable investment in new medicines, diagnostic tools, vaccines, and other interventions. How far along are we?
Still a long way to go. Photo: Shutterstock.
The World Health Organization (WHO) urged member states to develop their own context-specific national action plans (NAPs) and as of July 2021, 145 countries had developed National Action Plans on Antimicrobial Resistance (AMR) and an additional 41 are in the process of developing one (1).
Review of progress on NAP implementation
However, over five years after these National Action Plans were initiated, there is need for systematic review of their strategy, quality of implementation and overall impact on the problem of antimicrobial resistance. This has to be done with a view to figure out what exactly are the political, technical, infrastructural or resource-related obstacles, at both national and global levels that prevent the National Action Plans from being more effective in achieving their objectives.
The Comprehensive Review identifies critical weaknesses not only in implementation of the WHO Global Action Plan on AMR, but also in the efforts to monitor and track its activities. The lack of:
a detailed work plan,
need for greater coordination with international and national partners,
lack of coordination across these structures, and
lack of progress in mobilizing financial resources
have impeded the implementation globally.
It concluded that the greatest improvements were seen in focusing on One Health arrangements and preparing National Action Plan, but the least progress was made on infection prevention and control in human health and optimizing antimicrobial usage in animal health – key pillars for One Health action and country-level National Action Plans on AMR.
ReAct briefing note showing 8 cross-cutting issues slowing down GAP AMR agenda
ARC identified 8 pillars of action to address global solutions to AMR. Photo: Tarang Dave, Unsplash.
A briefing note prepared subsequently by ReAct on the WHO’s review of GAP AMR brought together eight cross-cutting issues that have slowed progress on the GAP AMR agenda across all five strategic objectives.
The first of these was the global governance challenge, with the note pointing out that the current AMR Governance structure worldwide needs to be revised as it does not engage the breadth of international agencies that must be enlisted, mobilize financing required for carrying out its work, nor ensure the necessary accountability.
The second issue was the access vs excess problem in healthcare. According to the ReAct note, 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 all peoples, including those in low- and middle-income countries.
The ReAct briefing note also called for a coordinated approach enlisting international agencies and with meaningful engagement of civil society organizations to strengthen the One Health response to antimicrobial resistance. Other issues highlighted by the note included the pathway to innovation, monitoring for accountability, financing of National Action Plans and need for pandemic preparedness and prevention of antimicrobial resistance.
Adequate resources needed to address NAP implementation challenges
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. It also observed the lack of clarity on how these governance structures would fit together or work in connection with existing structures. The review highlighted concerns over the mobilization of resources needed to sustain the global antimicrobial resistance efforts, noting how the Global Leaders Group on AMR (GLG on AMR) had fallen short of respondent expectations in identifying such financing. One opportunity for moving the issue of resource mobilization forward may be the High level ministerial conference on AMR planned for 24-25 November 2022 in Muscat.
As a caveat it must be mentioned here though that five or six years is not a very long time in dealing with the multifaceted and planetary nature of the AMR problem, which is driven by a very complex set of factors. These include the high burden of infectious diseases in many low- and-middle income countries, as well as::
poor access to quality health facilities
lack of health professionals and
even absence of basic infrastructure related to safe drinking water or sanitation.
In other words, overall paucity of human and financial resources – both historically and currently – seem to be a key barrier to the speedy implementation of National Action Plans.
Human and financial resources major challenges
For example, data from the Tripartite AMR country self-assessment survey (TrACSS) carried out by the WHO and the United Nations Food and Agriculture Organization (FAO), in 2021 suggests that only 20% of the countries are actively monitoring their implementation and have allocated funding (2, 3) for their National Action Plans. While 86% of the 163 responding countries had developed multi-sectoral AMR national action plans, only 50% of countries have a functional mechanism to help prioritize, cost, implement and monitor these plans.
Mirfin Mpundu, Director, ReAct Africa.
“In Africa there hasn’t been political commitment that has translated into funding of these National Action Plans. And, because they are not funded, there has not been any implementation of these plans, most of these plans just gather dust.”
Dr Mirfin Mpundu, Director ReAct Africa
According to Mirfin Mpundu, Director ReAct Africa, most low-and middle-income countries in Africa, were supported financially to develop their National Action Plans on AMR showing the importance of funding for implementation. Despite this, the ministries of finance, who are key to funding, are often left out of discussions leading to a lack of support from them. According to Dr. Mpundu, politicians often appear for launching ceremonies of AMR NAPs, but this does not translate into allocating resources and for National Action Plan activities in national budgets.
As a result, while governance structures have been set up for National Action Plan implementation in many low-and middle-income countries they do not function optimally as their staff have other primary obligations and responsibilities with AMR activity just another added responsibility. They lack resources like information systems, office equipment and staff to support them, limiting their optimal function. Inter-ministerial meetings, intended to strengthen coordination among line ministries do not occur, this often leads to only one ministry taking on the implementation of activities. In many low resource settings around the world there is also a lack of surveillance data to inform decision-making and interventions as well as poor infrastructure and a lack of funding for activities.
In December 2018, ReAct and the Dag Hammarskjöld Foundation hosted a meeting in Uppsala, Sweden, inviting around 20 experts in the field of antimicrobial resistance and global health, to discuss funding for the global crisis of antimicrobial resistance. They identified six principles for antimicrobial resistance financing:
Pay now or have to pay much more later.
The form of funding mechanisms to follow the allocation of functions.
Harnessing existing funds to become more AMR-oriented.
Global financing channels to be visible and accessible to countries.
A systems approach and the promotion of sustainability.
Promote long-term sustainability.
According to another discussion paper on National Action Plans, prepared by the International Coordination Group on Antimicrobial Resistance (IACG), in the long term, mainstreaming antimicrobial resistance means that governments will have to resource implementation of their National Action Plans, building it into national and local budgets and planning cycles to ensure sustainability. Putting resources into stopping antimicrobial resistance now is one of the highest-yield investments countries can make it says.
How should urgently needed work on antimicrobial resistance be funded?
Short overview of international funding calls for AMR
UNGA Political Declaration on AMR 2016: countries noted that funding should be made available “to support the development and implementation of national action plans, including surveillance and monitoring, the strengthening of health systems and research and regulatory capacity”.
IACG recommendations 2019: calls on governments; global, regional, national, bilateral and multilateral financing and development institutions and banks; and private investors to systematically apply standards all stakeholders need to systematically assess risks and impacts related to AMR when making investments.
2015-21 G7 & G20: a number of declarations mentioning AMR – little on financing. G7 2021Finance ministers declaration makes a reference to AMR but only as it relates to establishing new models for R&D financing.
2021 Call to Action on AMR commits signatories to work towards funding for AMR specific and AMR sensitive actions across One Health, incl. as part of COVID-19 recovery plans and achieving UHC, as well as integration of AMR into UN Financing for Development Agendas.
A health systems approach is critical
Beyond the issue of mobilizing resources there is also the need to take a whole of society approach to tackling antimicrobial resistance, given the deeply interconnected nature of the problem – spanning everything from water, sanitation and hygiene infrastructure to good access to healthcare as well as effective regulation and behavior change. In an article published online in The Lancet Global Health June 15, 2021, authors from the senior leadership of ReAct have argued that a health system approach nationally and globally is critical to mitigate the devastating consequences of antibiotic resistance.
According to them the COVID-19 pandemic has highlighted the need for resilient health systems and resulted in an unprecedented rate of collaboration in scientific, medical, social, and political dimensions. Antibiotic resistance also requires a similar response in terms of adequate investments, international collaboration, and collective action.
Principles to strengthen global governance
Such a health systems response will require strengthening mechanisms for effective governance of AMR programs and interventions also at global level. According to an analysis by ReAct the global governance mechanism should operate on the basis of the following principles:
provide leadership,
advocate for political will,
promote social and resource mobilization, and
address the challenging barriers for innovation of needed technologies such as new treatments, diagnostics and vaccines
Implementing these principles in practice will require countries to show much greater individual and collective commitment for action through both appropriate investments and multi-sectoral teamwork.
Global functions – implementation of a national action plan
Figure: Four key pillars in the implementation of a national action plan on antimicrobial resistance, supported by global functions. Infographic adopted from Lancet Global Health. Click infographic for larger version.
One Health and communities
On the positive side so far, the process of drafting and adoption of National Action Plans has made more and more countries aware of the need to adopt the One Health principle, recognizing that antimicrobial resistance affects human, animal, plant, and environmental health and the impacts on each sector spills over into the others too. This has resulted in greater coordination of efforts across ministries and government agencies and a more holistic and trans-disciplinary approach.
At the global level too, the recognition of the importance of One Health has brought together the Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO) and the World Organization for Animal Health (OIE) and very recently the United Nation Environment Programme (UNEP) into a ‘Quadripartite’ of agencies working together to tackle antimicrobial resistance in all its aspects.
Yet another positive development has been the realization that National Action Plans can be quite unwieldy, especially in countries with large and diverse populations as well as complex food and agricultural systems. This has led to efforts to break down the National Action Plans into smaller components and mobilize state and non-state stakeholders at the sub-regional level to take local contexts into account.
Colloquium on State Action Plans on #AMR in India, hosted b ReAct Asia Pacific, in association with World Animal Protection India and WHO Country Office for India. Discussing strategies to advance the AMR-agenda, by engaging states and lessons learned from Covid-19. Photo: ReAct Asia Pacific.
In India for example, ReAct Asia Pacific has been helping provincial governments to develop State Action Plans for Containment of Antimicrobial Resistance (SAPCAR) to effectively contain the AMR problem at the ground level. In a communique issued on 14 March 2022 representatives from the Government of India, state governments, academia, animal welfare groups, civil society organizations, United Nations agencies, and research institutions called for more and more states in the Indian federal system to adopt action plans on AMR, both in parallel and in coordination with national efforts. The communique also called for development of strategy to involve local self-government institutions and other community groups in initiatives to contain the AMR issue.
The engagement of communities in particular is likely to be very strategic to implementing NAPs as often a lot of use and misuse of antibiotics happens at the local levels in many LMICs where national governments have very poor data on or understanding of the context. ReAct Asia Pacific’s Antibiotic Smart Communities’ project, ongoing since 2018, has developed a set of indicators to analyze the local context from an AMR-lens and also to help measure the progress of National Action Plan implementation.
The engagement of communities in particular is likely to be very strategic to implementing National Action Plans as often a lot of use and misuse of antibiotics happens at the local levels in many low-and middle-income countries where national governments have very poor data on or understanding of the context. ReAct Asia Pacific’s “Antibiotic Smart Communities” project, ongoing since 2018, has developed a set of indicators to analyze the local context from an AMR lens and also to help measure the progress of National Action Plan implementation.
Role of communities
ReAct Latin America too has emphasized the role of communities in helping tackle antimicrobial resistance and is working on developing “Community Action Plans” to take National Action Plan implementation to an even more microlevel.
“The foundations for the development and implementation of action plans against AMR require a robust conception of the ‘One Health’ approach along with effective participation of local governments and communities”
The Community Action Plans that ReAct Latin America is currently working on are meant to take the strategic objectives of Global Action Plan and National Action Plans
> adapt them to the social and environmental reality of each community
> and allow communities to take the problem and the solutions into their own hands.
National Action Plans in the ReAct Toolbox
The ReAct Toolbox online resource provides tools and information to support countries in their implementation of AMR interventions.
Sections focusing on National Action Plans in the Toolbox:
National action plans gives an overview of the importance of coordinated national action and some potential challenges in the process.
Develop a national action plan provides a step-wise guide for planning, implementing and evaluating a national action plan on antibiotic resistance.
Implement a plan presents possible components to include in an action plan framework, and resources/tools to help implement these components.
ICARS, ReAct and the Toolbox to help implement National Action Plans
Many countries would benefit from further instruments that can support them in developing situational analyses – that are prioritizing needed actions within the existing settings and prerequisites. To address the gap, ReAct collaborates with ICARS to develop and disseminate applied implementation tools and guidance that are context-specific, including a tool for developing a comprehensive country analysis. This project will focus on the African context, specifically the sub-Saharan African countries, and is intended to support their NAP implementation, and will build on tools available in for example the ReAct Toolbox.
Antimicrobial resistance impact the Sustainable Development Goals
Why is antibiotic resistance a sustainable development problem?
All these new and innovative approaches will have to be evaluated for their true impact on implementation of National Action Plan – and adopted widely if found successful. Failure to implement National Action Plans effectively would mean threatening the achievement of the 2030 Agenda, as most Sustainable Development Goals (SDGs) are impacted directly or indirectly by antimicrobial resistance.
The report shows how antibiotic resistance is a global development problem by highlighting existing data and people’s experiences.
All these new and innovative approaches will have to be evaluated for their true impact on NAP implementation and adopted widely if found successful. Failure to implement National Action Plans effectively would mean threatening the achievement of the 2030 Agenda, as most Sustainable Development Goals (SDGs) are impacted directly or indirectly by antimicrobial resistance.
A more immediate consequence of antimicrobial resistance is the failure of antibiotic treatments, resulting in longer hospitalizations, increased costs, increased nosocomial spread of multi-resistant bacteria, but above all more than 1.2 million global yearly deaths.
