Developing systems thinking is the only hope for effectively addressing the Antimicrobial Resistance crisis
It’s been more than five years since the Global Action Plan on Antimicrobial Resistance (AMR) was launched by the World Health Organization. Since then, AMR has received the highest possible attention from the global policy community, with United Nations General Assembly (UNGA) discussing it and the Inter-Agency Coordination Group (IACG) on AMR submitting its report to the United Nations Secretary General in 2019. Now, more than 95% of the world’s population live in countries which has an action plan for AMR. The Tripartite organizations, that is World Health Organization (WHO), Food & Agriculture Organization (FAO) and World Organization for Animal Health (OIE), has established a joint secretariat for coordinating global action on the issue while considering the ‘One-Health’ character of AMR1. The process to put together a Global Leadership Group (GLG) on AMR is underway and this body is hoped to provide guidance to ensure greater buy-in from countries. All of these developments may seem like progress, however if you look at the impact of these changes on the ground, it is a depressing scenario.
National Action Plans are lagging behind
The National Action Plans on AMR, though quite robust on paper, are mostly dysfunctional with namesake focal points (who are usually bogged down by lot of other responsibilities) and poor financial allocation. Most of the country level AMR focal points are from a microbiology background, from the Ministries of Health of the national governments. Their expertise, experience and outlook determine the way in which the NAPs are implemented. With little exposure to the policy space and food systems, most of the focal points are forced to limit the NAP implementation process to their comfort space- that is laboratories and hospitals in human healthcare sector. The focal points cannot be blamed for this predicament and most of the time they do not have access to resources to engage other sectors. The end result is that a lot of energies are spend on surveillance activities, however very little progress is visible in developing localised strategies for rationalizing antibiotic use across various domains. This also results in a flawed narrative which implies that AMR is an issue driven by antibiotic use in hospitals and affects only healthcare facilities. This is probably the reason behind the limited traction achieved in engaging the larger civil society on the AMR problem. We will be able to understand it better by just comparing the number of civil society groups working on Human Immunodeficiency Virus (HIV) and AMR. Almost 20 years after WHO released its Global Strategy on AMR, we only have a handful of organizations with an active portfolio of work related to AMR. Also, this number has not increased significantly even after the launch of Global/National Action Plans.
Looking for bottlenecks
Therefore, we need to accept that there is a problem and start looking for possible barriers in broad basing the issue. A very simplistic view of the issue is a part of the problem; and it can prevent decision makers from understanding the complexities of the drivers of AMR and the inter-disciplinary nature of its solutions. When people start thinking in silos, a complex problem like AMR will be difficult to contain. I will give an example to illustrate the inter-disciplinary character of the issue. Intensified agriculture has transformed the food production landscape of the world. In many low-resource settings, intensified food animal production is practiced unscientifically and with poor investment. The stocking density (the number of animals in standard area) is increased, infection prevention measures are sub-optimal, workers may not be trained properly and there are no provisions for waste management. All of these increase the likelihood of infections in farm animals and is overcome by extensive use of antibiotics. Besides, the belief that antibiotics can increase the rate of weight gain in farm animals by improving the Feed Conversion Ratio (FCR), entices many farmers to use more antibiotics2. The end result is that the prices of many meat products, especially poultry, has remained stable for over half a century and it became accessible to the poorer population in developing countries. When the income level of people are rising, there is an increased demand for high quality proteins and this is satisfied by the ‘cheap’ animal products coming out from intensified agricultural systems. While contributing to food security and improving quality of diet in developing nations, these sub-optimal intensification practices have a huge sustainability cost that we are transferring to future generations. The extensive use of antibiotics contribute to antibiotic selection pressure and can result in AMR emerging in community settings too. Also, food animal production is said to contribute significantly to greenhouse gas emission and deforestation for feed production. Therefore, we can observe that food production, food security, antibiotic resistance and climate change are all connected in this context. If we are not able to untangle this complex web and understand the implications of our interventions, effective action to contain AMR will be difficult. The same complexities are visible in other domains too, like use of antibiotics in human healthcare or antibiotic pollution from various sources. We have to move away from a linear thinking to systems thinking, in order to grasp the issue and contain it effectively.
Involving local stakeholders and groups
Apart from identifying interconnectedness, one of the primary features of systems thinking is the presence of a feedback loop and result oriented activities. Though the NAPs have a Monitoring & Evaluation Plan, the options for an effective feedback is minimal. The top-down paradigm followed in implementation efforts make it difficult to incorporate the aspirations of the lower rungs of government apparatus or the civil society. In the context of larger and more populous countries, the one-size-fits-all approach for NAP implementation may fail to take into account local realities and existing resources. Therefore a balanced approach, dependent on provision for local adaptation, may be the ideal way forward; with local self-government institution having a say in the implementation efforts of NAPs. This can prevent emergence of a reinforcing loop, which can result in specific areas of NAPs getting all the resources and attention. In the absence of a holistic and balanced approach, people tasked within NAP implementation will start to focus on domains which fall within their comfort zone. Also, in conditions like AMR which assumes the form of a slow pandemic, balancing feedback loops are essential in ensuring that we proceed in the right direction. Some of the changes expected from the action plan are long term in nature and may not be discernable in the short term; therefore it requires a systems thinking for feedback and accountability. Another problem that most of the developing countries face is the extensive use of process indicators in any implementation process. An action plan is often limited to processes like number of meetings organized or number of people trained or number of products procured. In the case of ambitious action plans like that of AMR, these process indicators really do not mean anything and cannot be taken as surrogate markers for impact. The outcome or impact indicators in the case of AMR will have to measure changes in antibiotic use, resistance levels or incidence of infections. But often, this kind of long term approach is lacking and the end result is utilization of resources without tangible benefits. This creates a piquant situation similar to a vicious cycle. High resource utilization and relatively low impact will lead to less resource allocation in the future and even less impact. The political capital available for AMR and the momentum around the issue, albeit small, can dissipate fast if the impact of the action plan is minimal.
Designing messaging strategies and interventions
There is a need to engage local stakeholder groups in the action on AMR, to ensure greater uptake of interventions and local resource mobilization for sustainability. For this, the messaging around AMR needs to be iterated so that we are able to develop specific competencies among the target groups. For example, there have been several initiatives worldwide to teach the students about AMR and lot of resources have been used up for the same. But if we analyse carefully, we can find that most of these educational efforts on AMR are quite myopic in approach with a lack of clarity about what competencies can be reasonably expected from a child who attends the sensitization program. The connection between awareness raising and behaviour change is not well studied before launching such large interventional programs. Equally important is the development and piloting of interventions, which is based on local resources and understanding. The Antibiotic Smart Use project in Thailand is an example for incorporating local realities into development process for interventions directed at rationalizing antibiotic use in rural communities3. They found out that over-the-counter antibiotic use is high in the case of upper respiratory infections, diarrhoeal illness and small wounds; and they worked hard to increase positive behaviour in case of these three disease conditions. The program managers realised that penalizing over-the-counter antibiotic use may not work in the local context, so they tried to rationalize it by simple tools. Throat self-examination kits (simple concave mirrors with torches and attached pictorial instructions) were placed at retail pharmacies to encourage clients to look at their own throats and understand that they may not need antibiotics for all their sore throats. Thorough system mapping exercises are vital tools in systems thinking; and it can enable decision makers to understand the complexities in systems and develop interventions which can work. Similarly, revitalizing the drug discovery pipeline for antibiotics also require a more holistic approach in designing the various incentives; apart from innovative methodologies to ensure access.
Need for more investment in social sector and health programs
Lastly, the AMR situation is very much related to financial inequities in a country and the people’s access to healthcare. Much of the informal healthcare delivery system exists because people do not have physical access to formal health systems or they cannot afford it. Therefore, systemic improvements are needed to ensure that these action plans on AMR actually take-off in developing countries. These systemic improvements are possible only with greater social sector spending and higher investment in healthcare. Most developing countries still shy away from increasing their spending in health; and that is the reason why Abuja declaration targets (to increase health spending to 15% of government budgets) are elusive in most of the African countries even after 20 years of the landmark summit. Though the UNGA and WHO have been pushing the Universal Health Coverage agenda in developing countries, it is yet to receive good traction in the national capitals. A robust healthcare system can automatically solve many problems associated with AMR too, but we cannot expect that to happen overnight. Till then we need to advance the implementation process of the NAPs at the country level. This needs a greater understanding of the complexities of the issue and has to adopt a practical problem-solving approach in designing AMR sensitive or specific interventions.
References
1- Ruckert A, Fafard P, Hindmarch S, et al. Governing antimicrobial resistance: a narrative review of global governance mechanisms [published online ahead of print, 2020 Sep 9]. J Public Health Policy. 2020;1–14.
2-Landers TF, Cohen B, Wittum TE, Larson EL. A review of antibiotic use in food animals: perspective, policy, and potential. Public Health Rep. 2012;127(1):4–22.
3-Sumpradit N, Chongtrakul P, Anuwong K, et al. Antibiotics Smart Use: a workable model for promoting the rational use of medicines in Thailand. Bull World Health Organ. 2012;90(12):905–913.
(Dr Philip Mathew is a Public Health Consultant and an Associate Professor of Community Medicine based in India. Opinions are personal)
(This article was originally published in e-Pharmalink, Ecumenical Pharmaceutical Network’s monthly newsletter, in December 2020)