An Inconvenient Truth of Inadequate Global Response to Antimicrobial Resistance

An analysis of the actions taken to combat antimicrobial resistance in 114 countries finds national action plans easier to develop than to implement.

In a recent analysis of countries’ efforts to combat the development of antimicrobial resistance, investigators offer an understated conclusion, that “international response might not be commensurate with (its) scale and severity.”

Jay Patel, Global Health Governance Programme, Usher Institute, University of Edinburgh, Edinburgh, UK and colleagues found that their evidence “suggests that simply developing a NAP (national action plan) might not necessarily make a country prepared to respond to the threat of antimicrobial resistance.”

In accompanying commentary in The Lancet Infectious Diseases, Alessandro Cassini, MD, MSc, Cantonal Doctor Office, Canton of Vaud, Lausanne, Switzerland, and Evelina Tacconelli, MD, PhD, Infection Prevention and Control Unit, Infectious Diseases Service, Lausanne University Hospital, Switzerland, point out that there were more than 1.2 million deaths directly attributable to infections with resistant bacteria in 2019, and find that the analysis by Patel and colleagues yields a “generally bleak overview of the commitment of various countries to effectively overcome antimicrobial resistance.”

In the analysis of global response in 2020-21, which Patel and colleagues characterize as the first to comprehensively examine the international response to antimicrobial resistance, 114 countries are ranked on having and implementing a governance framework covering 18 domains and including over 50 indicators in 3 integral areas: policy design, implementation tools, and monitoring and evaluation.

Overall country scores were derived from the mean average of all governance areas; and composite scores for each area from the mean value of each domain. Aggregated indicator scores for domains and governance areas were transformed into a scale from 0 (worst) to 100 (best) by 3 of the investigators, who were blinded to the respective countries; and who then met unblinded to resolve any disagreements in scoring and to reach consensus agreement.

The investigators indicated that their “grading” criteria were drawn, in part, from the countries’ NAPS, and their entries in the WHO Tripartite Antimicrobial resistance Country Self-Assessment Survey (TrACSS), the Global Antimicrobial Resistance and Use Surveillance System GLASS), the Global Antimicrobial Resistance Research and Development Hub, the WHO 2018 South-East Asia Region Situational Analysis, and the WHO 2020 Immunization Dashboard.

Perhaps not unexpectedly, the investigators found lower scores (46-48) in the countries that also ranked in the low- and middle-World Bank income groups. Norway ranked highest, mean 85 (SD 32) and the Federated States of Micronesia lowest (28 [37]).The highest scoring domain was participation (83 [16]) and the lowest scoring domains were accountability (30 [18]) and feedback mechanism (30 [25]).

“Education was the lowest scoring domain of all implementation tools,” Patel and colleagues observed, “highlighting that basic and continuous education for healthcare workers has not been robustly established inmost countries.”

Sustainability, which considered whether countries had assessed the budget requirements of their NAPS, was the lowest scored indicator. Only Austria receiving a positive score for sustainability.

Cassini and Tacconelli welcomed the approach taken by the investigators, indicating that their assessment tool, “should be considered an essential component of, and integrated into the multifaceted country approach to antimicrobial resistance.”

The next step, recommended Cassini and Tacconelli, is to develop appropriate and easily measurable outcome indicators, which should be regularly and independently measured at the country level and used as a baseline for further comparisons.

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