Detailed deliberations

The 2024 HLM: balancing ambition and pragmatism

The 2024 HLM provides a unique opportunity to raise AMR back up the political agenda, crystalizing the successes that have been made since the first HLM in 2016 while setting the world on the path to addressing AMR in the years ahead.

“While there is value in having high-level conversation, at some point we need to have specifics in order for it to survive contact with reality.”

During the meeting, participants highlighted the importance of developing a realistic political agenda for AMR, with tangible goals to which all 193 Member States can commit. Within a complex geopolitical landscape, countries with very different contexts and economic conditions and widely differing experiences of AMR need to reach agreement. The Declaration will need to recognise country differences, while emphasising the shared responsibility and benefits of addressing AMR.

Recognising the political nature of the Member State process and the political context in which negotiations will take place, participants stressed the importance of balancing pragmatism and aspiration. The goal to inject vision and ambition into the zero draft of the Political Declaration should not be lost amidst the complex negotiation process.

Finding the right balance between aspirational goals and action grounded in evidence is also crucial, and political targets must be based on science and evidence. Three potential broad areas were suggested as areas of focus in the zero draft: implementation mechanisms, sustainability mechanisms, and finance mechanisms.

The drafting process will draw on the experience of the 2023 HLMs, and the AMR community is keen to learn from previous HLM processes. Aligning around a small number of issues and positioning them alongside broader Member State priorities such as development and tackling poverty will be key to take advantage of this narrow window of opportunity.

“We need to find way to address the finance problem, otherwise for LMIC – the politics and implementation will not be successful.”

Raising AMR up the political agenda will require multi-sector action throughout the UN System in New York and through Capitals. AMR is a critical issue particularly for Ministries addressing Development, Health, Finance, Agriculture, Fisheries, Climate, Environment, Tourism, Research and Education.

Inclusive multi-stakeholder processes, including strong representation of countries and sectors including the private sector, academia, and civil society, must drive the reinvigoration of this agenda. Identifying possibilities for the convergence of aims and ambitions across sectors and stakeholders in a contested space is vital. While LMICs need to be able to increase domestic funding for implementing NAPs, it is unrealistic to expect all countries to have the resources to do so. Considerations for how to support LMICs to strengthen, cost and fund their NAPs will be key.  

Making progress towards evidence-based targets

Participants were in broad agreement that high-level evidence-based targets are valuable as tools for raising the political profile of AMR and in focusing and accelerating action to address the challenge. Ideally these targets will be timebound, specific, accountable, and actionable.

“Accountability is lacking for targets that affect AMR. With no accountability enforcement is poor.”

A high-level overarching target to galvanise momentum could be centred on reducing the overall burden of drug resistant infections or reductions in mortality. Such a target would need to ambitious yet achievable and grounded in evidence.

However, caution was expressed about international targets in tension with ensuring a firm sense of ownership at country level. Some participants argued that countries should, in addition, define their own specific targets and mechanisms could be identified to independently hold countries accountable to these. Some examples of voluntary accountability mechanisms exist in other sectors and can be explored.

A scientific modelling framework could support the development of AMR targets.  Surveillance is crucial for ensuring quality data to design such targets. Institutionalising surveillance through national systems to better support data gathering and sharing regionally and globally is a foundational step.

“Can we separate the scientific and technical targets from the political targets, as this will helps us focus support and drive the political engagement that needs to happen for the HLM.”

The inclusion of new targets within the political declaration will be challenging. Discussions concluded that surfacing existing and agreed targets reached through UN processes, (including through WHO, FAO and WOAH) which are evidence-driven and have broad Member State support, will be most likely to survive the negotiating process. Existing political commitments on AMR also provide entry points for action.

Targets should be informed by WHO AWaRe (Access, Watch, Reserve) antibiotic classification and associated treatment guidelines.

Work on the global burden of disease could support modelling to identify appropriate levels of AMR use in different countries and contexts.

The Lancet Commission on AMR will be publishing a series of papers proposing high-level targets for AMR in the first quarter of 2024. The high-level “10/20/30” targets refer to a: 10% reduction in deaths / 20% reduction of use in humans / 30% reduction of use in animals. Overall, participants acknowledged the need for further work to develop and define evidence-based targets. An interim goal would be to agree a process, such as the establishment of an Independent Science Panel with a mandate to develop targets.

Recognising AMR as a global development challenge

AMR affects everyone, but especially the world’s most vulnerable people.

“Linking AMR explicitly to the development agenda and demonstrating the impact of AMR on country’s development agenda is fertile ground as everyone is focused on the SDGS.”

Access to effective antimicrobials underpins our health, food, environment, and economic security. This is all essential infrastructure for life and livelihoods, to which everyone has a right. AMR must therefore be recognised as a development challenge and a social justice issue. Poverty, inequality, and lack of access to health care have accelerated AMR, and its subsequent rapid spread is sending more people into poverty.

The SDGs can only be achieved when AMR is contained and controlled. Advancing specific SDGs, including SDG 6 on clean water and sanitation and SDG 3 on good health and wellbeing, is pivotal to combating AMR. Notably, the outcomes of 8 of 10 diseases on the WHO priority list can be improved if AMR is addressed.   Post-2030 agenda negotiations and the UN Sustainable Development Cooperation Framework plans are critical moments for including AMR as a fundamental development issue. While global and regional collaboration and engagement are essential, responses to AMR must be contextualised to address the experiences, needs, and priorities of countries and communities.

Supporting national action through global collaboration

“Partnership and collaboration between governments, international agencies, private sector, civil society and others are crucial for tackling AMR.”

Responses to AMR are highly contextualized, and need to be designed, developed, and implemented at national and local levels.

National Action Plans (NAPs), when multi-sectoral, costed, and funded, provide a foundation for countries to address AMR and remain the basis for country-led action.

The development of NAPs been a major step forward since 2016, but the funding and implementation of NAPs has lagged. While plans should be country-led, LMICs must be adequately supported to develop and implement their plans, both technically and financially, with a recognition of the global benefits of tacking AMR.

Overcoming barriers preventing sustained funding

Ongoing and multiple global shocks and crises have caused fiscal space to shrink in all countries, but with disproportionate negative impacts on LMIC economies.

In the context of de-prioritised public health investments and increasing tensions between domestic and external financing, how can Ministries of Finance be convinced the issue of AMR is a comprehensive development agenda that can unlock multi-sector investment?

“We forget our finance colleagues at our peril. Most people in Ministries of Finance do not know what AMR is about.”

Inadequate finance for implementing NAPs in LMICs was raised repeatedly during the discussions. While 90% of countries have costed NAPs only 10% are adequately financed and only 1 in 4 have M&E tools, emphasising that what does not get measured does not get funded.

Communicating the predicted global burden of AMR in 2050, the threat to global health security and human capital and the subsequent economic burden to countries, along with the strong economic benefits of tackling AMR, may help to unlock funds. However, it was also noted that politicians rarely act upon future threats, but rather respond to current ones.

Demonstrating the existence of constructive and innovative tools that do not cramp fiscal space, and providing data on current or immediate economic impacts may help to raise AMR up the political agenda.

“Show that there are constructive, innovative tools for financing AMR that do not cramp fiscal space.”

From an LMIC perspective, countries could attract funds by making a specific case for AMR (e.g. in their proposals to the Global Fund). It is rare to see a separate line for AMR in national budgets, and including this would demonstrate that AMR is an emergency issue. It could potentially facilitate access to finance domestically if policy makers see the cost of action versus inaction, and to external financing if donors see AMR is prioritised.

Innovative finance mechanisms working within and outside of sectoral boundaries that can unlock finance from domestic and private sources, and international partners and multilateral development banks (MDBs) are urgently needed.

Innovative finance models also exist at the community level with local innovation and community engagement from the bottom-up. Taking a contextual finance approach that looks at the most relevant needs, and costs versus savings is important.

Harnessing existing finance is essential. A useful approach might be to ensure that countries are fully informed of all currently available sources of funding, such as the Pandemic Fund and other World Bank instruments, and a coordinating mechanism could support this. Opportunities to leverage funding for AMR from existing mechanisms may exist, such as COVAX (if AMR is framed as a health emergency and global security issue). 

“Antibiotics are not an attractive investment proposition for governments. We need incentives that encourage private sector R&D.”

Currently, four entry points for World Bank support to countries on AMR exist: prevent and reduce infections; strengthen monitoring; improve access and rational use/stewardship; strengthen multisectoral engagement and governance.

International financial institutions and MDBs can provide more clarity about financing instruments and lending envelopes. Given fiscal challenges and that new funding for AMR is unlikely, any opportunities and trade-offs for redirecting budgets towards AMR need to be appropriately examined for gains and potential harms. Examples are the areas of overlap when funding for pandemic prevention, preparedness and response (PPPR), and universal health coverage also contribute to addressing AMR.

Strengthening prevention as the foundation for addressing AMR

“We have to talk about prevention, and we have to have prevention-based targets. We need to increase vaccination, IPC and WASH in every country.”

The prevention of AMR needs higher attention in LMICs including the link between reducing AMR and improving access to water, sanitation and hygiene (WASH), vaccines, universal health coverage (UHC), and infection prevention and control (IPC).

Participants discussed the need to have targets focused on prevention as this significantly reduces the risk of AMR. Within the 2024 HLM, it will be strategic to highlight existing targets on prevention that countries have already committed to achieve, such as SDG3 and SDG6.

Ensuring equitable access

Equitable access and appropriate use of antibiotics – along with prevention such as WASH, IPC, and vaccines – are the cornerstones of efforts to address AMR across human health, animal health, and the environment. Significant efforts are needed to achieve availability, affordability, accessibility, and appropriate use of existing and new antibiotics. For human health this means universal access to key essential antibiotics as defined by WHO.

“In global health when we discuss equity, it tends to be about LIC and income levels, but we need all countries to have an equity lens.”

Equitable access to antibiotics and their appropriate and sustainable use in humans and animals are key to reducing the burden of AMR. Current patterns of antibiotics use for human health across the globe are neither equitable nor fair. HICs, with a low burden of disease use the most antibiotics and LICs, with the highest burden of disease use the least amount of antibiotics. In some contexts, inappropriate use is a major challenge, while across LMIC contexts, a lack of access to antibiotics causes more deaths than AMR itself.

Other areas of access were also considered strategically important from access to knowledge and information about AMR and real time use of data to diagnostics, novel therapeutics, health services and finance.

While patients in LMIC are grappling with access to basic drugs and antibiotics, it is challenging for the public to understand and agree with regulation and restrictions on their use.

Half the world’s population does not have access to diagnostics. Recognizing the critical role of rapid access and innovative diagnostics especially in LMICs, a resolution to strengthen diagnostics capacity was adopted at the World Health Assembly in 2023. This could be harnessed further where appropriate to implement actions to improve access to diagnostics.

Critically linked to access is the issue of quality drugs, with substandard and falsified medicines still posing a significant risk in LMICs. Access to the benefits of research and innovation, such as vaccines, diagnostics and treatments, remains challenging, especially for LMICs. Achieving a sustainable innovation ecosystem with robust investment can also help accelerate efforts to address these gaps in global access.

Accelerating innovation

“Strengthening and building innovation and R&D in countries with high AMR is already in the pandemic accord discussions.”

A narrative is urgently needed that frames innovation not as a goal in itself, but as a tool though which to tackle AMR. Innovation is not an isolated activity and should be linked to access; it may include areas such as new antibiotics, diagnostics, biosecurity on farms, and digital warning systems. Innovation is also linked to tools for stewardship and beyond.

Innovation and R&D must be promoted as an inclusive process, so that LMIC are engaged and included in efforts.

Adequate, predictable, and sustainable financing for AMR research and innovation is needed for the development of vaccines, diagnostics, and treatments, including vaccines for animal health, and for operational and implementation science to facilitate the scaling of evidence-based interventions.

“Add research to innovation and support home grown innovation and local research.”

Experts agree that the most effective way to incentivize much-needed innovation is via a combination of push and pull mechanisms. Countries should commit to further support existing global initiatives that accelerate R&D, such as CARB-X and GARDP, and implement new pull incentive mechanisms that separate the return on investment in research and development from the price and volume of sales. It is important to create a research and development ecosystem that is needs-driven, evidence-based and guided by core principles of affordability, accessibility, efficiency, effectiveness and equity by rapid deployment of recently approved tools, as they become available, in countries with the greatest need.

Strengthening stewardship

“Good stewardship can mean either an increased or decreased use, depending on context.”

Addressing AMR requires multisector collaboration and coordination across the One Health spectrum over a multi-year timeframe.

Antibiotic use and burden are only one part of the equation, with transmission between humans, environment, animals and wildlife also a major aspect. Wildlife reservoirs of AMR exist across the world, and most antibiotics are used outside the clinic.

The agri-food sector consumes most of the world’s antibiotics (approx. 70%^[2]) and up to 90% of antibiotics consumed in humans and animals are excreted back into the environment. It is important to include the significance of the environment in narratives on AMR, to build a complete picture of the development challenge.

Stewardship must be considered across animal, human, and environment sectors so it goes beyond the human health definition of appropriate use of antibiotics.

Good stewardship can mean either an increase or a decrease in use of antimicrobials depending on the context. Surveillance should not be construed as negative, but rather as an opportunity to improve and to optimize the use of antimicrobials.

“Stewardship of sustainability of the agenda needs to be emphasised; that this agenda is a continued effort.”

A regulatory body in each country could evolve as part of NAPs to develop guidelines and set targets on accessibility, appropriateness, and effectiveness across human, animal, and environmental health. Support for countries to implement this may be needed.

Agreement is needed for a standardised methodology for target-setting and monitoring and evaluation at national and global levels. This could be based on the AWaRe systems to create risk-adjusted, burden-adjusted, needs-based targets. Countries can then look at their own data and set their own level of ambition. This would be continually adjusted depending on burden, and evidence gathering would be for the country’s use primarily.

Community buy-in from leaders and influencers, including religious and political leaders, is important to engage the public over issues of stewardship. Engaging AMR with school curricular and education institutions, including for workforces for human and animal health, and the environment is important, alongside professional training bodies to ensure all health and allied professionals continue to be trained in core elements of AMR.

For the Political Declaration, it is not necessary to reinvent messaging on stewardship as the Quadripartite has already provided guidelines and language. Therefore, it is about applying and using approaches, and updating where necessary. Principles around stewardship for the zero draft of the Political Declaration should be clear, simple, and deliverable, and acceptable to all countries to withstand the negotiation process. 

Promoting strong governance and monitoring

Strong national governance mechanisms with a clear mandate, alongside sustainable financing and coordination, are needed to implement AMR NAPS effectively.

“Establish clear perimeters for establishing this governance mechanisms. This is currently a weak area in the NAPs.”

Well-funded governance, that embraces multi-sector engagement, is essential to embrace One Health principles and tackle the complexities of AMR, yet often this is a weak area within NAPs.

Monitoring of progress is a crucial part of governance; this requires environments to be conducive to effective implementation and monitoring of policies. Non-state actors need to be integrated into governance structures and engaged in activities.

Every country should have a regulatory framework that includes human health, animal health, and the environment and that is contextual and responsive to communities. Based on this framework, countries can create targets that meet their needs based on the AMR challenges they face.

The institutionalisation of surveillance systems is needed to support quality data and evidence-based decision-making processes, including for regulatory actions. Countries need to commit to and engage with the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS), the International FAO Antimicrobial Resistance Monitoring (InFARM), and WOAH’s global database on ANImal antiMicrobial USE (ANIMUSE). Monitoring and reporting across the One Health spectrum are key to inform national decision-making and to support knowledge sharing at the regional and global level.

Global governance, to harmonize resources and data across countries, must possess a strong mandate in terms of target-setting and governance in countries, and use existing structures and models acceptable to states. For success, how can global level actors support countries that need greater capacity to strengthen their monitoring systems? Participants proposed an Independent Science Panel to provide better global coordination and monitoring of AMR.

Communicating and advocating AMR

Discussions around communications and advocacy highlighted the critical need for coordination of efforts and the need for clear messaging on the risk of AMR, political asks for the HLM on AMR, and what every sector of society can do. Communication strategies and rallying approaches are needed to make AMR issues urgent, concrete, and actionable leading up to the HLM.

“AMR will set cancer patients back. They are three times more likely to die of serious infection.”

Considering negotiations in the lead up to the HLM, one key communication challenge is that a large constituency does not understand what AMR is, and another constituency thinks it is only a problem in the global north. Linking AMR more explicitly to the development agenda to demonstrate the impact of AMR on a country’s development agenda and progress to the SDGs is important.

Participants shared elevator pitches to political actors with key messages to reach their hearts, minds, and pockets. Common elements included three dimensions: i) AMR is personal (this could happen to you or a loved one); ii) addressing AMR can help you win an election; and iii) AMR will have an economic impact that will affect your country.

Currently, organisations globally are campaigning for AMR in an uncoordinated manner, and there is a need to align efforts to achieve more effective and powerful influencing than at present. Coordination and support are needed, along with a pool of shared assets, and a clear central messaging framework.

Approaches to communicating with a more collective voice could focus more on engaging different audiences and sectors meaningfully, rather than an activist approach.

“Meaningful engagement of civil society, patients, and other stakeholder is needed to involve everyone in efforts to address AMR.”

Advocacy and communications campaigns must also engage young people, both as influencers, future leaders, and the generation who will be most affected by the risk of AMR and who will need to address AMR as part of the wider challenges facing the planet.

The Wellcome Trust volunteered to support efforts to facilitate greater coordination and collaboration around communications messaging focused on the HLM.

In general, narratives on AMR are frequently articulated in silos, according to different sectors. There is an urgent need for coordinated communication, interaction, and engagement between ministries and sectors addressing development, health, finance, agriculture, fisheries, climate, environment, tourism, research, and education to speak with a unified voice about the urgency of AMR.

Initiatives such as the Global Legislators Initiative, coordinated by H20, provide an opportunity for AMR experts to engage directly with legislators to raise awareness of the key political asks and priority areas of action.

Parliamentarians shared experiences and suggested that many parliamentarians see AMR as an abstract concept. Sometimes there needs to be an element of fear to spark action. For African countries, analogies can be drawn with the crisis of HIV where increased cases and patient advocacy sparked action. The lack of new antibiotics available and the prevalence of antibiotic resistant TB and malaria should also spark the same fear and concern, but yet, do not.

The public need greater levels of education and communication about AMR as a threat. Strong messages could potentially be formulated around the notion of ‘superbugs’ which resonates with the public; and the threats of infection to those with cancer and undergoing treatment as an area of health that all can relate to.

Communication approaches also need to consider how to turn negative messages about the fear of AMR into positive incentives, for example moving from emphasising the burden of infection and deaths to savings gained monetarily and through human lives.

“The personal and financial cost of inaction is greater than the cost of action.”

Experiences and testimonies of AMR survivors are one of the most powerful tools in communicating the reality of AMR to a range of audiences. AMR advocates need support and funding to undertake this invaluable work. The WHO Task Force of AMR Survivors has just been established and provides opportunities to communicate the patient perspective.

Various communication approaches to addressing AMR are needed including behaviour change communication, public awareness raising, and community engagement.  

At regional level, several discussions are taking place across regional and trade blocs (such as SADAC, Africa CDC) presenting the opportunity to embed AMR within dialogues.   Communication and advocacy for action on AMR will benefit from sharing examples of good practice, for example action in the food and agricultural sectors that support work on AMR. A key message is that solutions are ready to be implemented, and the financial and personal costs of inaction are greater than the costs of action.

Conclusion

The meeting created space for strategic and nuanced thinking among the AMR community to prioritise the political agenda and reinvigorate action on AMR. The discussions that took place among key stakeholders from human health, animal health, and the environment were invaluable to inform the contents of the zero draft of the Political Declaration for the UNGA HLM 2024. The meeting also provided opportunity to develop plan longer-term processes for beyond the HLM, and garner support for a collective vision for action.

[2]Global Trends in Antimicrobial Use in Food Animals from 2017 to 2030 (nih.gov) and Antimicrobial use in agriculture: critical review of the factors influencing behaviour – PMC (nih.gov)

Alison Dunn and Henry Mark

Wilton Park | December 2023