Abstract
Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.
Highlights
Despite high-level political commitment to tackle antimicrobial resistance (AMR), moving from rhetoric to action is proving to be far from straightforward [1,2]
Existing literature documents a gap in evidence about the types of interventions that might be locally appropriate in low- and middle-income countries (LMIC) [26] and about strategies to tackle ‘local barriers’ [11]; our findings address this gap in evidence for Pakistan, and have implications for other LMIC developing AMR action plans
Enactment and enforcement of regulations has been advocated as an important approach to tackle inappropriate use of antibiotics, many interviewees suggested that doctors and the pharmaceutical and livestock industries may be too powerful for government agencies to enforce rules on; the latter were presented as under-resourced, poorly organised, and lacking in authority to implement the existing regulations, which is similar to the status of regulatory bodies in many LMIC
Summary
Despite high-level political commitment to tackle antimicrobial resistance (AMR), moving from rhetoric to action is proving to be far from straightforward [1,2]. Organization (WHO) member states endorsed the Global Action Plan on AMR, and committed to developing multisectoral national action plans (NAP) – considering human, animal and environmental drivers of AMR - within two years. The reason for this heightened attention to AMR is the huge predicted impact on morbidity and mortality in humans and animals, on food production, on economic growth and on global trade and travel [1]. Tackling one of the major drivers of AMR – inappropriate use of antibiotics – requires actions that affect multiple sectors, including human and veterinary medicine, agriculture, and trade [7,8]; this is why a One Health approach has been proposed
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