What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan

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.

Exploring the One Health Perspective in Sweden’s Policies for Containing Antibiotic Resistance

“…The Swedish strategy, therefore, aims for Sweden to show leadership internationally through cooperation in various fora, such as the EU, OIE, WHO, FAO, and OECD. The One Health concept and AMR has rapidly reached the political agenda globally, but policy development and implementation in the field in low- and middle-income countries is often lagging behind and needs special consideration [ 32 , 33 ]. To be able to implement the “Swedish model” in other countries, a clear set of adaptable process and outcome indicators need to be developed using an implementation research framework.…”

Conflicts of interest: an invisible force shaping health systems and policies

“…For example, the reliance on unlicenced medicine sellers to provide access to essential medicines for populations in under-resourced areas is hugely challenging for policy makers in numerous countries. 2,8 Policies to reduce service provision by private providers, including those that are untrained and providing substandard care, are often avoided due to concerns that they will expose gaps in health care that the public sector should be providing. 5 We have discussed the role of conflicts of interest in mixed health systems with weak governance mechanisms, but the influence of conflicts of interest on health policies is widespread.…”

“…8 In our research, we have found that analysis of, and action on, conflicts of interest will be essential for properly managing the use of antibiotics to stem antimicrobial resistance and for achieving universal health coverage by reducing out-of-pocket payments. 2,3,5 Although conflicts of interest remain a global issue that is neglected, underestimated, and overlooked by health policy makers and researchers, conflicts of interest connect with many wider issues within health policy and systems research. At present, there is a growing body of evidence and concern surrounding corruption in health systems.…”

“…For example, owners of pharmaceutical companies or their family members often hold decision-making power in drug regulatory agencies responsible for making and implementing policies on drug quality and ethical marketing practices. 2 Thus, key decision makers are incentivised to influence the design of new policies or the resources allocated to implement policies, such that sales of medicines are not affected. Ultimately, this process protects their financial interests or those of their friends and families.…”

“…5 For example, in many countries, doctors and pharmacists illegally rent their professional licences to set up drug shops and clinics where lower paid attendants, typically without the desired or prescribed qualifications, can provide services. 2,6 Policies to address inappropriate delivery of health care by unqualified providers in such drug shops and clinics would, therefore, reduce a source of income for doctors and pharmacists, resulting in their often tacit opposition.…”