Countries reaffirmed commitment, considered progress on tackling antimicrobial resistance

Geneva, 30 January (Mirza Alas*) – World Health Organization Member States reaffirmed once again their commitment to combat antibiotics resistance at the ongoing 140th meeting of the Executive Board.

A progress report on the implementation of the Global Action Plan on Antimicrobial Resistance was considered at the Executive Board that is taking place in Geneva from 23 January to 1 February. 32 countries have submitted National Action Plans and 59 are in the process of drafting it. A more detailed progress report will be presented at the 70th session of the World Health Assembly (WHA) in May.

The 68th session of the WHA adopted the Global Action Plan (GAP) on antimicrobial resistance (AMR) by resolution WHA68.7 in May 2015 and as part of the GAP all countries should have National Action Plans in place by the 70th Assembly in May 2017.  The United Nations General Assembly (UNGA) adopted a political declaration on AMR under resolution A/RES/71/3 following a High Level Meeting on AMR on 21 September 2016.

The UNGA political declaration clearly specifies the need for WHO to finalize the Global Development and Stewardship Framework and requested the Secretary-General to establish, in consultation with WHO, Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE), an ad hoc inter-agency coordination group, co-chaired by the Executive Office of the Secretary-General and the WHO.

Developing countries, during their interventions at the Executive Board evening session on 25 January, highlighted the urgency of ensuring financial and technical assistance, as well as the need for transparency in the appointment of the interagency group. Countries also expressed their support for advancing the negotiations on the Stewardship and Development Framework, reaffirming the principles (affordability, effectiveness, efficiency, equity and the principle of de-linkage) of the Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG). They also called for ensuring that during the process of the development of the Stewardship and Development Framework there should be consultations with experts but also with Member States.

Developing countries also stressed the important role governments will need to play in the regulation aspect for tackling antimicrobial resistance and the need to ensure affordable access to medicines, vaccines and diagnostics. Member States further highlighted the importance of looking at the animal health and agricultural aspects as key challenge areas.

The Member States’ statements were accompanied by important calls made by several NGOs referring to the necessity to guarantee health system strengthening, policy coherence, and civil society’s involvement in the process taking place not only at the headquarters level of WHO but at the regional and national levels too.  Civil society groups also emphasized the importance of ensuring a transparent and free of conflict of interest process around the UNGA’s call for an ad hoc interagency coordination group and the critical need for affordable access to vaccines, diagnostics and drugs.

Below are highlights from some Member States’ statements.

India emphasized that AMR has emerged as a major public health challenge and is rightly receiving increasing attention globally. At the national level, India has adopted a National Antibiotic Policy in 2011. The development of their National Action Plan has commenced and will be completed in time for the May 2017 commitment. India also noted that surveillance networks have been established for various pathogens and it has made amendments to its drugs law and rules to better regulate the sale of antimicrobials and promote rational use of drugs.  India explained that all antibiotics have a mandatory ‘redline’ displayed on their packs and the country has launched a multi-media campaign based on the ‘redline’ to educate consumers and other stakeholders so that drugs with redline are only consumed as prescribed by the doctor and the full course is completed.

India pointed out that the progress on the development of a Global Development & Stewardship Framework is slow and requested to know the reasons from the WHO Secretariat. It further noted that there should not be any unbalanced emphasis on a Stewardship Framework that focuses only on controlling the production, distribution and sale of antibiotics. There is a need to also focus on the equally important and interrelated issues of research and development and affordable access to new and existing antibiotics and diagnostics in tackling the challenge of AMR, including in HIV, TB and malaria and that the Strategic and Technical Advisory group (STAG) on AMR and the WHO Secretariat are not paying enough attention on these issues.

India supported that all the three interconnected issues of antibiotic stewardship, R&D in new antibiotics, and access to new and existing antibiotics are reflected in a balanced manner in any eventual global framework on AMR. The delineation of such a framework should be done through an intergovernmental process and not left to the experts alone.

India reiterated that AMR should be addressed in a comprehensive manner with adequate attention given to the development and equity related aspects of AMR. The focus should not only be on development of national action plans but more importantly on supporting member states in proper implementation of such plans through adequate technical support and mobilization of resources as emphasized in the UN High-level political declaration on AMR.

Brazil supported convening an ad hoc interagency group, as called for in the UNGA resolution. It also concurred with the Secretariat report that further expert consultation is required on the framework, followed by consultation with Member States and all relevant stakeholders. Brazil further noted a concern has been that the market focus on intellectual property rights (IPRs) has not led to innovative medicines as was also pointed out by the O’Neill report. Further, the One Health is a valid approach, as long as it tackles the human-animal interface on the basis of scientific evidence, said Brazil.

The Philippines endorsed the progress report and is currently working on the national action plan. It has also facilitated an ASEAN approach on AMR, leading to a declaration. It encouraged other leaders’ forums to make such high-level declarations and to raise multi-sectorial awareness and support for AMR.

China said that it has adopted and began implementing a national plan. China also remarked on the need to strengthen cooperation between health and farming ministries and suggested to WHO to continue with its technical support, and requested help for surveillance and capacity for use of antimicrobials. It also requested WHO to facilitate communication exchange among regions.

Vietnam acknowledged the high-level commitment on AMR at the global level. It was the first country in the region to have a national action plan on AMR and is currently working on raising public awareness. Vietnam would like WHO to have a wide-ranging consultation on the stewardship framework and to consider contextual needs of countries. It called on WHO to lead the process to mobilize technical expertise.

Algeria spoke on behalf of the 47 Member States of the African Region (AFRO). It welcomed the adoption of the GAP in 2015 and the successful collaboration between WHO, FAO and OIE in this area. Algeria also noted that the growing threat of AMR in the areas of human health, animal health and agriculture, particularly in developing countries, requires an urgent and concerted general response.

The African Region welcomed the demands made in the high-level political declaration on AMR calling on WHO and its partners to:

(i) establish a global framework for the development and management of antimicrobial resistance;

(ii) support national action plans; and

(iii) establish an ad hoc inter-agency coordination group.

Furthermore,  the African Region stressed the need for affordable access to quality old and new health products such as antibiotics, vaccines and diagnostic tools, and to take into account the needs of all countries, especially developing countries, and in the fight against AMR the need to include HIV, multiresistant tuberculosis and malaria in line with the recommendations of the September 2016 report of the High-Level Group on Access to Medicines, established by the UN Secretary-General.

The region also welcomed the report prepared by WHO, the World TradeOrganization and World Intellectual Property Organization, and recalled the importance of public investment in research and development (R&D), the transfer of technology and the removal of intellectual property barriers in the field of health.

Regarding the establishing of the Stewarship and Development Framework it supported WHO’s proposal for a consultation with experts, followed by discussions with Member States and all relevant partners.

The AFRO region also stressed the need for adequate technical and financial support for the development, implementation and monitoring and evaluation of national action plans and its prioritization for WHO to allow all Member States to meet the deadline of May 2017 (for submission of those national plans).

Congo endorsed the AFRO statement and referred to the issue of spurious and false drugs that can have an impact in the development of AMR. Congo referred to the growing gulf between developed and developing countries, particularly on the access to new drugs that are expensive and it also noted that some anti-HIV drugs are becoming ineffective because they have not been used properly. Congo also made a reference to the emergence of MDR-TB in poorly funded clinics. It noted the importance of having a National Action Plan and the need to get help to do that.

Jamaica noted the significance of antibiotics resistant organisms, especially the use of antibiotics in agriculture. It will complete its National Action plan by May 2017 but also noted the need for research and knowledge particularly for medical doctors and general public, and emphasized the importance of the ad hoc inter agency group to help push this work forward.

Thailand expressed its concern about the slow completion of national action plans and welcomed the inclusion of TB, HIV and Malaria.

Dominican Republic emphasized the importance to strengthen the health authorities to better regulate the use of drugs. It noted its progress regarding TB and malaria. It also emphasized the urgency to get support from WHO and also the need to look at the impact of AMR on veterinary health.

Nepal observed that South East-Asia bears a high burden of AMR and that it would become a major public health problem if not taken seriously. Nepal also spoke of the need to ensure rational use of antibiotics and the critical importance of having access to major antibiotics.

Pakistan pointed out that specific areas need to be addressed and this requires the effort of many stakeholders. It noted the lack of access to medicines and other diagnostics and the importance to have access to affordable vaccines to prevent the use of more antibiotics.  Pakistan also stressed that the regulation of the private sector is a challenge and that the situation in the animal sector is alarming and therefore the government should have a multisectoral platform to address AMR and multisectoral action that put the needs of the patient and health workers first.

Bangladesh pointed out that it has developed a national strategy for AMR and also a draft action plan and has given attention to strengthening laboratory capacity. The 2030 Agenda on Sustainable Development does not specifically address AMR, however AMR will have an impact on health and there is a need to address it. Bangladesh supported the stewardship framework of WHO to fight AMR.

Indonesia emphasized that it has conducted AMR control and has implemented a plan since 2016 to increase awareness and capacity building. There are some challenges that Indonesia faces such as the lack of effective laboratories, surveillance and control of AMR. Indonesia also encouraged a multisectoral approach in line with the One Health approach. Indonesia requested WHO, FAO and OIE to provide support to countries to fight AMR.

Ghana aligned with the statement of Algeria and welcomed the political declaration from the UNGA. It also observed the slow progress for establishing the global development and stewardship framework and noted that the report did not provide information on the barriers to its progress. Ghana requested clarity on the progress of the framework and noted the need for strengthening regulation through globally agreed principles and models, not yet developed, which will have an impact, for example, on the regulation of marketing, promotion, use and sales of antibiotics.

Panama noted the need to increase awareness and understanding of the issue as well as the need to have health worker training to recognize and treat the problem and also the need for the rational use of antibiotics. Furthermore, Panama remarked on the need for effective action at all levels and take into account hospitals, clinical and veterinary medicine and the development of new antibiotics. It also mentioned the importance of preventative action and improved sanitation and to tackle the problem throughout life cycle, including having good vaccination from early life to prevent infections.

Venezuela recognized the important results but pointed out some shortcomings. There is need for policy to prevent AMR and also multisectoral input and global coordination. It requested WHO to provide information for Member States about the work that has been carried out. For LMICs (low and middle income countries) it is difficult to craft policy, said Venezuela, stating that WHO should help with a draft framework to assist countries. A major challenge for many countries is working with deficiencies in health systems.

Zimbabwe aligned with Algeria´s statement and stressed that AMR is a global public health problem. Scaling up momentum is necessary to address the problems of AMR. Zimbabwe has put in place public awareness campaign through the media. It requested a briefing on the expert working group and asked WHO to provide technical assistance to Member States to set up surveillance and disease control, and hoped to see the progress on the document on stewardship of AMR.

Mexico welcomed the report and the outcome of the UNGA, stressing the need for multisectoral efforts. It also noted the need to improve training of health workers and to analyze the use of traditional medicines. It highlighted the need to review health regulations and the monitoring of antimicrobials in animals and humans, and pointed out that there needs to be development of a framework and guidelines should be implemented, and to support the One Health approach (with OIE and FAO).

Fiji said it has launched its national plan, however there are many challenges.  It expressed concern at growing non-communicable diseases and the inappropriate use of antibiotics in diabetes. Fiji is easily connected to larger cities with high rates of infections and recognized the need to build capacity and the need to ensure no Antibiotic Apocalypse as described by the United Kingdom Executive Board member.

Malta speaking on behalf of the European Union welcomed the outcome document of the UNGA on AMR and the adoption of the resolution there. The political declaration boosts awareness and the need to move to action. Malta urged the establishment of the interagency group to address AMR as a matter of urgency. It acknowledged the importance of WHO working on interagency coordination but noted that time is scarce and expressed concern over the two-year timeline, stressing the importance to see the interagency group running in the first quarter of 2017.

The EU welcomed the support of WHO, in collaboration with FAO and OIE, to Member States in developing National Action Plans, however it noted that progress is not uniform and it was concerned with the low number of countries with national plans in place. Especially important is the responsible and appropriate use of antimicrobials. The EU has initiated joint action on AMR and expressed its support of the development and review of national action plans including self-assessment tools.

The United Kingdom supported Malta’s intervention and also acknowledged the progress made at UN High level meeting and welcomed the report. It highlighted the importance of the High- level panel.  The UK pointed out that drug resistance is important and needs to be considered, especially multidrug resistant TB, HIV, and malaria and noted the need to work with UNITAID and to have multisectoral collaboration and to work on One Health.  It also stressed the importance to ensure access to proper treatments and diagnostics for people all over the world.

Canada said the multisectoral approach has been very effective. Canada noted its contribution of 9 million dollars to the AMR secretariat.  It will take a new leadership role in the global health security agenda. It further stressed the common mission of the successful implementation of One Health and the importance of fair and equitable access to antimicrobials for those who need them, and the need for a gradual and phased approach to the stewardship and development framework.

The Netherlands also echoed concerns with the lack of progress adding that UN organizations need to get their act together. It called for a joint effort, with a multisectoral approach.

The Russian Federation suggested the inclusion of preventive measures such as immunization and diagnosis. It also mentioned the need for an innovative approach and development of innovative drugs including new vaccines and the need to improve vaccines schedules.

Sweden welcomed the efforts of Member States to adopt National Action Plans and welcomed the support of the Secretariat. It remarked on the importance of national action plans and pointed out that global surveillance is crucial.

The United States noted that it was encouraged by the work to develop national action plans but said that there needs to be work in 4 areas: (i) improve surveillance and response; (ii) improve infection control: (iii) help countries improve stewardship; and (iv) develop new diagnostics, vaccines, and methods for infection control.

The US also remarked that a strong leadership from this group was critical and expressed its concern that they will not be able to realize the goals by September 2017 and the urgent need for action.

Japan welcomed the efforts made and has put AMR high on the agenda. On the basis on this momentum ideas need to be translated into action. Japan noted the need to promote education for health workers.

Australia noted the need for action, cooperation, and momentum. It also expressed its support for the interagency group and the advancement of the development and stewardship framework. Australia welcomed further engagement with Member States on the development of the framework.

Norway took note of progress against AMR including that more than 32 countries have completed national action plans and have started to implement them. For the rest of the countries Norway requested the Secretariat to give information on the steps that are being taken to follow up.  It noted that the role of the environment and of the total ecosystem has to be taken into consideration in AMR, including contamination from pharmaceutical manufacturing. It also mentioned the importance of One Health and encouraged WHO to work with UNEP and other intergovernmental organizations working on Sustainable Development Goals. Norway added that  the expert consultations should be conducted before May and that urgency must be balanced with good processes to engage all relevant stakeholders.

Germany commended the successful achievement towards implementation of the GAP on AMR, for example the launch of the Global Antibiotic Research and Development Partnership (GARDP) together with DNDi. It requested to know more about the joint partnership with FAO and OIE, noting the need for joint action at all levels.  Germany stressed that during its G20 Presidency there will be focus on AMR, noting the commitment of agricultural ministers on 22 January 2017 to use antibacterials only for therapeutic use in veterinary medicine.

(Antibiotic use for growth promotion in the livestock industry is controversial and some countries have moved to ban such use.)

Switzerland emphasized the need to get politicians at the highest level to be aware of the problem and requested to learn more about the development of the inter-agency task force. Switzerland has had visits with partner countries to learn from their experience and believe all partners need to invest more in R&D. This has been neglected for too long because of problems in the market. It stressed the need for coordinated and harmonized actions among different actors because no one can address this on their own. It is committed to stepping up public private partnerships, i.e. GARDP, and will continue to support international and intersectoral cooperation.

Denmark pointed out that the political declaration confirmed the fight on AMR. It has taken the initiative and drafted an action plan on AMR and was the first to develop and implement a national AMR surveillance. Denmark has also introduced a new real time hospital monitoring system to monitor hospital-acquired infections. It is also committed to the One Health approach.

There were 9 NGOs that made interventions under this item, including Medicus Mundi International (MMI) who delivered the intervention with the support of members of the global Antibiotic Resistance Coalition.

MMI said that while finalising the Global Stewardship and Development Framework, the WHO and Member States must ensure that a “development” framework means supporting a sustainable ecosystem for antimicrobial innovation through open, collaborative models of R&D that ensure fair returns on public investment. Civil society’s involvement, as in the past, needs to continue at the planned regional meetings on National Action Plans and future consultations on both the framework and monitoring and evaluation efforts.

The statement echoed the call to ensure CEWG principles of affordability, equity and de-linkage are incorporated in all mechanisms that address the problem of AMR, stressing that this also presents an ideal opportunity to exercise policy coherence, reiterated in the final report of the UN High Level Panel Report on Access to Medicines.

MMI called attention to the critical gaps in national action plans, adding that without commitment of adequate financial and technical resources from the WHO and partners, particularly for developing and least developed countries, development and implementation of these National Action Plans will not occur.

Together with many NGOs, MMI called on WHO to be fully transparent of the process around the UN General Assembly’s call for an ad hoc interagency coordination group. Such a process must be inclusive of all concerned, including civil society, remain free of conflict of interest, and be representative both of the global North and South.

We also urged WHO to exercise leadership, working intersectionally with Member States and Inter-Governmental Organisations to advance the Global Stewardship and Development Framework for public health interests.

Medecins Sans Frontieres (MSF) stressed that it is time to move from commitment to action. Now the focus must be on fully implementing these commitments through the development, funding, and execution of national action plans, as well as normative and regulatory frameworks. This includes a global framework for development and stewardship to ensure needs-driven innovation, and affordable and sustainable access to existing and new health technologies.

It further said that the AMR response must recognise the multifactorial nature of AMR, with a public health-driven agenda that puts the needs of patients at the core of the response. Referring to its own work in developing countries, MSF said there is a need to improve surveillance, laboratory-diagnostic capacity, and infection prevention and control; strengthening human resources and health systems are also essential.

It welcomed Member States’ agreement to hold a UN high-level meeting on tuberculosis in 2018, and urged Member States and WHO to implement commitments to increase affordable access to vaccines, diagnostics, and drugs, which are critical to reduce antibiotic use, improve specificity of diagnosis, and ensure patients have the medicines they need in a timely fashion.

Emphasizing that R&D on new health technologies is crucial, MSF also pointed out Member States must ensure affordable access on public R&D investments, with full implementation of the public health safeguards that Member States and WHO have already agreed to in the CEWG and GSPOA (Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property)processes, including de-linking R&D costs from prices and sales.

The Director-General of WHO, Dr. Margaret Chan, stressed that AMR is an important subject and thanked all Member States for their global action plan and also for approving the political declaration. Dr. Chan mentioned that the interagency group is being stalled by the transition of the new UN Secretary General into office but WHO is working on it. WHO has proposed a way forward to the new Secretary-General to uphold the political declaration. Dr. Chan remarked that it is difficult to get women scientists who know the subject in developing countries to address the gender balance. On the technical level, WHO has not slowed down to support countries, she said.

Senior Advisor to the Director-General and Special Representative for Antimicrobial Resistance, Dr. Hajime Inoue remarked that all the interventions showed strong commitment. Dr. Inoue said that WHO is currently working closely with the UN Secretary-General’s office to move forward on the interagency group and is expecting a decision soon and WHO is ready to move forward as soon as it is launched. Dr. Inoue observed that Member States had asked for transparency and noted that there will be an occasional mission briefing in Geneva to all Member States to provide updates once the interagency group is established.

On the National Action Plans, all Member States have agreed to finish by this year’s WHA session in May. The current progress shows 49 completed national plans and 67 countries in good progress which covers around 80% of the global population, so generally work is on track and WHO is working with Member states who are behind and updates will be provided at the coming WHA.

On the Global Antimicrobial Resistance Surveillance System (GLASS)this was launched in March 2016 and now 30 countries are involved and additional 10 in progress.

On the Development and Stewardship framework WHO is not ready to make a final report at the forthcoming WHA but there is good progress including:

1.     Establishment of an essential medicines list including antibiotics, and a draft will be ready this week and more details in the forthcoming WHA.

2.      Working to guide R&D priorities, including a priority list for pathogens for which product development is needed. More updates will be provided at forthcoming WHA.

The Board noted the Secretariat’s report.

(* With inputs from the Watch team of the People´s Health Movement, and edited by Chee Yoke Ling.)