4. Special focus: Assessing the landscape of national action plans on antimicrobial resistance

In recent years, the global community made important strides to tackle AMR. In May 2015, all members of the World Health Organization (WHO) made a commitment to tackling AMR by adopting the Global Action Plan (AMR-GAP) (WHO, 2015[1]). The AMR-GAP articulated five strategic objectives (Box 4.1) and urged countries to develop their own AMR national action plans (AMR-NAPs) in line with these strategic objectives, as well as the standards and guidelines championed by other intergovernmental bodies like the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (WOAH) and the Codex Alimentarius Commission.

Following the publication of the AMR-GAP, global efforts to tackle AMR gained momentum. In 2016, the members of the United Nations (UN) reaffirmed their commitment to the vision laid out in the AMR-GAP in the UN Political Declaration on AMR (UN, 2016[2]). The following year, G20 countries endorsed the AMR-GAP and called for the development of a global AMR R&D collaboration hub, which was launched in 2018. In 2019, the UN Ad Hoc Interagency Co-ordination Group on Antimicrobial Resistance (ICGAR) issued an urgent call to establish a One Health Global Leaders Group on Antimicrobial Resistance (WHO, 2019[3]). In 2020, AMR was highlighted as one of the five priority areas for global action in the WHO Thirteenth General Program of Work (2019-23) to improve population health and well-being (WHO, 2020[4]). This programme of work included one indicator – the proportion of bloodstream infections due to resistant organisms – as part of 46 key performance indicators to track progress by 2023 (WHO, 2020[4]). Importantly, many of these efforts have fostered collective, multi-sectoral action widely referred to as the One Health framework (Box 4.2). In 2022, the WHO, FAO, WOAH and United Nations Environment Programme (UNEP) published a new framework which describes the background and context of collaboration to tackle AMR and presents a theory of change associated with collaboration across agencies, including goals and objectives, desired country-level impact, intermediate outcomes, assumptions and risks, and implementation arrangements (WHO et al., 2022[5]).

The goal of this chapter is to review the AMR-NAP landscape in OECD members, key partners and G20 countries. As the first of the two policy chapters included in this publication, it starts by documenting the global progress in the development of AMR-NAPs and describes the factors that enable or hinder the implementation of these documents. Data used for this analysis come primarily from the most recent wave of the Tripartite AMR Country Self-Assessment Surveys conducted by the WHO, WOAH and FAO in 2020-21 (WHO/FAO/WOAH, 2022[12]). Next, the chapter takes a deep dive into the content of 21 AMR-NAPs selected among OECD and G20 countries. To do this, the chapter provides new evidence on the selected design features of the AMR-NAPs that may influence the effectiveness of the implementation of the vision set out in these documents. Next, the chapter assesses the level of alignment between the AMR-NAPs and the AMR-GAP. Complementing this analysis, Chapter 5 then provides an overview of emerging evidence on the effectiveness of selected AMR interventions.

The launch of the AMR-GAP in 2015 augured well for the development of AMR-NAPs across the globe, though many countries grapple with challenges in the execution of their action plans. The number of countries with AMR-NAPs more than doubled since 2016-17, reaching 149 countries in 2021-22 (WHO/FAO/WOAH, 2022[12]). Despite this, only 10% (17/166) of action plans proceeded to the most advanced stage of implementation in 2020-21, which involves the inclusion of financial provision for AMR-NAPs in the national plans and budgets (WHO/FAO/WOAH, 2022[12]). These findings are consistent with a recent discussion paper by the UN ICGAR, which showed that most countries face challenges in the execution of their AMR-NAPs rather than the development of these documents (ICGAR, 2018[13]).

AMR remains prominent in the public health agenda in OECD , EU/EEA and G20 countries but challenges persist (Figure 4.1). In 2021-22, about 92% (47/51) of OECD countries, key partners, EU/EEA and G20 countries finished developing their AMR-NAPs. However, the majority of these countries have not yet proceeded to the most advanced stage of implementation. In 2021-22, only around 20% (10/51) of these countries proceeded to the final stage of implementation, where financial provisions for the implementation of AMR-NAPs were included in the national plans and budgets (WHO/FAO/WOAH, 2022[12]). Importantly, many OECD countries reported that the AMR-relevant activities that they highlighted in their AMR-NAPs have been adversely impacted by the COVID-19 pandemic (Box 4.3).

A socio-economic development gradient emerges in the implementation of AMR-NAPs. In 2021-22, among high-income countries (HICs), about 20% of AMR-NAPs advanced to the final stage of implementation, compared to 7% in upper-middle-income countries (UMICs) and in lower-middle-income countries (LMICs) and none of the low-income countries (LICs) (WHO/FAO/WOAH, 2022[12]). While the evidence base that can help explain these discrepancies remains limited, previous works from low-resource settings point to the deficits in technical capacity and staffing, institutional bottlenecks that hinder efforts to scale up local efforts (ICGAR, 2018[13]) and the differences in the governance approach to managing AMR (Birgand et al., 2018[15]).

Insufficient funding devoted to AMR is another bottleneck. A recent Wellcome Trust analysis concluded that financial limitations present a major impediment to implementing AMR-NAPs in many LMICs. Even when these countries identify funding to support the implementation of their AMR-NAPs, the level of funding may be insufficient to cover all of the intended activities (Wellcome, 2020[16]). In addition, access to high-quality drugs remains a challenge in many LMICs (Hauk et al., 2020[17]), which can exacerbate the emergence of drug-resistant pathogens. In recognition, new pooled funding mechanisms have emerged in recent years to overcome these financial constraints (Box 4.4).

In recent years, AMR has been reframed as a public health issue with important consequences for socio-economic development in resource-constrained settings. In 2018, the ICGAR suggested that AMR is not perceived as a priority issue in many LMICs (2018[13]). The publication analysis indicated that this perception may limit access to development funding and projects. The following year, the World Bank highlighted the need for reframing AMR not only as a public health challenge but also as a global development issue by arguing that AMR has far-reaching implications for human capital in developing countries, and failing to curb the AMR burden may impede progress towards United Nations Sustainable Development Goals (2019[21]).

G7 and OECD countries remain steadfast in their commitment to financing AMR-related activities across the globe but the current level of development funding allocated to AMR is unlikely to fill the existing gaps in domestic funding (Figure 4.3). In 2020, G7 and OECD countries were the leading sources of DAH allocated to AMR, including Australia, France, Germany, the United Kingdom and the United States (IHME, 2021[22]). Yet, the current level of DAH allocated to AMR remains low, with AMR receiving close to around 2% of DAH dedicated to communicable diseases in 2019. Considering that many countries across the globe are marshalling financial resources to address the COVID-19 pandemic, the current level of DAH for AMR is unlikely to make up for the funding gap in low-resource settings.

The period following the publication of the AMR-GAP has seen improvements in the number of countries that sought multi-sectoral feedback while developing their AMR-NAPs. In 2021-22, globally, more than 1 sector was actively involved in the development and implementation of AMR-NAPs in about 98% (162/166) of countries (WHO/FAO/WOAH, 2022[12]). Similarly, in all OECD countries, EU/EEA and G20 countries, at least two sectors actively participated in the development and implementation of action plans in 2021-22 (WHO/FAO/WOAH, 2022[12]). This finding is in congruence with earlier studies which showed that most countries across the globe adopted some form of multi-sectoral approach in the development and implementation of their AMR-NAPs (Munkholm et al., 2021[23]).

Yet, the development and implementation of AMR-NAPs do not always entail the active involvement of all relevant sectors (Figure 4.4). The linkages between human and animal health appears to be well recognised. In 2021-22, in nearly all (165/166) of countries that reported data to the Tripartite AMR Country Self-Assessment Survey, the process to develop and implement AMR-NAPs actively involved the terrestrial animal health sector and, in 96% (158/166) of countries, this process involved the health of aquatic animals. Yet only a fraction of AMR-NAPs, globally, were developed and implemented with the active involvement of the other sectors. In 2021-22, the development and implementation of about 79% (131/166) of AMR-NAPs involved the food safety sector, whereas 65% (108/166) involved the environment, 55% (90/166) food production and only 51% (84/166) reflected the active involvement of the plant health sector (WHO/FAO/WOAH, 2022[12]).

Across OECD countries and key partners, EU/EEA and G20 countries, stakeholders from the animal health sector most commonly take an active role in the development and implementation of AMR-NAPs, whereas stakeholders representing food safety and security, the transmission of AMR in the environment and plant health are less involved. In 2021-22, animal health was nearly universally acknowledged in the AMR-NAPs by OECD members and key partners, EU/EEA and G20 countries. In comparison, in around 90% (46/51) of these countries, the development and implementation of action plans involved the active participation of the food safety sector (WHO/FAO/WOAH, 2022[12]). Similarly, the environment sector was actively involved in the development and implementation of around 71% (36/51) of action plans. In the same period, the food production and plant health sectors were actively involved in the development and implementation of 75% (38/51) and 59% (30/51) of AMR-NAPs respectively.

Globally, important strides have been made in building multi-sectoral co-ordination mechanisms to support multi-sectoral approaches to tackling AMR (Figure 4.5). Establishing multi-sectoral co-ordination mechanisms is an important first step towards facilitating multi-sectoral AMR response (Box 4.5). Globally, 87% (144/166) of countries established some form of a formal multi-sectoral governance or co-ordination mechanism on AMR 2021-22 (WHO/FAO/WOAH, 2022[12]). In 2021-22, nearly all OECD countries, key partners, EU/EEA and G20 countries (49/51) put in place some form of multi-sectoral co-ordination mechanism (i.e. working groups/co-ordination committees) to promote multi-sectoral AMR-relevant policy development and implementation. Importantly, new multinational initiatives emerged to promote multi-sectoral action across countries (Box 4.6). While relatively little is known about the factors that influence the effectiveness of multi-sectoral co-ordination mechanisms, limited evidence suggests that various factors may influence the co-ordination of multi-sectoral action including political will, administrative and financial support, as well as the dearth of available AMR data that can be used to facilitate dialogue and varying priorities across stakeholders (Joshi et al., 2021[24]).

Table 4.1 provides a dashboard of AMR-relevant multi-sectoral policies implemented in OECD countries and key partners, EU/EEA and G20 countries in congruence with the AMR-GAP based on responses provided by countries in the latest round of the Tripartite AMR Country Self-Assessment Survey (2021-22) (WHO/FAO/WOAH, 2022[12]) (Annex 4.A provides more detailed information on the methodology used to develop the dashboard). Findings emerging from this dashboard point to important gaps in implementation:

  • In nearly all OECD countries and key partners, EU/EEA and G20 countries, there are national policies for antimicrobial governance that pertains to the community and healthcare settings. However, only eight of these countries currently have in place guidelines for optimising antibiotic use in human health for all major syndromes, with data on antibiotic use shared back with prescribers in a systematic manner.

  • In nearly all OECD countries and key partners, EU/EEA and G20 countries, a national policy or legislation exists to regulate the quality, safety and efficacy of antimicrobial productions used in terrestrial and aquatic animal health, as well as their distribution sale or use. But, only in 18 of these countries, enforcement and control mechanisms are reportedly in place to ensure compliance with the existing policy or legislation.

  • Nearly all OECD countries and key partners, EU/EEA and G20 countries have a national plan or system for monitoring antimicrobial use in their own settings. But only 26 of these countries regularly collect and report data on antimicrobial sales and consumption at the national level for human use, and data on antibiotic prescribing and appropriate/rational antibiotic use are drawn from a representative sample of health facilities in the public and private sectors.

  • All OECD countries and key partners, EU/EEA and G20 countries reported having the capacity to: i) generate data on antibiotic susceptibility testing, as well as related clinical and epidemiological data; and ii) report AMR. However, only 14 of these countries have a national AMR surveillance system that links AMR surveillance with antimicrobial consumption and/or use data in the human health sector.

  • 23 OECD countries and key partners, EU/EEA and G20 countries reported that infection prevention and control (IPC) programmes are in place and functioning at the national and health facility levels in line with the WHO IPC core components. In these countries, compliance and effectiveness are regularly evaluated and published, and guidance is updated in accordance with monitoring.

  • All OECD countries and key partners, EU/EEA and G20 countries promote AMR awareness, but only nine of these countries have in place routine targeted, nationwide, government-supported activities to raise AMR awareness to facilitate behaviour change among priority stakeholders, with regular monitoring of these activities.

  • All OECD countries and key partners, EU/EEA and G20 countries provide training and professional education opportunities to raise awareness of AMR among health professionals in the human health sector, though only eleven of these countries systematically incorporate AMR in pre-service training curricula for all relevant human health cadres, and in-service training and other professional education opportunities are taken up by relevant groups for the human health sector in public and private sectors.

  • All OECD countries and key partners, EU/EEA and G20 countries reported having in place some systematic efforts to improve good animal husbandry and biosecurity practices in terrestrial animal health. But only eight of these countries monitor the implementation of their nationwide plans periodically. Similarly, 43 OECD countries and key partners, EU/EEA and G20 countries make systematic efforts to improve good practices for aquatic animals and only six of these countries monitor the implementation of their nationwide plans regularly.

  • Forty-eight OECD countries and key partners, EU/EEA and G20 countries reported having in place some mechanisms to improve good practices in food processing. However, only ten of these countries monitor the implementation of their nationwide action plans periodically.

The remainder of this chapter presents results from a systematic assessment of the content of AMR-NAPs from selected OECD countries and key partners, EU/EEA and G20 countries based on a natural language processing (NLP) approach (Box 4.7). The OECD analysis first looks at the selected design features of AMR-NAPs, including performance tracking over time, engagement with international and regional bodies, and financial considerations and cost-effectiveness assessments. These features were selected because they were proposed as part of key design aspects of the AMR-NAPs that impact the effectiveness of the vision laid out in these documents (Chua et al., 2021[28]; Ogyu et al., 2020[29]; Anderson et al., 2019[30]). Next, the level of alignment between AMR-NAPs and the AMR-GAP is examined in terms of the strategic objectives and interventions recommended in the AMR-GAP.

OECD countries and key partners, EU/EEA and G20 countries are diverse in terms of the time period of implementation they cover in their AMR-NAPs. Typically, AMR-NAPs are forward-looking documents that set out strategic goals and objectives to be realised in a predetermined period of time. The OECD analysis shows that, on average, the AMR-NAPs from the countries included in the analysis cover a span of nearly five years. But exceptions arise. The AMR-NAP from the Slovak Republic has the narrowest time span covering the two-year period 2019-21, whereas the AMR-NAP from Australia sets a 20-year vision for the years from 2020 to 2040. In addition, the OECD analysis shows that AMR-NAPs from 6 OECD countries and key partners, EU/EEA and G20 countries predate the AMR-GAP and have not yet been updated since their initial publication, while many other AMR-NAPs are approaching the end of their coverage period.

There is a need to streamline the process to track performance relevant to the commitments made in the AMR-NAPs. Once they develop their AMR-NAPs, OECD members rely on different approaches to tracking their performance. For example, following the publication of its AMR-NAP in 2015, Germany regularly published interim reports that describe the national and subnational progress towards the goals stated in its AMR-NAP. France provides annual updates on the country’s progress towards the strategic priorities discussed in its AMR-NAP. Similarly, Australia publishes technical reports and analyses in regular intervals to continue to improve AMR awareness in hospital and community settings (ACSQHC, 2021[37]). While these efforts provide a valuable avenue to assess each country’s performance, there is little cross-country standardisation in the ways in which OECD countries examine their performance, making it difficult to compare cross-country performance over time.

The OECD countries and key partners, EU/EEA and G20 countries explicitly recognise that curtailing AMR requires building international alliances and partnerships, but the nature of engagement with international bodies is often left undiscussed. While all 21 AMR-NAPs referred to the WHO as a key partner in tackling AMR, only around 71% (15/21) directly referenced the AMR-GAP. In addition to the WHO, nearly all OECD countries and key partners, EU/EEA and G20 countries made references to the WOAH, reflecting increasing attention to animal health as a pathway to tackle AMR. In comparison, the FAO was mentioned only by two-thirds of AMR-NAPs (14/21) and UNEP was highlighted in less than 15% (4/21) of these documents. Importantly, even when these documents reference international bodies in their action plans, they do not often provide details on the extent of their engagement.

Globally, a number of regional AMR initiatives proliferated in recent years to tackle AMR (Box 4.8). In 2017, EU member states adopted the 2017 European One Health Action Plan against Antimicrobial Resistance, with the aim of bringing the EU to the forefront of efforts to tackle AMR (European Commission, 2017[38]). Another important regional initiative was initiated when AMR was included in the five-year work programme of the Association of the Southeast Asian Nations (ASEAN) from 2016 to 2020 (Yam et al., 2019[39]). ASEAN members reiterated their commitment to regional co-operation in tackling AMR in the 2017 Joint Declaration on Action against AMR and 2018 ASEAN Plus Three Leaders’ Statement on Co-operation against Antimicrobial Resistance. In 2018, the newly launched Africa Centres for Disease Control and Prevention (Africa CDC) network developed a framework for tackling AMR (Africa CDC, 2018[40]). In this framework, the members of Africa CDC committed to establishing the Antimicrobial Resistance Surveillance Network, which will serve as a platform to foster collaboration across national public health institutions in the region.

Most AMR-NAPs lack detailed discussions around financial resources allocated to supporting the AMR agenda. The AMR-GAP underscores that countries need to make financial commitments to ensure advancements towards the policy vision laid out in their action plans (WHO, 2015[1]). Further, the WHO, FAO and WOAH recommend that countries perform regular assessments and reviews of the existing financial commitments in order to ascertain whether funds are dispersed in a timely fashion and in accordance with the priorities discussed in the AMR-NAPs (WHO/FAO/WOAH, 2019[42]). Despite this, only 57% (12/21) of the AMR-NAPs from OECD countries and key partners, EU/EEA and G20 countries discuss financial considerations and, even when financial considerations are mentioned, the level of financial resources committed to the AMR agenda often remains unclear.

Return on AMR-relevant investments can be better understood by utilising evidence generated by cost-effectiveness assessments of interventions highlighted in AMR-NAPs. The OECD analysis shows that only around 43% (9/21) of OECD countries and key partners, EU/EEA and G20 countries refer to the cost-effectiveness of AMR-relevant investments that they consider in their action plans. For instance, the AMR-NAP from Switzerland highlights that research efforts focusing on the development of new diagnostic products are considered to be a cost-effective measure to facilitate the rapid detection of AMR. The AMR-NAP from the United Kingdom also alludes to the cost-effectiveness of diagnostic tools and suggests that evidence generated by cost-effectiveness models that demonstrate the value of diagnostic tools can be used to spur behaviour change among prescribers and health commissioners and encourage greater use of diagnostic tools. The AMR-NAP from Canada highlights that establishing a fast-track process to license antimicrobial drugs, alternatives to antimicrobials and new diagnostics is a cost-effective strategy to scale up investments in the development of pharmaceuticals. In the AMR-NAP from Malta, raising the awareness of employers on the benefits of extending options for home rest for employees who recover from mild infections is highlighted as a cost-effective strategy to interrupt the transmission of diseases in the workplace.

The OECD countries and key partners, EU/EEA and G20 countries are consistent with the AMR-GAP in terms of strategic objectives that they adopt in their action plans (Figure 4.7). Much like the AMR-GAP, the most frequently emphasised strategic objective by OECD, EU/EEA and G20 countries relates to interventions aiming to optimise the use of antimicrobial medicines in human and animal health, followed by strengthening AMR surveillance, enhancing sanitation, hygiene and waste management practices and spurring investments in AMR technologies. In comparison, increasing AMR awareness and education is the least frequently discussed strategic priority by countries and key partners, EU/EEA and G20 countries, as well as the AMR-GAP.

Different AMR-relevant interventions receive varying levels of attention across AMR-NAPs from the OECD countries and key partners, EU/EEA and G20 countries. For instance, with respect to interventions aiming to raise AMR awareness and understanding, Denmark and France stand out as countries that more frequently emphasise strategies to improve public awareness of AMR compared to others. Integrating AMR in professional education and training is more frequently highlighted in the action plans from Germany and the Slovak Republic. In terms of strengthening AMR knowledge and surveillance, Japan, New Zealand and the United States more frequently emphasise considerations around integrating new data sources into AMR surveillance, compared to the other countries included in the analysis. With respect to interventions to optimise antimicrobial use, Denmark, France and Norway more frequently discuss efforts to monitor antimicrobial consumption compared to other countries. Discussions around the importance of vaccines are more distinctly highlighted by Norway compared to other countries. In comparison, Finland, France and Japan more frequently discuss concerns related to enhancing biosecurity, and food safety and security. With respect to initiatives that aim to make an economic case for AMR investments, Switzerland and the United Kingdom more distinctly include discussions around exploring new market models and economic incentives, whereas Australia and France more distinctly highlight promoting public-private partnerships (PPP).

Several factors help explain the diverging patterns in interventions that countries emphasise in their AMR-NAPs. A greater emphasis on one intervention does not imply that countries neglect other interventions. Instead, these diverging patterns may reflect the range of challenges that influence health system performance in each country at the time that policy makers develop these guiding documents. For example, India – one of the global AMR hotspots – is among the countries that explicitly highlight the importance of restricting the sale of antimicrobials without proper prescription. This pronounced emphasis may be partly due to the high prevalence of informal healthcare providers with no formal medical training in prescribing antimicrobials without prescription (Das et al., 2016[43]).

Alternatively, countries may choose to highlight strategies that they aspire to implement in the future rather than discussing strategies that they already put in place. For instance, Denmark does not provide in-depth discussions on the use of antimicrobials as growth promoters in its action plan even though this practice has been outlawed in the country in 1995. Similarly, in the United States, the AMR action plan does not specifically refer to electronic prescribing (e-prescribing) because this practice is considered to be well-integrated into the health system. Another alternative explanation relates to the socio-economic, historical and political factors, as well as the broader health system governance arrangements that may influence which interventions are ultimately featured in the AMR-NAPs. For instance, in Denmark and Sweden, veterinarians, farmers and regulatory authorities have a long history of co-operation and collaboration, which has been shown to affect the ways in which the AMR agenda has developed in these countries (Björkman et al., 2021[44]; FAO, 2020[45]).

Most policies that aim to optimise the use of antibiotics recognise that the choices made by individuals are an important part of antibiotic use. Health professionals’ prescription behaviours are influenced by a range of factors including their medical training, the availability of systems that support clinical decision-making, provider compensation methods, professional and social preferences, and norms. Similarly, patient knowledge, preferences and attitudes play an important role in antibiotic use. Patient behaviours such as self-medication and non-compliance with the recommended course of treatment undermine efforts to curb AMR. Interactions between healthcare providers and patients have also been shown to influence behaviours around antibiotics.

All 21 AMR-NAPs explicitly recognise the importance of optimising the use of antibiotics, though these documents lay out a wide array of approaches to achieve this goal (Figure 4.8). Much like the AMR-GAP, AMR-NAPs from OECD countries and key partners, EU/EEA and G20 countries most frequently highlight efforts to strengthen antimicrobial stewardship programmes (ASPs) to promote the prudent use of antimicrobials. ASPs typically refer to a set of complex programmes that involve the implementation of multiple interventions designed to improve the ways in which antibiotics are prescribed by health professionals and used by patients. In addition to ASPs, enhancing the use of diagnostic tools is another frequently mentioned strategy in action plans, as well as monitoring the consumption of antimicrobials. In comparison to other interventions to optimise antibiotic use, OECD countries and key partners, EU/EEA and G20 countries less frequently mention efforts to limit the sale of antibiotics without a prescription and counterfeit or substandard antimicrobial sales, optimise animal feeding practices and restrict the use of antibiotics as growth promoters.

OECD countries rely on ASPs with varying design features to optimise antibiotic use to reflect the needs and priorities in their own settings. For example, in its AMR-NAP, Denmark considers a range of national and local measures to reduce the overall consumption of antibiotics in primary healthcare, with a recognition that different regions may require different measures to achieve the desired reductions in antibiotic consumption. The Danish approach has an explicit focus on the treatment of specific target groups like respiratory infections in children, coughs in adults or urinary tract infections in women. In addition, the Danish AMR-NAP encourages delayed prescribing practices, co-operation with regional consultants and promotion of tools that can provide electronic overviews and comparisons of prescribing practices. In comparison, in its AMR-NAP, Sweden aims to promote the responsible use of antibiotics rather than an overall reduction in antibiotic consumption. To achieve this goal, Sweden relies on a multi-modal approach that includes a continued focus on antibiotics prescriptions by authorised professionals, continued measurement of data on compliance with treatment guidelines both in human healthcare and veterinary medicine, adequate access to new and older antibiotics, and an emphasis on quality assured and adequate diagnostics, as well as the management of common infections. Importantly, Sweden combines interventions focusing on prescribing behaviours in the human health sector with efforts to promote responsible antibiotic manufacturing, safe disposal of antibiotics and waste management to promote responsible use in the lifetime of the antibiotics, as well as efforts to optimise antibiotic prescribing in veterinary medicine.

Recent WHO guidance points out that course corrections may be needed in the implementation of activities carried out under the overall organisation of ASPs over time. These modifications may be introduced either by altering the ways in which the interventions are implemented on the ground or by introducing new interventions to reflect the evolving needs in a given context of care (WHO, 2019[46]). The WHO guidance notes that the ease of implementation of each type of ASP will largely correlate with the availability of resources and competencies in health facilities and recommends the prioritisation of interventions in accordance with resource availability in a given context.

The effectiveness of many ASPs can be enhanced by extending antibiotic guidance to healthcare settings beyond hospital and acute care. The OECD analysis shows that hospitals and acute care facilities constitute around 75% of different types of healthcare settings discussed in AMR-NAPs from OECD countries and key partners, EU/EEA and G20 countries, followed by primary healthcare, and community settings (14%) and long-term care (11%). Moreover, none of the AMR-NAPs makes any references to developing guidance for telemedicine, even though this mode of healthcare delivery had already been on the rise even before the COVID-19 pandemic (Oliveira Hashiguchi, 2020[47]).

Only a handful of OECD countries adopt a comprehensive approach to tackling AMR in older populations. For example, Japan is considering options to incorporate materials concerning AMR, IPC and antimicrobial stewardship into the undergraduate curriculum and training guidelines for professionals deployed in nursing care. In addition, the national qualification examinations for nursing care staff will expand their focus on these topics. Japan also aims to strengthen AMR surveillance in nursing care, while conducting research to establish the current status of AMR in nursing care facilities. Complementing these efforts, Japan aims to establish clinical reference centres for AMR at the local level. These centres will be responsible for developing AMR-relevant educational materials to be used in a variety of settings, including nursing homes. These interventions will be supported by revising the IPC guidelines and manuals, which will introduce AMR and AMR screening components.

The Access, Watch and Reserve (AWaRe) framework offers another important avenue for OECD countries to support their local, national and global efforts to strengthen ASPs. The WHO developed the AWaRe framework in 2017 as part of the Essential Medicines List (EML) (WHO, 2021[48]). The AWaRe classifications provide a valuable framework for monitoring the use of antibiotics, setting targets and evaluating the effectiveness of ASPs (WHO, 2021[48]). It also provides a list of drugs that are is considered essential for the provision of basic healthcare services. In 2021, the AWaRe framework classified a total of 258 antibiotics across three groups:

  • Access: Broadly, Access antibiotics are comprised of lower-spectrum drugs used primarily as first- or second-line therapies. The WHO recommends that Access antibiotics constitute at least 60% of total consumption at the national level by 2023.

  • Watch: The Watch antibiotics contain broad-spectrum antibiotics and they pose a greater risk for AMR. The WHO recommends that Watch antibiotics are used only for treating specific indications.

  • Reserve: The Reserve antibiotics should be considered as a last resort, with their use being monitored closely and targeting multidrug resistant infections.

Emerging evidence suggests that, without urgent policy action, the WHO national-level targets for Access antibiotics is unlikely to be met. In its General Programme of Work 2019-23, the WHO adopted a country-level target of the Access antibiotics accounting for at least 60% of the total consumption by 2023 (WHO, 2020[4]). Recent trends in antibiotic use across the globe suggest that this goal is unlikely to be met. Between 2000 and 2015, global antibiotic consumption increased by 39% between 2000 and 2015 (Klein et al., 2018[49]). While a rise in antibiotic use does not necessarily imply a rise in the imprudent use of antibiotics, this period has seen an alarming rise in the use of Watch antibiotics, especially in LMICs. The consumption of Watch antibiotics rose as much as 91% from 2000 to 2015, as measured by an increase from 3.3 to 6.3 defined daily doses (DDD) per 1 000 inhabitants per day (Klein et al., 2021[50]). At the same time, per-capita consumption of Access antibiotics as a share of total antibiotic consumption has seen an increase of 26% from 2000 to 2015 (Klein et al., 2021[50]). Compared to the Access and Watch antibiotics, the consumption of the Reserve group remains low. The rapid rise of Watch antibiotics points to challenges in the execution of ASPs, particularly in LMICs, and makes it difficult to achieve the WHO target for the use of Access antibiotics by 2023 (Klein et al., 2021[50]; Roberts and Zembower, 2021[51]).

The OECD countries and key partners, EU/EEA and G20 countries should also consider increasing access to older antibiotics. As discussed earlier, some older classes of antibiotics like tetracyclines and temocillin can still be used to treat certain indications. Despite this, only about 24% of AMR-NAPs (5/21) included in the analysis reference older antimicrobials. Different OECD countries put forward different motivations for promoting the use of older antibiotics in their AMR-NAPs. For instance, Sweden indicates that the use of older antibiotics, combined with access to newer antibiotics, is one strategy to increase the availability and use of antibiotics in the drug market in order to provide the best possible care. The United States also highlights the need for identifying new avenues for using older agents. In its AMR-NAP, the United States aims to make progress towards this goal by supporting data collection and evaluation, and by supporting the establishment/revision of antibiotic susceptibility testing standards.

E-prescribing offers another promising avenue to improve monitoring antimicrobial use. Only 4 out of 21 AMR-NAPs included in the OECD analysis reference e-prescribing. E-prescribing practices are often featured in the AMR-NAPs as a way to improve the existing arrangements for monitoring antimicrobial use in healthcare settings. For example, the AMR-NAP from the United Kingdom indicates that, in Scotland, unique patient identifiers are used across primary and secondary care to track patients and monitor changes in antimicrobial use over time. In Finland, the option to use e-prescribing is explored as an option to improve the surveillance of the consumption of antimicrobials. In Malta, e-prescribing is considered as one option to measure antibiotic use at the farm level and information gathered through e-prescribing can be used to link clinical indication, microbiological and consumption data.

Enhancing the use of diagnostics is another highly emphasised strategy by OECD countries and key partners, EU/EEA and G20 countries. New diagnostic technologies like rapid diagnostic tests can aid providers in their decisions in the course of medical treatment by helping to obtain information about their patients rapidly, thereby curbing the unnecessary use of antibiotics. In recent years, OECD countries have made important strides to improve the availability of rapid diagnostics. For instance, the United Kingdom established the Longitude Prize in 2014 – an innovation fund aimed at incentivising the development of novel rapid tests to help reduce the overuse and misuse of antibiotics in human health. In the United States, the Antimicrobial Resistance Diagnostic Challenge – a federal prize competition – seeks to incentivise the development of novel rapid point-of-care and in-vitro laboratory diagnostic tests that can help identify and categorise resistant bacteria and/or discriminate between viral and bacterial infections (NIH, 2020[52]). These continued investments in the development of new diagnostic technologies have been instrumental in the development of a new point-of-care Clostridioides difficile diagnostic assay in 2017 and a diagnostic test for gonorrhoea in 2020 (Trevas et al., 2020[53]).

Most AMR-NAPs do not include indicators to monitor the consumption of antimicrobials. The AMR-GAP and subsequent guidance from the WHO, FAO and WOAH underscore the importance of tracking patterns in the consumption of antimicrobials to assess the performance of antimicrobial stewardship efforts (WHO/FAO/WOAH, 2019[42]; WHO, 2015[1]). Despite this, only around 19% of AMR-NAPs (4/21) refer to having at least one indicator based on a measure of DDDs or days of therapy. Moreover, none of the countries included in the OECD analysis refer to performance indicators that can help track changes in the fraction of bloodstream infections due to selected AMR organisms as recommended by the WHO (2020[4]).

OECD countries vary substantially in terms of the quantifiable performance targets that they adopt (Table 4.2). For example, in its AMR-NAP dating October 2020, the United States sets out a 20% reduction in the number of healthcare-associated resistant infections by 2025 and a 10% decline in community-acquired resistant infections. In comparison, the AMR-NAP from Denmark describes three related goals for optimising antibiotic consumption from 2016 to 2020. In the primary healthcare sector, a 24% reduction is set in the number of antibiotic prescriptions redeemed from 450 to 350 per 1 000 inhabitants from 2016 to 2020. In this period, a 10% reduction is aimed at the consumption of critically important antibiotics, while increasing its reliance on narrow-spectrum antibiotics like penicillin V. Norway also sets a comprehensive list of targets in optimising antibiotic use in its AMR-NAP. For instance, Norway aims to become one of the European countries with the lowest levels of antibiotic consumption. To achieve this goal, a 30% reduction in antibiotic use is set from 2012 to 2020, as measured in DDD per 1 000 inhabitants per day. In addition, Norway aims to reduce the use of antibiotics prescribed for respiratory infections by 20% in the same period. These targets in the human health sector are supplemented with quantifiable targets in animal health. For instance, for food-producing animals and household pets, Norway aims to achieve at least a 10% and 30% respective reduction in antimicrobial use from 2013 to 2020.

Providers in the human and animal health sectors often rely on the same or highly related antibiotics for treatment (WHO, 2017[54]). The WHO systematically groups antimicrobials into separate categories in accordance with their importance to human health: important, highly important or critically important for human medicine. This classification system underpins the WHO List of Critically Important Antimicrobials for Human Medicine (CIA List). CIAs are antibiotic classes that are used either: i) as the sole or among the limited therapies to treat serious bacterial infections in humans; or ii) to treat infections in humans caused by either bacteria that may be spread from non-human sources, or bacteria that may attain resistance genes from non-human sources (WHO, 2017[54]).

The WHO urges countries to consider the list of CIAs in the development and implementation of interventions to manage risks associated with antimicrobial use in food animals (WHO, 2017[54]). Yet, the OECD analysis suggests that gaps remain in the available antibiotic guidance in veterinary medicine, with about one-third of AMR-NAPs (6/21) from 21 countries included in the analysis lacking any references to the CIAs altogether. Moreover, none of the action plans include a performance measure to track the volume of CIAs sold, even though this is one of the indicators recommended by the WHO to assess progress in the implementation of the AMR-GAP (WHO, 2017[55]).

Efforts to provide guidance on the veterinary use of antibiotics are often supplemented with regulatory measures to limit the use of antimicrobials as growth enhancers on otherwise healthy animals to accelerate weight gain and improve feed efficiency as recommended by the WHO (2017[54]). Currently, regulatory frameworks that restrict the use of antimicrobials for growth promotion remain uneven across geographic regions. In 2018, around 23% (35/153) of countries that participated in the most recent WOAH global survey indicated that they currently allowed the use of antimicrobials for growth promotion (WOAH, 2020[56]). Most countries that allowed antibiotics to be used for growth promotion were located in the Americas region (17/30), followed by the Asia, Far East and Oceania regions (9/25) and the Africa region (8/44). In contrast, in Europe, only 1 out of 48 countries in the region allowed antimicrobials to be used as growth promoters (WOAH, 2020[56]).

Most OECD countries and EU/EEA members have regulations in place that restrict access to veterinary antimicrobials (e.g. purchases only through authorised pharmacies, veterinarians and wholesalers and based on prescription). For instance, in early 2022, the Veterinary Medicinal Products Regulation (i.e. Regulation EU 2019/6) became applicable (EMA, 2022[57]). This regulation contains measures which outlaw the use of antimicrobial medicinal products, including designated antimicrobials, for prophylactic purposes with certain exceptions and enforce new restrictions for metaphylactic use (EMA, 2018[58]). Moreover, the new regulations include measures for imports from third parties outside the EU area. Specifically, with the new regulations, third county operators that export animals and animal products to the EU area are required to abide by the bans on the use of antimicrobials for growth enhancement purposes (Article 107(2)) and the use of antimicrobials for treating certain infections in human health (Article 37(5)) (EMA, 2018[58]). This is in stark contrast to many LMICs where the over-the-counter purchase of veterinary antimicrobials without the need for a prescription remains the norm and access to veterinary antimicrobials is largely unchecked due to the existing regulatory gaps and difficulties around enforcing existing regulations (Sulis et al., 2020[59]).

Enhancing animal feeding practices is another strategy to optimise the veterinary use of antimicrobials. The FAO indicates that improving animal feeding practices can help reduce the need to use antibiotics by enhancing gut health, fortifying the immune system and building resistance against the pathogens that exist in the environment (FAO, 2012[60]). OECD analysis has showed that OECD countries and key partners, EU/EEA and G20 countries do not consistently refer to options to improve animal feeding practices in their own settings, with only around 52% (11/21) of action plans referring to this strategy.

Some OECD countries are making headways in improving animal feeding practices in their own settings. In 2019, the EC adopted a new regulation in 2019 (i.e. Regulation EU 2019/4), which regulates the use of medicated feed in animal populations (European Commission, 2022[61]). With the introduction of the new regulatory framework, the EU banned the use of antimicrobials in medicated feed for prophylaxis and growth enhancement purposes, established common limits for including antimicrobials in ordinary feed and set common standards for manufacturing safe medicated feed (European Commission, 2022[61]). In addition, the new regulations serve as a legal framework for manufacturing and distributing medicated feeds used for pets.

Strengthening AMR surveillance is key to addressing the AMR burden. Data gathered through surveillance provide the basis for developing and revising clinical treatment guidelines and inform the design and implementation of many ASPs and IPC guidelines, as well as the implementation of public health initiatives like vaccination programmes. Similar to the AMR-GAP, all OECD countries and key partners, EU/EEA and G20 countries included in the OECD analysis refer to the importance of strengthening AMR surveillance. These countries most frequently discuss strategies to enhance AMR surveillance capacity, while options to deepen the level of engagement with global and regional AMR surveillance networks and to promote new data sources in AMR surveillance are discussed to a lesser extent (Figure 4.9).

While OECD countries and key partners, EU/EEA and G20 countries universally acknowledge the centrality of AMR surveillance in their action plans, further advancements can be made by harmonising methodological approaches in data collection. A lack of harmonisation in the standardisation of epidemiological definitions of AMR, coupled with the variations in data and sample collection approaches, and microbial testing methods and data sharing policies hinder reliable and collaborative AMR surveillance. For instance, one recent study found that only one-third of EU/EEA member states with AMR surveillance networks provide a clear definition of AMR in their technical guidelines and close to half do not indicate whether the definitions that they use are consistent with the definition used by European Committee on Antimicrobial Susceptibility Testing or Clinical and Laboratory Standards Institute guidelines (Tacconelli et al., 2018[62]).

Expanding the laboratory network capacity can help enhance rapid detection of AMR, identify new threats and inform the development of strategies to prevent the emergence of infections. Efforts to expand the laboratory network capacity are not often discussed in the AMR-NAPs, though there are notable exceptions. For instance, in its AMR-NAP, the United States refers to the Antibiotic Resistance Laboratory Network, which was established in 2016 as a network of laboratories across 50 states, including 7 regional laboratories and the National TB Molecular Surveillance Centre. In Europe, 29 EU countries participate in the European Antimicrobial Resistance Surveillance Network (EARS-Net), which is the largest publicly funded AMR surveillance platform. Other OECD countries are also taking steps to improve the existing standards around laboratory testing. As part of an effort to establish national minimum standards for laboratory testing and reporting antimicrobial susceptibility, New Zealand aims to establish a committee that will be tasked with providing expert guidance for laboratories and other stakeholders, with a specific focus on human susceptibility testing and reporting. This move will be supplemented with efforts to standardise the methodology and reporting of AMR data from human health laboratories.

OECD countries, EU/EEA and G20 countries will benefit from clarifying the ways in which they engage with the existing global and regional surveillance networks. Since 2000, more than 72 supranational networks have been developed to monitor AMR in bacteria, fungi, human immunodeficiency virus (HIV), TB and malaria (Ashley et al., 2018[63]). Yet earlier studies suggest that many local and national AMR surveillance systems have very little co-ordination, harmonisation and information sharing with international surveillance frameworks (Tacconelli et al., 2018[62]). Consistent with this study, the OECD analysis shows that 16 out of 21 OECD countries and key partners, EU/EEA and G20 countries make references to global and regional AMR surveillance networks like the Central Asian and European Surveillance of Antimicrobial Resistance (CAESAR), EARS-Net, the Global Antimicrobial Resistance and Use Surveillance System (GLASS) and the Global Antibiotic Research and Development Partnership (GARDP). However, even when countries refer to these networks, they do not consistently describe the ways in which they engage with these networks, nor do they always provide a vision for future engagement.

Further progress is needed to scale up international and national-level surveillance systems for AMR in animal populations and in the food chain. While some OECD countries lack surveillance systems to monitor AMR in animals, others have made efforts in recent years to build their own systems, including the Czech Republic, Denmark, Finland, France, Germany, Norway, Sweden and the United Kingdom (EU-JAMRAI, 2021[64]). While this is good news, previous studies highlight that the existing surveillance networks are highly fragmented, with countries monitoring different animal specials, antimicrobials and bacterial species (EU-JAMRAI, 2021[64]). Moreover, cross-country comparison of available data is often not possible due to methodological differences in data collection efforts.

Investing in timely and targeted dissemination of surveillance data is another vital strategy to strengthen AMR surveillance. Currently, point-prevalence surveys and laboratory-based surveillance are the primary sources of AMR-related information in many countries (Tacconelli et al., 2018[62]). Data collected through these means often take time to publish and disseminate, which limits the usefulness of these data for informing clinical and regulatory decision making. Many OECD countries continue to rely primarily on point-prevalence surveys and laboratory-based surveillance. For instance, in Europe, only about 3% of AMR surveillance systems are equipped to provide access to real-time data (Tacconelli et al., 2018[62]).

Integrating data from novel sources can help enhance AMR surveillance and help generate more accurate estimates of the true AMR burden. A growing body of evidence demonstrates the potential of new data sources and technologies like whole-genome sequencing and whole-metagenome sequencing to study the genetic determinants of AMR (Boolchandani, D’Souza and Dantas, 2019[65]). Some OECD countries refer to these technologies in their AMR-NAPs. For instance, in its action plan, the United States sets goals to improve the data infrastructure, data collection and analysis methods. As part of these efforts, it aims to build a new accelerator programme that will progress the implementation of whole-genome sequencing, metagenomics and other molecular testing for resistant pathogens in human, animal and plant populations, food as well as in the environment.

Integrating data from novel sources will require co-ordination across multiple stakeholders. For instance, in the United States, the Genomics for Food Safety (Gen-FS) consortium is one body that co-ordinates efforts to facilitate whole-genome sequencing among federal and state partners, with a focus on crosscutting priorities for molecular sequencing of foodborne and other zoonotic pathogens causing human illness, including the emergence and spread of the genetic determinants of antibiotic resistance, and using this information to support surveillance and outbreak investigation activities. The Gen-FS includes the U.S. Department of Agriculture, Food Safety and Inspection Service, as well as the Food and Drug Administration, the US Centers for Disease Control and Prevention (CDC), the Agricultural Research Service (ARS), the Animal and Plant Health Inspection Service (USDA/APHIS) and the National Center for Biotechnology Information (NIH/NLM/NCBI).

Efforts to reduce the incidence of infections through improved IPC measures are vital to tackling AMR. While all 21 AMR-NAPs from OECD countries and partners, EU/EEA and G20 countries are consistent with the AMR-GAP in that they all highlight the importance of IPC measures, they differ from the AMR-GAP in terms of the interventions that they most frequently emphasise (Figure 4.10). For instance, the AMR-GAP most frequently highlights the need for improving vaccination coverage. In comparison, the OECD countries and partners, EU/EEA and G20 countries most frequently focus on supporting their IPC programmes and practices. Both in the AMR-GAP and the AMR-NAPs from OECD countries and partners, EU/EEA and G20 countries, options to promote food safety and security and enhance biosecurity are given less emphasis compared to the other IPC measures.

The AMR-GAP underscores the importance of IPC programmes and guidelines to creating a robust framework to tackle AMR. Despite this, in 2021-22, about 9% of countries (14/163), globally, lacked a national IPC programme or operational plan, compared to 11.4% (18/158) in 2017 (WHO/FAO/WOAH, 2022[12]). The first Global Report on the status of IPC also pointed to important deficits in the implementation of IPC programmes across countries different levels of socio-economic development (WHO, 2022[66]).

The OECD analysis reveals that all AMR-NAPs from the selected OECD countries and key partners, EU/EEA and G20 countries explicitly reference the importance of IPC programmes in healthcare settings but only a fraction of these countries have mechanisms in place to monitor these programmes. The results from the OECD analysis are in line with the latest AMR Country Self-Assessment Survey. In 2021-22, nearly all OECD members, key partners and G20 countries (49/51) indicated that had in place national and facility-level IPC programmes in accordance with the WHO Guidelines on Core Components of IPC but only 45% (23/51) reported having IPC programmes that function both at the national and health facility levels consistent with the WHO IPC core components guidelines, where compliance and effectiveness are monitored and evaluated on a regular basis and guidance is updated in accordance with the results from monitoring (WHO/FAO/WOAH, 2022[12]). While the OECD countries and key partners, EU/EEA and G20 countries frequently discuss IPC interventions, they do not always describe efforts to improve the existing IPC practices. For instance, only a handful of AMR-NAPs mention IPC measures like decolonisation and environmental hygiene, and only around 57% (12/21) AMR-NAPs highlight the importance of hand hygiene practices.

Even when these documents refer to IPC measures, specific actions to enhance the existing IPC practices are not always described. Some exceptions emerge. For example, South Africa indicates in its AMR-NAP that it aims to scale up community outreach to enhance hand hygiene practices and aspires to supplement this activity with changes in legislation and national guidelines to include core IPC requirements and facilities for improved hand hygiene practices, whereas Ireland integrates compliance with the WHO’s My 5 Moments for Hand Hygiene approach into its monitoring and evaluation framework by tracking the level of compliance among hospital staff as a key performance measure of the performance of the overall health system. In Australia, the National Hand Hygiene Initiative was launched in 2008, which relies on a multi-model strategy involving the use of alcohol-based hand rubs at the point of care, provision of IPC education and training, monitoring of hand hygiene compliance and feedback, and encouraging culture change around hand hygiene practices (ACSQHC, 2008[67]).

Increasing vaccination coverage is another widely recognised strategy to curb the spread of infections. All AMR-NAPs refer to vaccines as part of efforts to prevent the spread of resistant infections in human health. Moreover, OECD countries like Norway, the United Kingdom and the United States indicate in their action plans to continue supporting vaccination campaigns in other countries not only through bilateral contributions but also by funding contributions to international initiatives like Gavi, the Vaccine Alliance. The widespread recognition of the value of vaccines is also reflected in the high vaccination coverage among OECD members, though some countries are facing challenges in maintaining the vaccination rates high (Chapter 5 provides more detailed information on a wide range of strategies to improve vaccination coverage).

Less attention has been paid to improving the coverage of veterinary vaccines. Norway is among the OECD countries that place veterinary vaccines at the centre of efforts to curb the spread of infections. In its action plan, Norway attributes the near elimination of antimicrobial use in aquaculture production since 1987 to the expansion of access to and use of veterinary vaccines. The country highlights that the scale-up of veterinary vaccines over the last three decades coincided with a 20-fold increase in national fish production, allaying potential concerns over agricultural production capacity. Building on its own experience, Norway stresses that the advancements in the development and application of veterinary vaccines remain to be the most prominent strategy to avoid the need for using antibiotics in aquaculture production.

Biosecurity measures can help curb the emergence and spread of infections among animals that share the same environment. Broadly, biosecurity measures can be classified into two groups (Alarcón, Alberto and Mateu, 2021[68]): external and internal. Combined, these measures are meant to reduce the transmission of pathogens between and within farms. External biosecurity covers the range of strategies that aim to prevent the emergence of pathogens within the farm (e.g. test livestock and feed before their purchase; develop a list of health requirements for incoming animals that group diseases in accordance with risks they present to the farm, and identify verification tests that will be routinely performed; protect feed from contact with wildlife; practice safe animal transport) (Alarcón, Alberto and Mateu, 2021[68]). In comparison, internal biosecurity relates to strategies that can help reduce the spread of pathogens once they are already detected on the farm. Internal biosecurity measures can be grouped as: those that relate to herd management (e.g. strict application of an all-in/all-out system); improvements in sanitary measures (e.g. separate infected animals from the rest of the animals; avoid reusing bedding from infected animals); cleaning and disinfection (e.g. cleaning and disinfecting facilities before a new batch of animals enters into the farm); and farm personnel strategies (e.g. use gloves; practice routine hand washing and foot baths) (Alarcón, Alberto and Mateu, 2021[68]).

Despite its potential benefits, enhancing biosecurity in agricultural production is not a frequently mentioned strategy by OECD countries and key partners, EU/EEA and G20 countries in their AMR-NAPs. Only 3 out of 21 countries included in the OECD analysis discuss biosecurity measures in their AMR-NAPs. Among OECD countries that discuss biosecurity in their action plans, different approaches are pursued. For instance, France highlights that biosecurity measures will focus on strengthening stockbreeding conditions. Whereas Ireland underscores the need to adopt a holistic approach to biosecurity and animal husbandry, which involves actions to scale up of national guidelines and standards on biosecurity and hygiene practices. In comparison, the United Kingdom highlights the importance of raising awareness around the centrality of disease prevention and co-ordinating with the livestock industry and animal keepers.

Curtailing the AMR burden will require new developments in new antimicrobial drugs, treatments and diagnostic tools. Currently, 50 antibiotics are in different stages of clinical trials, 32 of which target pathogens identified in the WHO’s priority list (WHO, 2020[69]). However, the vast majority of these antibiotics offer only marginal benefits in comparison to already existing antibiotics. Recognising this, the AMR-GAP acknowledges that the existing deficits in investments for AMR-related R&D partly reflect the deteriorating market conditions that limit the potential revenue streams and concerns over lower expected return on investment compared to other therapeutic fields. To address these concerns, the AMR-GAP stresses the importance of spurring AMR-related R&D activities through incentives and public-private partnerships.

Broadly, countries have in their arsenal two types of incentives to spur AMR-related R&D: pull and push (Table 4.3). Push incentives typically refer to those that aim to reduce entry barriers by reducing costs associated with developing new drugs (Renwick, Simpkin and Mossialos, 2016[70]). In comparison, pull incentives are those that aim to spur the development of new drugs by increasing the expected future revenues. Previous works note that both types of incentives come with certain advantages and caveats and that countries may benefit from adapting a mixed strategy that combined these incentives to spur AMR-related innovation (Simpkin et al., 2017[71]; Outterson, 2021[72]).

OECD countries will benefit from putting greater emphasis on the pull incentives to spur AMR-related innovations without scaling back on their current comments for push incentives (Box 4.9). With respect to strategies to spur sustainable AMR investments, 21 countries included in the OECD analysis primarily highlight push incentives in their action plans such as direct funding, product development partnerships, scientific grants dedicated to AMR-related research projects and increasing engagement with domestic and international scientific research communities and collaborations. This finding is in congruence with earlier works showing that the major international R&D funding programmes, as well as those funded by the EU, the United Kingdom and the United States prioritise early-stage push incentives (Simpkin et al., 2017[71]). While a robust commitment to push incentives is welcomed, recent modelling studies underscore the need to supplement push incentives with additional commitments to pull incentives (Outterson, 2021[72]).

A handful of OECD countries highlight in their AMR-NAPs a range of pull incentives and pilot initiatives to encourage AMR-related innovations. For example, in Japan, new regulatory approval processes have been introduced, including priority reviews for new antimicrobials that can be used for treating resistant infections. The United States is considering obtaining antibiotic products directly through Public Health and National Security purchases to encourage commercialisation. Some OECD countries are also enacting pull incentives for AMR-related innovations. Since publishing its AMR-NAP, the United Kingdom embarked on a new pilot project in 2019 that aims to interrupt the link between sales volume and sales revenues. Through this programme, the National Health Service committed to paying an annual subscription fee of up to GBP 10 million per each new antibiotic covering WHO-priority pathogens regardless of the consumption volume of the antibiotic.

There is a need to build a measurement framework that can help track cross-country progress in bolstering the different stages of AMR-relevant R&D activities over time. Currently, only a handful of OECD countries use measurable performance indicators to track performance in spurring AMR-relevant R&D over time, with a particular emphasis on the earlier stage of clinical development. For example, the United States – the leading funder of AMR-relevant R&D – measures performance using three indicators: i) support the publication of at least 1 000 publications focusing on basic, traditional, and clinical AMR research by 2021; ii) support the training of at least 60 new/early career researchers whose research is applicable to AMR; and iii) build at least two collaborations between human health and agriculture sectors via agreements across agencies. Japan is another country that uses evaluation indices for measuring progress in supporting R&D innovations. These indices include: i) the number of publications applicable to AMR funded through national grants; and ii) the number of genomes accumulated in the genome database to promote AMR genome surveillance.

Fostering PPPs to garner AMR innovations is an overlooked area, though notable examples are emerging. PPPs offer an important means to harness the comparative advantage of public and private organisations. Around 67% (14/21) of OECD and G20 countries explicitly reference considerations around PPPs. In recent years, examples of PPPs relevant to AMR emerged. For example, in 2016, the Combating Antibiotic-Resistant Bacteria X (CARB-X) was launched as a global partnership to help finance the preclinical development of drug candidates to prevent and treat resistant infections (CARB-X, 2021[74]). Today, CARB-X has become the world’s largest PPP that funds the early development pipeline of new antibiotics, diagnostics and relevant products, with contributions from the United Kingdom and the United States. In Europe, the Innovative Medicines Initiative (IMI) was formed in 2007 as a PPP between the European Union and the European pharmaceutical industry. Considered to be the largest life sciences PPP globally, the IMI aims to enhance the efficiency and effectiveness of drug development processes. In 2012, the IMI created the New Drugs for Bad Bugs project that funded eight projects costing EUR 650 (IMI, 2017[75]). In 2018, the IMI launched the AMR Accelerator which aims to develop new medicines for preventing and treating resistant infections with Mycobacterium tuberculosis, nontuberculous mycobacteria and Gram-negative bacteria.

Raising awareness and understanding around AMR is paramount to promoting behaviour change among antibiotic prescribers and users. In recognition, the AMR-GAP urges countries to scale up programmes targeting a variety of stakeholders in the human and animal health sectors, including prescribers, pharmacists, veterinarians, farmers and consumers (WHO, 2015[1]). Much like the AMR-GAP, OECD countries and key partners, EU/EEA and G20 countries primarily emphasise interventions that aim to raise AMR awareness and understanding among healthcare professionals and the general public, whereas school-based interventions for young children are less frequently discussed (Figure 4.12).

OECD countries and key partners, EU/EEA and G20 countries pursue a range of interventions to integrate AMR-relevant materials in the education and training of health professionals across different stages of their professional development. Many countries rely on revising/updating the curriculum in undergraduate and postgraduate training to include materials relevant to infection and disease prevention and AMR. For example, in Ireland, undergraduate and postgraduate core curricula and examinations involve academic materials on disease prevention, AMR as well as prudent antibiotic use. In Switzerland, infectious disease specialists undergo extensive training and education on AMR as part of their specialisation requirements. In Germany, health professionals have access to advanced training programmes on rational antibiotic therapy, as well as training courses on the prevention of nosocomial infections in hospital settings. AMR-related materials are also integrated into the licensing and accreditation examinations. This is the case in Japan, where the national examinations for obtaining the required qualifications as a professional in human and veterinary medicine, nursing care and public welfare are aimed at including a more expanded focus on AMR, IPC and antimicrobial stewardship.

In addition, OECD countries provide new avenues for continuous professional education (e.g. organising training workshops, websites, e-learning initiatives). For instance, France recently launched new webpages on AMR and the prudent use of antibiotics for both healthcare professionals as well as the general public. In the United Kingdom, a new Animal Medicines Best Practice training course, a set of online courses targeting farmers and veterinary surgeons, was kicked off in 2018 in order to promote the prudent use of antibiotics in farm settings.

The OECD countries and key partners, EU/EEA and G20 countries often rely on antibiotic awareness campaigns to raise awareness and education in the general public. Awareness campaigns offer a tempting option for governments, as they can help disseminate valuable information to large audiences at a relatively low cost (Huttner et al., 2019[76]). They are typically organised by public health authorities and target the general community and healthcare professionals at the same time. They tend to rely on communication and educational materials disseminated through print materials, television, radio and online platforms.

The OECD analysis shows that 16 out of 21 OECD countries and key partners, EU/EEA and G20 countries explicitly discuss activities related to some version of an antibiotic awareness campaign (e.g. World Antibiotic Awareness Week) in their own setting. For instance, across EU/EEA members included in the analysis, five out of nine explicitly highlighted the European Antibiotic Awareness Day.

Translating AMR knowledge into changes in attitudes and behaviours around antibiotics remains an important public health challenge. Echoing earlier works, the 2018 Eurobarometer survey found that 85% of respondents were aware of the adverse effects of unnecessary use of antibiotics and 85% indicated that they knew that compliance with prescribed antibiotic dosage was important (Eurobarometer, 2018[77]; Paget et al., 2017[78]). But the same survey also showed that having AMR knowledge did not guarantee changes in attitudes towards antibiotics and behaviours. Only 29% of respondents indicated that AMR information changed their views on the misuse of antibiotics and 7% indicated that they used antibiotics in the last 12 months without a prescription.

The OECD analysis suggests that integrating AMR into the education of young children is not a consistently used strategy among OECD countries and key partners, EU/EEA and G20 countries. Broadly, interventions that attempt to incorporate AMR in the education of school-aged children aim at improving the knowledge and understanding of antimicrobials among future users. A promising body of evidence suggests that these interventions may decrease infections among children and reduce school absenteeism (Willmott et al., 2015[79]). Despite this, the OECD analysis shows that only a handful of AMR-NAPs from OECD countries and key partners, EU/EEA and G20 countries explicitly mention the potential options to introduce and scale up educational initiatives targeting young children.

In recent years, the e-Bug programme has emerged as one international education initiative aiming to enhance hygiene and AMR knowledge among young children by providing free educational materials. Launched in 2006, e-Bug has been adopted by 29 countries by 2019 (Hayes et al., 2020[80]). Emerging evidence, primarily from OECD countries such as the Czech Republic, France and the United Kingdom shows that the e-Bug programme can be effective in improving awareness and understanding of antibiotics and hygiene among young children (e-Bug Working Group, 2010[81]; Farrell et al., 2011[82]; Hawking et al., 2013[83]). Some OECD countries explicitly refer to the programme in their AMR-NAPs. For instance, in its AMR-NAP, Ireland indicates that first- and secondary-level school students are among the primary target of activities to improve AMR knowledge and awareness, and the e-Bug initiative should be adopted in primary and post-primary curricula. The United Kingdom also refers to a recent e-Bug initiative, which was specifically designed in collaboration with Farming and Countryside Education and farmers to improve young school children’s understanding of farm hygiene.

This chapter provides an overview of the global progress made in the implementation of action plans to tackle AMR. Findings from the chapter demonstrate that there have been important advancements in the development of action plans to tackle AMR across the globe. However, the implementation of AMR-NAPs globally is characterised by a socio-economic development gradient, with LMICs lagging in terms of advancing the implementation and financing of AMR-NAPs.

Among OECD countries and key partners, EU/EEA and G20 countries, there has been notable progress in the uptake of multi-sectoral approaches, with the animal sector being involved in the development of all action plans. Yet, further progress is needed to expand multi-sectoral action to include plant health and the AMR transition in the environment. Having developed their action plans, many of these countries are now grappling with the implementation of their AMR-NAPs. Rigorous monitoring and evaluation of the implementation of AMR-NAPs are paramount to ensure course corrections can be made based on lessons learned from the execution of these documents on the ground.

Further, the OECD analysis pointed to the importance of keeping the AMR-NAPs up to date. It showed that some OECD countries have not updated their action plans since their initial publication, while others are nearing to the end of their coverage period. At a time when health systems across the world are grappling with the COVID-19 pandemic, updating and/or revising AMR-NAPs is key to ensuring that these documents reflect the lessons learned from implementation, filling the gaps in the existing guidance and incorporating new guidance that considers the evolving health financing and delivery needs.

The analysis also suggested little cross-country standardisation in measuring performance over time in terms of the goals stated in AMR-NAPs, which hinders efforts to benchmark cross-country performance. Another important finding showed that funding considerations and cost-effectiveness of interventions to tackle AMR are often left undiscussed. Addressing these gaps in the design of the action plans helps improve the effectiveness of the vision laid out in these documents.

Finally, the chapter presented a systematic assessment of the strategic priorities and interventions adapted by OECD countries and key partners, EU/EEA and G20 countries in action plans using the AMR-GAP as a blueprint. The results suggested a high degree of alignment between countries included in the OECD analysis and the AMR-GAP in terms of their strategic objectives. Coupled with this, there is a diversity of interventions countries consider to achieve their strategic objectives. The diverging patterns in terms of the preferred interventions are likely a reflection of the health system challenges, as well as the broader historical, socio-economic and political factors that shape policy design and implementation in each setting. Combined, evidence generated by this chapter suggests that countries that are considering developing new action plans and/or revising the existing ones will benefit from examining the main drivers of AMR in their own settings and identify interventions to address these challenges in congruence with the strategic objectives and interventions recommended by the WHO.


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In this chapter, a combination of NLP-guided techniques is deployed to systematically examine the content included in the AMR-NAPs from OECD countries and key partners, EU/EEA and G20 countries. First, a unique, text-based dataset was assembled. This was done by identifying the AMR-NAPs that were developed after the publication of the Global Action Plan on Antimicrobial Resistance (AMR-GAP) and extracting them from the World Health Organization (WHO) AMR-NAP repository, the European Centre for Disease Prevention and Control (ECDC) AMR-NAP library and publicly available websites. In occasions when more than one AMR-NAP was published by a country in the analysis period, only the most recent document was included. Supplementary materials (e.g. progress reports, commentaries, complementary operational sectoral plans) were excluded. Only documents written in English were included. These steps resulted in the inclusion of 21 AMR-NAPs in the final assessment. A list of countries included in the OECD analysis is provided.

The text from 21 AMR-NAPs was transformed into an analysable dataset in several steps. First, the pages that may not include substantive information were discarded (e.g. acknowledgements, cover pages). Next, each document was split into smaller units referred to as tokens (e.g. words, web links, punctuations) and tokens that may contain little analytical value were removed. Once this procedure was completed, the entirety of the sample was converted to lowercase characters. The next step entailed the removal of stop words: high-frequency terms that contribute no substantive information (e.g. and, also, a, etc.). Next, all terms were stemmed such that different variations of the same term are recorded as the same entry with the same root. Finally, the pre-processed data were transformed into a document term matrix, which enabled to count the number of times each term occurred in each AMR-NAP.

Dictionary-based NLP techniques were deployed to assess the level of alignment between the AMR-NAPs and the AMR-GAP. Dictionary-based methods offer a suitable option for textual analysis when reliable information is already available to help guide the development of a term dictionary, with limited availability of datasets that can be used to train text-based models (Gentzkow, Kelly and Taddy, 2019[36]). An AMR term dictionary was developed using a two-step approach. As the first step, the AMR-GAP was reviewed to extract terms that were used to describe each strategic objective and recommended intervention. Next, the other AMR publications were reviewed, with the aim of identifying additional terms. The process of building the term dictionary was iterative. Multiple labels were assigned to interventions that were relevant to more than one strategic objective.

Methods that rely on simply counting the number of times that terms occur in a document are not sufficient to consider the differences in the length of documents. Recognising this, the OECD analysis makes use of two commonly used NLP metrics to assess the level of alignment between AMR-NAPs and the AMR-GAP: i) term frequency (TF); and ii) term frequency-inverse document frequency (TF-IDF). TF is a measure of the frequency with which each term occurs within an AMR-NAP with respect to the entire length of that document. Quantifying TF associated with each strategic objective/intervention facilitates a comparative assessment of the relative prominence of each strategic objective/intervention in the collection of AMR-NAPs. TF-IDF facilitates a comparative analysis of the interventions to tackle AMR that occur in a given AMR-NAP in comparison to how frequently it features across the collection of documents. By deriving TF-IDF scores, the interventions that are most distinctly highlighted in each AMR-NAP compared to the others are identified.

The OECD analysis relies on the self-reported responses recorded in the WHO Tripartite AMR Country Self-Assessment Survey (2021-22) to characterise the implementation of selected AMR-relevant multi-sectoral policies in each country. All questions extracted from this survey include a five-point rating scaling (from A to E) to summarise a country’s progress. In the OECD analysis, countries that reported an “A” rating for any question were categorised as having no implementation with respect to that specific intervention whereas countries that reported an “E” rating were grouped as achieving the most advanced stage of implementation.

The questions and response categories from the Tripartite AMR Country Self-Assessment Survey (2021-22) used to build the dashboard are as follows:

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