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Pulling together to beat superbugs

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Presented by Jonathan Wadsworth and Franck Berthe (World Bank Group) at the CGIAR Antimicrobial Resistance Hub Launching, ILRI Nairobi, 21-22 February 2019

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Pulling together to beat superbugs

  1. 1. Pulling Together to beat superbugs Jonathan Wadsworth Franck Berthe World Bank Group CGIAR Antimicrobial Resistance hub launching, ILRI Nairobi, 21-22 February 2019
  2. 2. Human Cost of AMR – Lives Lost Economic Cost – Global GDP Lost TACKLING DRUG-RESISTANT INFECTIONS GLOBALLY: FINAL REPORT AND RECOMMENDATIONS THE REVIEW ON ANTIMICROBIAL RESISTANCE CHAIRED BY JIM O’NEILL MAY 2016
  3. 3. Cumulative savings of extra health care costs to 2030 are $4 trillion if “low-AMR” case is avoided and $11 trillion if “high-AMR” case is avoided​ US $ Trillions 2016-30 10 5 Implementation cost Costs Avoided High AMR Scenario Costs Avoided Low AMR Scenario
  4. 4. SPOT QUIZ: HOW MUCH DOES THIS 10-DAY COURSE OF ANTIBIOTIC COST IN USA?
  5. 5. Similar scale effect to financial crisis of 2008 – but AMR will be continuous. Not a “one-off” event.
  6. 6. Reframing AMR not just as a public health or agricultural problem, but as an adaptive development challenge (problem of development) 6 An adaptive development challenge • AMR is a development challenge that will disproportionately affect low- and middle- income countries from an economic and social perspective • AMR will negatively affect some SDGs; on the other hand – progress on some SDGs will help combating AMR
  7. 7. …….. after some “jagged” thinking we identified a set of principles to guide our approach….. 7 Principles of our approach Focus on behavioral and political economy issues over technical, scientific approachesFocus on country level actions and options Aim to reach a broad audience, beyond those conversant in AMR Focus on knowledge and implementation gaps Not making assumptions about new financing but focusing on smarter financing
  8. 8. Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis. (Collignon et al. 2018, Lancet Planetary Health) AGGREGATE RESISTANCE INFRASTRUCTURE CORRUPTION AND GOVERNANCE LOW SEVERITY HIGH SEVERITY Better infrastructure and governance significantly associated with lower AMR – but not antibiotic consumption. Reducing antibiotic consumption will not be sufficient to control antimicrobial resistance because contagion (spread of resistant strains) seems to be dominant factor. Better sanitation, access to clean water, good governance, and increasing public health-care expenditure all need to be addressed to reduce global AMR.
  9. 9. Seeking to articulate the importance of context in relation to AMR 9 Recognizing the importance of context and the distinction between emergence and spread • AMR is often understood in terms of use [mis- and over- use] of antimicrobials; however, limiting consumption of antimicrobials will not be sufficient to control AMR. • Context, determined by anthropological and socioeconomic factors, is critical to understanding the spread of resistance determinants. • The use of antimicrobials has a bearing on emergence of AMR, but the spread -sometimes referred to as contagion- is driven by context. • We need to address the underlying weaknesses of systems to be able to address AMR; hence the need for alignment of the AMR and Sustainable Development agendas. • AMR specific plus AMR sensitive investments.
  10. 10. Exploring three broad tensions: the way we think about antimicrobials, the way we use them and external factors – as infrastructure of modernity 10 A challenge associated with knowledge, attitudes and behavior • Human behavior is about what people know and the views they take of things. • AMR is a behavioral and adaptive challenge, that requires both technical and adaptive approaches. • It is growing not because of the absence of new antimicrobials but because of the way antimicrobials have become entrenched into our social, cultural, political and economic lives. The way we think antimicrobials The way we use them External factors influencing the system
  11. 11. Antibiotic resistance policy loops (after Homer et al 2000) EDUCATION HEALTH SERVICE BUDGETS LEGISLATION REGULATION CONTAGION CYCLE R & D FUNDING PUBLIC BELIEFS AB ACCESS CONTROL SURVEILLANCEABR EMERGENCE CYCLE SELF DIAGNOSIS
  12. 12. Effect of GDP per capita on antimicrobial consumption (human health) Source: Authors
  13. 13. Describing typologies of countries, in terms of AMR risk 14 Type A Type B Type C Type D Level of economic development Low income Low & lower- middle income Upper-middle & high income Upper-middle & high income Antimicrobial use Low High High Low Exposure to other contextual risk factors High High Medium Low Expected level of AMR Medium High Medium/High Low Lower- and Middle-income countries have the most dangerous combination of risk factors for emergence and spread of antimicrobial resistance While the theoretical curve [above] exposes a historical transition process for countries from type A to D, the global action on AMR is expected to offer avenues for new trajectories towards type D. Type A Type B Type C Type D
  14. 14. Typologies could help to understand how best to channel resources and build effective interventions 15 Type A Type B Type C Type D Status of the AMR agenda AMR agenda focused on access to quality services and quality of medicinal products, strengthening of basic public and animal health systems, education on hygiene and infection prevention AMR agenda focused on responsible and prudent use of antimicrobials, further basic health system strengthening and capacity building, piloting new programs, establish baselines through surveillance and monitoring, continued efforts in education on hygiene and infection prevention Building strong political and societal consensus on addressing AMR, scaling up of pilot programs, monitoring and surveillance, complete policy and regulation reforms, mass awareness campaigns Mature public and animal health systems, regular light- touch AMR interventions and programs, continuous adjustments needed to respond new risks, maintained awareness, continued surveillance Status of AMU and AMR Low use of antimicrobials, lack of access to quality medicinal products, basic systems and services failed Increasing use of antimicrobials with increasing revenues and consumption, under-performing systems and services, AMR is slowly emerging as an issue in the civil society Systems still struggling to manage the rise of antimicrobial demand and use, AMR is on the rise and high on the civil society agenda, outcomes of surveillance and monitoring will raise public concern over AMR Achievements in reducing use of antimicrobials, AMR remains a concern but citizen trust restored in the system, established capacity to detect emergence of new resistance determinant Country type (GDP) Low-income Low and lower Middle-income Upper middle and high income Upper middle and high income Returns to AMR-sensitive interventions are highest in low- and middle-income countries
  15. 15. ?
  16. 16. WICKED PROBLEMS: • Are difficult to clearly define – cannot first understand and then solve. • Multi-causal with many interdependencies. • Unforeseen consequences of addressing them. • Solutions are not right or wrong – they are better-worse; good enough-not good enough. • Are socially complex, context matters, making each one unique • Responsibility of multiple organizations • Solutions involve changes in behavior • Often characterized by chronic policy failure
  17. 17. Traditional wisdom for solving complex problems: the ‘waterfall’ Tame problems
  18. 18. Opportunity-driven problem solving: the “jagged line of learning” Wicked problems
  19. 19. N. B.
  20. 20. Von Moltke famously viewed strategy as a "system of expedients." He was suspicious of rigid, inflexible, and totalizing grand strategies and theories, instead advocating strategy as a series of plug-in points that could be fashioned and molded to fit the situation. He coined the oft-repeated saying that "no plan survives first contact with the enemy“. “….no plan survives first contact with the enemy.”
  21. 21. “One of the greatest challenges facing the global health community is how to take proven interventions and implement them in the real world. Research on health systems, such as implementation research is crucial to meeting that challenge, providing a basis for the context- specific, evidence-informed decision- making needed to make what is possible in theory a reality in practice.” Marie-Paule Kieny Assistant Director-General Health Systems and Innovation Cluster World Health Organization Foreword - Implementation Research in Health: A Practical Guide, WHO (2013)
  22. 22. CONTINUUM OF IMPLEMENTATION RESEARCH (WHO 2013)
  23. 23. Relevance of Implementation Research to the AMR Challenge and the ILRI Hub • Despite growing evidence of the efficacy of numerous AMR interventions, there is little understanding of how to deliver those interventions effectively in diverse settings and within the wide range of existing health systems. • Implementation issues often arise as a result of contextual factors that policy-makers and implementation managers have not even considered. • Implementation research is crucial to improving our understanding of the challenges we face in confronting the real world by broadening and deepening our understanding of these real-world factors and how they impact implementation. • Implementation research is of immense value in shining a light on the often bumpy interface between what can be achieved in theory and what happens in practice.
  24. 24. Pragmatic approach – implementation research with existing mechanisms and considerations for tackling AMR at the country level 26 Financing options National Action Plans Understanding what works in a given context, enablers and barriers Situation analysis, system bottlenecks, and blending of AMR-sensitive and AMR- specific interventions AMR-sensitive and AMR- specific interventions aimed at: 1. maintaining an enabling environment for AMR control; 2. reducing the need for antimicrobial usage; and 3. self-limiting the use of antimicrobials.
  25. 25. Finally, important knowledge gaps and challenges that are consistent across countries… 27 • Big gaps in understanding real world implementation processes and options • Heavy focus on use of antimicrobials as a driver of AMR emergence - whilst AMR spread and related risk factors relatively unresearched • Impacts of AMR-specific interventions have been modelled but very little evidence for estimating co-benefits of AMR-sensitive interventions • An “AMR resilience and preparedness index” combining drivers for emergence and spread of AMR might enable measurement of progress in a country’s capacity to mitigate risks relating to AMR
  26. 26. ILRI AMR Hub and Partners is well positioned to do research where it’s really needed – in the real world – thank you for your attention.

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