Why is a comrehensive national plan essential for combating

The factors which favour the emergence and spread of resistant microbes, and the measures needed to combat antimicrobial resistance (AMR), are well known.  A comprehensive plan brings all the elements together so that everyone can do more to make a difference:

Policy-makers and planners in government must provide the legal framework and strategy that people need to work together effectively to combat AMR and its public health consequences.

Civil society and patients' groups raise awareness of the issues, and demand action by policy-makers and all stakeholders. Everyone can play a part by using prescribed medicines correctly.

Practitioners and prescribers need to combine appropriate prescription of antimicrobials with clear, accurate and understandable advice to patients. Veterinarians should resist pressures to use antibiotics as growth promoters and for disease prevention in livestock.

Pharmacists and dispensers must ensure that antimicrobials are safe: obtained from an approved source and stored properly, and supplied in line with prescriptions.

Providers, institution managers, and communities should apply infection control measures to prevent the emergence and spread of AMR.

The diagnostic and pharmaceutical industry, through research and development, will need to produce the tools needed to better prevent and detect disease, identify AMR earlier, and develop new antimicrobials needed to replace those that have become ineffective.

Challenges to overcome

Limited public awareness and government commitment: Media attention focuses on individual outbreaks but gives little attention to the wider threat of AMR. It is therefore not a priority of national governments or linked to the achievement of the health-related Millennium Development Goals. Despite their potential to influence policy too few nongovernmental, donor and health advocacy agencies have recognized the threat of AMR. 

Fragmentation of effort: Specific activities to combat AMR are taken forward by individual programmes, institutions and regulatory bodies, but too often in the absence of an overall strategy; without an adequate budget; and with no accountability for results.  

Perverse incentives contribute to AMR, through the unregulated marketing of antimicrobials, their use for growth promotion in livestock, or profit-seeking prescribing of antibiotics in human health care. Where legal frameworks exist they are rarely accompanied by effective sanctions.

The voiceless are the worst affected: Poor people are among those who are at greatest risk of infections and those most likely to lack access to quality services and suffer severe illness.  They usually lack information or opportunity to demand or become involved in actions to combat AMR.

The role of government

A concerted attack on AMR requires leadership, advocacy, and resources. Governments therefore have a special role.  The national ‘Master Plan’ should set out what has to be done, how and by whom.

(A)  Provide stewardship and coordination

AMR is a threat to health which requires a multi-sectoral response. Stewardship by government is therefore key  to success.  In practice, stewardship starts with the legal, policy and regulatory framework that covers all aspects of drug supply and use. It also means bringing together departments across government, along with the private and non-governmental organizations in ways that ensure concerted action.

Establish a national intersectoral government steering committee mandated to forge a partnership with all stakeholders.

Ensure that the committee is supported by a secretariat with the resources, skills and authority required to coordinate action across government.

Develop a national AMR action plan, based on a needs assessment, with a clear strategy and prioritized annual targets for all six elements of the policy package; integrate the plan into the national health plan and other relevant sectoral plans.

Ensure that adequate resources are earmarked for capacity building at all levels within the national plan.

Set up a monitoring framework, with measurable indicators of action, and report annually against these indicators.

 (B) Cost plans and mobilize resources 

All stakeholders – including ministries of finance – must recognize the urgency of the threat if they are to contribute to a national effort. A realistic assessment of costs to meet needs, as well as estimates of the potential savings from reducing AMR, will help in mobilizing resources.

Estimate the cost of all elements of the national AMR plan, develop a complete budget, and integrate it into the national health budget and other relevant budgets.

Mobilize human and financial resources to support the plan through regular budget allocations, mainstreaming of activities within core programmatic and management systems and within other priority health  initiatives.

 (C) Build partnerships with civil society 

If people – especially patients, civil society and consumer groups – fully understand the problem and are enabled to engage, they can help drive progress.

Involve civil society representatives in a formal arrangement for the development of AMR policy, membership of coordinating bodies or alliances, and monitoring actions to combat AMR.

Hold regular public information and discussion meetings, and assign roles and responsibilities in joint activities and partnerships with patient organizations, consumer groups and other public interest groups.

Educate consumers about the efficacy, safety, quality and correct (rational) use of medicines.

Encourage capacity-building in civil society organizations so that they can participate in and benefit from educational and collaborative activities.

Thailand has developed a draft national AMR containment policy and a committee to promote appropriate use of antimicrobials. The policy covers: standardization of testing by microbiology laboratories, human resources development, antibiotic systems in hospitals, ethical guidelines for drug dispensing and prescribing, antimicrobial resistance surveillance and monitoring, antimicrobial use in livestock, and other issues. An antibiotic formulary was also developed and a surveillance network established as well as a campaign on antibiotic use in community hospitals.   Using resources from a national health promotion fund, a special three-year project began under leadership of the Chulalongkorn University to strengthen surveillance, communications, advocacy, partnering and knowledge sharing.

The US Government has an Interagency Task Force on Antimicrobial Resistance to plan and coordinate federal government activities.  The Task Force has three co-chairs: the US Centers for Disease Control and Prevention, Food and Drug Administration, and National Institutes of Health. Seven other US federal agencies also participate: Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Services, Department of Agriculture, Department of Defense, Veterans Administration, Environmental Protection Agency, and Healthcare Resources and Services Administration.  A first Public Health Action Plan to Combat Antimicrobial Resistance was released in 2001 and has been subsequently updated.  Main elements of the Plan include "reducing inappropriate antimicrobial use, reducing the spread of antimicrobial resistant microorganisms in institutions, communities, and agriculture; encouraging the development of new anti-infection products, vaccines and adjunct therapies; and supporting basic research on antimicrobial resistance" (http://www.cdc.gov/drugresistance/actionplan/taskforce.html