UN High-Level Meeting on Antimicrobials—What Do We Need?

Ramanan Laxminarayan ・ Princeton Environmental Institute

Global access to effective antimicrobials is under threat.1 Over 700 000 deaths worldwide, including 214 000 neonatal sepsis deaths, are attributable to resistant bacterial pathogens each year.2,3 Currently, insufficient access and delays in access to antibiotics cause more deaths than antibiotic resistance, but more resistance-related deaths are being reported in all countries irrespective of income level.3 The key is to promote universal provision of antimicrobials while ensuring continued effectiveness. The UN General Assembly High-Level Meeting of Heads of State will discuss sustainable access to effective antimicrobials in September, 2016. The meeting must develop realistic goals, stimulate political will, mobilise resources, and agree on an accountability mechanism for global collective action on this issue.

Providing sustainable access to effective antimicrobials is a prerequisite for achieving several of the Sustainable Development Goals (SDGs)4 and requires global collective action within and across countries and among sectors that deal with health, agriculture, environment, animal husbandry, and trade.5 The elements of effective country-level action are described in WHO’s Global Action Plan on Antimicrobial Resistance,6 which has been ratified by the World Health Assembly and is supported by the Food and Agricultural Organization of the United Nations and the World Organisation for Animal Health (OIE). Yet, antimicrobial resistance transcends the capabilities of these organisations and requires the involvement of UNICEF, UNDP, UNEP, UNESCO, the World Bank, and other multilateral agencies as part of a globally coordinated plan.

We believe that the UN General Assembly High-Level Meeting should establish a UN High-Level Coordinating Mechanism on Antimicrobial Resistance (HLCM) with four core functions (panel), which are similar to those of UNAIDS when it was first established in 1996.

First, advocacy is needed to raise awareness about lack of access to antibiotics and drug resistance. The primary goal of a global campaign should be to change attitudes and norms towards antibiotics to enable health-care and veterinary professionals and the public understand the value and potential side-effects of antibiotics.

Second, robust monitoring and evaluation is needed on global and national enforceable targets for antimicrobial access, appropriate use, policies implemented, and resistance rates in human, agricultural, veterinary, and environmental sectors. The HLCM should achieve consensus on strategies and targets across the animal and human health sectors, which encompass interventions proposed by the WHO Global Action Plan6 and others that would move towards sustainable access to antimicrobials.7 The HLCM should agree on targets to reduce both the global burden of deaths avertable by effective antimicrobials and inappropriate consumption of antimicrobials in human and animal sectors. A global monitoring and review platform is needed to assess progress on these goals. The platform should track key indicators related to: public health; burden of bacterial infections caused by resistant pathogens; proportion of populations without access to antimicrobials (including number of children younger than 5 years dying from pneumonia due to lack of access to antibiotics) as a global indicator; and volume of therapeutic and non-therapeutic antimicrobial consumption in human, environmental, and animal sectors. Tracking is also needed to measure progress on innovation in vaccines, alternatives to antimicrobials, and the pipeline for new antimicrobials. Support for low-income and middle-income countries is needed to build capacity for surveillance and data collection. An independent, transparent, expert-led process in which the performance of countries, donors, and non-state actors is analysed, appraised, and reported to identify shortfalls in performance should be part of the global monitoring and review platform.

The third function of the HLCM is mobilisation of resources. The HLCM would encourage financial commitments from donors, aid agencies, and countries to finance the implementation of global and national level action plans, as well as a global coordination and monitoring platform. Global financing should be targeted to goals that benefit the global public good. Goals are needed to: support HLCM functions; enable existing global financing mechanisms (eg, the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, the Vaccine Alliance, and UNITAID) to expand their mandate to assist countries in expanding access to antibiotics, diagnostics, and vaccines; assist low-income and lower-middle-income countries with planning and implementing national action plans, including on improving surveillance, pharmaceutical regulation, and public health; and support a global innovation fund to stimulate a pipeline of vaccines, diagnostics, alternatives to antimicrobials, and new antimicrobials in a way that encourages delinkage and conservation of effectiveness. The HLCM affords the opportunity to expand from the donor-driven model and link the mobilisation of financial resources to overall global financing needs that have been proposed for achieving universal health coverage.

The fourth function is multisectoral domestic coordination.The HLCM can support member states to pursue national level, multisectoral action involving non-governmental organisations, civil society, and the private sector for the implementation of WHO’s Global Action Plan alongside national efforts to improve access to effective antimicrobials. Such multisectoral action should be supported technically by the HLCM. Although targets should be set through the HLCM, country level strategies should be country specific rather than centrally mandated. Countries should develop a robust stewardship framework that promotes appropriate use of antimicrobials within the context of sustainable access to effective antimicrobials.

The HLCM structure could select elements from the Framework Convention on Tobacco Control,8 the Intergovernmental Panel on Climate Change,9 or other specific international agreements or initiatives to solve problems that require global cooperation across sectors. The HLCM must include UN organisations and key countries representing their regions, civil society, industry, and development agencies that periodically report to the UN Secretary General and to the UN General Assembly on progress towards achieving sustainable access to effective antimicrobials goals. Sustainable access to effective antimicrobials is a key development issue and the September 2016 UN General Assembly High-Level Meeting is a rare opportunity to change how we as a global community use the only currently feasible method to treat bacterial infections. It is an opportunity that should not be squandered because of lack of ambition.

* Ramanan Laxminarayan, Carlos F Amábile-Cuevas, Otto Cars, Timothy Evans, David L Heymann, Steven Hoff man, Alison Holmes, Marc Mendelson, Devi Sridhar, Mark Woolhouse, John-Arne Røttingen Center for Disease Dynamics, Economics & Policy, Washington, DC 20005, USA (RL); Princeton Environmental Institute, Princeton University, Princeton, NJ, USA (RL); Public Health Foundation of India, New Delhi, India (RL); Fundación Lusara para la Investigación Científi ca, Mexico City, Mexico (CFA-C); ReAct, Department of Medical Sciences, Uppsala University, Uppsala, Sweden (OC); The World Bank, Washington, DC, USA (TE); The Center for Global Health Security, Chatham House, London, UK (DLH); University of Ottawa, Ottawa, ON, Canada (SH); Imperial College, London, UK (AH); University of Cape Town, Cape Town, South Africa (MM); University of Edinburgh, Edinburgh, UK (DS, MW); Norwegian Institute of Public Health, Oslo, Norway (J-AR); Institute of Health and Society, University of Oslo, Oslo, Norway (J-AR); and Harvard T H Chan School of Public Health, Boston, MA, USA (J-AR) ramanan@cddep.org.

We declare no competing interests.

  1. Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance—the need for global solutions. Lancet Infect Dis 2013; 13: 1057–98.
  2. O’Neill J. Tackling drug-resistant infections globally: fi nal report and recommendations. London: H M Government/Wellcome Trust, 2016.
  3. Laxminarayan R, Matsoso P, Pant S, et al. Access to eff ective antimicrobials: a worldwide challenge. Lancet 2016; 387: 168–75.
  4. Jasovsky D, Littmann J, Zorzet A, Cars O. Antimicrobial resistance—a threat to the world’s sustainable development. Upsala J Med Sci 2016; 121: 159–64.
  5. Ardal C, Outterson K, Hoff man SJ, et al. International cooperation to improve access to and sustain eff ectiveness of antimicrobials. Lancet 2016; 387: 296–307.
  6. WHO. Global action plan on antimicrobial resistance. Geneva: World Health Organization, 2015.
  7. Mendelson M, Røttingen JA, Gopinathan U, et al. Maximising access to achieve appropriate human antimicrobial use in low-income and middle-income countries. Lancet 2016; 387: 188–98.
  8. Heymann DL. What to do about antimicrobial resistance. BMJ 2016; 353: i3087.
  9. Woolhouse M, Ward M, van Bunnik B, Farrar J. Antimicrobial resistance in humans, livestock and the wider environment. Philos Trans R Soc Lond B Biol Sci 2015; 370: 20140083.

Article in PDF format: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)31079-0.pdf