|Home | About | Journals | Submit | Contact Us | Français|
Manish Kakkar and colleagues discuss the development of a tool to assess how programmes tackling antimicrobial resistance in South East Asia are faring
Antimicrobial resistance (AMR) is no longer defined by national or political boundaries. Isolates of Escherichia coli bearing mcr-1 were first identified in China, but shortly after were found in clinical and animal samples in the US.1 2 The World Health Organization and its partners have warned of the global rise of resistance against antibiotics, particularly those of “last resort.”3
Evidence shows that the main drivers of AMR are antibiotic selection pressure and transmission of resistant microbes.3 But drivers at the level of policies and systems also contribute.16 This complexity calls for a comprehensive, holistic, collaborative approach. The 68th World Health Assembly in 2015 adopted the global action plan on AMR (GAP-AMR, box 1), which was expected to translate into national action plans by May 2017.4 17 National action plans should include a strategic action plan, based on a “One Health” approach, bringing together multiple sectors to combat resistance in the local context. In the context of containment of AMR, the One Health approach provides opportunities to integrate multiple disciplines, working locally, nationally, regionally, and globally to tackle the drivers of AMR emergence.
To assist the member states, WHO, the Food and Agriculture Organization of the United Nations, and the World Organisation for Animal Health have developed a manual and sample templates, as well as a library of existing national action plans.5 The manual recommends performing a situation analysis before developing a national action plan. Countries differ widely in their capacity to develop a comprehensive, holistic national action plan. Of 133 countries surveyed in the worldwide situation analysis conducted by WHO, very few reported to have a comprehensive, multisectoral national action plan for containment of AMR supported by sustainable financing.4 Conducting a comprehensive situation analysis is essential for tailoring a national action plan to the setting of a particular member state, which would inform the subsequent steps of the process.
The WHO South East Asia Regional Office (SEARO) developed a tool to conduct a system-wide analysis of AMR containment programmes. We developed indicators based on existing evidence to evaluate the progress made in each member state of the region over five years (2016-20). The tool was developed to identify vulnerabilities in the system, to identify the stage of implementation of GAP-AMR related activities, and to assess the progress made over time.
The situation analysis tool is being piloted in several countries. Here we present the tool and discuss its potential in identifying gaps in implementing the GAP-AMR, its shortcomings, and its relevance in comparison to other available tools. This will be instrumental for WHO to fulfil its obligations, in accordance with the resolution of the 68th World Health Assembly to report on the development, implementation, monitoring, and evaluation of the national action plans for the containment of AMR developed by member states.6
The tool was based on a scoping literature review. We systematically searched for major frameworks for monitoring AMR in different countries. In the first stage, we searched PubMed for published, peer reviewed documents; in the second stage, we identified AMR containment programmes that had been operational and searched their websites for related documents. Finally, in the third stage, we manually searched through the bibliographies of the included documents to identify other relevant documents that we may have missed on the two previous steps. We included documents associated with national action plans, monitoring and surveillance frameworks at the national and supranational levels, and policy frameworks dealing with the drivers of and plan for the mitigation of AMR. Documents dealing with surveillance, prevention, control, and containment of AMR were obtained from national and supranational programmes, such as the AMR containment programmes in developed countries like Sweden and the US, those in developing countries like India, and supranational policy documents from bodies like the Joint Programming Initiative on AMR. We looked for further documents mentioned in the body or reference list of all documents until no more were found. We found a total of 42 documents—12 in the initial phase, 16 in the second stage, and14 through hand searching the included texts.
Indicators for system-wide evaluation were extracted from the documents and, after expert input, were classified into seven focus areas, each of which tackled one or more of the five strategic objectives outlined in the GAP-AMR (box 1).6 The seven focus areas were: national AMR action plan; awareness raising; national AMR surveillance; rational antimicrobial use and surveillance; antimicrobial stewardship and infection prevention and control; research and innovation; and One Health engagement(table 11).
Each indicator was graded on the extent of implementation using an incremental scale consisting of five phases based on an adaptation of the stages of implementation defined by Fixsen et al (table 22).7 The first phase—that of exploration and adoption—indicates that the process of designing an AMR containment programme has been initiated. Once the decision to implement the programme has been made, systems progress to the second phase—programme installation. The third phase— initial implementation—is one of the most challenging phases for programmes in developing countries. After the early implementation barrier is overcome and the programme is scaled up, the fourth stage—full operation—is achieved. Once the programme starts to function at the highest grade of operational efficiency, the fifth and final stage— sustainable operation—is attained.
The situation analysis process using our tool is designed to be a multi-stakeholder review, to be performed jointly by national stakeholders and WHO. National stakeholders assess themselves and provide evidence and justification. WHO facilitates the process and helps reach a consensus on the grading through guided discussions. The guided discussion technique8 9 is used to elicit dialogue and exchanges between reviewers and stakeholders. Core questions trigger discussions on each focus area. We defined a functional system as a system that shows sound procedures, interdepartmental interactions, leadership, governance and funding capacity, and outputs (reports, decisions translated into actions).10
Based on the outcome of the multi-stakeholder review, a thematic situation analysis might be conducted. A combination of the review for capacity and that for functionality describe at which stage the AMR containment programme is positioned for each focus area.
Results of the process can be summarised in the form of an analysis of strengths and challenges, mapped using the phases attained by the indicators for each strategic objective. Indicators in the first two phases of implementation are considered to contribute to challenges and vulnerability of the system, whereas those in the three higher phases are considered to be strengths of the system.
Two monitoring and evaluation frameworks have been widely implemented globally for assessment of national AMR containment programmes—the WHO rapid assessment tool for country situation analysis and the international health regulations joint external evaluation tool.
The WHO rapid assessment tool was used to determine the extent to which effective practices and structures to tackle AMR were already in place and where gaps remained.4 A total of 133 of the 194 WHO member states provided information. The tool covered the six objectives of the 2011 WHO strategy as a questionnaire with largely close ended questions; it was submitted to national health authorities for self assessment and reporting, which may be biased and of limited credibility. The WHO rapid assessment tool has a limited scope to provide insights on how operational an AMR containment programme is. Furthermore, it does not adequately assess engagement with and response from One Health and related mechanisms that are important for AMR prevention and control.
More recently AMR has been acknowledged as a threat to global economic stability and security.11 The Global Health Security Agenda—a partnership between countries to “prevent, detect, and respond to biological threats”—was launched in 2013 and included AMR as one of the 11 priorities for global action.12 13 Building on this agenda12 and other assessments, WHO developed the joint external evaluation tool 13 14 to foster compliance with the core capacity requirements of the international health regulations. AMR is part of a larger set of public health issues concerning global health.15 Despite having functional indicators that might assess improvements in programme implementation over time, the joint external evaluation tool fails to capture the complexity of AMR containment as detailed in the GAP-AMR. Many aspects of the strategic objectives of the global action plan are missing, including research and innovation and capacity strengthening. It does not capture the multisectoral essence and has minimal alignment with GAP-AMR. The One Health approach is measured in a broad way so that multisectoral governance over AMR containment is diluted. Stewardship activities are bundled together in one category. Although the joint external evaluation tool captures key elements of system-wide functionality regarding AMR containment programmes, progress against the threat of AMR requires comprehensive and concrete metrics that can be monitored and measured efficiently.
AMR is an ongoing silent epidemic across the world, which many countries have limited capacity to detect. Given the limited resources, competing priorities and political challenges could derail the implementation goals of the national action plan. Enabling all countries to measure progress towards sustained operations of the AMR containment programme is, therefore, essential.
The SEARO tool is organised around the development and implementation of national action plans (table 33).). Through an extensive set of indicators, the tool provides information on comprehensive governance, policy, and systems analysis and can be applied at the community as well as the systems level. It provides a combination of functionality and capacity assessment and can be used repeatedly over time to assess progress. It focuses on areas where active participation, political will, and stakeholder engagement are crucial to success, thereby giving a glimpse into the extent of involvement of the political and governance machinery in tackling AMR concerns. Additionally, it emphasises engagement with One Health in a trans-sectoral sense, at the policy implementation level, which is critical given that antimicrobial use in the veterinary sector is a major determinant of the emergence of AMR.
The incremental phases through which the indicators progress are also indicative of systems building over time, fostering ownership, collaboration, and transparency. Compared with other assessment tools, the language used to describe the different stages of development encourages countries and allows them to benchmark their progress.
Moreover, we provide a clear direction to AMR containment in terms of best practices, best policies, and system development including a roadmap in the form of an infographic (see data supplement on bmj.com). In the last phase— sustainable operation—components of sustainability are clearly implemented with secured funding and a monitoring and evaluation system that documents findings and subsequent changes made for improvement.
The SEARO tool is limited by its inability to assess the quality of implementation of framed policies and programmes, as it only assesses the extent to which the programmes are implemented. Considering that the countries currently using the tool have no or rudimentary programmes for AMR containment, however, assuring implementation is the essential first step. Once most countries reach phase 4—full operation—further steps could be added between phases 4 and 5 to monitor quality.
We have piloted the tool in three countries—Indonesia, Maldives, and Sri Lanka—and found that these countries appreciated the tailored tool and the one-to-one assistance we provided, which identified problems pertinent to the countries, many of which have systems gaps and relatively rudimentary programmes for containment of AMR that need extensive support and strengthening.
Traditionally, AMR surveillance has not been included in the health related priorities of countries in South East Asia. Consequently, in keeping with the GAP-AMR, tools that focus on building and strengthening systems are critical, rather than tools that assess the quality of programme implementation. Countries should focus on adopting pragmatic and relevant approaches that consider the regional peculiarities that drive the emergence and progress of AMR. Tools should not focus on inter-country comparisons but rather allow individual member states to prioritise and formally document the most urgent needs of individual nations to enhance implementation of AMR surveillance programmes. The SEARO tool is likely to fulfil these objectives by providing individual member states with an understanding of the current status of AMR surveillance implementation; this, in turn, should provide scaffolding for a customised national action plan that is driven by national priorities. WHO’s regional and country offices are committed to supporting administration of the tool to ensure that AMR is tackled successfully.
Extra material supplied by authors
Supplementary information: Roadmap for action on antimicrobrial resistance. WHO Regional Office for South East.
Contributors and sources: All authors participated in the development of the manuscript. SV conceptualised the article and, in discussion with AS and MK, drew up the outline. MK was responsible for conducting the review and developing the tool. He wrote the first draft of the article. AS and SV reviewed the tool, including pilot testing, and provided inputs in subsequent drafts based on pilot experiences. All authors participated in revising the drafts and approving the final. SV is the guarantor.
Funding: This work was commissioned by the WHO Regional Office of South East Asia using the UK government’s Fleming Fund. The authors alone are responsible for the views expressed in this article, which does not necessarily represent the views, decisions, or policies of the institutions with which the authors are affiliated.
Competing interests: The authors have read and understood BMJ policy on declaration of interests and declare no competing interests.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is one of a series commissioned by The BMJ based on an idea from WHO SEARO. The BMJ retained full editorial control over external peer review, editing, and publication.