The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research

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The socioeconomic drivers and impacts of Antimicrobial Resistance POLICY BRIEF 64 Implications for policy and research Michael Anderson Gunnar Ljungqvist Robin van Kessel Victoria Saint Elias Mossialos World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: eurocontact@who.int Website: www.euro.who.int HEALTH SYSTEMS AND POLICY ANALYSIS Print ISSN 1997-8065 Online ISSN 1997-8073 PolicyBrief_PB64_COVER_19052024_PRINT.qxp_Cover_policy_brief 02/07/2024 12:43 Page 1 This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence- informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. What is a Policy Brief? 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Suggested citation. Anderson M, Ljungqvist G, van Kessel R, Saint V, Mossialos E. The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research. Copenhagen: European Observatory on Health Systems and Policies, WHO Regional Office for Europe; 2024. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see https://www.who.int/publications/book-orders. To submit requests for commercial use and queries on rights and licensing, please contact contact@obs.who.int. Third-party materials. If you wish to reuse material from this work that is attri- buted to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. 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How to implement integrated care?: A framework with 12 overall strategies to transform care delivery Verena Struckmann, Nathan Shuftan, Giada Scarpetti, Willemijn Looman, Roland Bal, Maureen Rutten-van Mölken, Ewout van Ginneken The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/policy-briefs Keywords: Anti-bacterial agents Drug resistance, microbial Drug resistance, bacterial Health policy Health governance Socioeconomic Sociocultural Equity Gender One Health PolicyBrief_PB64_COVER_19052024_PRINT.qxp_Cover_policy_brief 16/10/2024 12:02 Page 2 Editor Dimitra Panteli Managing Editors Jonathan North Lucie Jackson The authors and editors are grateful to the reviewers who commented on this publication and contributed their expertise. Contents Acknowledgements 2 List of tables, figures and boxes 3 List of abbreviations 4 Key messages 5 Executive Summary 7 Policy Brief 9 1. Introduction 9 2. What are the key socioeconomic drivers of AMR 12 3. What are the key health and economic 16 impacts of AMR for individuals and households, health systems, and societies? 4. What are the principles that should underpin 20 a comprehensive policy response to the socioeconomic drivers and impacts of AMR? 5. How can considerations of socioeconomic 26 drivers and impacts of AMR be incorporated into key policy areas? 6. Conclusion: A call for action to address 29 the socioeconomic drivers and impacts of AMR References 30 Appendix 32 Authors Michael Anderson, 1) Health Organisation, Policy, Economics (HOPE), Centre for Primary Care & Health Services Research, The University of Manchester, United Kingdom and 2) LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom Gunnar Ljungqvist, 1) Center for Global Health Science and Security, Georgetown University, Washington, District of Columbia, United States of America and 2) LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom Robin van Kessel, 1) LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom, 2) Department of International Health, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands, and 3) Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom Victoria Saint, Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Germany Elias Mossialos, 1) LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom and 2) Institute of Global Health Innovation, Imperial College London, London, United Kingdom page The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Print ISSN 1997-8065 Online ISSN 1997-8073 PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 16/10/2024 12:05 Page 1 2Policy brief Acknowledgements We are grateful for comments and feedback on the policy document provided by several reviewers including Emma Pitchforth (Exeter University), Anthony McDonnell (Center for Global Development), Esmita Charani (University of Cape Town, University of Liverpool), Tom Fieldman (Cambridge University Hospitals NHS Foundation Trust), and Alison Shutt (Imperial College London). We are also appreciative to all stakeholders who agreed to be interviewed to inform the development of this policy document (see Appendix: 8.3 Expert interviews). We would also like to thank Isaac Bencomo-Bermudez, who assisted in organizing and conducting interviews. While insights from interviews and the reviewers influenced the development of this policy document, its contents do not reflect the views of individual reviewers or interview participants. Funding for the development of this document was kindly provided by the World Economic Forum, which was supported by the Novo Nordisk Foundation. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 2 3The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research List of tables, figures and boxes Tables Table 1: Selected key socioeconomic drivers of AMR 12 Table 2: Key health and economic impacts of AMR 16 Table 3: Key actions by government ministries 23 to address socioeconomic drivers of AMR Table 4: Research priorities to understand and mitigate 25 against the socioeconomic drivers of AMR Table Annex 1: Overview of the search string 36 for the literature review Figures Figure 1: All-age rate of deaths attributable 9 to bacterial AMR by region, 2019 Figure 2: Progress to develop and implement 10 national action plans on AMR globally, 2022 Figure 3: The health impact of bacterial AMR measured 17 according to disability-adjusted life years Figure 4: Annual per capita hospital expenditure 18 incurred due to AMR up to 2050, USD PPP Figure 5: Annual job losses, absenteeism and 19 presenteeism associated with AMR in OECD countries up to 2050 Figure 6: Overarching principles to incorporate 20 socioeconomic drivers and impacts of AMR into policy Figure 7: Governance framework for AMR 21 Figure 8: Challenges faced on the AMR people journey 22 Figure 9: Policy framework on socioeconomic drivers 26 and impacts of AM Figure 10: Overview of the proposed Grand Bargain to 28 Improve the Antimicrobial Market for Human Health Boxes Box 1: International and national action to combat AMR 10 Box 2: Overview of methods used for development 11 of policy brief Box 3: Policy actions to secure sustainable access 27 to antimicrobials PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 3 4Policy brief List of abbreviations AIDS Acquired immunodeficiency syndrome AMR Antimicrobial resistance ARG Antimicrobial-resistant gene AMU Antimicrobial usage DALY Disability-adjusted life year FAO Food and Agriculture Organization of the United Nations FTE Full-time equivalent G20 Group of 20 countries G7 Group of 7 countries GBD Global burden of disease GDP Gross domestic product HCAI Healthcare-associated infection HiAP Health in All Policies HIC High-income countries HIV Human immunodeficiency virus ICM Intersectoral coordinating mechanism IPC Infection prevention and control LMIC Low- and middle-income country MRSA Methicillin-resistant Staphylococcus aureus MSSA Methicillin-sensitive Staphylococcus aureus MAR Multiple antibiotic resistance MSC Minimum selective concentrations NAP National action plan NGO Non-governmental organization OECD Organisation for Economic Co-operation and Development OTC Over-the-counter PNECs Predicted no-effect concentrations PPP Purchasing power parity SMA Self-medication with antibiotics TB Tuberculosis UN United Nations UNEP United Nations Environment Programme USD United States dollar WASH Water, sanitation and hygiene WHO World Health Organization WOAH World Organisation for Animal Health PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 4 5The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Key messages The policy community, international and national, recognizes the significant health and economic impacts of antimicrobial resistance (AMR) on individuals, households, health systems and society. It is seeking sustainable solutions but often ne- glects the socioeconomic and sociocultural drivers of AMR. • Socioeconomic and sociocultural factors play a critical role in driving AMR, shaping its health and economic impacts, and influencing the effectiveness of innovations that seek to tackle it. • AMR policy needs to take socioeconomic drivers and impacts into account. • Socioeconomic drivers of AMR in humans are complex but understanding them can inform better interventions. The emergence and spread of AMR relate to a mix of factors including gender, living situations, educational level, healthcare access, (poor) governance, human mobility, conflict, climate change, agriculture and pollution. Policy that understands these and the way they interact with one another will be more likely to achieve its aims. • Building key elements into design of AMR policy can help ensure socioeconomic considerations are embedded during policy implementation, monitoring, and evaluation: • People-centredness fosters an equity-orientation and encourages policies that are responsive to individuals’ needs and challenges. • Multisectorality recognizes AMR policy as a cross- cutting issue and brings on board various government departments and stakeholders reflecting the socioeconomic context. • Effective governance and leadership that are mindful of the drivers of AMR are central to coordinating multisectoral action to address AMR’s wider determinants. • Evidence-based policy helps ensure that policy formulation looks beyond the biomedical model and involves interdisciplinary research and surveillance to understand and tackle the socioeconomic drivers of AMR. • There are four policy areas that policy-makers could usefully regard as priorities: • Prevention, including infection prevention and control (IPC) in healthcare; biosecurity measures in agricultural settings; and equitable, global access to clean water, sanitation and hygiene (WASH) infrastructure. • Access involves promoting equitable access to diagnostics and treatments for infection. This requires reducing barriers to accessing essential healthcare services, and strengthening procurement and the supply-chain. • Innovation, which requires investment in new technologies and incentives for research and development but which must also respond to global needs and contexts, including in low and middle- income countries (LMICs), and address access and affordability. • Stewardship policies are also needed to conserve pre- existing and emerging antimicrobials and to promote responsible use in ways that acknowledge the constraints and realities of different global contexts and avoid inadvertent discrimination against particular populations. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 5 6Policy brief PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 6 7The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Executive summary • AMR is one of the biggest public health challenges of our time, and was estimated to be directly responsible for 1.27 million deaths in 2019 alone, equivalent to approximately 3500 people each day. Without substantial action to tackle AMR, this number is estimated to reach 10 million per annum by 2050. • Our understanding of AMR has predominantly focused on the biomedical model while interactions between the socioeconomic and sociocultural determinants of health and AMR have not been studied extensively. • There are several critical socioeconomic drivers of AMR. We focused on socioeconomic drivers of AMR in humans specifically, although this captures interactions of humans with animals and the environment. • Gender: Social, cultural and biological factors mean that women are more likely than men to experience occupational exposure to AMR, and to be prescribed antimicrobials. • Living situations: The risk of AMR is increased for populations living in urban and overcrowded environments, as well as with limited access to clean water, sanitation and hygiene (WASH) infrastructure. • Educational level: Higher education is associated with greater capacity to understand the dangers of inappropriate antimicrobial use (AMU), and the risk of AMR. • Healthcare access: Limited access to healthcare can result in more inappropriate use of antimicrobials in contexts with weak regulation of access to antimicrobials. Persistent shortages of antimicrobials can also lead to prolonged infections, and substitution with suboptimal antimicrobials. • Poor governance: Implementing sustainable and effective policies to combat AMR is challenging in contexts with political instability, limited rule of law and higher levels of corruption. • Human mobility: Movement of people, due to migration, conflict or tourism, is associated with the introduction of new strains of antimicrobial-resistant microbes. • Conflict: Disruptions to healthcare systems, surveillance, supply-chains of essential antimicrobials, access to clean WASH, and populations being forcibly displaced create conditions that mean infections are difficult to treat and spread easily. • Climate change: Rising ambient temperatures increase bacterial growth rates, and also contribute to extreme weather events that can disrupt healthcare services, displace populations and reduce access to WASH infrastructure. • Agriculture: Evidence exists of animal-to-human transmission of resistant pathogens following occupational exposure and food contamination. Improper disposal of waste products and effluent are also responsible for high concentrations of antimicrobial-resistant microbes in the environment. • Pollution: Waste from the pharmaceutical and healthcare industries, heavy metals from industrial and agricultural processes, airborne particulate matter, and plastic waste in water bodies can all drive AMR in the environment. • There are several health and economic impacts of AMR for individuals and households, health systems and society. • Individuals and households: Individuals who contract antimicrobial-resistant infections are at risk of mortality, long-term disability, catastrophic health expenditure and lost income, as well as delay of effective treatment, with suffering and socioeconomic impacts for families and communities. • Health systems: AMR is responsible for increased hospitalization rates, greater length of stay, increased treatment costs and reduced ability to safely provide treatments such as chemotherapy and surgical care. • Society: Reductions in the size and productivity of the workforce, increased healthcare expenditure and negative impacts on livestock production and trade all contribute to reduced gross domestic product (GDP) associated with AMR. • A potential policy framework to respond to the socioeconomic drivers and impacts of AMR includes four overarching principles: • Effective governance: Coordinating such multisectoral action requires significant coordination and effective leadership, which may be especially challenging in countries with governance challenges. • People-centred and equity-oriented: Policy needs to be responsive to individuals’ needs and challenges related to the prevention, diagnosis and treatment of AMR. • Multisectoral: AMR needs to be reframed as a cross- cutting issue requiring mobilization across various governmental departments and stakeholders. • Evidence-based: Moving away from a biomedical understanding of AMR requires interdisciplinary research on socioeconomic drivers and impacts of AMR, and robust and comprehensive surveillance systems. • These overarching principles can be used to support the incorporation of key considerations of the socioeconomic drivers and impacts of AMR during development and implementation of interventions in four core policy areas: • Stewardship: Conservation of pre-existing and emerging antimicrobials requires a coherent set of actions to promote their responsible use in both human and animal health that considers the constraints and realities of individuals in different contexts globally. • Prevention: Alongside IPC in healthcare and biosecurity measures in agricultural settings, a key priority is equitable access to WASH infrastructure globally. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 7 8Policy brief • Access: Equitable access to diagnostics and treatment of infection requires reducing barriers to accessing essential healthcare services and ensuring access to essential antimicrobials through changes in procurement policy, and strengthening the antimicrobial supply-chain in both LMICs and high- income countries (HICs). • Innovation: Increased investment in incentives to stimulate research and development of AMR health technologies needs to be responsive to the needs and operational contexts of LMICs, including access and affordability. • There is increasing evidence of the critical role that socioeconomic and sociocultural factors play in driving AMR, shaping the health and economic impacts of AMR, and influencing the effectiveness of innovations and progress to tackle AMR at the individual, health system and societal level. It is essential that AMR policy takes these socioeconomic drivers and impacts into account moving forward. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 8 9The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 1. Introduction The development of antimicrobials is one of the major achievements of modern medicine, and has revolutionized the treatment of communicable diseases and facilitated other breakthroughs in cancer and surgical care (Anderson et al., 2019b). AMR arises when microorganisms such as bacteria, viruses, parasites or fungi evolve to develop the ability to withstand treatments with antimicrobial agents to which they were previously susceptible. Some resistance to antimicrobials can occur naturally over time. The increasing use and misuse of antimicrobials, however, is accelerating this process as antimicrobials exert a “selection pressure” that provides micro-organisms with favourable conditions for mutations that promote resistance to survive and prolifer- ate among hosts, the wider population and the environment (Holmes et al., 2016). Continued growth and transmission of antimicrobial-resis- tant pathogens is responsible for significant mortality, healthcare costs and negative impacts on trade and economies globally. It is estimated that AMR was directly re- sponsible for 1.27 million deaths in 2019 alone (Murray et al., 2022), which is equivalent to approximately 3500 people each day. Without substantial action to tackle AMR, this number is estimated to reach 10 million deaths per annum by 2050 (Review on Antimicrobial Resistance, 2016). The health burden of AMR is also heavily skewed towards LMICs. It is highest in Western Sub-Saharan Africa and South Asia, where the death rate attributed to AMR in 2019 was 27.3 per 100 000, and 21.5 per 100 000 respectively (Figure 1) (Murray et al., 2022). This is significantly higher than in Western Europe, where the death rate attributed to AMR was 11.7 per 100 000, although comparable to the rate in Eastern Europe of 19.9 per 100 000. While interna- tional and national efforts are increasing (Box 1), these often fail to consider socioeconomic drivers and impacts. POLICY BRIEF Note: Regions are classified according to the Global Burden of Disease (GBD) project. Source: Authors generated this figure using data from Murray et al, 2022 Figure 1. All-age rate of deaths attributable to bacterial AMR by region, 2019 0 5 10 15 20 25 30 35 40 Australasia East Asia North Africa and Middle East Western Europe High-income North America Central Latin America Central Asia Southeast Asia Tropical Latin America Andean Latin America Caribbean High-income Asia Pacific Central Europe Oceania Southern Latin America Southern Sub-Saharan Africa Eastern Europe Central Sub-Saharan Africa Eastern Sub-Saharan Africa South Asia Western Sub-Saharan Africa Deaths Attributable to AMR per 100,000 PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 9 10 Policy brief Box 1. International and national action to combat AMR International and national efforts to combat AMR have grown steadily over the last two decades, underpinned by two major landmark developments. The World Health Organization (WHO) Global Action Plan on AMR was launched in 2015, calling on all countries to develop national action plans by 2017 (WHO, 2015). In 2016 the United Nations (UN) General Assembly agreed on a political declaration on AMR, with countries committing to work at national, regional and global levels to develop and implement multisectoral national action plans in accordance with the One Health approach (UN, 2016). Figure 2. Progress to develop and implement national action plans on AMR globally, 2022 A – No national AMR action plan or plan under development B – National AMR action plan developed C – National AMR action plan approved by government and is being implemented D – National AMR action plan has costed and budgeted operational plan and monitoring mechanism in place E – Financial provision for the National AMR action plan implementation is included in the national plans and budgets Notes: African Region (AFR), Region of the Americas (AMER), Eastern Mediterranean Region (EMR), European Region (EUR), South-East Asian Region (SEAR), Western Pacific Region (WPR). Source: Food and Agriculture Organization of the United Nations (FAO)/United Nations Environment Programme (UNEP)/World Health Organization (WHO)/World Organisation for Animal Health (WOAH) Global Database for Antimicrobial Resistance Country Self- Assessment (WHO et al., 2018). Important follow-up initiatives to support implementation of policies include, for example, an implementation handbook (WHO, 2022b), guidance for monitoring and evaluation (WHO, 2023b), and monitoring of progress by the Global Database for Antimicrobial Resistance Country Self-Assessment (Figure 2). In total, 67% (109/166) of countries that completed the self-assessment questionnaire had implemented an AMR national action plan. Implementation challenges remain in many countries that have designed national action plans, including limited resources, poor participation and engagement among relevant stakeholders, and an absence of transparency and accountability mechanisms (Pitchforth et al., 2022; Patel et al., 2023). A critical limitation to current national and global efforts, however, is that our understanding of the drivers and im- pacts of AMR has predominantly focused on the biomedical model, often at individual and microbiological level. The in- teractions between the socioeconomic determinants of health and the emergence and spread of AMR have often been neglected. However, evidence from a range of health issues – whether HIV/AIDS, TB, COVID-19 or noncom- municable diseases – has repeatedly demonstrated that so- cioeconomic and sociocultural factors play a critical role in driving health behaviour and health outcomes, as well as in- fluencing treatment and health service access and outcomes (WHO, 2008). In a recent global review of AMR national action plans (NAPs), no NAP acknowledged the need to tailor messages regarding AMR to different audiences and there was “little to no recognition of the need for addressing cultural drivers of health-seeking and health-providing behaviours” (Charani et al., 2023). A more sophisticated and sustainable approach to the implementation of national AMR policy requires stronger understanding of the specific socioeconomic and sociocultural drivers of AMR, and taking account of these drivers in the adaptation and design of interventions for specific populations and contexts. 0 2 4 6 8 10 12 14 16 18 20 AFR AMER EMR EUR SEAR WPR A B C D E PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 10 11 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research The policy brief is structured according to three policy questions: • What are the key socioeconomic drivers of AMR? • What are the key health and economic impacts of AMR for individuals and households, health systems and societies? • How can we develop a comprehensive policy response to reflect the socioeconomic drivers and impacts of AMR? Our overview of methods is contained in Box 2. We consider socioeconomic drivers of AMR in humans specifically, includ- ing the interaction of humans in animal and environmental health settings. We do not focus on the specific drivers of AMR within healthcare services, such as poor antimicrobial stewardship and IPC, which are covered extensively else- where (Anderson, Cecchini & Mossialos, 2019; Anderson et al., 2019b). In our analysis the impacts of AMR are consid- ered predominantly from a human health perspective, in- cluding the health and economic impact on individuals and households, health systems and broader society. The target audience of this policy brief is international, national and regional policy-makers responsible for designing and implementing AMR interventions through multisectoral national action plans. The secondary audience is health workers, academics, communities, civil society groups, professional organizations and the private sector involved in development, implementation and monitoring of AMR multisectoral national action plans. Box 2. Overview of methods used for development of policy brief The development of this policy brief has been informed by an umbrella literature review and semi-structured stakeholder interviews. The umbrella review identified pre-existing systematic reviews that contained quantitative evidence on socioeconomic drivers and impacts of AMR. The full details of the methods for the umbrella review are contained in the Appendix (8.1. Umbrella review methodology). An academic publication that further expands on the methodology of the umbrella review and the findings of each identified article is currently in development. The stakeholders were recruited for interviews through purposive sampling (Palinkas et al., 2015), which is a method to select participants for interviews based upon their expertise and characteristics. We selected interviews to ensure representations from policy-makers and academics from both HICs and LMICs. Snowball sampling was also used (Parker, Scott & Geddes, 2019), with interviewees asked to assist in identifying other potential subjects. Interviews were semi-structured, with a topic guide developed interactively among co-authors (see Appendix: 8.2 Interview topic guide). The full list of interviewees is also contained in the Appendix (8.3 Expert interviewees). PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 11 12 Policy brief 2. What are the key socioeconomic drivers of AMR? A broad range of socioeconomic drivers of AMR are in play, in an interlinked and multisectoral way. Selected key socio - economic drivers, which were identified through our litera- ture review and stakeholder interviews, are outlined below (Table 1). Table 1. Selected key socioeconomic drivers of AMR DRIVER EXPLANATION Gender The relationship between gender and AMR is multifaceted and underinvestigated in the literature. Social, cultural and biological factors mean that women are more likely to be prescribed antimicrobials than men. Women have increased exposure to pathogens given they are more likely to undertake caregiving roles and work in frontline healthcare settings, presenting higher occupational risk. Living conditions Overcrowding and the number of children per household are associated with increased risk of AMR. Limited access to clean WASH infrastructure in both urban and rural contexts is also a major driver of AMR, particularly in LMICs. Educational level Higher educational levels are associated with greater capacity to understand the dangers of inappropriate AMU and the risk of AMR, but is also correlated with increased income and reduced barriers to access healthcare services. Lower education may be associated with higher levels of antimicrobial misuse in contexts with weak regulation of over-the-counter (OTC) access to antimicrobials. Therefore, there are mixed associations between educational levels and AMR. Access to healthcare Many people in situations of disadvantage and vulnerability face financial, social and practical barriers to access formal healthcare services. More people are estimated to die owing to lack of access to antimicrobials than from resistant infections. Many countries experience shortages of antimicrobials that can lead to prolonged infections, and substitution to broader spectrum antimicrobials that exacerbate AMR. Poor governance Multi-country analyses indicate better governance – including public voice and accountability, political stability, regulatory quality, rule of law and control of corruption – is significantly correlated with lower rates of AMR and AMU. Human mobility Human mobility, driven by either migration, forcibly displaced populations or tourism, appears to be associated with the introduction of new strains of antimicrobial-resistant microbes in different countries. Further research is needed to understand the extent to which this drives the transmission dynamics of antimicrobial-resistant pathogens nationally, regionally and globally. Conflict Conflict disrupts healthcare systems, surveillance of AMR and AMU, supply-chains of essential antimicrobials, and access to clean WASH. Conflict also forcibly displaces populations, resulting in overcrowded conditions in refugee camps. These consequences of conflict collectively create environments where infections are difficult to treat, and spread among populations. Climate change Climate change can influence AMR in several ways. Increased ambient temperatures can lead to higher growth rates of bacteria and therefore the dissemination of AMR. Climate change is also responsible for extreme weather events, which can disrupt healthcare services, displace populations and reduce access to clean WASH infrastructure. Agriculture Antimicrobial-resistant pathogens can be transmitted across human, animal and environmental health interfaces. Animal-to- human transmission can occur due to occupational exposure in agricultural workers, and contamination of food with resistant organisms. High concentrations of antimicrobial-resistant microbes can also spread in the environment following improper disposal of waste products and effluents from agricultural settings. Pollution The release of several pollutants in various ecosystems can drive increases of AMR including waste from the pharmaceutical and healthcare industries, heavy metals from industrial and agricultural processes, plastic waste in water bodies and airborne particulate matter from industrial processes. Note: These socioeconomic drivers of AMR were identified during a literature review and stakeholder interviews. We acknowledge that there may be other socioeconomic drivers of AMR not captured through these processes. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 12 13 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 2.1 Gender Gender refers to the characteristics of women, men, girls and boys that are socially constructed. This includes norms, behaviours and roles associated with being a woman, man, girl or boy, as well as relationships with each other. As a social construct, gender varies from society to society and can change over time. Gender has important implications for expected roles and responsibilities (including occupation), health-seeking behaviours and exposures to risk of infection. Gender interacts with but is different from sex, which refers to the different biological and physiological characteristics of females, males and intersex persons, such as chromosomes, hormones and reproductive organs (WHO, 2023a). The evidence on the relationship between gender and AMR remains limited and largely unexplored in the literature, with mixed findings that vary across contexts, organism-drug combination and parameter studied (Pham-Duc & Sriparamananthan, 2021). Women were found to be 27% more likely than men to have an antimicrobial prescribed in their lifetimes, in a sys- tematic review and meta-analysis of antimicrobial prescribing in the community (Schröder et al., 2016). Several factors are potentially driving this trend. Biological factors may expose women to higher rates of infection necessitating greater need for antimicrobials, for example, due to pregnancy and childbirth (Schilling, Rody & Bossung, 2022), and higher like- lihood of contracting urinary tract infections (Medina & Castillo-Pino, 2019). Occupational factors, such as a greater propensity to work in the healthcare profession, may also ex- pose women to greater risk of infections, particularly profes- sions with high patient contact (Connor et al., 2020). Gender bias also influences antimicrobial prescribing by healthcare professionals, with some studies indicating that clinicians are more likely to prescribe antimicrobials to women than to men for the same illnesses (Eggermont et al., 2018). In many regions gender inequalities in access to healthcare and education persist. In these contexts, especially in LMICs, women frequently face obstacles that prevent them from getting appropriate and timely care and having sufficient knowledge regarding prudent antimicrobial use. Where women are often expected to carry out childcare duties, these obstacles may also affect their children. As un- treated or poorly treated infections are more likely to lead to resistant bacterial strains, these discrepancies contribute to the cycle of AMR. 2.2 Living conditions Living conditions can significantly increase or reduce the risk of contracting infections and subsequent need for antimicro- bials. Poor WASH promotes the spread of infectious diseases and AMR genes (Fuhrmeister et al., 2023), and investment in improved WASH can reduce both AMR carriage rates and AMU (Ryan, Christian & Wohlrabe, 2001; Kampf, Löffler & Gastmeier, 2009). Overcrowding (Alividza et al., 2018) and the number of children per household (Bert et al., 2022; Coope et al., 2022) are also associated with AMR and AMU, indicating that the more people in the household, the higher the risk of self-medication with antimicrobials (SMA) and AMR carriage. The relationship between number of children per household and AMU is complex. Studies analysing factors that increase SMA indicate that carers often bypass formal healthcare because SMA is a more convenient option that exposes households to lower financial burden (Bert et al., 2022; Coope et al., 2022). Child day-care attendance may also favour transmission of antimicrobial-resistant or- ganisms such as MRSA (Chen & Huang, 2014; Chan et al., 2022). People who are unhoused or incarcerated are also at higher risk of AMR carriage, likely due to higher density ac- commodation in shelters and prisons (Mitevska et al., 2021). Urban settings may be more prone to population density and overcrowding, promoting transmission of a range of ill- nesses including viral illnesses, leading to overconsumption of antibiotics (Duan, Liu & Wang, 2021; Chen et al., 2021; Guo et al., 2021). On the other hand, rural communities are more likely to experience geographic and financial barriers to accessing high-quality healthcare services, and thus are more likely to self-medicate (Aslam et al., 2020; Bert et al., 2022; Sun et al., 2022). In this way, urbanicity is not inher- ently associated with AMR directly, but in a multifactorial way. 2.3 Educational level People’s understanding and behaviour in relation to health- care, the use of antimicrobials and the prevention of AMR are significantly influenced by educational level (Tsuzuki et al., 2020; Wang & Ogunseitan, 2022). Firstly, people with higher education may be better able to comprehend the dangers of misusing medication, how AMR is created and how crucial it is to finish prescription antimicrobial courses. However, more educated people are likely to have higher in- comes and therefore face fewer barriers in accessing health- care services. It is therefore not surprising that the evidence on educational level and AMR is mixed and varies consider- ably according to country context. For instance, a systematic review and meta-analysis found that higher educational level was associated with increased risk of inappropriate antimi- crobial use in Europe, but lower levels of antimicrobial usage in LMICs (Mallah et al., 2022). Inappropriate antimicrobial use was defined as any of the following practices: unpre- scribed use of antibiotics (self-medication), non-adherence to treatment guidelines, and storage of leftover antibiotics for future use. 2.4 Access to healthcare Differences in access to healthcare between populations can impact AMR in several ways. Many people in situations of disadvantage and vulnerability face persistent financial, social and practical barriers to access formal healthcare services, and it has been estimated that more people die owing to a lack of access to antimicrobials than from resistant infections (Laxminarayan et al., 2016; Kariuki et al., 2022). Limited access to formal healthcare services can also lead people to engage in SMA, particularly in countries with weak regulation on OTC access to antimicrobials (Sulis & Gandra, 2021). This can result in increased inappropriate use of antimicrobials, which in turn can contribute to the development and proliferation of AMR. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 13 14 Policy brief This is compounded by the fact that many countries experience prolonged shortages and limited access to antimicrobials, which has several implications for AMR (ReAct, 2020). First, shortages may cause healthcare facilities to store antimicrobials longer than advisable. The use of degraded and less effective antimicrobials can lead to prolonged infections and greater risk for resistance emerging. Second, physicians often need to prescribe suboptimal broad-spectrum antimicrobials when more appropriate, narrow spectrum versions are not available, risking gratuitously exacerbating AMR. Third, insufficient supply of existing antimicrobials can encourage the supply of substandard and falsified antimicrobials that are less effective and drive resistance (Chokshi et al., 2019; Iskandar et al., 2020; Chansamouth et al., 2021; Sun et al., 2022). 2.5 Poor governance The concept of governance is not synonymous with government; rather governance is concerned with actions by a broad range of societal organizations, how they relate to the public and how decisions are taken and implemented. Weak governance at the national level – measured through a combination of indicators such as voice and accountability, political stability, regulatory quality, rule of law and control of corruption – has been found to be significantly correlated with higher rates of AMR and AMU in several multi-country international analyses (Collignon et al., 2018; Maugeri et al., 2023). These analyses only indicate associations rather than causation. Nevertheless, they emphasize the importance of applying the principles of good governance to develop sustainable national policies to combat AMR, which require multisectoral coordination across government bodies, healthcare sectors and with industry. Greater involvement of patients and the public in the development, implementation and monitoring of these policies can create awareness and enhanced engagement with initiatives to tackle AMR. 2.6 Human mobility The movement of people across borders can facilitate the international spread of AMR as it exposes individuals to diverse environments, including healthcare systems with varying AMR prevalence (Godijk, Bootsma & Bonten, 2022). Travellers may acquire resistant infections during journeys, which can lead to the introduction of new resistant strains to their home countries. This has been described to varying extents in international recreational tourism (Wuerz, Kassim & Atkins, 2020; Bokhary et al., 2021; Vicente de la Cruz, Giesen & Díaz-Menéndez, 2022), international migration (Nellums et al., 2018; Coope et al., 2022) and with forcibly displaced populations (Nellums et al., 2018). The increased risk of AMR in refugees and asylum seekers, and other migrant groups, is particularly well described in the literature (Nellums et al., 2018), and this is likely due to poor sanitation, overcrowding and barriers to accessing healthcare including vaccination programmes. While there is a recognized association between human mobility and AMR, further research is needed to explore the dynamics and specific contributions of different forms of human mobility to the spread of AMR in different contexts. 2.7 Conflict Conflict can exacerbate AMR through several interconnected factors (Abbara et al., 2018; Truppa & Abo-Shehada, 2020; Kobeissi et al., 2021; Skinner, 2024). Conflict disrupts healthcare systems and can lead to a breakdown in the delivery of basic health services for many populations (Pallett et al., 2023). This can lead to challenges accessing healthcare services, limited surveillance and poor regulation of antimicrobial use (Kanapathipillai et al., 2019). Infections and injuries are common as a result of conflict and may result in overreliance on broad-spectrum antibiotics (Pallett et al., 2023). This can be due to a lack of proper medical infrastructure and trained personnel to optimize antibiotic choice, or supply-chain issues may result in shortages of essential antibiotics and restricted treatment options for infections. Conflict also disrupts essential public infrastructure, including access to clean WASH (Petrosillo, Petersen & Antoniak, 2023). This creates environments where infections continue to develop and spread among populations, increasing the demand for antibiotics and selection pressure on bacteria. Conflict also forcibly displaces populations from their homes (Nellums et al., 2018), resulting in overcrowded living conditions in refugee camps or temporary settlements that also have limited access to WASH. These environments also create conditions that encourage the spread of infectious diseases. 2.8 Climate change Climate change influences the emergence and dissemination of AMR through multiple pathways. Increased ambient temperatures can lead to higher growth rates of bacteria, which can promote the development and spread of antimicrobial-resistant bacteria (Lio et al., 2023). Warmer temperatures can also expand the geographic range of disease-carrying vectors such as mosquitoes and ticks, which can increase the prevalence of infectious diseases, leading to higher rates of AMU and, consequently, AMR (Lio et al., 2023). Climate change also causes extreme weather events, such as wildfires, heatwaves and floods, which can disrupt healthcare systems, reducing access to care and antimicrobials, contributing to the increased disease burden and the emergence and spread of AMR (Burnham, 2021). Extreme weather events can also displace populations and reduce access to WASH and other essential infrastructure. Both factors are known to increase the risk of AMR emerging and spreading. Temperature (Collignon et al., 2018; Reverter et al., 2020) and tropical climate (Bonell et al., 2019) appear to be correlated with AMR, even when analyses adjust for potential confounders such as antimicrobial consumption and human population density. Climate vulnerability, describing the vulnerability of a country’s infrastructure to extreme weather events, is also correlated with AMR (Reverter et al., 2020). PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 14 15 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 2.9 Agriculture Antimicrobial-resistant pathogens can be transmitted between humans and animals, as well as through shared environments (Lim et al., 2019; Ogyu et al., 2020). Animal- to-human transmission of antimicrobial-resistant pathogens has been explored in several ecological studies describing disproportionately high MRSA rates in farmers compared to the general population (Chen & Huang, 2014; Chokshi et al., 2019; Wu et al., 2019), and sometimes even temporal correlation between first use of specific antimicrobials in animals and emergence of attributable resistances in humans (Scott et al., 2018). Food can become contaminated with antimicrobial-resistant bacteria during various stages of production, processing and distribution. Several studies describe meat contamination with resistant organisms, from MRSA to MAR-Listeria (Richter et al., 2015; Chokshi et al., 2019; Chansamouth et al., 2021). It is not always clear if this is due to AMU in animal farming or post-production contamination, and further evidence is needed in this regard. However, there is evidence that poor hygiene during the food supply-chain carries independent risk as a driver of AMR (Leangapichart et al., 2017). Worldwide, it is estimated that approximately two thirds of all antimicrobials are used in animals rather than humans (Tiseo et al., 2020). This is driven by the continued use of antimicrobials in animals for the purpose of growth promotion (Landers et al., 2012; Ramtahal et al., 2022) or mass prophylaxis (Landers et al., 2012; Phu et al., 2022), or to keep up with intensification of demand (Phu et al., 2022). This can lead to contamination of the environment, as improper disposal or handling of waste products can release resistant bacteria from animal urine and faeces into soil and water systems, facilitating the development and spread of AMR (Larsson & Flach, 2022). 2.10 Pollution More generally, environmental sources, such as water bodies (rivers, lakes, sediments), sewage, soil, air and wildlife, can act as reservoirs and conduits for the spread of AMR agents within ecosystems (Zheng et al., 2021; Larsson & Flach, 2022). The disposal of waste from healthcare facilities and the pharmaceutical industry can introduce high levels of antimicrobials into waste water supplies, potentially contributing to the emergence and spread of resistance (Singer et al., 2016). The release of several other pollutants in various ecosystems is known to influence microbial communities and facilitate the development of AMR. Heavy metals, such as mercury, arsenic and lead, are often released from industrial activities and agricultural runoff (Edet, Bassey & Joseph, 2023). This can drive AMR because exposure to heavy metals can induce stress responses in bacteria, leading to the activation of resistance mechanisms that also confer resistance to antimicrobials (Baker-Austin, 2006). Airborne pollutants, such as particulate matter and pollutants from industrial processes, may also contribute to the spread of resistant bacteria by acting as carriers for these microorganisms (Zhou et al., 2023). There is also emerging evidence that plastic pollution can harbour resistant bacteria and serve as a reservoir for antimicrobial-resistant genes (ARGs) (Zadjelovic et al., 2023). The buoyancy and recalcitrance of plastics also mean these reservoirs of ARGs are particularly persistent in the environment. More research is needed to understand the risks of environment-to-human transfer of antimicrobial-resistant pathogens from these important reservoirs of antimicrobial-resistant pathogens in the environment (Stanton et al., 2022). PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 15 16 Policy brief 3. What are the key health and economic impacts of AMR for individuals and house- holds, health systems and societies? The health and economic impacts of AMR affect individuals and households, health systems and broader societies in different ways. A range of different indicators that map these impacts is described below (Table 2). In our analysis the health and economic impacts of AMR are considered predominantly from a human health perspective (see Chapter 1 for a discussion on the structure and scope of the policy brief), although we acknowledge that further research is needed to map the health and economic impacts of AMR in the animal and environmental health settings, and through a One Health perspective. 3.1 Increased mortality and disability AMR is responsible for considerably increased risk of mortal- ity and morbidity. An estimated 4.95 million deaths were as- sociated with bacterial AMR in 2019, including 1.27 million deaths directly attributable to bacterial AMR (Murray et al., 2022). AMR is also responsible for worse health outcomes and long-term disability for patients who survive their illness, through delay of effective treatment (Zasowski et al., 2020), longer hospital stays (MacKinnon et al., 2015; Parisi et al., 2018; Serra-Buriel et al., 2020; Poudel et al., 2023) and higher complication rates following medical procedures (Dadgostar, 2019). The potential long-term health outcomes from AMR are vast, encompassing anything from kidney fail- ure to amputation (Kobeissi et al., 2021). Bacterial AMR is associated with reductions of 192 million disability-adjusted life-years (DALYs), including 47.9 million DALYs directly at- tributed to AMR (Figure 3). Furthermore, this health burden is unequally distributed globally, with reductions in DALYs per 100 000 population approximately seven times higher in Sub-Saharan Africa compared with HICs (Figure 3). Table 2. Key health and economic impacts of AMR DOMAIN IMPACT EXPLANATION Individuals and households Increased mortality Contracting an antimicrobial-resistant infection significantly increases risk of death. Increased morbidity AMR is associated with longer and more severe illnesses. Once recovered from an antimicrobial-resistant infection, there is also increased risk of long-term disability. Treatment delay Individuals who contract antimicrobial-resistant infections are more likely to experience delay in appropriate treatment. Financial costs Antimicrobial-resistant infections are a significant cause of catastrophic health expenditure and lost income, which can push households into poverty. Health systems Increased hospitalization AMR is associated with increased risk of hospitalization, and therefore increased burden on hospitals. Increased length of stay Treating antimicrobial-resistant infections is associated with increased length of stay, and therefore increased burden on hospitals. Increased treatment costs AMR is associated with higher treatment intensification, including greater use of critical care, and higher risk of surgery, which increases overall treatment costs. Reduced enablement value Ineffective antimicrobials limit the ability of healthcare services to safely delivery chemotherapy and provide surgical care. Societies Productivity losses AMR can negatively impact the size and productivity of the labour market, which results in productivity losses. Reduced livestock production Limited access to effective antimicrobials can result in inability to treat infections and increased animal mortality and morbidity, which reduces overall production. Reduction in GDP The combined impact of productivity losses, aggregate healthcare costs and reduced livestock production can significantly reduce GDP. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 16 17 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 3.2 Increased household poverty Not only can lower socioeconomic status act as a driver for AMR, but AMR can also significantly impact individual and household poverty, in particular through increased healthcare utilization and disability. When healthcare costs are incurred, people with low income have to spend a greater proportion of their money than their higher-income counterparts. As a result, there is a higher risk for any healthcare costs incurred through AMR to push individuals and their households below or more deeply past the poverty threshold. This will threaten the achievement of the UN Sustainable Development Goals, which include the commitment to eradicate extreme poverty for all people, everywhere, by 2030 (UNDP, n.d.). Up to 28.3 million additional people could be pushed into extreme poverty by 2050 due to AMR, with the vast majority (26.2 million) living in low-income countries (Ahmed et al., 2018). 3.3 Increased healthcare utilization Patients with antimicrobial-resistant infections experience drastically increased healthcare utilization. Antimicrobial- resistant infections are associated with increased hospitalization rates, increased length of stay per admission, and a higher readmission rate (Chiang et al., 2017; Parisi et al., 2018; Poudel et al., 2023). Increased healthcare utilization happens in two ways. Firstly, resistance to first-line antimicrobials may lead to delays before the patient receives effective antimicrobial treatment, leaving longer for the bacteria to cause tissue damage and resulting in more severe infections, and thus increasing the risk of needing hospitalization. For instance, one systematic review found that patients with multi-drug resistant Salmonella were 2.51 times more likely to need hospital admission, compared to those with pan-susceptible Salmonella infections (Parisi et al., 2018). Secondly, studies also indicate the possibility of an additive effect of AMR on disease incidence, where the resistant strains create a new burden of disease, while the incidence of the original sensitive bacterial strains remains stable. It is thought that this mechanism is prevalent in MRSA for instance, where it has been found that an increase of MRSA cases is not associated with a reduction in Methicillin-Sensitive Staphylococcus Aureus (MSSA) (Mostofsky, Lipsitch & Regev- Yochay, 2011). It is possible that both mechanisms coexist in the wider population of AMR organisms, thus creating higher healthcare utilization through both increased disease incidence and increased disease severity. 3.4 Increased healthcare expenditure Antimicrobial-resistant infections are responsible for significantly increased treatment costs and healthcare expenditure, because of the increased healthcare utilization. While there are variations according to pathogen and infection type, additional treatment costs associated with AMR are driven by additional costs owing to longer duration of illness, additional diagnostic tests, longer hospital stays, the need for more expensive drugs and greater intensive care utilization (Gandra, Barter & Laxminarayan, 2014). In a recent review of 29 studies quantifying the additional costs of antimicrobial-resistant infections, the attributable cost of resistant infection ranged from -USD 2371.4 to +USD 29 289.1 (price adjusted) per patient episode, with a mean excess length of stay (LoS) of 7.4 days (Poudel et al., 2023). The additional treatment costs associated with AMR significantly increase healthcare expenditure (Figure 4). The annual cost of treating complications caused by AMR is estimated at more than USD 28.9 billion across 34 OECD and EU/EEA countries, equivalent to almost USD PPP 26 per capita (estimates adjusted for purchasing power parity; PPP) (OECD, 2023). The same OECD analysis estimated that an additional 32.5 million days are spent in hospital each year in these countries to treat the consequences of AMR, which is approximately equivalent to using the entire acute hospital bed capacity of Spain for a whole year (OECD, 2023). Figure 3. The health impact of bacterial AMR measured according to disability-adjusted life years 0 200 400 600 800 1000 1200 1400 1600 1800 2000 High income countries Southeast Asia, east Asia, and Oceania Latin America and Caribbean North Africa and Middle East Central Europe, eastern Europe, and central Asia South Asia Sub-Saharan Africa DALYs Attributable to AMR per 100,000 Source: Authors based on data from Murray et al., 2022 PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 17 18 Policy brief 3.5 Reduced enablement value The advent of antimicrobials marked the start of the age of modern medicine. With many infectious diseases now curable, healthcare was able to perform hitherto unimaginable therapies. Surgery, organ transplant and cancer chemotherapy are examples of therapies that are possible today thanks to the existence of antimicrobials. AMR poses a fundamental threat to this, as the prospect of incurable infections may lead to reduced survivability from, and ultimately reduced availability of, surgery. It is estimated, for instance, that a 30% reduction in the efficacy of perioperative prophylactic antimicrobials could lead to an additional 120 000 surgical site and post-chemotherapy infections per year in the USA (ranging from 40 000 for a 10% reduction in efficacy to 280 000 for a 70% reduction in efficacy), and 6300 infection-related deaths (ranging from 2100 for a 10% reduction in efficacy, to 15 000 for a 70% reduction) (Teillant et al., 2015). While the healthcare and societal cost of this is significant, the loss of the therapeutic options enabled by effective antimicrobials threatens to make the world a much deadlier place. 3.6 Loss of productivity The impacts of AMR on mortality and morbidity can also have significant economic impacts because of productivity losses. The largest driver of productivity losses is reductions in the size of the working population because of mortality or long-term disability. Other drivers include absence from work due to ill health (i.e. absenteeism) or lost productivity that occurs when employees are not fully functioning in the workplace due to illness or injury (i.e. presenteeism). The OECD has estimated that AMR could cause a decline in the labour market output of about 734 000 full-time equivalents (FTEs) in the working population every year across 34 OECD and EU/EEA countries (Figure 5) (OECD, 2023). These economic losses cost in total USD PPP 36.9 billion each year, equivalent to approximately one fifth of GDP in Portugal in 2020 (OECD, 2023). As mentioned above, projected reductions in the global workforce associated with AMR could reach up to 10.2 million working-age people per year under a 100% resistance scenario, compared with a loss of 2.1 million per year under current levels of resistance (Taylor et al., 2014). Note: These cross-country differences in hospital expenditure are driven both by the incidence of resistant infections and by the cost of medical treatment in each country. Source: OECD, 2023 Figure 4. Annual per capita hospital expenditure incurred due to AMR up to 2050, USD PPP 0 10 20 30 40 50 LTU HR V BG R HU N ES T NL D PO L NO R FIN IS L RO U SW E SV N GB R DN K SV K AU T CZ E ES P CY P FR A IRL ML T BE L PR T DE U LV A LU X ITA TU R GR C JPN CH E US A EU /EE A OE CD All co un trie s Annual per capita hospital expenditure USD PPP PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 18 19 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 3.7 Reduced livestock production The use of antimicrobials on animals is a recognized driver of AMR, be it for therapeutic, prophylactic or growth promotion purposes (Dewulf, Sternberg-Lewerin & Ryan, 2020). Antimicrobial use in animals has been harder to curb than in human health, but little has been made of the potential impact on the agriculture business of AMR, when antimicrobials no longer work. Ineffective antimicrobials result in increased livestock mortality and culling, leading to overall lower agricultural productivity of animal farming. At the current rate of AMR, it is expected that the world will see an 11% reduction in livestock by 2050 (World Bank, 2017). This is likely to have significant impacts on food supply and food cost, in an environment of increased demand and agricultural intensification, but as yet this has not been sufficiently quantified. 3.8 Reduced GDP The combined aggregate effect of the above costs in terms of healthcare and loss of productivity, trade opportunities and agricultural productivity illustrates the varied landscape of economic impacts born to AMR. Many models have adopted a macroscopic GDP lens to estimate the macroeconomic impact of AMR. Individual countries are likely to experience differing costs to their GDP depending on the diversification of their economy, but most estimates agree that LMICs are likely to face a higher proportion of GDP loss due to AMR. This is because international trade and agriculture represent a larger segment of their national economy. Nevertheless, all countries are expected to feel an impact in their economy, with the World Bank estimating a drop of 1.1% in global GDP by 2050 in the best-case scenario of low AMR rates, and a decrease of 3.8% when modelling a worse scenario of high rates of AMR (World Bank, 2017). 0 50 100 150 200 250 300 N OR N LD HR V IS L DN K FI N HU N AU T ES T SW E SV N LV A LU X ES P CY P BE L FR A IR L G BR DE U BG R PO L CZ E LT U SV K M LT PR T RO U IT A CH E G RC JP N U SA TU R EU /EE A Al l c ou ntr ies O EC D Rate per 100 000 working population Employment Absenteeism Presenteeism Figure 5. Annual job losses, absenteeism and presenteeism associated with AMR in OECD countries up to 2050 Source: OECD, 2023 PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 19 20 Policy brief 4. What are the principles that should underpin a comprehensive policy response to the socio - economic drivers and impacts of AMR? Developing sustainable and impactful national and international responses to AMR will require policies that consider the socioeconomic drivers and impacts of AMR for different population groups and contexts. Drawing upon insights from 13 stakeholder interviews and reviewed literature, we have developed four overarching principles that should underpin a comprehensive policy response to the socioeconomic drivers and impacts of AMR (Figure 6). The overarching principles are intended to be key considerations that are essential to mitigate against the socioeconomic drivers and impacts of AMR when designing and implementing policy. They are interrelated principles that should be embedded within actions taken by key stakeholders within the four core policy areas described in the next section (access, prevention, stewardship and innovation). 4.1 Effective governance is needed to promote sustainable implementation Developing and implementing multisectoral, people-centred and equity-oriented policies to tackle AMR require significant coordination and effective leadership, which may be particularly challenging in countries with weak or complex systems of governance. Therefore, it is important that national AMR policy embodies the principles of “good governance” to promote sustainable implementation. It is also important that policy-makers and leadership prioritize the socioeconomic drivers and impacts of AMR throughout policy design, implementation and evaluation. Strengthening governance has been framed as a key enabler to health system strengthening over the last few decades, but the concepts that underlie effective governance are applicable to most areas of public policy. A review of health system governance frameworks identified several common principles of good governance, including strategic vision, participation, coordination, responsibility, accountability, transparency, sustainability, equity, monitoring and evaluation.100 Anderson et al. (2019a) incorporated these key concepts alongside specific policy actions relevant to AMR to develop a governance framework specific to AMR policy (Figure 7). Figure 6. Overarching principles to incorporate socioeconomic drivers and impacts of AMR into policy Source: Authors’ compilation PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 20 21 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Strategic vision refers to the extent to which there is effective leadership and oversight of national AMR strategies. This requires a clear statement of objectives and goals, and should include acknowledgement that addressing socioeconomic drivers of AMR needs to be integrated within AMR national action plans and broader public policy. Targets can be useful mechanisms to help mobilize people and define more concrete action on socioeconomic issues, even if the first target is to get more data on such issues through situational analysis, robust surveillance or complementary studies. Effective leadership should also facilitate the inclusive participation and engagement of relevant stakeholders in policy development and implementation. This includes all relevant ministries (Table 3) and One Health sectors. Many countries now use a national intersectoral coordinating mechanism (ICM) for this purpose, but it is important that this involves representation from population groups, especially those in situations of marginalization that can put them at increased risk of AMR and inappropriate AMU. Effective coordination of policy both between and within sectors is also critical. For example, coordinating activities across different levels of the healthcare sector, such as ambulatory, hospital and long-term care, is particularly important. Such coordination can provide more meaningful understanding about what socioeconomic drivers and impacts are operating in which levels and contexts, and how they are acting as barriers for effective AMR action and outcomes. Responsibility and accountability can be promoted by outlining specific, measurable, achievable, relevant and time- bound (SMART) objectives within AMR national strategies, combined with designated clear roles for relevant institutions and individuals. Setting SMART objectives is also part of strategic vision, as is facilitating the monitoring and evaluation phase of national AMR strategies. Transparency can be understood as ensuring that AMR policy development, implementation and evaluation occur in an open and accessible manner. This also relates to participation, including ensuring there are mechanisms within national ICMs for open channels of feedback and discussion on what is working well, and what is not working for different stakeholders and population groups. This can help identify gaps and differential unintended impacts of policy, as well as instances where socioeconomic drivers of AMR are influencing the process and effectiveness of policy implementation. Sustainability is needed to ensure any positive change is consistent and maintained, and requires that policy actions are appropriately costed and granted a dedicated budget for implementation. The sustainability of a national AMR strategy may also be dependent upon its legitimacy, which can be achieved through a formal agreement from all relevant sectors to implement policy through a socioeconomic lens, and the ongoing support of an interdisciplinary technical group to ensure policy is evidence- based and thoroughly evaluated. MONITORING AND EVALUATION Reporting Feedback mechanisms Effectiveness AMR research POLICY DESIGN Strategic vision Participation Coordination Accountability Sustainability Equity IMPLEMENTATION TOOLS Surveillance Antimicrobial stewardship Infection prevention and control Education Public awareness Medicines regulation Fostering R&D and facilitating Market access to novel products Figure 7. Governance framework for AMR Source: Anderson et al., 2019a PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 21 22 Policy brief Equity is concerned with minimizing unfair, avoidable or remediable differences among groups of people (whether defined socially, economically or otherwise – see details in next principle on equity-orientation), in terms of access to essential health services and effective antimicrobials, and the health burden of AMR. Effective governance of national AMR policy requires a cyclical process where progress is continuously monitored and evaluated, and priorities and activities are adjusted. This requires investment in research and evaluation of existing and novel policy interventions to inform prioritization. This also requires a sophisticated understanding of the socioeconomic drivers of AMR and how policies can be designed and implemented to mitigate against them, including through education and capacity building of AMR stakeholders (see “Information & Intelligence Generation”). 4.2 AMR policy should be people-centred and equity-oriented The WHO defines a people-centred approach as an approach that “consciously adopts individuals’, carers’, families’ and communities’ perspectives as participants in, and beneficiaries of, trusted health systems that respond to their needs and preferences in humane and holistic ways” (WHO, 2023d). Equity is defined as the “absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (e.g. sex, gender, ethnicity, disability, or sexual orientation)” (WHO, 2023c). In the context of AMR, the WHO emphasize that developing a people-centred approach includes “not only engaging and empowering people and communities to be AMR champions and to promote responsible use of antimicrobials but also to prioritize people’s needs and values and ensure equitable access in the design and delivery of health care services from prevention to diagnosis, treatment and care of infections, including drug-resistant infections” (WHO, 2023d). Equity in relation to AMR is concerned with minimizing unfair, avoidable or remediable differences among groups of people in access to essential health services and effective antimicrobials, and the health burden of AMR. From a practical perspective, this approach requires policy-makers to develop national action plans that do not neglect the people-based challenges that drive AMR, such as individuals’ living situations, access to clean WASH, barriers to accessing healthcare services, or understanding of AMR as an issue. The WHO has contextualized the differences between system and people’s challenges across “the AMR people journey”, including prevention of infection, access to health services, diagnosis and treatment (Figure 8). Achieving this goal will require multisectoral approaches to address AMR Figure 8. Challenges faced on the AMR people journey Note: Infection prevention is important in both communities and healthcare facilities and continues throughout the journey. Treatment includes the continuous care that might be required for an AMR infection. The list of challenges may not be exhaustive or applicable to all countries. Source: WHO, 2023d s liaboric d fieialsfr s d ans liaboric , sceivrese rac-htlae e ritnee htr fo k lacd ane agreovc pu-wollofo ts soL• sceivresh tlaehl acole lbalaiva f os seenrawaf ok lacd ano ts sccear oPo• seniicdemr os citsnogaid, sceivresh tlaeh n og ndinepst ekcpof ot uoc ihoprtsataC ycnatisehe ncicav d ans noitnaiccavd sesmir os sccear oPo• noitcefnif on oissismanrt t neverpo ts ceitcarpo te cenrhedar oPo• noitatinasr or etawn aelco ts scceao N• n oitacudeh tlaehr oPo semamrgor sceitcarpd an e afsd ann RMAn on oitacude ystem allenges Prevention of infection Access to health services People’s challenges r • •e tnmetaertderussaytilauqoN• senicidem) COT( r etnuoc-het-reovf on oitlaugerk aeW• )elcyctnmetaert ocni, sliaboricimtnar eovtfelr oC OT u. ge(n iotacidem-flese tairoprppanI• sceivresc itsnogaidr oPo• stlsureg nisur og niterpretni n id ans citsongiade tairoprppa n in oitacuder ekrowh tlaehd etiimL• yticapacy rotarbald etiimL sisongiade tarucca, ylmeit natropmie htf os seenrawad etiimL• vresc itsongiadl acolo ts sccear oPo• sisongiadd eyaledr ot cerrocnI smetsysl arreferk aeW• imtnad ans citsongiad od radantsbusf oe sU• rekrowh tlaehd enairt imtnad ans citsongiad ht neciiuffinsr ok caL• noitaluopp noitcetorpl ciananfif o civresh tlaehd etiimL pn oitazmunimik aeW• s emamrgorpC PIr oPo• tnemeagname tsaw oitatinas, retawr oPo• ekrowh tlaehd etiimL S ch Treatment Diagnosis • • •• r ot ae e udy t , tnem e tlepm f oe s f oe c scei s liaborciimtnaf og nibircsrepe tairporppanI• pishdraewtsr o s enlieidugt nmetaertd ezidradants , - eblataertnu rto tt lcuiffide rat hats noitcefnio t ialtrmor oy tidibrmof ok isrr ehgiH• yreovcer r engolr os noitacilpmoco tg ndiael taertl amitopbusf ok isrd seaerncI• PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 22 23 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research with involvement of multiple government ministries and agencies (see next paragraph titled “AMR policy needs to take a multisectoral and inclusive approach”). 4.3 AMR policy needs to take a multisectoral and inclusive approach International, national and regional AMR policy needs to be framed as a cross-cutting and multisectoral issue requiring mobilization across various government departments whose interests and objectives are also impacted by, or are impacting, AMR. There has been some progress in this regard, and there is now consensus that tackling AMR requires a One Health approach integrating policy and a diverse range of actors across human, animal and environmental health sectors. However, it has been argued that a One Health vision of AMR can increase tendencies of policy-makers and researchers to focus on the specific interfaces that increase risk of contamination and transition of pathogens, rather than on the socioeconomic and sociocultural drivers that influence zoonotic disease risk and health-seeking behaviours (Hinchliffe, 2015). Looking to the future, AMR policy needs to draw lessons from other public health problems such as tobacco use, obesity, TB and HIV/AIDS that acknowledge that poor health is driven by a variety of factors both inside and outside the healthcare sector, and requires interdisciplinary and equity-focused approaches to policy, such as a “Health in All Policies (HiAP)” approach (Leppo et al., 2013). For AMR, such an approach should recognize that addressing the socioeconomic determinants of AMR requires multisectoral and integrated approaches that address health inequalities, with important roles for most government ministries (Table 3). However, multisectoral approaches to tackle AMR require actions from not just government, but also the private sector and non- governmental organizations (NGOs). There is a particularly important role for civil society organizations, which can contribute to tackling AMR by advocating for policy change, lobbying industry and promoting awareness of AMR (Ranganathan & Ranjalkar, 2023). In many respects, there are synergies between actions taken to address AMR and strategies for the management and control of communicable diseases more generally, and achievement of the UN Sustainable Development Goals (Jasovský et al., 2016). GOVERNMENT MINISTRY KEY ACTIONS TO TACKLE AMR AS PART OF A MULTISECTORAL APPROACH Department of Health • Invest in ensuring affordable and accessible healthcare services for all based on clinical need and not on ability to pay. • Involve disadvantaged and marginalized communities in developing policies and strategies (i.e. stewardship, infection prevention and awareness campaigns), considering their unique socioeconomic challenges. • Invest in surveillance systems that monitor inequality in AMU and AMR patterns across the population, disaggregated by characteristics such as gender, ethnicity, age, deprivation, occupation and living conditions. • Fund interdisciplinary research into socioeconomic factors contributing to AMR, leading to targeted policy interventions. Department of Agriculture • Invest in research and dialogue to understand the structural and socioeconomic challenges for actors in the agricultural setting at different levels, from individual farmers and veterinarians to large industry. • Establish robust data collection and surveillance systems to monitor AMU in agricultural settings, and collaborate with surveillance systems in human health to generate data on the risk of AMR in agricultural staff working in different contexts and surrounding populations. • Build the economic case for investment in good animal husbandry practices, biosecurity measures and vaccination to prevent infections and promote their use through guidelines and evaluations. • Regulate the use of antimicrobials in livestock and aquaculture to reduce inappropriate use, such as for growth promotion purposes, and evaluate policies to monitor livestock yields and financial impact for farmers. Environmental Agencies • Implement monitoring systems for antimicrobial residues in waste water treatment plants and soil to identify sources of contamination. • Enforce regulations on antimicrobial residue concentrations on pharmaceutical manufacturing and hospital waste disposal to limit the release of antimicrobials into the environment. • Advocate for eco-friendly agricultural practices that reduce the use of antimicrobials in crop and livestock production, which can contribute to environmental contamination. • Invest in research to understand linkages between AMR and climate change, and opportunities to create policy alignment to address both issues. Department of Education • Develop education curricula for healthcare professionals that promote non-discriminatory antimicrobial prescribing practices and understanding of the socioeconomic, gender and other factors that influence health behaviour and healthcare access and outcomes. • Develop agricultural and environmental education curricula that emphasize benefits of responsible antimicrobial use and improved biosecurity, and dangers of AMR for livestock, crops and the broader environment. • Integrate education on responsible antimicrobial use and the consequences of AMR into school, university and training curricula in related subjects to raise awareness of AMR as a cross-cutting issue and promote interdisciplinary and multisectoral exchange and collaboration across a range of fields relevant to AMR policy. Table 3. Key actions by government ministries to address socioeconomic drivers of AMR >>> Continued on next page PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 23 24 Policy brief Realizing multisectoral approaches requires that policy is developed in an inclusive manner that considers the needs and perspectives of all stakeholders, including representation from diverse and marginalized communities. This is particu- larly important as certain aspects of policy to tackle AMR, such as increased regulation of antimicrobials, may have trade-offs in relation to access to healthcare services and medicines that could exacerbate health inequalities (Kirch- helle et al., 2020). Therefore, it is important that “Informa- tion & Intelligence Generation” is focused on policy evaluation that considers the intended and unintended impacts on socioeconomic drivers of AMR for different population groups, using interdisciplinary research. 4.4 Evidence-based policy requires continuous intel- ligence generation and evaluation of interventions This principle encapsulates the importance of ensuring that policy design is evidence-based and driven by continual intel- ligence generation and evaluation of different interventions, including their differential impact in different sociocultural and socioeconomic contexts and for different groups, both within and between countries. Policy design and evaluation also need to be informed by a much broader investigation and understanding of complex, multifaceted phenomena re- lated to socioeconomic status and AMR, and how this mani- fests at structural, societal, household and individual level. Drawing upon unmet research needs frequently identified within the literature and in expert interviews, we outline major research priorities to understand and mitigate against the socioeconomic drivers of AMR (Table 4). Moving away from a predominantly biomedical understanding of the socioeconomic drivers of AMR requires information and intelligence generation from a broad range of different disciplines, and using a range of theoretical and methodological approaches. For example, sustainable and consistent implementation of antimicrobial stewardship programmes often requires frameworks, theories and methods from behavioural and psychological sciences at an individual level (Borek et al., 2022). Considering the One Health approach also draws upon social sciences to address AMR from the societal, historical and economic perspectives (Lu, Sheldenkar & Lwin, 2020). There is also a need for implementation science approaches to capture the relevant organizational, regulatory, financial and behavioural enablers and barriers to the consistent implementation of AMR policy interventions in different socioeconomic and sociocultural contexts (Khurana et al., 2023). From a quantitative perspective, surveillance data on both AMR and AMU need to be routinely disaggregated according to different socioeconomic characteristics such as gender, race, ethnicity, age, deprivation, occupation, socioeconomic status and living conditions (Charani et al., 2021). However, it should be acknowledged that existing system-level inequities create vulnerable situations and can exclude populations from surveillance data, for example for undocumented migrants, people who do not speak the dominant language, and those with poor literacy skills (Frost et al., 2021). Therefore, surveillance studies need to routinely consider which populations may be excluded, and what additional efforts can be made to ensure they are captured in surveillance exercises. Alongside this, longitudinal cohort studies are needed that collect demographic, social, economic and lifestyle information over time to truly understand the lived experiences of different individuals and how this relates to risks and impacts of AMR (Collignon & Beggs, 2019). GOVERNMENT MINISTRY KEY ACTIONS TO TACKLE AMR AS PART OF A MULTISECTORAL APPROACH Department of Housing • Promote urban planning that encourages equitable access to green spaces, reduced pollution and access to clean WASH for all populations. • Invest in access to affordable housing, which can reduce overcrowding and unsanitary living conditions that may contribute to the spread of infections, including those resistant to antimicrobials. Department of International Development • Allocate resources to international interdisciplinary research initiatives focused on understanding the socioeconomic factors contributing to AMR in LMICs, where the burden of AMR is often higher. • Support capacity-building programmes to enhance healthcare infrastructure, surveillance systems, access to WASH, improved housing, training and awareness of AMR in countries with limited resources. • Utilize international platforms, such as the WHO, UN, G7 and G20, to advocate for policy action and to implement a coordinated global response to AMR. Department of Industry and Trade • Work with pharmaceutical companies and other actors to develop and adopt sustainable manufacturing practices that reduce the environmental impact of antimicrobial production and minimize antimicrobial concentration residues in waste effluent. • Invest in research and innovation to incentivize the development of novel antimicrobials, alternative treatments and diagnostics for AMR that include terms and conditions for equitable access in LMICs. >>> Continued from previous page PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 24 25 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Developing a better understanding of how the transmission of antimicrobial-resistant pathogens is influenced by the interfaces between human, animal and environmental health is crucial to identify targets for policy action. This will require metagenomic studies that analyse the transmission of antimicrobial-resistant genes across different interfaces and settings (de Abreu, Perdigão & Almeida, 2021). However, there is also an unmet need for interdisciplinary research that draws upon political and social science approaches to map different stakeholders involved in One Health transmission dynamics and the relevant behavioural, regulatory and economic incentives that may enable or prevent the implementation of policies to limit the spread and emergence of AMR. There is also a need to undertake more sampling studies to establish to what extent antimicrobial-resistant genes and microbes exist in different environmental settings, for example, waste water, soils, discharge effluent from industry and healthcare settings (Wellcome Trust et al., 2018). Once established, standards need to be established regarding acceptable levels of antimicrobial concentrations in different environmental health settings (Vestel et al., 2022). Table 4. Research priorities to understand and mitigate against the socioeconomic drivers of AMR Note: Minimum selective concentrations represent the lowest concentration of antimicrobials that gives the resistant strains a competitive advantage based on growth rates. The predicted no-effect concentration is the concentration of a chemical which marks the limit below which no adverse effects of exposure in an ecosystem are measured. RESEARCH PRIORITY TYPES OF INFORMATION REQUIRED Understand trends and drivers for inappropriate AMU in different populations • Qualitative data (from diverse disciplinary perspectives) on the socioeconomic and structural drivers of inappropriate AMU in different populations and contexts, at individual, community and societal level. • Surveillance data on AMU disaggregated according to prescriber and patient characteristics, such as gender, race, ethnicity, age, deprivation, occupation and living conditions. Understand trends and drivers for inappropriate AMU in animal health • Qualitative data (from diverse disciplinary perspectives) on the socioeconomic and structural drivers of inappropriate AMU in animal health, including a variety of settings including smallholdings, larger farms, veterinarian practices and the food industry. • Surveillance data on AMU disaggregated according to different animals, agricultural setting and farm characteristics (e.g., size, location and function). Identify enablers and barriers to uptake of technologies and behavioural interventions in different contexts • Qualitative data (e.g., from interviews, observations, surveys and focus groups) to identify the different organizational, regulatory, financial and behavioural enablers and barriers to uptake of technologies (e.g., rapid diagnostics and vaccinations) and impact of behavioural interventions (e.g., awareness campaigns, stewardship policies and incentives) in different socioeconomic and sociocultural contexts. Understand the relative risk of AMR in different populations • Surveillance data and other complementary studies on AMR in different population groups, disaggregated by socioeconomic and sociocultural factors such as gender, race, ethnicity, age, deprivation, occupation and living conditions. • Longitudinal cohort studies that collect information on a range of demographic, socioeconomic, sociocultural, lifestyle and behavioural factors that follow individuals, households or neighbourhoods over time and establish their risk factors for AMR. Understand the relative risk of AMR in different populations • Metagenomic studies that analyse the transmission of antimicrobial-resistant genes across different interfaces and settings, such as healthcare settings, animal contacts and water sources. • Interdisciplinary research that maps stakeholders involved in One Health transmission dynamics and the relevant behavioural, regulatory and economic incentives that influence policy implementation. Understand the relative risk of AMR in different populations • Sampling studies of antimicrobial concentrations from waste water, soils and discharge effluents from manufacturing and healthcare facilities, and investigations of the health impacts for surrounding communities. • Define minimum selective concentrations (MSC) and predicted no-effect concentrations (PNECs) for antimicrobials in waste water, soils and discharge effluents from manufacturing and healthcare facilities. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 25 26 Policy brief 5. How can considerations of socioeconomic drivers and impacts of AMR be incorporated into key policy areas? Developing policy responses to the socioeconomic drivers and impacts of AMR will require embedding the aforementioned principles (i.e. effective governance, people- centred and equitable, multisectoral and evidence-based) into core policy areas familiar to policy-makers working in AMR (Figure 9). We focus on four key policy areas: stewardship, prevention, access and innovation. These broadly align with the key policy domains contained within the WHO global action plan on AMR (WHO, 2015), with the exception of surveillance, which is captured within the “Evidence-based” principle described above. 5.1 Actions to promote sustainable use of antimicro- bials need to consider the constraints and realities of individuals in different contexts globally Antimicrobial stewardship can be defined as a “a coherent set of actions which promote using antimicrobials responsibly” (Dyar et al., 2017). However, a balanced approach is needed to ensure that antimicrobial stewardship policies do not discriminate against or inadvertently have disproportional negative impacts on population groups in situations of vulnerability. Diverse stakeholder engagement, including involvement of different patient groups, is essential from the very start of processes to develop a policy. Public awareness campaigns also need to adapt materials and content for different population groups to be understandable, culturally sensitive and applicable for their lived realities (Price et al., 2018). Education and training can be provided to healthcare staff on the importance of unbiased decision-making and avoiding discrimination in antimicrobial prescribing, and regular audits and monitoring mechanisms can be used to detect significant disparities in antimicrobial use. From the animal health perspective, antimicrobial stewardship requires investment in improved biosecurity and hygiene, better use of vaccination and alternative treatments, and changes in animal housing and husbandry practices (Gozdzielewska et al., 2020). There is also a need for strengthened regulation of inappropriate use of antimicrobials for prophylactic and growth promotion purposes (Pokharel, Shrestha & Adhikari, 2020), with a particular emphasis on critically important antimicrobials for human medicine (Umair et al., 2023). However, it is also important that policies and education campaigns to limit antimicrobial use in animal health are designed to reflect the constraints and realities of agricultural workers and veterinarians operating in different contexts globally. Insurance schemes could be used to protect farmers’ incomes and mitigate any potential losses if they commit to avoiding the use of antimicrobials for preventative purposes, but research is needed to understand the optimal arrangements of such insurance models (Lhermie, Gröhn & Raboisson, 2017). Figure 9. Policy framework on socioeconomic drivers and impacts of AMR Source: Authors’ compilation PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 26 27 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 5.2 Prevention of infection requires action outside the healthcare sector, with investment in equitable access to clean WASH an urgent policy priority Developing a comprehensive strategy for the prevention of infection requires multisectoral approaches that acknowledge the relationships between living situations and housing, occupational exposure, access to clean WASH, climate change, and displacement of populations and risk of developing communicable disease (Fouque et al., 2020; Fieldman, Mossialos & Anderson, 2023). These broader issues need to be considered alongside the implementation of IPC programmes in healthcare settings that include interventions such as standard hygiene measures (i.e. hand washing), the isolation of infected patients and environmental cleaning, as well as active screening of incoming patients (Tacconelli et al., 2014). However, IPC programmes need to be codesigned with broad involvement of all relevant stakeholders to ensure they consider organizational, socioeconomic and behavioural barriers and facilitators for implementation (Lacotte, Årdal & Ploy, 2020). It is also important to develop policies that consider transmission pathways of antimicrobial-resistant pathogens across human, animal and environmental health settings. There are several pathways via which this occurs, including poor sanitation, sewage and waste effluent from humans, waste effluent from pharmaceutical manufacturing, waste effluent from healthcare facilities, use of antimicrobials and manure in crop production, and waste effluent from animal production (UNEP, 2022). For these reasons, the AMR policy community have emphasized the need for coordinated and multisectoral action to strengthen access to clean WASH. This will not only prevent the transmission of communicable disease but improve overall population health, narrow health inequalities and reduce demand on healthcare services (Amebelu et al., 2021). 5.3 Sustainable and equitable access to antimicrobials for all populations is needed to avoid prolonged infections and suboptimal treatment regimes Unfortunately, many disadvantaged populations experience barriers to accessing healthcare and therefore appropriate antimicrobial treatment. This results in a disproportionally higher burden of disease for disadvantaged populations associated with infection (Alividza et al., 2018; Nellums et al., 2018). In LMICs there are often competing narratives regarding antimicrobial use. On one hand, there is a pressing need for improved and equitable access to antimicrobials to address significant mortality and morbidity associated with communicable disease (Resman, 2020). On the other hand, there are concerns about unrestricted access to antimicrobials and calls for strengthened regulation of access to antimicrobials. Overcoming this will require reframing antimicrobial stewardship as a key component of health system strengthening. Alongside this, there need to be specific policies targeted towards sustainable and equitable access to antimicrobials in both HICs and LMICs. It is known that health systems in both LMICs and HICs encounter challenges to secure consistent access to antimicrobials and experience persistent shortages (Laxminarayan et al., 2016; Edwards et al., 2023). For example, a report on shortages in EU Member States found that systemic anti-infectives were the third most frequent class of medicines for which shortages were reported in 2020 (European Commission et al., 2021). Similar data do not exist in LMICs, but shortages of essential antimicrobials are known to be a major issue with weak forecasting systems and absent or underdeveloped systems for pooled procurement identified as significant drivers (Shafiq et al., 2021). Securing sustainable access to antimicrobials internationally would require a global strategy and policy actions that target multiple stages of the antimicrobial supply-chain (Box 3). Box 3. Policy actions to secure sustainable access to antimicrobials Joint procurement exercises between countries can be used for antimicrobials used in small volumes or for countries with smaller populations that have limited purchasing power. Conditions can be included in contracts to improve security of supply, such as requirements that more than one supplier is contracted, and longer- term purchasing commitments to build the economic case for investment in manufacturing capacity. There is also scope to pilot annual revenue guarantees in both HICs and LMICs in exchange for predefined available supply volumes. This has been used effectively by Sweden to secure consistent access to antimicrobials of important public health value (Public Health Agency of Sweden, 2023), and could be replicated elsewhere. Physical and virtual stockpiling could be used to ensure sustainable access during surges of demand that occur seasonally or because of disease outbreaks. There is also a need for greater transparency across the supply-chain and mapping of production capacities and product availability. This information can be used to forecast misalignment between future supply and demand. International institutions such as the WHO also need to engage with industry to identify vulnerabilities across the supply- chain and to build the business case for investment in diversification of manufacturing capacity internationally. This is important as a global analysis of 40 antimicrobials found that close to 70% of the manufacturing sites for antimicrobial active pharmaceutical ingredients (APIs) are found in India (35%) and in China (34%) (BCG, 2021). In some cases the production of APIs for specific antimicrobials is dependent on a few suppliers in these countries, and the supply-chain is particularly vulnerable if there are any issues with these suppliers. 5.4 Innovation in the research and development of novel AMR technologies needs to be responsive to the needs of, and accessible and affordable for, LMICs Constant innovation is required to achieve access to novel antimicrobials of public health value, diagnostics, vaccines and alternative treatments for AMR (Anderson et al., 2023). However, the WHO has described the current antimicrobial pipeline as insufficient to meet public health needs (WHO, 2022a). Despite growing health and economic impacts, market failures mean that the antimicrobial pipeline remains insufficient to tackle AMR (Renwick & Mossialos, 2018; WHO, 2022a). Overcoming these market failures for PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 27 28 Policy brief antimicrobials will require investment in push incentives, such as direct funding and grants, in the pre-clinical and early clinical stages of development (Brogan & Mossialos, 2016; Renwick et al., 2016). This will also need to be combined with investment in pull incentives, such as annual revenue guarantees or market entry rewards, which can help create a viable market for antimicrobials (Anderson, Panteli & Mossialos, 2023). To avoid further exacerbating socioeconomic inequities in the health burden of AMR, increased investment in research and development of antimicrobials by HICs needs to consider the needs of LMICs, including issues such as affordability, accessibility and ease of administration. There is also a need for research into how new health technologies to tackle AMR are disseminated and used across populations (between and within countries), with a focus on potential socioeconomic drivers and impacts of AMR, to help ensure that technical innovations are used to maximum effect to reduce the health burden of AMR (Olliaro et al., 2023; Ondoa et al., 2021). One potential policy option is to combine investments in research and development with terms and conditions related to global access and affordability (Anderson, Panteli & Mossialos, 2023). For example, pull incentives deployed by G7 or G20 countries could include requirements that antimicrobial developers supply new antimicrobials to LMICs at the marginal cost of production. This is of mutual benefit for all countries as without comprehensive access to pre- existing and new antimicrobials in LMICs, certain countries may become reservoirs for multi-drug resistant infections. The Center for Global Development has developed a set of proposed commitments by HICs, LMICs, the pharmaceutical industry and international organizations to address antimicrobial market and access failures globally (Figure 10). These include commitments by HICs to adequately fund research and development, and facilitate global access to antimicrobials, by LMICs to prevent unnecessary use of antimicrobials and adequately fund national action plans, and by the pharmaceutical industry to undertake research and development in critical areas that meet all countries’ needs and to manufacture antimicrobials in an environmentally sustainable way. Figure 10. Overview of the proposed Grand Bargain to Improve the Antimicrobial Market for Human Health Source: Reproduced with permission from Center for Global Development, 2023 High-income country governments Pharmaceutical industry Low- and middle-income country governments International organizations In return for a system that ensures sustain- able access to effective antimicrobials: • Adequately fund research and development • Collect and report data on resistance • Facilitate global access to essential diagnostics and antimicrobials • Protect drugs from unnecessary use • Adequately fund National Action Plans domestically and in low-income countries • Support the creation of a sustainable access hub for antimicrobials In return for a system that ensures sustain- able access to effective antimicrobials: • Support and conduct clinical trials • Collect and report data on resistance • Protect drugs from unnecessary use • Reduce unnecessary barriers to access and stewardship • Adequately fund national action plans • Support the creation of a sustainable access hub for antimicrobials • Coordinate between countries and ensure commitments are followed • Set global targets for access, innovation and stewardship of antimicrobials • Monitor resistance rates and antimicrobial consumption • Provide finance and technical advice to governments to implement goals In return for a system that adequately remunerates research and removes barriers to selling antimicrobials in LMICs: • Undertake research and development in critical areas that meet all countries needs • Protect drugs from unnecessary use • Manufacture antibiotics in an environmen- tally sustainable way • Improve production standards and supply chains globally • Ensure drugs are available in all countries PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 28 29 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 6. Conclusion: A call for action to address the socioeconomic drivers and impacts of AMR Until recently, the relationship between socioeconomic determinants of health and the emergence and transmission of antimicrobial-resistant pathogens has not been a focus of the policy and academic community. There is now increasing acknowledgement of the critical role that socioeconomic factors play in driving AMR, shaping the health and economic impacts of AMR, and influencing the effectiveness of innovations and progress to tackle AMR at the individual, health system and societal level. Addressing the socioeconomic drivers and impacts of AMR will require policy-makers to move away from the biomedical model of AMR when designing and implementing national action plans to develop people-centred, equity-oriented and multisectoral responses to AMR. Increased investment in evidence generation is also needed to leverage interdisciplinary approaches to build a more comprehensive understanding of socioeconomic drivers and impacts of AMR, and how the uptake and effectiveness of technologies and behavioural interventions vary across populations. Crucially, this information needs to be conveyed to those who develop and implement policy to ensure that policies and actions are evidence-based and incorporate socioeconomic considerations moving forward. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 29 30 Policy brief 7. References Abbara A et al. (2018). Antimicrobial resistance in the con- text of the Syrian conflict: Drivers before and after the onset of conflict and key recommendations. International Journal of Infectious Diseases, 73:1–6. Ahmed SA, Barış E, Go DS, Lofgren H, Osorio-Rodarte I, Thierfelder K (2018). Assessing the global poverty effects of antimicrobial resistance. World Development, 111:148– 60. Alividza V et al. (2018). Investigating the impact of poverty on colonization and infection with drug-resistant organ- isms in humans: a systematic review. Infectious Diseases of Poverty, 7:76. Amebelu A et al. (2021). The Lancet Commission on water, sanitation and hygiene, and health. Lancet, 398:1469–70. Anderson M, Cecchini M, Mossialos E (2019). Challenges in Tackling Antimicrobial Resistance: Economic and Policy Re- sponses. Cambridge University Press. Anderson M, Panteli D, Mossialos E (2023). How can the EU support sustainable innovation and access to effective an- tibiotics? Policy options for existing and new medicines. Copenhagen: WHO Regional Office for Europe (on behalf of the European Observatory on Health Systems and Poli- cies). Available at: https://eurohealthobservatory.who.int/publications/i/how- can-the-eu-support-sustainable-innovation-and-access-to- effective-antibiotics-policy-options-for-existing-and-new-m edicines (accessed 29 June 2023). Anderson M, Panteli D, van Kessel R, Ljungqvist G, Colombo F, Mossialos E (2023). Challenges and opportunities for in- centivising antibiotic research and development in Europe. Lancet Regional Health – Europe, 33:100705. Anderson M, Schulze K, Cassini A, Plachouras D, Mossialos E (2019a). A governance framework for development and assessment of national action plans on antimicrobial resis- tance. Lancet Infectious Diseases, 19:e371–84. Anderson M et al. (2019b). Averting the AMR crisis: what are the avenues for policy action for countries in Europe? Geneva: World Health Organization. Available at: https://iris.who.int/handle/10665/331973 (accessed 17 April 2024). Aslam A et al. (2020). Evidence of the Practice of Self-Medi- cation with Antibiotics among the Lay Public in Low- and Middle-Income Countries: A Scoping Review. Antibiotics (Basel), 9:597. Baker-Austin C, Wright MS, Stepanauskas R, McArthur JV (2006). Co-selection of antibiotic and metal resistance. Trends in Microbiology, 14:176–82. BCG (2021). Understanding the antibiotic manufacturing ecosystem: A view of global supply chains, pressure points, and implications for antimicrobial resistance response. Boston Consulting group/Wellcome. Available at: https://cms.wellcome.org/sites/default/files/2022-04/under- standing-the-antibiotic-manufacturing-ecosystem- 2022.pdf (accessed 20 May 2023). Bert F, Previti C, Calabrese F, Scaioli G, Siliquini R (2022). Antibiotics Self Medication among Children: A Systematic Review. Antibiotics (Basel), 11. DOI:10.3390/antibiotics11111583. Bokhary H, Pangesti KNA, Rashid H, Abd El Ghany M, Hill- Cawthorne GA (2021). Travel-Related Antimicrobial Resis- tance: A Systematic Review. Tropical Medicine and Infectious Disease, 6. DOI:10.3390/tropicalmed6010011. Bonell A et al. (2019). A Systematic Review and Meta-analy- sis of Ventilator-associated Pneumonia in Adults in Asia: An Analysis of National Income Level on Incidence and Etiology. Clinical Infectious Diseases, 68:511–8. Borek AJ, Santillo M, Wanat M, Butler CC, Tonkin-Crine S (2022). How can behavioural science contribute to qualita- tive research on antimicrobial stewardship in primary care? JAC Antimicrobial Resistance, 4. DOI:10.1093/jacamr/dlac007. Brogan DM, Mossialos E (2016). Systems, not pills: The op- tions market for antibiotics seeks to rejuvenate the antibi- otic pipeline. Social Science and Medicine, 151:167–72. Burnham JP (2021). Climate change and antibiotic resis- tance: a deadly combination. Therapeutic Advances in In- fection, 8:2049936121991374. Center for Global Development (2023). A New Grand Bar- gain To Improve The Antimicrobial Market for Human Health. Washington DC: Center for Global Development. Available at: https://www.cgdev.org/sites/default/files/new- grand-bargain-improve-antimicrobial-market-human- health.pdf (accessed 23 November 2023). Chan YQ et al. (2022). Risk factors for carriage of antimicro- bial-resistant bacteria in community dwelling-children in the Asia-Pacific region: a systematic review and meta-anal- ysis. JAC-Antimicrobial Resistance, 4:dlac036. Chansamouth V et al. (2021). Antimicrobial use and resis- tance data in human and animal sectors in the Lao PDR: evidence to inform policy. BMJ Global Health, 6. DOI:10.1136/bmjgh-2021-007009. Charani E et al. (2021). Navigating sociocultural disparities in relation to infection and antibiotic resistance – the need for an intersectional approach. JAC Antimicrobial Resis- tance, 3(4):dlab123. Charani E et al. (2023). An analysis of existing national ac- tion plans for antimicrobial resistance – gaps and opportu- nities in strategies optimising antibiotic use in human populations. Lancet Global Health, 11:e466–74. Chen C-J, Huang Y-C (2014). New epidemiology of Staphy- lococcus aureus infection in Asia. Clinical Microbiology and Infection, 20:605–23. Chen Q et al. (2021). Risk factors for antibiotic resistance de- velopment in healthcare settings in China: a systematic re- view. Epidemiology and Infectection, 149:e141. Chiang H-Y et al. (2017). Incidence and Outcomes Associ- ated With Infections Caused by Vancomycin-Resistant En- terococci in the United States: Systematic Literature Review and Meta-Analysis. Infection Control and Hospital Epi- demiology, 38:203–15. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 30 31 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Chokshi A, Sifri Z, Cennimo D, Horng H (2019). Global con- tributors to antibiotic resistance. Journal of Global Infec- tious Diseases, 11:36–42. Collignon P, Beggs JJ (2019). Socioeconomic Enablers for Contagion: Factors Impelling the Antimicrobial Resistance Epidemic. Antibiotics (Basel), 8:86. Collignon P, Beggs JJ, Walsh TR, Gandra S, Laxminarayan R (2018). Anthropological and socioeconomic factors con- tributing to global antimicrobial resistance: a univariate and multivariable analysis. Lancet Planetary Health, 2:e398–405. Connor J et al. (2020). Health risks and outcomes that dis- proportionately affect women during the Covid-19 pan- demic: A review. Social Science and Medicine, 266:113364. Coope C et al. (2022). Identifying key influences on antibi- otic use in China: a systematic scoping review and narra- tive synthesis. BMJ Open, 12. DOI:10.1136/bmjopen-2021-056348. Dadgostar P (2019). Antimicrobial Resistance: Implications and Costs. Infection and Drug Resistance, 12:3903–10. de Abreu VAC, Perdigão J, Almeida S (2021). Metagenomic Approaches to Analyze Antimicrobial Resistance: An Overview. Frontiers in Genetics, 11:575592. Dewulf J, Sternberg-Lewerin S, Ryan M (2020). Tackling an- timicrobial resistance in the food and livestock sector, in Anderson M, Cecchini M, Mossialos E (eds), Challenges in Tackling Antimicrobial Resistance: Economic and Policy Re- sponses. European Observatory on Health Systems and Policies. Cambridge University Press, pp. 99–124). Duan L, Liu C, Wang D (2021). The General Population’s In- appropriate Behaviors and Misunderstanding of Antibiotic Use in China: A Systematic Review and Meta-Analysis. An- tibiotics, 10. DOI:10.3390/antibiotics10050497. Dyar OJ, Huttner B, Schouten J, Pulcini C, ESGAP (ESCMID Study Group for Antimicrobial stewardshiP) (2017, 4 September). What is antimicrobial stewardship? Clinical microbiology and infection (the official publication of the European Society of Clinical Microbiology and Infectious Diseases), published online. DOI:10.1016/j.cmi.2017.08.026. Edet UO, Bassey IU, Joseph AP (2023). Heavy metal co-resis- tance with antibiotics amongst bacteria isolates from an open dumpsite soil. Heliyon, 9:e13457. Edwards S, Humbert T, Berdzuli N, Azzopardi-Muscat N (2023). Tackling TB in Europe: treatment gaps and deterio- rating treatment availability is undermining progress. Inter- national Journal of Tuberculosis and Lung Disease, 27:793–6. Eggermont D, Smit MAM, Kwestroo GA, Verheij RA, Hek K, Kunst AE (2018). The influence of gender concordance be- tween general practitioner and patient on antibiotic pre- scribing for sore throat symptoms: a retrospective study. BMC Family Practice, 19:175. European Commission et al. (2021). Future-proofing phar- maceutical legislation: study on medicine shortages: final report (revised). Publications Office of the European Union. DOI:10.2875/211485. Fieldman T, Mossialos E, Anderson M (2023). Enhancing global insight into AMR spread and generation: prospects and limitations of the WHO and quadripartite research agendas. Journal of Antimicrobial Chemotherapy, 79(2):207–10. doi:10.1093/jac/dkad393. Fouque F, Gross K, Leung Z, Boutsika K (2020). Introduction to a Landscape Analysis of Multisectoral Approaches for Prevention and Control of Infectious and Vector-Borne Dis- eases. Journal of Infectious Diseases, 222:S695–700. Frost I, Kapoor G, Craig J, Liu D, Laxminarayan R (2021). Sta- tus, challenges and gaps in antimicrobial resistance surveil- lance around the world. Journal of Global Antimicrobial Resistance, 25:222–6. Fuhrmeister ER et al. (2023). Evaluating the relationship be- tween community water and sanitation access and the global burden of antibiotic resistance: an ecological study. Lancet Microbe, 4:e591–600. Gandra S, Barter DM, Laxminarayan R (2014). Economic bur- den of antibiotic resistance: how much do we really know? Clinical Microbiology and Infection, 20:973–80. Godijk NG, Bootsma MCJ, Bonten MJM (2022). Transmission routes of antibiotic resistant bacteria: a systematic review. BMC Infectious Diseases, 22:482. Gozdzielewska L, King C, Flowers P, Mellor D, Dunlop P, Price L (2020). Scoping review of approaches for improving antimicrobial stewardship in livestock farmers and veteri- narians. Preventive Veterinary Medicine, 180:105025. Greer SL (2014). Governance: A framework, in Greer S, Wis- mar M, Figueras J (eds), Strengthening Health System Gov- ernance: Better policies, stronger performance. Copenhagen: WHO Regional Office for Europe (on behalf of the European Observatory on Health Systems and Poli- cies). McGraw Hill Education/Open University Press, pp. 27–56. Guo S, Sun Q, Zhao X, Shen L, Zhen X (2021). Prevalence and risk factors for antibiotic utilization in Chinese chil- dren. BMC Pediatrics, 21. DOI:10.1186/s12887-021- 02706-z. Hinchliffe S (2015). More than one world, more than one health: Re-configuring interspecies health. Social Science and Medicine, 129:28–35. Holmes AH et al. (2016). Understanding the mechanisms and drivers of antimicrobial resistance. Lancet, 387:176– 87. Iskandar K et al. (2020). Drivers of Antibiotic Resistance Transmission in Low- and Middle-Income Countries from a ‘One Health’ Perspective – A Review. Antibiotics (Basel), 9. DOI:10.3390/antibiotics9070372. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 31 32 Policy brief Jasovský D, Littmann J, Zorzet A, Cars O (2016). Antimicro- bial resistance – a threat to the world’s sustainable devel- opment. Upsala Journal of Medical Sciences, 121:159–64. Kampf G, Löffler H, Gastmeier P (2009). Hand Hygiene for the Prevention of Nosocomial Infections. Deutsches Arzteblatt International, 106:649–55. Kanapathipillai R et al. (2019). Antibiotic resistance in con- flict settings: lessons learned in the Middle East. JAC An- timicrobial Resistance, 1:dlz002. Kariuki S, Kering K, Wairimu C, Onsare R, Mbae C (2022). Antimicrobial Resistance Rates and Surveillance in Sub-Sa- haran Africa: Where Are We Now? Infection and Drug Re- sistance, 15:3589–609. Khurana MP et al. (2023). Mitigating antimicrobial resistance (AMR) using implementation research: a development fun- der’s approach. JAC Antimicrobial Resistance, 5. DOI:10.1093/jacamr/dlad031. Kirchhelle C et al. (2020). Setting the standard: multidisci- plinary hallmarks for structural, equitable and tracked an- tibiotic policy. BMJ Global Health, 5:e003091. Kobeissi E et al. (2021). The socioeconomic burden of antibi- otic resistance in conflict-affected settings and refugee hosting countries: a systematic scoping review. Conflict and Health, 15:21. Lacotte Y, Årdal C, Ploy M-C, on behalf of the European Union Joint Action on Antimicrobial Resistance and Health- care-Associated Infections (EU-JAMRAI) (2020). Infection prevention and control research priorities: what do we need to combat healthcare-associated infections and an- timicrobial resistance? Results of a narrative literature re- view and survey analysis. Antimicrobial Resistance and Infection Control, 9:142. Landers TF, Cohen B, Wittum TE, Larson EL (2012). A review of antibiotic use in food animals: Perspective, policy, and potential. Public Health Reports, 127:4–22. Larsson DGJ, Flach C-F (2022). Antibiotic resistance in the environment. Nature Reviews Microbiology, 20:257–69. Laxminarayan R et al. (2016). Access to effective antimicro- bials: a worldwide challenge. Lancet, 387:168–75. Leangapichart T, Rolain J-M, Memish ZA, Al-Tawfiq JA, Gautret P (2017). Emergence of drug resistant bacteria at the Hajj: A systematic review. Travel Medicine and Infec- tious Disease, 18:3–17. Leppo K, Ollila E, Peña S, Wismar M, Cook S (2013). Health in All Policies: Seizing Opportunities, Implementing Poli- cies. Copenhagen: WHO Regional Office for Europe (on behalf of the European Observatory on Health Systems and Policies). Available at: https://eurohealthobservatory.who.int/publications/m/healt h-in-all-policies-seizing-opportunities-implementing-poli- cies (accessed 16 September 2023). Lhermie G, Gröhn YT, Raboisson D (2017). Addressing An- timicrobial Resistance: An Overview of Priority Actions to Prevent Suboptimal Antimicrobial Use in Food-Animal Pro- duction. Frontiers in Microbiology, 7. Available at: https://www.frontiersin.org/articles/10.3389/fmicb.2016.0 2114 (accessed 15 September 2023). Lim WW et al. (2019). Determinants of MRSA prevalence in the Asia Pacific Region: a systematic review and meta-anal- ysis. Journal of Global Antimicrobial Resistance, 16:17–27. Lio RMS, Favara G, Maugeri A, Barchitta M, Agodi A (2023). How Antimicrobial Resistance Is Linked to Climate Change: An Overview of Two Intertwined Global Challenges. Inter- national Journal of Environmental Research and Public Health, 20. DOI:10.3390/ijerph20031681. Lu J, Sheldenkar A, Lwin MO (2020). A decade of antimicro- bial resistance research in social science fields: a sciento- metric review. Antimicrobial Resistance and Infection Control, 9. DOI:10.1186/s13756-020-00834-2. MacKinnon RJ, Kennedy C, Doherty C, Shepherd M, Cole J, Stenfors-Hayes T (2015). Fitness for purpose study of the Field Assessment Conditioning Tool (FACT): a research pro- tocol. BMJ Open, 5:e006386. Mallah N, Orsini N, Figueiras A, Takkouche B (2022). Educa- tion level and misuse of antibiotics in the general popula- tion: a systematic review and dose–response meta-analysis. Antimicrobial Resistance and Infection Control, 11:24. Maugeri A, Barchitta M, Puglisi F, Agodi A (2023). Socio-eco- nomic, governance and health indicators shaping antimi- crobial resistance: an ecological analysis of 30 european countries. Global Health, 19:1–12. Medina M, Castillo-Pino E (2019). An introduction to the epidemiology and burden of urinary tract infections. Ther- apeutic Advances in Urology, 11:1756287219832172. Mitevska E, Wong B, Surewaard BGJ, Jenne CN (2021). The prevalence, risk, and management of methicillin-resistant Staphylococcus aureus infection in diverse populations across Canada: A systematic review. Pathogens, 10:393. Mostofsky E, Lipsitch M, Regev-Yochay G (2011). Is methi- cillin-resistant Staphylococcus aureus replacing methicillin- susceptible S. aureus? Journal of Antimicrobial Chemotherapy, 66:2199–214. Murray CJ et al. (2022). Global burden of bacterial antimi- crobial resistance in 2019: a systematic analysis. Lancet, 399:629–55. Nellums LB et al. (2018). Antimicrobial resistance among mi- grants in Europe: a systematic review and meta-analysis. Lancet Infectious Diseases, 18:796–811. OECD (2023). OECD Health Policy Studies: Embracing a One Health Framework to Fight Antimicrobial Resistance. Paris: Organisation for Economic Co-operation and Develop- ment. Available at: https://www.oecd-ilibrary.org/doc- server/ce44c755-en.pdf?expires=1694784272&id=id&accn ame=guest&checksum=898DC59FE7D408DA835983186 A2B0FE6 (accessed 15 September 2023). Ogyu A et al. (2020). National action to combat AMR: a One-Health approach to assess policy priorities in action plans. BMJ Global Health, 5:e002427. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 32 33 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research Olliaro P et al. (2023). Advancing Access to Diagnostic Tools Essential for Universal Health Coverage and Antimicrobial Resistance Prevention: An Overview of Trials in Sub-Saha- ran Africa. Clinical Infectious Diseases, 77:S125–33. Ondoa P, Oskam L, Loembe MM, Okeke IN (2021). Trans- forming access to diagnostics: how to turn good intentions into action? Lancet, 398:1947–9. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementa- tion research. Administration and Policy in Mental Health, 42:533–44. Pallett SJC, Boyd SE, O’Shea MK, Martin J, Jenkins DR, Hut- ley EJ (2023). The contribution of human conflict to the development of antimicrobial resistance. Communications Medicine, 3:1–4. Parisi A et al. (2018). Health Outcomes from Multidrug-Re- sistant Salmonella Infections in High-Income Countries: A Systematic Review and Meta-Analysis. Foodborne Pathogens and Disease, 15:428–36. Parker C, Scott S, Geddes A (2019). Snowball Sampling. SAGE Publications Ltd. DOI:10.4135/9781526421036831710. Patel J et al. (2023). Measuring the global response to an- timicrobial resistance, 2020–21: a systematic governance analysis of 114 countries. Lancet Infectious Diseases, 23(6):706–18. DOI:10.1016/S1473-3099(22)00796-4. Petrosillo N, Petersen E, Antoniak S (2023). Ukraine war and antimicrobial resistance. Lancet Infectious Diseases, 23:653–4. Pham-Duc P, Sriparamananthan K (2021). Exploring gender differences in knowledge and practices related to antibiotic use in Southeast Asia: A scoping review. Plos One, 16:e0259069. Phu DH, Wongtawan T, Truong DB, Van Cuong N, Carrique- Mas J, Thomrongsuwannakij T (2022). A systematic review and meta-analysis of integrated studies on antimicrobial resistance in Vietnam, with a focus on Enterobacteriaceae, from a One Health perspective. One Health, 15:100465. Pitchforth E, Smith E, Taylor J, Davies S, Ali G-C, d’Angelo C (2022). Global action on antimicrobial resistance: lessons from the history of climate change and tobacco control policy. BMJ Global Health, 7:e009283. Pokharel S, Shrestha P, Adhikari B (2020). Antimicrobial use in food animals and human health: time to implement a ‘One Health’ approach. Antimicrobial Resistance and Infec- tion Control, 9:181. Poudel AN et al. (2023). The economic burden of antibiotic resistance: A systematic review and meta-analysis. Plos One, 18:e0285170. Price L et al. (2018). Effectiveness of interventions to im- prove the public’s antimicrobial resistance awareness and behaviours associated with prudent use of antimicrobials: a systematic review. Journal of Antimicrobial Chemother- apy, 73:1464–78. Public Health Agency of Sweden (2023). Availability of cer- tain antibiotics – A pilot study of an alternative reimburse- ment model. Public Health Agency of Sweden. Available at: https://www.folkhalsomyndigheten.se/publikationer- och-material/publikationsarkiv/t/tillganglighet-till-vissa-an- tibiotika-en-pilotstudie-av-en-alternativ-ersattningsmodell/ (accessed 20 May 2023). Ramtahal MA, Amoako DG, Akebe ALK, Somboro AM, Bester LA, Essack SY (2022). A Public Health Insight into Salmonella in Poultry in Africa: A Review of the Past Decade: 2010–2020. Microbial Drug Resistance, 28:710– 33. Ranganathan R, Ranjalkar J (2023). Potential role of civil so- ciety organizations (CSOs) in antimicrobial resistance (AMR) mitigation efforts in low- and middle-income coun- tries: A report from India. Journal of Infection and Public Health, 16(S1):125–8. ReAct (2020). Shortages and AMR – why should we care? 4 consequences of antibiotic shortages. ReAct. Available at: https://www.reactgroup.org/news-and-views/news-and- opinions/year-2020/shortages-and-amr-why-should-we- care-4-consequences-of-antibiotic-shortages/ (accessed 20 May 2023). Renwick M, Mossialos E (2018). What are the economic bar- riers of antibiotic R&D and how can we overcome them? Expert Opinion on Drug Discovery, 13:889–92. Renwick MJ et al. (2016). Targeting innovation in antibiotic drug discovery and development: the need for a One Health – One Europe – One World Framework. Copen- hagen: WHO Regional Office for Europe (on behalf of the European Observatory on Health Systems and Policies). Available at: http://www.ncbi.nlm.nih.gov/books/NBK447337/ (accessed 10 August 2018). Resman F (2020). Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy. Part II: Ten questions reflecting knowledge gaps and issues of controversy in the field of antimicrobial stewardship. Therapeutic Advances in Infectious Disease, 7:2049936120945083. Reverter M et al. (2020). Aquaculture at the crossroads of global warming and antimicrobial resistance. Nature Com- munications, 11:1870. Review on Antimicrobial Resistance (2016). Tackling Drug- Resistant Infections Globally: Final Report and Recommen- dations. Available at: https://amr-review.org/ (accessed 16 June 2019). Richter CH, Custer B, Steele JA, Wilcox BA, Xu J (2015). In- tensified food production and correlated risks to human health in the Greater Mekong Subregion: A systematic re- view. Environmental Health: A Global Access Science Source, 14:43. Ryan MA, Christian RS, Wohlrabe J (2001). Handwashing and respiratory illness among young adults in military training. American Journal of Preventive Medicine, 21:79–83. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 33 34 Policy brief Schilling A-L, Rody A, Bossung V (2022). Antibiotic Use Dur- ing Pregnancy and Childbirth: Prospective Observational Study on Prevalence, Indications, and Prescribing Patterns in a German Tertiary Center. Geburtshilfe Frauenheilkunde, 83:192–200. Schröder W et al. (2016). Gender differences in antibiotic prescribing in the community: a systematic review and meta-analysis. Journal of Antimicrobial Chemotherapy, 71:1800–6. Scott AM et al. (2018). Is antimicrobial administration to food animals a direct threat to human health? A rapid sys- tematic review. International Journal of Antimicrobial Agents, 52:316–23. Serra-Burriel M et al. (2020). Impact of multi-drug resistant bacteria on economic and clinical outcomes of healthcare- associated infections in adults: Systematic review and meta-analysis. PLoS One, 15:e0227139. Shafiq N et al. (2021). Shortage of essential antimicrobials: a major challenge to global health security. BMJ Global Health, 6:e006961. Singer AC, Shaw H, Rhodes V, Hart A (2016). Review of An- timicrobial Resistance in the Environment and Its Relevance to Environmental Regulators. Frontiers in Microbiology, 7. DOI:10.3389/fmicb.2016.01728. Skinner H (2024, 4 January). Tracking superbugs in the wake of war. Harvard Public Health Magazine, published online. Available at: https://harvardpublichealth.org/conflict- health/superbugs-thrive-in-the-ruins-of-war/ (accessed 15 January 2024). Stanton IC, Bethel A, Leonard AFC, Gaze WH, Garside R (2022). Existing evidence on antibiotic resistance exposure and transmission to humans from the environment: a sys- tematic map. Environmental Evidence, 11:8. Sulis G, Gandra S (2021). Access to antibiotics: not a prob- lem in some LMICs. Lancet Global Health, 9:e561–2. Sun R, Yao T, Zhou X, Harbarth S, Lin L (2022). Non-biomed- ical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis. Clini- cal Microbiology and Infection, 28:345–54. Tacconelli E et al. (2014). ESCMID guidelines for the man- agement of the infection control measures to reduce trans- mission of multidrug-resistant Gram-negative bacteria in hospitalized patients. Clinical Microbiology and Infection (the official publication of the European Society of Clinical Microbiology and Infectious Diseases), 20(S1):1– 55. Taylor J et al. (2014). Estimating the economic costs of an- timicrobial resistance: Model and Results. Rand Corpora- tion Research Reports. DOI: https://doi.org/10.7249/RR911. Teillant A, Gandra S, Barter D, Morgan DJ, Laxminarayan R (2015). Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study. Lancet Infec- tious Diseases, 15:1429–37. Tiseo K, Huber L, Gilbert M, Robinson TP, Van Boeckel TP (2020). Global Trends in Antimicrobial Use in Food Animals from 2017 to 2030. Antibiotics (Basel), 9:918. Truppa C, Abo-Shehada MN (2020). Antimicrobial resistance among GLASS pathogens in conflict and non-conflict af- fected settings in the Middle East: a systematic review. BMC Infectious Diseases, 20:936. Tsuzuki S et al. (2020). Factors associated with sufficient knowledge of antibiotics and antimicrobial resistance in the Japanese general population. Scientific Reports, 10:3502. Umair M et al. (2023). International manufacturing and trade in colistin, its implications in colistin resistance and One Health global policies: a microbiological, economic, and anthropological study. Lancet Microbe, 4:e264–76. UN (2016). UN General Assembly. President, UN. General Assembly (71st sess. : 2016-2017). High-Level Plenary Meeting on Antimicrobial Resistance. Available at: https://digitallibrary.un.org/record/842813?ln=en (accessed 6 February 2019). UNDP (n.d.). Goal 1: No poverty. United Nations Develop- ment Programme. Available at: https://www.undp.org/sus- tainable-development-goals/no-poverty (accessed 4 September 2023). UNEP (2022). Environmental Dimensions of Antimicrobial Resistance: Summary for Policymakers. United Nations En- vironment Programme. Available at: https://wedocs.unep.org/bitstream/handle/20.500.11822/3 8373/antimicrobial_R.pdf (accessed 16 September 2023). Vestel J et al. (2022). Default predicted no‐effect target con- centrations for antibiotics in the absence of data for the protection against antibiotic resistance and environmental toxicity. Integrated Environmental Assessment and Man- agement, 18:863–7. Vicente de la Cruz M de LM, Giesen C, Díaz-Menéndez M (2022). International travels and transmission of multidrug resistant Neisseria gonorrhoeae in Europe: A systematic re- view. Travel Medicine and Infectious Disease, 49:102401. Wang S, Ogunseitan O (2022). Assessment of College Stu- dents’ Knowledge, Attitudes, and Practices Regarding An- tibiotics Stewardship. International Journal of Infectious Diseases, 116:S14–15. Wellcome Trust, US Centers for Disease Control and Preven- tion, UK Science & Innovation Network (2018). Initiatives for Addressing Antimicrobial Resistance in the Environ- ment: Current Situation and Challenges. 2018. London: Wellcome Trust. Available at: https://wellcome.org/sites/de- fault/files/antimicrobial-resistance-environment-report.pdf (accessed 17 September 2023). WHO (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization. Available at: http://www.who.int/social_determinants/thecommission/fi- nalreport/en/ (accessed 7 June 2019). PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 34 35 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research WHO (2015). Global Action Plan On Antimicrobial Resis- tance. Geneva: World Health Organization. Available at: http://apps.who.int/iris/bitstream/handle/10665/193736/97 89241509763_eng.pdf?sequence=1 (accessed 7 Decem- ber 2018). WHO (2022a). 2021 Antibacterial agents in clinical and pre- clinical development: an overview and analysis. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789240047655 (accessed 24 May 2023). WHO (2022b). WHO implementation handbook for national action plans on antimicrobial resistance: guidance for the human health sector. Geneva: World Health Organization. Available at: https://www.who.int/publications/i/item/9789240041981 (accessed 15 September 2023). WHO (2023a). Gender and health. Geneva: World Health Organization. Available at: https://www.who.int/health- topics/gender (accessed 31 October 2023). WHO (2023b). Guidance to facilitate monitoring and evalua- tion for antimicrobial resistance national action plans. Geneva: World Health Organization. Available at: https://www.who.int/publications-detail- redirect/9789240069763 (accessed 15 September 2023). WHO (2023c). Health equity. Geneva: World Health Organi- zation. Available at: https://www.who.int/health- topics/health-equity (accessed 23 November 2023). WHO (2023d). People-centred approach to addressing an- timicrobial resistance in human health: WHO core package of interventions to support national action plans. Geneva: World Health Organization. Available at: https://iris.who.int/bitstream/handle/10665/373458/97892 40082496-eng.pdf?sequence=1 (accessed 23 November 2023). WHO et al. (2018). Global Database for Antimicrobial Resis- tance Country Self Assessment. Geneva: World Health Or- ganization. Available at: https://amrcountryprogress.org/ (accessed 6 November 2018). World Bank (2017). Drug-Resistant Infections: A Threat to our Economic Future. Washington DC: World Bank. Avail- able at: https://documents1.worldbank.org/curated/en/323311493 396993758/pdf/final-report.pdf (accessed 15 January 2023). Wu M, Tong X, Liu S, Wang D, Wang L, Fan H (2019). Preva- lence of methicillin-resistant Staphylococcus aureus in healthy Chinese population: A system review and meta- analysis. Plos One, 14:e0223599. Wuerz TC, Kassim SS, Atkins KE (2020). Acquisition of ex- tended-spectrum beta-lactamase-producing Enterobacteri- aceae (ESBL-PE) carriage after exposure to systemic antimicrobials during travel: Systematic review and meta- analysis. Travel Medicine and Infectious Disease, 37:101823. Zadjelovic V et al. (2023). Microbial hitchhikers harbouring antimicrobial-resistance genes in the riverine plastisphere. Microbiome, 11:225. Zasowski EJ et al. (2020). A Systematic Review of the Effect of Delayed Appropriate Antibiotic Treatment on the Out- comes of Patients With Severe Bacterial Infections. Chest, 158:929–38. Zheng D et al. (2021). A systematic review of antibiotics and antibiotic resistance genes in estuarine and coastal envi- ronments. Science of the Total Environment, 777:146009. Zhou Z et al. (2023). Association between particulate matter (PM) 2·5 air pollution and clinical antibiotic resistance: a global analysis. Lancet Planetary Health, 7:e649–59. PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 35 36 Policy brief 8. Appendix 8.1 Umbrella review methodology We performed an umbrella review of reviews, and focused specifically on quantitative evidence on socioeconomic drivers and impacts of AMR. Drivers were conceptualized as having a direct association with either a metric of AMR (such as aggregate indices, prevalence rates or resistance rates) or behaviours with a well-established causality (such as antibiotic use [ABU], or self-medication with antibiotics [SMA]). Evidence on drivers of AMR in animal and environmental health settings were captured if studies estimated the relationship between these drivers and the increased risk of AMR in humans. An impact of AMR was defined from a strictly human domain, and included both health and socioeconomic factors. We performed systematic searches in four scientific databases: MEDLINE, Embase, Global Health and the Cochrane Database of Systematic Reviews. The scientific search was supplemented with a non-systematic search for gray literature using Google Scholar (first 200 hits). The full query for the scientific databases is shown in Table 1 below. An information specialist at the London School of Economics and Political Science Library further validated the search strategy. Studies were included based on the following criteria: (1) studies should be systematic reviews, rapid reviews, umbrella reviews, scoping reviews, or any review where an explicit methodological search strategy was employed; (2) studies should explicitly report on AMR; (3) the identification of drivers and impacts was allowed to remain implicit; (4) studies needed to contain quantitative data relating to either drivers or impacts of AMR; (5) studies needed to either relate to the human dimension alone, or discuss either the animal-human interface or the environment-human interface; and (6) studies should be written in English and published on or after 1 January 2010. The complete screening process was performed by one reviewer (GL), and a second reviewer (RVK) screened a subset of approximately 20% of identified articles to improve the methodological robustness of the literature review and inter-rater reliability scores were computed. Any disagreements between the reviewers were resolved by an independent third reviewer (MA). Table Annex 1. Overview of the search string for the literature review DATABASE SEARCH STRING MEDLINE 1 (AMR or ABR or AFR or (antibiotic* adj3 resist*) or ((anti?microbial* or "anti microbial*") adj3 resist*) or ((anti?bacterial* or "anti bacterial*") adj3 resist*) or ((anti?fungal* or "anti fungal*") adj3 resist*) or ((anti?viral* or "anti viral*") adj3 resist*) or (microb* adj3 resist*)).ti,ab. 2 exp Drug Resistance, Bacterial/ or exp Drug Resistance, Viral/ or exp Drug Resistance, Fungal/ or exp Drug Resistance, Microbial/ 3 or/1-2 4 (socio?economic* or social* or economic* or inequalit* or inequit* or poverty or corrupt* or financ*).ti,ab. 5 exp Low Socioeconomic Status/ or exp Socioeconomic Disparities in Health/ or exp Socioeconomic Factors/ or exp Social Status/ or exp Social Class/ or exp Health Inequities/ or exp Poverty/ or exp Child Poverty/ or exp Poverty Areas/ or exp Health Status Disparities/ or exp Healthcare Disparities/ 6 (employ* or unemploy* or occupation* or income or salar* or pay).ti,ab. 7 exp Workforce/ or exp Employment/ or exp "Salaries and Fringe Benefits"/ 8 (education* or school* or tuition* or training* or literacy).ti,ab. 9 exp Educational Status/ or exp Literacy/ or exp Health Literacy/ or exp Information Literacy/ or exp Computer Literacy/ or exp Health Education/ 10 (house* or housing or residen* or home* or neighbo?rhood*).ti,ab. 11 exp Housing/ or exp Residence Characteristics/ or exp Catchment Area, Health/ or exp Home Environment/ or exp Neighborhood Characteristics/ 12 ("Health* Seek*" or "Seek* Behav*" or (Health* adj3 Access*) or (Health* adj3 afford*) or "Health* insur*" or Self?medicat* or "self medicat*").ti,ab. 13 exp Health Knowledge, Attitudes, Practice/ or exp Health Behavior/ or exp Health Services Accessibility/ or exp Insurance, Health/ or exp Insurance Coverage/ or exp Self Medication/ or exp Nonprescription Drugs/ 14 (ethnic* or race* or racis* or "minorit* group*" or racial* or asian* or black* or white* or latin* or hispanic* or "African American*" or Afro?caribbean* or "Afro Caribbean*" or Caribbean* or "Afro Latin*" or "American Indian*" or "Han Chinese" or "Native Hawaiian*" or Caucasian* or "Native American* Alaskan Native*" or "Pacific Islander*" or "Mixed Race" or "African Ancestry" or Roma or Gypsy or Aborigin* or Indigen* or "First Nation*" or "Middle Eastern" or Jew* or Hindu* or Islam* or Muslim* or Sikh* or BME or BAME or POC).ti,ab. 15 exp Ethnicity/ or exp "Ethnic and Racial Minorities"/ or exp Racial Groups/ or exp White People/ or exp "Black or African American"/ or exp Black People/ or exp Southeast Asian/ or exp Asian People/ or exp West Asian People/ or exp Southeast Asian People/ or exp Central Asian People/ or exp East Asian People/ or exp Asian/ or exp South Asian People/ or exp Alaskan Natives/ or exp "American Indian or Alaska Native"/ or exp "Hispanic or Latino"/ or exp "Native Hawaiian or Other Pacific Islander"/ or exp Pacific Island People/ or exp Arabs/ or exp Jews/ or exp Indigenous Peoples/ or exp "Australian Aboriginal and Torres Strait Islander Peoples"/ or exp Indians, North American/ or exp Roma/ or exp Indians, South American/ 16 or/4-15 17 (One?health or "One Health" or Sanitation* or Hygien* or EcoHealth or "One World" or "One Medicine" or Stewards* or Governance or Zoono* or animal-human or human-animal or environment-human or human-environment or animal-environment or environment-animal or "Environmental Health" or ecosystem* or soil or wastewater or surfacewater or groundwater or "drinking water" or manure or biosolid*).ti,ab. 18 exp One Health/ or exp Zoonoses/ or exp Environmental Health/ or exp Ecosystem/ or exp Soil/ or exp Soil Microbiology/ or exp Wastewater/ or exp Groundwater/ or exp manure/ or exp Drinking Water/ or exp Biosolids/ >>> Continued on next page PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 36 37 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research DATABASE SEARCH STRING MEDLINE 19 (Agriculture or Livestock or Farm* or veterinar* or Bovine or Cattle or Dairy or Beef or Feedlot or Cow* or Sheep or Lamb* or Goat* or Dog or Dogs or Canine* or Cat or Cats or Feline* or "Domestic Animal*" or "Companion Animal*" or Swine or Hog* or Pig or Pigs or Porcine or Pork or Caprine or Ovine or Horse* or Equine or Poultry or Turkey* or Broiler or Hen or Hens or Duck* or Flock* or Avian or Chicken* or "Animal Health" or "Animal Welfare" or "Animal Production*" or Fish or Aquaculture or Tilapia or Shrimp or Mussel* or Salmon or Albacore or Trout* or Seafood or carp or "Cat Fish" or catfish or Shellfish or Mollusk* or Clams or Oyster* or Scallop* or Walleye or Perch or Halibut or Cod or "Sea Bass" or Tuna or "Farmed Fish" or Mink or Rabbit* or Lepus or Hare or Buffalo or Bison or "Bos Taurus" or "Bos Indicus" or elk or Deer or Cervid* or Camel* or Wildlife or Zoo or Carcass* or Abattoir* or Slaughter*).ti,ab. 20 exp Agriculture/ or exp Observational Study, Veterinary/ or exp Veterinary Drugs/ or exp Veterinary Medicine/ or exp Animal Diseases/ or exp Livestock/ or exp Animals/ or exp Cattle/ or exp Cattle Diseases/ or exp Goats/ or exp Cats/ or exp Dogs/ or exp Animals, Domestic/ or exp Swine Diseases/ or exp Horses/ or exp Chickens/ or exp Poultry/ or exp Poultry Diseases/ or exp Animal Husbandry/ or exp Animal Welfare/ or exp Fish Diseases/ or exp Aquaculture/ or exp Camelus/ or exp Animals, Wild/ or exp Abattoirs/ 21 or/17-20 22 3 and (16 or (16 and 21)) 23 limit 22 to (english language and "review articles" and yr="2010 -Current") Embase 1 (AMR or ABR or AFR or (antibiotic* adj3 resist*) or ((anti?microbial* or "anti microbial*") adj3 resist*) or ((anti?bacterial* or "anti bacterial*") adj3 resist*) or ((anti?fungal* or "anti fungal*") adj3 resist*) or ((anti?viral* or "anti viral*") adj3 resist*) or (microb* adj3 resist*)).ti,ab. 2 exp antibiotic resistance/ 3 or/1-2 4 (socio?economic* or social* or economic* or inequalit* or inequit* or poverty or corrupt* or financ*).ti,ab. 5 exp socioeconomics/ or exp social segregation/ or exp social status/ or exp health disparity/ or exp child poverty/ or exp poverty/ or exp health care disparity/ 6 (employ* or unemploy* or occupation* or income or salar* or pay).ti,ab. 7 exp Employment/ or exp Employment Status/ or exp Salary/ or exp "Salaries and Fringe Benefits"/ 8 (education* or school* or tuition* or training* or literacy).ti,ab. 9 exp Education/ or exp Literacy/ or exp Health Literacy/ or exp Information Literacy/ or exp Computer Literacy/ or exp Health Education/ 10 (house* or housing or residen* or home* or neighbo?rhood*).ti,ab. 11 exp Housing/ or exp Residence Characteristics/ or exp "Catchment Area (Health)"/ or exp Home Environment/ or exp Neighborhood Characteristic/ 12 ("Health* Seek*" or "Seek* Behav*" or (Health* adj3 Access*) or (Health* adj3 afford*) or "Health* insur*" or Self?medicat* or "self medicat*").ti,ab. 13 exp attitude to health/ or exp Health Behavior/ or exp health care access/ or exp health insurance/ or exp Insurance Coverage/ or exp Self Medication/ or exp Non Prescription Drugs/ 14 (ethnic* or race* or racis* or "minorit* group*" or racial* or asian* or black* or white* or latin* or hispanic* or "African American*" or Afro?caribbean* or "Afro Caribbean*" or Caribbean* or "Afro Latin*" or "American Indian*" or "Han Chinese" or "Native Hawaiian*" or Caucasian* or "Native American*" or "Alaskan Native*" or "Pacific Islander*" or "Mixed Race" or "African Ancestry" or Roma or Gypsy or Aborigin* or Indigen* or "First Nation*" or "Middle Eastern" or Jew* or Hindu* or Islam* or Muslim* or Sikh* or BME or BAME or POC).ti,ab. 15 exp Ethnicity/ or exp "Ethnic and Racial Aspects"/ or exp Ethnic Group/ or exp Caucasian/ or exp Black Person/ or exp Southeast Asian/ or exp Asian/ or exp West Asian/ or exp Central Asian/ or exp East Asian/ or exp South Asian/ or exp Alaska Natives/ or exp American Indian/ or exp Hispanic/ or exp Pacific Islander/ or exp Arab/ or exp Jew/ or exp Indigenous People/ or exp "Romani (people)"/ 16 or/4-15 17 (One?health or "One Health" or Sanitation* or Hygien* or EcoHealth or "One World" or "One Medicine" or Stewards* or Governance or Zoono* or animal-human or human-animal or environment-human or human-environment or animal-environment or environment-animal or "Environmental Health" or ecosystem* or soil or wastewater or surfacewater or groundwater or "drinking water" or manure or biosolid*).ti,ab. 18 exp One Health/ or exp Zoonosis/ or exp Environmental Health/ or exp Ecosystem/ or exp Soil/ or exp Wastewater/ or exp Ground water/ or exp manure/ or exp Drinking Water/ or exp Biosolid/ 19 (Agriculture or Livestock or Farm* or veterinar* or Bovine or Cattle or Dairy or Beef or Feedlot or Cow* or Sheep or Lamb* or Goat* or Dog or Dogs or Canine* or Cat or Cats or Feline* or "Domestic Animal*" or "Companion Animal*" or Swine or Hog* or Pig or Pigs or Porcine or Pork or Caprine or Ovine or Horse* or Equine or Poultry or Turkey* or Broiler or Hen or Hens or Duck* or Flock* or Avian or Chicken* or "Animal Health" or "Animal Welfare" or "Animal Production*" or Fish or Aquaculture or Tilapia or Shrimp or Mussel* or Salmon or Albacore or Trout* or Seafood or carp or "Cat Fish" or catfish or Shellfish or Mollusk* or Clams or Oyster* or Scallop* or Walleye or Perch or Halibut or Cod or "Sea Bass" or Tuna or "Farmed Fish" or Mink or Rabbit* or Lepus or Hare or Buffalo or Bison or "Bos Taurus" or "Bos Indicus" or elk or Deer or Cervid* or Camel* or Wildlife or Zoo or Carcass* or Abattoir* or Slaughter*).ti,ab. 20 exp Agriculture/ or exp Animal Disease/ or exp Veterinary Medicine/ or exp Livestock/ or exp Bovine/ or exp Cattle Disease/ or exp Goat/ or exp Cat/ or exp Dog/ or exp Domestic Animal/ or exp Swine Disease/ or exp Horse/ or exp Chicken/ or exp Poultry/ or exp Bird Disease/ or exp Animal Husbandry/ or exp Animal Welfare/ or exp Fish Disease/ or exp Aquaculture/ or exp Camel/ or exp Wild Animal/ or exp slaughterhouse/ 21 or/17-20 22 3 and (16 or (16 and 21)) 23 exp review/ 24 (literature adj3 review$).ti,ab. 25 exp "Systematic Review"/ 26 exp meta analysis/ 27 or/23-26 28 22 and 27 29 limit 28 to (english language and yr="2010 -Current") >>> Continued on next page >>> Continued from previous page PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 37 38 Policy brief DATABASE SEARCH STRING Global health 1 (AMR or ABR or AFR or (antibiotic* adj3 resist*) or ((anti?microbial* or "anti microbial*") adj3 resist*) or ((anti?bacterial* or "anti bacterial*") adj3 resist*) or ((anti?fungal* or "anti fungal*") adj3 resist*) or ((anti?viral* or "anti viral*") adj3 resist*) or (microb* adj3 resist*)).ti,ab. 2 exp antibiotic resistance/ 3 or/1-2 4 (socio?economic* or social* or economic* or inequalit* or inequit* or poverty or corrupt* or financ*).ti,ab. 5 exp socioeconomic status/ or exp socioeconomics/ or exp social status/ or exp social classes/ or exp poverty/ or exp health inequalities/ 6 (employ* or unemploy* or occupation* or income or salar* or pay).ti,ab. 7 exp low income/ or exp employment/ or exp workers/ or exp salaries/ 8 (education* or school* or tuition* or training* or literacy).ti,ab. 9 exp literacy/ or exp education/ 10 (house* or housing or residen* or home* or neighbo?rhood*).ti,ab. 11 exp housing/ or exp neighborhoods/ 12 ("Health* Seek*" or "Seek* Behav*" or (Health* adj3 Access*) or (Health* adj3 afford*) or "Health* insur*" or Self?medicat* or "self medicat*").ti,ab. 13 exp health behaviour/ or exp health insurance/ 14 (ethnic* or race* or racis* or "minorit* group*" or racial* or asian* or black* or white* or latin* or hispanic* or "African American*" or Afro?caribbean* or "Afro Caribbean*" or Caribbean* or "Afro Latin*" or "American Indian*" or "Han Chinese" or "Native Hawaiian*" or Caucasian* or "Native American* Alaskan Native*" or "Pacific Islander*" or "Mixed Race" or "African Ancestry" or Roma or Gypsy or Aborigin* or Indigen* or "First Nation*" or "Middle Eastern" or Jew* or Hindu* or Islam* or Muslim* or Sikh* or BME or BAME or POC).ti,ab. 15 exp ethnic groups/ or exp ethnicity/ or exp black people/ or exp white people/ or exp Hispanics/ or exp ethnic groups/ or exp Asians/ or exp Inuit/ or exp indigenous people/ or exp Alaska Natives/ or exp Native Americans/ or exp Jews/ or exp Asians/ or exp Pacific Islanders/ or exp aborigines/ or exp Roma/ 16 or/4-15 17 (One?health or "One Health" or Sanitation* or Hygien* or EcoHealth or "One World" or "One Medicine" or Stewards* or Governance or Zoono* or animal-human or human-animal or environment-human or human-environment or animal-environment or environment-animal or "Environmental Health" or ecosystem* or soil or wastewater or surfacewater or groundwater or "drinking water" or manure or biosolid*).ti,ab. 18 exp zoonoses/ or exp environmental health/ or exp ecosystems/ or exp soil/ or exp soil bacteria/ or exp wastewater/ or exp groundwater/ or exp surface water/ or exp animal manures/ or exp drinking water/ 19 (Agriculture or Livestock or Farm* or veterinar* or Bovine or Cattle or Dairy or Beef or Feedlot or Cow* or Sheep or Lamb* or Goat* or Dog* or Canine* or Cat* or Feline* or "Domestic Animal*" or "Companion Animal*" or Swine or Hog* or Pig* or Porcine or Pork or Caprine or Ovine or Horse* or Equine or Poultry or Turkey* or Broiler or Hen or Hens or Duck* or Flock* or Avian or Chicken* or "Animal Health" or "Animal Welfare" or "Animal Production*" or Fish or Aquaculture or Tilapia or Shrimp or Mussel* or Salmon or Albacore or Trout* or Seafood or carp or "Cat Fish" or catfish or Shellfish or Mollusk* or Clams or Oyster* or Scallop* or Walleye or Perch or Halibut or Cod or "Sea Bass" or Tuna or "Farmed Fish" or Mink or Rabbit* or Lepus or Hare or Buffalo or Bison or "Bos Taurus" or "Bos Indicus" or elk or Deer or Cervid* or Camel* or Wildlife or Zoo or Carcass* or Abattoir* or Slaughter*).ti,ab. 20 exp agriculture/ or exp veterinary medicine/ or exp animal diseases/ or exp livestock/ or exp cattle/ or exp cattle diseases/ or exp goats/ or exp cats/ or exp dogs/ or exp domestic animals/ or exp swine diseases/ or exp horses/ or exp fowls/ or exp poultry diseases/ or exp poultry/ or exp animal husbandry/ or exp animal welfare/ or exp fish diseases/ or exp aquaculture/ or exp wild animals/ or exp abattoirs/ 21 or/17-20 22 3 and 16 23 21 and 16 24 3 and 23 25 22 or 24 26 (Evidence review or evidence reviews or evidence synthesis or evidence-based review or evidence report or "Evidence Reports - Agency for Healthcare Research and Quality" or publication bias or campbell collaboration).mp. [mp=abstract, title, original title, heading words, cabicodes words] 27 (meta-analysis or meta-analyses or metaanalyses or metaanalysis).mp. [mp=abstract, title, original title, heading words, cabicodes words] Cochrane library 1 (AMR OR ABR OR AFR OR (Antibiotic* NEAR/3 Resist*) OR ((Anti?microbial* OR "Anti Microbial*") NEAR/3 Resist*) OR ((Anti?bacterial* OR "Anti bacterial*") NEAR/3 Resist*) OR ((Anti?viral* OR "Anti viral*") NEAR/3 Resist*) OR ((Anti?fungal* OR "Anti fungal*") NEAR/3 Resist*) OR (Microbial* NEAR/3 resist*)):ti,ab 2 MeSH descriptor: [Drug Resistance, Bacterial] explode all trees 3 MeSH descriptor: [Drug Resistance, Fungal] explode all trees 4 MeSH descriptor: [Drug Resistance, Microbial] explode all trees 5 MeSH descriptor: [Drug Resistance, Viral] explode all trees 6 1 OR 2 OR 3 OR 4 OR 5 7 (Socio?economic* OR social* OR economic* OR inequalit* OR inequit* OR poverty OR corrupt* OR financ*):ti,ab 8 MeSH descriptor: [Social Class] explode all trees 9 MeSH descriptor: [Poverty] explode all trees 10 MeSH descriptor: [Health Status Disparities] explode all trees 16 MeSH descriptor: [Employment] explode all trees 17 MeSH descriptor: [Salaries and Fringe Benefits] explode all trees 18 14 OR 15 OR 16 OR 17 >>> Continued from previous page >>> Continued on next page PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 38 39 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research DATABASE SEARCH STRING Cochrane library 19 (education* OR school* OR tuition* OR training OR literacy):ti,ab 20 MeSH descriptor: [Education] explode all trees 21 MeSH descriptor: [Literacy] explode all trees 22 MeSH descriptor: [Health Literacy] explode all trees 23 MeSH descriptor: [Information Literacy] explode all trees 24 MeSH descriptor: [Computer Literacy] explode all trees 25 19 OR 20 OR 21 OR 22 OR 23 OR 24 26 (House* OR housing OR residen* OR home* OR neighbo?rhood*):ti,ab 27 MeSH descriptor: [Housing] explode all trees 28 MeSH descriptor: [Residence Characteristics] explode all trees 29 26 OR 27 OR 28 30 ((health* NEXT seek*) OR (seek* NEXT behav*) OR (health* NEAR/3 access*) OR (health* NEAR/3 afford*) OR (health* NEXT service*) OR (health* NEXT insur*) OR self?medicat* OR (self NEXT medicat*)):ti,ab 31 MeSH descriptor: [Attitude to Health] explode all trees 32 MeSH descriptor: [Health Services] explode all trees 33 MeSH descriptor: [Insurance, Health] explode all trees 34 MeSH descriptor: [Health Services Accessibility] explode all trees 35 30 OR 31 OR 32 OR 33 OR 34 36 (ethnic* OR race* OR racis* OR (minorit* NEXT group*) OR racial* OR asian* OR black* OR white* OR latin* OR hispanic* OR (African NEXT American*) OR afro?caribbean* OR (Afro NEXT Caribbean*) OR caribbean* OR (American NEXT Indian) OR (Han NEXT Chinese) OR (Native NEXT Hawaiian*) OR caucasian* OR (Alaska* NEXT Native*) OR (Pacific NEXT Islander*) OR (mixed NEXT race*) OR (african NEXT ancestry) OR Roma OR Gypsy OR aborigin* OR indigen* OR (First NEXT Nation*) OR BME OR BAME OR (Middle NEXT Eastern) OR POC OR Jew* OR Islam* OR Muslim* OR Sikh* OR Hindu*):ti,ab 37 MeSH descriptor: [Minority Health] explode all trees 38 MeSH descriptor: [Minority Groups] explode all trees 39 MeSH descriptor: [Racial Groups] explode all trees 40 MeSH descriptor: [Black People] explode all trees 41 MeSH descriptor: [Asian People] explode all trees 42 MeSH descriptor: [North American People] explode all trees 43 MeSH descriptor: [Asian American Native Hawaiian and Pacific Islander] explode all trees 44 MeSH descriptor: [Indigenous Peoples] explode all trees 45 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44 46 13 OR 18 OR 25 OR 29 OR 35 OR 45 47 (One?Health OR (One NEXT Health) OR sanitation* OR hygien* OR eco health OR (One NEXT World) OR (One NEXT Medicine) OR stewards* OR governance OR ozone* OR animal-human OR human-animal OR human-environment OR environment-human OR environment-animal OR animal- environment OR (environmental NEXT health) OR ecosystem* OR soil OR wastewater OR groundwater OR manure OR (drinking NEXT water) OR biosolid*):ti,ab 48 MeSH descriptor: [Environmental Health] explode all trees 49 MeSH descriptor: [Ecosystem] explode all trees 50 MeSH descriptor: [Soil] explode all trees 51 MeSH descriptor: [Drinking Water] explode all trees 52 47 OR 48 OR 49 OR 50 OR 51 53 (Agriculture* OR livestock OR farm* OR veterinar* OR bovine OR cattle or dairy OR beef OR feedlot OR cow* OR sheep OR lamb* OR goat* OR (dog OR dogs) OR canine* OR (cat OR cats) OR feline* OR (domestic NEXT animal*) OR (companion NEXT animal*) OR swine OR hog OR (pig OR pigs) OR porcine OR ovine OR horse* OR equine OR poultry OR turkey* OR broiler OR (hen OR hens) OR duck OR flock OR avian OR chicken* OR (animal NEXT welfare) OR (animal NEXT health) OR (animal NEXT production) OR fish OR aquaculture OR tilapia OR shrimp OR mussel* OR salmon OR albacore OR trout* OR seafood OR carp OR catfish OR shellfish OR mollusk* OR clams OR oyster* OR scallop* OR perch OR halibut OR cod OR (sea NEXT bass) OR tuna OR (farmed NEXT fish) OR mink OR rabbit* OR Lepus OR hare OR buffalo OR bison OR (bos NEXT (taurus OR indicus)) OR elk OR deer OR cervid* OR camel* OR wildlife OR zoo OR carcass* OR abattoir* OR slaughter*):ti,ab 54 MeSH descriptor: [Agriculture] explode all trees 55 MeSH descriptor: [Animal Diseases] explode all trees 56 MeSH descriptor: [Cattle] explode all trees 57 MeSH descriptor: [Cats] explode all trees 58 MeSH descriptor: [Dogs] explode all trees 59 MeSH descriptor: [Animals, Domestic] explode all trees 60 MeSH descriptor: [Horses] explode all trees 61 MeSH descriptor: [Poultry] explode all trees 62 MeSH descriptor: [Animal Husbandry] explode all trees 63 MeSH descriptor: [Fish Diseases] explode all trees 64 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59 OR 60 OR 61 OR 62 OR 63 65 52 OR 64 66 6 AND 46 67 46 AND 65 68 6 AND 67 69 66 OR 68 with Cochrane Library publication date Between Jan 2010 and Mar 2023, in Cochrane Reviews (Word variations have been searched) >>> Continued from previous page PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 39 40 Policy brief 8.2 Interview topic guide 1. Can you tell us briefly how your current role is related to the management or study of infections and AMR? 2. Thinking about the key drivers of antimicrobial resistance (AMR), in your opinion what are the key factors that drive AMR? 3. Where do you think the impacts of these drivers are greatest, in human health or other parts of One Health space, e.g., environment, agriculture, etc? Why do you think this? 4. Which specific sociocultural characteristics of individuals do you think would increase their likelihood or risk of contracting drug-resistant infections? Do you think this varies by geographic and social boundaries? If yes, how so? 5. Which specific factors that define and position people in society do you think would influence their infection- related behaviours? 6. (If knowledgeable regarding animal/environmental health) Within the One Health space, specifically farming and agriculture, what current practices do you think increase risk of contracting or spread of resistant infections amongst the livestock? What are the risks of this leading to spread of AMR to other fields within One Health, e.g. into human populations? 7. Which societal factors do you think contribute most to the spread and dissemination of drug-resistant infections within human populations? What about in animal and environmental health settings? 8. Where in One Health do you think is the biggest economic burden of AMR? Why is that? 9. Do you think we have sufficient data on the economic consequences of AMR? What do we need to change to create more knowledge in this subject? 10. (If not already discussed) How do you think economic factors (such as income, employment and procurement practices) influence the spread and dissemination of drug-resistant infections within human populations? What about in animal and environmental health settings? 11. (If not already discussed) Which cultural factors influence the spread and dissemination of drug-resistant infections within human populations? What about in animal and environmental health settings? 12. (If not already discussed) Which health system factors influence the spread and dissemination of drug-resistant infections within human populations? What about animal and environmental health settings? 13. What policy actions do you think need to be prioritized at the national level to address these societal, economic, cultural and health system factors that are driving antimicrobial resistance? 14. What policy actions do you think need to be prioritized at the organizational level (hospital, primary care practice, farm, veterinary practice) to address these societal, economic, cultural and health system factors that are driving AMR? 15. What policy actions do you think need to be prioritized at the individual level (patient, companion animal owner, farmer, veterinary surgeons) to address these societal, economic, cultural and health system factors that are driving AMR? Thank you for your time, is there anything else you would like to add to what we have discussed? PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 40 41 The socioeconomic drivers and impacts of Antimicrobial Resistance: Implications for policy and research 8.3 Expert interviewees EXPERT NAME AFFILIATION Professor Timo Minssen Director, Center for Advanced Studies in Biomedical Innovation Law (CeBIL), University of Copenhagen (UCPH), Copenhagen Denmark Professor Robert Leo Skov Scientific Director, International Centre for Antimicrobial Resistance Solutions (ICARs), Copenhagen, Denmark Jeremy Knox Head of Policy, Infectious Disease, Wellcome Trust, London, United Kingdom Dr Michele Cecchini Lead, Public Health, Health Division, Directorate for Employment, Labour and Social Affairs (ELS), Organisation for Economic Co- operation and Development (OECD), Paris, France Dr Danilo Lo Fo Wong Programme Manager, Control of Antimicrobial Resistance (AMR), WHO Regional Office for Europe, Copenhagen, Denmark Dr Esmita Charani Associate Professor, University of Cape Town, Wellcome Trust Career Development Fellow, Cape Town, South Africa Reader in Infectious Diseases and Global Health, University of Liverpool, Liverpool, United Kingdom Dr Andrew Singer Principal Scientist, UK Centre for Ecology & Hydrology, Lancaster, United Kingdom Dr Ramanan Laximinarayan Founder and President, One Health Trust, New Delhi, India Professor Kevin Outterson Executive Director and Principal Investigator, CARB-X, Boston, United States Professor Clare Chandler Professor of Medical Anthropology; Co-founding Director, LSHTM Antimicrobial Resistance Centre, London, United Kingdom Professor Susan Rogers Van Katwyk Managing Director, AMR Policy Accelerator; Research Director, Global Antimicrobial Resistance, Adjunct Professor, York University, Toronto, Canada Professor Sabiha Essack South African Research Chair in Antibiotic Resistance, Pharmaceutical Sciences Antimicrobial Research Unit, University of Yakwazulu-Natali, Durban, South Africa Dr Faisal Sultan Former Special Assistant to Prime Minister/Minister of Health, Ministry of National Health Services, Regulations & Coordination, Islamabad, Pakistan PolicyBrief_PB64_02072024_ONLINE.qxp_Policy_brief_A4 02/07/2024 12:37 Page 41 This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence- informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation. What is a Policy Brief? A policy brief is a short publication specifically designed to provide policy makers with evidence on a policy ques- tion or priority. Policy briefs • Bring together existing evidence and present it in an accessible format • Use systematic methods and make these transparent so that users can have confidence in the material • Tailor the way evidence is identified and synthesised to reflect the nature of the policy question and the evidence available • Are underpinned by a formal and rigorous open peer review process to ensure the independence of the evidence presented. Each brief has a one page key messages section; a two page executive summary giving a succinct overview of the find- ings; and a 20 page review setting out the evidence. 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The views and opinions expressed in Observatory publications do not necessarily represent the official policy of the Participating Organizations. The Policy Brief Series 1. How can European health systems support investment in and the implementation of population health strategies? David McDaid, Michael Drummond, Marc Suhrcke 2. How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen, Reinhard Busse 3. Where are the patients in decision-making about their own care? Angela Coulter, Suzanne Parsons, Janet Askham 4. How can the settings used to provide care to older people be balanced? Peter C. Coyte, Nick Goodwin, Audrey Laporte 5. When do vertical (stand-alone) programmes have a place in health systems? Rifat A. Atun, Sara Bennett, Antonio Duran 6. How can chronic disease management programmes operate across care settings and providers? Debbie Singh 7. How can the migration of health service professionals be managed so as to reduce any negative effects on supply? James Buchan 8. How can optimal skill mix be effectively implemented and why? Ivy Lynn Bourgeault, Ellen Kuhlmann, Elena Neiterman, Sirpa Wrede 9. Do lifelong learning and revalidation ensure that physicians are fit to practise? Sherry Merkur, Philipa Mladovsky, Elias Mossialos, Martin McKee 10. How can health systems respond to population ageing? Bernd Rechel, Yvonne Doyle, Emily Grundy, Martin McKee 11. How can European states design efficient, equitable and sustainable funding systems for long-term care for older people? José-Luis Fernández, Julien Forder, Birgit Trukeschitz, Martina Rokosová, David McDaid 12. How can gender equity be addressed through health systems? Sarah Payne 13. How can telehealth help in the provision of integrated care? Karl A. Stroetmann, Lutz Kubitschke, Simon Robinson, Veli Stroetmann, Kevin Cullen, David McDaid 14. How to create conditions for adapting physicians’ skills to new needs and lifelong learning Tanya Horsley, Jeremy Grimshaw, Craig Campbell 15. How to create an attractive and supportive working environment for health professionals Christiane Wiskow, Tit Albreht, Carlo de Pietro 16. How can knowledge brokering be better supported across European health systems? John N. Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 17. How can knowledge brokering be advanced in a country’s health system? John. N Lavis, Govin Permanand, Cristina Catallo, BRIDGE Study Team 18. How can countries address the efficiency and equity implications of health professional mobility in Europe? Adapting policies in the context of the WHO Code and EU freedom of movement Irene A. Glinos, Matthias Wismar, James Buchan,Ivo Rakovac 19. Investing in health literacy: What do we know about the co-benefits to the education sector of actions targeted at children and young people? David McDaid 20. How can structured cooperation between countries address health workforce challenges related to highly specialized health care? Improving access to services through voluntary cooperation in the EU Marieke Kroezen, James Buchan, Gilles Dussault, Irene Glinos, Matthias Wismar 21. How can voluntary cross-border collaboration in public procurement improve access to health technologies in Europe? Jaime Espín, Joan Rovira, Antoinette Calleja, Natasha Azzopardi-Muscat, Erica Richardson,Willy Palm, Dimitra Panteli 22. How to strengthen patient-centredness in caring for people with multimorbidity in Europe? Iris van der Heide, Sanne P Snoeijs, Wienke GW Boerma, François GW Schellevis, Mieke P Rijken. On behalf of the ICARE4EU consortium 23. How to improve care for people with multimorbidity in Europe? Mieke Rijken, Verena Struckmann, Iris van der Heide, Anneli Hujala, Francesco Barbabella, Ewout van Ginneken, François Schellevis. On behalf of the ICARE4EU consortium 24. How to strengthen financing mechanisms to promote care for people with multimorbidity in Europe? Verena Struckmann, Wilm Quentin, Reinhard Busse, Ewout van Ginneken. On behalf of the ICARE4EU consortium 25. How can eHealth improve care for people with multimorbidity in Europe? Francesco Barbabella, Maria Gabriella Melchiorre, Sabrina Quattrini, Roberta Papa, Giovanni Lamura. On behalf of the ICARE4EU consortium 26. How to support integration to promote care for people with multimorbidity in Europe? Anneli Hujala, Helena Taskinen, Sari Rissanen. On behalf of the ICARE4EU consortium 27. How to make sense of health system efficiency comparisons? Jonathan Cylus, Irene Papanicolas, Peter C Smith 28. What is the experience of decentralized hospital governance in Europe? Bernd Rechel, Antonio Duran, Richard Saltman 29. Ensuring access to medicines: How to stimulate innovation to meet patients’ needs? Dimitra Panteli, Suzanne Edwards 30. Ensuring access to medicines: How to redesign pricing, reimbursement and procurement? Sabine Vogler, Valérie Paris, Dimitra Panteli 31. Connecting food systems for co-benefits: How can food systems combine diet-related health with environmental and economic policy goals?Kelly Parsons, Corinna Hawkes 32. Averting the AMR crisis: What are the avenues for policy action for countries in Europe? Michael Anderson, Charles Clift, Kai Schulze, Anna Sagan, Saskia Nahrgang, Driss Ait Ouakrim, Elias Mossialos 33. It’s the governance, stupid! TAPIC: a governance framework to strengthen decision making and implementation Scott L. Greer, Nikolai Vasev, Holly Jarman, Matthias Wismar, Josep Figueras 34. How to enhance the integration of primary care and public health? Approaches, facilitating factors and policy options Bernd Rechel 35. Screening. When is it appropriate and how can we get it right? Anna Sagan, David McDaid, Selina Rajan, Jill Farrington, Martin McKee 36. Strengthening health systems resilience: key concepts and strategies Steve Thomas, Anna Sagan, James Larkin, Jonathan Cylus, Josep Figueras, Marina Karanikolos 37. Building on value-based health care Peter C Smith, Anna Sagan, Luigi Siciliani, Dimitra Panteli, Martin McKee, Agnès Soucat, Josep Figueras 38. Regulating the unknown: A guide to regulating genomics for health policy- makers Gemma A Williams, Sandra Liede, Nick Fahy, Kristiina Aittomaki, Markus Perola, Tuula Helander, Martin McKee, Anna Sagan 39. In the wake of the pandemic: Preparing for Long COVID Selina Rajan, Kamlesh Khunti, Nisreen Alwan, Claire Steves, Trish Greenhalgh, Nathalie MacDermott, Anna Sagan, Martin McKee 40. How can we transfer service and policy innovations between health systems? Ellen Nolte, Peter Groenewegen 41. What are the key priority areas where European health systems can learn from each other? Johan Hansen, Alexander Haarmann, Peter Groenewegen, Natasha Azzopardi Muscat, Gianpaolo Tomaselli, Mircha Poldrugovac 42. Use of digital health tools in Europe: Before, during and after COVID-19 Nick Fahy, Gemma A Williams, COVID-19 Health System Response Monitor Network 43. European support for improving health and care systems Nick Fahy, Nicole Mauer, Dimitra Panteli 44. What are patient navigators and how can they improve integration of care? Hannah Budde, Gemma A Williams, Giada Scarpetti, Marieke Kroezen, Claudia B Maier 45. What are the implications of policies increasing transparency of prices paid for pharmaceuticals? Erin Webb, Erica Richardson, Sabine Vogler, Dimitra Panteli 46. How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity? Juliane Winkelmann, Giada Scarpetti, Gemma A Williams, Claudia B Maier 47. Addressing backlogs and managing waiting lists during and beyond the COVID-19 pandemic Ewout van Ginneken, Sarah Reed, Luigi Siciliani, Astrid Eriksen, Laura Schlepper, Florian Tille, Tomas Zapata 48. Does provider competition improve health care quality and efficiency? Luigi Siciliani, Martin Chalkley, Hugh Gravelle 49. Health system performance assessment: A primer for policy-makers Dheepa Rajan, Irene Papanicolas, Marina Karanikolos, Kira Koch, Katja Rohrer- Herold, Josep Figueras 50. Making Health for All Policies: Harnessing the co-benefits of health Scott L. Greer, Michelle Falkenbach, Luigi Siciliani, Martin McKee, Matthias Wismar, Praneetha Vissapragada, Marie C. Montás, Janamarie Perroud, Olivia Rockwell, Josep Figueras 51. How can the EU support sustainable innovation and access to effective antibiotics? Michael Anderson, Dimitra Panteli, Elias Mossialos 52. Global Health Workforce responses to address the COVID-19 pandemic Margaret Ziemann, Candice Chen, Rebecca Forman, Anna Sagan, Patricia Pittman 53. What can intersectoral governance do to strengthen the health and care workforce? Margaret Caffrey, Tara Tancred, Joanna Raven 54. What steps can improve and promote investment in the health and care workforce? Barbara McPake, Prarthna Dayal, Julia Zimmermann, Gemma A Williams 55. Strengthening primary care in Europe: How to increase the attractiveness of primary care for medical students and primary care physicians? Marieke Kroezen, Dheepa Rajan, Erica Richardson 56. Engaging the private sector in delivering health care and goods: governance lessons from the COVID-19 pandemic Anna Maresso, Ruth Waitzberg, Florian Tille, Yulia Litvinova, Gabriele Pastorino, Naomi Nathan, David Clarke 57. European support for improving global health systems and policies Scott L Greer, Nicole Mauer, Holly Jarman, Michelle Falkenbach, Ilona Kickbusch, Dimitra Panteli, Matthias Wismar 58. Transforming health service delivery: What can policy-makers do to drive change? Dimitra Panteli, Nicole Mauer, Juliane Winkelmann, Nick Fahy 59. Financing for health system transformation: spending more or spending better (or both)? Rebecca Forman, Govin Permanand, Jonathan Cylus 60. Assessing health system performance: Proof of concept for a HSPA dashboard of key indicators Josep Figueras, Marina Karanikolos, Frederico Guanais, Suszy Lessof, Guillaume Dedet, Natasha Azzopardi Muscat, Govin Permanand, Francesca Colombo 61. Health as a driver of political participation and preferences: Implications for policy-makers and political actors Nolan M Kavanagh, Anil Menon 62. How to implement integrated care?: A framework with 12 overall strategies to transform care delivery Verena Struckmann, Nathan Shuftan, Giada Scarpetti, Willemijn Looman, Roland Bal, Maureen Rutten-van Mölken, Ewout van Ginneken 63. Strengthening the EU response to prevention and control of Antimicrobial Resistance: Policy priorities for effective implementation Michael Anderson, Dimitra Panteli, Elias Mossialos The European Observatory has an independent programme of policy briefs and summaries which are available here: https://eurohealthobservatory.who.int/publications/policy-briefs Keywords: Anti-bacterial agents Drug resistance, microbial Drug resistance, bacterial Health policy Health governance Socioeconomic Sociocultural Equity Gender One Health PolicyBrief_PB64_COVER_19052024_PRINT.qxp_Cover_policy_brief 04/10/2024 11:27 Page 2 The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory’s products are available on its website (www.healthobservatory.eu). The socioeconomic drivers and impacts of Antimicrobial Resistance (AMR) POLICY BRIEF 63 Implications for policy and research Michael Anderson Gunnar Ljungqvist Robin van Kessel Victoria Saint Elias Mossialos World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: eurocontact@who.int Website: www.euro.who.int HEALTH SYSTEMS AND POLICY ANALYSIS Print ISSN 1997-8065 Online ISSN 1997-8073 PolicyBrief_PB63_COVER.qxp_Cover_policy_brief 01/05/2024 13:00 Page 1