How do policymaker perceptions of antimicrobial resistance drive behaviour and policies for appropriate antimicrobial use? A case study of Pakistan

The research proposed here is for a pump prime award to determine how policymakers' perceptions of Antimicrobial Resistance (AMR) drive their behaviour and selection of policy options aimed at appropriate use of antimicrobials, focusing on one lower middle income country: Pakistan. Applying qualitative methods and engaging a multidisciplinary team with human and animal health expertise, it will map policy actors and their networks, drawing on the Social Construction Framework, to identify how motivation, social constructions, power relations and contextual factors shape policy maker behaviour. Research findings will be essential to achieving the ESRC's underlying objective to identify the specific economic factors, cultural norms, experiences and practices relating to antibiotics that enable the best strategies for action, by providing concrete knowledge and tools for working with policymakers in low- and middle-income countries (LMICs) as they adapt and adopt national policies for appropriate use of antimicrobials.

Key questions this research will address include:

a. Who are the key policy actors to engage for effective implementation of interventions and policies concerning appropriate antimicrobial use? How are these actors currently, and potentially, connected?
b. How are the selected policy options socially constructed and how do social constructions reinforce or weaken support or opposition for the selected policies?
c. What other motivations, power relations and contextual factors drive the selection of specific policies?
d. How do these differ among different groups of policymakers identified under objective 1 (e.g. animal health versus human health or political affiliation)?
e. Based on analysis of the questions above, how do policies for appropriate use need to be presented and framed to ensure that essential groups of policy actors engage with and respond to these effectively?

This project focuses on the drivers of policy actor behaviour in one high risk AMR country in South Asia - Pakistan. With a population of 185 million, it is possibly the largest country without a national policy or guideline on AMR (Horton 2013). A key consideration for appropriate use interventions is care provision through the for-profit and informal health sector. This issue is particularly critical in South Asia where 80% of patients seek care within the poorly regulated private or informal sector (Private Sector for Health, 2016), and Pakistan provides an ideal case study to investigate this as 78% of the population pay out-of-pocket and the private sector provides 75% of health services (Nishtar 2013). The project will then follow a step wise approach to triangulate findings at national level, at regional level in South Asia and with global policymakers. Research outputs include guides for policymakers working on AMR, a research methodology, as well as scientific outputs and papers.

Research will be begin by comprehensively mapping the range of policy actors involved in policy processes relating to appropriate use of AMs, across the One Health spectrum including private and public sector actors. Using the list of policy actors generated by the mapping exercise, we will purposively select policy actors for in-depth interviews (IDI). As part of the IDI process, actors will be asked questions to explore their perceptions about AMR and AM use and to then rank the five policy options while talking through their rationale using a 'thinking aloud' methodological approach.

Research will be conducted by an interdisciplinary team of social and animal scientists from the London School of Hygiene and Tropical Medicine, the Aga Khan University in Pakistan, the National University of Singapore and the Royal Veterinary College in London. Research will in addition benefit from advice and oversight of an academic and an impact advisory panel to ensure maximum impact on policy and future research on AMR.

International development assistance plays a critical role in the social and economic development of low and middle income countries (LMICs), but often does not achieve maximum impact because the local policy and regulatory environment is poorly understood. The Global Action Plan on AMR relies on the World Health Organisation (WHO), the Food and Agricultural Organisation (FAO) and World Organisation for Animal Health (OIE) facilitating the preparation of multi-sectoral national AMR action plans, which few LMICs have initiated. This research will impact on policies and responses for appropriate antimicrobial use currently being developed in LMICs.
Beneficiaries
1) International policy organisations that are looking to shape LMIC policy responses to AMR, including the WHO, FAO, OIE, the Centre for Global Health Security at Chatham House and Public Health England
2) National actors involved in AMR policy formation in Pakistan
3) Academics, including policy researchers and those focusing on AMR/One Health approaches
Steps to maximise impact
1) We engaged our end users prior to designing the study, and allowed the research objectives and scope to be driven by them. Members of the research team and leading policy and academic actors in AMR summarised evidence gaps on policies for AMR control in LMICs, as part of a Lancet Series on AMR. We also held structured discussions with representatives of academic, government, private sector, international animal and human health and donor organisations at national meetings in Pakistan, Southeast Asia regional meetings in Singapore and at a One Health colloquium hosted by Chatham House (CH).
2) To maintain relevance to end users, we have arranged an Impact Advisory Panel of end user representatives, selected to enable input from the high level policy actors focused on global health policy and security, global animal health policy, health policy in Pakistan, South Asian One Health policies and the pharmaceutical industry.
3) We will adapt academic outputs to present our findings in ways that are most appropriate for policy actors. Key outputs will be short policy briefs, including one targeted towards policy planners and another in the form of How-to-do Notes. We will also develop policy briefs in Urdu, adapted to the local context to enable this research to maximally benefit national stakeholders. In developing policy materials, we will benefit from the expertise of CH.
4) Dissemination and engagement: 1) National - In the final quarter of the project we will hold full-day meetings in each of the three study sites in Pakistan, inviting national policy actors identified during the stakeholder analysis, and representatives of media, academic and funding organisations; 2) Regional - In addition to engagement with IAP members from South Asia we will present our findings at a key regional event such as the Prince Mahidol Award Conference in Bangkok; 3) Global - We will coordinate with the CH Centre on Global Health Security to organise round table meeting as part of their One Health Colloquia.
5) Academic impact - we will add to the small body of literature of policy development in LMICs and on AMR policy responses, producing outputs relevant to researchers interested in novel qualitative methodologies; operationalization of policy design theory in the health field; stakeholder analysis for One Health issues and designing appropriate AM use interventions.
6) Benefits extending beyond the project - stakeholder analysis findings will be presented as tool mapping key actors for planning policy responses to AMR and will be made available on an open source web interface. This will allow it to be adapted for other LMICs, enabling a series of such maps to be developed for different contexts and for policy issues beyond AMR.