The Global Governance of Antimicrobial Resistance: An Empirical Analysis of Participation and Effectiveness

Antimicrobial resistance (AMR) happens when micro-organisms such as bacteria, viruses and fungi evolve to become resistant to antimicrobial medicines. AMR is accelerated by the use, and especially the overuse and misuse, of antibiotics in health care and farming. It is also exacerbated by insufficient and inequitable access to sanitation, clean water and health care. Experts warn that AMR could lead to a future without effective antibiotics. Because drug-resistant bacteria spread internationally across borders, maintaining antimicrobial protection has the features of a global public good that requires international cooperation.

To provide public goods effectively, international cooperation arrangements typically need to meet three conditions simultaneously: ambitious policy commitments, thorough implementation of those commitments, and participation of many countries across the world. The overarching research question of the project is the following: Which kind of international agreement on AMR has the best chance of attaining deep ambition, thorough implementation, and wide participation? The project will address the overarching research question by examining three more specific questions.

First, how effective are existing international institutional arrangements in promoting meaningful progress in tackling the AMR problem? Current efforts pivot around the "Global Action Plan on Antimicrobial Resistance" endorsed by the general assemblies of the WHO, FAO and OIE in 2015, supported by the "Political Declaration" issued in 2016 by the United Nations. The project will apply statistical methods to data on most countries in the world between 2010 and 2020 to estimate the influence of a variety of factors on the adoption and content of national AMR action plans and trends in antibiotic consumption at the country level. These factors include the normative pressure created by the Global Action Plan and specifically by the publication of country performance indicators; external funding, such as the Fleming Fund of the UK Government; the adoption and implementation by countries closely connected through international organizations and other channels; and transnational civil society networks.

Second, given a range of conceivable global agreements on AMR, which one is most likely to attain wide participation, ambitious goals and thorough implementation in the collective judgement of experts of national AMR policies? Using a statistical tool known as conjoint analysis, the project will survey experts on individual countries and ask them to estimate (a) the likelihood that the country would ratify a new global agreement on AMR with specified provisions, and (b), if accepted, the likelihood that the country would implement it thoroughly. The potential provisions include targets for human and animal antibiotic consumption to be reached within a specified timeframe; international monitoring; targets for contributions to two global funds for equitable antibiotics innovation and conservation; a governance structure that ensures transparent decision-making and gives significant voice to low- and middle-income countries.

Third, would knowledge of a legally binding international treaty on AMR affect demand for antibiotics among the general population? Finding that international law on AMR could help align demand for antibiotics among the general population with evidence-based policy could provide a rationale for creating an international treaty. The project will conduct surveys (vignette experiments) involving representative samples of the general population of six countries, to examine whether information about legally binding international commitments on AMR affects the declared likelihood that individuals will ask a medical professional for antibiotics if they were to consult for symptoms that normally should be treated in other ways.