Presented by Jonathan Wadsworth and Franck Berthe (World Bank Group) at the CGIAR Antimicrobial Resistance Hub Launching, ILRI Nairobi, 21-22 February 2019

1. Pulling Together
to beat superbugs
Jonathan Wadsworth
Franck Berthe
World Bank Group
CGIAR Antimicrobial Resistance
hub launching, ILRI Nairobi,
21-22 February 2019

2. Human Cost of AMR – Lives Lost Economic Cost – Global GDP Lost
TACKLING DRUG-RESISTANT INFECTIONS GLOBALLY: FINAL REPORT AND RECOMMENDATIONS THE REVIEW ON ANTIMICROBIAL RESISTANCE CHAIRED BY JIM O’NEILL MAY 2016

3. Cumulative savings of extra health care costs to 2030 are
$4 trillion if “low-AMR” case is avoided and $11 trillion if
“high-AMR” case is avoided​
US $
Trillions
2016-30
10
5
Implementation
cost
Costs
Avoided
High AMR
Scenario
Costs
Avoided
Low AMR
Scenario

4. SPOT QUIZ: HOW MUCH DOES THIS 10-DAY COURSE OF ANTIBIOTIC COST IN USA?

5. Similar scale effect to financial crisis
of 2008 – but AMR will be continuous.
Not a “one-off” event.

6. Reframing AMR not just as a public health or agricultural problem, but as an
adaptive development challenge (problem of development)
6
An adaptive development challenge
• AMR is a development challenge that will disproportionately affect low- and middle- income countries from an
economic and social perspective
• AMR will negatively affect some SDGs; on the other hand – progress on some SDGs will help combating AMR

7. …….. after some “jagged” thinking we identified a set of principles
to guide our approach…..
7
Principles
of our
approach
Focus on behavioral
and political
economy issues
over technical,
scientific
approachesFocus on
country
level
actions and
options
Aim to reach a
broad audience,
beyond those
conversant in
AMR
Focus on
knowledge and
implementation
gaps
Not making
assumptions about
new financing but
focusing on
smarter
financing

8. Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a
univariate and multivariable analysis. (Collignon et al. 2018, Lancet Planetary Health)
AGGREGATE RESISTANCE
INFRASTRUCTURE
CORRUPTION AND GOVERNANCE
LOW SEVERITY HIGH SEVERITY
Better infrastructure and governance significantly associated
with lower AMR – but not antibiotic consumption.
Reducing antibiotic consumption will not be sufficient
to control antimicrobial resistance because contagion (spread
of resistant strains) seems to be dominant factor.
Better sanitation, access to clean water, good governance,
and increasing public health-care expenditure all need to be
addressed to reduce global AMR.

9. Seeking to articulate the importance of context in relation to AMR
9
Recognizing the importance of context and
the distinction between emergence and
spread
• AMR is often understood in terms of use [mis- and over-
use] of antimicrobials; however, limiting consumption of
antimicrobials will not be sufficient to control AMR.
• Context, determined by anthropological and
socioeconomic factors, is critical to understanding the
spread of resistance determinants.
• The use of antimicrobials has a bearing on emergence
of AMR, but the spread -sometimes referred to as
contagion- is driven by context.
• We need to address the underlying weaknesses of
systems to be able to address AMR; hence the need for
alignment of the AMR and Sustainable Development
agendas.
• AMR specific plus AMR sensitive investments.

10. Exploring three broad tensions: the way we think about antimicrobials, the
way we use them and external factors – as infrastructure of modernity
10
A challenge associated with knowledge,
attitudes and behavior
• Human behavior is about what people
know and the views they take of things.
• AMR is a behavioral and adaptive
challenge, that requires both technical
and adaptive approaches.
• It is growing not because of the absence
of new antimicrobials but because of the
way antimicrobials have become
entrenched into our social, cultural,
political and economic lives.
The way we
think
antimicrobials
The way we use them
External factors
influencing the system

11. Antibiotic resistance policy loops (after Homer et al 2000)
EDUCATION
HEALTH
SERVICE
BUDGETS
LEGISLATION
REGULATION
CONTAGION
CYCLE
R & D
FUNDING
PUBLIC
BELIEFS
AB ACCESS
CONTROL
SURVEILLANCEABR
EMERGENCE
CYCLE
SELF
DIAGNOSIS

13. Effect of GDP per capita on antimicrobial consumption (human health)
Source: Authors

14. Describing typologies of countries, in terms of AMR risk
14
Type A Type B Type C Type D
Level of
economic
development
Low
income
Low & lower-
middle income
Upper-middle
& high income
Upper-middle
& high income
Antimicrobial
use
Low High High Low
Exposure to
other
contextual
risk factors
High High Medium Low
Expected level
of AMR
Medium High Medium/High Low
Lower- and Middle-income countries have the most dangerous
combination of risk factors for emergence and spread of
antimicrobial resistance
While the theoretical curve [above] exposes a historical transition process for countries from type A to D, the global action on AMR is expected to
offer avenues for new trajectories towards type D.
Type A Type B Type C Type D

15. Typologies could help to understand how best to channel resources and build
effective interventions
15
Type A Type B Type C Type D
Status of
the AMR
agenda
AMR agenda focused on access to
quality services and quality of
medicinal products, strengthening of
basic public and animal health
systems, education on hygiene and
infection prevention
AMR agenda focused on
responsible and prudent use of
antimicrobials, further basic
health system strengthening
and capacity building, piloting
new programs, establish
baselines through surveillance
and monitoring, continued
efforts in education on hygiene
and infection prevention
Building strong political and
societal consensus on
addressing AMR, scaling up of
pilot programs, monitoring and
surveillance, complete policy
and regulation reforms, mass
awareness campaigns
Mature public and animal
health systems, regular light-
touch AMR interventions and
programs, continuous
adjustments needed to respond
new risks, maintained
awareness, continued
surveillance
Status of
AMU and
AMR
Low use of antimicrobials, lack of
access to quality medicinal
products, basic systems and
services failed
Increasing use of antimicrobials
with increasing revenues and
consumption, under-performing
systems and services, AMR is
slowly emerging as an issue in
the civil society
Systems still struggling to
manage the rise of
antimicrobial demand and use,
AMR is on the rise and high on
the civil society agenda,
outcomes of surveillance and
monitoring will raise public
concern over AMR
Achievements in reducing use
of antimicrobials, AMR remains
a concern but citizen trust
restored in the system,
established capacity to detect
emergence of new resistance
determinant
Country
type (GDP)
Low-income Low and lower Middle-income Upper middle and high income Upper middle and high income
Returns to AMR-sensitive interventions are highest in low- and middle-income countries

16. ?

17. WICKED PROBLEMS:
• Are difficult to clearly define – cannot first
understand and then solve.
• Multi-causal with many interdependencies.
• Unforeseen consequences of addressing
them.
• Solutions are not right or wrong – they are
better-worse; good enough-not good
enough.
• Are socially complex, context matters,
making each one unique
• Responsibility of multiple organizations
• Solutions involve changes in behavior
• Often characterized by chronic policy failure

18. Traditional wisdom for solving complex
problems: the ‘waterfall’
Tame problems

19. Opportunity-driven problem solving:
the “jagged line of learning”
Wicked problems

21. N. B.

22. Von Moltke famously viewed strategy as a "system of
expedients." He was suspicious of rigid, inflexible, and
totalizing grand strategies and theories, instead
advocating strategy as a series of plug-in points that could
be fashioned and molded to fit the situation. He coined the
oft-repeated saying that "no plan survives first contact with
the enemy“.
“….no plan
survives first
contact with the
enemy.”

23. “One of the greatest challenges facing
the global health community is how to
take proven interventions and
implement them in the real world.
Research on health systems, such as
implementation research is
crucial to meeting that challenge,
providing a basis for the context-
specific, evidence-informed decision-
making needed to make what is
possible in theory a reality in practice.”
Marie-Paule Kieny
Assistant Director-General
Health Systems and Innovation Cluster
World Health Organization
Foreword - Implementation Research in
Health: A Practical Guide, WHO (2013)

24. CONTINUUM OF IMPLEMENTATION RESEARCH (WHO 2013)

25. Relevance of Implementation Research to the AMR
Challenge and the ILRI Hub
• Despite growing evidence of the efficacy of numerous AMR interventions,
there is little understanding of how to deliver those interventions effectively
in diverse settings and within the wide range of existing health
systems.
• Implementation issues often arise as a result of contextual factors that
policy-makers and implementation managers have not even considered.
• Implementation research is crucial to improving our understanding of the
challenges we face in confronting the real world by broadening and
deepening our understanding of these real-world factors and how they
impact implementation.
• Implementation research is of immense value in shining a light on the
often bumpy interface between what can be achieved in theory and what
happens in practice.

26. Pragmatic approach – implementation research with existing mechanisms
and considerations for tackling AMR at the country level
26
Financing
options
National Action Plans
Understanding what works in a
given context, enablers and
barriers
Situation
analysis,
system
bottlenecks,
and blending of
AMR-sensitive
and AMR-
specific
interventions
AMR-sensitive and AMR-
specific interventions aimed
at:
1. maintaining an enabling
environment for AMR
control;
2. reducing the need for
antimicrobial usage; and
3. self-limiting the use of
antimicrobials.

27. Finally, important knowledge gaps and challenges that are consistent
across countries…
27
• Big gaps in understanding real world implementation processes and options
• Heavy focus on use of antimicrobials as a driver of AMR emergence - whilst AMR
spread and related risk factors relatively unresearched
• Impacts of AMR-specific interventions have been modelled but very little
evidence for estimating co-benefits of AMR-sensitive interventions
• An “AMR resilience and preparedness index” combining drivers for emergence
and spread of AMR might enable measurement of progress in a country’s
capacity to mitigate risks relating to AMR

28. ILRI AMR Hub and Partners is well positioned to
do research where it’s really needed – in the real
world – thank you for your attention.