2021 AMR Preparedness Index - Global Coalition On Aging
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2021 AMR Preparedness Index
Table of Contents
Introductory Letter 3
List of Definitions 6
Acknowledgements7
Executive Summary 9
Overall Scores 12
Methodology13
National Strategy 16
Awareness & Prevention 22
Case Study: Saudi Arabia 26
Innovation29
Case Study: Australia 33
Access35
Case Study: Sweden 38
Appropriate & Responsible Use 40
Case Study: Kenya 42
AMR & the Environment 46
Collaborative Engagement 50
Case Study: Russia 52
Conclusion54
Appendix A: Country Profiles 55
Appendix B: Scoring Breakdown 78
Endnotes78
2021 AMR PREPAREDNESS INDEX 2Introductory Letter
As the world attempts to learn lessons from the ongoing COVID-19 pandemic,
national policymakers must address another public health crisis that already
kills an estimated 700,000 people each year1: the growth of antimicrobial
resistance (AMR). If governments fail to combat this growing threat, the
consequences could be catastrophic. One study projects that drug-resistant
infections could claim 10 million lives annually by 2050.2
As resistance grows, our arsenal of antibiotics health authorities seeking to raise awareness
becomes less and less effective, undermining and increase prevention efforts, regulatory
the foundation of our entire medical system. officials and research funders attempting to
Without effective antibiotics, C-sections, organ spur innovations, decisionmakers working to
transplants, chemotherapy, and even routine improve access, clinicians striving to reduce
outpatient procedures become potentially misuse and overuse, environmental agencies
life-threatening events. More broadly, the aiming to limit antimicrobials in the environ-
longevity revolution that has helped millions ment, and the multitude of actors endeavoring
of people worldwide live longer, healthier, to foster global collaboration and cooperation.
more productive lives is at risk. As the UN
National governments must develop and imple-
and WHO Decade of Healthy Ageing brings
ment national strategies holistically to address
greater attention and energy to our remarkable
the multiple factors driving the crisis. This
demographic achievement, we must fully
includes ensuring that the public becomes more
acknowledge the threat that AMR poses to the
aware and knowledgeable about AMR and their
very prospect of human longevity. Without true
role in bringing it under control. Further, gov-
action to effectively address AMR, millions of
ernments and health systems must strengthen
lives – both young and old – will be cut short.
surveillance to track and monitor AMR and to
Despite the urgency of the threat, policymakers inform outbreak control and prevention.
have not shifted commitments to action on
To actively slow the continued growth of
AMR. The AMR challenge requires a concerted
resistance and promote optimal patient
effort from cross-governmental stakeholders
outcomes, appropriate antimicrobials must be
to effectively tackle the myriad factors that
made reliably accessible to those who need
contribute to the AMR crisis. There needs to be
them in parallel with sufficiently resourced
a focus on harmonizing these efforts: policy-
stewardship programs in all healthcare settings
makers developing national strategies, public
Introductory Letter 2021 AMR PREPAREDNESS INDEX 3to guide their appropriate use and preserve the need for action to address AMR and
their effectiveness. Measures to better control meaningful progress through these platforms
antimicrobials in environmental settings – will hopefully continue. This report assesses the
including for manufacturing, use in livestock, implementation of these and other proposed
and the disposal of antimicrobials – are another initiatives, highlighting a global misalignment
critical strategy. between stated commitments at the high level
and tangible actions within countries.
Though initiatives in these areas are necessary
to slow the growth of resistance, a robust To help countries drive progress, we are proud
pipeline of new therapies and tools – including to share this AMR Preparedness Index, a first-
antibiotics, antifungals, new technologies, of-its-kind examination of national level
diagnostics, and vaccines – is another essential commitments to address AMR. Our research
part of the solution. Unfortunately, that pipeline team examined 11 of the largest economies in
has been in decline for decades. According the world to create a benchmark for measuring
to the Pew Trust 2021 tracker, only 43 new progress across seven areas crucial to
antibiotics are under development worldwide, combating AMR. In creating this Index, we set
and only one in four of these are classified as forth four main goals:
novel.3 Yet, many governments are failing to
follow through on previous commitments to
adopt the innovative incentive programs widely
recognized as central to addressing AMR.4
The world’s slow start against COVID-19 teaches
us – or at least should teach us – that delays
1 IDENTIFY BEST PRACTICES
in responding to an urgent public health crisis
have deadly consequences. The cost for AMR
initiatives pales in comparison to the cost of
CREATE A FRAMEWORK
inaction. The World Bank estimates that on 2 FOR ACCOUNTABILITY
AND EVALUATION
its current trajectory, AMR could drag down
annual global GDP by 1.1% to 3.8% by 2050.5
Should AMR go unchecked, the potential annual
economic damage would likely exceed the 2008
financial crisis.6 The World Bank also estimates
3 D RIVE POLICY CHANGE
that investing $200 billion in AMR containment
measures through 2050 could avoid this
$10 trillion to $27 trillion projected expense.7 TIMULATE ACTION
4 AND
S
However, most countries have yet to dedicate COLLABORATION
adequate resources to successfully prepare for
and address AMR.
Through G7 and G20 commitments, all of the
countries in this Index have publicly articulated
Introductory Letter 2021 AMR PREPAREDNESS INDEX 4Our assessment is based on insights and perspectives gathered from surveys and one-on-one interviews with cross-sector and multidisciplinary experts, coupled with our extensive analysis of publicly available AMR data and research at the country level. We hope you will use the AMR Preparedness Index as a tool to support ongoing research and to advocate for the policies that will help us work together to avert catastrophe and solve this urgent public health crisis. Over the coming years, we will continue to monitor progress in the evaluated countries to help policymakers successfully meet the growing challenge of AMR. We look forward to further collaborating with AMR stakeholders globally to promote innovative solutions to accelerate progress in combatting AMR and achieving healthy longevity for all. Michael Hodin, PhD CEO Global Coalition on Aging Barbara Alexander, MD President Infectious Diseases Society of America Introductory Letter 2021 AMR PREPAREDNESS INDEX 5
List of Definitions
AMR HTA OIE
Antimicrobial resistance Health technology assessment World Organization for Animal
Health
APIs IAPO
Active pharmaceutical International Alliance of Patient One Health approach
ingredients Organizations An approach that recognizes
the connections between the
BARDA IDSA
health of people, animals, and
Biomedical Advanced Research Infectious Diseases Society of
the environment and that uses
and Development Authority America
cross-sectoral engagement
CARB-X IMI and communication for the
Combating Antibiotic-Resistant Innovative Medicines Initiative design and implementation
Bacteria Biopharmaceutical of policies to improve public
IPC
Accelerator health outcomes8
Infection prevention and control
CDC OTC
JPIAMR
Centers for Disease Control and Over-the-counter
Joint Programming Initiative on
Prevention, US
Antimicrobial Resistance PNECs
DDD Predicted no-effect
LMICs
Defined Daily Dose concentrations
Low- and middle-income
FAO countries Pull incentives
Food and Agriculture Financial incentives that
NAPs
Organization reward drug development9
National action plans
GDP Push incentives
NHSN AUR Module
Gross domestic product Financial incentives that lower
National Healthcare Safety
the cost of drug development10
GLASS Network Antibiotic Use and
Global antimicrobial resistance Resistance Module, US SPIDAAR
and use surveillance system Surveillance Partnership to
NIAID
Improve Data for Action on
GMPs National Institute of Allergy and
Antimicrobial Resistance
Good manufacturing practices Infectious Diseases, US
WASH
GPs NIH
Water, sanitation, and hygiene
General practitioners National Institutes of Health, US
WHO
HAI Novel antimicrobials
World Health Organization
Hospital-acquired infection or Either novel class drugs, which
healthcare-associated infection have a chemical structure
not used previously in human
HCPs
antibacterial contexts, or novel
Healthcare professionals
target drugs, which target new
HICs bacterial structures in human
High-income countries contexts
6 2021 AMR PREPAREDNESS INDEXAcknowledgements
The Global Coalition on Aging (GCOA) and the Infectious Diseases Society of America (IDSA)
would like to thank the International Federation of Pharmaceutical Manufacturers and Associations
(IFPMA) for sponsoring the development of this report. Further, we wish to recognize the members
of our AMR Preparedness Index Advisory Council for their leadership and insights. Our Council
includes leading voices in the fight against AMR as well as cross-sector leaders with expertise
in the fields of aging, economics, and health policy. The members of the AMR Innovation Index
Advisory Council are:
Helen Boucher, MD, Chief, Division of Ryoji Noritake, CEO & Board Member, Health
Geographic Medicine and Infectious Diseases, and Global Policy Institute, leader of Japan
Tufts Medical Center; Director, Levy Center AMR Task Force
for Integrated Management of Antimicrobial
Resistance; Treasurer, Infectious Diseases John Rex, MD, Chief Medical Officer & Director,
Society of America F2G, Ltd; Operating Partner, Advent Life
Sciences; Adjunct Professor of Medicine,
Professor Dame Sally Davies, UK Special University of Texas Medical School, Houston
Envoy on Antimicrobial Resistance
Ninie Wang, Founder & CEO, Pinetree
Gemma Buckland Merrett, PhD, Science Care Group
Innovation Lead, Drug Resistant Infections,
Wellcome Trust Zhang Zhenzhong, Secretary General,
China Health Economics Association;
Alexandre Kalache, MD, PhD, President, Professor, China National Health
International Longevity Centre-Brazil, Development Research Center
and co-President, International Longevity
Centre Global Alliance
Ramanan Laxminarayan, PhD, Founder
& Director, Center for Disease Dynamics,
Economics & Policy; Affiliate Professor,
Global Health, University of Washington
Acknowledgements 2021 AMR PREPAREDNESS INDEX 7Further, we would like to express our gratitude to the numerous stakeholders across the AMR
landscape, including researchers, advocates, patient organizations, and healthcare professionals,
who provided their unique expertise in support of this report:
Anand Anandkumar, PhD, Presidential Assistant Matt McEnany Health and Mauro Racaniello, PhD,
Bugworks Research, Indian Professor Caesar de la Global Policy Institute Farmindustria - Association
Advisory Board of Global Fuente, PhD, University of Nathalie Moll, European of Pharmaceutical
Antibiotic R&D Partnership Pennsylvania Federation of Companies
Sherly Antony, MD, Tara Hadviger, European Pharmaceutical Industries David Sinclair, International
Pushpagiri Research Centre Parliament (Assistant to and Associations Longevity Centre-UK
Christine Årdal, PhD, MEP Tiemo Wölken) Cristina Mussini, MD, Professor Steffanie
European Union Joint Reiko Hayashi, PhD, University of Modena and Strathdee, PhD, University
Action: Antimicrobial National Institute of Reggio Emilia of California, San Diego
Resistance and Healthcare- Population and Social Elmar Nimmesgern, PhD Casey Sullivan, PhD, US
Associated Infections; Security Research Department of Health and
Norwegian Institute of Norio Ohmagari, MD,
HealthCareCAN National Center for Global Human Services (HHS)
Public Health
Klaus Hellman, DVM, Health and Medicine Kathy Talkington, The Pew
Fabrizio Azzola, Klifovet Hospital Charitable Trusts
Farmindustria - Association
of Pharmaceutical Jean-Pierre Hermet, World Professor Kevin Outterson Dr. Siegfried Throm,
Companies Alliance Against Antibiotic Hyunjoo Pai, MD, Hanyang German Association
Resistance University of Research-based
Giacomo Borgo, Pharmaceutical Companies
European Federation of Professor Anna Hirsch, Professor David Patrick, MD,
Pharmaceutical Industries PhD, Helmholtz Centre for British Columbia Centre for Jocelyn Ulrich,
and Associations Infection Research Disease Control Pharmaceutical Research
David Hyun, MD, The Pew and Manufacturers of
Steve Brooks, AMR Industry Kristine Peers, America
Alliance Charitable Trusts European Federation of
Peter Jackson, PhD, AMR Pharmaceutical Industries Tiemo Wölken, Member
Jean Carlet, MD, World of European Parliament,
Alliance Against Antibiotic Centre; Infex Therapeutics and Associations
Germany
Resistance Professor Vincent Jarlier, Professor Bruno de Araujo
MD, PhD, World Alliance Penna, PhD, Federal Professor Yonghong
Amanda Cash, DrPH, US Xiao, MD, PhD, Zhejiang
Department of Health and Against Antibiotic University of Rio de Janeiro
Resistance University School of
Human Services Danielle Peters, Canadian Medicine
Professor Jean-Marc Jyoti Joshi, MD, Center Antimicrobial Innovation
for Disease Dynamics, Coalition; Magnet Strategy Bo Zhu, R&D-based
Cavaillon, DrSc, Institut Pharmaceutical Association
Pasteur Economics & Policy Group
Committee
Professor Henry Chambers, Lawrence Kerr, PhD, US Ian Philp, MD, Age Care
Department of Health and Technologies Finally, GCOA and IDSA
III, MD, University of wish to thank the individual
California, San Francisco Human Services Sheuli Porkess, MD, The members of GCOA, IDSA,
Ron Daniels, MD, BEM, UK Bongyoung Kim, PhD Association of the British and IFPMA who contributed
Sepsis Trust Professor Hong Bin Kim, MD, Pharmaceutical Industry time and support to the
PhD Professor Rosa Prato, MD, Index.
Lynn Filpi, PhD, US
Department of Health and Natalie LaHood, US University of Foggia
Human Services Department of Health and Professor Jieming Qu, The contents of this report
Greg Frank, PhD, formerly Human Services MD, Shanghai Jiao Tong are solely the responsibility
Biotechnology Innovation Joe Larsen, PhD, Venatorx University, School of of the authoring
Organization Pharmaceuticals Medicine organizations.
Acknowledgements 2021 AMR PREPAREDNESS INDEX 8Executive Summary
Antimicrobial resistance (AMR) is a growing public health crisis and represents
one of the most urgent challenges facing national governments. AMR is a result
of bacteria, fungi, viruses, and parasites adapting to existing antimicrobials –
antibiotics, antifungals, antivirals, and antiparasitics. Over time, this process
renders the drugs in our arsenal ineffective, leading to greater spread of
infection, more severe infections, and fewer treatment options.11 If countries
do not adequately prepare for and address AMR, the very foundation of modern
healthcare will fall away, taking with it the great achievement of human longevity.
Yet, government action to date has failed to match the severity of the crisis.
To ensure AMR receives the attention and action
it demands, the Global Coalition on Aging (GCOA),
in partnership with the Infectious Disease NATIONAL STRATEGY
Society of America (IDSA) and with support from FOR AMR
the International Federation of Pharmaceutical
Manufacturers & Associations (IFPMA), has
AWARENESS & PREVENTION
developed the AMR Preparedness Index, a first-
of-its-kind examination of country-level progress
in areas critical to combating AMR. The Index is INNOVATION
intended to drive awareness, stimulate high-level
discussions, and spur governments to implement
ACCESS
policies needed to address this serious threat.
The AMR Preparedness Index builds on previous
APPROPRIATE &
calls for collective action on AMR, including
RESPONSIBLE USE
the need to expand access to antimicrobials,
curb inappropriate use, facilitate new drug
development, and enforce stronger manufacturing AMR & THE ENVIRONMENT
and disposal standards.12
In this Index, we assessed how 11 countries13 COLLABORATIVE
are performing across seven distinct, yet ENVIRONMENT
interconnected categories that contribute to the
AMR challenge.
Executive Summary 2021 AMR PREPAREDNESS INDEX 9In our findings, we define these categories Bolster surveillance and leverage data across
and the metrics used to evaluate progress AMR efforts
within them. For each category, we identify key Though great disparities exist in the quality
insights and put forward concrete calls to action. and sophistication of the AMR surveillance
Below, we summarize the top-level priorities networks, it remains critical to other efforts
and opportunities for impactful government that all are strengthened. Investments in
action, based on the research. surveillance have myriad returns, helping
to direct infection prevention and control
Strengthen and fully implement national
efforts, inform stewardship programs, increase
AMR strategies
understanding of AMR’s impacts, and guide R&D
The massive threat posed by AMR has yet to investments towards the most critical needs.
generate the political will needed to fund ade- In these ways, surveillance infrastructure
quate solutions, including budgetary allocations is foundational in the fight against AMR.
for stronger surveillance networks, incentives Yet, in some countries these programs are
for drug development, equitable access to drugs underfunded, and in other countries levels of
and diagnostics, stewardship programs, and reporting and sophistication remain alarmingly
environmental management initiatives. Without low. Further, there is increasing evidence
proper funding, national strategies cannot be that surveillance networks stopped collecting
implemented effectively. National governments data during COVID-19, demonstrating the
must bolster AMR national action plans (NAPs) fragility of these systems, and hindering global
and create accountability for robust implemen- understanding of how AMR developed across
tation and funding. the pandemic.
Raise awareness of AMR and its consequences, Enable a restructured antimicrobial
while targeting prevention opportunities marketplace to stimulate innovation
Patients and prescribers lack sufficient To facilitate a robust innovation pipeline and
awareness about the AMR threat and their role to ensure access to effective medicines,
in reducing it, which leads to antibiotic misuse the antimicrobial marketplace must be
and overuse. Governments must commit to fundamentally restructured in three ways:
national, regional, and segment-specific First, governments must decouple the return
awareness campaigns to discourage overuse on investment for antimicrobials from volume
by patients and to curb inappropriate prescrib- of sales. Second, governments must adopt
ing by providers. To help prevent the growth new models that better reflect the full value of
and spread of resistant infections, while also antimicrobials. Third, governments can spur
reducing future antimicrobial use, governments private sector innovation by implementing
should strive to increase the uptake of and incentives and improving access to new
access to AMR-relevant vaccines.14 antimicrobials through reimbursement reform.
Executive Summary 2021 AMR PREPAREDNESS INDEX 10Promote responsible and appropriate use More effectively integrate the One Health
of antibiotics approach, including environmental
Public demand, lack of healthcare provider considerations, into national strategies
training, lack of access to diagnostic tools, and The One Health approach language is being
inadequate stewardship lead to over-prescription integrated into most national action plans and
and misuse of antimicrobials. Governments can national-level policies, yet greater funding and
do more to enhance sanitation infrastructure, broader implementation is needed. Though
accelerate vaccination programs, and strengthen not AMR-specific, most countries have general
surveillance and monitoring, all of which will re- legislation and policies for pharmaceutical
duce AMR. Most healthcare settings, especially manufacturing environments and pollutants,
outpatient facilities, lack the stringent stewardship but the degree of enforcement and efficacy of
regimes needed to improve monitoring and these policies vary. Likewise, the role of AMR
decrease misuse and over-prescription. in agriculture and animals must be further
Governments must improve stewardship by investigated, and policies to reduce the use
funding the training, expert personnel, and IT of antimicrobials in these settings must be
infrastructure needed to implement evidence- further developed. Finally, private and third-
based stewardship programs, tailored to the party investments in the fight against AMR
needs of individual sites. Further, to reduce are often not integrated into a holistic One
and ultimately eliminate over-the-counter sales Health approach, leading to isolated and
of antibiotics, governments must strengthen fragmented interventions.
systems and ensure equitable access to
Better engage with other governments, third-
appropriate healthcare.
party organizations, and advocacy groups
Enable reliable and consistent access to Current levels of government engagement are
needed and novel antimicrobials not realizing the full potential of collaborative
In high-income countries, many patients lack efforts in innovation, research, environmental
timely access to novel antimicrobials, while in and manufacturing standards, and surveillance
many low- and moderate-income countries, and monitoring. Governments should establish,
access to antimicrobials generally is not engage with, and promote cross-sectoral and
guaranteed. Regulatory inefficiencies inhibit public-private partnerships, which can leverage
access to new antimicrobials in some countries, efforts to combat AMR from governments,
and global supply-chain frailty threatens NGOs, advocacy groups, and the private sector.
access to needed pharmaceutical ingredients These recommendations are discussed in
and drugs in all countries. Governments must more detail throughout the report. Our hope
address regulatory bottlenecks while working is that the Index’s findings and calls to action
to shore up supply-chain networks will inspire policymakers to take action to
and infrastructure. address AMR in their own countries and enable
coordinated action across countries.
Executive Summary 2021 AMR PREPAREDNESS INDEX 11Overall Scores
The graph below provides a holistic view of each country’s scores. It highlights categories where
countries have the most opportunity for improvement and areas where countries are demonstrating best
or “better” practices. Further scoring visuals for specific categories are provided throughout the Index.
The category scores have been equally weighted – with a maximum of approximately 14% per category
– to construct an overall Index score on a 100-point scale. For all countries, there is clearly much room
for improvement, though some trends have emerged: most countries (bar the UK and US who fare
slightly better) perform especially poorly in the National Strategy, Innovation, and Collaborative Engage-
ment categories, with scores in the Innovation category being the lowest overall; all countries perform
insufficiently in the Awareness & Prevention and Access categories, with India lagging behind; and
more developed countries tended to fare better in the Appropriate & Responsible Use category.
Overall Scores with Category Contributions
Brazil 34
Canada 49
China 37
France 61
Germany 64
India 37
Italy 49
Japan 52
South Korea 47
UK 76
US 68
National Strategy Innovation Appropriate & Responsible Use Collaborative Environment
Awareness & Prevention Access AMR & the Environment
Overall Scores 2021 AMR PREPAREDNESS INDEX 12Methodology
The 2021 AMR Preparedness Index was developed using primary and secondary
data sources collected and analyzed by GCOA. The primary data consist
of interviews and surveys of global key opinion leaders and subject matter
experts, including advocates, researchers, clinicians, and business leaders
who are directly involved in combatting AMR.
The secondary data consist of existing research • What is being done to improve awareness and
gathered from global authorities, including training?
the Organisation for Economic Cooperation
• What is the status of the broader ecosystem
and Development (OECD) and the World Health
for antimicrobial development?
Organization (WHO), as well as reports from
national governments, nonprofit organizations, • How are countries working to improve
and other publicly available sources. Data antimicrobial access, particularly to novel
sources, key secondary metrics, and the antimicrobials?
scoring framework are detailed in the report’s • What is being done to curb abuse, misuse,
appendices. The countries chosen for this Index and overuse of antibiotics?
include Group of 7 members (Canada, France,
Germany, Italy, Japan, the UK and US) and key • What are countries doing to build better
G20 economies (Brazil, China, India, and South infrastructure to curb AMR?
Korea), which all must fully commit to the • What types of pull incentives are being
global AMR fight. considered and adopted to facilitate the
development and availability of novel
Framework
antimicrobials and other innovations?
The Index is designed to evaluate the level
of attention governments give to AMR and Categories and Indicators
assess their performance. The results serve To evaluate performance, we developed seven
as a benchmark against which future progress categories to cover a broad range of issues
can be measured. To understand how national related to AMR.
governments are performing today, we asked
National Strategy: Evaluates the high-level
the following questions:
policies, commitments, and investments that
• How robust are countries’ national action national governments have undertaken to
plans, and how are they being implemented? combat AMR.
Methodology 2021 AMR PREPAREDNESS INDEX 13Awareness & Prevention: Assesses the level Scoring
of commitment within countries to fund and Countries were scored on a 100-point scale,
facilitate efforts to increase awareness among with final scores reflecting a composite of both
stakeholder groups and improve mechanisms qualitative and quantitative data across seven
that can prevent and monitor AMR. equally weighted categories, 25 component
Innovation: Quantifies government areas, and more than 100 metrics. The full list
commitments to foster and support AMR of metrics, indicators, evaluation criteria,
innovation, especially in areas of greatest and specific metric scores can be found in
opportunity, including novel valuation and the appendices.
pull mechanisms. Individual metric scores were determined
Access: Measures patient access to both older through a variety of methods, including
and novel antimicrobials. direct numerical conversations to a 100-point
scale, the assignment of relative scores
Appropriate & Responsible Use: Assesses based on assessed distance from highest
governments’ efforts to reduce misuse and achievable condition, and binary and
overuse of antimicrobials and promote qualitative conversions to a scale or banded
rational diagnosis. scale. Wherever relevant, quantitative data
AMR & the Environment: Examines how were adjusted for substantial differences in
national governments are attempting to population size and gross domestic product
manage antimicrobials throughout their life (GDP). For some metrics, expert judgment
cycle: production, procurement, usage across directly informed scoring. The purpose of
sectors (including non-human applications), employing this mixed methodology was to
and disposal. derive both useful and meaningful insights from
complex and sometimes irregular data.
Collaborative Engagement: Captures how
effectively national governments are facilitating Individual metrics were then grouped into
collaborative engagement to address AMR. component areas and weighted to create a
100-point score for each. In turn, the component
These categories are based on an assessment
areas that comprise each category were
of the current AMR landscape and insights
weighted to produce a total category score, on
gleaned from other reports, such as the
a 100-point scale. Finally, these category scores
AMR Industry Alliance Progress Report,15
were weighted equally and compiled to produce
Drive AB’s Revitalizing the antibiotic pipeline
the overall Index composite score, again on a
report,16 Charles Clift’s Review of Progress
100-point scale.
on Antimicrobial Resistance,17 WHO Global
Action Plan,18 and the Food and Agriculture Component area and metric scores were
Organization’s (FAO) Action Plan on Antimicrobial weighted with the goal of more accurately
Resistance 2016-2020.19 reflecting country performance and impact
within categories. The weights aimed to
decrease the scoring influence of self-reported
data while increasing the scoring influence
Methodology 2021 AMR PREPAREDNESS INDEX 14of externally validated data and data deemed of Innovation, Access, Awareness & Prevention,
most impactful to AMR preparedness by the and AMR & the Environment. In some instances,
experts and the literature consulted. Where all we have controlled for factors like GDP or pop-
else was equal, weights were not applied. The ulation size in an effort to create a more level
research team iteratively adjusted and validated playing field on which to evaluate country-level
the weights in consultation with the expert progress, but this is an imperfect approximation.
contributors to the report.
The survey was available only in English and
Additional details on scoring methodology can performed online. Interviews were conducted
be found in the appendices. in English. All surveys and interviews were
completed from September 2020 through
Assumptions and Limitations June 2021. As a result, the research inputs and
While AMR is a global crisis, the scope of this expertise available to the research team were
report is limited to the 11 countries identified limited by both time and access.
and the framework articulated within this
section. The data cited and expert input
evaluated do not fully reflect the breadth and
scale of the AMR challenge; rather, they aim to
highlight key strengths and opportunities within
each country.
It should be noted that this Index is not an
exhaustive compilation of all AMR data, rather
it represents a distinct effort to collect
accessible, “apples to apples” data to present
a high-level representative overview of
countries’ performance across set categories,
with a focus on human health. Lack of data
accessibility, recency, and comparability posed
limitations. Further, the complexity of the
dynamics impacting AMR and the need for more
research means that some AMR impacts and
drivers are still not fully understood and remain
difficult to capture. Still others fell outside the
scope of this report.
The majority of countries evaluated are
classified as high income by the World Bank.
Though high-income countries did not score
higher in every category, the economic
circumstances of a country did contribute to
overall scores, particularly in the categories
Methodology 2021 AMR PREPAREDNESS INDEX 15National Strategy
Evaluates the high-level policies, commitments, and investments that national
governments have undertaken to combat AMR.
National Strategy Country Comparison
Brazil 17
Canada 37
China 37
France 48
Germany 40
India 40
Italy 29
Japan 38
South Korea 25
UK 77
US 67
National Strategy 2021 AMR PREPAREDNESS INDEX 16Greater support and collaboration is necessary
Key Findings to increase capacity in many LMICs, while HICs
must collect and provide more complete data
Countries are not making adequate
investments to combat the AMR threat to increase the robustness of international,
regional, and domestic efforts.23
Most countries examined in this report are
simply not spending enough to address AMR. Even countries identified as leaders on
In analysis of national level expenditures, multiple AMR metrics have yet to adequately
only the US and UK have committed material support antimicrobial development. In the UK,
investments to address AMR, and experts experts described an inadequate innovation
in these countries agree that the resources pipeline, with fewer than 20 biotech firms
available are still far from sufficient.20 Even and 150 researchers working on developing
controlling for GDP, China, Brazil, Italy, novel antimicrobials,24 compared to over 200
and India have paltry allocations, and the commercial clinical trials a year for cancer.25 In
borderless nature of AMR means that this lack India, which has no shortage of scientists and
of commitment is felt globally. When looking innovators, the government does not actively
at total public AMR research funding, an area support and fund critical research efforts. One
in which middle-income countries may look to expert reported that most funding for promising
close the gap, huge disparities remain. startups in the country came from foreign or
external sources.26,27
National programs to increase public and HCP
awareness are also falling short. AMR is one Beyond a lack of direct funding to support
of the largest public health crises in which the AMR innovation, governments have also failed
general public and clinicians play a key role. to adopt policy reforms to improve market
Despite being one of the top five global health conditions. EU experts told us that while pan-
challenges cited by the WHO,21 a large majority European reforms are an important factor in
of the public remains uninformed and unaware jumpstarting the antimicrobial pipeline, national
of their role. More robust national campaigns policy reforms could play a much bigger role in
are needed to raise awareness. Likewise, many promoting change.28
HCPs continue to unknowingly contribute to In most countries examined in the Index,
the problem. National efforts to target and train efforts to implement pull incentives were not
these professionals require further investment. robust enough to address failures within the
National initiatives for surveillance and antimicrobial market. In France, Germany, Italy,
monitoring remain insufficient to address Brazil, India, China, Japan, and South Korea,
AMR. Though the WHO’s Global antimicrobial governments have shown little commitment to
resistance and use surveillance system these innovation-catalyzing programs.
(GLASS) 2020 report did mention political will Despite a clear need to improve access to
to improve surveillance efforts in LMICs, greater novel antimicrobials and first- and second-line
investments must be made to track and assess antimicrobials in LMICs, governments have not
AMR threats and drivers and to inform infection implemented the policies needed to ensure
outbreak control and prevention efforts.22 these drugs are available and affordable to
National Strategy 2021 AMR PREPAREDNESS INDEX 17patients. Governments have yet to implement Many experts believe the details of the NAPs
regulatory and reimbursement improvements are overly broad and lack actionable items
to enhance access to these new antimicrobials. that could be implemented and measured at
Globally, governments have not funded or the country level. Experts also felt that many
otherwise addressed the required supply chain countries were not sufficiently committed to
improvements necessary to ensure stable building a robust surveillance and monitoring
access to older drugs and APIs necessary to infrastructure.30 Many suggested specific issue
produce these drugs, as has been shown by areas are not being fully funded or financed,31
disruptions during the COVID-19 pandemic. while others felt that NAPs fail to frame the
issue for a wider range of stakeholders.32 This
All countries recognize rampant overuse and
is particularly worrying given the importance
misuse and have paid lip service to the issue
placed on surveillance, especially monitoring
in national plans. Yet, stewardship programs
of healthcare-associated infections, in WHO
to reduce improper usage have not been
minimum guidelines for infection prevention
implemented widely or sufficiently funded.
and control.33
Though many governments have championed
the One Health approach and erected bans or AMR is not a political priority in most countries
policies to limit the use of antimicrobials in Across the board, there is a gross disparity
animals, there have been few efforts to actually between the scale of the AMR crisis and the
address environmental effluents that contribute level of attention from governments.34 Experts
to AMR, such as from manufacturing processes. noted the low awareness of the problem among
Programs to specifically combat AMR in the policymakers.35 Many policymakers do not
environment remain vastly underfunded, fully understand the large incentive proposals
preventing the full integration of a One Health recognized by experts as necessary to restore
approach across all sectors. the antibiotic innovation pipeline; the collective,
long-term, and devastating costs associated
As a global threat requiring global action, AMR
with inaction; and the long runway that is
also needs greater investment in international
required to develop the needed antimicrobials.
and regional programs that promote
cooperation and collaboration to protect the NGOs, advocacy groups, and patient
common good – a fact national governments organizations are often missing from national
must recognize and prioritize. conversations
Interviews and research revealed that third-
National actions plans and their
party organizations and interest groups are not
implementation must be bolstered
being fully involved in AMR efforts. The patient
While almost every country examined has
community could be more fully engaged as a
modeled their NAPs on the recommendations
partner that supports both developing national
of the WHO and other leading organizations,
AMR policies and communicating key messages
experts agree these plans either lack substance
to the broader public.36 The AMR Patient
or little is being done to properly implement
Alliance, run by the IAPO-P4PS Observatory
NAP goals and commitments.29
(International Alliance of Patient Organizations),
National Strategy 2021 AMR PREPAREDNESS INDEX 18brings together many voices for patient-led must better engage with governments. As
efforts against AMR,37 providing a platform AMR remains largely unintegrated within the
for policymakers seeking to better engage framework of the Sustainable Development
patient groups in domestic AMR discussions. Goals, the threat can be left unaddressed by
Additionally, only a few organizations, including LMICs. So, when this is the case the global AMR
Sepsis Alliance, Peggy Lillis Foundation and community and fellow governments should
Cystic Fibrosis Foundation, are actively working seek to engage with the relevant domestic
to educate policymakers about AMR and its policymakers to ensure that AMR is properly
impact on patients. Yet, given the tremendous prioritized and assistance can be provided.
impact of AMR on patients, particularly
Despite the generally lackluster state of
those with compromised immune systems,
participation, some are leading the way. For
patient advocacy on AMR remains a relatively
example, the EU’s Joint Programming Initiative
underleveraged opportunity within countries.
on AMR (JPIAMR) represents a multi-faceted
The global nature of antimicrobial resistance collaborative effort to combat AMR. The
(AMR) has discouraged countries from taking program provides a platform for 28 countries
bold, unilateral actions over five continents to engage on the issue
Experts nearly universally agree that of AMR, developing a Strategic Research and
policymakers in their countries understand Innovation Agenda (SRIA) in 2018 to promote and
that unilateral action alone cannot adequately fund innovation.40
address the AMR challenge. Experts also Like most aspects of AMR, environmental
acknowledged that decisionmakers know that challenges are completely borderless. Thus,
cross-sectoral multilateral initiatives are the collaboration across national borders
most effective paths to progress. Yet, many is essential to effectively addressing
countries are playing a high-stakes game of antimicrobials that pollute our environment
“chicken,” experts observed, waiting for other and contribute to AMR. The Antimicrobial
nations to initiate programs and policies.38,39 Resistance Summit Asia in 2019, held in
Singapore, demonstrated a great regional
Many countries are insufficiently engaged with
the global AMR community effort.41 Likewise, South Korea’s hosting
of the 7th Session of the Ad Hoc Codex
Research also found that many governments
Intergovernmental Task Force on Antimicrobial
are not fully engaged with international
Resistance in 2019 also demonstrates a
organizations working to combat AMR. This lack
commitment to collaborate on environment
of engagement risks depriving stakeholders
facets of AMR, including the development of
of critical tools, assets, best practices, and
risk management guidelines that address the
knowledge that can be applied locally. Given the
role of veterinary applications, plant protection
global nature of this challenge, participation
and food processing on AMR, based on FAO
in formal and informal organizations can help
and WHO recommendations.42 Additionally, the
facilitate key exchanges, which can ultimately
Codex Alimentarius Commission (CAC), has
help strengthen domestic plans. Equally, in
produced guidelines and codes on how to best
many LMIC contexts the global AMR community
National Strategy 2021 AMR PREPAREDNESS INDEX 19minimize and contain AMR in animal husbandry, term through the full implementation of NAPs
veterinary drugs, and food.43 and adoption of new commercial models.
COVID-19 has virtually halted implementation Governments should better engage NGOs,
of national AMR strategies advocacy groups, and the patient community
The COVID-19 pandemic has caused a large in developing and implementing NAPs and
other AMR initiatives
reallocation of resources, which in turn has
slowed implementation of national AMR plans; Effective, long-term policies require the
delayed renewals of plans; and diverted staff, support of a diverse group of stakeholders. Yet,
tools, and resources away from AMR efforts.44 even in countries where some policy efforts are
Pre-COVID AMR challenges are also being underway, nations like the US and UK both lack
exacerbated by a rise in healthcare-associated the incorporation of patient groups, which could
infections and decreased oversight on the use help bolster future efforts.
of prescription antibiotics. NGOs and especially the patient community can
The pandemic has indefinitely delayed the be a critical partner to government and also
possibility of political action on AMR in many play an essential role in keeping policymakers
settings. New incentives, pilots, and projects well informed about emerging AMR issues. Most
have been sidelined.45 Diverted funding has, in policymakers lack a strong understanding of
some cases, impeded antimicrobial research AMR – especially the severity of the threat and
and development. While this is not surprising the market failure that inhibits the development
given the severity of the COVID-19 threat, as of new antimicrobials. As long as this continues,
governments move past the initial phases of policymakers are unlikely to prioritize AMR
the pandemic, AMR must become a key priority or champion the needed policy solutions.
for policymakers. Increasing the level of policymaker awareness
and understanding is critical to advancing AMR
policy priorities.
Calls to Action Governments should develop more ambitious
NAPs and provide sufficient funding to achieve
Governments must make bolder financial goals
investments to tackle AMR
While governments have crafted NAPs based on
As countries wait for others to act, many guidelines developed by the WHO, many plans
decisionmakers are also waiting for constituent do not go beyond minimum standards. It is also
pressure to advance solutions for AMR. difficult to determine whether plans are being
However, as we learned from the slow COVID-19 effectively implemented or funded, due to a lack
response, a public health crisis requires of evaluation studies.
governments to lead rather than wait for public
consensus. To start, governments must build
support for innovative, aggressive policy action
now to prevent greater suffering in the long
National Strategy 2021 AMR PREPAREDNESS INDEX 20Governments should lean into AMR initiatives and actions now Experts in most countries report government reluctance to be a “first mover” on AMR initiatives. This wait-and-see approach delays progress and inhibits a collective approach against AMR. National strategies must not only implement the commitments in NAPs; new programs must be developed and piloted. Waiting for new advancements in surveillance and monitoring programs further endangers populations. Implementing pilots for pull incentives, novel valuation models, and reformed reimbursement can help broaden the antimicrobial pipeline. To allow for equal access, governments must adopt policies that bring new drugs to patients and shore up supply chains for older drugs. Broader, more intensive stewardship programs are needed to help reduce the misuse and overuse of antimicrobials. Finally, piloting more well- integrated One Health approaches is necessary to combat AMR in the environment. National Strategy 2021 AMR PREPAREDNESS INDEX 21
Awareness & Prevention
Assesses the level of commitment within countries to fund and facilitate efforts to
increase awareness among stakeholder groups and improve mechanisms that can
prevent and monitor AMR.
Awareness & Prevention Country Comparison
Brazil 48
Canada 76
China 54
France 65
Germany 79
India 43
Italy 64
Japan 75
South Korea 54
UK 78
US 75
Awareness & Prevention 2021 AMR PREPAREDNESS INDEX 22diphtheria, and tuberculosis, or even viruses like
Key Findings influenza and the novel coronavirus is a critical
step to combating AMR. Yet, many countries
Public awareness across most countries
remains low, driving overuse we examined are failing in this area. In some
countries, vaccine administration is disjointed
Most people are unaware of the AMR threat,
and decentralized. In others, such as the US,
with little understanding of the link between
there is no national-level vaccination mandate,51
antibiotic usage and consequences of AMR.
while many European countries require
Based on recent survey data, only 46% in Brazil,
vaccines.52 Canada’s regionalized system for
51% in the US, 63% in China, and 68% in India
healthcare delivery can complicate efforts
recognize AMR as a term.46 In Canada, one
to vaccinate the population. Jurisdictional
survey indicated that 57% believed antibiotics
issues also undermine efforts in countries like
can be used to treat viral infections. In other
Italy, where several regions decided to abolish
countries, such as Germany, the public had
vaccine requirements in 2005, leading to an
greater awareness of AMR due to extensive
alarming drop in immunization rates. Some
media coverage of AMR-related deaths.
governments, like South Korea, do not fully
Low patient and prescriber awareness drives cover vaccination costs, which impedes access
the misuse and overuse of antimicrobials, and reduces uptake. A few countries are failing
increasing the prevalence of AMR.47 Over the to adequately invest in national vaccination
past two decades, misuse of broad-spectrum programs: our analysis showed that China and
and last-resort antimicrobials, in particular, India substantially lag behind other countries in
has risen in LMICs, and misuse persists in HICs, per capita spending. Additionally, lapses in adult
despite awareness campaigns.48 coverage remains worrisome, as vaccinating
older adults is a key contributor to healthy aging
Since not all forms of awareness generate
as well as the fight against AMR.53
behavior change, more work must be done
to identify the most effective methods to Despite these challenges, most countries
communicate the dangers of AMR and the are working to improve vaccination rates,
role of patients and providers in combating such as Brazil and Italy who have worked to
it.49 Higher levels of awareness in Germany integrate vaccination programs into efforts to
suggest that increased media coverage is a key combat AMR. There are also many examples
factor. Greater investment to promote public of national campaigns critical to reducing
understanding is critical; in fact, it is the first vaccine hesitancy. In Germany, the Robert Koch
strategic objective of the WHO Global Action Institute runs vaccine awareness programs to
Plan to increase understanding of AMR across reduce skepticism and increase uptake, and to
stakeholder groups.50 improve vaccination rates in veterinary contexts
the French Department of Agriculture ran two
Countries’ vaccination programs are not being
successful initiatives, “Immunization, Health
fully leveraged
Investment for Your Flock” and “Nourished,
Adequately vaccinating populations against Housed, Vaccinated.”
infections such as pneumococcal pneumonia,
Awareness & Prevention 2021 AMR PREPAREDNESS INDEX 23Most countries have also integrated vaccine coordination and stakeholder engagement
policies into national AMR plans; however, in the design of regulatory processes.55
this effort is often poorly implemented or
Without these programs, countries can
underleveraged. Despite the obvious benefits,
experience worse health outcomes and poor
governments are not utilizing vaccine
antimicrobial management. An American
advisory committees to reduce the threat
study on neonatal sepsis found that point-of-
of AMR. Further, countries have not sought
care diagnostics, more timely processing,
to describe how vaccines can combat AMR,
and improved laboratory techniques were
monitor the effect of vaccination efforts on
necessary to improve the screening and
AMR development, track the implementation
treatment of these cases.56 In other words,
of vaccine initiatives, or effectively promote
a lack of proper healthcare infrastructure
vaccine R&D, while also failing to set clear
was limiting access to needed antimicrobials
targets for vaccines more generally.
and, in cases of inappropriate prescription,
Weak, insufficient healthcare systems and worsening health outcomes.57
inadequate public health infrastructure are Even in countries with highly developed
major barriers
healthcare systems, a lack of infectious
In countries where hospital settings lack diseases specialists, who have expertise in
sanitation standards or fail to enforce them, the managing patients with multidrug resistant
rates of healthcare-associated infections (HAIs) infections and leading antimicrobial
rise dramatically. At a community level, poor stewardship and infection prevention and
sanitation increases the number of bacterial control programs, is impeding national
infections and directly contributes to increased responses to AMR. In the US, infectious disease
antibiotic usage and AMR. Some countries is one of the lowest compensated specialties,
are still failing to reduce HAIs and WASH- which hampers recruitment to the field.58
attributable deaths. Both India and Brazil scored
poorly in this area. Most countries have dedicated surveillance
and monitoring systems, but the degree of
In settings with a low doctor-to-patient ratio, sophistication and transparency varies
general practitioners (GPs) are more pressed
In recent years, several countries have
for time, reducing their ability to accurately
implemented systems to surveil and monitor
diagnose patients. GPs in most countries also
antimicrobial resistance, with varying
lack access to diagnostic tools needed to re-
effectiveness. Since 2016, South Korea
duce unnecessary prescriptions of antibiotics.
has implemented several systems, including
Stewardship practices and programs used in
Kor-GLASS, a GLASS-compatible national
HICs may need to be adjusted for other contexts,
surveillance system for AMR,59 a One Health-
given stark differences in access to resources,
based research project to monitor surveillance
technologies, and expertise as well as greater
of drug usage and disease transmission in
need for antimicrobials.54 Many have champi-
human-animal environments, and a system
oned the adoption of “smart regulation” in LMICs
to measure and compare antibiotic usage
to help address AMR, emphasizing cross-sectoral
rates in hospitals.
Awareness & Prevention 2021 AMR PREPAREDNESS INDEX 24In Canada, an intergovernmental taskforce is AMR training for medical professionals
seeking to establish more rigid surveillance is available but needs strengthening
guidelines for the Canadian Antimicrobial In the UK, medical schools offer training on AMR,
Surveillance System (CARSS). Brazil’s however, these curricula are not standardized
improvements in surveillance and monitoring throughout the country. The Society for AMR
have been used to inform patient safety and Chemotherapy is currently seeking to rectify
now contribute data to GLASS. In 2014, China this problem by formally incorporating AMR into
also established a new surveillance system all pre-service training, while in-service training
to replace older infrastructure, yet still has is also provided. In Brazil, healthcare provider
refused to participate in international efforts. training (pre- and in-service) on AMR is outlined
Several European nations, including Germany, in the NAP. Training is also provided in India,
Italy, and France, have surveillance efforts that including for veterinary-related professions,
emphasize laboratory networks, reference where AMR is formally incorporated into
libraries, and integration within NAPs. pre-service training and relevant human
health groups handle in-service or continuing
Despite these initiatives, several countries
professional development nationwide.
are struggling with lower quality surveillance
programs. Research for this Index found that Further, there needs to be a larger commitment
the surveillance programs in Brazil, India, and by governments to ensure that the future
South Korea were fundamentally less robust, generations of HCPs are able to actively
despite initial efforts. In many cases, this is contribute to reducing antimicrobial overuse
due to lack of program oversight and a simple and misuse, enabling stewardship from a
inability to access the laboratory facilities and bottom-up approach. IDSA has developed
reference libraries necessary to administer a a curriculum for medical students on
complex surveillance system. Further, China’s antimicrobial stewardship and began offering
unwillingness to participate in the WHO’s GLASS it to all medical students free of charge in April
demonstrates a lack of commitment to high- 2020. To date, over 200 medical students have
quality international surveillance efforts. participated. This curriculum allows medical
students to model stewardship best practices
In many countries, data collected in monitoring
in inpatient and outpatients settings, speak
systems are inadequate and do not drive
with patients and clinicians about appropriate
decision making
antibiotic use, and utilize behavioral psychology
While many countries are developing,
techniques to talk with other prescribes to help
maintaining, and growing surveillance and
effect change in antimicrobial prescribing.
monitoring systems, the data being collected
are not being optimized. Experts mentioned Despite ongoing challenges, many
that collected data were not necessarily used governments and NGOs have successfully
to respond to spikes in resistance nor to inform implemented awareness campaigns
decisions about how and where to allocate Recognizing the critical role of public
and deploy resources. Additionally, GLASS and awareness in the fight against AMR, many
national systems should leverage the collective governments and NGOs have implemented
data from industry to bolster existing databases. campaigns to reduce overuse and misuse.
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