Public Consultation on UN Interagency Coordination Group Workplan
We appreciate the opportunity to share this input on the UN Interagency Coordination Group’s Work Plan. Given its charge from the UN Political Declaration on AMR, the Interagency Coordination Group serves a key role in monitoring global progress on antimicrobial resistance, ensuring cooperation across UN agencies and other stakeholders, and providing a roadmap for sustained, effective action globally on this looming challenge to public health and global development. Beyond the important work of the tripartite collaboration among WHO, FAO and OIE, there remain significant gaps and opportunities for synergy across UN agencies in tackling antimicrobial resistance. We encourage the IACG to make clear and concrete commitments that advance the objectives of the UN Political declaration on AMR and Global Action Plans. In particular, the UN Political Declaration on AMR underscores the link between AMR and the 2030 Agenda on sustainable development, the importance of ensuring access, equity and affordability of existing and new medicines, vaccines and diagnostics, and the need for models of financing of R&D that are delinked from volumes and price of life-saving medicines. In response to this public consultation, members of the Antibiotic Resistance Coalition have worked together to call attention to both issues of process and substance.
Representation of key stakeholders
Tackling antimicrobial resistance will require an inter-sectoral response. The composition of the IACG has an impressive number of government officials from Member State governments, but among UN agencies, strikingly leaves out the UN Development Programme which has a key role in supporting countries’ efforts to achieve the 2030 Sustainable Development Goals and UNESCO which coordinates international efforts in education, science, culture and communication. We would recommend that these two agencies be added to the roster of IACG members.
Transparency, accountability and conflicts of interest
Objective 5 of the IACG work plan requires “regular reporting on progress and on IACG meetings.” We encourage the IACG to embrace a strong commitment to transparency and accountability for all of its deliberations. For example, if IACG members are asked to provide input into an external consulting report as if it were an input to IACG’s deliberations, then that should be done transparently. Heartening as it is to see other groups step up to provide resources for policy convenings on AMR, it would be important not to privilege these inputs over valuable sources such as intergovernmental committees and civil society meetings on AMR.
In a manner consistent with WHO’s FENSA regulations, the IACG should disclose potential financial conflicts of interest among its members and those who provide testimony and inputs to the IACG’s work. All materials made available for policy deliberation by the members of the IACG should also be publicly posted on a website. Following the example of UN high-level panels, there should be a public component to all future meetings, including webcasting for broader participation, and the opportunity for public comment.
Engagement of civil society
Under Objective 1, the IACG work plan calls for a “Stakeholder Engagement Plan.” Indeed, the IACG can build off existing civil society networks and mechanisms, including the annual WHO-NGO Dialogue, as mechanisms to gather and provide feedback to IACG, along with calls for submissions, public expert input, and public hearings in various locations. IACG should also look for opportunities to reach out and engage those outside of New York City and hold consultations at the regional level.
Substantive Content Issues
Synergy and Gaps in need of IACG focus
The mandate for the IACG stems from the UNGA political declaration, yet the links to this declaration in the work plan should be strengthened. With very modest resources, IACG needs to integrate its mission into the work of UN agencies.
Additionally, the links to the SDGs mentioned in Objective 1.1 should be much stronger. The priority for the IACG should not only be to remain “in line with SDGs,” but also to identify the key associated actors and develop a plan to mainstream AMR into all relevant SDGs. In particular, there might be significant gains from such measures as the development and uptake of bacterial vaccines and diagnostics.
Objective 1.2 enumerates supplemental objectives to the Global Action Plan (GAP), but it is unclear how these objectives might be implemented. In “ensuring sustainable production and access to existing and future antibiotics and other antimicrobial medicines,” the UN Political Declaration on AMR calls for delinkage as a key guiding principle in ensuring equitable and affordable access to new products. As part of objective 1.2, the IACG should include that it will provide a clear definition and practical guidance for delinkage approaches for R&D in medical products aligned with the principles of equity, affordability and access for human health. In addition, the IACG should support the WHO, FAO and OIE to complete the normative work on the WHO Stewardship and Development Framework as called for by the UN Political Declaration. The IACG should also support policies that ensure sustainable production and access to vaccines and diagnostics in addition to antibiotics.
In “ensuring sustainable and safe food production as part of responsible use,” the IACG might go further than the GAP, which addresses only the need to ban the use of antibiotics as growth promoters. Unless routine prophylaxis is also phased out, the IACG will not have effectively achieved this objective. The IACG should commit to work towards a ban of non-therapeutic use of antibiotics in food animal production that includes growth promotion, prophylaxis, and routine metaphylaxis. The WHO has also highlighted the importance of certain antibiotics as critically important to human medicine, and the IACG should recommend countries implement legal restrictions on the use of critically important antibiotics in sectors outside of healthcare. Finally, the IACG should work with UN agencies and other stakeholders to call for greater investment and transition efforts to more sustainable animal husbandry, agricultural, and aquaculture practices that require a less intensive use of antibiotics while protecting animal health and welfare. The “greater focus on the management of waste that might contain antimicrobial residues or resistant microbes” must not only address the wastewater discharge of pharmaceutical manufacturing plants, but importantly the antibiotic pollution throughout the value chain, from hospital discharge as point sources of such pollution to agricultural run-off from the mass administration of antibiotics in food animal production.
Closing the gaps through stakeholder engagement
In the mapping exercise of Objective 2, the IACG should invite participation by UN agencies and other stakeholders to discuss what they are and are not currently doing. Specifically, the IACG should ask the UN Deputy SG to require all relevant UN agencies submit a report on what they are doing and their possible future role. In its effort to improve collaboration, the work plan should also provide recommendations on improving the coordination between actors. In doing so, the IACG should make specific calls for action by the UN and other agencies. For example, UNICEF could use its procurement facility as well as its country-level operations to support antimicrobial stewardship and improve access to vaccines important to the AMR response, especially for middle-income countries that are paying some of the higher prices for important vaccines in the AMR response. The World Customs Union could make transparent trade data such that antibiotics destined for animal use is distinguishable from that destined for human use. UNDP and UNESCO should also be included in these efforts. We also urge the IACG to expand their stakeholder engagement to include regional development banks and agencies (e.g., ASEAN, BRICS, UNESCAP) that may not deal directly with health, but which work on broader development issues in a range of low and middle income countries. Creating a roadmap and vison based on the declaration and on the input of multiple stakeholders will be critical. This roadmap must then be analyzed with respect to the identified barriers and gaps, and lead to needed stakeholder coordination and action.
Need for mobilizing financing and technical assistance for NAP implementation
The UN Political Declaration on AMR refers to the need for financial and technical cooperation and support. Yet neither the WHO GAP nor the IACG work plan suggest concrete measures to turn this goal into reality. In Objective 1.4, the IACG seeks partners to fill the gaps, strengthen existing systems and share best practices, but they should go beyond the sharing of ongoing work and also play a role in mobilizing needed resources. We urge the IACG to provide recommendations to reduce the gaps identified and improve coordination of financing mechanisms to assist countries in their NAP implementation. Consultations at the regional level will also require resources. Therefore, we believe the IACG should develop a list of options for financing of objectives beyond those currently funded (e.g., surveillance under Fleming Fund) and that are necessary for an effective response to AMR. Other areas (such as animal husbandry) are not receiving the funding needed for the transition of low and middle-income countries in their National Action Plans. Given the projected increase in antibiotic use in food animal production, the IACG should make the case that we must pay now or pay much more later.
Indicators and milestones
The regular reporting in Objective 5 is not meaningful without clear milestones and indicators. There is a need for specific targets for achievement. These may need to complement WHO, FAO and OIE indicators under development. The IACG’s supplemental set of indicators could address UN agency performance on these shared objectives. Only six countries in this last round of voluntary national reviews during the UN High-level Political Forum make mention of antimicrobial resistance in their progress toward SDG targets. IACG could ensure greater attention and integration of AMR into the SDG targets.
There is also a mismatch between the five to ten year time horizon envisioned in the Tripartite’s Monitoring & Evaluation framework and the IACG’s nearer term report back by September 2019. So the IACG will also need to complement the Tripartite M&E indicators with clear, nearer term objectives.
Along with setting more concrete objectives, the IACG needs to measure their accomplishment and hold itself accountable as well. Curbing non-therapeutic use of antibiotics for growth-promotion, prophylaxis and routine metaphylactic use as well as restricting the use of critically important antimicrobials in human medicine from food production are targets that are measurable. The spread of resistance to one of our last-line antibiotics, colistin, underscore the need for a globally coordinated response. The IACG should also examine to what extent NAPs implement guidance from WHO, FAO and OIE on use of antimicrobials in agriculture (e.g. OIE Health Codes, Codex Alimentarius Guidance, and WHO guidance on Integrated Surveillance) and take steps to improve adoption if implementation is low.
Finally, the IACG should work to make data to monitor the use, price, sales, trade and resistance to antimicrobials more publicly available. These efforts should also harmonize data collection and thereby enable cross-country comparisons. Various members of the Tripartite collaboration and members of the IACG can do their part, and the IACG, its part in ensuring collective responsibility in ensuring accountability to such transparency. The World Custom Union’s trade data on antibiotics could distinguish among veterinary, human and crop pesticide use in the UN Comtrade system. The OIE and FAO have some distance to go to make the voluntary reporting by countries more transparent. Among member states, antibiotic use data should be disaggregated by livestock type.
Maintaining and extending the political commitment to AMR
Whether the mandate of the IACG is renewed or not in 2019, the political commitment and the efforts put forth by the UN Political Declaration on AMR, the WHO GAP and the IACG Work Plan must continue. The IACG work plan should put forth mechanisms for sustainable political commitment and long-lasting global coordination to tackle antimicrobial resistance among UN agencies, Member States and other stakeholders.
Alliance to Save Our Antibiotics (Coilin Nunan)
American Medical Student Association (Daniel Gouger)
Center for Science and the Environment (Amit Khurana)
Ecumenical Pharmaceutical Network (Mirfin Mpundu)
Food Animal Concerns Trust (Steve Roach)
Health Action International Asia Pacific (Shila Kaur)
Health Care Without Harm Europe (Adela Maghear)
IFARMA Colombia (Francisco Rossi)
Natural Resources Defense Council (David Wallinga and Jonathan Kaplan)
People’s Health Movement (Amit Sengupta)
ReAct (Mirfin Mpundu – ReAct Africa Node, Sujith Chandy – ReAct Asia Pacific, Anna Zorzet – ReAct Europe, Arturo Quizhpe – ReAct Latin America, Anthony So – ReAct North America/Strategic Policy Program)
South Center (Viviana Munoz and Mirza Alas)
Sustainable Food Trust (Richard Young)
Third World Network (Yoke Ling Chee)
What Next Forum (Niclas Hallstrom)