What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan
What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan
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DOI：
10.1093/heapol/czaa065
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发表时间：
2020-10-01
影响因子：
3.2
通讯作者：
Hanefeld, Johanna
中科院分区：
文献类型：
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作者：
Khan, Mishal S.;Durrance-Bagale, Anna;Hanefeld, Johanna
尽管各国在解决抗生素耐药性（AMR）方面做出了政治承诺，但在实施减少抗生素不当使用的政策方面仍面临挑战。在低收入和中等收入国家成功执行政策的关键因素，如执行能力、有影响力的利益攸关方的支持和财政利益，没有得到充分考虑。以巴基斯坦作为代表一个抗生素使用率极高的人口大国的案例研究，我们确定了195名通过滚雪球过程影响人类和动物抗生素使用政策的行为者，并采访了其中48名被提名为最有影响力的人。我们使用了一种新颖的基于纸牌游戏的方法来调查政策参与者对实施不同监管方法的支持，这些方法涉及一线医疗服务提供者和抗生素生产商在同一健康范围内的行动。我们发现，只有广泛支持对权力很小的抗生素供应商（如不合格/非正式的医疗保健提供者和动物饲料生产商）实施硬性规定（禁止某些行为），但不针对更强大的群体，如医生，农民和制药公司。政策参与者在制定实施计划以解决动物中抗生素的不当使用方面的知识有限，尽管这被认为是AMR的关键驱动因素。我们的研究结果表明，当地的政治和经济动态可能是更突出的政策参与者影响AMR国家行动计划的实施比解决方案，在全球指导方针，依赖于实施硬性规定。这突出表明，AMR行动计划与执行的当地环境之间存在脱节。因此，如果应对抗生素耐药性的全球战略要成为LMIC可实施的政策，它们将需要更多地了解与许多拟议战略相关的权力动态和系统性限制。
Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low-and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.