How do policymaker perceptions of antimicrobial resistance drive behaviour and policies for appropriate antimicrobial use? A case study of Pakistan

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The research proposed here is for a pump prime award to determine how policymakers' perceptions of Antimicrobial Resistance (AMR) drive their behaviour and selection of policy options aimed at appropriate use of antimicrobials, focusing on one lower middle income country: Pakistan. Applying qualitative methods and engaging a multidisciplinary team with human and animal health expertise, it will map policy actors and their networks, drawing on the Social Construction Framework, to identify how motivation, social constructions, power relations and contextual factors shape policy maker behaviour. Research findings will be essential to achieving the ESRC's underlying objective to identify the specific economic factors, cultural norms, experiences and practices relating to antibiotics that enable the best strategies for action, by providing concrete knowledge and tools for working with policymakers in low- and middle-income countries (LMICs) as they adapt and adopt national policies for appropriate use of antimicrobials. Key questions this research will address include: a. Who are the key policy actors to engage for effective implementation of interventions and policies concerning appropriate antimicrobial use? How are these actors currently, and potentially, connected?b. How are the selected policy options socially constructed and how do social constructions reinforce or weaken support or opposition for the selected policies?c. What other motivations, power relations and contextual factors drive the selection of specific policies?d. How do these differ among different groups of policymakers identified under objective 1 (e.g. animal health versus human health or political affiliation)?e. Based on analysis of the questions above, how do policies for appropriate use need to be presented and framed to ensure that essential groups of policy actors engage with and respond to these effectively? This project focuses on the drivers of policy actor behaviour in one high risk AMR country in South Asia - Pakistan. With a population of 185 million, it is possibly the largest country without a national policy or guideline on AMR (Horton 2013). A key consideration for appropriate use interventions is care provision through the for-profit and informal health sector. This issue is particularly critical in South Asia where 80% of patients seek care within the poorly regulated private or informal sector (Private Sector for Health, 2016), and Pakistan provides an ideal case study to investigate this as 78% of the population pay out-of-pocket and the private sector provides 75% of health services (Nishtar 2013). The project will then follow a step wise approach to triangulate findings at national level, at regional level in South Asia and with global policymakers. Research outputs include guides for policymakers working on AMR, a research methodology, as well as scientific outputs and papers.Research will be begin by comprehensively mapping the range of policy actors involved in policy processes relating to appropriate use of AMs, across the One Health spectrum including private and public sector actors. Using the list of policy actors generated by the mapping exercise, we will purposively select policy actors for in-depth interviews (IDI). As part of the IDI process, actors will be asked questions to explore their perceptions about AMR and AM use and to then rank the five policy options while talking through their rationale using a 'thinking aloud' methodological approach. Research will be conducted by an interdisciplinary team of social and animal scientists from the London School of Hygiene and Tropical Medicine, the Aga Khan University in Pakistan, the National University of Singapore and the Royal Veterinary College in London. Research will in addition benefit from advice and oversight of an academic and an impact advisory panel to ensure maximum impact on policy and future research on AMR.