The Global Governance of Antimicrobial Resistance: An Empirical Analysis of Participation and Effectiveness

当细菌、病毒和真菌等微生物进化成对抗菌素药物具有耐药性时，就会发生抗菌素耐药性。抗生素耐药性因在卫生保健和农业中使用，特别是过度使用和误用抗生素而加速。获得卫生设施、清洁水和保健的机会不足和不公平也加剧了这一问题。专家警告说，抗生素耐药性可能导致一个没有有效抗生素的未来。由于耐药细菌在国际上跨越国界传播，维持抗微生物药物保护具有全球公益的特点，需要国际合作。为了有效提供公共产品，国际合作安排通常需要同时满足三个条件：雄心勃勃的政策承诺、承诺的彻底落实以及世界上许多国家的参与。该项目的首要研究问题是：哪种关于抗微生物药物耐药性的国际协议最有可能实现远大目标、彻底实施和广泛参与？该项目将通过检查三个更具体的问题来解决总体研究问题。第一，现有国际机制安排在推动应对抗生素耐药性问题取得有意义进展方面的有效性如何？目前的工作围绕2015年世卫组织、粮农组织和国际兽疫局大会批准的《抗微生物药物耐药性全球行动计划》展开，并得到联合国2016年发表的《政治宣言》的支持。该项目将对2010年至2020年期间世界上大多数国家的数据应用统计方法，以估计各种因素对国家抗生素耐药性行动计划的采用和内容以及国家一级抗生素消费趋势的影响。这些因素包括《全球行动计划》，特别是国家业绩指标的出版所造成的规范压力；外部资金，如英国政府的弗莱明基金；密切联系的国家通过国际组织等渠道制定和实施；以及跨国公民社会网络。第二，鉴于一系列可想象的抗微生物药物耐药性全球协议，哪一个最有可能在各国抗微生物药物耐药性政策专家的集体判断中获得广泛参与、雄心勃勃的目标和彻底实施？该项目将使用一种被称为联合分析的统计工具，对个别国家的专家进行调查，并请他们估计(a)该国批准一项具有特定条款的新的抗微生物药物耐药性全球协议的可能性，以及(b)如果接受，该国彻底实施该协议的可能性。潜在的规定包括在规定的时间范围内达到的人类和动物抗生素消费目标；国际监测;向两个公平的抗生素创新和保护全球基金捐款的具体目标；确保决策透明并给予中低收入国家重要发言权的治理结构。第三，关于抗生素耐药性的具有法律约束力的国际条约的知识会影响普通人群对抗生素的需求吗？发现关于抗菌素耐药性的国际法可以帮助将普通人群对抗生素的需求与基于证据的政策结合起来，可以为制定一项国际条约提供理由。该项目将进行调查（小故事实验），涉及六个国家的一般人口的代表性样本，以审查关于抗微生物药物耐药性的具有法律约束力的国际承诺的信息是否会影响个人在咨询通常应以其他方式治疗的症状时要求医疗专业人员使用抗生素的声明可能性。

Antimicrobial resistance (AMR) happens when micro-organisms such as bacteria, viruses and fungi evolve to become resistant to antimicrobial medicines. AMR is accelerated by the use, and especially the overuse and misuse, of antibiotics in health care and farming. It is also exacerbated by insufficient and inequitable access to sanitation, clean water and health care. Experts warn that AMR could lead to a future without effective antibiotics. Because drug-resistant bacteria spread internationally across borders, maintaining antimicrobial protection has the features of a global public good that requires international cooperation.To provide public goods effectively, international cooperation arrangements typically need to meet three conditions simultaneously: ambitious policy commitments, thorough implementation of those commitments, and participation of many countries across the world. The overarching research question of the project is the following: Which kind of international agreement on AMR has the best chance of attaining deep ambition, thorough implementation, and wide participation? The project will address the overarching research question by examining three more specific questions. First, how effective are existing international institutional arrangements in promoting meaningful progress in tackling the AMR problem? Current efforts pivot around the "Global Action Plan on Antimicrobial Resistance" endorsed by the general assemblies of the WHO, FAO and OIE in 2015, supported by the "Political Declaration" issued in 2016 by the United Nations. The project will apply statistical methods to data on most countries in the world between 2010 and 2020 to estimate the influence of a variety of factors on the adoption and content of national AMR action plans and trends in antibiotic consumption at the country level. These factors include the normative pressure created by the Global Action Plan and specifically by the publication of country performance indicators; external funding, such as the Fleming Fund of the UK Government; the adoption and implementation by countries closely connected through international organizations and other channels; and transnational civil society networks.Second, given a range of conceivable global agreements on AMR, which one is most likely to attain wide participation, ambitious goals and thorough implementation in the collective judgement of experts of national AMR policies? Using a statistical tool known as conjoint analysis, the project will survey experts on individual countries and ask them to estimate (a) the likelihood that the country would ratify a new global agreement on AMR with specified provisions, and (b), if accepted, the likelihood that the country would implement it thoroughly. The potential provisions include targets for human and animal antibiotic consumption to be reached within a specified timeframe; international monitoring; targets for contributions to two global funds for equitable antibiotics innovation and conservation; a governance structure that ensures transparent decision-making and gives significant voice to low- and middle-income countries.Third, would knowledge of a legally binding international treaty on AMR affect demand for antibiotics among the general population? Finding that international law on AMR could help align demand for antibiotics among the general population with evidence-based policy could provide a rationale for creating an international treaty. The project will conduct surveys (vignette experiments) involving representative samples of the general population of six countries, to examine whether information about legally binding international commitments on AMR affects the declared likelihood that individuals will ask a medical professional for antibiotics if they were to consult for symptoms that normally should be treated in other ways.