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为对抗菌药产生抗药性时，就会发生抗菌素耐药性(AMR)。在卫生保健和农业中使用抗生素，特别是过度使用和误用抗生素，加速了AMR。不充分和不公平地获得卫生设施、清洁水和保健服务也加剧了这一问题。专家警告说，AMR可能会导致一个没有有效抗生素的未来。由于抗药性细菌在国际上跨境传播，维持抗菌素保护具有需要国际合作的全球公共产品的特征。为了有效地提供公共产品，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，彻底履行这些承诺，以及世界上许多国家的参与。该项目的首要研究问题是：关于AMR的哪种国际协议最有可能实现雄心壮志、彻底实施和广泛参与？该项目将通过研究三个更具体的问题来解决首要的研究问题。第一，现有的国际机构安排在促进在解决AMR问题方面取得有意义的进展方面有多有效？目前的努力以2015年世界卫生组织、粮农组织和世界动物卫生组织大会通过的《全球抗菌素耐药性行动计划》为中心，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AMR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》造成的规范性压力，特别是国家业绩指标的公布；外部资金，如英国政府的弗莱明基金；通过国际组织和其他渠道密切联系的国家通过和执行；以及跨国民间社会网络。第二，考虑到关于AMR的一系列全球协议，在专家对各国AMR政策的集体判断中，哪一项最有可能实现广泛参与、雄心勃勃的目标和彻底执行？该项目将使用一种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)该国批准一项有具体规定的新的全球反洗钱协定的可能性，以及(B)如果得到接受，该国彻底执行该协定的可能性。潜在的条款包括在规定的时间框架内实现人类和动物抗生素消费的目标；国际监测；为两个公平的抗生素创新和保护全球基金捐款的目标；确保决策透明并给予低收入和中等收入国家重大发言权的治理结构。第三，了解具有法律约束力的关于AMR的国际条约是否会影响普通民众对抗生素的需求？发现有关AMR的国际法可以帮助使普通人群对抗生素的需求与循证政策保持一致，这可能为制定一项国际条约提供理由。该项目将对六个国家的具有代表性的一般人口样本进行调查(Vignette实验)，以检查关于AMR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向医疗专业人员索要抗生素的宣布可能性。

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.