Abstract

Background

Over the last threeyears, antimicrobial resistance (AMR) has attracted unprecedented attention at the highest political levels, as evidenced by the 2015G7 meetings in Germany and Japan, several country-level initiatives,¹ resolutions and policy instruments produced by international organisations such as WHO, the Organization for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO)^2–4 and the September 2016 United Nations high-level meeting on AMR.⁵ This attention reflects the progression of the problem as rising AMR is ubiquitous, concerns virtually all pathogens relevant to human health and, in certain cases, is reaching levels where few options, if any, are left to treat infected patients. While AMR has been studied and addressed technically for decades, this attention also indicates that AMR has transformed into a global governance priority, which requires international cooperation. The global response to AMR also rests on collaboration between sectors including human and animal health, the environment, trade, intellectual property and innovation. Achieving collaborative action across sectors that have traditionally fallen within separate policy spheres is a difficult challenge. This challenge is even harder as the rise of AMR on the global health agenda means that typical political variables such as interests, power and narratives have become prominent components of the policy process. Today a growing number of actors are voicing their concern about the issue including national governments, international organisations, public–private partnerships, think tanks, academia, the pharmaceutical industry and civil society.⁶ These global health actors present AMR in different ways, which imply distinct values and solutions. Within what resembles a policy cacophony, it has become difficult to identify where ideas come from and what they entail and prioritise.⁷ We seek to disentangle this complexity by identifying how global health actors frame the issue of AMR. The analysis provides a framework to understand not only the diversity of opinions and interests, but also their potential to converge or to compete in a crowded global health arena. We suggest that broader discussion of AMR within its interlinked ecological and social dimensions can improve how we deal with AMR.

Methods

In the social world, participants often have competing perspectives about the origins, importance and unfolding of phenomena. Taken together these elements form ‘policy frames’. As key elements of the policy process, they not only provide an understanding of the problem (cognitive dimension) but they are also underpinned with values and by what ought to be done (normative dimension).⁸ Policy frames can be understood in the context of the relation between knowledge, policy and power. Timely and adequate framing can attract attention at the policy and political levels.⁹ With a growing literature dedicated to policy frames in global health,^8–12 recent analysis suggests that both competition and convergence can arise from differential framing of a policy issue.¹¹ In the early phase of policy attention, competition between frames is expected, especially when they originate in different sectors.¹³ Indeed, differential framing constitutes the basis of the policy debate. However, prolonged competition can be a symptom of diverging interests or irreconcilable values, which can in turn hamper policy coherence or result in gridlock. By contrast, we suggest that innovative framing based on an interdisciplinary approach can support policymaking by internalising tensions and providing an ideational space for negotiating and addressing them.

To identify global health frames relevant to AMR, we used a deductive approach starting from frames developed in previous works in global health. Frequent framing of global health issues includes evidence-based medicine,^{14 15} securitisation of global health issues,^{10 16 17} economics and innovation,^{16 18} and development, equity and human rights.^{8 16 19} The analysis was supported by policy documents on AMR collected from global health actors (eg, governments, international organisations, non-governmental organisations (NGOs)). By policy document, we refer to non-academic papers that articulate recommendations for interventions to be implemented. A pool of documents was assembled through complementary strategies. The first was based on searching the website of key actors in dealing with AMR (a useful list of actors on AMR was compiled by ReAct).⁶ In particular, key policy documents on AMR from international organisations including WHO, OIE and FAO were collected in relation to a parallel ongoing research project on the global governance of AMR. Second, we also collected national strategies on AMR based on the information provided by the WHO website. Third, further documents were retrieved by scanning the reference lists of the documents initially identified. In total, >200 documents were assigned to relevant global health frames. In addition to finding frequent use of these frames—healthcare, security, development and innovation—we found that a new frame that we labelled ‘One Health’ was relevant to the AMR policy discourse. To structure our critical discourse analysis of the frames identified above,^{20 21} we decomposed each of them into five constituents, which we defined as worldview, origin, the main actors involved, interventions and measurements (a short description of these variables is provided in table 1). We selected these variables to not only capture how different actors conceptualise the problem (worldview) and rely on scientific enquiry (origin), but also to understand what kind of interventions and measurement they prioritise to achieve their goals. As the WHO Global Action Plan (GAP) adopted in 2015 is the main policy instrument at the global level, we provide examples of current use of these frames in this document.

Results

Discussion

Our analysis identified five dominant frames addressing AMR (summarised in table 2) across the published and unpublished literature. Given the predominantly deductive approach taken in this paper, we cannot exclude that other relevant AMR frames exist. In addition, as important parts of the policy debate take place outside of formal documents, it is possible that we missed some frames. Finally, there is some variation in how these frames are used in the literature, which our categorisation does not fully reflect. Despite these limitations, our findings have implications for both science and governance. First, based on our analysis of frames’ worldview, it appears that the five frames above have largely been influenced by the structuring of knowledge into academic disciplines.⁷² While each frame provides a coherent understanding of the problem, none is sufficiently integrative to manage alone the complexity of the scientific challenge, which spans many academic disciplines. This underlines the importance of interdisciplinary research to underpin action regarding AMR. Second, recognising where ideas come from and what they imply contributes to understanding the policy process. As a multisectoral framework that seeks to trigger and sustain a society-wide effort, the GAP refers to some extent to all frames. Our findings provide then an approach to research how countries prioritise different aspects of the GAP as they are currently developing their own national action plan. Governments themselves may use these findings to understand the origins and implications of different frames and re-evaluate their approach to AMR. Third, the results corroborate the idea that global health governance is a contested scientific and political space where different actors pursue their own goals and seek to achieve and project power.⁷³ AMR is no exception even though it was historically a highly technical and biomedical issue. The recent proliferation of actors involved in and initiatives dedicated to AMR⁶ demonstrates that, having gained traction on the global health agenda, the problem is increasingly politicised. This means that countries and other actors privilege frames and policies that further their own interest regarding both health and other agenda such as trade, security and development as illustrated by recent discussion at the World Health Assembly.⁷⁴ As AMR intersects with the governance of areas such as food production, security, trade and innovation as summarised in table 3, this can give rise to forum shopping which ‘involves actors seeking to realise their policy objectives within preferred policy arenas on the basis of an arena’s particular governing characteristics’.⁷⁵

The intersectoral nature of AMR also generates tensions between policy priorities that are interdependent. First, the security frame tends to privilege the interest of HICs to protect themselves from global health threats coming from LMICs,⁷⁶ but it is difficult to achieve security without development as both are ultimately linked. The creation of a conservation fund to help LMICs to address the problem could help to reconcile these two goals.⁷⁷ Second, the development frame, which entails access to health technologies and is typically addressed in human rights arena,⁷⁸ conflicts with the innovation frame which is governed by the World Trade Organization (WTO) and the World Intellectual Property Organization (WIPO). The strong interest of HICs to protect their pharmaceutical sectors is illustrated by their pursuit of bilateral trade agreements, often labelled ‘TRIPS+’ (in reference to the Trade-Related Agreement on Intellectual Property administered by WTO), which have more stringent protection of intellectual property than WTO rules and seek to limit the use of flexibilities for the protection of public health.⁷⁹ The option of delinking revenues from unit sales might reconcile the two sides of the problem by overcoming the dilemma between rewarding innovation and providing access.⁸⁰ Finally, innovation makes no sense without (1) containment strategies such as stewardship and infection prevention and control in healthcare and (2) strategies on the conservation of antimicrobials effectiveness across sectors through the healthcare and the more integrative One Health frames. However, tensions exist between the human and animal health sectors. While the human health sector has generally advocated a ban of the use of antimicrobials as growth promoter in animal husbandry as the EU did in 2006,⁸¹ the issue is less prominent in animal health constituencies such as OIE, as illustrated by the absence of mention of growth promotion in the 2016 ‘OIE strategy on AMR and the prudent use of antimicrobials’.³ In many countries, powerful agriculture lobbies are opposed to phasing out growth promotion as commercial interest are at stake.

Overall, these examples suggest that an understanding of the interdependencies between policy priorities and their related frames is essential to strike a balance between competing views of the problem and support decisive policy innovation in dealing with AMR. An integrative scientific framework cannot by itself reconcile conflicting values and interests but it can certainly illuminate, clarify and help to explain the intrinsic tensions in the debate, and thereby facilitate discussion and negotiation in the global health arena. In other words, the role of science is to provide the appropriate stage on which negotiation can occur. Intersectoral action is by its nature challenging but the HIV-AIDS epidemic proved that action across sectors is possible when (1) political will and public pressure are present, (2) adequate convening fora are found and (3) frames can be aligned to achieve a common understanding of the problem.¹¹ While our analysis demonstrates that each frame shed light on an important aspect of AMR, One Health already provides a converging way to conceptualise and address AMR. In order to support policies that address the problem comprehensively, what is now needed is a social-ecological framework to consider the preservation of antimicrobials’ effectiveness as a planetary health issue,⁸² where the global microbiome is seen as a non-renewable resource that is essential for both human health and the health of the planet.⁴⁰ By assessing both the social and the ecological dimensions of the problem from a complex adaptive systems perspective, such holistic ‘planetary health’ framing can not only provide an umbrella for future negotiations on the topic but also further support the international and interorganisational cooperation that has become so crucial to addressing AMR.

Footnotes

References