National Action Plans (NAPs) to mitigate AMR: The good, the bad, and the ugly

In 2015, the World Health Organization (WHO) published its Global Action Plan (GAP) on Antimicrobial Resistance (see here) under instruction from the World Health Assembly. This was in response to the increasing urgency to mitigate the global rise in antibiotic-resistant bacterial infections.

Antibiotic resistance falls under the broader umbrella of antimicrobial resistance (AMR).

In essence, the GAP set out five strategic objectives, which can be simplified down to:

1. Increasing awareness and education of AMR;
2. Increasing surveillance (testing of bacteria that cause infection to understand changes in how well antibiotics will work against them);
3. Measures to prevent infections occurring in the first place and hence reduce the need for an antibiotic. Common measures include vaccination, access to clean water and safe sanitation (WASH), and taking actions in hospitals to stop the spread of bacteria from patient to patient, especially by increasing infection prevention measures such as washing hands;
4. Optimising the use of antibiotics (stopping the use of antibiotics deemed unnecessary in the first place and optimising the use of antibiotics when they are actually needed so that patient outcomes are better); and lastly,
5. To develop an economic argument for, and thus stimulate, research and development of new antibiotics, diagnostic tests and vaccines.

The GAP became the blueprint for countries to develop their own national action plan (NAP) on AMR, and as of 2024 according to WHO, 178 countries have a NAP (find yours here). That constitutes the ‘good’ i.e., there is a framework from which to build a response to the increase in antibiotic-resistant bacterial infections. Early iterations of NAPs focused only on human health issues, yet in recent years, the move towards understanding AMR in the context of ‘One Health’, an approach that connects the relatedness of human, animal, and environmental experiences, has been reflected in newer iterations of 170 NAPs. This too can be seen as good thing.

Sadly, there is also the ‘bad’, chief amongst which is that of those 178 countries only 11% (19/178) have provided funding to carry out the required actions. Failing to make provision for funding a NAP means that putting interventions into place rarely gets done and any outputs rely only on the goodwill of individuals who usually have other jobs or competing priorities. Having no or extremely limited funds (in South Africa, even the meetings of the Ministerial Advisory Committee relied on aid from international organisations) also means that one really has to think about which interventions will provide the major return on investment or ‘bang for buck’.

Which brings us to the 2^nd bad issue about NAPs. A country that tries to act on all strategic objectives of the GAP blueprint fails to prioritise the interventions that will make the most difference locally in their country. For example, the greatest factor that will mitigate AMR in low- and middle-income countries (LMICs), who bear the brunt of the world’s infectious diseases, is to reduce that burden of infection through primary prevention measures such as enabling access to WASH, vaccination programs and other primary health measures.

Additionally, LMICs often lack access to cheap, everyday antibiotics to treat common infections that rich nations take for granted. LMICs’ need for new, often unaffordable antibiotics to treat the most resistant bacteria in intensive care units is practically zero. Yet that is the need for high-income, rich nations that have gone through industrialisation, economic growth etc., and have been able to reduce their burden of infection by providing all the amenities they now take for granted. 

So, bottom line is that countries commonly fail to prioritise where their limited (or non-existent) funds should go and thus, which strategic objectives are the most important. Rather, they try to do everything to be seen as being compliant and keeping up with higher-income countries.

Finally, with the good and the bad, comes the ‘ugly’. To me, the ugliest aspect of NAPs reflect many governments’ attitude to the AMR public health crisis that is estimated to kill 39 million people in the next 25 years. The lack of funded NAPs points to political interest rather than political will. Government leaders attend Ministerial summits, the United Nations General Assembly High-Level meetings on AMR, World Health Assemblies, and World Health Summits, showing ‘interest’ but not political will i.e., they do not have the intention to ACT nor the capacity to implement solutions rather than just engagement and awareness.

When there is political interest and not political will, NAPs aren’t worth the paper they are written on.