together4AMR#4 Leading the Charge: Promoting Collaborative Approaches to AMR Across All Levels

The podcast series interviewed global health leaders about leadership roles in combating communicable diseases and antimicrobial resistance (AMR). Good governance and visionary leadership are essential for effective AMR plans. Collaboration with disease-specific programs is important, and involving the Director of Program Management or Director General for Health Services can help ensure strategic vision and collaboration. Monitoring progress and celebrating success are key. The World Health Organization (WHO) advocates for optimal use of antimicrobials and supports countries in strengthening antimicrobial stewardship. WHO also promotes integration of responses to HIV, STI, and hepatitis and provides leadership, technical assistance, and funding advocacy. Innovations in service delivery and engagement with civil society are needed. Openness, coordination, and collaboration between programs are crucial, and AMR should be integrated into existing health programs. A common governance fram My name is Anwar Parvez Syed and I welcome you to this series of podcasts together for AMR. In this podcast series, we interviewed five global health leaders who have dedicated their professional careers to combating communicable diseases and antimicrobial resistance. Although they are affiliated with esteemed organizations such as WHO, CDC and World Bank, the views they share in these interviews are personal and based on their extensive work experiences and they do not reflect the official positions of their organizations. This is the fourth episode of this series and in this episode, we asked our panel members what leadership roles could promote the collaborative approach to the AMR agenda at global, regional, national and local levels. And here is what they said. Governance of AMR is hard and it's a new program and because a good AMR plan is a plan of plans and incorporates all these different immunization, the TB plan, the medicine, as well as all the other sectors, one really does need to have very good governance and very strong visionary leadership. At a minimum, I think it's important that where there is a functioning National Action Plan, AMR Coordination Committee, then TB, HIV or malaria, you know, whichever is appropriate, those strong disease-specific programs should be involved in it. And this is one of the things where there's a big push towards having, talking about antimicrobial resistance rather than antibiotic resistance, because there are substantial benefits in getting the disease-specific programs involved in that coordination. But I think to make it work, there does need to be somebody, and it's probably somebody like the Director of Program Management, the Director General for Health Services or something who understands the importance of collaboration and how this fits and has that sort of strategic vision. Obviously, it's the Director of Communicable Diseases, but very often the AMR is dealt with by other teams. But anyway, somebody has to have the strategic vision and understand the need for collaboration and also the scope of where it's going to work. And then you need to have quite good management skills, because it's very easy to have a high-level vision, but then you need to have clear first steps as to what needs to happen with sort of practical, measurable, monitorable processes to take it forward. And then you need to monitor that and celebrate success. So you have to have those sorts of management skills, but also very good people skills to convince and inspire and motivate people to actually do this, to step outside their comfort zone, to work in a slightly different and more collaborative way. People who are good at this can make it fun and interesting and stimulating, but it's a really important art to have for that. When we talk of leadership role, it can be at the global level, regional level, government level, even at the district level. When we talk of global level, WHO is now strongly advocating for prescribers and users to assure optimal utilization of antimicrobial. It has been extending continuous support to the countries and regional offices in strengthening the antimicrobial stewardship, which encompasses interventions which are designed to promote optimal use of antibiotics. WHO is focusing on countries always to update their national essential list of medicines and incorporate the strategy which is called as access, watch and reserve classification for antimicrobials. This is a classification which has been advocated by WHO and the countries have been requested to adopt these classifications, but very few countries have adopted these categorization in the national essential medicine list. I am pretty sure that this will be an area which will be very essential so that we can really look which antibiotic we have to keep in access, easy access, watch and which antibiotics need to be kept in the reserve and these are not utilized without proper culture, sensitivity and other indications. Now, WHO has been also supporting that regional action plan, your national action plan and monitoring of these action plan is also important. It is not only that the action plans are developed, but they are monitored and there are clear monitoring indicators. In last two years, since 2021, integration of our response in terms of HIV, STI, hepatitis, there has been a lot of work done by CRO and CRO was the first which developed an integrated regional action plan for next four years, 2022 to 2026. And there were some actions for the countries to be taken, but there were some actions for WHO to be taken. How will WHO support the implementation of integration? So, at the regional and country level, WHO will support the integration by providing leadership, by driving awareness, by boosting the effectiveness, by maintaining the norms and standards. WHO will also provide direct technical assistance and support countries in their efforts to measure progress towards the ultimate integration and coordination. Under this integrated plan, WHO will also provide regional leadership across the three diseases, work with member states, continuously advocate for adequate and sustained funding and also on the awareness, development of norms and standards that is the key role of WHO as technical agency and also bringing in innovations. When we talk of integrations, we have to think of innovations basically in service delivery, new digital technologies, rapid diagnostic tests for testing of antimicrobial resistance, innovations in treatment, new formulations, newer antibiotics, focus on newer antibiotics. Along with that, we also need to engage with civil society and communities. That area is one area which is lacking in AMR, but there has been a focus in HIV and how do we engage civil society, community because awareness is a very important factor. Most people in villages still say, I will be happy only if I get an injection. Otherwise, they will not be happy with the treatment of the doctor. So, we have to continuously work on these areas and of course, monitor the progress. That is one thing which can be done at the global level. And of course, the regional level will be the same that how the regional offices adopt the global guidelines because global guidelines are too wide and their adaptability to the region is important to the regional office of WHO. And then regional office supports the country offices of WHO to have national plans which focus on AMR strategies or they come to national health plans. Whenever the five-year plan is developed, the WHO country office engages with the government to develop the national health plan, five-year plan and that AMR needs to come into the focus. And we also need to really look into what are the community specific needs. I think the most important thing is openness and being open and being inclusive. This is applicable globally, regionally, country level and even in the institutional level where these activities actually happen. So, you have to have an open mind to really look into the programs, what other programs are doing. This is always a leadership challenge. People work in their silos. At the leadership level, people have to really sit together, understand each other's programs, identify opportunities for mutual benefit. So, wherever it happens, we see success. When that doesn't happen, when the leadership is having a tunnel vision and they're not collaborative and open, we have problems. So, I think the most important thing is to be open in communication and coordinating and sitting together with various programs around a table and identifying what are the potential areas where the programs can collaborate. And then that will lead to identifying synergies and then probably lead to bringing or developing proposals which can benefit mutually and which also will be appreciated by funding agencies. AMR is really a cross-cutting theme. AMR cannot be a vertical. AMR has to be an integral component of several of our existing programs and then closely linked with healthcare workforce and primary healthcare approach. So, I think that AMR is like a classic scenario where you can have a lot of horizontal integration between programs and link to overall health system strengthening. At the global level, institutions which lead these programs, they have to also realize this. Ultimately, organizations are led by individuals at the highest level. When people in the leadership position show that magnanimous openness to come together and sit together and discuss, we will see big changes. That's like a moment that has to happen. And we have seen that happening and we see some very good examples in several countries and several regions. I think that cultural shift of moving from my program, my budget, my interest to a mutually beneficial collaborative environment of working, I think that's something which our future leaders have to learn and our academic institutions have a lot to contribute to this in terms of developing those capacities and those attitudes. We need a common governance framework for sure. There are some approaches which I think, you know, again, they are in early phase. For example, the One Health approach that many countries are trying to do. One Health primarily is between health and non-health sectors. But once we start doing that, we realize that there's still a lot of things to do within the health sector. There has been a point where within the health sector there was a realization to be more collaborative before we actually collaborate with non-health sectors. Having a highest level political ownership for this collaboration is important. Now once we have that at the highest level, then it is about translating them into programs and monitoring. So wherever there has been at a global and national level a strong interest for bringing them together, there has been success. We cannot be absolutely successful at all levels, but there will be difficulties when we go down to the lowest level of implementation. There will be a lot of ways to modify the behavior at the lower level if we have some higher level ownership for such collaborative work. So the most important thing is the government at the national level, at the Ministry of Health level, to have a common system to bring these different programs together at some time, time at a regular interval and identify synergies and opportunities. Which require a bit of out-of-box thinking and identifying incentives. Incentives can take different forms, but identifying those incentives can encourage people to come together and sit down. There was always this, when we talk about HIV and TB, which is a very classic case, there was a strong incentive for both programs to come together. It was clearly linked to the outcome for patients in both of the programs, which is very much linked to the overall outcomes of the individual program. Identifying that if my vaccination program improves, my AMR burden will come down and also realizing that vaccination is an important component for AMR. This actually should help us to allocate for vaccination programs. So that's really coming out with advocacy based on the incentives that can be generated. That's a critical thing that should happen at the highest level, which can then slowly come down to the lower levels of healthcare delivery system. At the global level, a lot of things are happening. So now there is going to be a UNGA meeting where AMR is going to be a top priority. So from the United Nations level, from the WHO level, so multiple NGOs, they can push multiple international agencies, international NGOs. They are really doing a good job, but still more efforts are needed. At the global level, more push is needed so that there is more pull for adapting those policies and adapting those strategies. At the national level, the Ministry of Health, for going into having a governance structure, first identify who are all the key stakeholders, map the stakeholders and have a clear cut responsibilities. Have a very clear governance structure for implementing the program and also for monitoring and evaluating the program to ensure each stakeholder who has been assigned a particular task, they are implementing that. If you do not have a governance structure and if you do not know what stakeholder is capable of doing what and if you do not have a clear cut mapping of stakeholders, then you will end up in doing many things, but ultimately you will end up in doing nothing. So that is what happens in many of the countries. There is no clear cut directive because there is no governance system. In many of the countries, it is very difficult. Who will lead this? If you want to have an integrated approach, whether TV program will lead or HAV will lead or AMR division will lead, is there an AMR division? So again, there is a lot of complexities here. So mapping the stakeholders, identifying their best capabilities and having a governance structure at the national level would be really needed. So you should have not only the national level, but also sub-national level. You may have to create a good governance structure. Another thing is at local level, the health facilities, you may have to identify champions for AMRs, champions for infection prevention control and you have to use these champions as brand ambassadors for educating and providing trainings and sharing the best practices and things like that. There should be adequate forums to disseminate the information. From the communities, you have to raise awareness and maybe you can target schools and colleges and all those things. The information easily gets disseminated and HAV and TV has really given us a lot of lessons. Educating communities and reaching to the villages to disseminate the messages about AMR, that is very important. And there should be periodic assessment to understand what is the knowledge, attitude and practice. Why people still want to have antibiotics like without prescriptions and how the pattern of resistant profile in the community. This type of data is not readily available in many of the Inlam ITs. We have a lot of information from the hospitals, but we don't have much information about the community. So again, educating community leaders is also important and also generating data from the community level to inform policies and guidelines, that is also equally important. From HAV and TV, there are a lot of champions. Those things, you can use it for this integrated synergistic approach. It is NDBs, UN, WHO all displaying a major role in terms of getting various countries and ministries together and trying to set up a collaborative approach for addressing AMR. And many of the recent pandemic related funding and also One Health related approach where we keep calling that AMR is a put in the door for One Health. There is an effort to move towards that and with the quarter apartheid agencies coming together to guide the planet. There is global leadership which is emerging and I think that is actually going in the right direction and with the NAP AMR 2.0 coming up and things like that, things are moving towards that. At the national level, one of the key things that I am seeing that is we are talking about One Health and we keep saying AMR is put in the door for One Health. But in this whole conversation, AMR is missing. When you look at One Health and One Health approach, One Health committees, you have all these various sectors involved and sector leaders involved even at the national and global level. But at the national level, we are seeing there is movement on the One Health, especially some of the zoonotic diseases and pandemic type of work. But focused AMR work is something which is missing from this collaborative groups at the national level. And because that is missing, it is not circulating down to the local or the regional levels or the state level. And AMR, unfortunately, has become the baby of health department. But we do know that there is a lot of antimicrobial use in the livestock, there is a lot of thing in aquaculture, there is a lot of other things which come into the picture. But somehow, some of those things are still not taking up the main stage. It is more, I think we will have to push a bit more on the overall One Health approach and probably have a very streamlined sidetrack for AMR in the overall discourse. Everybody knows AMR is a problem. But nobody understands it well, especially at the leadership level in terms of how to tackle it. And even if somebody understands, the sheer number of departments that needs to be involved or ministries that needs to be involved for making some meaningful impact actually becomes an administrative nightmare. And I'm saying this based on the experience that I've had in the recent past and also the previous work that I was doing. You need a champion. And many times the champion actually tries to push a lot, but coordination and collaboration and also reciprocation. So health department provides funding, but animal husbandry or environment department doesn't have any dedicated funding for AMR. And they say that, okay, whatever is there, we'll do with that. But I think it is mostly a problem of the human health. So health department should make sure that they work a lot on this. And it's good that they are trying to sort of put some money on that. So I think it's more in terms of, again, carving out specific TORs. I think that is something which has been seriously missing in terms of what each department or each ministry will have to look at at the national or sub-national level and define their responsibilities and make them accountable for that. I think that's what is really missing at this point in time. This is the end of episode four. So stay tuned for the next episode in which we will ask our panel about the essential leadership competencies for sustaining progress in AMR management. Stay tuned.