Measuring the global response to antimicrobial resistance, 2020-21: a systematic governance analysis of 114 countries.

BACKGROUND: Understanding strategic commitments and policy responses to overcome antimicrobial resistance at the national, regional, and global levels is required to evaluate current progress and direct future planning. National action plans (NAPs) are the primary mechanism for guiding national strategy and action for antimicrobial resistance governance. Although several NAPs have been developed, no comprehensive content analysis of these plans exists. Using a governance framework, we aimed to assess all publicly available NAPs on antimicrobial resistance. METHODS: We systematically reviewed the contents of NAPs on antimicrobial resistance from 114 countries, applying a governance framework containing 18 domains and 54 indicators in three integral areas: policy design, implementation tools, and monitoring and evaluation. As well as manually searching NAPs and doing online and literature searches that were relevant to specific indicators from repository inception to June 1, 2022, several data sources were used to generate scores, including the Tripartite Antimicrobial Resistance Country Self-Assessment Survey, the Global Antimicrobial Resistance and Use Surveillance System, the Global Antimicrobial Resistance Research and Development Hub, and various WHO datasets. NAPs were included if the country had also submitted the NAP to the Tripartite Antimicrobial Resistance Country Self-Assessment Survey 2020-21, if the NAP was retrievable through a publicly accessible database or website, and if the NAP was either published in English or eligible for machine translation. Three researchers independently reviewed each NAP and were initially blinded to the evaluations of other researchers. They generated a score using a quantification system for each of 54 indicators. The Cochrane protocol for ensuring reliability was followed. The three researchers were then unblinded and met to resolve any disagreements in scoring to reach a consensus agreement. In each case of discrepancy, consensus was reached between the researchers. We developed criteria to standardise the process of quantifying each indicator. We also weighted and collated relevant national data from various sources to generate composite scores concordant with the key governance areas. We transformed these data to a scale of 0 (worst) to 100 (best), ranked countries on the basis of their mean scores, and used descriptive statistics to analyse global and regional trends. FINDINGS: 306 NAPs were identified and 114 were eligible for analysis. Between 2020 and 2021, the mean antimicrobial resistance governance score was 51 (SD 14). Norway had the highest governance score (mean 85 [SD 32]), and the Federated States of Micronesia had the lowest governance score (28 [37]). The highest scoring domain was participation (83 [16]), and the lowest scoring domains were accountability (30 [18]) and feedback mechanism (30 [25]). Domains relating to policy design (55 [13]) and implementation tools (54 [17]) scored similarly, whereas monitoring and evaluation (38 [20]) efforts were lower. INTERPRETATION: International efforts to control antimicrobial resistance varied considerably between countries. Monitoring and evaluation efforts need improving for continuous understanding of national and international progress. International response might not be commensurate with the scale and severity of antimicrobial resistance. FUNDING: None.

Community-based asthma assessment in young children: adaptations for a multicentre longitudinal study in South Asia.

Background: Systematic assessment of childhood asthma is challenging in low- and middle-income country (LMIC) settings due to the lack of standardised and validated methodologies. We describe the contextual challenges and adaptation strategies in the implementation of a community-based asthma assessment in four resource-constrained settings in Bangladesh, India, and Pakistan. Method: We followed a group of children of age 6-8 years for 12 months to record their respiratory health outcomes. The study participants were enrolled at four study sites of the 'Aetiology of Neonatal Infection in South Asia (ANISA)' study. We standardised the research methods for the sites, trained field staff for uniform data collection and provided a 'Child Card' to the caregiver to record the illness history of the participants. We visited the children on three different occasions to collect data on respiratory-related illnesses. The lung function of the children was assessed in the outreach clinics using portable spirometers before and after 6-minute exercise, and capillary blood was examined under light microscopes to determine eosinophil levels. Results: We enrolled 1512 children, 95.5% (1476/1512) of them completed the follow-up, and 81.5% (1232/1512) participants attended the lung function assessment tests. Pre- and post-exercise spirometry was performed successfully in 88.6% (1091/1232) and 85.7% (1056/1232) of children who attempted these tests. Limited access to health care services, shortage of skilled human resources, and cultural diversity were the main challenges in adopting uniform procedures across all sites. Designing the study implementation plan based on the local contexts and providing extensive training of the healthcare workers helped us to overcome these challenges. Conclusion: This study can be seen as a large-scale feasibility assessment of applying spirometry and exercise challenge tests in community settings of LMICs and provides confidence to build capacity to evaluate children's respiratory outcomes in future translational research studies.

Introducing pulse oximetry in routine IMCI services in Bangladesh: A context-driven approach to influence policy and programme through stakeholder engagement.

Background: Pneumonia is the leading cause of under-five child deaths globally and in Bangladesh. Hypoxaemia or low (<90%) oxygen concentration in the arterial blood is one of the strongest predictors of child mortality from pneumonia and other acute respiratory infections. Since 2014, the World Health Organization recommends using pulse oximetry devices in Integrated Management of Childhood Illness (IMCI) services (outpatient child health services), but it was not routinely used in most health facilities in Bangladesh until 2018. This paper describes the stakeholder engagement process embedded in an implementation research study to influence national policy and programmes to introduce pulse oximetry in routine IMCI services in Bangladesh. Methods: Based on literature review and expert consultations, we developed a conceptual framework, which guided the planning and implementation of a 4-step stakeholder engagement process. Desk review, key informant interviews, consultative workshops and onsite demonstration were the key methods to involve and engage a wide range of stakeholders. In the first step, a comprehensive desk review and key informant interviews were conducted to identify stakeholder organisations and scored them based on their power and interest levels regarding IMCI implementation in Bangladesh. In the second step, two national level, two district level and five sub-district level sensitisation workshops were organised to orient all stakeholder organisations having high power or high interest regarding the importance of using pulse oximetry for pneumonia assessment and classification. In the third step, national and district level high power-high interest stakeholder organisations were involved in developing a joint action plan for introducing pulse oximetry in routine IMCI services. In the fourth step, led by a formal working group under the leadership of the Ministry of Health, we updated the national IMCI implementation package, including all guidelines, training manuals, services registers and referral forms in English and Bangla. Subsequently, we demonstrated its use in real-life settings involving various levels of (national, district and sub-district) stakeholders and worked alongside the government leaders towards carefully resuming activities despite the COVID-19 pandemic. Results: Our engagement process contributed to the national decision to introduce pulse oximetry in routine child health services and update the national IMCI implementation package demonstrating country ownership, government leadership and multi-partner involvement, which are steppingstones towards scalability and sustainability. However, our experience clearly delineates that stakeholder engagement is a context-driven, time-consuming, resource-intensive, iterative, mercurial process that demands meticulous planning, prioritisation, inclusiveness, and adaptability. It is also influenced by the expertise, experience and positionality of the facilitating organization. Conclusions: Our experience has demonstrated the value and potential of the approach that we adopted for stakeholder engagement. However, the approach needs to be conceptualised coupled with the allocation of adequate resources and time commitment to implement it effectively.

Interrogating the World Bank's role in global health knowledge production, governance, and finance.

BACKGROUND: In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping 'global health' in the current era? MAIN BODY: As a group of historians, social scientists, and public health officials with experience studying the effects of the institution's investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank's position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank's influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. CONCLUSIONS: As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank's financial and technical investments in the Global South.

Hindsight is 2020? Lessons in global health governance one year into the pandemic.

Fourteen months into the SARS-CoV-2 pandemic, we identify key lessons in the global and national responses to the pandemic. The World Health Organization has played a pivotal technical, normative and coordinating role, but has been constrained by its lack of authority over sovereign member states. Many governments also mistakenly attempted to manage COVID-19 like influenza, resulting in repeated lockdowns, high excess morbidity and mortality, and poor economic recovery. Despite the incredible speed of the development and approval of effective and safe vaccines, the emergence of new SARS-CoV-2 variants means that all countries will have to rely on a globally coordinated public health effort for several years to defeat this pandemic.