Leveraging universal health coverage to leave no one behind in tackling AMR

Authors: Pamela Cipriano, James Chau, Mariam Jashi, Ilona Kickbusch, Justin Koonin, Tlaleng Mofokeng, Joy Phumaphi, Magda Robalo, Akihisa Shiozaki

This article was first published in The Lancet Global Health.

Antimicrobial resistance (AMR) is a leading global health and development threat. Left unchecked, it will roll back a century of medical progress. Already an estimated 4.95 million deaths are associated with AMR every year, including 1.27 million deaths for which AMR is directly attributable.¹

The devastating effects of drug-resistant infections can affect anyone, anywhere, but those who are not protected by universal health coverage (UHC) are especially at risk of the emergence and spread of AMR.

A key reason for why this occurs is the limited availability of quality essential antimicrobials, vaccines, and diagnostics.²

In settings where people do not have access to preventive services, proper diagnosis and quality treatment, preventable and treatable diseases are more likely to spread and go undiagnosed or misdiagnosed, increasing the need for antibiotic consumption and the threat of AMR.

Another key driver of AMR is a lack of adequate infection prevention and control (IPC) and water, sanitation and hygiene (WASH) in health facilities. Data show that more than 1 billion people worldwide visit health-care facilities with inadequate or no WASH services, essential for preventing many hospital-associated infections.³

In such settings, health workers may resort to antimicrobials as a substitute for adequate IPC practices, especially when lacking training and awareness of adverse effects, further increasing AMR.^4,5

High prices of health services and poor financial protection add another layer of burden. Worldwide, 2 billion people experience financial hardship due to out-of-pocket spending on health.⁶

Unable to afford health services, patients may refrain from seeking medical diagnosis and treatment and self-medicate instead, particularly in settings where antimicrobials can be purchased without a prescription. Financial constraints paired with a lack of health literacy and poor knowledge about appropriate use of antimicrobials may lead patients to access informal sources of health care and buy falsified or substandard antimicrobials that further drive AMR—a problem which is apparent in countries of all income levels.^7,8,9

AMR-related goals and health for all by 2030 will only be achieved if the AMR response integrates with efforts to achieve UHC for everyone, everywhere. AMR can only be addressed equitably if all people have affordable access to quality health services, including for the prevention, diagnosis, and appropriate treatment of infections. As global leaders are preparing to convene at the UN General Assembly High-Level Meeting on Antimicrobial Resistance on Sept 26, 2024, we, the UHC Movement Political Panel, call on Member States to use this opportunity to leverage UHC to take a systems approach to addressing AMR, with individuals, families and communities at the centre by:

• Investing in health systems, based on a primary health care approach, that can deliver high-quality health services to people for prevention, diagnosis, and appropriate treatment of infections including drug-resistant infections

• Ensuring reliable supply of high-quality and affordable vaccines, laboratory supplies, and diagnostics and essential antimicrobials, as well as a well-trained and motivated health and care workforce working in clean and safe facilities with adequate water, sanitation, and hygiene and infection prevention and control measures

• Implementing adequate financial protection measures that enable individuals to access essential health-care services, including preventive services, timely and accurate diagnosis, and appropriate quality-assured treatment of infections including drug-resistant infections

• Supporting effective governance on AMR that promotes a strong human health sector response to AMR linked with UHC under the umbrella of multisectoral national action plans on AMR that address the interconnectedness of health issues across humans, animals, and the environment through a One Health approach, in line with the quadripartite call to action for One Health.¹⁰

The UNGA High-level Meeting on Antimicrobial Resistance will be a unique opportunity for Member States to commit to finding and implementing joint multisectoral solutions for addressing this health threat. By integrating actionable commitments on UHC into the political declaration and translating them into action at the national level, countries will be better equipped to ensure a strong AMR response that leaves no one behind.

We declare no competing interests. We thank Helena Schmitt for her support in drafting and editing this Comment.

References

1. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022; 399: 629-655

2. WHO. Antimicrobial resistance. Date accessed: July 2, 2024

3. Food and Agriculture Organization of the United Nations, World Organisation for Animal Health, WHO. Technical brief on water, sanitation, hygiene and wastewater management to prevent infections and reduce the spread of antimicrobial resistance. Date accessed: July 2, 2024

4. Denyer Willis L, Chandler C. Quick fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse. BMJ Global Health. 2019; 4e001590

5. Otaigbe II, Elikwu CJ. Drivers of inappropriate antibiotic use in low- and middle-income countries. JAC Antimicrob Resist. 2023; 5dlad062

6. WHO, World Bank Group. Tracking universal health coverage: 2023 global monitoring report. Date accessed: July 2, 2024

7. Janatolmakan M, Abdi A, Andayeshgar B, Soroush A, Khatony A. The reasons for self-medication from the perspective of Iranian nursing students: a qualitative study. Nurs Res Pract. 2022; 2022: 1-7

8. Belachew SA, Hall L, Erku DA, Selvey LA. No prescription? No problem. Drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies. BMC Public Health. 2021; 211056

9. Carney KA, Wisnieski L, Lackey T, Noah D. Prevalence and factors of self-medication with antibiotics in Claiborne County, Tennessee. J Appalachian Health. 2023; 5: 59-71

10. WHO. Quadripartite call to action for One Health for a safer world. Date accessed: July 9, 2024