Antimicrobial resistance (AMR) is a recognized threat to global public health. Increasing AMR and a dry pipeline of novel antimicrobial drugs have put AMR in the international spotlight. One strategy to combat AMR is to reduce antimicrobial drug consumption. Governments around the world have been experimenting with different policy interventions, such as regulating where antimicrobials can be sold, restricting the use of last-resort antimicrobials, funding AMR stewardship programs, and launching public awareness campaigns. To inform future action, governments should have access to synthesized data on the effectiveness of large-scale AMR interventions. This planned systematic review will (1) identify and describe previously evaluated government policy interventions to reduce human antimicrobial use and (2) estimate the effectiveness of these different strategies.
An electronic search strategy has been developed in consultation with two research librarians. Seven databases (MEDLINE, CINAHL, EMBASE, CENTRAL, PAIS Index, Web of Science, and PubMed excluding MEDLINE) will be searched, and additional studies will be identified using several gray literature search strategies. To be included, a study must (1) clearly describe the government policy and (2) use a rigorous design to quantitatively measure the impact of the policy on human antibiotic use. The intervention of interest is any policy intervention enacted by a government or government agency in any country to change human antimicrobial use. Two independent reviewers will screen for eligibility using criteria defined a priori.
Data will be extracted with Covidence software using a customized extraction form. If sufficient data exists, a meta-analysis by intervention type will be conducted as part of the effectiveness review. However, if there are too few studies or if the interventions are too heterogeneous, data will be tabulated and a narrative synthesis strategy will be used.
This evidence synthesis is intended for use by policymakers, public health practitioners, and researchers to inform future government policies aiming to address antimicrobial resistance. This review will also identify gaps in the evidence about the effectiveness of different policy interventions to inform future research priorities.
The 2013–16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.
The rapid proliferation of international institutions has been a defining feature of the postwar international architecture. Since the end of the Second World War, the international system has seen the creation of thousands of international treaties and organizations that have established rules governing a multitude of issues that range from international security to human rights, and from international trade to the environment.
The concept of an institutional bypass—that is, creating a parallel institution that performs exactly the same function of the dysfunctional institution—has already proven useful for analyzing institutional reforms undertaken at the domestic level. However, it has only recently been suggested as potentially applicable to the global governance context as well. To explore this possibility further, this project brought together a group of researchers who specialize in international governance and asked them whether the concept could be applied to their respective areas of expertise.
Among other things, these discussions revealed at least one major challenge with the use of institutional bypasses in the international context: while the possibility of “bypassing” existing institutions may be counterintuitive in the domestic sphere, it may actually constitute the norm, rather than the exception, in international governance. This is because sovereign states are often assumed to hold a monopoly in the provision of certain services and the performance of certain functions at the domestic level, as is notably the case with policing. Thus, recognizing that states can operate parallel institutions side by side, and in some cases even make them compete with each other, may constitute a paradigm shift for those concerned with institutional reforms and good governance in the domestic sphere. However, this same assumed monopoly does not exist in international governance, where academic researchers have extensively documented the related phenomena of institutional proliferation and duplication.
Accordingly, a question arises as to what value, if any, the concept of institutional bypasses can provide to the existing international governance literature. This is the first—and perhaps the main—challenge in applying the concept of institutional bypasses at the international level, especially since the phenomenon of institutional proliferation and duplication has already been extensively described and scrutinized across multiple disciplines, including law, political science, and sociology. The framing essay in this symposium attempts to provide an answer to this question by presenting a definition of international institutional bypasses, all the while articulating why this concept may prove useful to work on global governance.
Having framed the scope of our project, the other essays in this symposium provide three sets of examples that illustrate the application of international institutional bypasses. The first takes the form of the New Development Bank and the Asian Infrastructure Investment Bank, which serve as bypasses of the World Bank and the Asian Development Bank, respectively. The second set of examples are regional swap lines and regional central banks, which are presented as bypasses of the International Monetary Fund (IMF). Finally, regional institutions in West Africa, and particularly those providing health services, are framed as bypasses of domestic institutions that serve the same functions.
Taken together, these three sets of examples offer interesting illustrations of what we call “horizontal” and “vertical” international bypasses. The former refers to those bypasses that operate within the same jurisdiction as the dominant institution, as in the case of the China-led multilateral development banks that serve as international bypasses of a dominant international institution. By contrast, a vertical bypass means that the dominant institution and the bypass are located at different jurisdictional levels. This notion includes a domestic or a regional institution that tries to bypass an international one, or vice-versa. The international institution can thus be either the dominant institution being bypassed, as illustrated by the IMF essay, or the bypassing one, as illustrated by the West African Health Organization essay.
In summary, our aim in this symposium is to introduce readers to the concept of international institutional bypasses, provide concrete examples, and show that this concept can be of great value in attempts to understand and analyze changes and innovations in global governance. That being said, this is only the first step in a much larger and more ambitious project. Thus, we hope it will also serve as an invitation for readers to further explore the many interesting questions and implications of institutional bypasses in the international context
Background: Antimicrobial resistance (AMR) is a global issue. International trade, travel, agricultural practices, and environmental contamination all make it possible for resistant microbes to cross national borders. Global collective action is needed in the form of an international agreement or other mechanism that brings states together at the negotiation table and commits them to adopt or implement policies to limit the spread of resistant microorganisms. This article describes an approach to assessing whether political and stakeholder interests can align to commit to tackling AMR.
Methods: Two dimensions affecting political feasibility were selected and compared across 82 countries: 1) states’ global influence and 2) self-interest in addressing AMR. World Bank GDP ranking was used as a proxy for global influence, while human antibiotic consumption (10-year percent change) was used as a proxy for self-interest in addressing AMR. We used these data to outline a typology of four country archetypes, and discuss how these archetypes can be used to understand whether a proposed agreement may have sufficient support to be politically feasible.
Results: Four types of countries exist within our proposed typology: 1) wealthy countries who have the expertise and financial resources to push for global collective action on AMR, 2) wealthy countries who need to act on AMR, 3) countries who require external assistance to act on AMR, and 4) neutral countries who may support action where applicable. Any international agreement will require substantial support from countries of the first type to lead global action, and from countries of the second type who have large increasing antimicrobial consumption levels. A large number of barriers exist that could derail efforts towards global collective action on AMR; issues of capacity, infrastructure, regulation, and stakeholder interests will need to be addressed in coordination with other actors to achieve an agreement on AMR.
Conclusions: Achieving a global agreement on access, conservation, and innovation – the three pillars of AMR – will not be easy. However, smaller core groups of interested Initiator and Pivotal Countries could develop policy and resolve many issues. If highly influential countries take the lead, agreements could then be scaled up to achieve global action.
Keywords: AMR, Antibiotic Resistance, Global Health, Political Feasibility, International Affairs
Shortages of health workers in low-income countries are exacerbated by the international migration of health workers to more affluent countries. This problem is compounded by the active recruitment of health workers by destination countries, particularly Australia, Canada, UK and USA. The World Health Organization (WHO) adopted a voluntary Code of Practice in May 2010 to mitigate tensions between health workers’ right to migrate and the shortage of health workers in source countries. The first empirical impact evaluation of this Code was conducted 11-months after its adoption and demonstrated a lack of impact on health workforce recruitment policy and practice in the short-term. This second empirical impact evaluation was conducted 4-years post-adoption using the same methodology to determine whether there have been any changes in the perceived utility, applicability, and implementation of the Code in the medium-term.
Forty-four respondents representing government, civil society and the private sector from Australia, Canada, UK and USA completed an email-based survey evaluating their awareness of the Code, perceived impact, changes to policy or recruitment practices resulting from the Code, and the effectiveness of non-binding Codes generally. The same survey instrument from the original study was used to facilitate direct comparability of responses. Key lessons were identified through thematic analysis.
The main findings between the initial impact evaluation and the current one are unchanged. Both sets of key informants reported no significant policy or regulatory changes to health worker recruitment in their countries as a direct result of the Code due to its lack of incentives, institutional mechanisms and interest mobilizers. Participants emphasized the existence of previous bilateral and regional Codes, the WHO Code’s non-binding nature, and the primacy of competing domestic healthcare priorities in explaining this perceived lack of impact.
The Code has probably still not produced the tangible improvements in health worker flows it aspired to achieve. Several actions, including a focus on developing bilateral codes, linking the Code to topical global priorities, and reframing the Code’s purpose to emphasize health system sustainability, are proposed to improve the Code’s uptake and impact.
Health worker recruitment Migration Health systems sustainability Impact evaluation World Health Organization
In the fall of 2014, the Government of Canada formally split the role of the Chief Public Health Officer (CPHO) into two positions: the CPHO and the President of the Public Health Agency of Canada. Despite concerns raised by the public health community, these changes are consistent with the CPHO's authority. However, the nature of responsible government means that the CPHO cannot simultaneously serve as an independent advocate for policies and programs that might prevent disease and as a senior advisor to the government of the day.
À l'automne 2014, le gouvernement du Canada a annoncé le dédoublement officiel du rôle de l'Administrateur en chef de la santé publique (ACSP) en deux postes : l'ACSP et le président de l'Agence de la santé publique du Canada. Malgré les inquiétudes exprimées dans les milieux de la santé publique, ces changements sont compatibles avec le mandat original de l'ACSP. La nature d'un gouvernement responsable suppose que l'ACSP ne peut à la fois s'instituer en champion indépendant de politiques ou de programmes favorables à la santé et conserver son rôle de conseiller principal du gouvernement du jour.