Title: Antimicrobial Resistance and Universal Health Coverage
Citation: Bloom G, Merrett GB, Wilkinson A, et al. Antimicrobial resistance and universal
health coverage. BMJ Glob Health 2017;2:e000518. doi:10.1136/ bmjgh-2017-000518
Official URL: https://doi.org/10.1136/bmjgh-2017-000518
More details/abstract: The WHO launched a Global Action Plan on antimicrobial resistance
(AMR) in 2015. World leaders in the G7, G20 and the UN General Assembly have declared
AMR to be a global crisis. World leaders have also adopted universal health coverage (UHC)
as a key target under the sustainable development goals. This paper argues that neither
initiative is likely to succeed in isolation from the other and that the policy goals should be to
both provide access to appropriate antimicrobial treatment and reduce the risk of the
emergence and spread of resistance by taking a systems approach. It focuses on outpatient
treatment of human infections and identifies a number of interventions that would be needed
to achieve these policy goals. It then shows how a strategy for achieving key attributes of a
health system for UHC can take into account the need to address AMR as part of a UHC
strategy in any country. It concludes with a list of recommended priority actions for integrating
initiatives on AMR and UHC.
Version: Published version.
Terms of use: © Article author(s) (or their employer(s) unless otherwise stated in the text of
the article) 2017. This is an Open Access article distributed in accordance with the Creative
Commons Attribution Non Commercial (CC-BY-NC 4.0) license, which permits others to
distribute, remix, adapt, build upon this work non-commercially, and license their derivative
works on different terms, provided the original work in properly cited and the use is noncommercial. See http://creativecommons.org/licenses/by-nc/4.0/
This is a download from OpenDocs at the Institute of Development Studies
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
Analysis
Antimicrobial resistance and universal
health coverage
Gerald Bloom,1 Gemma Buckland Merrett,2 Annie Wilkinson,1 Vivian Lin,3
Sarah Paulin4
To cite: Bloom G, Merrett GB,
Wilkinson A, et al. Antimicrobial
resistance and universal health
coverage. BMJ Glob Health
2017;2:e000518. doi:10.1136/
bmjgh-2017-000518
AbstrAct
The WHO launched a Global Action Plan on antimicrobial
resistance (AMR) in 2015. World leaders in the G7, G20
and the UN General Assembly have declared AMR to be a
global crisis. World leaders have also adopted universal
health coverage (UHC) as a key target under the
sustainable development goals. This paper argues that
Handling editor Seye Abimbola
neither initiative is likely to succeed in isolation from
the other and that the policy goals should be to both
Parts of this paper have
provide access to appropriate antimicrobial treatment
previously been presented in a
and reduce the risk of the emergence and spread of
WHO publication entitled: Antimicrobial Resistance in the Asia resistance by taking a systems approach. It focuses on
Pacific Region: A Development
outpatient treatment of human infections and identifies a
Agenda. http://iris.wpro.who.
number of interventions that would be needed to achieve
int/bitstream/handle/10665.1/
these policy goals. It then shows how a strategy for
13570/9789290618126-eng.pdf
achieving key attributes of a health system for UHC can
take into account the need to address AMR as part of a
Received 10 August 2017
UHC strategy in any country. It concludes with a list of
Revised 18 September 2017
recommended priority actions for integrating initiatives
Accepted 11 October 2017
on AMR and UHC.
1
Institute of Development
Studies, University of Sussex,
Brighton, UK
2
Health Action International,
Amsterdam, The Netherlands
3
Division of Health Systems,
Western Pacific Regional Office
of World Health Organization,
Manilla, Philippines
4
Department of Essential
Medicines and Health Products,
World Health Organization,
Geneva, Switzerland
correspondence to
Dr Gerald Bloom;
g.bloom@ids.ac.uk
IntroductIon
In 2015, the WHO launched a Global
Action Plan on antimicrobial resistance
(AMR) to address a challenge, which its
director general characterised as: ‘threatening the very core of modern medicine and the
sustainability of an effective global public health
response to the enduring threat of infectious
diseases’. 1 The emergence and spread of
pathogens resistant to antimicrobials poses
a big challenge to policy makers, who need
to oversee the transformation of health
systems that evolved to provide easy access
to these drugs into ones that provide access
to appropriate antimicrobial treatment while
reducing the risk of the emergence and spread
of resistance. They also need to persuade
health workers, producers and distributors
of antimicrobials and the general public
that the right of access to the benefits of
antimicrobials needs to be complemented
by responsibility for preserving their efficacy.
There is a broad scientific consensus on
the magnitude of the challenge to the efficacy of existing antimicrobial drugs.2 3 A
Key questions
What is already known about this topic?
► The WHO and world leaders are giving high priority
to initiatives to make progress towards universal
health coverage (UHC) and to address the challenge
of AMR.
► In many health systems, widespread
inappropriate use of antimicrobials is combined
with inadequate access to them, especially for
the poor.
► Health system strengthening efforts have tended to
neglect measures to ensure access to appropriate
antibiotic treatment of infections.
What are the new findings?
► An effective strategy for addressing antimicrobial
resistance (AMR) needs to both ensure access to
effective therapy for common infections and reduce
the risk of emergence of resistance.
► A systems framework for UHC is necessary to
work across the continuum from prevention to
care and to address the many factors that lead
to AMR.
recommendations for policy
► It is important to understand the linkage between
the two priorities and ensure that the use of
antimicrobials is both just and sustainable.
► Action is needed at national and global levels to
ensure there is an integrated approach for making
progress towards UHC and for addressing AMR.
number of pathogenic organisms have been
found to be resistant to a variety of antimicrobial agents in a number of countries
around the world.4 Several authors have
explored the likely impact on avoidable sickness and death, increased cost of treatment
of infections and lost income and wealth.3 5 6
A recent World Bank estimate suggests that
global domestic product per annum will be
decreased by between 1.1% and 3.8% by
2050, if AMR remains unchecked and that
an investment of US$9 billion per year will
be needed to avoid this outcome.7 In this
paper, we argue that some of this investment
should be spent on building the capacity of
Bloom G, et al. BMJ Glob Health 2017;2:e000518. doi:10.1136/bmjgh-2017-000518
1
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
BMJ Global Health
health systems to provide access to effective treatment
of common infections while reducing the risk of AMR.
unIversAl HeAltH coverAge (uHc) And AMr
The WHO is leading two health initiatives with big implications for the use of antimicrobials. First, Sustainable
Development Goal 3 includes a commitment to achieve
UHC by the year 2030. This implies significant increases
in access to healthcare, including treatment of infections. Second, the Global Action Plan on AMR aims at
‘ensuring, for as long as possible, continuity of successful
treatment and prevention of infectious diseases with
effective and safe medicines that are quality assured,
used in a responsible way and accessible to all who need
them’.1 Neither initiative is likely to succeed in isolation
from the other. Action to address AMR should go hand
in hand with measures to strengthen attributes of health
systems that contribute to progress towards UHC such
as: equity, quality, efficiency, accountability, sustainability
and resilience. This paper explores the ways that efforts
to both make progress towards UHC and delay the emergence and spread of AMR are interconnected. It focuses
on the use of antimicrobials for outpatient treatment.
A number of global statements have recognised the
need to address the many routes of contact between
micro-organisms and antibiotics including through
ingestion by humans and animals and leakage into the
environment.8–11 A recent WHO publication incorporates this understanding into a regional action plan
for the Western Pacific Region.12 Figure 1 focuses only
on the drivers of human antibiotic use. It takes into
account the widespread existence of pluralistic health
systems, which include a mix of providers of healthcare and drugs in terms of their ownership and their
relationship to the regulatory system.13 Access to and
use of antibiotics in such a system involves interactions
between technical dimensions, such as availability of
treatment guidelines, low cost diagnostic technologies
and good quality drugs, behavioural dimensions, such
as knowledge, incentives and cultural beliefs, and the
influence of a wide range of actors including healthcare
practitioners, drug companies, medical schools and
regulatory agencies.
National governments and key stakeholders can undertake a number of actions to integrate AMR and UHC.
Some priority actions for low-income and middle-income
countries with relatively weak drug management and
regulatory arrangements could include the following:
Prevention
Improvements in basic public health and disease prevention.
►
Access and responsible use
Improved access to appropriate and affordable treatment of infections, especially for the poor through
enactment and enforcement of regulations, dissemination of treatment guidelines based on AMR surveillance data, along with awareness raising on the
responsible use of antimicrobials and the challenge
of AMR.
►
Financial incentives
Realignment of incentives within drug value chains
and delinking health worker income from the volume of antimicrobial drugs supplied.
► Measures to reduce financial barriers to access to antimicrobial treatment of infections, linked with measures to encourage judicious use of these drugs.
►
Figure 1 A complex system: human drivers of antibiotic resistance in pluralistic health system. Source: Antimicrobial
resistance in the Asia Pacific region: a development agenda. Geneva: World Health Organization, 2017.
2
Bloom G, et al. BMJ Glob Health 2017;2:e000518. doi:10.1136/bmjgh-2017-000518
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
BMJ Global Health
Institutional arrangements and partnerships
Strengthening the capacity of governments to play
a role as regulator and steward of the health system,
incorporating oversight of the private and informal
sector.
► Creation of partnerships, across the plurality of providers of drugs and information, that foster shared
visions, interests and commitments.
These actions are described in more detail below.
►
Prevention and population level action to decrease the burden of
infections
The risk of emergence and subsequent transmission of
AMR genes can be reduced by immunising the population against common infectious diseases and measures
to reduce exposure to infections through contaminated
water and food and reduce the susceptibility of people to
infections by improving nutrition and treating conditions
such as HIV infection. It is important that UHC strategies
take this into account.
Ensuring access to effective and appropriate treatment of
infections
In countries with a pluralistic health system, it is typical
for people to seek treatment for a large proportion of
common infections in weakly regulated markets.13 These
arrangements have enabled people to obtain treatment
for many infections and reduce mortality. However, there
are problems with the use of substandard drugs, taking
partial courses of treatment and overuse of antimicrobials. The simultaneous existence of insufficient access to
safe, effective and affordable treatment of common infections and high levels of inappropriate use of antibiotics
creates special challenges for government action.14
Enacting and enforcing laws that reserve the right
to prescribe antibiotics to licenced healthcare workers
may not be realistic in many pluralistic health systems,
where governments face a choice between denying
many people access to life-saving drugs and turning a
blind eye to nominally illegal practices. An alternative
is for governments to strengthen their role as regulator
and steward of the health sector and act to improve the
performance of informal health workers and drug sellers
in providing antibiotic treatment of common infections.
This will require a combination of measures to ensure
drug quality, encourage the use of treatment guidelines
and alter incentives that encourage excessive use of
antimicrobials.
Ensuring access to reliable information and advice
Health workers, drug sellers and the general public make
decisions about when and how to use antimicrobials in a
complex health knowledge economy.15 The boundaries
between information consumed by providers and the
public are blurred: healthcare worker training institutes
teach about the use of these drugs; government health
services issue public health messages and organise special
programmes, which sometimes recommend treatment
Bloom G, et al. BMJ Glob Health 2017;2:e000518. doi:10.1136/bmjgh-2017-000518
without a specific diagnosis; companies that produce
or distribute drugs provide information and advice to
healthcare workers and drug sellers; advertising companies seek to influence the general public through the
mass media; and the internet and mobile phones have
become important sources of health information and
advice for patients and providers. Government regulators, organised professions and industry associations
issue guidelines and standards.
Until recently, all these sources have emphasised the
efficacy of antimicrobials in treating sickness and saving
lives. The emphasis of policy debates has been on the
right of access to these drugs. Antibiotics have developed a reputation for being ‘strong’ medicines with the
capacity to cure a range of ailments.16 Patients expect
to have access to these drugs. Health workers use antibiotics for any possible indication of infection and risk
being accused of missing an infection if they deviate
from this practice. Efforts to limit the use of antibiotics
have to contend with these ingrained beliefs, norms and
entitlements.
A number of measures will be needed to align the
knowledge economy with current and emerging scientific knowledge. Strategies are needed to educate and
support healthcare providers in responsible prescribing.
For example, guidelines could be developed for treating
common infections, taking prevalent patterns of AMR
into account. These guidelines could be incorporated
into training courses and supplied to formal and informal
providers of health advice and drugs. Strategies to raise
awareness and reduce consumer demand for antimicrobials is also needed. The general public should be given
basic information on when to use antimicrobials. Two
important sources of information on antimicrobials are
the publications that pharmaceutical companies produce
and advertising on the mass media and social media.
Voluntary standards and/or government regulations
will be needed to provide impartial advice on the use of
antimicrobials.
Management of supply chains for antimicrobials
The organisation of the production, distribution and
supply of antimicrobials to patients strongly influences
the way people use these products. In many countries, there are serious problems with counterfeit and
substandard products. The packaging of antimicrobials
influences the way they are taken. For example, it would
be possible to produce combination therapy products
and package them in full courses of treatment.
Drug wholesalers influence the people to whom they
supply by providing information and advice and offering
financial incentives to encourage a high volume of sales.17
The influence of pharmaceutical marketing is considerable. Strategies to reduce the provision of misleading
information and perverse incentives throughout the
supply chain are needed. They need to involve government and private companies.18 Governments need to
set basic quality standards for drugs. They may also set
3
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
BMJ Global Health
standards concerning treatment guidelines and the
contents of promotional and advertising material. Effective interventions need the involvement of the pharmaceutical sector and leaders of the medical profession to
encourage adherence to agreed regulations and professional and industry quality standards.
Guidelines to promote responsible use
The international community has supported a number
of initiatives to promote treatment of infections where
people do not have easy access to a medical doctor. They
have typically employed a syndromic approach, in which
people with symptoms of an infection are treated with
an antibiotic without a definitive diagnosis. Some initiatives have advocated prophylactic use of antibiotics by
high-risk groups, such as sex workers. These initiatives
have contributed to the now widespread public perception of the efficacy and strength of antimicrobials and to
the high level of demand for them. The problem of AMR
raises questions about these strategies.
The alternative is to develop practical approaches for
diagnosing and offering specific treatment for infections.
New low-cost diagnostic tests are needed that can identify a specific pathogen or, at a minimum, distinguish
between bacterial and viral infections. This could be
linked to the development of appropriate ways of organising their use in countries without high levels of access
to the formal healthcare system.19 There are significant
challenges to the development, regulatory approval and
clinical integration of diagnostic tests that use new technologies. It will probably involve collaboration between
private, non-profit and academic institutions.
Research is needed to establish appropriate treatment guidelines for common infections in a context of
changing patterns of AMR. These guidelines need to be
updated based on the dynamics of antibiotic usage and
evidence of emerging resistance.20 Promotion of sequential use, cycling strategies or mixing strategies of different
antibiotics have all demonstrated positive effects on the
reduction of AMR.21 There is also a need to look more
thoroughly at the scientific and societal perspectives of
drug combination therapy as a means of combating drug
resistance. As a first step, the scientific community will
need to strengthen its assessment of appropriate usage,
defining parameters for deciding which antimicrobials
are effective in which areas of the world and useful at
various levels of the healthcare system. The WHO Global
Development and Stewardship Framework to Combat
AMR can facilitate progress in this area together with a
broader public–private engagement.
Finance
Strategies for making progress towards UHC emphasise
measures to reduce the financial burden of healthcare
on poor families. Out-of-pocket payments by individuals
account for a substantial share of total health expenditure in a number of countries. They account for 70%
of total health expenditure in India, and 70% of those
4
payments are for drugs. This section focuses on ways that
strategies for health finance can influence the use of antimicrobials.
Many countries are increasing the contribution of
government and health insurance to total health expenditure. If a scheme covers outpatient treatment of infections, it can substantially reduce the financial barriers to
access to antimicrobial treatment. This is likely to lead to
increases in the use of these drugs. This can save lives, but
it can also lead to unnecessary use. This is a particularly
high risk if the payment of health workers and the facility
is linked to the volume of drugs they supply. Measures to
reduce the cost of antimicrobials to patients need to be
complemented by actions to ensure that these drugs are
used appropriately by providing treatment guidelines,
monitoring the quality of treatment, altering the pattern
of incentives and supporting surveillance for AMR.
In countries where the poor rely heavily on informal
providers of healthcare and drugs, it may take a long
time to provide universal health insurance. Other
measures will be needed to increase access to effective treatment. One option is for government, donor
agencies and philanthropic organisations to reduce the
cost of antimicrobials through more effective procurement and/or by supplying drugs at a subsidised price.
This might involve programmes to address common
infections such as childhood and postnatal infections.
The provision of subsidised antimicrobials would
need to be linked to measures to ensure they are used
appropriately.
The Global Action Plan on AMR calls for substantial investments to combat AMR. A large proportion of
these funds is likely to be allocated to the development
of new antimicrobials, on the understanding that the
use of any new drugs would be severely limited. This is
unlikely to command support unless there is also investment in measures to increase access to effective treatment of common infections. A combined investment
strategy would address the factors that contribute to the
emergence of resistance and acknowledge the need to
ensure universal access to antimicrobials. That would
increase the likelihood of winning wide political
support. The effective implementation of this kind of
strategy would depend on effective partnerships, as
highlighted below. Without high levels of support, it
may be difficult to prevent the production and commercial use of new antimicrobials that are developed.
Partnerships
The achievement of progress towards UHC, while
containing AMR, hinges on partnerships and coalition
building. The activities of many stakeholders need to
be aligned to the cause of providing access to appropriate
antimicrobial treatment while reducing the risk of resistance.
For a partnership to survive, each partner must believe
that the benefits it derives from the effort of creating
and maintaining it outweigh the potential losses from
the constraints to pursuing its narrow interests. The
Bloom G, et al. BMJ Glob Health 2017;2:e000518. doi:10.1136/bmjgh-2017-000518
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
BMJ Global Health
way a partnership balances the interests of the different
members reflects the governance arrangements put
in place and the relative power of the different partners.22 Powerful actors such as pharmaceutical companies, especially the generic manufacturers who supply
cheap medicines to private providers, have not been
sufficiently persuaded that entering into partnerships
aiming to limit sales of antibiotics is in their economic
interest.
A sustained effort to induce system-wide changes
in the use of antibiotics will require informed and
committed coalitions at national, regional and global
levels. Partnerships between the public and private
sector, and the formal and informal sector, are especially important. Collaboration is also needed between
those responsible for health prevention and heath
provision. This will require a one-health approach that
extends beyond the boundaries of the government
health system. It will be important to ensure that the
perspectives of poor and powerless people are taken
into account so they are not required to bear unnecessary risks of treatment failure or high costs and so that
no one is left behind. One aim of this kind of coalition would be to establish basic standards of conduct
for healthcare workers and for drug companies that
emphasise the needs of patients and of the community.
This may require new business and financial models to
address perverse incentives. These coalitions will need
to be able to monitor progress in ensuring access to
treatment and reducing inappropriate use of antibiotics. The government will need to build its capacity to
play an effective role in this process.
conclusIons: A systeMs APProAcH to AddressIng AMr
Table 1 illustrates how the actions described above can
be integrated into the routine functioning of a health
system, through linking them to core health system
attributes and dimensions of health system strengthening
towards UHC.
Simple interventions can have unintended consequences. For example, measures to restrict access to
antibiotics to a doctor’s prescription may reduce equity
by decreasing access to treatment by the poor. Also,
strategies that focus disproportionately on one aspect
of the system, such as ensuring access to treatment of
infections, will have limited impact if basic public health
and disease prevention are neglected. The different
health system attributes are highly interdependent and
stewardship requires a multilevel systems perspective.23
Actions that are not based on an understanding of
the interdependencies relevant to antibiotic supply
and use may have relatively little impact. For example,
qualified doctors often blame patients or the informal
sector for inappropriate antibiotic use, when their own
practices are frequently no better. ‘Patient demand’ is
often noted to be a major factor in influencing inappropriate prescribing by healthcare workers. However,
observations of clinical interactions have not always
Table 1 Health system attributes and universal health coverage actions for addressing AMR
Health system attributes
Actions for addressing AMR
Equity
Reduce the burden of infectious disease among the poor by strengthening basic public health
and prevention
Ensure access to appropriate antibiotics at an affordable cost, including by the poor
Ensure that measures aimed at reducing inappropriate use of antimicrobials do not interfere
with access to them by the poor
Regulate the quality of antimicrobials
Include AMR in medical curriculum and training programmes
Ensure that guidelines for treatment of infections take into account surveillance findings
Ensure that advice on antimicrobial use provided to healthcare workers and through
advertisements reflects best-practice guidelines and acknowledges the threat of AMR
Increase access to low-cost diagnostic technologies for more accurate diagnosis
Quality
Efficiency
Alter financial incentives that encourage overuse of antimicrobials
Reduce need for expensive treatment of infections with resistant organisms
Accountability
Provide information on surveillance findings
Provide information on appropriate treatment for different infections
Strengthen public health services and immunisation to reduce exposure to infections
Establish partnerships for management of antimicrobials
Carry out awareness and educational campaigns to change understanding of healthcare
workers and the population on appropriate use of antimicrobials
Invest in research and development (R&D) of new drugs and in new approaches for providing
effective treatment of common infections
Sustainability and resilience
Source: WHO. Antimicrobial Resistance in the Asia Pacific region: a development Agenda. 2017. WHO, Geneva.
AMR, antimicrobial resistance.
Bloom G, et al. BMJ Glob Health 2017;2:e000518. doi:10.1136/bmjgh-2017-000518
5
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
BMJ Global Health
confirmed this.24 Also this demand has been stimulated
by the many public campaigns to convince people of
the value of antibiotics. Other factors that influence the
decisions to use antibiotics need to be considered, such
as perverse financial incentives and inadequate understanding of appropriate treatment guidelines.
There are no blueprints for implementing multilevel changes at scale in complex and rapidly changing
contexts. These changes include measures to address
immediate problems, such as inadequate access to
treatment and problems with drug quality, and the
longer term need to change attitudes and create more
effective mechanisms to govern and manage antimicrobial use. It is important to employ a learning approach
to the management of this kind of system change.
National action plans need to take into account
regional and global interdependencies. Dense transportation links, the movement of large quantities of
goods and people, the behaviour of international pharmaceutical companies and international media influence national systems. Countries with larger national
incomes and higher levels of economic and social
organisation have a stake in the success of measures by
relatively low-income countries to reduce their burden
of infectious diseases and increase access to effective
treatment. Measures to address AMR will need to be
built on the foundation of strong regional and global
agreements on actions that address the concerns of all
countries and all social groups through a whole-of-society approach.
contributors GB took the lead in preparing the draft, and GBM, AW, VL and SP
contributed to the final text.
Funding This paper draws on a background paper commissioned by the Western
Pacific Office of the World Health Organization. The work on producing the final
draft of the paper was supported by a grant by the UK Department of International
Development to the Future Health Systems Consortium.
competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
6
REFERENCES
1. World Health Organization. Global action plan on antimicrobial
resistance. Geneva: World Health Organization, 2015:1.
2. Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistance-the
need for global solutions. Lancet Infect Dis 2013;13:1057–98.
3. Wellcome Trust and Government of the United Kingdom. Review on
antimicrobial resistance. Tackling drug resistant infections globally:
final report and recommendations. London: Wellcome Trust and
Government of the United Kingdom.
4. World Health Organization,. Antimicrobial resistance: global report
on surveillance. Geneva: World Health Organization, 2014.
5. World Bank. Drug-resistant infections: a threat to our economic
future. Washington: World Bank, 2017.
6. Jasovsky D, Littmann J, Zorzet A, et al. Antimicrobial resistance: a
threat to the world’s sustainable development. Upsala Journal of
Medical Science 2016;16:159–64.
7. Baris EI, Thiebaud A, Evans TA. Containing antimicrobial resistance
is a smart investment in global public health and wealth. AMR
Control 2017 http://resistancecontrol.info/2017/containingantimicrobial-resistance-is-a-smart-investment-in-global-publichealth-and-wealth/
8. Group of 20. G20 leaders’ declaration: shaping an interconnected
world. Hamburg: G20 Germany, 2017. https://www.g20.org/
Content/EN/_Anlagen/G20/G20-leaders-declaration.pdf?__blob=
publicationFile&v=2
9. Group of 20. Berlin declaration of the G20 health ministers: together
today for a healthy tomorrow. Berlin, 2017. https://www.bundes
gesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/G20Gesundheitsministertreffen/G20_Health_Ministers_Declaration_engl.
pdf
10. Group of 7. G7 Ise-Shima Leader-s Declaration Ise-Shima, 2016.
http://www.mofa.go.jp/files/000160266.pdf
11. United Nations. Political declaration of the high-level meeting of
the general assembly on antimicrobial resistance. New York City:
Seventy-first session United Nations General Assembly, 2016.
12. WHO. Antimicrobial resistance in the Asia Pacific region: a
development agenda. Geneva: WHO Regional Office for the Western
Pacific, 2017.
13. Peters DH, Bloom G. Developing world: bring order to unregulated
health markets. Nature 2012;487:163–5.
14. Tomson G, Vlad I. The need to look at antibiotic resistance from a
health systems perspective. Ups J Med Sci 2014;119:117–24.
15. Bloom G, Standing H, Lloyd R. Markets, information asymmetry
and health care: towards new social contracts. Soc Sci Med
2008;66:2076–87.
16. Radyowijati A, Haak H. Improving antibiotic use in low-income
countries: an overview of evidence on determinants. Soc Sci Med
2003;57:733–44.
17. Rahman H, Agarwal S. Drug detailers and the pharmaceutical
market in Bangladesh. In: Bloom G, Kanjilal B, Lucas H, Peters
D, eds. Transforming health markets in Asia and Africa: improving
quality and access for the poor. Oxford: Routledge, 2013.
18. Bloom G, Henson S, Peters DH. Innovation in regulation of rapidly
changing health markets. Global Health 2014;10:53.
19. Okeke IN, Peeling RW, Goossens H, et al. Diagnostics as essential
tools for containing antibacterial resistance. Drug resistance
updates. , 2011:14, 95–106.
20. Worthington RJ, Melander C. Combination approaches to combat
multidrug-resistant bacteria. Trends Biotechnol 2013;31:177–84.
21. Baquero F, Lanza VF, Cantón R, et al. Public health evolutionary
biology of antimicrobial resistance: priorities for intervention. Evol
Appl 2015;8:223–39.
22. Buse K, Harmer A. Power to the partners?: the politics of publicprivate health partnerships. Development 2004;47:49–56.
23. Merrett GL, Bloom G, Wilkinson A, et al. Towards the just and
sustainable use of antibiotics. J Pharm Policy Pract 2016;9.
24. Paredes P, de la Peña M, Flores-Guerra E, et al. Factors influencing
physicians’ prescribing behaviour in the treatment of childhood
diarrhoea: knowledge may not be the clue. Soc Sci Med
1996;42:1141–53.
Bloom G, et al. BMJ Glob Health 2017;2:e000518. doi:10.1136/bmjgh-2017-000518
Downloaded from http://gh.bmj.com/ on December 5, 2017 - Published by group.bmj.com
Antimicrobial resistance and universal health
coverage
Gerald Bloom, Gemma Buckland Merrett, Annie Wilkinson, Vivian Lin and
Sarah Paulin
BMJ Glob Health 2017 2:
doi: 10.1136/bmjgh-2017-000518
Updated information and services can be found at:
http://gh.bmj.com/content/2/4/e000518
These include:
References
This article cites 12 articles, 0 of which you can access for free at:
http://gh.bmj.com/content/2/4/e000518#BIBL
Open Access
This is an Open Access article distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work
non-commercially, and license their derivative works on different terms,
provided the original work is properly cited and the use is
non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Email alerting
service
Receive free email alerts when new articles cite this article. Sign up in the
box at the top right corner of the online article.
Topic
Collections
Articles on similar topics can be found in the following collections
Health policy (10)
Open access (485)
Notes
To request permissions go to:
http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to:
http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to:
http://group.bmj.com/subscribe/