amr indicators and their relevance to the global …...amr indicators and their relevance to the...

AMR Indicators and their relevance to

the global indicator framework for the

SDGs and targets for the 2030 Agenda

for Sustainable Development

Analytic support provided by McKinsey & Company, funded by the

Wellcome Trust, to inform the United Nations Inter-Agency

Coordination Group (IACG) on Antimicrobial Resistance.

05 November 2018

2

Contents

▪ Executive summary

▪ Full analysis

3

Rationale to better anchor AMR

This effort explores opportunities to better anchor measurement of AMR

globally, primarily in the SDG indicators and secondarily beyond

Opportunities to

better anchor AMR

measurement

SDG indicators

▪ Leverage SDG platform to give AMR high-level

visibility and promote advocacy

▪ Seize synergies with SDG systems and

mechanisms

▪ Overarching global development

framework 2015-30

▪ Universal call to action

▪ Set of clear guidelines and

targets for all countries to adopt

in accordance with their own

priorities and challenges

Global efforts

beyond SDGs

▪ Enhance and leverage individual efforts, e.g.,

add AMR specific indicator into WHO 100

▪ Coordinate efforts horizontally (i.e., achieve full

coverage without duplications) and vertically

(i.e., aligned reporting logics)

▪ Translate efforts for specific

audiences/stakeholders

▪ Entirety of frameworks,

mechanisms, and guidelines

that promote, track, and evaluate

AMR relevant outcomes, e.g.,

WHO GPW, 10YFP1, WHO

100,WAHIS, GAP M&E approach

▪ Different scope, priorities and

custodians

Regional/national

efforts

▪ Broaden geographic coverage

▪ Build in-country capacity/capabilities to

improve data collection, reporting, and quality for

AMR

▪ Country-level frameworks and

reporting mechanisms, e.g., UK

“Fingertips”

What it is

Primary focus of this effortSecondary focus of this

effort (opportunistic)

SOURCE: Expert interviews; Team analysis 1 10-year framework of programmes on sustainable consumption and production

4

Detailed scope of this effort

Working steps What this effort aims to do What this effort does not aim to do

Scrutinize the

global indicator

framework for

SDGs

▪ Gain a comprehensive descriptive

understanding of the extent to which

AMR is covered in SDG indicators,

including identification of blindspots

▪ Make normative assessment of

linkages between SDG indicators and

AMR

▪ Define target-state coverage of AMR

in SDG indicators

Identify opportuni-

ties to better

anchor AMR in

the SDG

indicators

▪ Develop toolbox of potential

opportunities leveraging existing and

adding new indicators

▪ Balance opportunistic with blindspot-

and target-driven propositions

▪ Establish comprehensive menu of

changes to fully capture AMR in the

SDG indicators and beyond

▪ Identify target-state dashboard

of indicators

▪ Prioritize ‘best possible’ opportunities

for each option in the SDG indicators

based on relevance and feasibility

▪ Identify other opportunities beyond

SDGs, incl. options and key

considerations

▪ Give political advice on whether or not

any option should be pursued

▪ Make assessment of chances for

success

▪ Elaborate and further assess options

beyond SDG indicators

Prioritize shortlist

of indicators/

components to be

considered by

IACG SG 5

5

Summary

1 Incl. double-counting 2 AMR Framework for Action

3 Global Action Plan

Click on bolded blue

text for details To what extent is

AMR reflected in the

SDG indicators?

1

The SDG indicators cover indirectly many aspects of AMR

▪ 90/2441 (~40%) indicators in 12 SDGs are relevant for AMR

▪ 6 SDGs are of particular relevance for AMR (i.e., SDG 2, 3, 6, 9, 12, and 17)

▪ Key AMR topics captured include universal health coverage, disease incidence, and water/sanitation

What aspects of

AMR are missing in

the SDG indicators?

2

The SDG indicators are not specific for AMR, and critical blindspots remain

▪ There is no explicit mention of AMR in the SDGs beyond the pre-amble

▪ Indicators are often high-level and cover AMR broadly, lacking detail and specificity

▪ Blindspots are present in terms of both FFA2/GAP3, particularly on human use, biosafety/biosecurity and

animal use, or GAP strategic objective 1 and 5, respectively

▪ From a One Health perspective, the human health is 2-3x more represented than the other dimensions

How can AMR be

better anchored?3

The first approach is to anchor AMR within the SDG indicators, for which 3 options with different

visibility/feasibility profiles exist

▪ Anchoring AMR in the implementation of indicators by engaging with custodial agencies

▪ Explicitly calling out AMR in existing indicators

▪ Adding new, AMR-specific indicators to the framework

The second approach is to pursue other options beyond the SDG indicators, i.e., consolidating existing

information, adding indicators to other frameworks, or creating new independent or country-driven

mechanisms NOTE: prioritization of options beyond SDG indicators not in scope

What concrete

opportunities might

the IACG consider to

better anchor AMR in

the SDG indicators?

4

This effort identifies specific prioritized opportunities within the SDGs

▪ 5 opportunities to anchor AMR in implementation, e.g., by engaging with FAO to define sustainable

agriculture in an AMR-sensitive way (2.4.1)

▪ 3 call-outs of AMR in existing indicators, e.g., adding a resistance-flag to TB incidence (3.3.2)

▪ 3 potential new AMR-specific indicators, e.g., proportion of access vs. watch/reserve AMC

What are

the next steps? 5

Changes to SDG indicators can be proposed for the comprehensive review 2020 but are time sensitive

▪ In the first approach, i.e. within SDG indicators: Adjustments to existing indicators must be proposed by

summer 2018, new indicators by end of 2018. Engagement with custodial agencies is not timebound

▪ In the second approach, i.e. beyond SDGs: Other options to make opportunities that are not adopted for

inclusion in the SDGs come alive otherwise are not part of the formal indicator review process

6

The SDG indicators are very relevant to AMR and cover AMR broadly

19

13

3

2

12

11

2

3

5

8

2

10

Somewhat relevant Relevant Highly relevant

Examples, Selected, illustrativeSDGs

1.2.1 Proportion of population living below the national poverty

line, by sex and age1 No poverty

2.1.1 Prevalence of undernourishmentZero hunger

3.2.1 Under-5 mortality rateGood health & well-being

4.a.1 Proportion of schools with access to (...) basic drinking

water (…) basic handwashing facilities (…)4 Quality education

n/a5 Gender equality

6.1.1 Proportion of population using safely managed drinking

water services6 Clean water & sanitation

n/a7 Affordable & clean energy

8.1.1 Annual growth rate of real GDP per capita8Decent work & economic

growth

9.5.2 Researchers (in full-time equivalent) per million inhabitants9Industry, innovation &

infrastructure

11.1.1 Proportion of urban population living in slums, informal

settlements or inadequate housing11

Sustainable cities &

communities

12.4.2 Hazardous waste generated per capita and proportion of

hazardous waste treated (…) 12

Responsible consumption

& production

n/a13 Climate action

14.7.1 Sustainable fisheries as a proportion of GDP in small

island developing States (…) 14 Life below water

n/a15 Life on land

n/a16Peace & justice strong

institutions

17.14.1 Number of countries with mechanisms in place to

enhance policy coherence of sustainable development17 Partnerships for the goals

10.b.1 Total resource flows for development (…)10 Reduced inequalities

REFLECTION OF AMR IN SDG INDICATORS

1

100%

41%

95%

100%

26%

100%

33%

100%

63%

27%

0%

32%

%

Key AMR sensitive SDGsx% Representation of human dimension (One Health)1

1 Prevalence of human vs. other dimensions (based on # of indicators applicable per dimensions); 100% = all indicators only apply to human dimension, 25% =

equitable share among 4 dimensions

Key AMR sensitive topics, Selected

▪ Poverty and poverty reduction programs

▪ Access to basic services and infrastructure

▪ Food security and effects thereof

▪ (Sustainable) agriculture and food production

▪ Morbidity and mortality

▪ Healthcare coverage

▪ Infrastructure in schools

▪ Health of children

▪ n/a

▪ Water and sanitation (from ambient water quality

to water efficiency)

▪ n/a

▪ GDP growth

▪ R&D capacity, expenditures, and official

international support

▪ Access to basic services and infrastructure

▪ Sanitation

▪ Sustainability (education, R&D, SCP plans, etc)

▪ Sanitation and waste

▪ n/a

▪ Fishing and fish stocks

▪ n/a

▪ n/a

▪ SDG governance (monitoring and reporting)

▪ Cooperation and coordination (e.g., for science)

▪ Poverty rates

▪ Resource flows for development

AMR-relevant indicators, #, all sensitive (no

AMR-specific indicators in SDGs)

2

3

SOURCE: SDG indicator framework; Team analysis

Click here

for details

7

Human useClean water/sanitationHuman infection prevention Environmental contaminationBiosafety/biosecurity Food safety Animal/agricultural use

Laboratory capacity/surveillance Development of new therapeuticsBasic research Access to therapeutics Vaccine development and accessDiagnostics development and access

Quality Coalition buildingGlobal roadmapNational action plans 1 Awareness 2 Surveillance/research 3 Infection 4 Use 5 Economic case

SOURCE AMR, A Threat to the World’s Sustainable Development (ReAct); SDG indicator framework; Expert interviews; Team analysis

SDG indicators are not AMR specific, and there remain critical blindspots

Click here for details

Type of

blindspots

▪ Areas are neglected overall: Large parts are not covered, and those elements captured lack

often specificity, e.g.,

– Animal biosafety and biosecurity

– Animal/agricultural use

– Food safety (SDG indicators predominantly cover food from an access perspective)

– Quality (SDG indicators predominantly cover medicines from an access perspective)

Large

blindspots

Observations

Partial

blindspots

▪ Areas are in large parts covered, but key elements necessary for AMR are neglected, e.g.,

– Human use, lacking stewardship and prevention of misuse/wrong use

– Infection prevention and control, neglecting healthcare associated infections

– Vaccine development and access, not including veterinary immunization

Generally

covered,

but

lacking

specificity

▪ Areas are generally covered, but indicators are unable to capture AMR specific outcomes

due to too broad scope (e.g., development assistance to medical research, which could but

not necessarily does encompass medical research for AMs)

▪ Key areas where coverage is too broad are

– Surveillance and R&D (broad indicators not channeling resources to AMR)

– Environmental contamination (either specific (water-)protection or general sustainable

production/consumption indicators without mention of AMR)

– Enablers (SDG 17 governance mechanisms currently don’t cover AMR as AMR is not an

explicit part of SDGs)

– Access to therapeutics (broad indicator on essential medicines)

3

4

No major▪ Relatively strong coverage of water/sanitation, from ambient water to waste water and water

use/efficiency (as clean water/sanitation is not AMR specific per se)

GAPAMR FFA

Sample areas

1

2

5

AMR BLINDSPOTS IN SDG INDICATORS

2

8

Within the 2 approaches in scope, there are 4 complementary options to

better anchor AMR with specific profiles

1 I.e., number of indicators and burden for countries already high Source: Expert interviews; Team analysis

Options to better anchor

AMR Description

Assessment

Vis

ibilit

yF

easib

ilit

yF

easib

ilit

y“Making the changes to the

framework is theoretically

possible but practically very

difficult”Expert on SDG process

ChallengesOpportunities

▪ Provision of explicit

mention of AMR and

specific AMR indicator

▪ Targeted anchoring of

AMR outcomes

▪ Add new AMR

specific indicator(s)

to framework

▪ Dependency on custodial

agency

▪ Fit with indicator, e.g., purpose

and rationale

▪ Implications of inclusion of AMR

for data collection / indicator tier

status

▪ Informal process

▪ ‘Back door’ option for

AMR into SDGs

▪ Short-term horizon

(immediate engage-ment

possible)

▪ Do not change text of

framework

– Engage with

custodial agency

– Include AMR in

metadata

Anchor

AMR in

implement-

tation

a

Lev

era

ge e

xis

tin

g in

dic

ato

rs

Add new AMR

indicator(s)

Add AMR to

existing

indicator(s)

▪ Lengthy and formal inclusion

process

▪ Highly political process, and

limited willingness to re-engage

▪ Limited room for additions1

▪ Complex stakeholder

environment

▪ Explicitly call out

AMR in existing

indicators

▪ Provision of explicit

mention of AMR

▪ Increase of AMR-

sensitivity with low level of

intrusiveness

b

Wit

hin

SD

G in

dic

ato

rs

Explore options

beyond SDGs

▪ Varying reach and relevance

▪ Different requirements (depending

on framework)

▪ More degrees of freedom

for normative shaping of

AMR measurement

▪ Look at vehicles

beyond SDGs to

anchor AMR, e.g., in

exiting other

framework like WHO

100

Beyo

nd

SD

Gs

App-

roach

c

Deep-dive on the next page


3

APPROACH TO ANCHOR AMR

9

Other options beyond the SDGs can be further explored

Leveraging of

existing efforts

to better

communicate/

consolidate

Opportunities

SelectedObjectives Key considerations

▪ Use existing

reporting

▪ Consolidate and

synthesize to

achieve specific

targets

Inputs from

this effort

▪ Leverage

– Identified

blindspots

in coverage

of AMR

– Developed

toolbox of

potential

opportuni-

ties

(prioritized

and non-

prioritized)

▪ Drop

feasibility

constraints for

inclusion in

SDG indicators

▪ Define key stand-alone

composites / spiders

drawing on, e.g., SDG

indicators and M&E work

▪ Identify ‘neglected

audiences’ and create

tailored communication

Integration in

existing

reporting

framework

▪ Add AMR to existing

reporting, e.g., AMR

indicator into WHO 100,

GAP M&E approach, WHO

GPW, 10YFP1

▪ Requires mapping of

current efforts, incl.

timelines for changes

▪ Depends on respective

stakeholders and process

New indepen-

dent indicators/

dashboard by

NGOs

▪ Create new effort

through independent

actor

▪ Design normatively

targeted mechanism

▪ Leverage low constraints

of independent actors (e.g.,

like CARA by CDDEP)

▪ Needs building of targeted

stakeholder community

and support with political

clout

New indicators/

dashboard of

country-driven

data

▪ Create new reporting

logic through

country-driven data


targeted mechanism

▪ Build on countries to

create information (e.g.,

AMR decision-maker

dashboard)

▪ Requires balance

between what should be

and what is already there

in terms of data

▪ Needs identification of key

decision-relevant indicators

Other options

beyond SDGs

There are 4 options to make identified opportunities not prioritized/not adopted

by IACG come alive beyond the SDG indicators


3

▪ Requires understanding

of landscape of available

data

▪ Offers limited degrees of

freedom for target-driven

shaping of efforts

▪ Leverage existing

efforts to better

anchor AMR

SOURCE: Expert interviews; Team analysis1 10-year framework of programmes on sustainable consumption and production


Create new efforts Utilize existing efforts

10

Prioritized opportunities in SDG 2, 3, and 12 aim to better cover AMR

a Anchor AMR in implementation

b Add AMR to existing indicators

Additions bolded

Add new indicators

Additions bolded

c

12.8.1 Extent to which (i) global

citizenship education and (ii)

education for sustainable

development (including climate

change and AMR education) are

mainstreamed (…)

2.4.X Use of antimicrobial

agents in animals, adjusted for

animal biomass

3.3.1, 3.3.2, 3.3.3, 3.3.4

communicable disease incidence, %

of resistant cases

3.8.X Access-Watch Index of

AMC by country/region

3.8.X Level of resistance for top

1-3 drug/bug combinations

3.8.1 Coverage of essential health

services (defined as the average

coverage of essential services

based (…) infectious diseases (incl.

effective sanitation, hygiene and

infection prevention measures)

(…)

1 No poverty

2 Zero hunger

3Good health & well-

being

4 Quality education

5 Gender equality

6Clean water &

sanitation

7Affordable & clean

energy

8Decent work &

economic growth

9Industry, innovation &

infrastructure

11Sustainable cities &

communities

12Responsible con-

sumption & production

13 Climate action

14 Life below water

15 Life on land

16Peace & justice strong

institutions

17Partnerships for the

goals

10 Reduced inequalities

▪ Engage with WHO to disaggregate

resistant cases in communicable

diseases (3.3.1, 3.3.2, 3.3.3, 3.3.4)

▪ Engage with WHO/UNICEF/Gavi to

promote inclusion of vaccines

relevant in AMR context in

national immunization

programmes (3.b.1)

▪ Engage with WHO to disaggregate

access to essential AMs,

potentially adjusted for stewardship/

quality (3.b.3)

▪ Engage with FAO to define

‘sustainable agriculture’ in AMR-

sensitive terms (2.4.1)

▪ Engage with UNEP to include AMR

in assessment of sustainable

consumption and production

national action plans/ national

policies (12.1.1)

SDGs

POTENTIAL OPPORTUNITIES


4

SOURCE: Expert interviews; Team analysis

Exemplary details on next page

11

Example for proposal for a new indicator: 2.4.X Use of antimicrobial

agents in animals

SOURCE: OIE, Interviews

Background

1 Specifically Chapter 6.8 of the OIE Terrestrial Animal Health Code

2 Total weight of live domestic animals ipopulation, used as a proxy to represent those exposed to reported Ams

3 OIE annual report on the use of antimicrobial agents intended for use in animals, Second Report, see here

▪ OIE has received a mandate from its 182 member countries to collect

and report data on AM use in animals

▪ The methodology is established through OIE’s international standards1

and annual data collection and reporting is in place

▪ A training system has been established for Member Countries to

support their data collection and reporting

Data availability

As in OIE 2017 document based on country reported 2014 data3

▪ 107/146 (73%) countries reported quantitative data for one or more

years between 2013 to 2016

▪ Data based on different sources, mostly import and sales

▪ Possibility to analyze AM quantities reported adjusted by a

denominator (animal biomass)2

Initial results


▪ Global estimate of AM use in animals of 98.97 mg/kg (best estimate)

to 134.31 mg/kg (upper level estimate)

▪ Includes data from 60 countries during the first two phases of data

collection

Objectives ▪ Encourage prudent and responsible

use of antimicrobials in livestock

agriculture in accordance with the

Global Action Plan on AMR

Overview

Target 2.4: By 2030

ensure sustainable food

production systems and

implement resilient

agricultural practices (…) SDG

context

2.4.X Use of antimicrobial agents in

animals, adjusted for animal biomass

Proposed

indicator

Tier ▪ Conceptually clear with internationally

established methodology and

standards

▪ Data available and regularly produced

by countries for >50% of countries and

of the population in every region

where the indicator is relevant

I

Custodian Partner

Agencies More details here


4


http://www.oie.int/fileadmin/Home/eng/Our_scientific_expertise/docs/pdf/AMR/Annual_Report_AMR_2.pdf


12

SDG indicators are a living document – comprehensive reviews offer the

possibility to make changes to SDG indicators

SOURCE: http://sdg.iisd.org/news/ecosoc-adopts-sdg-indicator-framework; https://unstats.un.org/sdgs/files/meetings/sdg-inter-agency-meeting-

2018/11.%20IAEG-SDGs_7th%20Meeting.pdf; Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators 2017, 2018

Relevant to introduce new indicators/components SDG indicator framework inclusion process

Impact

5

Draft by IAEG-SDG Adoption by ECOSOC Adoption by GA

Review

cycles

4

1 2 3

Refinement by

IAEG-SDG

Description

No comprehensive

review has taken

place yet

▪ Follow up and

review of

sustainable

development

along indicator

framework

(resolution 70/1)

▪ Annual

progress report

on the SDGs

▪ Delivery by

2030

▪ Adoption through

resolution

A/RES/71/313

▪ Endorsement of

“initial set of

indicators to be

refined annually

and reviewed

comprehensi-

vely” by the

Statistical

Commission

▪ Adoption for

submission

to UN GA

Timeline2017-2030: annual reviews

2020; 2025: comprehensive review

2030 July 2017June 20172015-17

▪ Establishment of

IAEG-SDG by

UN Statistical

Commission

▪ Development of

draft resolution,

incl. indicators and

classification by

IAEG-SDG

▪ Bi-annual meetings

▪ Only editorial (no substantive)

changes

Annual reviews

▪ Two times, 2020 and 2025▪ Substantive changes possible,

e.g., potentially 35 new indicators suggested by IAEG in 2017 currently in consultation

▪ Open consultation of changes to framework in 2019

▪ Proposals for new indicators optimally in 2018 (timelines not fully clear yet)

▪ Final report by IAEG to UNSD end of 2019

Window for substantive

changes to the indicators

NOTE: (UN)GA: United Nations General Assembly; ECOSOC: United Nations Economic and Social Council; IAEG-SDG: Inter-agency Expert Group on SDG indicators

43 521

Comprehensive reviews

NEXT STEPS

5


http://sdg.iisd.org/news/ecosoc-adopts-sdg-indicator-framework

https://unstats.un.org/sdgs/files/meetings/sdg-inter-agency-meeting-2018/11. IAEG-SDGs_7th Meeting.pdf

14

Contents


▪ Full analysis

– Introduction and approach

– 1. To what extent is AMR reflected in the SDG indicators?

– 2. What aspects of AMR are missing in the SDG indicators?

– 3. How can AMR be better anchored?

– 4. What concrete opportunities might the IACG

consider to better anchor AMR in the SDG indicators?

– 5. What are next steps?

15

Rationale to better anchor AMR

This effort explores opportunities to better anchor measurement of AMR

globally, primarily in the SDG indicators and secondarily beyond

Opportunities to

better anchor AMR

measurement

SDG indicators

▪ Leverage SDG platform to give AMR high-level

visibility and promote advocacy

▪ Seize synergies with SDG systems and

mechanisms

▪ Overarching global development

framework 2015-30

▪ Universal call to action

▪ Set of clear guidelines and

targets for all countries to adopt

in accordance with their own

priorities and challenges

Global efforts

beyond SDGs

▪ Enhance and leverage individual efforts, e.g.,

add AMR specific indicator into WHO 100

▪ Coordinate efforts horizontally (i.e., achieve full

coverage without duplications) and vertically

(i.e., aligned reporting logics)

▪ Translate efforts for specific

audiences/stakeholders

▪ Entirety of frameworks,

mechanisms, and guidelines

that promote, track, and evaluate

AMR relevant outcomes, e.g.,

WHO GPW, 10YFP1, WHO

100,WAHIS, GAP M&E approach

▪ Different scope, priorities and

custodians

Regional/national

efforts

▪ Broaden geographic coverage

▪ Build in-country capacity/capabilities to

improve data collection, reporting, and quality for

AMR

▪ Country-level frameworks and

reporting mechanisms, e.g., UK

“Fingertips”

What it is

Primary focus of this effortSecondary focus of this

effort (opportunistic)

SOURCE: Expert interviews; Team analysis 1 10-year framework of programmes on sustainable consumption and production

INTRODUCTION AND APPROACH

16

Recap: Objectives of Commission 2

1

2Prioritize shortlist of ~5 indicators/components to be considered by

IACG sub-group five for proposing to the Statistical Commission for

inclusion in the SDG indicator framework

3Conduct a review of the AMR Actors to identify where indicators

already exist which provide the required data, or highlight where

there is a data gap

Scrutinize the global indicator framework for SDGs and identify:

▪ where it would be appropriate to incorporate new AMR indicators

▪ where components could be added to current indicators to broaden

their scope to include AMR


SOURCE: IACG; Request for Proposal

17

We assessed the degree to which AMR is reflected in the SDG indicators by

mapping all 232 SDG indicators to a set of key frameworks

4 key frameworks

232 SDG indicators

Excl. double counting

Bottom up classification on AMR

Where applicable

AMR framework for action

Global action plan objectives

One health dimensions

Results chain

Out-

puts

Inputs

& pro-

cesses

Out-

comesImpact

Level of relevance

▪ Strong link to AMR outcomes

▪ Example: Mortality from

infectious diseases

▪ Linkage with AMR outcomes

▪ Example: Government spending

on health services

▪ Some linkage with AMR outcomes

▪ Example: People living in poverty

▪ No/marginal linkage with AMR

outcomes

▪ Example: Air pollution

Specific vs. sensitive

Specific Sensitive

Relevant

Some-

what

relevant

Highly

relevant

Neutral

▪ Direct applicability

▪ Predominant

motivation for

indicator is AMR

▪ Example:

Resistance levels

▪ Indirect applicability

▪ Other predominant

motivation, but

covariant

▪ Example:

Mortality rates


SOURCE: Team analysis

18

1 Content areas are not classified by order of importance

2 Covers strengthening human, agricultural, food and environmental systems

3 In former version of AMR FFA: Animal infection prevention and control

SOURCE: IACG

Our analysis is based on the AMR framework for action that was adopted

last year and the WHO GAP, which are both interlinked

Global roadmap, governance & coordination (including evidence base)Enablers

Content areas1

Optimize use of

medicines

Human use

Laboratory capacity & surveillance

Invest in

innovation,

supply and

access

Reduce need

and

unintentional

exposure

Clean water and sanitation

Development of new therapeutics

Human infection prevention and control

Environmental contamination

Vaccine development and access

Biosafety and biosecurity3

Levers

Policy &

Regulation

Funding &

financial

incentives

Animal & agricultural use

Measure-

ment/

surveillance

2

Champion-

ing &

piloting

Awareness

& capability

building

1

Food safety

3

4

Diagnostics development and access

Coalition building and political commitment (including data transparency)

National action plans, System Strengthening2 and alignment with SDGs (including logistics for access)

Basic research

Quality

Access to therapeutics

5

2

The Global Action Plan sets out five strategic objectives:

1. Improve awareness and understanding of antimicrobial resistance

through effective communication, education and training

2. Strengthen the knowledge and evidence base through surveillance and

research

3. Reduce the incidence of infection through effective sanitation, hygiene

and infection prevention measures

4. Optimize the use of antimicrobial medicines in human and animal

health

5. Develop the economic case for sustainable investment that takes

account of the needs of all countries, and increase investment in new

medicines, diagnostic tools, vaccines and other interventions

1

2

3

4

5


19

Our work is based on extensive interactions with experts and

leverages a broad set of reports, frameworks, and scientific articles


Multi-

laterals

Govern-

ment

~50 reports, frameworks, and scientific

articles~40 expert interviews

Private

sector

Academia

Key experts interviewed

Selected key experts, preliminary Domain Type of source

Examples

Selected, illustrative

~15High level

reports E.g., EU joint scientific opinion, Global

Monitoring Report, Development

dialogue paper

~30Scientific

articles E.g., on AWaRe in the Lancet, or on the

challenge of measuring in PLOS

medicine

~10Frame-

worksE.g., GLASS, WAHIS, Tripartite GAP

M&E approach, WHO GPW…

Civil society

Marc Mendelson, University of Cape Town

Theo Kanellos, Zoetis

Jill Inverso, Pfizer

Thomas Cueni, IFPMA

Mike Catchpole, ECDC

John-Arne Rottingen, Norway Research Council

Josefin Wiklund, UNAIDS

Ramanan Laxminarayan, CDDEP

Harriet O’Brien, Gov. of UK

Virginie Marchand, ReAct

Anthony So, ReAct

Dominique Monnet, ECDC

Henk Jan Ormel, FAO

Liz Tayler, WHO

Sam Kariuki, Sanger

Nina Grundmann, IFPMA

Dik Mevius, University of Utrecht

Charles Price, DG SANTE

Neil Jackson, DFID

Chris Murray, IHME

Mike Sharland, St George’s, University of London

Carmem Pessoa, WHO

Ranieri Guerra, WHO

Matthew Stone, OIE

Daniel Carter, DFID

Claudia Nannei, WHO

Joakim Larsson, University of Gothenburg

Elisabeth Erlacher-Vindel, OIE

Ben Davies, OIE

Heather Page, IAEG-SDG

Benjamin Rae, IAEG-SDG

Nana Taoana Kuo, EWEC

Enis Baris, World Bank

Amit Khurana, CSE India


20

Contents


▪ Full analysis








21

Section summary: To what extent is AMR reflected in the SDG indicators?

1 AMR Framework for Action 2 Global Action Plan

▪ The SDG indicator framework is not specific,

but sensitive and highly relevant to AMR

– There is no AMR specific indicator in the SDGs

– 12 (~70%) of SDGs are sensitive and relevant to AMR

– 12/17 AMR FFA1 areas or 5/5 GAP2 strategic objectives

are covered by at least 1 highly relevant indicator

▪ AMR sensitive indicators focus on the human One

Health dimension

– Over 60% of AMR relevant indicators focus on 1 One

Health dimension, ~10% on 2 or 3 areas and ~30% on

all four areas

– Indicators relating to human health are ~2-3 times more

common than those relating to animal health, plant

health or the environment

1.1

1.2



22

SDGs

FFA1 content areas and enabler, based on descriptive relevance of SDG indicators

The SDG indicators are very relevant for AMR and have multiple

interfaces with the FFA1

Insights

▪ The SDG

framework is very

relevant to AMR –

~70% of SDGs

include indicators

relevant to AMR

(covering on

average ~50% of

AMR areas)

▪ There are currently

no AMR-specific

SDG indicators

▪ 12 out of 17 AMR

areas are covered

by at least 1 highly

relevant indicator,

however the

extent of

coverage and

relevance varies

significantly

between areas

Relevant Specific Sensitive Highly

relevant

Somewhat

relevantNeutral Enablers

1 AMR Framework for Action

11.1

SOURCE: AMR FFA1; SDG Indicator Framework; Expert interviews; Team analysis


Click here for backup

23

Consistent with the findings on the FFA1, SDG indicators are also very

relevant to the GAP

GAP strategic objectives, based on descriptive relevance of SDG indicators

Awareness

Surveillance

and research

Infection

control

Human and

animal use

Economic

Case 1 2 3 4 5

11.1

1 AMR Framework for Action

Insights

▪ There are currently

no AMR-specific

SDG indicators

▪ The SDG

framework is very

relevant to the

GAP – ~70% of

SDGs include

indicators

relevant to the

GAP (covering on

average 75% of

GAP objectives)

▪ All GAP

objectives are

covered by at

least 1 highly

relevant indicator,

however the

extent of

coverage and

relevance varies

significantly

between GAP

objectives

Relevant Specific Sensitive Highly

relevant

Somewhat

relevantNeutral

SOURCE: GAP; SDG Indicator Framework; Expert interviews; Team analysis


SDGs


24

One Health dimensions covered

# of indicators, incl. double indicators

Over 60% of AMR relevant indicators focus on 1 One Health dimension,

and the human dimension is ~2-3x more often represented

Prevalence of One Health dimensions in AMR

relevant indicators

% of AMR relevant indicators relating to dimension

37%

37%

Plant

Human

Animal

35%

Environ-

ment

93%

2-3X

E.g. 6.3.1 Proportion of

wastewater safely treated

SOURCE: One Health Initiative; SDG Indicator Framework; Expert interviews; Team analysis

244

90

54

154

27

Tota

l

3

Not

rele

vant 3

dim

ensio

ns

6

Rele

vant 4

dim

ensio

ns 2

dim

ensio

ns 1

dim

ensio

n

All Human

1.2


25

Contents


▪ Full analysis








26

Section summary: What aspects of AMR are missing in the SDG indicators?

Despite the high relevance of the SDG indicator framework to

AMR, blindspots remain across content areas, incl.

▪ Missing key elements, e.g., good stewardship and prevention of

human misuse/wrong use of AMs

▪ Missing specificity, e.g., on channeling R&D resources towards

the development of new AMs

▪ Overall neglect of topics, e.g., animal biosafety/biosecurity and

use


2


27

Human useClean water/sanitationHuman infection prevention Environmental contaminationBiosafety/biosecurity Food safety Animal/agricultural use

Laboratory capacity/surveillance Development of new therapeuticsBasic research Access to therapeutics Vaccine development and accessDiagnostics development and access

Quality Coalition buildingGlobal roadmapNational action plans 1 Awareness 2 Surveillance/research 3 Infection 4 Use 5 Economic case

SOURCE AMR, A Threat to the World’s Sustainable Development (ReAct); SDG Indicator Framework; Expert interviews; Team analysis

SDG indicators are not AMR specific, and there remain critical blindspots


Type of

blindspots

▪ Areas are neglected overall: Large parts are not covered, and those elements captured lack

often specificity, e.g.,

– Animal biosafety and biosecurity

– Animal/agricultural use

– Food safety (SDG indicators predominantly cover food from an access perspective)

– Quality (SDG indicators predominantly cover medicines from an access perspective)

Large

blindspots

Observations

Partial

blindspots

▪ Areas are in large parts covered, but key elements necessary for AMR are neglected, e.g.,

– Human use, lacking stewardship and prevention of misuse/wrong use

– Infection prevention and control, neglecting healthcare associated infections

– Vaccine development and access, not including veterinary immunization

Generally

covered,

but

lacking

specificity

▪ Areas are generally covered, but indicators are unable to capture AMR specific outcomes

due to too broad scope (e.g., development assistance to medical research, which could but

not necessarily does encompass medical research for AMs)

▪ Key areas where coverage is too broad are

– Surveillance and R&D (broad indicators not channeling resources to AMR)

– Environmental contamination (either specific (water-)protection or general sustainable

production/consumption indicators without mention of AMR)

– Enablers (SDG 17 governance mechanisms currently don’t cover AMR as AMR is not an

explicit part of SDGs)

– Access to therapeutics (broad indicator on essential medicines)

3

4

No major▪ Relatively strong coverage of water/sanitation, from ambient water to waste water and water

use/efficiency (as clean water/sanitation is not AMR specific per se)

GAPAMR FFA

Sample areas

1

2

5


2

28

Contents


▪ Full analysis








29

Section summary: How can AMR be better anchored?



For opportunities not prioritized/adopted for inclusion into SDG

indicators, the IACG can consider 4 other options to make

opportunities come alive otherwise

3.2

There are 3 options to better anchor AMR within the SDGs

▪ Leveraging existing indicators and engaging with custodial agencies to

anchor AMR in implementation

▪ Leveraging existing indicators and explicitly calling out AMR

▪ Adding new AMR-specific indicators

3.1

a

b

c

30

Options within and beyond the SDGs are explored to better anchor AMR,

leveraging both what already exists and what could be added

Examples

Strictly illustrative, additions bolded


Within the SDGs Beyond the SDGs

Options to better anchor AMR Objectives

Leverage

existing

indicators

▪ Anchor AMR through additional, AMR-specific

indicators

▪ Close main coverage gaps and promote global

AMR governance

▪ Position AMR more prominently on the global

stage

Proportion of AM consumption by AM

type

Immunization coverage in food

producing animals

Non-therapeutic use of AM in food

producing animals

Add new AMR indicator(s)

Explore options

beyond SDGs

▪ Look for different vehicles beyond SDG

indicators to anchor AMR on a global level, e.g., by

– Consolidating existing information

– Leveraging existing frameworks

– Setting up a new independent mechanism

– Setting up a new country-driven mechanism

▪ Include indicator into WHO100

▪ Synthesize information from GAP

M&E into stand-alone composite

indicator

▪ Create country-data driven dashboard

3.3.2 Tuberculosis (TB) incidence per

100,000 population, incl. % of new TB

cases with multi-drug resistant TB

3.b.2 Total net official development

assistance to medical research and

basic health sectors, incl. prevention of

AMR

▪ Explicitly call out AMR by including AMR

– Either in definition of indicator

– Or by disaggregating metric for AMR

▪ Bring AMR specificity into SDG indicators

▪ Promote AMR-relevant data collection/reporting

Add AMR to

existing

indicator(s)

Anchor

AMR in

implement-

tation

Engage with UNEP to promote inclusion

of AMR in country sustainable

consumption plans (12.1.1)

▪ Do not change text of framework

▪ “Backdoor” to SDG indicators

– Engage with custodial agency

– Include AMR in metadata

3.1


a

b

c

31

Other options beyond the SDGs can be further explored

Leveraging of

existing efforts

to better

communicate/

consolidate

Opportunities

SelectedObjectives Key considerations

▪ Use existing

reporting

▪ Consolidate and

synthesize to

achieve specific

targets

Inputs from

this effort

▪ Leverage

– Identified

blindspots

in coverage

of AMR

– Developed

toolbox of

potential

opportuni-

ties

(prioritized

and non-

prioritized)

▪ Drop

feasibility

constraints for

inclusion in

SDG indicators

▪ Define key stand-alone

composites / spiders

drawing on, e.g., SDG

indicators and M&E work

▪ Identify ‘neglected

audiences’ and create

tailored communication

Integration in

existing

reporting

framework

▪ Add AMR to existing

reporting, e.g., AMR

indicator into WHO 100,

GAP M&E approach, WHO

GPW, 10YFP1

▪ Requires mapping of

current efforts, incl.

timelines for changes

▪ Depends on respective

stakeholders and process

New indepen-

dent indicators/

dashboard by

NGOs

▪ Create new effort

through independent

actor


targeted mechanism

▪ Leverage low constraints

of independent actors (e.g.,

like CARA by CDDEP)

▪ Needs building of targeted

stakeholder community

and support with political

clout

New indicators/

dashboard of

country-driven

data

▪ Create new reporting

logic through

country-driven data


targeted mechanism

▪ Build on countries to

create information (e.g.,

AMR decision-maker

dashboard)

▪ Requires balance

between what should be

and what is already there

in terms of data

▪ Needs identification of key

decision-relevant indicators

Other options

beyond SDGs

There are 4 options to make identified opportunities not prioritized/not adopted

by IACG come alive beyond the SDG indicators


3.2

▪ Requires understanding

of landscape of available

data

▪ Offers limited degrees of

freedom for target-driven

shaping of efforts

▪ Leverage existing

efforts to better

anchor AMR

SOURCE: Expert interviews; Team analysis1 10-year framework of programmes on sustainable consumption and production


Create new efforts Utilize existing efforts

32

Other options beyond SDG indicators deep-dive (1/2)3.2

SOURCE: Global Reference List of 100 Core Health Indicators (plus health-related SDGs), 2018; Monitoring and evaluation of the Global Action Plan on

Antimicrobial Resistance: Proposed approach DRAFT FOR CONSULTATION, August 2017

Exemplary

WHO 100

▪ Global reference list of 100

Core Health Indicators

▪ Provides concise

information on the health

situation and trends, incl.

responses at national and

global levels

▪ Split in core and additional

indicators

Integration

in existing

reporting

framework

Leverage

existing

frameworks

and better

communicate/

consolidate

Challenges

▪ Bar for inclusion into core

set is high and requires,

e.g., ”strong track record of

extensive measurement

experience with the indicator”

▪ Additional indicators are

significantly less visible

▪ Limited ability to set

ambition and make a step

forward

▪ Constrained by scope of

M&E approach and survey

results

Option Opportunities

▪ Leverage extensive information

provided by annual global AMR

monitoring survey

▪ Generate impact with little

additional effort

Leverage data from GAP

M&E for targeted analysis/

communication, e.g., by

calculating composites

▪ Prominent framework with high

visibility for decision makers and

broader public

▪ Is a living document and annually

refined to reflect shifting global

health priorities

▪ Draws on other key frameworks,

incl. SDG indicators

▪ Endorsement by IACGs is explicit

reason to be included in core list

Include AMR indicator into

WHO 100

A

B

Example

GAP M&E approach

▪ System of AMR M&E

brought forward by

Tripartite (WHO, FAO, OIE)

▪ Informs operational

and strategic decision

making on AMR for the

next 5-10 years

▪ Extensively consulted with

countries and other

stakeholders



33

Other options beyond SDG indicators deep-dive (2/2)3.2Exemplary

SOURCE: CDDEP; Team analysis

AMR dashboard

▪ Proposal for AMR

dashboard and reporting

logic

▪ Provides tailored reporting

for key decision makers

▪ Cascade of M&E from

global to local level

New

indicators/

dashboard of

country-

driven data

New

independent

indicators/

dashboard by

NGOs

Challenges Option Opportunities

Build new independent

dashboard like CARA

Create country-driven

dashboard for decision

makers

C

D

Example

CARA (CDDEP)

▪ Alliance of public, private,

for-profit and non-profit

organizations

▪ Commitment to report

mutually agreed upon

indicators, incl. AMR, AMC,

IPC, and policies/guidelines

▪ Bi-annual reporting to

the UN

▪ Tailor reporting to key decision

makers, incl. bespoke breadth and

depth of M&E

▪ Make connection between global

high-level reporting and indicators

capturing realities and priorities of

each region or country

▪ Complement utilization of as-is

routine reporting with realistic

ambition

▪ Decentralized data collection and

reporting

▪ Bottom-up definition of priorities

and indicators

▪ Opportunity to operate beyond

constraints faced by UN and other

formal mechanisms to become

‘eyes and ears of the world’

▪ Stakeholder community

needs to be built from

scratch

▪ Voluntary participation

▪ Need to acquire resources

▪ Necessity to build

sponsorship and visibility

▪ Strike balance between

ambition and feasibility

▪ Get country buy-in and

necessary sponsorship

▪ Align stakeholder

interests and priorities



34

Contents


▪ Full analysis








35

Section summary: What concrete opportunities might the IACG consider to

better anchor AMR in the SDG indicators?


For all 3 options to anchor AMR in the SDG indicators concrete

opportunities are identified and prioritized

▪ 5 indicators in SDG 2, 3, and 12 have key opportunities to engage with

custodial agencies and anchor AMR in implementation

▪ 3 indicators in SDG 3 and 12 offer opportunities to explicitly call-out

AMR

▪ 3 new additional indicators are proposed for consideration by the IACG

4

a

b

c


36

8 opportunities to better anchor AMR within the existing framework

emerge from a core-set of ~30 indicators examined in detail# of indicators at the end of stagexDeep dive in the following

1 Incl. inclusion of AMR in implementation 2 Counting equivalent indicators as 1 (e.g., disease incidences)


4a,b

232

~90

~301~40

Start from AMR-sensitive

indicators

Filter-out indicators

with low relevance or

obviously not suitable

Perform quick

assessment and

identify key

opportunities

Example

in 3.b.2 Total net official

development assistance to

medical research and basic

health sectors

6.3.1 Proportion of

wastewater safely

treated

3.3.2 Tuberculosis

incidence per 100,000

population

Perform detailed

assessment and develop

suggestions for

consideration

Add AMR to existing

indicator(s)

Include AMR in

implementation

3.4.2 Suicide mortality rate

11.1.1 Proportion of

urban population living

in slums, informal

settlements or

inadequate housing

2.1.1 Prevalence of

undernourishment

Example

out

a

b

81,2


37

There are promising opportunities to engage with FAO, WHO and UNEP

to anchor AMR in implementation of indicators

4a


Good health

and well-being3

IndicatorSDG

Opportunities to include AMR

in implementation

Tier clas-

sification

Zero hunger22.4.1 Proportion of agricultural area under

productive and sustainable agriculture

Engage with FAO to include

AMR in definition of

sustainable agriculture

III

Engage with WHO, UNICEF

and Gavi to shape programs to

include vaccines relevant in

AMR context

3.b.1 Proportion of the target population covered

by all vaccines included in their national

programme

II

Responsible

consumption

and

production

12

12.1.1 Number of countries with sustainable

consumption and production (SCP) national action

plans or SCP mainstreamed as a priority or a target

into national policies

Engage with UN Environment

to include AMR in definition of

SCP policies

II

Custodial

agency

Details in the backup

II

I Engage with WHO to

disaggregate resistant cases 3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases incidences

(TB, Malaria, HIV, Hepatitis B) 3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases incidences



(TB, Malaria, HIV, Hepatitis B)

3.b.3 Proportion of health facilities that have a core

set of relevant essential medicines available and

affordable on a sustainable basis

Engage with WHO to

disaggregate access to

essential AMs, potentially

adjusted for stewardship/ quality

III

SOURCE: SDG indicator framework; Expert interviews; Team analysis


38

31 opportunities emerge to explicitly call-out AMR

SOURCE: SDG indicator framework; Expert interviews; Team analysis 1 Counting incidences as 1 opportunity


4b

Details in the backup

SDGs

3

12

Responsible

consumption

and production

Rationale

Adjusted indicators

Selected; proposed adjustments colored

and bolded

▪ Promote awareness on and

adequate behavior for AMR

as key global challenge

next to

climate change

12.8.1 Extent to which (i) global citizenship

education and (ii) education for sustainable

development (including climate change and AMR

education) are mainstreamed in (a) national

education policies; (b) curricula; (c) teacher

education; and (d) student assessment

Good health and

well-

being

▪ Establish resistance in

communicable diseases of

main concern as outcome

measure for AMR

3.2.1-3 Maternal, Under-5, and Neo-natal

mortality rate, incl. mortality due to AMR3.2.1-3 Maternal, Under-5, and Neo-natal


mortality rate, incl. mortality due to AMR3.3.1, 3.3.2, 3.3.3, 3.3.4 communicable disease

incidence, % of resistant cases

▪ Anchor AMR as component

of universal health

coverage

3.8.1 Coverage of essential health services

(defined as the average coverage of essential

services based on tracer interventions that include

reproductive, maternal, newborn and child health,

infectious diseases (incl. effective sanitation,

hygiene and infection prevention measures),

non-communicable diseases and service capacity

and access, among the general and the most

disadvantaged population)

3

12


39

3 indicators are prioritized to be considered by the IACG for inclusion into

the SDG indicators based on a long-list of ~300 indicators

# of indicators at

end of stage

xDeep dive in

the following

SOURCE: Team analysis; ECDC, EFSA, EMA Joint Scientific Opinion

4c

▪ Compile long-list of

AMR indicators,

e.g., from

– WHO Tripartite

work

– GLASS

– EU Scientific

Opinion

– Expert opinions

Long-list

indicators

▪ Synthesize and

integrate similar

indicators

▪ Identify

overarching

primary

indicators

▪ Exclude too

granular and

detailed

secondary

indicators

Synthesize and

consolidate

▪ Create high-

level shortlist of

indicators and

detail-out, incl.

feasibility,

relevance, and

One Health

dimensions

▪ Test indicators

with experts and

prioritize

Short-list

indicators

▪ Perform detailed

assessment of

identified key

indicators

alongside

– Metadata

requirements

– Established set

of key criteria

▪ Recommend for

consideration

Assess in detail and

identify key

opportunities

~300

15~50

…

Experts3


40

15 indicators are shortlisted for potential inclusion into the SDG indicators

SOURCE: WHO Tripartite; Classifying antibiotics in the WHO Essential Medicines List for optimal use—be AWaRe (Mike Sharland et al,

Lancet, 2018); ECDC, EFSA, and EMA joint scientific opinion on a list of outcome indicators as regards surveillance of antimicrobial resistance and

animicrobial consumption in humans and food-producing animals, 2017; expert interviews

1 Defined daily doses

4cRelevant R Current stakeholder alignment SA Implementable in countries IC Fitting into SDGsFSDG Potentially covered Most likely covered

Not/hardly given Mostly/fully givenPartly given Human See next page for prioritization Animal Plant Environment

Click on indicator

name for backup

Indicator


Drivers

Outcomes

Cross-type

composites

Optimize

use

Innovate and ensure access

Reduce

need

Type

Enablers

Description, indicative

x

Somewhat relevantRelevantVery relevantCritical Not/marginally relevant

Level of resistance

(in humans)2 ▪ Level of resistance for top 1-3 drug/bug combinations;

potential extension to animal health in future

Disease burden1▪ Disease burden caused by AMR in DALY; potential

extension to animal health in future

Drug resistance index 3 ▪ Effectiveness of available drugs as ability of antibiotics to treat

infections and the extent of their use in clinical practice

Investment level in R&D11 ▪ Investment in AMR R&D (incl. vaccines/alternatives), e.g., by

% of GDP, for novel types

Pipeline size12 ▪ # Novel drugs/alternatives in pipeline, e.g., attrition adjusted

Risk-weighed AMR capacity 14 ▪ Size of AMR-prevention toolbox vs. resistance level

Incremental economic

cost of AMR15 ▪ Marginal cost of AMR and AMR abatement

Health system capacity 13 ▪ Strength of AMR capacity of health system (often composite),

distinguished in human/veterinary

Infection rate of food

producing animals 5 ▪ Prevalence of clinical infections in food producing animals

(e.g., by biomass or % of animals)

Immunization coverage in

food producing animals4 ▪ Immunization in animal agri-/aquaculture by disease

(complementing indicator 3.b.1)

Regulation of growth-

promotion in food producing

animals

7 ▪ Potential dimensions include existence of regulation, scope

of regulation (e.g., AM classes, specifications), degree of ban

(e.g., full/partial/none)

Assessment

Rele-

vance ICSA FSDG

Feasibility

One Health

AM use in food

producing animals8 ▪ Quantities of AM use in food producing animals, e.g., by AM

class and biomass

Proportion of AM

consumption by AM type 9 ▪ % of Access AMC vs. Watch/Reserve AMC

Growth promotion in food

producing animals 6 ▪ Numbers of countries using AM for growth promotion

AMC in humans10 ▪ Total AMC for systemic use (DDDs)1

41

3 indicators are suggested for consideration by the IACG which strike a

balance between relevance and feasibility

4c


Feasibility/relevance matrix

Indicative

Rele

va

nc

e

Feasibility

2 8 93 5

6

10

4

11 12

13

14 15

Prioritized indicators

Preliminary definition Rationale

Proportion of AM

consumption by AM type

9

3.8.X Access-Watch

Index of AMC by

country/region

▪ Is widely respected,

robust, and universal

▪ Improves access and

clinical outcomes

▪ Reduces potential for

development of AMR

▪ Preserves effectiveness

of last-resort antibiotics

▪ Is foundational metric of

animal One Health

dimension

▪ Indicates potential

emergence of AMR

AMC in food

producing animals

8

2.4.X AM use in food

producing animals

by biomass

Level of resistance

(in humans)

2 ▪ Is foundational

metric for AMR

▪ Provides resistance level

for key community and

hospital acquired

pathogens

3.8.X Level of resistance

for top 1-3 drug/bug

combinations

Not feasible Primary opportunities (prioritized) Secondary opportunitiesx Indicators, see previous page

Ve

ry h

igh

Lo

w


1 7

Details on next page

42

Example for proposal for a new indicator: 2.4.X Use of antimicrobial

agents in animals

SOURCE: OIE, Interviews

Background

1 Specifically Chapter 6.8 of the OIE Terrestrial Animal Health Code

2 Total weight of live domestic animals ipopulation, used as a proxy to represent those exposed to reported Ams

3 OIE annual report on the use of antimicrobial agents intended for use in animals, Second Report, see here

▪ OIE has received a mandate from its 182 member countries to collect

and report data on AM use in animals

▪ The methodology is established through OIE’s international standards1

and annual data collection and reporting is in place

▪ A training system has been established for Member Countries to

support their data collection and reporting

Data availability


▪ 107/146 (73%) countries reported quantitative data for one or more

years between 2013 to 2016

▪ Data based on different sources, mostly import and sales

▪ Possibility to analyze AM quantities reported adjusted by a

denominator (animal biomass)2

Initial results


▪ Global estimate of AM use in animals of 98.97 mg/kg (best estimate)

to 134.31 mg/kg (upper level estimate)

▪ Includes data from 60 countries during the first two phases of data

collection

Objectives ▪ Encourage prudent and responsible

use of antimicrobials in livestock

agriculture in accordance with the

Global Action Plan on AMR

Overview

Target 2.4: By 2030

ensure sustainable food

production systems and

implement resilient

agricultural practices (…) SDG

context

2.4.X Use of antimicrobial agents in

animals, adjusted for animal biomass

Proposed

indicator

Tier ▪ Conceptually clear with internationally

established methodology and

standards

▪ Data available and regularly produced

by countries for at >50% of countries

and of the population in every region

where the indicator is relevant

I

Custodian Partner

Agencies More details here


4c



43

Contents


▪ Full analysis








44

Section summary: What are next steps?


NEXT STEPS

It is still possible to change the SDG indicator framework

▪ The SDG indicators are a living document that provides for changes in

annual reviews as well as comprehensive reviews 2020/2025

▪ Adjustments to existing indicators must be proposed by summer 2018,

new indicators by end of 2018. Engagement with custodial agencies is

not timebound

▪ There is reluctance to re-open the framework borne by political reasons

5.1

Chances of better anchoring AMR in the SDGs can be maximized by

aligning the ‘right’ indicator content with stakeholders and adopting

adequate tactics

5.2

45

Several options to better anchor AMR require changes in the text of the

indicators, which is possible but challenging

SOURCE: Expert interviews; IAEG-SDG; Team analysis; https://unstats.un.org/sdgs/files/meetings/sdg-inter-agency-meeting-2018/11.%20IAEG-

SDGs_7th%20Meeting.pdf; Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators 2017, 2018

▪ The SDG indicator framework is set up as living

document

▪ Adjustments and changes are explicitly endorsed by

resolution A/RES/71/313

▪ The 2020 and 2025 comprehensive reviews provide for

new indicators to be added, and the IAEG-SDG itself

considers currently 37 indicators for inclusion1

▪ Other stakeholders also attempt including new indicators2

Opportu-

nities

“Proposing a new indicator is ‘reopening Pandora’s

box’” IACG member

“Chances are very low to add more than 1 AMR-

specific indicator to the SDG indicator framework”

IAEG-SDG

“There is an unspoken agreement that we will not

touch the indicator framework”

Country representative to the UN

▪ The development of the indicator framework was highly

political and required extensive mutual concessions

▪ There is an apprehension that re-opening the framework

might induce extensive re-negotiations and might not be

worth the risk from country perspective

Challenges

Assessment of potential to realize changes to indicators

Possible without changing frameworkRequires change of framework text

Options to anchor AMR in SDG

indicators

Add AMR to existing

indicator(s)

Include AMR in implement-

tation

Add new AMR indicator(s)

5.1

a

b

c

1 E/CN.3/2017/2

2 E.g., "TOSSD";

https://www.oecd.org/dac/TOSSD%20flyer%20DAC%

20HLM%202017.pdf

NEXT STEPS


46

SDG indicators are a living document – comprehensive reviews offer the

possibility to make changes to SDG indicators

SOURCE: http://sdg.iisd.org/news/ecosoc-adopts-sdg-indicator-framework; https://unstats.un.org/sdgs/files/meetings/sdg-inter-agency-meeting-

2018/11.%20IAEG-SDGs_7th%20Meeting.pdf; Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators 2017, 2018

Relevant to introduce new indicators/components SDG indicator framework inclusion process

Impact

5

Draft by IAEG-SDG Adoption by ECOSOC Adoption by GA

Review

cycles

4

1 2 3

Refinement by

IAEG-SDG

Description

No comprehensive

review has taken

place yet

▪ Follow up and

review of

sustainable

development

along indicator

framework

(resolution 70/1)

▪ Annual

progress report

on the SDGs

▪ Delivery by

2030

▪ Adoption through

resolution

A/RES/71/313

▪ Endorsement of

“initial set of

indicators to be

refined annually

and reviewed

comprehensi-

vely” by the

Statistical

Commission

▪ Adoption for

submission

to UN GA

Timeline2017-2030: annual reviews

2020; 2025: comprehensive review

2030 July 2017June 20172015-17

▪ Establishment of

IAEG-SDG by

UN Statistical

Commission

▪ Development of

draft resolution,

incl. indicators and

classification by

IAEG-SDG

▪ Bi-annual meetings

▪ Only editorial (no substantive)

changes

Annual reviews

▪ Two times, 2020 and 2025▪ Substantive changes possible,

e.g., potentially 35 new indicators suggested by IAEG in 2017 currently in consultation

▪ Open consultation of changes to framework in 2019

▪ Proposals for new indicators optimally in 2018 (timelines not fully clear yet)

▪ Final report by IAEG to UNSD end of 2019

Window for substantive

changes to the indicators

NOTE: (UN)GA: United Nations General Assembly; ECOSOC: United Nations Economic and Social Council; IAEG-SDG: Inter-agency Expert Group on SDG indicators

43 521

Comprehensive reviews

NEXT STEPS

5.2


http://sdg.iisd.org/news/ecosoc-adopts-sdg-indicator-framework


47

To maximize chances of success, it is critical to align the ‘right’ content

extensively with stakeholders and adopt appropriate tactics Covered through this effort Priorities going forward

SOURCE: Expert interviews; Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators 2017, 2018

5.2

Stakeholder alignment

Ensure comprehensive

stakeholder buy-in

▪ Ensure buy-in and support

from key stakeholders, i.e.,

– DSG

– Potential custodial

agencies

– Tripartite

▪ Make extensive

consultation with broad

stakeholder public, incl.

(potential) custodial agency,

public health funds, country

statisticians

▪ Pre-align proposition with

IAEG members

Content

Tactics

Selected success factors

▪ Frame changes as necessary to

fully cover existing targets to

align with criteria for inclusion1

▪ Prioritize tier I indicators to not

burden countries more

▪ As possible, prioritize existing

indicators in SDG 3 and new

indicators in other SDGs2

▪ Rigorously limit number of

proposition to IAEG

▪ Target 2020 comprehensive

review, given that leeway for

change in 2025 is yet unclear

▪ Ensure alignment with all

possible guidelines, e.g.,

metadata template, SDSN1

recommendations

▪ Balance relevance

with feasibility, incl.

stakeholder alignment, ability

of countries to implement, and

fit with SDGs

Consider success

factors Develop content that

aligns with the SDGs

1 Report of the Inter-agency and Expert Group on Sustainable Development Goal Indicators (E/CN.3/2017/2), para. 22

NEXT STEPS

48

Backup

To what extent is AMR reflected in the SDG indicators?

What aspects of AMR are missing in the SDG indicators?

How can AMR be better anchored?

Introduction and approach

What concrete opportunities might the IACG consider to better anchor

AMR in the SDG indicators?

What are next steps?

Miscellaneous

49

Simple and clear targets and metrics can help drive progress on complex

global challenges

SOURCE: The Millennium Development Goals Report 2015; The Guardian: How successful were the millennium development goals?; Wernli et al.:

Antimicrobial resistance: The complex challenge of measurement to inform policy and the public

Rationale

▪ Bolster capacity

to tackle problems

▪ Enable informed

decisions based

on best scientific

evidence

▪ Reduce

information

uncertainty

▪ Allow countries to

benchmark their

national and

intranational

performance

▪ Create better

conditions for

cooperation and

disincentivize free-

riding

▪ Foster greater

involvement and

advocacy

Overarching

MDGs

▪ Overarching development

framework 2000-15

▪ >20 mn lives saved and >480

mn people lifted out of

poverty due to accelerated

progress

SDGs

▪ Overarching development

framework 2015-30

▪ Ambitious (“zero”) goals, with

more universal,

comprehensive, and inclusive

character

Examples

Topic

specific

Food

secur-

ity

Climate

change

Kyoto / Paris agreements

▪ Keep global warming to <2 centigrade

▪ Set emission targets by country

▪ Strengthen the ability of countries to deal with the impacts of climate

change

▪ Establishes set of partially new, partially otherwise reported

indicators to track food security

▪ Provides single data-base for effective monitoring

Food security indicators

OHCHR methodology for human rights

▪ Provides framework and methodology to track human rights globally

▪ E.g., dashboard tracking ratification of 18 International Human Rights

treaties as structural indicator

Human

rights


50

Sustainable development and AMR are highly interlinked

244

Reliant

165

Total

79

Not/

marginally

reliant

Highly reliant

n/a

Somewhat reliant

Reliant

Reliance of SDG indicators on AMR

# indicatorsAMR requires unprecedented levels of

global coordination

AMR puts the achievement of some

SDGs indirectly at risk, due to cascading

impacts on economic wellbeing & inequality

Further SDGs minimize the negative

impact of AMR and have implications for

the implementation of global and

national action plans

AMR puts the achievement of SDGs

related to health, agriculture, animals,

the environment and food directly at

risk. In addition, actions and objectives

related to these SDGs are closely related

to individual AMR content areas

SDG 3 “will be

impossible to

achieve without

effective

antimicrobials”1

1 Antibiotic resistance (ABR) - no sustainability without antibiotics. Otto Cars & Dusan Jasovsky, ReAct – Action on Antibiotic Resistance, reactgroup.org

SOURCE: Framework for Action Supported by the IAC, 2017


51

AMR is mentioned in the pre-amble to the SDGs – but only thereFocus of this effort

AMR SDG indicator framework

“AMR is a missing topic in the Sustainable Development Goals”1

Otto Cars & Dusan Jasovsky

1 Antibiotic resistance (ABR) - no sustainability without antibiotics. Otto Cars & Dusan Jasovsky, ReAct – Action on Antibiotic Resistance, reactgroup.org

▪ AMR threatens to undermine the effectiveness of

modern medicine with an ever rising number of

resistant bacterial strains

▪ Danger of reversion of much of the progress

made under the MDGs

▪ AMR is a highly complex topic, requiring but

lacking an agreed overarching metric

▪ There has been some progress on monitoring,

including Global Antimicrobial Resistance

Surveillance System (GLASS), World Animal Health

Information System (WAHIS), Global action plan on

AMR (GAP), and GAP M&E framework

▪ AMR is mentioned in UN Declaration on

Sustainable Development Goals, para. 26

▪ There is no explicit/specific mentioning of AMR in

the SDGs and related indicators

▪ However, sustainable development and AMR are

highly interlinked

▪ This warrants a more detailed analysis of the

degree to which AMR is reflected in the SDGs as

well as if and how AMR could be embedded

further in the SDGs and beyond



52

Backup




Context: The SDG indicators and AMR




Miscellaneous

53

The breadth of AMR coverage is overall high

Reduce need

and

unintentional

exposure

Invest in

innovation,

supply and

access

Enablers

Optimize use of

medicines

Key SDGs

Relevant

indicators, #,

all sensitiveAMR areas

1.1

Key AMR sensitive topics in SDG indicators

▪ Systemic factors, e.g., spending on R&D

▪ Country cooperation

Examples for indicators

▪ Governance and monitoring of SDG

▪ Disease incidence

▪ Country and private cooperation

▪ Systemic factors, e.g., spending on public health

17.14.1 Number of countries with mechanisms in place to enhance

policy coherence of sustainable development

▪ Water and sanitation (from ambient water quality

to water efficiency)6.1.1 Proportion of population using safely managed drinking water

services

▪ Sanitation and environmental protection

▪ Systemic factors (e.g., essential services)

▪ n/a 3.3.5 Number of people requiring interventions against neglected

tropical diseases

▪ Food security and undernourishment

▪ Mortality ratios

▪ n/a2.1.1 Prevalence of undernourishment

▪ Mortality, specific disease incidence, public

health system and sanitation / water 3.2.1 Under-5 mortality rate

▪ Water and sanitation

▪ Waste management and sustainable production6.3.1 Proportion of wastewater safely treated

▪ Systemic factors (e.g., poverty, food security)

▪ Sustainable production and agriculture

▪ n/a 1.2.1 Proportion of population living below the national poverty line,

by sex and age

▪ Public health systems

▪ Disease incidences 3.8.1 Coverage of essential health services

▪ Systemic factors, e.g., spending on public

health and health coverage 9.5.2 Researchers (in full-time equivalent) per million inhabitants

▪ Public health systems, e.g., access to basic

services 3.b.3 Proportion of health facilities that have a core set of relevant

essential medicines available and affordable on a sustainable basis

▪ Systemic factors, e.g., spending on R&D 9.5.1 Research and development expenditure as a proportion of

GDP

▪ Systemic factors, e.g., spending on R&D and

access to basic services 3.b.1 Proportion of the target population covered by all vaccines

included in their national programme


▪ Incidence of R&D critical diseases (e.g., TB)3.b.2 Total net official development assistance to medical research

and basic health sectors

▪ Disease incidence

▪ Systemic factors, e.g., access to basic services 1.a.2 Proportion of total government spending on essential services26

27

46

52

25

46

23

20

39

40

62

24

23

51

32

60

27

Somewhat relevant

Highly relevant

Relevant



54

The breadth and relevance of coverage varies across AMR areas1.1

▪ Relevance of

indicators depends

on AMR area, and

ranges from 0% highly

relevant indicators

(e.g., quality) to 33%

(access to all

therapeutics)

▪ Breadth varies, too,

from 20 relevant

indicators in animal

and agricultural use to

over 62 in clean water

and sanitation

▪ Breadth and

relevance are

indicative towards

depth of coverage, but

there are blindspots

across the board

Depth of coverage of AMR areas by SDG framework, indicative

Re

leva

nc

e

Medium/low

<30 indicators with relevance

High

>=30 indicators with relevance

Insights

Orphans

Targeted

coverage

Recurring themes

Broad coverage

Human

infection

prevention

Human use Clean water/

sanitation

National

action plans


Development of

new therapeutics

Basic research

Vaccine develop-

ment and access

Quality

Laboratory capacity/

surveillance

Animal/

agricultural use

Diagnostics develop-

ment and access

Animal

infection

prevention Coalition building

Food

safety

Global roadmap

Environmental

contamination

High

>=10% of

highly

relevant

indicators

Medium/

low

<10%

highly

relevant

indicators

Breadth



55

29

61

83

28

6

The breadth of coverage is relatively high1.1

Awareness

Surveillance

and research

Infection

control

Human and

animal use

Economic

Case

3.b.3 Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis

9.5.1 Research and development expenditure as a proportion

of GDP

3.b.2 Total net official development assistance to medical research and basic health sectors

6.1.1 Proportion of population using safely managed drinking

water services

2.1.1 Prevalence of undernourishment

3.2.1 Under-5 mortality rate

6.3.1 Proportion of wastewater safely treated

1.2.1 Proportion of population living below the national poverty

line, by sex and age


9.5.2 Researchers (in full-time equivalent) per million

inhabitants

3.b.2 Total net official development assistance to medical

research and basic health sectors

3.2.1 Under-5 mortality rate

9.5.1 Research and development expenditure as a proportion

of GDP

4.7.1 Extent to which (i) global citizenship education and (ii)

education for sustainable development, including gender

equality and human rights, are mainstreamed at all levels in

(a) national education policies; (b) curricula; (c) teacher


▪ Education on sustainable development in

education system

▪ Resource flows to and coverage of health

systems


▪ Incidence of R&D critical diseases

(e.g., TB)

▪ Country cooperation

▪ Public health systems, e.g., access to

basic services

▪ Mortality and specific disease incidence

▪ Sanitation and water protection

▪ Environmental protection

▪ Systemic factors (e.g., essential services,

undernourishment)

▪ Spending on public health and public health system access

▪ Disease incidence▪ Research spending (e.g., for diagnostics

development) ▪ Overarching themes, e.g.,

undernourishment, poverty

▪ Indications for economic cost of AMR,

e.g., <5 mortality rate

▪ Spending on R&D (as indication of

financing opportunities)

▪ Spending and access to public health

services (as indication of market size)

1

2

3

4

5

GAP objectives Examples for indicatorsKey SDGs

Key GAP sensitive topics in SDG

indicators

Relevant

indicators, #

Relevant

Highly relevant

Somewhat relevant



56

Like under the FFA, breadth and relevance varies across GAP strategic

objectives

1.1R

ele

va

nc

e

High

>=10% of

highly

relevant

indicators

Medium/

low

<10%

highly

relevant

indicators

Medium/low

<30 indicators with relevance

High

>=30 indicators with relevance

Orphans

Targeted

coverage

Recurring themes

Broad coverage

Insights

1

2

3 4

5

▪ Relevance of

indicators depends

on GAP objective,

and ranges from 3%

highly relevant

indicators (awareness)

to 29% (surveillance

and research)

▪ Breadth varies, too,

from 6 relevant

indicators in

awareness to as

many as over 83 in

infection control

▪ Although breadth and

relevance are

indicative towards

depth of coverage,

they are not conclusive

Awareness

Surveillance

and research

Infection

control

Human and

animal use

Economic Case

Breadth

Depth of coverage of GAP areas by SDG framework, indicative



57

Coverage of the results chain by AMR relevant indicators does not follow

any pre-defined logic

34 (38%) 19 (21%)

24435 (14%)

90

93 (38%)

17 (19%)

88 (36%) 28 (11%)

20 (22%)

Overall SDG

indicators

Thereof AMR

relevant

ImpactInput Output Outcome

20%

21%

23%

26%

23%

22%

33%

30%

AMR FFA

GAP

Distribution of indicators across the Results Chain by AMR frameworks

% of total, includes double countings for indicators applying to multiple FFA areas / GAP

objectives

3.1.1 Maternal mortality

ratio

9.5.1 Research

and development

expenditure as a

proportion of GDP

6.3.1 Proportion of

wastewater safely

treated

6.1.1 Proportion of

population using safely

managed drinking

water services

Examples, selected

▪ Overall, coverage of AMR-

relevant indicators across

the results chain does not

follow any pre-defined

logic

▪ The distribution is

input/impact heavy,

particularly on framework-

level. This implies rather

high-level input/impact

measures applicable for

many areas at once

Distribution of total indicators across the Results Chain

# indicators (% of total)

Insights


1


58

Backup








Miscellaneous

59

The breadth of AMR coverage is high,

but there are multiple blindspots

2 No major

Generally covered, but lacking specificity

Partial blindspots

Large blindspots


Reduce

need and

uninten-

tional

exposure

Invest in

innovatio

n, supply

and

access

Enablers

Optimize

use of

medicines

AMR areas

▪ No major

▪ Biosafety and biosecurity are neglected (e.g., husbandry/vaccines)

▪ Overall neglected, SDG indicators focus on access to food

▪ Healthcare associated infections and IPC are not covered

▪ Lacking specificity, i.e., targeted capturing of AMR outcomes

▪ Overall neglected, broad coverage through sustainable production

▪ Stewardship and correct use not captured

▪ SDG indicators focus on universal coverage

▪ Lacking specificity, implicitly and limitedly covered through health systems

▪ Lacking specificity, i.e., only covered broadly under access to medicines / healthcare

▪ Limited link to supply side and suppliers

▪ Lacking specificity

▪ Only indirect link to IPC

▪ Lacking specificity for AMs and AMR relevant vaccines

▪ Veterinary vaccines not captured

▪ Since AMR is not explicit part of SDG indicators, SDG 17 governance mechanisms

currently do not capture AMR

▪ Only indirectly covered under access to medicines / universal health coverage

▪ SDG indicators focus on access rather than quality

▪ Lacking specificity, e.g., channeling of resources to AMR relevant R&D

Blindspots, selected

Human use

Clean water/sanitation

Human infection prevention


Biosafety/biosecurity

Food safety

Animal/agricultural use

Laboratory capacity/surveillance

Basic research



Diagnostics development and

access


Quality

Coalition building

Global roadmap

National action plans


60

From the perspective of GAP there are significant gaps, which are

largely overlapping with those identified under the AMR FFA

2

No major Generally covered, but lacking specificity Partial blindspots Large blindspots

Key gaps, selectedGAP objectives

Economic

Case

▪ Missing linkage of AMR and sustainable economic development

▪ Only “bits and pieces” necessary for investment case development, such as components of AMR impact (e.g.,

mortality under 5; GDP development) or market size (spend on R&D, overall public healthcare access)

▪ No coherent quantification/tracking of economic impact of AMR and/or investment case

▪ Lacking de-linking of investment in research and development from price and the volume of sales

Human and

animal use

▪ No indicators targeting wrong use (indication, agent, or treatment duration) or misuse

▪ Strong focus on access to basic medication, but neglect of proper distribution, use, treatment compliance, and

availability of broad choice of drugs

▪ Animal use hardly covered

▪ Focus on R&D and access vs. diagnostics and proper use

▪ Neglect of veterinary vaccines

▪ Neglect of quality vs. availability of healthcare

Infection

control

▪ Weak coverage of healthcare associated infections

▪ Weak link to animal husbandry and agri- or aquaculture

▪ Preponderance of food availability over quality focus, e.g., undernourishment vs. food without resistant pathogens

Surveillance

and research

▪ No specific links to AMR

▪ Focus on R&D and access vs. diagnostics and proper use

▪ Missing propensity of indicator to resolve funding gap for antibiotics development due to lack of specificity

▪ Limited coverage of research agenda building, alignment, as well as research targets/outcomes

▪ Sometimes focus on particular pathogens (e.g., NTDs, Malaria, HIV), rather than broadly AMR relevant pathogens

(e.g., bacteria)

▪ Very limited supply/supplier focus

Awareness

▪ No specific link to AMR awareness; only awareness/education on general sustainable development, if at all

▪ Mostly indirect coverage, e.g., through general level of education/healthcare systems

▪ Missing targeting of different audiences, such as human health, animal health and agricultural practice as well

as consumers

1

2

3

4

5


SOURCE: Global Action Plan; SDG indicator framework; McKinsey analysis

61

Backup








Miscellaneous

62

There are 2 options to better anchor AMR in existing indicators Options changing

indicator text

Indicators can fit into multiple options


3.1

Example

Strictly

illustra-

tive

3.b.2 Total net official development

assistance to medical research and

basic health sectors

3.3.2 Tuberculosis incidence per

100,000 population

▪ Indicator remains the same

▪ Engage with OECD and try to include

AMR angle in tracking, e.g., assistance

for development of AMs or AMR

prevention programs

3.3.2 Tuberculosis (TB) incidence

per 100,000 population, incl. % of

new TB cases with multi-drug

resistant TB

When

to use

▪ Indicator is on different ‘flight-level’;

explicitly pointing out AMR would be

arbitrary/awkward

▪ AMR would fit well into meta-data for

indicator; carrier organization could be

sensitized for AMR

▪ Particularly tier II and III indicators

allow for inclusion of AMR in imple-

mentation, since they are method-

ologically not fully fledged yet

▪ AMR is a subset of indicator, but

currently not differentiated

▪ Specificity is required to capture

AMR and to increase AMR-

relevance of indicator

▪ Disaggregation of AMR fits into

broader picture of indicator

What it

is

▪ Text of indicator remains unchanged

▪ Suggestions are developed how to

implement indicator AMR sensitively

by

– Engaging with custodial agency;

and/or

– Rooting AMR in indicator metadata

▪ Text of indicator is changed and

AMR called-out explicitly

▪ Indicator is disaggregated to

include AMR

b

Include AMR in implementationa Disaggregate indicator for AMR

3.b.3 Proportion of health facilities that

have (…)

Proportion of health facilities that have

a core set of relevant essential medi-

cines available and affordable on a

sustainable basis and follow good

AMR stewardship

▪ AMR is currently not part of the

indicator, but would fit in

complementarily

▪ AMR is on same ‘flight level’ like

indicator (e.g., indicator already calls

out exemplary areas)

▪ Text of indicator is changed and

AMR called-out explicitly

▪ AMR is integrated into definition of

indicator

Reference AMR in the indicator itself

Add AMR to existing indicator(s)


63

Overview to AMR-relevant efforts beyond SDGs3.2Exemplary; opportunistic


One pagers in the following

Integration

in existing reporting

framework

Leverage existing

frameworks and

better communicate/

consolidate

Examples for key AMR-relevant

efforts, selected

New indicators/

dashboard of

country-driven data

▪ The FAO action plan on antimicrobial

resistance (and related publications, e.g.,

scientific material provided)

▪ WHO GPW

▪ The OIE Strategy on Antimicrobial

Resistance and the Prudent Use of

Antimicrobials

▪ WAHIS (OIE)

▪ FAOLEX

▪ OIE collection of AMU data

▪ World Health Statistics (WHO)

Examples for other AMR-relevant efforts,

selected

Global Action Plan M&E

approacha

WHO 100c

GLASSd

▪ CARA (CDDEP)

▪ AMR industry alliance (IFPMA)

▪ AMR benchmark (see call out under )

Access to medicines indexe

Resistance map fNew independent

indicators/

dashboard by NGOs

Potential decision-maker

dashboard g

e

10 YFPb

64

One pager: GAP M&E approach

What is

it?

Why

does it

exist?

How

does it

work?

Who are

key

stake-

holders?

Description Description

▪ Global and national performance

on GAP progress

Measured

subjects

In a nutshell: Framework of ~40 standard core indicators to

measure global and national progress on GAP

3.2a

▪ Countries, agencies, general

public

Users

▪ Tripartite of WHO, OIE, and FAO Carrier

▪ Measures progress on GAP, incl.

– Monitoring the process of GAP

implementation and evaluating how

to improve the response

– Monitoring outcomes and evaluating

the results at outcome and goal levels

▪ Set of c. 40 core-indicators and addi-

tional standard AMR progress indicators

▪ Comprehensive scope, incl. all One

Health dimensions and across the results

chain

▪ GAP defines responsibilities for national

governments, Tripartite, and others in

responding to AMR

▪ M&E approach sets out to ensure

action is being taken, and to assess

whether those actions are having the

intended results by

– Developing a manageable system

– Generating useful data to inform

operational and strategic decision

making

– Focusing on the next five to ten years

▪ Indicators aligned to structure and strategic

objectives of GAP

▪ Extensive consultation and strong focus on data

availability and systems capacity

▪ Data provided by countries (incl. via central tools

and dedicated Tripartite Global AMR survey; see

here) or globally via secondary sources (e.g.,

IHME)


SOURCE: Monitoring and evaluation of the Global Action Plan on Antimicrobial Resistance: Proposed approach: Executive summary, Draft 23 Janurary 2018

65

One pager: 10-year framework of programmes on

sustainable consumption and production patterns (10YFP)

What is

it?

Why

does it

exist?

How

does it

work?

Who

are key

stake-

holders

?

▪ Global framework of action to enhance

international cooperation to accelerate the

shift towards sustainable consumption

and production (SCP)

▪ Covers developed and developing

countries

▪ Generates collective impact through

multi-stakeholder programs

(governments, private sector, civil society,

researchers, UN agencies, financial

institutions, and other major groups and

partnerships), which develop, replicate

and scale up SCP policies and initiatives

at all levels

▪ Channels efforts through “programs”, which bring

together existing efforts, highlighting good practices,

build synergies/cooperation among stakeholders to

leverage and minimize duplication of ongoing efforts

▪ Current programs are

- Sustainable lifestyles and education;

- Sustainable public procurement;

- Sustainable buildings and construction;

- Sustainable tourism, including ecotourism.

▪ Current programs are not a numerus clausus, but

can be extended based on consultations and

stakeholder requests

▪ Promote important transversal role of

SCP as integral part of SDGs (SDG 12)

▪ Codified in indicator 12.1 “Number of

countries with SCP NAPs mainstreamed

as a priority or a target into national

policies”

▪ Aims to induce shift by, e.g., supporting

national policies, supporting capacity

building, facilitate information sharing,..


In a nutshell: Global framework for action to induce shift towards

sustainable consumption and production patterns

Measured

subjects

▪ Mostly governments / policy

makers (see M&E framework for

details)

Users ▪ Broad stakeholder public,

including governments

Carrier ▪ Multi-stakeholder initiative

▪ UN environment as custodian

3.2b


SOURCE: resistancemap.cddep.org

66

One pager: WHO 100

What is

it?

Why

does it

exist?

How

does it

work?

Who

are key

stake-

holders

?

▪ Global reference list of 100 Core Health

Indicators for global, regional, and

national reporting

▪ Aims to provide concise information on

the health situation and trends, incl.

responses at national and global levels,

and harmonize efforts and investments

▪ Split in core and additional indicators

▪ Initial set of 100 reference indicators defined on

basis of MDGs, key health priorities, and SDGs in

order to monitor

– International commitments and resolutions

(e.g., SDGs, UNGASS)

– Disease- and program-specific outcomes

(e.g., WHO/UNICEF joint reporting for

immunization)

▪ Prioritization based on prominence, robustness,

track-record measurement, utilization by countries

▪ Periodic update of reference list to reflect current

health priorities


▪ Global, national, and regional

reporting

▪ Reference list (no measurement)

Measured

subjects

▪ Interagency Working Group on

Indicators and Reporting Burden

▪ WHO

Carrier

▪ Broad stakeholder public, incl.

measuring entities, such as

countries

Users

In a nutshell: Reference list of overarching 100 core health

indicators (without reporting thereof)

▪ Disease- and program-specific

monitoring and evaluation programs by

different agencies led to inefficient

reporting and high burden for

countries

▪ Effort to prioritize set of indicators for

the purposes of

– Monitoring national and global

progress,

– Maintaining program support

– Advocating for resources and

funding

3.2c


SOURCE: Global Reference List of 100 Core Health Indicators (plus health-related SDGs), 2015, 2018

67

One pager: GLASS

In a nutshell: AMR surveillance system for collection and exchange of data under GAP

SOURCE: Global Antimicrobial Resistance Surveillance System; Manual for Early Implementation; Glass report early implementation 2016-17

3.2d

Why

does it

exist?

Who are

key

stake-

holders?

▪ Central information system to collect and share AMR

surveillance data

▪ Provides evidence for interventions and advocacy

by enabling

– Collection of comparable and validated data

– Sharing among countries/partners


How

does it

work?

What is

it?

▪ Implements GAP strategic objective to strengthen the

evidence base through enhanced global surveillance and

research

▪ Fosters standardized AMR surveillance globally

▪ Informs decision-making

▪ Drives local, national and regional action

▪ Collects and reports data on AMR rates

aggregated at national level, incl. patient,

laboratory and epidemiological surveillance

data

▪ Provides capacity building tools including

IT resources for AMR surveillance and

reporting to GLASS

▪ Is currently in early implementation until

2019 focusing on routine surveillance

based on microbiological and clinical

information on priority bacterial infections in

humans

▪ Subsequently gradual extension, e.g., to

clinical syndromes, foodborne AMR, or

impact metrics

▪ WHO

▪ Varying (healthcare data on

different geographic levels)

Measured

subjects

▪ Countries, agencies, general

public

Users

Carrier

Data not available

2017 enrollment map

Enrolment completed by

the end of the data call

Enrolment completed

after the data call


68

One pager: Access to medicine index

What is

it?

Why

does it

exist?

How

does it

work?

Who

are key

stake-

holders

?

▪ Analyses 20 of the world’s largest

research-based pharmacos on how they

make medicines, vaccines and

diagnostics more accessible in LMICs

▪ Produces ranking, key findings and

insights (e.g., industry level analyses)

▪ “Shines a light on good practice” by

recognizing good practice within the

pharmaceutical industry regarding access

to medicines

▪ Employs 83 indicators

across 7 technical areas

and 4 strategic pillars

▪ Assesses pharmaco

impact in 107 countries

▪ Obtains data from

pharmacos, as well as

expert and stakeholder

consultations/dialogue

▪ Reviews methodology

every 2 years (“index

cycles”) ▪ 2 billion people in the world have no

access to medicine. The Index gives

insight into what the pharmaceutical

industry is doing to improve this situation

▪ Provides public recognition for

investments in access to medicine

▪ Raises awareness of relevant issues

within pharmacos

▪ Offers transparent means by which

pharmacos can assess, monitor and

improve their own performance as well as

their public and investment profiles


▪ Largest 20 R&D pharmacosMeasured

subjects

▪ General public, open stakeholders Users

▪ NGO to stimulate/guide

pharmacos to do more for people

LMICs without access to medicine

▪ Funded by BMGF and UK/NL

government

Carrier

In a nutshell: Index assessing the largest R&D based pharmacos

on their activities to enhance access to medicine in LMICs

3.2e

The access to

medicines foundation

also published in 2018

the first AMR

benchmark to assess

how the

pharmaceutical

industry is responding

to the threat

of AMR


SOURCE: accesstomedicineindex.org

69

One pager: Resistance map

What is

it?

Why

does it

exist?

How

does it

work?

Who

are key

stake-

holders

?

Countries Drug Resistance

Index

AMRAntibiotic use

(humans/animals)

▪ Web-based collection of data visuali-

zation tools that allows interactive

exploration of AMR and antibiotic use

trends

▪ Features newly Drug Resistance Index

for the US, tracking antibiotic resistance

applied to two common infection

▪ Has 4 pillars:

▪ Provides data and indexes based on processing of

various national and private data sources

▪ Antibiotic consumption

– 75 countries (subnational only for US)

– 17 antibiotics

– 2000-2015

▪ AMR

– 49 countries

– 12 pathogens (bacteria)

– 1999-2015

Example AMR Example use

▪ Homogenize data and allow

comparability

▪ Provide transparency, information, and

data to various stakeholders, incl. policy

makers


In a nutshell: Visualization tool for AMR and antibiotic use, both in

humans and animals

Measured

subjects

▪ Countries and use/consumption

therein

Users ▪ Health policy makers

▪ General public

Carrier ▪ Produces research to support

better decision-making in health

policy

▪ Various funders, current iteration

strongly funded by BMGF

3.2f


SOURCE: resistancemap.cddep.org

70

One pager: Decision maker dashboard 3.2g Idea – not yet existing

Why

should it

exist?

How

does it

work?

Who are

key

stake-

holders?

▪ Provides prioritized set of ~20 core indicators to

measure success of AMR and inform decision-

makers

▪ Definition of indicator cascade across geographic

hierarchies, connecting also to other efforts (e.g.,

GAP M&E approach)

▪ Current indicator sets have limited focus

on decision-makers

▪ There is a lack of connection between

globally uniform indicators vs. more

tailored sets of indicators at

regional/local level

▪ No clear prioritization of investments in

the underlying in-country surveillance and

data generation capacities

Description

What

could it

be?

Description

In a nutshell: Indicator dashboard and reporting logic for key

decision-makers at global, regional and national levels

Measured

subjects

▪ Various

Users ▪ Health policy makers

▪ General public

▪ TBD; initiation by IACG in close

alignment with key stakeholders

(e.g., Tripartite)

Carrier

▪ Comprehensive AMR dashboard of ~20

core indicators, incl. reporting logic

▪ Aimed at supporting decision-making

(e.g., on resource allocation and policy

action)


SOURCE: Team analysis; IACG SG 5 and 6

71

Backup





What concrete opportunities might the IACG consider to

better anchor AMR in the SDG indicators?


Miscellaneous

72

To prioritize opportunities, a set of key criteria is applied

Type Criterion

SOURCE: Sustainable Development Solutions Network; Expert interviews; Team analysis

4

OPPORTUNITIES TO BETTER ANCHOR AMR

Relevance

Implementable

by countries

Current

Stakeholder

alignment

Fit with SDG

indicators

Key components Description

Valuable goal for

AMR

▪ Serves purpose highly impactful for AMR

Relevant for

decision making

▪ Enables and supports decision making for key

stakeholders

Reflective of

overall AMR

▪ Proxies large components/areas of AMR

Supported by

countries

▪ Elicits support, buy-in and advocacy of countries

▪ Has low potential for conflict

Endorsed by

experts

▪ Is sufficiently robust to be considered a viable

indicator

Clearly defined

methodology

▪ Is specific and conceptually clear / unambiguous

Based on routine

data

▪ Draws on data either currently or within the next 3-5

years routinely collected/collectable by countries

Not in conflict

with other SDG

▪ Does not contravene any other goal/target/indicator

Universal ▪ Is broadly applicable and relevant for all / the majority

of countries without bias

Suitable in type

and kind

▪ Is on same flight level and of same nature like other

SDG indicators, e.g., no complex composits

Implication

Qualitative

analysis

Tickbox

logic

Fe

as

ibil

ity

Hygiene factorsSatisfiers

73SOURCE: Report of the Inter-agency and Expert Group on Sustainable Development Goal IndicatorsE/CN.3/2017/2

The IAEG-SG lays out 5 potential reasons for substantively changing the

SDG indicator framework

4


22. Two comprehensive reviews of the indicator

framework are planned, and their results are to

be submitted for consideration and decision by

the Statistical Commission at its 2020 and 2025

sessions. They could include the addition,

deletion, refinement or adjustment of indicators

on the basis of the following:

a)Indicator does not map well to the target;

b)Additional indicator(s) is needed to cover all

aspects of the target;

c)New data sources are available;

d)Methodological development of tier III

indicator has stalled or has not produced

expected results;

e)Indicator is not measuring progress towards

meeting the target

74

10 criteria for Global Monitoring Indicators Description

▪ Trade-off between exhaustiveness and harmonization/align-ability

▪ 232 are already beyond original intention; high bar for new ones

▪ Simple to compile and easy to interpret and communicate

▪ Clear implications for policies

▪ Preferably single-variable; composite indicators discouraged

▪ Operate on annual cycle to correspond with planning/budgetary processes

▪ Optimally, are measured bi- or tri-annually with annual intermediate result

▪ Correspond to internationally harmonized monitoring cycles

▪ Be underpinned by a broad international consensus on measurement

▪ Correspond with international standards, recommendations, and best practices

▪ Reflect systems of national accounts, and other systems-based information

▪ Draw on well-established sources of public and private data

▪ Be consistent to enable measurement over time

▪ Allow tracking of inequalities in SDG achievement

▪ Key disaggregation criteria include: characteristics of the individual or household,

economic activity, and spatial dimensions

▪ Apply to developed as well as developing countries

▪ Relate to global, regional, national, and local levels

▪ Track outcomes (or the ends) rather than means

▪ Resolve to input/output measures if crucial to track and drive change and/or outcome/

impact have significant lag (particularly in health anticipated)

▪ Account for changing global dynamics

▪ Anticipate future changes

▪ Track broader concepts

▪ Proxy complex problems through key components

Limited in number and globally

harmonized

Simple, single-variable indicators, with

straightforward policy implications

Allow for high frequency monitoring

Consensus based, in line with

international standards and system-based

information

Constructed from well-established data

sources

Disaggregated

Universal

Mainly outcome-focused

Science-based and forward-looking

A proxy for broader issues or conditions

SOURCE: Leadership Council of the Sustainable Development Solutions Network: Indicators and a Monitoring Framework for the Sustainable Development

Goals - Launching a data revolution for the SDGs

The SDSN has developed a set of 10 key criteria for SDG indicators 4


75

Opportunities to include AMR in implementation (1/3)

SOURCE: SDG indicator framework; IAEG Tier Classification; expert interviews; Team analysis

4aI Tier 1 II Tier 2 III Tier 3

Key opportunities

Examples, selected

SDG Indicator

Tier classi-

fication Opportunities to anchor AMR

II

Engage with UNISDR to position

AMR as impending disaster

Custodial

agency

II

Sensitize for point 2 of FIES, with

emphasis on food without

resistant microbes

2.1.2 Prevalence of moderate or severe food insecurity

in the population, based on the Food Insecurity

Experience Scale (FIES)

2.4.1 Proportion of agricultural area under productive

and sustainable agricultureIII

Sensitize to define sustainability

with regard to use of AM in food

production

I

Sensitize OECD to disaggregate

into AMR relevant funding,

e.g., AM development

II

I3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases incidences (TB,

Malaria, HIV, Hepatitis B) 3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases incidences (TB,

Malaria, HIV, Hepatitis B) 3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases incidences (TB,

Malaria, HIV, Hepatitis B) 3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases incidences

(TB, Malaria, HIV, Hepatitis B)

Engage with WHO to refine

indicator towards measurement of

resistance

II

I Engage with WHO to refine

indicator towards resistant

infectious diseases

3.b.2 Total net official development assistance to

medical research and basic health sectors

3.1.1, 3.2.1, 3.2.2, 3.9.2 Mortality rates3.1.1, 3.2.1, 3.2.2, 3.9.2 Mortality rates3.1.1, 3.2.1, 3.2.2, 3.9.2 Mortality rates (neo-natal,

maternal, <5, unsafe water/lack of hygiene)

II3.b.1 Proportion of the target population covered by all

vaccines included in their national programme

Engage with WHO, UNICEF and

Gavi to shape programs to include

vaccines relevant in AMR context

1.5.1 Number of deaths, missing persons and directly

affected persons attributed to disasters

per 100,000 population

1.a.2 Proportion of total government spending on essential

services (education, health and social protection)III

Engage in indicator development to

anchor adequate access to AMs

Under dis-

cussion

among

agencies


76

Opportunities to include AMR in implementation (2/3) 4a


Key opportunities

Sensitize UNESCO to

disaggregate into AMR relevant

expenditures and researchers,

e.g., AM development

Sensitize for API-containing waste

and disaggregate III

12.4.2 Hazardous waste generated per capita and

proportion of hazardous waste treated, by type of

treatment

Promote inclusion of AMR topics

in sensitive companiesIII12.6.1 Number of companies publishing sustainability

reports

Promote inclusion of AMR

relevant factors in plansIII

II

Engage with UN Environment to

include AMR specific question in

country surveys

12.7.1 Number of countries implementing sustainable

public procurement policies and action plans

12.1.1 Number of countries with sustainable consumption

and production (SCP) national action plans or SCP

mainstreamed as a priority or a target into national

policies

I

I


inhabitants

II6.3.1 Proportion of wastewater safely treated

6.3.2 Proportion of bodies of water with good

ambient water qualityIII

Sensitize UN Water to API and

API residuals in waste water

9.5.1 Research and development expenditure as a

proportion of GDP

Engage with WHO to disaggre-

gate access to essential AMs, pot.

adjusted for stewardship/quality

3.b.3 Proportion of health facilities that have a core set of

relevant essential medicines available and affordable on

a sustainable basis

III

Examples, selected

SDG Indicator

Tier classi-


Custodial

agency

I Tier 1 II Tier 2 III Tier 3


77

Opportunities to include AMR in implementation (3/3) 4a


Engage to include AM-use in

sustainability definition I

III

Foster emergence of AMR

relevant cooperation agreementsIII

III

Foster emergence of AMR

relevant partnerships

Promote capacity building to

report comprehensively on

AMR results chain

I

I

14.7.1 Sustainable fisheries as a proportion of GDP in

small island developing States, least developed

countries and all countries

17.17.1 Amount of United States dollars committed to

public-private and civil society partnerships

17.6.1 Number of science and/or technology cooperation

agreements and programmes between countries, by

type of cooperation

17.19.1 Dollar value of all resources made available to

strengthen statistical capacity in developing countries

17.18.1 Proportion of sustainable development indicators

produced at the national level with full disaggregation when

relevant to the target, in accordance with the Fundamental

Principles of Official Statistics

14.4.1 Proportion of fish stocks within biologically

sustainable levels

Key opportunities

Lead indicator development to be

AMR relevant n/aIII

12.a.1 Amount of support to developing countries on

research and development for sustainable consumption

and production and environmentally sound technologies

I Tier 1 II Tier 2 III Tier 3

Examples, selected

SDG Indicator

Tier classi-


Custodial

agency


78

Deep-dive on key opportunities to better anchor AMR in implementations4a


Deep dive on the next pages Relevant R Current stakeholder alignment SA Implementable in countries IC Fitting into SDGsFSDG

Not/hardly given Mostly/fully givenPartly given Somewhat relevantRelevantVery relevantCritical Not/marginally relevant

SOURCE: Indicator metadata; Team analysis

Indicator ICSA FSDG

2.4.1 Proportion of agricultural area

under productive and sustainable

agriculture

Engage with FAO to define

sustainability sensitive to AMR

▪ Strong opportunity to shape tier III

indicator and cover multiple

blindspots at once

3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases

incidences (TB, Malaria, HIV,

Hepatitis B)

3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases


Hepatitis B)

3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases


Hepatitis B)

3.3.1, 3.3.2, 3.3.3, 3.3.4 diseases


Hepatitis B)

Engage with WHO to refine

indicator towards

measurement of resistance

▪ Good data availability, esp. for

malaria and TB

3.b.1 Proportion of the target population

covered by all vaccines included in

their national programme

Engage with WHO, UNICEF

and Gavi to shape programs to

include vaccines relevant in

AMR context

▪ Depending on vaccines in scope

varying feasibility

▪ Increasing importance with

development of new vaccines

3.b.3 Proportion of health facilities that

have a core set of relevant essential

medicines available and affordable on

a sustainable basis

Engage with WHO to

disaggregate access to


adjusted for stewardship/

quality

▪ Get specific access-metric for

essential AMs

▪ Potential to include

stewardship/quality perspective

(by proxies and opportunistically)

Comments

Rele-

vance

Feasibility

Engage with UN Environment

to include AMR specific

question in country surveys

▪ Broad indicator covering multiple

topics at once

▪ Fit under 10YFP1 to be assessed

(AMR/healthcare could be but

currently isn’t part of 10YFP

programs)

12.1.1 Number of countries with

sustainable consumption and production

(SCP) national action plans or SCP

mainstreamed as a priority or a target

into national policies

Assessment

Opportunities to include

AMR in implementation

1 10-year framework of programmes on sustainable consumption and production

79

Deep-dive: Implementation of sustainable agriculture (2.4.1)

SOURCE: FAO; SDG indicator framework metadata; Team analysis

4a

Objectives ▪ Ensure definition of sustainable

agriculture is AMR sensitive

Rationale ▪ AMR is an important component

of sustainable production

capturing all 3 dimensions of

the indicator

▪ There are multiple options to

include AMR, many of which are

also important for sustainability

beyond AMR, e.g., treatment of

wastewater, biosafety/security

Context ▪ Sustainability defined in social,

environmental, and economic

terms, incl. productivity,

profitability, resilience, land and

water, decent work and well-being

▪ Measured through farm surveys

▪ Disaggregated into sub-outcomes

Overview Next steps to anchor AMR

Key

indicators2.4.1 Proportion of

agricultural area under

productive and

sustainable agriculture

Zero

hunger2 Engage

Align with

working

plan

Refine farm

surveys for

AMR

Support

and sustain

Key steps Description

▪ Get key stakeholders within FAO at the table

▪ Discuss potential to include AMR

▪ Understand current progress of tier III

working plan, including

– Latest working draft of farm survey

– Data collection and validation plan

– Sub-outcomes to be disaggregated

▪ Establish AMR sensitive components in farm survey

▪ Identify gaps and propose AMR sensitive/specific

additions to farm surveys, e.g., AMC by biomass,

husbandry

▪ Propose AMR specific/sensitive outcomes to be

disaggregated

▪ Test propositions with FAO/stakeholders and

experts

▪ Track inclusion, reporting and results of AMR

relevant outcomes

▪ Collaboratively sustain impact and ensure

communication to other AMR stakeholders


80

Deep-dive: Implementation of disease incidence (3.3.1, 3.3.2, 3.3.3, 3.3.4)4a

Objectives ▪ Disaggregate resistant cases in

communicable diseases

Rationale ▪ Establish extent of AMR-problem

in key communicable diseases

▪ Link AMR to communicable

diseases and seize synergies

with advocacy and systems for

respective diseases

Context ▪ Resistance is important

problem in all SDG-mentioned

communicable diseases

▪ Proxies broader outputs, e.g.,

health system capacity and

stewardship for communi-cable

diseases (e.g. HIV)

▪ Data availability is quite

strong, especially for TB


Key

indicators3.3.1, 3.3.2, 3.3.3, 3.3.4

diseases incidences

(TB, Malaria, HIV,

Hepatitis B)

Good

health

and

well-

being

3


▪ Get key stakeholders within WHO at the table

▪ Discuss potential to disaggregate AMR by indicator

(e.g., HIV, TB)

▪ Understand data availability and methodology by

indicator to disaggregate AMR

▪ Prioritize indicators

▪ Define timeline for prioritized indicators

▪ Set measurements targets (e.g., geographic

coverage, data quality, etc.)

▪ Adapt methodology to enable disaggregation of

AMR

▪ Identify enablers and roadblocks and engage as

far as possible

▪ Track inclusion, reporting and results of AMR

relevant outcomes

▪ Collaboratively sustain impact and ensure

communication to other AMR stakeholders

SOURCE: SDG indicator framework metadata; Expert interviews; Team analysis

Engage

Prioritize

causes of

deaths

Define

ambition

and

implement

Support

and sustain


81

Deep-dive: Implementation of vaccine coverage (3.b.1)4a

Objectives ▪ Promote inclusion of vaccines

relevant for AMR (e.g.,

pneumococcus for IPC) in

national programs

Rationale ▪ Vaccines and immunization

coverage are key components

of IPC

▪ Particularly as new vaccines

develop (e.g., Malaria), indicator

gains importance

Context ▪ Indicator is tier 3, methodology

is currently under discussion

▪ Strong country-ownership

▪ Country reporting is difficult

and comparability across

national programs difficult

▪ Leeway for tailored

engagement relatively high


Key

indicators

3.b.1 Proportion of the

target population

covered by all vaccines

included in their

national programme

Good

health

and

well-

being

3

Engage

Take stock

and identify

need

Provide

tailored

guidance to

countries


▪ Gather key stakeholders (e.g., WHO, Gavi,

countries) for a round table

▪ Align closely with tier III working plan to ensure

seamless inclusion of AMR in development of 3.b.1

reporting

▪ Establish key set of vaccinations relevant for AMR

to be included in national programs

▪ Take stock of coverage of key vaccines relevant for

AMR in country programs and in actual

immunization coverage

▪ Identify gaps and consult with Gavi / countries

▪ Provide tailored advice to countries to adapt

national programs to reflect key AMR outcomes

▪ Maintain close collaboration with WHO, Gavi, and

countries

▪ Leverage synergies among stakeholders, e.g.,

through Gavi grants or WHO engagement with MoHs

SOURCE: SDG indicator framework metadata; Expert interviews; Team analysis


82

Deep-dive: Implementation of access to medicines (3.b.3)4a

Objectives ▪ Disaggregate access to


adjusted for stewardship/quality

Rationale ▪ Create access metric for

essential AMs

▪ Anchor stewardship/quality

opportunistically

Context ▪ Indicator is tier 3, but tier update

is in process (until EOY 2018)

▪ Current set of essential

medicines includes 4 AMs at

facility level; disaggregation is

possible under reporting plan

▪ Quality/stewardship is proxied

by national-level adjustment for

maturity of regulatory authority


Key

indicators3.b.3 Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis

Good

health

and

well-

being

3


▪ Engage with WHO to assess extent of changes to

indicator possible as well as timebound windows for

inputs

▪ Identify key stakeholders and consultatively set

scope of potential opportunity, e.g., possible

disaggregation of AM access

▪ Align with key stakeholders on possible

adaptations / disaggregation

▪ File proposal at IAEG-SDG in consultation with

WHO until EOY 2018 (during tier update of indicator)

▪ Define sporadic touchpoints aligned with

windows for further changes to give inputs and

promote inclusion of AMR in indicator implementation

▪ Track development of AM disaggregation

SOURCE: SDG indicator framework metadata; Expert interviews (incl. WHO); Team analysis

Assess

scope of

opportunity

Propose

adaptations

Sustain

impact and

refine


83

Deep-dive: Implementation of streamlining of SCP in national policies (12.1.1)

SOURCE: http://spaces.oneplanetnetwork.org/system/files/indicators_of_success_for_the_10yfp_-_principles_process_and_methodology-3.pdf;

https://sustainabledevelopment.un.org/content/documents/944brochure10yfp.pdf; SDG indicator metadata

4a

Objectives ▪ Include key AMR outcomes

along AM value chain through

SCP

Rationale ▪ AMR outcomes are relevant

across value chain, e.g.,

wastewater in production or

sustainable use

▪ Framing AMR as part of SCP can

induce relevant policy cycles

Context ▪ Indicator is tier 3▪ Implements 10YFP1 by

measuring policy efforts ▪ Current 10YFP programs do not

explicitly focus healthcare/AMs, and overall seems more ecology focused (however, incl. water/sanitation and waste)

▪ Room to further include AMR-relevant outcomes


Key

indicators

12.1.1 Number of countries with sustainable consumption and production (SCP) national action plans or SCP mainstreamed as a priority or a target into national policies

Respon-sibleconsumption and produc-tion

12


▪ Identify AMR-relevant outcomes that can be framed

as component of SCP under current 10YFP1

▪ Engage with UNEP to assess current and potential

extent of inclusion of AMR relevant outcomes into

indicator measurement

▪ Develop guidance on potential programs for SCP

with respect to AMR

▪ Discuss opportunities and share possibilities for

policy development under 10YFP with key

stakeholders, incl. countries and UNEP

▪ Assess opportunity to engage within existing or

new 10YFP programs to further anchor AMR as

component of SCP

1 10-year framework of programmes on sustainable consumption and production

Assess

scope of

opportunity

Propose

adaptations

Explore

alternative

options


http://spaces.oneplanetnetwork.org/system/files/indicators_of_success_for_the_10yfp_-_principles_process_and_methodology-3.pdf

https://sustainabledevelopment.un.org/content/documents/944brochure10yfp.pdf

84

Deep-dive on key opportunities of adding AMR to existing indicators

SOURCE: Indicator Metadata; Team analysis

4b


Deep dive on the next pages Relevant R Current stakeholder alignment SA Implementable in countries IC Fitting into SDGsFSDG

Not/hardly given Mostly/fully givenPartly given Somewhat relevantRelevantVery relevantCritical Not/marginally relevant

12.8.1 Extent to which (i) global citizenship

education and (ii) education for sustainable

development (including climate change and AMR

education) are mainstreamed in (a) national

education policies; (b) curricula; (c) teacher


3.2.1-3 Maternal, Under-5, and Neo-natal



mortality rate, incl. mortality due to AMR3.3.1, 3.3.2, 3.3.3, 3.3.4 communicable disease

incidence, % of resistant cases


(defined as the average coverage of essential

services based on tracer interventions that include

(…), infectious diseases (incl. effective

sanitation, hygiene and infection prevention

measures), non-communicable diseases and

service capacity and access, among the general

and the most disadvantaged population)

Adjusted indicators

Selected; proposed adjustments colored and bolded ICSA FSDG

▪ Opportunity to anchor stewardship

▪ Fit within essential health

services differently assessed by

expert

▪ Call-out of AMR predominantly for

visibility reasons; impact on

implementation by countries limited

given methodology of indicator

▪ Good data availability, esp. for

malaria and TB

▪ Fit of AMR into underlying

education Recommendations1 to

be verified together with UNESCO

▪ Potentially mostly visibility-driven

inclusion of AMR

Comments

Rele-

vance

Feasibility

Assessment

1 Recommendations concerning Education for International Understanding, Co-operation and Peace and Education relating to Human Rights and Fundamental Freedoms

85

Opportunities to reference AMR in the indicator itself Key opportunities

Rationale

3.8.1 Coverage of essential health services (defined as

the average coverage of essential services based on

tracer interventions that include reproductive, maternal,

newborn and child health, infectious diseases (incl.

effective sanitation, hygiene and infection

prevention measures), non-communicable diseases

and service capacity and access, among the general

and the most disadvantaged population)

▪ Potential political

resistance from

access perspective

▪ Anchors AMR in essential

health services

▪ Strikes balance between

access and use control

▪ Fits meta-data, covering

interventions like

sanitation, essential

medicine access,

immunization, etc.

▪ Potential difficulty to

include AMR in

essential medicines

as pre-defined term

3.b.3 Proportion of health facilities that have a core set

of relevant essential medicines available and affordable

on a sustainable basis and follow good AMR

stewardship

▪ Anchors stewardship in

access to essential

medicines

▪ Potential to disaggregate

in AWaRe medicines

Potential challenges

Adjusted indicators

Selected; proposed adjustments colored and boldedSDGs

Good health

and well- being3

12.8.1 Extent to which (i) global citizenship education

and (ii) education for sustainable development

(including climate change and AMR education) are

mainstreamed in (a) national education policies; (b)

curricula; (c) teacher education; and (d) student

assessment

▪ Juxtaposition of

climate change and

AMR could face

political resistance

▪ Supports dissemination of

awareness

▪ Key relevance under both

GAP and AMR FFA

▪ Puts climate change and

AMR as topics covered by

High Level Meetings on

similar footing

Responsible

consumption

and production

12

SOURCE: SDG indicator framework; expert interviews; Team analysis

4b


86

▪ Root AMR use in

animals/food production

▪ Link with

Opportunities to disaggregate indicators for AMR (1/2)

3.3.3 Malaria incidence per 1,000 population, incl. % of

multi-drug resistant malaria

3.3.2 Tuberculosis incidence per 100,000 population

incl. % of resistant new cases

2.a.2 Total official flows (official development

assistance plus other official flows) to the agriculture

sector, incl. % flows to sustainable agriculture

▪ Could be perceived

as policy

interference

3.3.1 Number of new HIV infections per 1,000

uninfected population, by sex, age and key populations

and by % of multi-drug resistant cases

4a

3.9.2 Mortality rate attributed to unsafe water, unsafe

sanitation and lack of hygiene (exposure to unsafe

Water, Sanitation and Hygiene for All (WASH) services,

incl. mortality due to AMR)

3.2.1 Under-5 mortality rate, incl. mortality due to

AMR

3.3.4 Hepatitis B incidence per 100,000 population,

incl. % of multi-drug resistant chronic cases

3.1.1 Maternal mortality ratio, incl. mortality due to

AMR

3.2.2 Neonatal mortality rate, incl. mortality due to

AMR

▪ Data availability low

and methodology not

clearly defined yet

▪ Level of causality

might be considered

insufficient

▪ Potentially too

different ‘flight level’

of indicators

▪ Link AMR explicitly to

health impacts

▪ Potentially too


of indicators

▪ Links AMR explicitly to

specific health

outcomes

▪ Especially for TB very

prominent/relevant

▪ Promotes awareness

beyond bacterial AMR

Rationale Potential challenges

Adjusted indicators

Selected; proposed adjustments colored and boldedSDGs

Key opportunities

SDGs

Zero

hunger

2

Good health

and well- being3


4b


87

Opportunities to disaggregate indicators for AMR (2/2)

9.5.1 Research and development expenditure as a

proportion of GDP, incl. % to AM(R) research and

programs


inhabitants, incl. % on AM(R) research and programs

▪ Could be perceived

as policy

interference

▪ Potentially too


of indicators

▪ Channels health ODA

resources to AMR as

preeminent problem

▪ Promotes innovation

and access

Rationale Potential challenges

Adjusted indicators

Selected; proposed adjustments colored and boldedSDGsSDGs

Industry,

innovation and

infrastructure

9


4b Key opportunities


88

Indicator deep-dive: Disease burden

Description

Assessment

4c

CommentsCriterion Rating


Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High

Not/hardly given Mostly/fully givenPartly given

Proposed

definition

▪ DALY (or QALY/YLD)1 for top

X drug/bug combinations

▪ Is key impact metric

▪ Lacks sensitivity within

2030 horizon Relevance

Rationale ▪ Translates AMR to patient

outcomes

▪ Is covered by ongoing efforts

to calculate DALYs (e.g.,

IHME, but also global burden

of animal diseases by OIE)

▪ Estimates by IHME for top

diseases available within

next years

▪ Country-level reporting very

limited IITier:

Implemen-

table by

countries

Data

sources

▪ Third parties (e.g., IHME),

countries for crude data

▪ No apparent conflict

▪ Good match under SDG 3 Fit with

SDG

indicators

Descrip-

tion

▪ Measures DALYs caused by

AMR

▪ Reflects impact of AMR

Current

Stakeholder

alignment

▪ Is in key interest of every

country

Click here for

overview page

1

1 DALY: Disability Adjusted Life Years; QALY: Quality Adjusted Life Years; YLD: Years lost due to disease


89

Indicator deep-dive: Level of resistance

Description

Assessment

4c



Proposed

definition

▪ Level of resistant drug/bug

combinations (e.g., MRSA and

3GCR E. Coli)

▪ Key outcome metric

▪ Single pathogens are not

exhaustive, with varying

relevance by country Relevance

Data

sources

▪ Relies on standard clinical

testing, where available

▪ Has no apparent conflict

▪ Matches well under SDG 3 Fit with SDG

indicators

Descrip-

tion

▪ Measures resistance level

identified in standard clinical

testing Current

Stakeholder

alignment

▪ In interest of every country

▪ Considered foundational

metric by many experts

Rationale ▪ Represents key outcome metric

for AMR

▪ Aims to capture key pathogens

of international concern (e.g., .,

MRSA and 3GCR E. Coli)

Implemen-

table by

countries

IITier:

▪ Data points available and

collected by various players

(e.g., ATLAS)

▪ Some blindspots and

concerns in comparability and

robustness

Click here for

overview page

2




90

Metadata: Level of resistance

1 Preliminary

Cross cutting

Indicative

Goals and Targets addressed

3.8 Achieve universal health coverage, including financial

risk protection, access to quality essential health-care

services and access to safe, effective, quality and affordable

essential medicines and vaccines for all

▪ Level of resistant drug/bug combinations (e.g., MRSA and

3GCR E. Coli)

Definition and method of computation

▪ Proportion of resistant, vs intermediate or susceptible samples

Sources and data collection

▪ Routine clinical AM susceptibility testing (AST)

Current data availability / indicator tier

▪ In EU/North strong

▪ Beyond data available, but robustness/comparability concerns

Data collection and data release calendar

▪ Tbd

Regional and global estimates & data collection for global

monitoring

▪ Tbd

Rationale and interpretation

▪ Resistance levels are key outcome of AMR

▪ Selection of top pathogens aims to ensure comparability of

resistance levels without need to build composite indicator

▪ Although pathogens of concern vary by country, there are

certain common denominators, e.g., MRSA and 3GCR E. Coli)

Disaggregation

▪ Different drug/bug/origin combinations

▪ Potentially to animals, but difficult (not in scope here)

▪ Explicit disaggregation in hospital/community acquired

Comments and limitations

▪ Reflects highest priority AMR cases, but are not exhaustive

(especially beyond AB)

▪ Data availability in animal domain very low

Sources of differences between global and national figures

▪ Sampling sizes

▪ Disease burden

▪ AM use

Out-

come

References

▪ ECDC, EFSA, and EMA joint scientific opinion

TypeOne Health Custodial agencies1AMR FFA/GAP

I

4c


2

SOURCE: Expert interviews; Team analysis; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3932395/

Proposed indicator

▪ Level of resistant drug/bug combinations (e.g., MRSA and

3GCR E. Coli)

91

Indicator deep-dive: Drug-resistance index

Description

Assessment

4c


Proposed

definition

▪ Level of Drug Resistance

Index by country / disease


▪ Aggregates multiple key

outcomes into 1

communicable metricRelevance

Data

sources

▪ Country data

▪ Third-party providers, e.g.,

CDDEP

▪ Composites disencouraged

under SDG 3Fit with

SDG

indicators

Descrip-

tion

▪ Effectiveness of available

drugs as ability of antibiotics to

treat infections with the extent

of their use in clinical practice

Current

Stakeholder

alignment

▪ Is in key interest of every

country

▪ Raises robustness

concerns with experts

Rationale ▪ Combines AMR toolbox and

risk level

▪ Communicates overall ability

to treat diseases with AMs

▪ Is intuitively understandable

Implemen-

table by

countries “We are still in the early

days for the Drug

Resistance Index”AMR expert

IITier:

▪ Central calculation by

CDDEP possible for 60+

countries

▪ Methodology and country-

level reporting missing

Click here for

overview page

3



92

Indicator deep-dive: Immunization coverage in food producing animals

Description

Assessment

4c





Proposed

definition

▪ Immunization coverage for

food producing animals, by

vaccination and species or as

aggregate

▪ Unanimously considered

important by experts

▪ Necessary but not sufficient

for biosafety/-security

Relevance

Descrip-

tion

▪ Measures immunization of

food producing animals (both

agri- and aquaculture)

▪ Ambitious for many

countriesCurrent

Stakeholder

alignment

Data

sources

▪ Veterinary services or overall

sales/tender data

▪ No apparent conflict

▪ Fits One Health approach Fit with

SDG

indicators

Rationale ▪ Indicates biosafety/

biosecurity in animals

▪ Is considered key driver of

AMR by experts

▪ Complements indicator 3.b.1

on human vaccine coverage

Implemen-

table by

countries

▪ Data presumably n/a within

short- to mid-term

▪ Veterinary immunization

very limited in many

countries

IITier:

Click here for

overview page

4


93

Indicator deep-dive: Infection rate of food producing animals

Description

Assessment

4c





Proposed

definition

▪ % of food producing animals

with a clinical infection

▪ Closes gap (biosafety) and

reflects One HealthRelevance

Rationale ▪ Definition and specification

not clear

▪ Data hardly collected/

reported

▪ Measures success of

biosafety and biosecurity in

livestock, incl. husbandry

▪ Indicates potential therapeutic

use of AMs IIITier:

Implemen-

table by

countries

Data

sources

▪ Fits well into SDG 2 and 12

▪ Has no apparent conflicts

with other indicators

▪ Veterinary systems Fit with

SDG

indicators

Current

Stakeholder

alignment

Descrip-

tion

▪ Assesses proportion of

animals with clinically

showing infections in

livestock

▪ Importance of husbandry

generally accepted

▪ Support from large meat-

exporters unclear

Click here for

overview page

5


94

Indicator deep-dive: Growth promotion in food producing animals

Description

Assessment

4c





Proposed

definition

▪ Numbers of countries using

AM for growth promotion

▪ Does not cover level of use

and husbandry (rough)

▪ Closes gap (animal AM

use) and reflects One

Health

Relevance

Descrip-

tion

▪ Foundational measure for use

for growth-promotion in

livestock

▪ Problem of over- and

misuse in livestock

generally accepted

Current

Stakeholder

alignment

Data

sources

▪ OIE data collection ▪ Fits well into SDG 2,3,12


with other indicators Fit with

SDGs

Implemen-

table by

countries

Rationale ▪ Measures component of

‘unnecessary’ and avoidable

AM use

▪ Quantities of growth-

promotion often n/a IITier:

▪ Data well available

Click here for

overview page

6


95

Indicator deep-dive: Regulation of growth-promotion in food

producing animals

Description

Assessment

4c





Proposed

definition

▪ Regulation of growth-

promotion in food producing

animals (e.g., trends)

▪ Closes gap (animal AM use)

and strengthens One Health

▪ Input measure with limited

indication of outcome

Relevance

▪ Problem of over- and

misuse in livestock

generally accepted

Descrip-

tion

▪ Measures regulation

regarding AM use for growth

promotion, e.g., existence of

regulation, scope and

specifications, degree of ban,

and (potentially) enforcement

Current

Stakeholder

alignment


▪ Atypical as fragmented

measure

Data

sources

▪ Country reporting (OIE

currently in the process of

defining and collecting)

Fit with

SDG

indicators

Click here for

overview page

IITier:

Implemen-

table by

countries

Rationale ▪ Regulation is prerequisite to

steer AM use in food

producing animals

▪ Different aspects of regulation

together form non-binary,

meaningful picture

▪ Countries already report to

OIE

7


96

Metadata: Regulation of growth-promotion in FPAs

1 Preliminary

SOURCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3932395/

Indicative


▪ E.g., Index of level of regulation by country


▪ C.f. OIE standards and databases


▪ Country reporting (currently surveyed by OIE)


▪ Ability to routinely report in multiple countries



monitoring

▪ Given


▪ Regulatory strength is key input metric for AM use in food

producing animals and proxies unknown absolute levels thereof

▪ Regulation is not binary; e.g., scope and enforcement provide

qualitative information

▪ Trends help provide longitudinal development

Disaggregation▪ Animal categories

▪ Type of use and classes of AMs

▪ Region, country, state


▪ Comparability for qualitative factors is limited

▪ Regulation is prerequisite input but not sufficient measure for

AM use for growth-promotion


▪ Regulatory systems

Input

References

▪ OIE data collection, 2nd annual Report on antimicrobial agents

intended for use in animals


4c


7

4

12.1 Implement the 10-Year Framework of Programmes(…)

2.4 By 2030, ensure sustainable food production systems(…)

II

Proposed indicator

▪ Regulation of growth-promotion in food producing animals

(e.g., trends)

▪ Annual collection

▪ Currently not ubiquitous annual release

97

Indicator deep-dive: AM use in food-producing animals

Description

Assessment

4c





Descrip-

tion

▪ Overall AM use in livestock,

adjusted by biomass ▪ Problem of over- and

misuse in livestock

generally accepted

Current

Stakeholder

alignment

Proposed

definition

▪ AM use in food

producing animals (e.g., by

class and biomass)

▪ Closes gap (animal AM

use) and strengthens One

HealthRelevance

Data

sources

▪ Country reporting (OIE

surveys already)



with other indicators

Fit with

SDG

indicators

Rationale ▪ Allows measurement of

trends and implementation of

prudent use standards at

national level

▪ Proxies larger problem, e.g.,

given economically viable

production, reduced AM use

requires awareness, capacity,

& improvements in husbandry ITier:

▪ OIE already collects

extensive information

▪ Country reporting possible

within short- to mid-term

Implemen-

table by

countries

Click here for

overview page

8


98

Metadata: AM use in food-producing animals

1 Preliminary

Indicative

Goals and Targets addressed, selected


▪ Mg of active ingredient per kg of biomass


▪ Country reporting (currently surveyed by OIE)


▪ Data can be routinely reported in multiple countries


▪ Annual collection

▪ Currently not ubiquitous annual release


monitoring

▪ Ongoing


▪ Makes up significant volume of total AM use globally

▪ Proxies larger problem, e.g., given economically viable

production, reduced AM use requires awareness, capacity, and

standard improvements in husbandry

▪ Standardization on biomass allows comparison of data and

benchmarking

Disaggregation▪ Animal groups (terrestrial, aquatic, and companion)

▪ AM classes

▪ Region, country, state


▪ Black/shadow market cannot be captured

▪ Distinction by species not yet feasible in most countries

▪ Indirect link to husbandry and biosafety/biosecurity


▪ Production patterns

▪ Farming practices

Out-

put

References

▪ OIE data collection, 2nd annual Report on antimicrobial agents

intended for use in animals


I

4c


8

Click here for

overview page

4

12.1 Implement the 10-Year Framework of Programmes(…)

2.4 By 2030, ensure sustainable food production systems(…)


Proposed indicator

▪ AM use in food producing animals, e.g., by class and biomass

99

Indicator deep-dive: Proportion of AM consumption by type

Description

Assessment

4c





Proposed

definition

▪ Access-Watch Index of AMC by

country for countries with

minimal (to be defined) AMC

level

▪ Closes key gap (stewardship)

▪ Brings in perspective on

quality of access

▪ Key relevance together with

absolute AMC levels

Relevance

Rationale ▪ Improves access and clinical

outcomes

▪ Reduces potential for

development of AMR

▪ Preserves effectiveness of last-

resort antibiotics

▪ Is covered by high availability

of third-party sources

▪ Is ambition to be reported

within M&E approach

ITier:

Implemen-

table by

countries

Data

sources

▪ Access-Watch Index (WHO)

▪ Sales/trade data (e.g., IMS)

▪ Potentially country-reporting

▪ Fits well into SDG 3


with other indicators Fit with SDG

indicators

Descrip-

tion

▪ Measures consumption of

access vs. watch/reserve AMs

▪ Is covered by classification of

AMs provided by WHO expert

commission

▪ Is universal (not dependent

on AMC levels)

▪ Does not constrain access Current

Stakeholder

alignment

Click here for

overview page

9

SOURCE: Expert interviews; Team analysis; Classifying antibiotics in the WHO Essential Medicines List for optimal use—be AWaRe (Sharland et al., The

Lancet 2018)

100

Indicative

Metadata Proportion of AM consumption by type

1 Preliminary

Rational and interpretation

▪ Improve access and clinical outcomes

▪ Reduce potential for development of AMR

▪ Preserve effectiveness of last-resort antibiotics

▪ Only assess countries with minimal access to limit distortions

and bring in component of access to medicines

Disaggregation

▪ Human vs. animal use (potentially)

▪ Prescription vs. OTC vs. shadow use (as available)


▪ Culture of prescription and AMC

▪ Regulation, enforcement (e.g., shadow use), stewardship

▪ Disease burden


▪ Focuses on ABs (currently, e.g., not capturing anti-malarials)

▪ Not all classes of antibiotics are included in current index

▪ There is a weak evidence base to indicate that specific

antibiotics or classes should go into the different categories

References

▪ Classifying antibiotics in the WHO Essential Medicines List for

optimal use—be AWaRe (Mike Sharland et al,

Lancet, 2018)

Proposed indicator

▪ Access-Watch Index of AMC by country for countries with

minimal (to be defined) AMC level

TypeOne Health

Output

Custodial agencies1AMR FFA/GAP

4( )


▪ Net trade and sales data in standard units

▪ Categorization of APIs by WHO Expert Commission / AWaRe

index


▪ Country data

▪ Third party providers, e.g., IMS data on AB sales

(ATC code J011), incl. pharmacy exit survey


▪ Methodology and concept established

▪ Country collection partially given

▪ If IMS data used, potentially even tier III


▪ Annual


monitoring

▪ E.g., IMS health data (ATC code J011)

II


3.8 Achieve universal health coverage, including financial

risk protection, access to quality essential health-care

services and access to safe, effective, quality and affordable

essential medicines and vaccines for all

4c


SOURCE: Expert interviews; Team analysis; Classifying antibiotics in the WHO Essential Medicines List for optimal use—be AWaRe (Sharland et al., The

Lancet 2018)

( )

101

Indicator deep-dive: AMC in humans

Description

Assessment

4c


1 EU Joint Scientific Opinion




Proposed

definition

▪ Total consumption of AMs for

systemic use (DDD per 1,000

inhabitants and

per day)

▪ Foundational measure for

AMR

▪ Highest scoring indicator in

EU working group1

Relevance

Descrip-

tion

▪ Could be considered

constraining access

▪ Represents AMC in humans

in both the hospital and

community sector

▪ Summary indicator for

multiple AMs

Current

Stakeholder

alignment

Rationale ▪ Key priority under M&E

approach

▪ Total consumption indicates

the potential development of

AMR

▪ Allows comparative

monitoring through reliance

on DDD

IITier:

Implemen-

table by

countries

Data

sources

▪ Potential conflict with target

3.8 (access)

▪ Third parties (e.g., IHME)

▪ Countries Fit with

SDG

indicators

Click here for

overview page

10


102

Indicator deep-dive: Investment level in R&D

Description

Assessment

4c

Proposed

definition

▪ Investment in AMR R&D, e.g.

by % of GDP and for novel

types





Rationale ▪ Takes level of investment as

proxy for level of R&D effort

▪ Aims to measure and foster

innovation IITier:

▪ Not part of routine reportingImplemen-

table by

countries

▪ Innovation is key for AMR

▪ Level of investment in USD

captures effective R&D only

partly

Relevance

Descrip-

tion

▪ Measures R&D intensity by

quantifying level of

investment in R&D for AMs

▪ R&D carried by few

countries Current

Stakeholder

alignment

Data

sources

▪ Tbd ▪ Fits well into SDG 3

▪ Not universal Fit with

SDG

indicators

Click here for

overview page

11


103

Indicator deep-dive: Pipeline size

Description

Assessment

4c





Rationale ▪ Indicates future availability of

effective AMs

▪ Relies on novel AMs to set

incentives for relevant

outcomes

▪ Data is generally well

available by WHO

▪ Attrition rates not part of

routine reporting

ITier:

Implemen-

table by

countries

Proposed

definition

▪ # Novel drugs in pipeline,

e.g., attrition adjusted

▪ Adjusted pipeline of novel

drugs is basic measure of

future AM availability

▪ Long time-lag

Relevance

Data

sources

▪ WHO

▪ WIPO (IP related resources)


▪ Not universal Fit with

SDG

indicators

Descrip-

tion

▪ Measures expected

emergence of novel AMs from

current pipeline

▪ R&D carried by few

countries Current

Stakeholder

alignment

Click here for

overview page

12


104

Indicator deep-dive: Health system capacity

Description

Assessment

4c

Proposed

definition

▪ Strength of health systems to

deliver AMR outcomes

(composite index)

Comments

▪ Limited reflection of overall

AMR outcomes as input

metric

Criterion Rating




Rationale ▪ Health/veterinary systems are

key ingredient to prevent

AMR

▪ Definition and specification

not yet set

▪ Data availability and

country reporting unclear

IIITier:

Implemen-

table by

countries

Relevance

Data

sources


▪ Atypical as composite

▪ E.g., PBS Animal Health Fit with

SDG

indicators

Descrip-

tion

▪ Importance of health

systems broadly accepted

▪ Definition of composite

offers potential for

controversy among country

stakeholders

▪ Meausures toolbox, capacity,

and capabilities of human and

veterinary systems to deliver

AMR outcomes

Current

Stakeholder

alignment

Click here for

overview page

13


105

Indicator deep-dive: Risk-weighed AMR capacity

Description

Assessment

4c





Proposed

definition

▪ Size of AMR-prevention

toolbox vs. resistance level

▪ Integrates multiple highly

relevant factors

▪ Offers high-level tracking

of overall development

Relevance

Rationale ▪ Depends on specification

of indicator, but not part of

routine reporting

▪ Assess and track capacity to

tackle AMR vs. development

of AMR risk

▪ Integrate exogeneous and

endogeneous factors IIITier:

Implemen-

table by

countries

Data

sources

▪ Is atypical for SDG

indicators as composite

▪ Stretches across multiple

SDGs

▪ tbdFit with

SDG

indicators

Descrip-

tion

▪ Has high potential for

controversy due to many

degrees of freedom in

definition

▪ Numerator: Composite of

AMR toolbox, e.g., AMs

available

▪ Denominator: Composite of

resistance measures

Current

Stakeholder

alignment

Click here for

overview page

14


106

Indicator deep-dive: Incremental economic cost of AMR 4c




Description

Assessment


Rationale ▪ Underpins economic validity

of AMR measures and is

universally important

▪ Links One Health approach

with economic impact (OIE

working already on this)

▪ Depends on specification of

indicator, but not part of

routine reporting

IIITier:

Implemen-

table by

countries

Proposed

definition

▪ Marginal cost of AMR/AMR

abatement in human, animal,

plant (and environment)

dimension

▪ Link between AMR/

economic outcomes is

critical, especially in

developing context

Relevance

Data

sources


▪ As composite atypical for

SDG indicators

▪ Tbd Fitting into

SDG

indicators

Fit with

SDG

indicators

Descrip-

tion

▪ Relevant for all countries

▪ Definition and specification

has a lot of potential for

controversy

▪ Measures economic cost of

risk increase/decrease for

AMR outcomes

Current

Stakeholder

alignment

Click here for

overview page

15


107

Backup








Miscellaneous

108

Key stakeholders in SDG indicator inclusion process

ECOSOC

Statistical

commission

IAEG-

SDG

GA▪ Adopts SDG framework

▪ Is highest body of the global statistical system

▪ Established and mandates IAEG

▪ Puts SDG framework before ECOSOC

▪ Develops and implements the global indicator

framework

▪ Continuously refines and reviews framework

▪ Is at heart of the UN system to advance sustainable

development

▪ Puts SDG framework before GA

▪ Coordinates efforts to achieve internationally agreed

goals

Description

LOOK AHEAD

5

SOURCE: UN

109

Backup








Miscellaneous

110

Tier classification

1 50% of countries and of the population in every region where the indicator is relevant

Clear concept

Clear

methodology/

standards

Data collected

by countries1

Either

▪ All indicators are

equally important

▪ The establishment

of the tier system

is intended solely

to assist in the

development of

global

implementation

strategiesn/a

Tier 2

Tier 1

Tier 3

I

II

III


5

SOURCE: IAEG-SDG

111

Icon index

Human use

Clean water/sanitation

Human infection prevention


Biosafety/biosecurity

Food safety

Animal/agricultural use

Laboratory capacity/surveillance

Basic research


Quality

Coalition building


Diagnostics development and access


Global roadmap

National action plans

AMR FFA areas

Awareness1 Surveillance/research2 Infection 3 Use 4 Economic case 5

GAP

Human Plant Environment

One Health

Animal

Tier rating

I II IIITier 1 Tier 2 Tier 3

112

Abbreviations

SDGs Sustainable Development Goals

UN SG United Nations Secretary-General

R&D Research & Development

IPC Infection Prevention & Control

LMIC Lower and Middle Income Countries

MRSA Multi resistant staphylococcus aureus

PCU Population Correction Unit

NAP National Action Plan

3GCR Third generation cephalosporin resistant

IAEG-SDG Inter – Agency Expert Group for SDGs

MDGs Millennium development goals

IACG Inter – Agency Coordination Group

GA General Assembly

GLASS Global Antimicrobial Resistance

Surveillance System

AB Antibiotic

GAP Global Action Plan

AMC Antimicrobial consumption

AMR Antimicrobial Resistance

DDD Daily dose defined

FFA Framework for Action

DG Director-General

HIC High Income Countries

AM Antimicrobial

AWaRe Access Watch Reserve

HSS Health System Strengthening

EOY End of year

FPA Food producing animals

DSG Deputy Secretary-General

GPW General program of work

SCP Sustainable consumption/production

MoH Ministry of Health

DALY Disability adjusted life-years

ECOSOC UN economic and social council

API Active pharmaceutical ingredient

ODA Official development assistance

M&E Monitoring and evaluation

amr indicators and their relevance to the global …...amr indicators and their relevance to the...

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