Table 3

Opportunities for further development of the global governance of AMR based on clusters of competencies and functions

Cluster of relevant organisations	Addressing gaps in global governance	Potential for further involvement of global stakeholders
Infection prevention DESA, FAO, GAVI, ILO, ISO, OIE, UNISDR, UN-Water, UNICEF, WHO, WTO	AMR is another strong argument for the implementation of water, sanitation and hygiene (WASH) interventions in LMICs (SDG6) and for better immunisation (SDG3). Synergies between AMR and interventions to tackle infectious diseases and pandemic preparedness should be better assessed. There is currently limited coordination to design intervention based on co-benefits.	The ILO could raise awareness of the standards in occupational health and hygiene and develop the capacity of national actors to use them. GAVI activities on improving immunisation coverage in LMICs can be better linked to the goal of reducing AMR. In food-producing animals, standards of hygiene could be set up on the ISO model as there are already standards for food safety. UNISDR may incorporate AMR concerns into disaster reduction strategies. DESA could strengthen its AMR objectives by encouraging Member States to use the SDGs review processes to highlight the links between AMR and SDG under review. UN-Water could take action to reduce water contamination by advocating for improvements in the sewage system.
Surveillance UNEP, WHO, OIE, FAO, IMF	The Tripartite has strengthened surveillance of AMR but there are gaps in capacities between countries. In addition, there is limited effort for surveillance of antimicrobial use in animal health and a lack of environmental surveillance of AMR. Another need is a better integration/harmonisation of surveillance standards across sectors.	The WHO-OIE-FAO Tripartite could improve integration of AMR surveillance with the IHR and PVS pathways to foster an integrated approach to zoonosis. UNEP should become more involved in environmental surveillance of antibiotic residues and AMR. IMF could integrate vulnerabilities of countries to infectious diseases including AMR in its evaluation about countries’ economic growth and stability.85 What has been created for AGISAR could be scaled up by combining its strength with the work of GLASS for the collection of epidemiological data.
Conservation WHO, IFAD, UN-Habitat, ISO, FAO, OIE	Current global mechanisms for the conservation of antimicrobials rely mainly on the diffusion of information and adoption of standards. Promotion of antimicrobial use is poorly controlled. The responsibility for conservation is shared between different entities. More efforts are needed to translate this into actionable mechanisms, which are currently more developed in human health than in other sectors. An important challenge is to define common standards for the different areas (ban of antibiotics as growth promoters, critically important antibiotics).	The Tripartite could work together to ban the use of antibiotics as growth promoters. A code of conduct, like the international code on breastmilk substitute, could be used to restrict promotion and advertising of antimicrobials by pharmaceutical companies. The Tripartite could set up a mechanism like the consultative Expert Working Group on research and development to assess the potential effectiveness and feasibility of conservation strategies. IFAD can build global capacity in the agricultural sector to address AMR. UN-Habitat could provide a relevant entry point for the important topic of AMR dissemination through wastewater and the treatment plan. ISO could be involved in setting standards regarding antimicrobial use and further embed actions against AMR in the global economy.
Containment ICAO, IMO, UNEP, UNWTO, WHO, OIE, FAO, Wellcome Trust, BMGF	Expansion of containment strategies should be based on the identification of new ways to prevent the dissemination of AMR in different settings, including in the environment.	Organisations related to transport (IMO or ICAO) or tourism (UNWTO) could help address international containment of AMR through their respective mandate. Funding agencies might support more research on the ecology and transmission of AMR including the flow of antimicrobial residues and genetic elements.
Innovation GARDP, ITU, UNCTAD, Wellcome Trust, WIPO, WHO	Addressing market failures against AMR requires market incentives and innovative funding mechanisms. Current efforts should build on existing structures that have proven to be effective.	ITU could help facilitate the discussion regarding innovation. UNCTAD could play a supporting role given its wide range of activities in the development of new therapies and diagnostics, and its efforts to improve access to these therapies and diagnostics.
Access Doctors without Borders (MSF), Global Fund, HRC, OHCHR, UNAIDS, UNCTAD, UNDP, UNICRI, UNODC, UNOPS, WHO	Access to antimicrobials has been mainly supported in specific diseases. A current challenge is that access to medicines can conflict with other challenges of global collective action such as conservation. However, enhancing access can also reduce the use of substandard medicines. The report of the UN Secretary-General’s high-level panel on access to medicines stated that an important issue for improved coherence is the diversity of accountability mechanisms between access and innovation.27	Extending the mandate of relevant organisations, with and without a primary health mandate, such as the Global Fund, UNAIDS and UNDP, to increase access and delivery to essential drugs in LMICs. HRC, OHCHR and other human rights bodies can raise awareness and build common international norms about access to medicines. IOs working to combat fake medicines (eg, UNICRI, UNODC) can contribute to limit the use of substandard antimicrobials (in partnership with the WHO, which created the Global Surveillance System for substandard and fake medical products in 2003). UNCTAD could play a supporting role given its wide range of activities in the development of new therapies and diagnostics, and its efforts to improve access to these therapies and diagnostics. UNOPS, in partnership with other organisations, could provide demand-driven operational support for the procurement and distribution of quality medicines.
Research education and awareness BMGF, ITC, UNCTAD, UNESCO, UNIATF, UNIDO, UNITAR, UNSSC, UNU, UNWTO, UN-Women, WEF, Wellcome Trust	The Tripartite produces communication material (eg, global campaign) but other IOs with specific commitments and targets are needed to raise awareness and build evidence on AMR, particularly in areas where AMR is not commonly discussed. An important contribution would be to better measure the (cost-)effectiveness of interventions about AMR and understand how to tailor intervention to the context.	IOs involved in knowledge creation and transmission (UNESCO, UNITAR, UNU, UNSSC) could leverage their expertise in training and education to raise awareness on AMR. IOs with specific constituencies that are important to tackle AMR (eg, chronic diseases (UNIATF), women (UN-Women), tourism (UNWTO) could also raise awareness about AMR for different constituencies. Several business-oriented organisations could play a role in advocacy for AMR. These organisations include UNCTAD, ITC or UNIDO but also the WEF which has already put AMR on its global health risks report. Several private foundations such as the Wellcome Trust, the BMGF and the Flemming fund have critical funding capacities for research and education on AMR.
Specific diseases GFATM, Medicine for Malaria Venture, Medicine Patent Pool, UNAIDS	AMR has been a growing problem in several specific diseases including TB, malaria and HIV-AIDS. AMR is another strong argument to build the case for tackling these diseases through an intersectoral approach. AMR is an important case for maximising positive synergies in strengthening health system in LMICs.86	Explore potential synergies in using the expertise and logistical support of GFATM and other organisations on specific diseases to build broader AMR capacity. Given its large funding power, the Global Fund could become a key player to address and coordinate AMR challenges regarding TB, HIV and malaria in LMICs among the different actors. The surveillance of resistant TB under the auspice of WHO could serve to strengthen laboratory capacity in LMICs for other types of bacteria.87 88
AMR in specific and/or discriminated population and conflicted areas CRPD, ICRC, IOM, MSF, OCHA, OSAA, the Tripartite, UNDP, UNFPA, UNHCR, UNIATF, UNICEF, UNRISD, UNRWA, UN-Women, WFP	Fragile and discriminated people may be more at risk of AMR.89 There is still a lack of empirical evidence on the link between inequalities and AMR but there is a growing sense that AMR can be an obstacle to poverty reduction.8 90 Several IOs may contribute to raise awareness and, in some cases, mitigate the effect of AMR in these populations.	(Humanitarian) agencies working in fragile context such as OCHA, WFP, UNHCR, UNICEF, MSF and ICRC can improve access, infection prevention, surveillance, containment and conservation. Some IOs can also raise awareness about AMR in specific populations, particularly women and poor communities. This can be done in collaboration with the Tripartite and UNDP, which already play a leading role in assessing the impact of AMR on the SDGs. Some mechanisms such as the UNIATF as well as treaty-based organisations (ie, Convention on the Rights of Persons with Disabilities) can also raise awareness about AMR in specific populations.
Sustainable funding Asian Infrastructure Investment Bank, IMF, World Bank	Sustainable funding is a key issue for many AMR efforts. A first challenge is funding dedicated to strengthening global governance. Some countries have helped through earmarked funding for AMR. The other is development aid to strengthen capacities in LMICs. While savings regarding One Health approach have been estimated for important components in tackling infectious diseases, more precise assessment and pilot studies are needed regarding AMR.91	IMF could include assessments of countries’ systemic risk caused by infectious diseases in financial evaluation to strengthen nations’ government incentives to act on AMR as access to financial market is capital for them.92 The World Bank can further identify and prioritise interventions that are relevant to LMICs. The World Bank, IMF and/or the Asian Infrastructure Investment Bank along with other financial players can better link the financial sector to health goals.93 Financial organisations could provide expertise in quantifying AMR risks and efforts, which will be important in securing funding for such projects amidst fierce competition for attention and resources. Engaging insurance (or, more importantly, reinsurance) companies that could play an important role in this group. These evaluations should not only focus on costs but also on potential savings.
Coordination CEB, ECOSOC, JIU, UNGA, UNSG, HLPF	AMR requires coordination and collaboration across many different areas. In addition to mechanisms specific to AMR, several IOs and mechanisms share a coordination mandate which could provide relevant fora for discussion on AMR. This should facilitate the definition of a common agenda on infectious disease and issue linkages with other pressing global challenges.	Due to near universal membership, the UNGA is an appropriate forum to encourage continuous high-level support on AMR. ECOSOC might be an important forum for discussion related to the socioeconomic impact of AMR. EOSG could advocate for AMR and encourage alignment across the One Health agenda. Other high-level relevant fora for attention grabbing include the G7 and G20 which have already included AMR in their agenda. With its broad mandate on sustainable development, the HLPF provides a platform for follow-up and review of AMR-sensitive activities.

AGISAR, Advisory Group on Integrated Surveillance of Antimicrobial Resistance; AMR, antimicrobial resistance; BMGF, Bill and Melinda Gates Foundation; CEB, Chief Executive Board; CRPD, Convention on the Rights of Persons with Disabilities; DESA, Department of Economic and Social Affairs; ECOSOC, Economic and Social Council; EOSG, Executive Office of the Secretary-General; FAO, Food and Agriculture Organization; GARDP, Global Antibiotic Research and Development Partnership; GAVI, The Vaccine Alliance; GFATM, Global Fund to Fight AIDS, Tuberculosis and Malaria; GLASS, Global Antimicrobial Surveillance System; HLPF, High-Level Political Forum on sustainable development; HRC, Human Rights Council; ICAO, International Civil Aviation Organization; ICRC, International Committee of the Red Cross; IFAD, International Fund for Agricultural Development; IHR, International Health Regulations; ILO, International Labour Organization; IMF, International Monetary Fund; IMO, International Maritime Organization; IOM, International Organization for Migration; IOs, international organisations; ISO, International Organization for Standardization; ITC, International Trade Center; ITU, International Telecommunication Union; JIU, Joint Inspection Unit; LMICs, low/middle-income countries; MSF, Médecins Sans Frontières; OCHA, Office for the Coordination of Humanitarian Affairs; OHCHR, Office of the United Nations High Commissioner for Human Rights; OIE, World Organization for Animal Health; OSAA, Office of the Special Adviser on Africa; PVS, Performance of Veterinary Services; SDGs, Sustainable Development Goals; TB, tuberculosis; UN, United Nations; UNAIDS, United Nations Programme on HIV/AIDS; UNCTAD, United Nations Conferences on Trade and Development; UNDP, United Nations Development Programme; UNEP, United Nations Environment Programme; UNFPA, United Nations Population Fund; UNGA, United Nations General Assembly; UNHCR, United Nations High Commissioner for Refugees; UNIATF, United Nations Interagency Task Force on Non-Communicable Diseases; UNICRI, United Nations Interregional Crime and Justice Research Institute; UNIDO, United Nations Industrial Development Organization; UNISDR, United Nations Office for Disaster Risk Reduction; UNITAR, United Nations Institute for Training and Research; UNODC, United Nations Office on Drugs and Crime; UNOPS, United Nations Office for Project Services; UNRISD, United Nations Research Institute for Social Development; UNRWA, United Nations Relief and Works Agency; UNSG, United Nations Secretary-General; UNSSC, United Nations System Staff College; UNU, United Nations University; UNWTO, World Tourism Organization; WEF, World Economic Forum; WFP, World Food Programme; WIPO, World Intellectual Property Organization; WTO, World Trade Organization.