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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
Click here for details
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
▪ Design normatively
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
Click here for details
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
APPROACH TO ANCHOR AMR
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
Click here for details
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
As in OIE 2017 document based on country reported 2014 data3
▪ 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
POTENTIAL OPPORTUNITIES
4
Click here for details
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
Click here for details
14
Contents
▪ Executive summary
▪ 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
INTRODUCTION AND APPROACH
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
INTRODUCTION AND APPROACH
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
INTRODUCTION AND APPROACH
19
Our work is based on extensive interactions with experts and
leverages a broad set of reports, frameworks, and scientific articles
INTRODUCTION AND APPROACH
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
SOURCE: Team analysis
20
Contents
▪ Executive summary
▪ 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?
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
REFLECTION OF AMR IN SDG INDICATORS
SOURCE: Team analysis
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
REFLECTION OF AMR IN SDG INDICATORS
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
REFLECTION OF AMR IN SDG INDICATORS
SDGs
Click here for backup
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
REFLECTION OF AMR IN SDG INDICATORS
25
Contents
▪ Executive summary
▪ 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?
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
AMR BLINDSPOTS IN SDG INDICATORS
2
SOURCE: Team analysis
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
Click here for backup
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
28
Contents
▪ Executive summary
▪ 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?
29
Section summary: How can AMR be better anchored?
APPROACH TO ANCHOR AMR
SOURCE: Team analysis
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
SOURCE: Team analysis
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
APPROACH TO ANCHOR AMR
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
▪ 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
▪ Design normatively
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
Click here for backup
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
APPROACH TO ANCHOR AMR
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
APPROACH TO ANCHOR AMR
Click here for backup
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
APPROACH TO ANCHOR AMR
Click here for backup
34
Contents
▪ Executive summary
▪ 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?
35
Section summary: What concrete opportunities might the IACG consider to
better anchor AMR in the SDG indicators?
POTENTIAL OPPORTUNITIES
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
SOURCE: Team analysis
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)
SOURCE: Team analysis
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
POTENTIAL OPPORTUNITIES
37
There are promising opportunities to engage with FAO, WHO and UNEP
to anchor AMR in implementation of indicators
4a
POTENTIAL OPPORTUNITIES
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) 3.3.1, 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
Click here for backup
38
31 opportunities emerge to explicitly call-out AMR
SOURCE: SDG indicator framework; Expert interviews; Team analysis 1 Counting incidences as 1 opportunity
Click here for backup
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 AMR3.2.1-3 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
POTENTIAL OPPORTUNITIES
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
POTENTIAL OPPORTUNITIES
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
POTENTIAL OPPORTUNITIES
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
POTENTIAL OPPORTUNITIES
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
SOURCE: Team analysis
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
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
As in OIE 2017 document based on country reported 2014 data3
▪ 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
POTENTIAL OPPORTUNITIES
4c
43
Contents
▪ Executive summary
▪ 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?
44
Section summary: What are next steps?
SOURCE: Team analysis
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
Click here for details
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
INTRODUCTION AND APPROACH
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
INTRODUCTION AND APPROACH
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
SOURCE: Team analysis
INTRODUCTION AND APPROACH
52
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?
Context: The SDG indicators and AMR
What concrete opportunities might the IACG consider to better anchor
AMR in the SDG indicators?
What are next steps?
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
▪ Systemic factors, e.g., spending on R&D
▪ 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
REFLECTION OF AMR IN SDG INDICATORS
SOURCE: SDG indicator framework; Expert interviews; Team analysis
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
Access to therapeutics
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
REFLECTION OF AMR IN SDG INDICATORS
SOURCE: SDG indicator framework; Expert interviews; Team analysis
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
3.8.1 Coverage of essential health services
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; and (d) student assessment
▪ Education on sustainable development in
education system
▪ Resource flows to and coverage of health
systems
▪ Systemic factors, e.g., spending on R&D
▪ 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
REFLECTION OF AMR IN SDG INDICATORS
SOURCE: SDG indicator framework; Expert interviews; Team analysis
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
REFLECTION OF AMR IN SDG INDICATORS
SOURCE: SDG indicator framework; Expert interviews; Team analysis
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
REFLECTION OF AMR IN SDG INDICATORS
1
SOURCE: SDG indicator framework; Expert interviews; Team analysis
58
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?
Context: The SDG indicators and AMR
What concrete opportunities might the IACG consider to better anchor
AMR in the SDG indicators?
What are next steps?
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
AMR BLINDSPOTS IN SDG INDICATORS
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
Environmental contamination
Biosafety/biosecurity
Food safety
Animal/agricultural use
Laboratory capacity/surveillance
Basic research
Vaccine development and access
Access to therapeutics
Diagnostics development and
access
Development of new therapeutics
Quality
Coalition building
Global roadmap
National action plans
SOURCE: SDG indicator framework; Expert interviews; Team analysis
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
AMR BLINDSPOTS IN SDG INDICATORS
SOURCE: Global Action Plan; SDG indicator framework; McKinsey analysis
61
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?
Context: The SDG indicators and AMR
What concrete opportunities might the IACG consider to better anchor
AMR in the SDG indicators?
What are next steps?
Miscellaneous
62
There are 2 options to better anchor AMR in existing indicators Options changing
indicator text
Indicators can fit into multiple options
SOURCE: Team analysis
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)
APPROACH TO ANCHOR AMR
63
Overview to AMR-relevant efforts beyond SDGs3.2Exemplary; opportunistic
APPROACH TO ANCHOR AMR
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)
APPROACH TO ANCHOR AMR
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,..
Description Description
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
APPROACH TO ANCHOR AMR
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
Description Description
▪ 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
APPROACH TO ANCHOR AMR
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
Description Description
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
APPROACH TO ANCHOR AMR
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
Description Description
▪ 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
APPROACH TO ANCHOR 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
Description Description
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
APPROACH TO ANCHOR AMR
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)
APPROACH TO ANCHOR AMR
SOURCE: Team analysis; IACG SG 5 and 6
71
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?
Context: The SDG indicators and AMR
What concrete opportunities might the IACG consider to
better anchor AMR in the SDG indicators?
What are next steps?
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
OPPORTUNITIES TO BETTER ANCHOR AMR
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
OPPORTUNITIES TO BETTER ANCHOR AMR
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
OPPORTUNITIES TO BETTER ANCHOR AMR
76
Opportunities to include AMR in implementation (2/3) 4a
SOURCE: SDG indicator framework; IAEG Tier Classification; expert interviews; Team analysis
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
9.5.2 Researchers (in full-time equivalent) per million
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-
fication Opportunities to anchor AMR
Custodial
agency
I Tier 1 II Tier 2 III Tier 3
OPPORTUNITIES TO BETTER ANCHOR AMR
77
Opportunities to include AMR in implementation (3/3) 4a
SOURCE: SDG indicator framework; IAEG Tier Classification; expert interviews; Team analysis
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-
fication Opportunities to anchor AMR
Custodial
agency
OPPORTUNITIES TO BETTER ANCHOR AMR
78
Deep-dive on key opportunities to better anchor AMR in implementations4a
POTENTIAL OPPORTUNITIES
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
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
▪ 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
essential AMs, potentially
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
APPROACH TO ANCHOR AMR
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
Overview Next steps to anchor AMR
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
Key steps Description
▪ 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
APPROACH TO ANCHOR AMR
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
Overview Next steps to anchor AMR
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
Key steps Description
▪ 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
APPROACH TO ANCHOR AMR
82
Deep-dive: Implementation of access to medicines (3.b.3)4a
Objectives ▪ Disaggregate access to
essential AMs, potentially
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
Overview Next steps to anchor AMR
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
Key steps Description
▪ 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
APPROACH TO ANCHOR AMR
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
Overview Next steps to anchor AMR
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
Key steps Description
▪ 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
APPROACH TO ANCHOR AMR
84
Deep-dive on key opportunities of adding AMR to existing indicators
SOURCE: Indicator Metadata; Team analysis
4b
POTENTIAL OPPORTUNITIES
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
education; and (d) student assessment
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 AMR3.2.1-3 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
3.8.1 Coverage of essential health services
(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
OPPORTUNITIES TO BETTER ANCHOR AMR
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
different ‘flight level’
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
SOURCE: SDG indicator framework; expert interviews; Team analysis
4b
OPPORTUNITIES TO BETTER ANCHOR AMR
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
9.5.2 Researchers (in full-time equivalent) per million
inhabitants, incl. % on AM(R) research and programs
▪ Could be perceived
as policy
interference
▪ Potentially too
different ‘flight level’
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
SOURCE: SDG indicator framework; expert interviews; Team analysis
4b Key opportunities
OPPORTUNITIES TO BETTER ANCHOR AMR
88
Indicator deep-dive: Disease burden
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
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
SOURCE: Expert interviews; Team analysis
89
Indicator deep-dive: Level of resistance
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
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
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
SOURCE: Expert interviews; Team analysis
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
OPPORTUNITIES TO BETTER ANCHOR AMR
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
CommentsCriterion Rating
Proposed
definition
▪ Level of Drug Resistance
Index by country / disease
OPPORTUNITIES TO BETTER ANCHOR AMR
▪ 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
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
92
Indicator deep-dive: Immunization coverage in food producing animals
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
SOURCE: Expert interviews; Team analysis
93
Indicator deep-dive: Infection rate of food producing animals
Description
Assessment
4c
CommentsCriterion Rating
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
OPPORTUNITIES TO BETTER ANCHOR AMR
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
SOURCE: Expert interviews; Team analysis
94
Indicator deep-dive: Growth promotion in food producing animals
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
▪ Has no apparent conflicts
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
SOURCE: Expert interviews; Team analysis
95
Indicator deep-dive: Regulation of growth-promotion in food
producing animals
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
▪ Fits well into SDG 2 and 12
▪ 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
SOURCE: Expert interviews; Team analysis
96
Metadata: Regulation of growth-promotion in FPAs
1 Preliminary
SOURCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3932395/
Indicative
Goals and Targets addressed
▪ E.g., Index of level of regulation by country
Definition and method of computation
▪ C.f. OIE standards and databases
Sources and data collection
▪ Country reporting (currently surveyed by OIE)
Current data availability / indicator tier
▪ Ability to routinely report in multiple countries
Data collection and data release calendar
Regional and global estimates & data collection for global
monitoring
▪ Given
Rationale and interpretation
▪ 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
Comments and limitations
▪ Comparability for qualitative factors is limited
▪ Regulation is prerequisite input but not sufficient measure for
AM use for growth-promotion
Sources of differences between global and national figures
▪ Regulatory systems
Input
References
▪ OIE data collection, 2nd annual Report on antimicrobial agents
intended for use in animals
TypeOne Health Custodial agencies1AMR FFA/GAP
4c
OPPORTUNITIES TO BETTER ANCHOR AMR
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
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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)
▪ Fits well into SDG 2 and 12
▪ Has no apparent conflicts
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
SOURCE: Expert interviews; Team analysis
98
Metadata: AM use in food-producing animals
1 Preliminary
Indicative
Goals and Targets addressed, selected
Definition and method of computation
▪ Mg of active ingredient per kg of biomass
Sources and data collection
▪ Country reporting (currently surveyed by OIE)
Current data availability / indicator tier
▪ Data can be routinely reported in multiple countries
Data collection and data release calendar
▪ Annual collection
▪ Currently not ubiquitous annual release
Regional and global estimates & data collection for global
monitoring
▪ Ongoing
Rationale and interpretation
▪ 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
Comments and limitations
▪ Black/shadow market cannot be captured
▪ Distinction by species not yet feasible in most countries
▪ Indirect link to husbandry and biosafety/biosecurity
Sources of differences between global and national figures
▪ Production patterns
▪ Farming practices
Out-
put
References
▪ OIE data collection, 2nd annual Report on antimicrobial agents
intended for use in animals
TypeOne Health Custodial agencies1AMR FFA/GAP
I
4c
OPPORTUNITIES TO BETTER ANCHOR AMR
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(…)
SOURCE: Expert interviews; Team analysis
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
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
▪ Has no apparent conflicts
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)
Sources of differences between global and national figures
▪ Culture of prescription and AMC
▪ Regulation, enforcement (e.g., shadow use), stewardship
▪ Disease burden
Comments and limitations
▪ 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( )
Definition and method of computation
▪ Net trade and sales data in standard units
▪ Categorization of APIs by WHO Expert Commission / AWaRe
index
Sources and data collection
▪ Country data
▪ Third party providers, e.g., IMS data on AB sales
(ATC code J011), incl. pharmacy exit survey
Current data availability / indicator tier
▪ Methodology and concept established
▪ Country collection partially given
▪ If IMS data used, potentially even tier III
Data collection and data release calendar
▪ Annual
Regional and global estimates & data collection for global
monitoring
▪ E.g., IMS health data (ATC code J011)
II
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
4c
OPPORTUNITIES TO BETTER ANCHOR AMR
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
CommentsCriterion Rating
1 EU Joint Scientific Opinion
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
SOURCE: Expert interviews; Team analysis
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
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
SOURCE: Expert interviews; Team analysis
103
Indicator deep-dive: Pipeline size
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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)
▪ Fits well into SDG 3
▪ 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
SOURCE: Expert interviews; Team analysis
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
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
▪ Fits well into SDG 3
▪ 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
SOURCE: Expert interviews; Team analysis
105
Indicator deep-dive: Risk-weighed AMR capacity
Description
Assessment
4c
CommentsCriterion Rating
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
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
SOURCE: Expert interviews; Team analysis
106
Indicator deep-dive: Incremental economic cost of AMR 4c
OPPORTUNITIES TO BETTER ANCHOR AMR
Hygiene factors (necessary) Satisfiers (sufficient) Very low Very high MediumLow High
Not/hardly given Mostly/fully givenPartly given
Description
Assessment
CommentsCriterion Rating
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
▪ Fits well into SDG 3
▪ 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
SOURCE: Expert interviews; Team analysis
107
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?
Context: The SDG indicators and AMR
What concrete opportunities might the IACG consider to better anchor
AMR in the SDG indicators?
What are next steps?
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
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?
Context: The SDG indicators and AMR
What concrete opportunities might the IACG consider to better anchor
AMR in the SDG indicators?
What are next steps?
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
OPPORTUNITIES TO BETTER ANCHOR AMR
5
SOURCE: IAEG-SDG
111
Icon index
Human use
Clean water/sanitation
Human infection prevention
Environmental contamination
Biosafety/biosecurity
Food safety
Animal/agricultural use
Laboratory capacity/surveillance
Basic research
Vaccine development and access
Quality
Coalition building
Access to therapeutics
Diagnostics development and access
Development of new therapeutics
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