Universal health coverage: an opportunity to address antimicrobial resistance?
Authors: Elizabeth Tayler, Richard Gregory, Gerry Bloom, Peter Salama, Hanan Balkhy
Journal: The Lancet Global Health (2019)

On Sept 23, 2019, global leaders will gather at the UN for a high-level meeting on universal health coverage1UNPolitical declaration of the high level meeting on universal health coverage. 2019https://www.un.org/pga/73/2019/05/17/universal-health-coverage-8/Date accessed: September 19, 2019Google Scholar and discuss commitments and action to extend essential health services to over half of the world's population that have no access to them. 3 years ago, leaders met similarly at the UN General Assembly to consider antimicrobial resistance, perhaps the greatest threat to public health of our time. These two major global health priorities are much more closely linked than they might appear at first. If antimicrobial resistance is not controlled, health care will become more difficult, less effective, and more expensive. Conversely, action towards universal health coverage—and a positive response by countries at the meeting to the key asks2UHC 2030Moving together to build a healthier world: key asks from the UHC movement. 2019https://www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/UN_HLM/UHC_Key_Asks_final.pdfDate accessed: September 19, 2019Google Scholar proposed by the universal health coverage movement—can help expand coverage of measures to prevent and manage infection, including appropriate use of antibiotics. Countries have a great opportunity to both accelerate universal health coverage progress and tackle antimicrobial resistance, with substantial and sustainable gains. Over the past 50 years, antibiotics have often been used as a substitute for good quality care. They have enabled health facilities to provide sophisticated treatments without investing in hygiene and good quality nursing to reduce exposure to infections. Antibiotics have allowed health workers to treat many patients without the inputs (time, skills, and equipment) necessary to make a diagnosis. Indiscriminate use of antibiotics is a quick way to handle patients and provides benefits to those with a bacterial infection. However, excessive exposure of people and their microbiomes to antibiotics is making these drugs less effective for everyone. In many parts of the world, the burden of infectious diseases is still great and people are dying because they do not get the right antibiotics when they need them.3Laxminarayan R Matsoso P Pant S et al.Access to effective antimicrobials: a worldwide challenge.Lancet. 2016; 387: 168-175Summary Full Text Full Text PDF PubMed Scopus (667) Google Scholar In line with universal health coverage goals, improving access to appropriate antibiotics is a priority, as well as immunisation and provision of safe, clean care. Addressing antimicrobial resistance is equally important in the management of non-communicable diseases, where the risks of infection are substantial when patients are immunocompromised or undergoing surgery. Although some aspects of the response to antimicrobial resistance, such as surveillance of resistance patterns and antibiotic stewardship programmes, are done specifically to address antimicrobial resistance itself, much of the response focuses on good public health and clinical care.4Bloom G Merrett GB Wilkinson A Lin V Paulin S Antimicrobial resistance and universal health coverage.BMJ Glob Health. 2017; 2: e000518Crossref PubMed Scopus (52) Google Scholar All health facilities should have a water supply and functioning toilet and handwashing facilities. Infection prevention, management and quality assurance of medicines, and rational prescribing should be priorities in their own right. Antimicrobial resistance is an urgent reason to scale up these measures in a systematic manner.5World BankDrug-resistant infections: a threat to our economic future.http://www.worldbank.org/en/topic/health/publication/drug-resistant-infections-a-threat-to-our-economic-futureDate accessed: June 18, 2019Google Scholar, 6WHOGlobal action plan on antimicrobial resistance. 2015https://www.who.int/antimicrobial-resistance/global-action-plan/en/Date accessed: September 19, 2019Google Scholar Getting the basic components of a health system right is fundamental to antimicrobial resistance control, and addressing antimicrobial resistance is a much greater challenge in weak health systems than in those that are more developed. Sufficient health workers with the time, motivation, and skills to offer quality service are needed. For that, health workers need proper training and ongoing education, and they should work in facilities that are clean and safe, where patients do not risk becoming infected with resistant bacteria. The reliable supply of quality antibiotics is crucial and should be part of a coherent approach to the management of infections that includes appropriate preventive measures and proper diagnosis and treatment, in accordance with evidence-based guidelines.7WHOTechnical series on primary health care: antimicrobial resistance and primary health care. 2018https://www.who.int/docs/default-source/primary-health-care-conference/amr.pdf?sfvrsn=8817d5ba_2Date accessed: September 19, 2019Google Scholar Strengthening the regulation of products, premises, and practitioners is essential. In many countries, poor individuals rely heavily on informal drug sellers and health workers operating largely outside the regulatory framework. Governments need to find innovative ways to ensure that regulation and quality standards are effectively applied across the public, private, formal, and informal sectors, without constraining access to health care. Dialogue with the private sector is needed to find realistic ways to remove the incentives to increase drug sales that result in promotion of inappropriate use. Both universal health coverage and antimicrobial resistance require political leadership and collaboration that goes beyond health. In many countries, more antibiotics are fed to healthy animals than to sick humans, and a growing demand for cheap meat means that antibiotic consumption is set to rise.8Boeckel TPV Brower C Gilbert M et al.Global trends in antimicrobial use in food animals.Proc Natl Acad Sci. 2015; 112: 5649-5654Crossref PubMed Scopus (1831) Google Scholar Antibiotics are sprayed on crops and their residues contaminate rivers. High-level political engagement and intersectoral collaboration is needed to manage the tensions and trade-offs that could arise between sectors. Countries are beginning to increase investment in the discovery of new antibiotics. This is an essential component of the global effort to address antimicrobial resistance. However, if new effective drugs are introduced into contexts in which systems for managing infection remain weak, they will not remain effective for long. Because resistance can spread so fast, we need action in all countries, for all people, and across public and private sectors. If not, resistance levels will continue to rise, making inexpensive first-line drugs ineffective. As seen with resistant tuberculosis, resistant infections are more difficult and costly to treat.5World BankDrug-resistant infections: a threat to our economic future.http://www.worldbank.org/en/topic/health/publication/drug-resistant-infections-a-threat-to-our-economic-futureDate accessed: June 18, 2019Google Scholar The universal health coverage movement is asking countries to invest more and better in health systems. Investing in antimicrobial resistance control is an exceptionally good buy.5World BankDrug-resistant infections: a threat to our economic future.http://www.worldbank.org/en/topic/health/publication/drug-resistant-infections-a-threat-to-our-economic-futureDate accessed: June 18, 2019Google Scholar, 9Organisation for Economic Co-operation and DevelopmentStemming the superbug tide: just a few dollars more.https://www.oecd.org/health/stemming-the-superbug-tide-9789264307599-en.htmDate accessed: June 19, 2019Google Scholar All countries need to do more; for low-income countries, where the needs are great and resilience and resources are lowest, additional development finance is required. More broadly, the universal health coverage movement is calling on political leaders to legislate, invest, and collaborate with all of society to make universal health coverage a reality. Much of what is called for is also crucial for tackling antimicrobial resistance, and strengthening systems for prevention and management of infection will be of mutual benefit for both antimicrobial resistance control and universal health coverage goals. We declare no competing interests.