From the superbug scare in Pennsylvania last month to the UK’s recently released Review on Antimicrobial Resistance, slowing the rate at which infections become resistant to antibiotics is rising up the list of global health priorities—and rightfully so. The Review estimates that deaths from antimicrobial resistance (AMR) could reach 10 million people a year by 2050 if we don’t reduce the overuse and misuse of antimicrobials, including antibiotics, and that the economic damage could add up to a staggering $100 trillion by 2050.
Despite some misperceptions, this is not just a problem of wealthier countries. In fact, it is what governments in low- and middle-income countries (LMIC) do to conserve the effectiveness of antimicrobials that will make a significant difference for us all going forward.
We know that we need to get to collective action to confront this global threat; the UK Review, the World Health Organization’s action plan, and US national action plan for AMR all call for global measures. Yet the money and mechanisms at the international level remain inadequate; aid agencies and multilateral development banks lack the appetite to support LMIC efforts to tackle AMR. Case in point: although several LMIC have developed national action plans to deal with AMR, most remain underfunded and lack the necessary support both from within their own countries and from external actors.
The multilateral development banks are particularly well suited to help solve this seemingly intractable issue. They’re inter-sectoral, with expertise and projects spanning across the health, financial, environment, and agricultural sectors. Institutions like the World Bank are also adept at raising funds and possess the knowledge, analytical skills, and operational assistance required by LMIC programs to prevent and control AMR. Furthermore, the multilateral development banks can operate with a long-term perspective; their funding is not directly affected by government budgets or election cycles, their concessional windows have been regularly replenished for decades, and many of their soft loans have a 40-year repayment term. They have the capacity for effective and sustained AMR action, but they have yet to step up to the plate.
So, what should the World Bank and the other multilateral development banks be doing to help? How can they be most effective in supporting the development and rollout of countries’ national action plans on AMR? And if they do not help, can we afford the outcome?
To start, the World Bank needs a mandate to work on global public goods such as the battle against AMR. One reason the Bank has not yet made progress is that the Bank’s programs are predominantly demand-driven lending that follows LMIC governments’ priorities. A few countries have identified AMR as a priority; however, given competing demands for other projects (in health, infrastructure, education, agriculture, etc.), the public-health systems that are needed to control AMR have remained a low priority for decades. A mandate to the World Bank from its shareholders is needed because only then can the Bank start to systematically encourage countries to prioritize prevention and control of AMR and to increase the performance of the requisite veterinary and human public-health systems.
The Bank, and even the International Finance Corporation, could use pay-for-performance schemes to incentivize actions against AMR. For example, countries could be rewarded for performance on surveillance and diagnostic labs; for reporting; for raising their Global Health Security Agenda evaluation scores; for infection prevention in healthcare; for active antimicrobial stewardship to promote more rational use; for patient adherence to medications; for effective communications to farmers, patients, and others; and/or for educating providers on rational antibiotics use. This type of payment scheme would focus on performance and incentivize countries to improve their preparedness and response to AMR, with knock-on benefits for other global health security issues.
Whether low-income countries prioritize public-health systems will hinge on how the projects are financed—for this, a small modification of IDA’s successful regional program could be a practical solution.
Fewer than 3 percent of projects in the IDA regional program have been in health over the last 15 years. The main culprit may be the regional program’s eligibility requirement of joint activities by at least three countries. (Most IDA countries have extremely weak public-health systems, poorly equipped for joint work with other countries.) To overcome this—and because an entire region benefits significantly when even just one country builds the capacity to comply with IHR and reduce AMR—projects that build public-health systems to comply with IHR and control AMR should be included in the IDA regional program. This will provide incentives to reorder priorities and shift resources to investments with very high public-health, economic, and pro-poor growth benefits. Such investments will also put countries in a better position to contribute to regional coordination on AMR and disease control.
Here’s how it would work: IDA would fund each public-health system project using the existing regional projects formula, meaning a project would take only one-third of its financing from a country’s IDA allocation and the other two-thirds would be provided as a top-up credit or grant from IDA’s regional “window.” This formula, which has successfully raised the priority of regional projects within country lending programs, would reflect the public interest in encouraging all countries to comply with the IHR so as to mitigate AMR and other disease outbreaks.
What might it cost? The World Bank (2012) estimated that the 77 IDA-eligible low-income countries would require $1.5 billion annually to support their veterinary and human public-health systems. If we optimistically assume that all IDA countries would take advantage of the regional top-up by embarking on strong AMR control measures, and if we further assume, pessimistically, that other banks and donors don’t contribute to funding these projects, then the IDA financing required would be $4.5 billion over three years. IDA18 for financing projects in 2018-2020 could reach $90 billion, so the public-health system project top-up would come to about 5 percent of IDA resources.
This sum is remarkably small compared to the benefits it would generate. For pandemic risk alone, the expected benefit generated by capable public-health systems is $60 billion annually. The expected benefit of AMR control is higher still; the UK Review on AMR estimates that benefits from AMR control will rise to more than $2 trillion annually by 2030 and further to $8 trillion annually by 2050.
Public-health systems in IDA countries are “the weakest links” in global health and economic security, and IDA could help fix the riskiest gaps in their performance globally. Active engagement by IDA would also prompt a rediscovery of prevention and preparedness using One Health approaches. Without the top-up in the IDA allocation to change the incentives, AMR and global health security projects will fall far short of what is warranted by the health and economic benefits.
Importantly, this change could be implemented in the near term—the 18th replenishment of IDA is being negotiated this year. Recent global health security challenges like Ebola and Zika are already getting air time in discussions. Moving public-health capacity-building projects from the bottom to the top of the priority list may well come to be seen as a groundbreaking IDA18 achievement; as CGD board chair Larry Summers has aptly pointed out, veterinary and human public-health systems are “probably the single most important area for productive investment on behalf of mankind.”
This is a global problem with a global solution, and—with interest from IDA’s donors—there is low-hanging fruit to be had at the World Bank.
Olga Jonas is an economic adviser at the World Bank.