Table 2.

Possible legal hooks and institutional mandates for addressing ten key issues in antimicrobial resistance

Access
	Key global actions on AMR	Possible legal hooks
1	Develop equitable pricing and licensing models to support access to antimicrobials in resource limited settings	TRIPS Authorize compulsory licenses for generic antimicrobials for those resource limited setting that have effective stewardship regimes in place	IHR Create a global pooled fund that would equitably support appropriate access to antimicrobials, the conservation of these medicines, and infection prevention initiatives	GAVI/Global Fund Participate in a global procurement mechanism that minimizes the costs of existing antimicrobials and related technologies	TRIPS/TBT Implement a global tiered pricing system and mitigate parallel importation so that antimicrobials and related technologies can be sold at lower prices in lower-income countries without diminishing markets in higher-income countries	TBT Strategically use tariffs and tax policy to make antimicrobials less expensive as appropriate for countries where antimicrobials are currently underutilized
2	End the manufacturing, sale and export of substandard, falsified and banned antimicrobial products	TBT Ensure monitoring and compliance with rigorous quality assurance standards for antimicrobials	HCDCS Enforce compliance with rigorous quality assurance standards for antimicrobials at time of import/export	WHO/FAO/OIE Require surveillance of substandard and falsified antimicrobials, and education about the harms of using these products
3	Strengthen health systems to improve infection prevention and control and reduce the need for antimicrobials	IHR Provide financial and technical support for all countries to achieve core public health capacities and universal health coverage	IHR Create and finance a global fund to improve access, stewardship, health care, food security, and water, sanitation and hygiene systems

Conservation
	Key global actions on AMR	Possible legal hooks
4	Strengthen the surveillance of antimicrobial usage and AMR in humans, animals and the environment	IHR Set international standards for laboratory testing, antimicrobial usage and AMR surveillance, and data harmonization in humans, animals, and the environment	IHR or WHO/FAO/OIE mandate Designate an international expert authority to develop antimicrobial usage guidelines for humans, animals, and the environment	IHR or WHO/FAO/OIE mandate Develop national and regional authorities on antimicrobial stewardship, drug standards, and AMR surveillance to report back to the international expert authority	IHR or WHO/OIE/FAO Make available technical expertise to strengthen AMR and antimicrobial usage surveillance infrastructures	SPS Provide funding for strengthening monitoring and surveillance of antimicrobial usage/AMR in LMIC through the Standards and Trade Development Facility
5	Promote the responsible use of antimicrobials in humans	TBT/SPS/IHR/WHO Ban commercial advertising and marketing of antimicrobials	WHO mandate Require a prescription from an authorized health worker for all antimicrobial use in humans	WHO mandate Regulate prescribers to delink any provision of antimicrobials from their financial remuneration
6	Promote the responsible use of antimicrobials in animals and agriculture	SPS or FAO mandate Ban the use of antimicrobials for growth promotion in animals	SPS or FAO mandate Limit prophylactic antimicrobial use to single animals	SPS or FAO Ban the metaphylactic use of antimicrobials in animal production	TBT or FAO mandate Require a prescription from an authorized animal health worker for all antimicrobial use in animals and ban cascade prescribing	FAO mandate Regulate prescribers to delink any provision of antimicrobials from their financial remuneration
7	Safeguard the effectiveness of new antimicrobials	IHR or WHO/FAO mandate Create an expert committee to monitor resistance and, as needed, designate and reserve particular antimicrobials for human-only use	TRIPS/TBT or WHO mandate Automatically reserve new antimicrobial classes for exclusive human usage	TBT Strategically use tariffs and tax policy to make antimicrobials more expensive as appropriate for countries where antimicrobials are currently overutilized	TRIPS/TBT Prevent the manufacturing, sale and export of new antimicrobial classes for animal use until authorized by a designated international entity
8	Limit antimicrobial contamination in the environment	Basel, Rotterdam, Stockholm Set, monitor and enforce national guidelines for antimicrobial waste management in the environment	UNEP Develop international regulations on the disposal of antimicrobial waste	UNEP Make available technical expertise to limit antimicrobial contamination in the environment

Innovation
	Key global actions on AMR	Possible legal hooks
9	Incentivize the development of new antimicrobials and related technologies	IHR Require national investments in R&D for new antimicrobials, alternative therapeutics, diagnostics, social interventions and infection prevention that are proportional to national economic capacity and antimicrobial use	UNITAID or GARDP Experiment with innovative financing mechanisms for R&D needed to address AMR	WHO/global fund Participate in a global pooled fund that would equitably support open research in those countries that have achieved progress towards conserving antimicrobials
10	Facilitate the development of new antimicrobials and related technologies	WHO/FAO/OIE/UNEP Create a process to develop product profiles and designate social outcomes for new technologies or approaches that should be prioritized	TBT/international conference on harmonization Expedite the assessment and regulatory approval of prospective new antimicrobials and related technologies	WHO Report annually on all investments in antimicrobial R&D