Table 2.

Actors of the global health system and their role on AMR

Types of actor and examples	Role in the global health system	Role in the global governance of AMR
National governments Bilateral development cooperation agencies; Ministries of Foreign Affairs; Ministries of Health	Health is primarily a national responsibility; Nation States are the traditional actors in global health. National, and to some extent, international public health depends on Ministries of Health. Donor countries are involved in development assistance for health through their bilateral development cooperation agencies. Recently, as health has gained political prominence as ‘soft’ power, Ministries of Foreign Affairs have been increasingly involved in global health policymaking.	National and subnational governments adopt AMR policies and implement them.6 The responsibility to address AMR usually spans several ministries including health, trade and economy. Since the adoption of the WHO GAP AMR in 2015, national governments have developed national action plans to combat AMR. There is however a gap in implementation. In this regard, national and subnational actors are ultimately the ones that need to be involved and convinced about the need and urgency of implementing AMR policies through a coordinated multisectoral and multilevel approach where authority is increasingly dispersed.49
Other IOs and mechanisms OECD, ISO, EU, ICRC, TATFAR	The international system has seen a proliferation of IOs. Among these organisations, some are active at the global level while others work at the regional level (eg, EU which adopted a strategy on global health).	Several non-UN IOs are already involved in tackling AMR. For example, the EU adopted plans on AMR.82 Within the European region, ECDC aggregates data from EU countries on AMR. JPIAMR supports research on AMR. OECD has also published reports on AMR. The International Committee of the Red Cross has been involved in the fight against AMR mainly in conflict areas. TATFAR was created in 2009 to enhance expert transatlantic collaboration on AMR.
Global health initiatives Drugs for Neglected Diseases; Global Fund to Fight AIDS, Tuberculosis, and Malaria; GAVI; Unitaid; GARDP; MPP	A central innovation in global health governance has been the development of new mechanisms to deliver targeted funding and health technologies in LMICs.83 Global health initiatives are hybrid organisations which mix elements of the private and public sector. They are typically programmes targeted at specific diseases that were created to address major communicable diseases in LMICs. Their number has risen sharply since 2000 with now about 100 organisations active in global health. They take different forms such as a finance mechanism, implementation programme or product development partnership which aims to research and develop new products such as drugs for neglected tropical diseases. These organisations have been endowed with large means and have developed strong expertise in the delivery of health technologies, medications and preventive strategies in LMICs.	Global health initiatives have played a critical role regarding innovation, access to medicines and infection prevention. Organisations such as GAVI have been critical to step immunisation. Regarding access, the main solution has been for HICs to subsidise access to antimicrobials in LMICs through the establishment of funding and procurement organisations (eg, Global Fund or the Medicine Patent Pool, UNITAID). On innovation, several organisations are conducting R&D activities. Recently, efforts have resulted in the creation of GARDP which develops new treatments for drug-resistant infections that pose the most significant threat to health.
Philanthropic organisations Bill and Melinda Gates Foundation, Rockefeller Foundation, Wellcome Trust, Aga Khan Foundation	Philanthropic organisations have contributed significantly to the increase of funding in global health in the last 20 years. Founded in 2000, the Bill and Melinda Gates Foundation has become a prominent player with total payments of more than US$58.8 billion since inception. With their huge financial means, the largest philanthropies can set priorities and influence the global health agenda.	Philanthropic organisations are contributing to the collaboration between different actors to develop actions and funding programmes against AMR. Through its forums, the World Economic Forum, which included AMR as part of its global risks report, plays a leading role in calling for cooperation between the public and private sectors to develop innovative solutions to combat AMR.
Informal state grouping (quasi-IOs) G7 and G20	G7 and G20 are global and informal leadership groups that were primarily created to address financial and macroeconomic issues but have come to cover many pressing issues in global governance.	G8 and G20 have adopted declarations on AMR. These organisations have played a key role in putting AMR on the global political agenda.
Global civil society organisations Care International; Doctors without Borders (Médecins Sans Frontières); OXFAM International; Save the Children; People Health Movement; International Committee of the Red Cross	Global civil society organisations are non-governmental, non-business organisations or movements that are active across borders. International NGOs have been an important player in global health in implementation programmes as well as in advocacy (eg, the campaign for access to essential medicines by Doctors without Borders, which aims at increasing the availability of drugs in LMICs). Global civil society also encompasses networks such as the People Health Movement, which focuses on health equity and plays a critical role in advocacy and scrutiny of health policy.	Some NGOs have a mandate specifically on AMR while many other NGOs address AMR as part of a wider portfolio of activities on health or humanitarian issues. With a global reach such as Doctors without Borders have been critical in promoting access to medicines as illustrated by the access to medicine campaign which advocates for access to effective drugs for all.
Private industry Pharmaceutical companies; biotechnology companies; information and communication companies	The private industry researches, develops and disseminates products such as drugs, diagnostics and technologies through global markets. Some private companies have set up their own foundations and/or participated in public–private partnerships.	To address market failure in the research and development of new drugs, some governments have step up incentives.22 Most research on R&D on new antimicrobials is led by small firms. In addition, big pharmaceutical companies are contributing to global health initiatives and product development partnerships.
Academic institutions and professional associations ReAct	Academic institutions and networks play an essential role in global health education and research. Professional societies gather members of the same profession such as physicians or nurses and usually set professional standards. In global health, professional societies can enact recommendations for best practices and play a role in global health education.	Academic institutions conduct both fundamental and applied research on AMR including drug discovery, clinical research and wider public health and governance aspects of AMR. Additionally, academic experts contribute to technical meetings from IOs.

Adapted from ReAct.⁸⁴

AMR, antimicrobial resistance; ECDC, European Centre for Disease Prevention and Control; EU, European Union; GAP, Global Action Plan; GARDP, Global Antibiotic Research and Development Partnership; GAVI, The Vaccine Alliance; HICs, high-income countries; ICRC, International Committee of the Red Cross; IOs, international organisations; ISO, International Organization for Standardization; JPIAMR, Joint Programming Initiative on Antimicrobial Resistance; LMICs, low/middle-income countries; MPP, Medicine Patent Pool; NGOs, non-governmental organisations; OECD, Organization for Economic Co-operation and Development; R&D, research and development; TATFAR, Transatlantic Taskforce on Antimicrobial Resistance; UN, United Nations.