Stakeholder engagement in NAP implementation

Although the NAP is currently implemented within the healthcare sector, staff in Nam Dinh CDC revealed that they had not been assigned any plans or implemented any activities that contribute to the NAP or AMR mitigation goals. The other sectors, including animal health and environmental protection, reported similar situations. However, from the discussion, all stakeholders perceived that they could contribute to AMR mitigation through different approaches and collaboration mechanisms. Figure 1 illustrates the relationships between relevant stakeholders at the provincial level and how they could be involved in the AMR mitigation strategy under the local government’s coordination in overall or in specific sectors, which requires coordination vertically (across People Committee levels), horizontally (among departments), and cross-sectorally. All stakeholders in our study believed that it is necessary for both public and private stakeholders to cooperate under the coordination of government regulatory agencies to achieve the ambitious goals laid out in the NAP. These regulatory agencies, especially at the provincial level, are responsible for adapting the NAP into a local action plan as well as allocating budgets to engage other stakeholders in its implementation. However, they have not yet established a collaboration mechanism among Departments and People’s Committees at the district level to implement the plan.

Figure 1. Relevant stakeholders who should be involved in the provincial AMR mitigation strategy.

At the community level, the unions might play essential roles in AMR mitigation efforts by coordinating communities and facilitating communication events via their extensive network embedded in communities and experienced community facilitators. However, they need directions from the higher levels of the organisation and input from expert actors to leverage their advantages. Similarly, the private sector—especially input suppliers such as drug companies (for human health or animal health treatment) or feed providers—may take part in AMR-related communication activities, often in collaboration with these unions within the scope of local authorities’ supervision.

Finally, specialised technical agencies are primarily in charge of technical tasks, such as instructing how to use antibiotics appropriately for human health and animal health, monitoring antibiotic usage or residues, and supporting communication and outreach efforts with their expertise. Through discussions with the research team, these agencies’ representatives suggested some potential contributions from their disciplines to AMR mitigation plans; for example, the environmental agencies might monitor antibiotic residues in water or soil. Still, they require cross-sectoral mechanisms to synergise their efforts for AMR prevention.

Procedural justice

Procedural justice refers to the involvement of relevant individuals or groups in the decision-making process to make sure that the outcomes are fair.Footnote ⁴¹ This process ensures that the interests and concerns of people are considered, thereby aiming for policies that equitably balance benefits across groups and individuals.Footnote ⁴² For example, the DOH and hospitals in Ho Chi Minh City and Hanoi combined information from the NAP and local data about antibiotic-resistant bacteria to develop appropriate antibiotic guidance for the cities.Footnote ⁴³ Experts also agreed on the necessity of contributions across sectors to the AMR surveillance system at the design stage.Footnote ⁴⁴ In a top-down governance system like Vietnam, however, local contributions to developing strategic plans were not considered carefully in NAP implementation, except for some special cases as above, but only for the healthcare context.

According to the Law of Promulgation of Legislative Documents, the NAP had been consulted by relevant actors through a social criticism process, which was conducted by the Vietnam Fatherland Front, while the 2023 NAP also assigned the Provincial People Committee to delegate their subordinates to implement the NAP within their discipline and scope of authorities.Footnote ⁴⁵ However, in the meetings, none of the participating stakeholder groups were involved in developing or implementing the national or local AMR action plans, and only healthcare staff and drug sellers had activities assigned to them (Table 2). Staff in national, provincial, and district hospitals had formed AMS teams, but their activities were limited due to constraints in resources and guidance. The healthcare staff, even at the national hospital, reported that they were rarely involved in institutional planning or given responsibilities for action. They mainly followed national-level MOH guidelines, but they felt that in some cases these may not be well-aligned to their local contexts, leading to deviating practice from the guidelines to better fit local needs. That reflection is consistent with a study by Pham et al.,Footnote ⁴⁶ which revealed the divergence between the national guidelines and the practical use of antibiotics for children under 2 months in another province of Vietnam. Similarly, the national hospital staff in our study explained that provincial hospitals could contribute to their AMR prevention actions by providing local AMR data so that they can develop appropriate antibiotic guidelines. This collaboration cannot be applied without the approval and direction of the DOH. However, the provincial government, including the Departments of Health, Agriculture, and Environment, did not proactively develop AMR mitigation strategies but waited for detailed plans or specific task assignments from their national ministries. This situation was also reported in other provinces of Vietnam.Footnote ⁴⁷

Table 2. Summary of NAP activities and associated justice and equity concerns for different stakeholder groups

Similarly, the Women’s and Farmers’ Union members reflected that they rarely developed their own action plans based on their specific commune context. Instead, they tended to follow the plans from higher-level authorities or collaborative plans led by other stakeholders (such as specialised agencies or private companies). Their reflection aligns with the limited involvement of public stakeholders in the AMR NAP in Southeast Asian countries reported in a previous study.Footnote ⁴⁸ This lack of involvement has led to various consequences, which will be discussed later. Members in the WASH group reported that AMR management was not yet included in their annual plan as a monitoring indicator. There were no concrete plans from the Ministry of Agriculture and Rural Development (MARD) or the Ministry of Natural Resources and Environment (MONRE) to address the AMR issue, and therefore, there have not been many resources allocated to implement the NAP activities in their sector.

Distributive justice

Distributive justice refers to the fair distribution of outcomes such as disease burden, burdens of programme implementation, and programme benefits.Footnote ⁴⁹ AMR is widely accepted as a global public health crisis, but in our case study, most stakeholders did not clearly perceive or experience its impact, except the AMS team at the national hospital (Table 2). According to the AMS staff, the limited diagnostic capacity in provincial and district hospitals hindered their ability to test for microbial resistance, and patients who did not respond to treatment were transferred to higher-level hospitals, thus rendering AMR an invisible problem. Therefore, the national hospital staff was concerned that the benefits of the NAP implementation, especially in strengthening the drug resistance surveillance system, would mostly go to urban populations, especially in big cities where well-equipped hospitals were located. Other experts also shared the same concern about the distributive injustice of AMR mitigation strategies in the Global South.Footnote ⁵⁰ At the individual patient level, participants recognised that patients with AMR would bear the burden of longer treatment duration and higher costs. Consequently, with the implementation of NAP activities in hospitals, the AMS team expected that patient outcomes would improve, and treatment complications and costs would be reduced. In addition, they also thought that hospitals would benefit economically through reduced patient load and staff workload since they can optimise their resources for severe patients and services. Moreover, this would lead to an increase in hospital credibility as hospital-acquired infections would decline.

Many stakeholders believed that drug suppliers would be disproportionately burdened by NAP implementation without receiving any benefits. They predicted that the sales volume of drug stores would be reduced significantly if the current regulations to monitor antibiotic consumption from pharmacies were implemented more efficiently. In contrast, participants believed that the decrease in AMR burden would not directly bring them any advantages. The uncertainty from AMR containment is reasonable, as it is a wicked public health issue challenging the involved stakeholders with economic and ethical tensions and trade-offs.Footnote ⁵¹ The drug sellers themselves reported that AMR posed a problem to their businesses by rendering treatments ineffective, so addressing the problem would be beneficial. They believed they might be able to adapt to reduced antibiotic revenues by adjusting their business strategy and promoting sales of other drugs and health products. As half of the drug sellers in the meetings were from franchise pharmacies, they suggested that these pharmacies might suffer more negative impact than small independent drugstores, as they have to handle larger inventories and face high operational costs.

Community participants identified specific groups who they thought could be at higher risk of AMR, such as pregnant women, children, the elderly, and those working in hazardous environments, such as laboratory technicians. However, all stakeholders struggled to link the impact of AMR to their personal lives or daily work, or did not feel it to be an immediate concern. As a result, participants tended to view AMR impacts as an externality that affects others more than themselves, and they believed the primary beneficiaries of current mitigation efforts would be within the healthcare sector, such as medical staff or patients. Similarly, it was difficult for participants to consider distributive justice for a problem they did not see and were not involved in the implementation of actions to address. Therefore, they discussed distributive justice in a normative sense, discussing who should receive the most benefits from AMR mitigation. Participants considered benefit distribution through the lens of a need principle: distribution outcomes should be proportional to the needs of the recipients, which in this case are the patients.Footnote ⁵² They reported that patients are directly affected by AMR, which can lead to higher treatment costs due to prolonged treatment duration or the need for expensive drugs to replace ineffective antibiotics. Therefore, if the AMR situation improved, patients would receive the largest share of benefits. In terms of collective benefits, participants felt that activities related to NAP implementation would reduce health system overload and improve the environment, with benefits for all.

The Farmers’ Union perceived that industrial farms would benefit more from AMR interventions due to economies of scale, while smallholder farms may bear higher relative costs, for example, the cost of implementing biosecurity measures or accessibility to veterinary services. In fact, research in the province indicates that smallholder farmers use fewer antibiotics and harbour fewer antibiotic-resistant bacteria.Footnote ⁵³ So, smallholder farmers who contribute less to the AMR problem due to their limited use of antibiotics may nevertheless bear a greater share of the burden from NAP policy implementation. They are often required to invest in costly biosecurity systems, yet may not receive proportionate benefits. This inequity is a predictable consequence of Vietnam’s animal health regulations, which provide insufficient support for small-scale farms. For example, new animal health regulations require farmers to have prescriptions from registered veterinarians in order to purchase drugs. However, the number of qualified veterinarians is insufficient, and it is costly to access them for prescriptions, making this regulation inappropriate for small- and medium-scale farms to adapt, although they represent the majority of farmers in Vietnam.Footnote ⁵⁴ While the veterinary drug sellers were perceived as a reliable and common source of antibiotic recommendation in animal health in other studies, the Farmers’ Union in our study indicated that the drug sellers tend to preserve the farmers’ dependence on their services by hiding the drug use instructions from them.Footnote ⁵⁵ It was suggested to modify this business model and separate veterinary advice from the veterinary drugs market, which could help to reduce AMR risks in small-scale farms.Footnote ⁵⁶

Meanwhile, animal traders, important actors in agriculture value chains, were seen as “free riders” in the NAP implementation, since they experience minimal direct impact from AMR, yet would still benefit when the AMR-related risks are reduced across the system. Meat handlers reported that the traders did not contribute to any effort to reduce AMR or animal disease burden, but they would benefit when the situation improved due to the increase in trading activities. Meat handlers perceived that slaughterhouse workers and consumers were the groups most at risk of AMR. They were the only group to mention issues related to restorative justice, suggesting that food suppliers should be held accountable for cases of food poisoning and provide compensation.

Tensions and trade-offs

Participants also discussed tensions and trade-offs whose resolution would benefit from a distributive justice approach. The greatest perceived tension among all stakeholders for implementing the AMR mitigation plan was reported as the lack of resources (Table 2).

Within the healthcare sector, staff felt that there were insufficient human resources to implement NAP activities, placing strain on their workloads and potentially compromising patient care. Furthermore, inadequate human resources for monitoring and evaluation may lead to inaccurate data for developing appropriate AMS strategies. Many facilities also lacked the necessary physical resources, particularly laboratory and diagnostic resources required to guide antibiotic prescribing and produce local surveillance data. The provincial and district health centre reported that limited capacities prevented them from developing their own antibiograms and localised hospital prescribing guidelines, while their colleagues at the national hospital highlighted slow and untransparent medical supply chains to procure resources needed for implementing AMS programmes. They also discussed the differences in disease profiles across hospital levels, making it difficult to adapt a top-down protocol for AMR prevention. Health system processes, such as procurement mechanisms and health insurance, also created lock-ins and perverse incentives for antibiotic prescribing. Furthermore, physicians also had to balance the tensions arising from patient demand for antibiotics with decisions about appropriateness. The participants and those from other studies pointed out the tendency of local people to depend on antibiotics as an effective treatment for common illnesses.Footnote ⁵⁷ Overall, hospitals had to balance costs and profits for each activity and tended to focus on investments in activities with short-term returns that increased revenues, rather than AMS activities requiring longer-term investment to achieve wider population-level benefits.

From the drug sellers’ perspectives, the main tensions are related to sustaining their business in the face of competition. Responding to antibiotic demands from patients fosters reciprocal and trusting relationships as well as increases profits.Footnote ⁵⁸ Drug sellers, who wanted to comply with regulations on restricting antibiotic sales, had to balance this tension of keeping customers happy and sustaining their economic profits. Another tension related to drug sellers’ perception that dispensing antibiotics is a compassionate action when patients are not able to access expensive formal healthcare.Footnote ⁵⁹ Other studies have confirmed high levels of inappropriate antibiotic prescription in Vietnamese hospitals and unrestricted access to antibiotics in the community despite regulations.Footnote ⁶⁰

Participants from Women’s and Farmers’ Unions believed that if AMR mitigation plans were included in their annual plans, this would create financial constraints. This might significantly limit their capacity, forcing them to deprioritise other programmes or reallocate budget from existing activities to fund AMR-related activities. In turn, this could lead to unintended consequences: decreased overall efficiency of other programmes, while AMR mitigation goals remain incomplete, and this could further result in undermining the organisation’s credibility.

Environmental officers discussed AMR as a form of environmental pollution but reported inadequate government response and a lack of AMR regulations in their sector. There were no legal frameworks, policies, indicators, or budgets for environmental AMR surveillance and management. Most attention to AMR in the environment focused on hospitals and hospital waste management. This echoes the national and global situation, where the environmental sector has so far received less attention. Local offices lacked guidelines to monitor antibiotic residues in the environment, although they were equipped with adequate facilities to conduct the testing. Through discussion, the lab technique to test and monitor antibiotic residues in the human health sector is adaptable to the environmental sector, but they need official approval from national agencies and a detailed plan to conduct it.

A cross-cutting theme related to the tension between commercial and public health goals. Health workers, drug sellers, and farmers all mentioned that in the absence of clear guidance from within their sectors, drug companies often provided training and capacity-building opportunities. However, commercial interests may not align with the goal of reducing overall consumption of antibiotics but instead focus on selling specific products. When their training activities do address AMR, this may be through promoting the use of different antibiotic products rather than reducing overall use or reducing the use of “watch-group” antibiotics with higher resistance potential. From a broader perspective, pharmaceutical companies should also invest in the AMS programme—not only to demonstrate their social responsibility, but also to expand their patient reach, improve product quality and portfolio, extend the commercial lifespan of their products, and reduce research and development costs.Footnote ⁶¹

To overcome these tensions, effective multi-stakeholder collaboration is essential, particularly with the existing network of local unions, which are well-positioned to engage both community members and the private sector. However, participants reflected that provincial governments have not yet established a mechanism to utilise these resources for AMR mitigation. Other studies also highlighted the inefficiency of collaboration to combat AMR, even within the healthcare system.Footnote ⁶² Some participants intimated that it might be due to low levels of awareness among staff (especially at intermediate and higher levels) regarding the impact of AMR. Initiating and maintaining the collaboration and network could significantly contribute to AMR management in Vietnam.Footnote ⁶³ However, there would be a challenge to set up this collaboration, since even the experts experienced difficulties in understanding other sectors’ AMR surveillance systems.Footnote ⁶⁴

Unintended consequences

Except for the healthcare context, NAP implementation had not resulted in any significant actions at the provincial or district level at the time of this case study. As a result, participants discussed unintended consequences in terms of concerns about what might or should happen if certain policies were implemented (Table 2). For example, drug suppliers were concerned that the impact of stricter enforcement of antibiotic management may affect their performance and lead to loss of potential customers or increased operational costs to meet the regulatory standards. The participants were also concerned that limiting OTC sales of antibiotics might reduce accessibility to essential medicines in the community for both human health and animal health, if regulations were enforced. This could inadvertently increase the risk of disease outbreaks, which, in turn, may erode public trust in the NAP and discourage efforts by participating stakeholders. Costs of NAP implementation were another concern due to the lack of financial funds from the government. For example, the healthcare staff suggested that reducing antibiotic residues or antibiotic-resistant genes might increase the cost of environmental treatment (e.g., wastewater management in hospitals), but these expenses are difficult to finance under the financial autonomy mechanism. This mechanism is the national strategy to reform the public hospital system from state-funded to a mix of state subsidy and fees-for-services.Footnote ⁶⁵ According to the healthcare staff, the requirement for financial autonomy limits budget flexibility within healthcare institutions, making it difficult to cover this additional environmental treatment cost. The healthcare participants also suggested that physicians might be reluctant to implement hospital-level AMS interventions, as they tend to prioritise treating patients, instead of planning AMR mitigation strategies. Furthermore, the physicians were thought to care more about their after-hours clinics and benefit from prescribing antibiotics by directing patients to their private clinics to prescribe them antibiotics. In our study, the physicians mentioned the dilemma of antibiotic management in public hospitals. In detail, the MOH requested the hospitals to appoint an AMS member who is responsible for approving or declining prescriptions of restricted antibiotics.Footnote ⁶⁶ However, the physicians tended to prescribe more accessible antibiotics since they were afraid of the slow approval process, but they perceived that this could potentially lead to inappropriate and less effective treatment. The AMS team at a national hospital also mentioned the MOH’s request for hospitals to maintain low fees for microbiology tests on patients as an effort to motivate them to use the necessary diagnostics for antibiotic prescribing. However, this forced the hospitals to subsidise these tests from their own budget, leading to a reduction in the budget available for other AMS activities.

Drug sellers discussed the influences of drug manufacturers, who provided incentives in the form of training and conferences. They explained that they sometimes corrected physicians’ inappropriate antibiotic prescriptions. They felt that although this action might help to improve patients’ health, it might unintentionally reduce patients’ trust in physicians’ expertise and influence their future preference for seeking treatment at pharmacies. They also discussed the implementation of the national electronic drug management system to regulate antibiotic consumption and reduce OTC antibiotic sales. Private drug stores admitted that they sustain OTC antibiotic sales for economic reasons and maintain another reporting system in parallel to hide these sales from the authorities while managing their actual sales data. In addition, the more frequent supervision of authorities regarding antibiotic monitoring may interrupt their operations since they have to postpone their sales business to collaborate with the authorities. The reaction of drug suppliers to NAP implementation raised a concern among the WASH group about the risk of drug shortages. They were concerned that the pharmaceutical manufacturers might withdraw from the unattractive market due to stricter regulation enforcement within the scope of the NAP. On the other hand, the meat handlers were concerned that reduced access to antibiotics could delay timely treatment of foodborne diseases in humans or hinder effective outbreak control in animal husbandry.

Previous studies emphasised the need to involve relevant stakeholders to address AMR in order to include diverse perspectives in the strategic plan.Footnote ⁶⁷ In our study, the participants pointed out that collaboration with the private sector, while potentially beneficial, might pose risks if not properly coordinated. For example, the involvement of pharmaceutical companies in conducting AMR-related campaigns in communities might help to reduce constraints on the budget and staff of local unions or public hospitals. However, participants were concerned that this partnership might be exploited by pharmaceutical companies to promote or sell other products. On the other hand, the local unions suggested that a partnership with large, labour-intensive companies might help the government to implement public health awareness campaigns, including those about AMR among workers. But they also faced challenges in identifying whether such collaborations might lack transparency and be a waste of resources, especially if the campaign fails to reach the intended target group.