Participation

Engagement of relevant actors, including public and private sector representatives as well as technical experts, is an important aspect of any governance system and a crucial ingredient of the OH approach. The commitment of stakeholders through the involvement of their representatives in a collective decision-making process can lead to the inclusion of important sectoral considerations that enhance policy outcomes. Participant adherence to proposed policy frameworks is fostered, thereby creating the conditions for policy success (Bordier et al., Reference Bordier, Goutard, Antoine-Moussiaux, Pham-Duc, Lailler and Binot2021). Participation is the “active involvement of a group of individuals in a collective process on actual or intended actions of administrative authorities” (Addink, Reference Addink and Addink2019). To embody the OH ethos in their governance, surveillance systems for AMR should involve participation from stakeholders across the human and animal health, agriculture, fisheries, and environmental sectors that impact and are impacted by AMR so that surveillance priorities are determined collectively (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018; Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022). Stakeholders include members of the public and private sectors, such as government ministries, professional, statutory, and regulatory bodies, the pharmaceutical, food, and agricultural industries, academia, laboratories, donors, development partners, research networks, media, and civil society organizations, such as community groups and patient organizations (Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022).

Broad participation increases support for activities and the evaluation of surveillance systems, informs strategic direction, and aids in the identification of potential implementation issues (Tangcharoensathien et al., Reference Tangcharoensathien, Sattayawutthipong, Kanjanapimai, Kanpravidth, Brown and Sommanustweechai2017; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). High rates of participation and community engagement diversify the perspectives involved and enhance the legitimacy and sustainability of surveillance systems and policies (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Holding consensus-building consultations – if well-designed – facilitates a redistribution of knowledge and power that increases credibility and decreases politicization of initiatives (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018). Early and extensive engagement that includes stakeholder perspectives can build consensus on values and vision during the conceptualization stages of the surveillance system (Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). The limitations and needs of stakeholders and end-users ideally influence the structure and processes of surveillance systems, for example, through the participatory development of indicators relevant to stakeholders’ aims and through the harmonization of intersectoral efforts and priorities (Wielinga et al., Reference Wielinga, Jensen, Aarestrup and Schlundt2014; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018). The engagement of subject matter experts and/or technical advisory committees supports the development of evidence-informed policies and lends credibility to initiatives (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Involving local stakeholders in the analysis of surveillance data facilitates stronger feedback mechanisms that are more aligned with users’ needs (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Finally, participant feedback can aid in the development of effective evaluation tools to assess the effectiveness, sustainability, and equity of integrated surveillance systems (Haworth-Brockman et al., Reference Haworth-Brockman, Saxinger, Miazga-Rodriguez, Wierzbowski and Otto2021).

Shared leadership and participatory governance mechanisms facilitate active and ongoing stakeholder involvement in the planning, implementation, operation, and evaluation of OH surveillance systems (Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Engagement of independent agencies in evidence synthesis may aid in discerning which sectors, scales, and disciplines to include in the governance and implementation of new surveillance systems and the development of complementary participatory mechanisms (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018). Governments, policymakers, and practitioners should take the initiative to expand the relevant sectors and disciplines as AMR is assessed, monitoring becomes more refined, and the knowledge more precise (Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019). Inclusion of the environment sector, which is often absent from AMR-related activities yet represents an important transmission pathway, must be ensured (Baum et al., Reference Baum, Machalaba, Daszak, Salerno and Karesh2017; Bennani et al., Reference Bennani, Cornelsen, Stärk and Häsler2021; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Johnson et al., Reference Johnson, Hansen and Bi2018). Other underrepresented fields vary by surveillance system but include human health, social science, economics, anthropology, veterinary medicine, and experts from the wildlife sector (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Engagement of community actors is difficult but can be facilitated through culturally appropriate communications and clear messaging in the local language that includes the benefits of participation (Donado-Godoy et al., Reference Donado-Godoy, Castellanos, León, Arevalo, Clavijo, Bernal, León, Tafur, Byrne, Smith and Perez-Gutierrez2015; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Harant, Reference Harant2022). Finally, non-binding and binding but unenforceable national and international treaties may also increase participation but not necessarily compliance (Phelan and Gostin, Reference Phelan and Gostin2017).

Collaboration and coordination

Collaboration and coordination are crucial elements in any governance system that aims to achieve policy goals through the engagement of a multiplicity of actors across a variety of sectors. A collaborative governance structure is important for building trust, credibility, and a sense of ownership over initiatives among a diverse set of stakeholders (Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). While collaboration and coordination differ, the two concepts were often conflated in the reviewed literature and are therefore addressed in the same section. Coordination is the arrangement of team members’ actions so that the correct type of action(s) is performed at the right time(s) and location(s) to increase efficiency and synergy during policy implementation (Eccles, Reference Eccles, Schinke, McGannon and Smith2016). From the ‘global commons’ perspective of Elinor Ostrom (Reference Ostrom2000) and Bruno Latour (Reference Latour2007), coordination can be scaled up at the sectoral level as a collective set of actions and to manage the evolution of social norms. These actions must be coordinated vertically within governance bodies that structure knowledge exchanges from local to global and horizontally across sectors and disciplines (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). In the context of surveillance systems, coordination is also influenced by international guidance, context, constraints, and expectations of local actors (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018).

To embody the OH approach, collaboration should involve active participation from a diverse group of actors during all stages of the surveillance program working toward a common goal (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022). Actors involved would engage through roles and responsibilities, technical mechanisms, and allocation of resources that facilitate the coordination of collaboration, and thus represents conjoint operation (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018). Engagement can include activities within a specific discipline in service of cross-sectoral aims, or cross-sectoral collaborative efforts to meet metrics set by one sector (Baum et al., Reference Baum, Machalaba, Daszak, Salerno and Karesh2017). Such cooperation allows for the development of ‘boundary-spanning approaches’, whether conceptual, such as ‘ecosystem services’ or practical, such as policies, norms, and standards, facilitating the translation of goals, challenges, and issues across sectors (Limmathurotsakul et al., Reference Limmathurotsakul, Sandoe, Barrett, Corley, Hsu, Mendelson, Collignon, Laxminarayan, Peacock and Howard2019).

Collaboration and coordination across the various levels of governance is necessary for the planning, management, implementation, and evaluation of effective AMR-related activities (Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). International and regional collaboration increases the expertise and quality of national surveillance systems, especially in low and middle-income countries (LMICs), facilitating knowledge sharing and reducing overlap and duplication of efforts (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020). Integrating surveillance systems increases the sustainability and cost-effectiveness of initiatives by allowing participants to build social capital and share resources, facilities, and skills (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Queenan et al., Reference Queenan, Häsler and Rushton2016). In addition, collaboration can lead to the co-construction of norms and values that guide strategies and actions (Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). A shared vision can overcome competing interests to create a culture of change, strengthen leadership, and increase participants’ ability to advocate for regulatory or policy reform (Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018; Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). As Ostrom (Reference Ostrom2000) emphasizes, the management of shared goods (e.g., monitoring data) and collective issues (e.g., AMR) requires the coordination of collaborative efforts, built on a consensual premise. An absence of consensus and trust may lead to a tragedy of the commons, as individual management of public goods, matched with shared consequences, can hasten depletion of common pool resources which is ultimately detrimental to all. In the challenge of identifying a consensus within a multi-stakeholder system of diverse interests, Michael Heller (Reference Heller2013) proposes a focus on losses and waste – since resources (here technologies, as the data of surveillance and antibiotics in medicine) are shared, such understanding can build the impetus for responsible resource management (e.g., ensuring data protection and judicious use of antibiotics) as a first step towards consensus. Through its Global Action Plan (GAP) on AMR in 2015 and the creation of the Global Antimicrobial Resistance and Use Surveillance System (GLASS), the WHO offers guidance on the creation of national action plans (NAPs) on AMR and coordinates international surveillance (Kaiser et al., Reference Kaiser, Taing and Bhatia2022). This work was followed by the creation of an AMR Quadripartite. Global health governance actors thus play a significant role in steering action against AMU and AMR.

Incorporating mechanisms to facilitate intersectoral and interdisciplinary coordination and collaboration at every level of governance and in each stage can help to overcome the fragmentation and siloing that has marked previous attempts to build surveillance systems in many countries (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Tangcharoensathien et al., Reference Tangcharoensathien, Sattayawutthipong, Kanjanapimai, Kanpravidth, Brown and Sommanustweechai2017; Johnson et al., Reference Johnson, Hansen and Bi2018). Cross-sectoral collaboration can foster a multidisciplinary approach that promotes a more in-depth understanding of each sector’s stakeholders and their knowledge, interests, constraints, and obligations, leading to better outcomes for human, animal, and environmental health (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Queenan et al., Reference Queenan, Häsler and Rushton2016; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018). Intersectoral coordination promotes active stakeholder participation, emergence of leaders valued by their peers, and increases the effectiveness of coalitions during implementation (Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022).

Collaboration and coordination within AMR surveillance systems contribute to human and animal health through the development of more effective epidemiological tools and efficient diagnoses of human and animal diseases and reduce the risk of environmental contingencies that may arise from the (theoretically) predictable ecological cascades of antibiotic use (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015). Involving the private sector will also increase access to data, sampling sites, and laboratory capacity for surveillance (Donado-Godoy et al., Reference Donado-Godoy, Castellanos, León, Arevalo, Clavijo, Bernal, León, Tafur, Byrne, Smith and Perez-Gutierrez2015; Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022). Greater research and disease mapping increases trust between stakeholders, which leads to greater data sharing. Enhanced communication can reduce redundant data collection and related costs and promotes better data management, analysis, and reporting practices (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018). In addition, collaboration facilitates more cohesive, multidisciplinary data analyses and promotes rapid communication and contingency planning between human and animal health sectors if new AMR risks are detected (Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018; Bennani et al., Reference Bennani, Cornelsen, Stärk and Häsler2021).

To understand what level and form collaboration must take to progressively realize the OH approach while remaining cost-effective (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018), recognition of all the systems and linkages involved is necessary for effective coordination (Bennani et al., Reference Bennani, Cornelsen, Stärk and Häsler2021). This entails organization and planning at the policy, institutional, and operational levels and the inclusion of experts in OH (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022; Tangcharoensathien et al., Reference Tangcharoensathien, Sattayawutthipong, Kanjanapimai, Kanpravidth, Brown and Sommanustweechai2017; Johnson et al., Reference Johnson, Hansen and Bi2018). Democratizing governance by reframing solutions in terms of their shared value while maintaining the functionality of systems can increase the influence of civil society, non-governmental organizations (NGOs), public-private collaborations, and other key non-governmental stakeholders (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018). Sustaining collaborative governance can be facilitated by technical and steering committees that bring members of different sectors, disciplines, government ministries, professional and civil society organizations, and academia together with subcommittees and working groups for specific activities as needed (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022). Stakeholder commitment to the collaborative process can be fostered through the creation of strong communication and consultation channels within surveillance systems. The need for shared language (terminologies, ontologies, and even philosophies) is particularly salient throughout the planning and implementation processes, contributing to development of transdisciplinary and trans-sectoral ethics that facilitate ongoing communication and data sharing (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Wielinga et al., Reference Wielinga, Jensen, Aarestrup and Schlundt2014; Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015). Clarity on the mandates and obligations of each committee, sector, discipline, and public-private partnership involved in surveillance can help to address questions of jurisdiction and responsibility (Baum et al., Reference Baum, Machalaba, Daszak, Salerno and Karesh2017; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018).

Management

The management domain involves steering, coordinating, and ensuring technical and scientific support, comprising the institutional processes, agencies, and resources used to govern a surveillance system for AMR. Strategic planning focuses efforts to drive action on goals with Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) objectives and quantitative targets, supported by situational analyses (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Management also involves building OH surveillance capacity early enough to foster strategic and ethical leadership that guides coordination and learning between stakeholders and policymakers (Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Management further includes monitoring the synergistic effects and impacts of integrated surveillance systems over time, including adherence to surveillance commitments and protocols (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018).

Leadership can dismantle silos and advance multisectoral implementation plans to operationalize the OH approach in surveillance systems (Johnson et al., Reference Johnson, Hansen and Bi2018). Effective management practices strengthen implementation, build monitoring capacity, and facilitate adherence to guidelines (Mölstad et al., Reference Mölstad, Löfmark, Carlin, Erntell, Aspevall, Blad, Hanberger, Hedin, Hellman, Norman, Skoog, Stålsby-Lundborg, Tegmark Wisell, Åhrén and Cars2017; Tangcharoensathien et al., Reference Tangcharoensathien, Sattayawutthipong, Kanjanapimai, Kanpravidth, Brown and Sommanustweechai2017; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018; Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022). Management also ensures the availability and administration of human and economic resources and addresses systemic or institutionalized issues, enabling sustainable collaboration (Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Committed leadership is necessary for nonhierarchical, trusting relationships built on flexibility, reflexivity, recursiveness, and democratic decision-making (Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018). Situational analyses support management by enabling an understanding of factors driving AMR in a particular context to inform surveillance of AMU aims and actions, identify best medical and administrative practices, and align regional, national, and international efforts to address the collective issue (Essack et al., Reference Essack, Desta, Abotsi and Agoba2017; Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021).

Clear quantitative goals for AMU and AMR surveillance systems can promote accountability and motivate stakeholders to work towards a common objective (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021). Setting and adhering to SMART targets and indicators and embedding monitoring and evaluation activities within surveillance systems can inform future AMR policies and increase resource mobilization (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Johnson et al., Reference Johnson, Hansen and Bi2018; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018). A OH database sensitive to the effects of governance and other situational factors could increase understanding of the range of interventions feasible in a particular context (Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020). Surveillance metrics should capture AMU and AMR in human, animal, and environmental sectors, the quality of antimicrobial data, and laboratory and human resource capacity, and support external evaluation (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Greater specificity on the actions necessary to achieve objectives is needed in most National Action Plans (NAPs), and in many national surveillance systems (Munkholm and Rubin, Reference Munkholm and Rubin2020). Linking surveillance to quantitative targets should be incremental for countries with lower capacity for OH surveillance and tailored to the local context (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022; Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022), while enabling local stakeholders to develop their own specific, time-bound action plans could foster progress towards national targets (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019).

Management also entails assessing the strengths, weaknesses, and gaps of current systems using regular baseline assessment and self-report surveys (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Routine and interim monitoring mechanisms with defined process indicators are essential to track performance and to offer the evidence needed to inform policies and resource allocation (Johnson et al., Reference Johnson, Hansen and Bi2018; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018). Alignment of data across sectors and addressing data limitations are key steps (Bennani et al., Reference Bennani, Cornelsen, Stärk and Häsler2021). For decentralized governance systems, policy consensus on standardization, data collection, storage, and reporting at the subnational level needs to be developed (Otto et al., Reference Otto, Haworth-Brockman, Miazga-Rodriguez, Wierzbowski and Saxinger2022). Local stakeholders should assist with interpretation of data to ensure that it meets their needs and aligns with national targets and deadlines (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). The transmission of regional and organizational level data and establishing deadlines to review the progress of specific activities is important to facilitate the creation of feedback mechanisms and measure improvements in surveillance systems over time (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022). Data sharing guidelines, agreements, standards, and reporting and information flow systems should first be developed (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019). The WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS) can assist with data reliability and representativeness by facilitating standardized national data collection and reporting (Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Feedback can be built into surveillance systems for AMU and AMR (Johnson et al., Reference Johnson, Hansen and Bi2018); several European animal bacterial pathogen surveillance systems provide data tailored to guide AMR policymaking and to measure the impact of the NAP (Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022). Creating a national coordinating center to guide national strategic planning and monitor implementation and quality of surveillance systems is advised (Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). In Thailand, a strategic coordinating group promoted horizontal policy coordination across responsible agencies (Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021).

Making AMR a national priority is essential for improved governance, leadership, and funding (Otto et al., Reference Otto, Haworth-Brockman, Miazga-Rodriguez, Wierzbowski and Saxinger2022). A formal OH governance body is important to guide the organization, momentum, and implementation of a OH surveillance system, as is moving towards a network governance approach that is less hierarchical (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018; Johnson et al., Reference Johnson, Hansen and Bi2018; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021). Network governance involves the fusion of ‘collaborative public goods and service provision with collective policymaking’ (Isett et al., Reference Isett, Mergel, LeRoux, Mischen and Rethemeyer2011) guided by trust, mutual interdependence, reciprocity, and negotiation among actors (Provan and Kenis, Reference Provan and Kenis2008). Network governance arises in situations where administrative or political actors need to engage with others to form alliances, attain resources, and address problems that go beyond one sector (Wang and Ran, Reference Wang and Ran2021).

Development of an iterative roadmap that factors in differences in values, interests, and perceptions can facilitate strategic, ethical, and empowering leadership within multisectoral or multidisciplinary teams (Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). Providing evidence of success by, for example, demonstrating the cost-effectiveness of OH surveillance systems may assist in increasing buy-in (Baum et al., Reference Baum, Machalaba, Daszak, Salerno and Karesh2017; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022; Johnson et al., Reference Johnson, Hansen and Bi2018; Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021), with the results made public to improve confidence in the system (Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Attention to the SDGs and fit with the local context can also increase the likelihood of successful implementation (Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020). Demonstrating success can support political will to sustain funding; some states made reimbursement for AMR stewardship activities conditional on meeting performance targets (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Mölstad et al., Reference Mölstad, Löfmark, Carlin, Erntell, Aspevall, Blad, Hanberger, Hedin, Hellman, Norman, Skoog, Stålsby-Lundborg, Tegmark Wisell, Åhrén and Cars2017; Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021; Harant, Reference Harant2022; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). As funding was highlighted as a major constraint on effective surveillance in many studies (Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Harant, Reference Harant2022; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022; Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022; Wakimoto et al., Reference Wakimoto, Menezes, Pereira, Nery, Castro-Alves, Penetra, Ruckert, Labonté and Veloso2022), improving the financial, human, and physical resources available for surveillance is essential (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Otto et al., Reference Otto, Haworth-Brockman, Miazga-Rodriguez, Wierzbowski and Saxinger2022). Funding processes may need to be restructured to enable intersectoral collaboration, communication, and the expansion of surveillance (Johnson et al., Reference Johnson, Hansen and Bi2018).

Sustainability

Political sustainability is a central component of effective governance of AMR surveillance, especially as surveillance systems can be ad-hoc, time-bound, and resource-intensive policy initiatives. It includes the structures and processes, such as funding stability, partnerships, communications, political support, and program evaluation, that facilitate the use of resources to implement and sustain evidence-based policies and programs (Schell et al., Reference Schell, Luke, Schooley, Elliott, Herbers, Mueller and Bunger2013). To operationalize a OH approach to surveillance systems for AMU and AMR, all sectors need adequate funding with the ability to build networks and coordinate budgets, policy reviews, and monitoring (Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018).

Sustainability ensures that beneficial surveillance activities, monitoring, and evaluation can be implemented and maintained over time (Mölstad et al., Reference Mölstad, Löfmark, Carlin, Erntell, Aspevall, Blad, Hanberger, Hedin, Hellman, Norman, Skoog, Stålsby-Lundborg, Tegmark Wisell, Åhrén and Cars2017; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; Harant, Reference Harant2022). Economic security can facilitate more representative data collection and advanced analyses (Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022). Inadequate funding was cited as the greatest threat to animal health surveillance systems in Europe (Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022). Investing in a skilled workforce also enables the production and communication of in-depth multi-program data within a reasonable timeframe and reduces staff turnover and loss of corporate memory (Otto et al., Reference Otto, Haworth-Brockman, Miazga-Rodriguez, Wierzbowski and Saxinger2022).

Several mechanisms can enhance the sustainability of AMR surveillance systems. Alignment with existing national and international health efforts, such as national health policies and the SDGs, a clear government mandate, voluntary intersectoral agreement, or national coordinating center involving a ‘whole-of-government’ approach may increase the legitimacy of interventions by addressing AMR (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Surveillance systems must be seen as able to fulfill objectives of stakeholders involved in governance and management processes (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018). Funding for collaborative activities is best embedded within each implementing agency (Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018), realized at both the governance and operational levels, and should draw attention to future budget needs to enable sustainable expansion of surveillance activities (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Dedicated budgets should be transparent, explicitly outline funding sources, and cover both surveillance activities and advisory committee work (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Intersectoral and interdisciplinary technical advisory committees can ensure that initiatives are evidence-informed and subject to monitoring and evaluation with adequate support to prevent implementation fatigue (Mölstad et al., Reference Mölstad, Löfmark, Carlin, Erntell, Aspevall, Blad, Hanberger, Hedin, Hellman, Norman, Skoog, Stålsby-Lundborg, Tegmark Wisell, Åhrén and Cars2017; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Clear costing of data and an understanding of minimum levels of data collaboration needed can reduce program inefficiencies and redundancy, and increase political support, yet standards for data coordination and collaboration are often vague or absent (Baum et al., Reference Baum, Machalaba, Daszak, Salerno and Karesh2017; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Harant, Reference Harant2022).

Diversifying funding to include public and private grants, endowments, and levies from domestic and international sources has proven particularly important for animal health surveillance (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018). In resource-constrained settings, external donors, including overseas development assistance flows and nonprofit foundations, can help countries overcome financial challenges and implement their NAPs (Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Donors can also build capacity by funding training, education, and research that fosters sustainability and addresses gaps in expertise (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). While dialog and partnerships with international partners and NGOs is critical for knowledge sharing and system strengthening, evidence suggests that national AMU and AMR surveillance systems require domestic funding and ongoing political engagement and support for long-term sustainability (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Intersectoral efforts to develop a strong message, collaborate with policymakers, and raise public awareness of AMR and the benefits of a OH approach can also help to generate policy support and funding (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). The initial impetus for advocacy and AMR initiatives can be built through calls to action and kickoff meetings, sustained through fundraising and organizational commitment or via institutionalization within the government (Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018). National forums that provide progress updates to stakeholders and facilitate multi-level intersectoral collaboration may encourage continued political engagement in AMR surveillance (Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021).

Accountability and transparency

Accountability and transparency are integral to evaluation of AMR surveillance systems. Answerability is central to the concept of accountability and is defined by a relationship between parties that includes both the obligation to produce explanations for decisions or actions taken and the ability of the governing institution to levy sanctions for failure to meet standards or commitments (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Transparency, defined as open and accessible AMR policy development, implementation, and evaluation is necessary for accountability (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). It includes making NAPs, progress reports, funding information, and accurate, up-to-date surveillance data publicly available (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021).

Accountability promotes a sense of ownership over decisions and activities among stakeholders (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Answerability mechanisms that include the expectation of collaboratively-established, measurable outcomes that are straightforward foster more constructive dialog between sectors, disciplines, and stakeholders (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Sanctions that lack enforceability reduce accountability, diminishing stakeholder and public trust (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Transparency and accountability around funding and expenditures can promote fiscal responsibility and enhance the sustainability of initiatives (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Ensuring that AMR policies and surveillance data are publicly accessible in an understandable format can increase political awareness and civil society engagement (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021), enhancing public support for specific actions to address AMR (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Harant, Reference Harant2022). For LMICs, this would help to close the implementation gap (Harant, Reference Harant2022).

Accountability can be facilitated in numerous ways. Participatory processes that prioritize collaboration and cooperation lead to policies that are perceived as more legitimate and sustainable than rigid, hierarchical governance structures that operate using a top-down approach (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018). Adopting a multi-stakeholder, bottom-up approach may enable greater accountability and more democratic collaboration, improving information sharing (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018). Governing bodies should therefore involve stakeholders including healthcare providers, the agricultural sector, the public, and media in the design and implementation of accountability frameworks for surveillance systems (Birgand et al., Reference Birgand, Castro-Sánchez, Hansen, Gastmeier, Lucet, Ferlie, Holmes and Ahmad2018; Boudreau LeBlanc et al., Reference Boudreau LeBlanc, Williams-Jones and Aenishaenslin2022). Creating connections between policymakers and the pharmaceutical and livestock industries may help to prevent and manage conflicts of interest at the local level that hinder fairer regulatory approaches (Khan et al., Reference Khan, Durrance-Bagale, Mateus, Sultana, Hasan and Hanefeld2020; Harant, Reference Harant2022). Involving relevant representatives may also increase ownership over initiatives in countries where monitoring and evaluation is technocratic and consultation often perfunctory (Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022).

Surveillance data should be reported annually to improve transparency, ease of monitoring and evaluation, and the quality of progress reports (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Information on available resources, expenditures, and funding gaps should be publicly available (Harant, Reference Harant2022), along with detailed monitoring and evaluation plans and gray literature from relevant stakeholders and institutions (Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). In addition, all reports should include publication dates, be made available and easily searchable on government websites, and use the same terminology as the WHO’s Global Action Plan (GAP) on AMR (Harant, Reference Harant2022).

Accountability for NAPs was often weak and commitments were not met within the prescribed timeframe in many countries (Harant, Reference Harant2022). Providing a public explanation for failure to meet commitments can increase public trust in the government, which is necessary for increased uptake of policies and practices that limit the spread of AMR (Harant, Reference Harant2022). Another way to foster accountability is by clearly defining the roles and responsibilities of implementing agencies, political bodies, and individuals (Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022; Harant, Reference Harant2022). The nomination of one person accountable for each sector (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019) and the creation of an effective intersectoral committee to support implementing agencies would be important. Implementing agencies, in turn, should be accountable to this body (Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018). In the coordination process, frameworks can provide clarity on how governing bodies are established, how often they meet, and which members are responsible for coordination and implementation activities, analysis, and provision of feedback to health professionals and agricultural trade associations, for example (Hawes et al., Reference Hawes, Buising and Mazza2020; Harant, Reference Harant2022), deepening the meaning of transparency to include the upstream governance planning. More clearly articulated accountability mechanisms are needed for NAPs and the development of surveillance systems, particularly regarding repercussions if targets are not met (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). AMR policies should set clear goals and name the agency responsible for meeting them (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021), along with identifying regional and organizational feedback mechanisms and providing dates for progress evaluations of specific interventions (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019). Identifying individualized responsibilities of members of a collaboration or agency could also help reduce isomorphic mimicry and incentivize progress (Munkholm and Rubin, Reference Munkholm and Rubin2020), increasing accountability for attainable surveillance targets with tangible consequences if unmet.

Equity

Incorporating equity into a OH approach requires attention to both systemic processes and individual-level attributes that unfairly limit access to the resources and opportunities necessary for human, animal, and environmental health to be progressively and fully realized (Gislason and Stephen, Reference Gislason, Stephen and Stephen2020; WHO, 2018). Surveillance systems must consider the accessibility of healthcare services and antimicrobials and the vulnerability of certain groups to AMR exposure due to factors such as gender, socioeconomic status, and geographic location (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Historical inequities in the distribution of socioeconomic, political, technical, and environmental resources between and within high-income countries (HICs) and LMICs continue to shape access to antimicrobials and to decision-making and implementation processes, resulting in uneven AMU and AMR policies that prioritize the conservation of important antimicrobials over issues of access and mortality (Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Munkholm and Rubin, Reference Munkholm and Rubin2020; Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020).

The creation of equitable AMU and AMR policies at the national and local levels involves attention to issues of access to antimicrobials and technical solutions to improve capacity for surveillance. While policies that limit over-the-counter access to antimicrobials can mitigate AMR (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Mdegela et al., Reference Mdegela, Mwakapeje, Rubegwa, Gebeyehu, Niyigena, Msambichaka, Nonga, Antoine-Moussiaux and Fasina2021; Ahmed et al., Reference Ahmed, Naher, Tune and Islam2022), they may reduce access to life-saving drugs for populations with specific vulnerabilities in some contexts (Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Munkholm and Rubin, Reference Munkholm and Rubin2020; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). To prevent such inequitable consequences, policymakers are encouraged to adopt a broader conceptualization of equity during the development of surveillance programs and to incorporate metrics that capture wider societal impacts, including on livelihoods, poverty, and for specific marginalized groups such as women, forced migrants, and those with lower socioeconomic status (Baum et al., Reference Baum, Machalaba, Daszak, Salerno and Karesh2017; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Countries that lack a safe, accessible, and affordable drug supply should consider actions to strengthen supply chain management, promote clinical guidelines, publish an essential medicine list, and regulate the post-market quality of antimicrobials (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Mdegela et al., Reference Mdegela, Mwakapeje, Rubegwa, Gebeyehu, Niyigena, Msambichaka, Nonga, Antoine-Moussiaux and Fasina2021; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). Where possible, local microbiologists and medical and veterinary professionals should be provided with training and networking opportunities to improve access to health expertise in underserved areas and capacity for data management (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Equity-conscious surveillance systems should be informed by a sex/gender-based analysis prior to implementation (Government of Canada, 2022).

At the global level, AMR increases more rapidly in LMICs than HICs (Laxminarayan et al., Reference Laxminarayan, Boeckel, Frost, Kariuki, Khan, Limmathurotsakul, Larsson, Levy-Hara, Mendelson, Outterson, Peacock and Zhu2020), yet competing policy priorities, inadequate access to laboratory equipment, human and economic resources, and pay-walled academic literature has serious implications for the ability of LMICs to conduct surveillance (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021; Harant, Reference Harant2022). Global AMR policy must account for the diversity of inequity across countries and regions. Diverse governance factors, such as political stability, regime type (democratic versus authoritarian states), and geographic disparities directly and indirectly affect their AMR landscape. This complexity extends beyond the simplistic dichotomy of HICs and LMICs, as the gap in health indicators, disease burden, and AMU can be greater between LICs and MICs than that between MICs and HICs (Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). While this lack of uniformity presents challenges for global antimicrobial reform, deliberate attention to equity at the global level can help address structural inequities, particularly for marginalized groups (Anderson et al., Reference Anderson, Schulze, Cassini, Plachouras and Mossialos2019; Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021). Increasing the capacity of LMICs to generate timely, reliable, and representative data can facilitate the implementation of international surveillance policies and guidelines that meet their needs, bolster their profile on the global AMR stage, and reduce reliance on HIC data (Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021; Harant, Reference Harant2022). It may also help to prevent capability traps, in which LMIC governments are pushed to adopt unattainable AMU and AMR policy targets (Munkholm and Rubin, Reference Munkholm and Rubin2020).

Long-term commitment and sustainable funding are crucial for building infrastructure and laboratory capacity (Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021; Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). This may require a transfer of resources from HICs to LMICs to expedite the development of user-friendly surveillance methods suited to resource-constrained settings, such as rapid on-site test kits and diagnostics and equipment that can handle high temperatures and humidity (Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). In some countries, improvements to basic infrastructure are needed first (Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Academic networks can also help strengthen laboratory and clinical capabilities in LMICs (Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Proportional international contributions to agencies like the WHO and Fleming Fund and creation of a Global Antimicrobial Conservation Fund may facilitate noncommercial, collaborative research that advances bacteriology and OH surveillance capacity in LMICs (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Kirchhelle et al., Reference Kirchhelle, Atkinson, Broom, Chuengsatiansup, Ferreira, Fortané, Frost, Gradmann, Hinchliffe, Hoffman, Lezaun, Nayiga, Outterson, Podolsky, Raymond, Roberts, Singer, So, Sringernyuang, Tayler, Rogers Van Katwyk and Chandler2020; Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Any international organizations active in LMICs must, however, be wary of contributing to “brain drain” from local health systems (Hein et al., Reference Hein, Aglanu, Mensah-Sekyere, Harant, Brinkel, Lamshöft, Lorenz, Eibach and Amuasi2022). This may be partially mitigated by soliciting political commitment to increased health budgets in LMICs, as donor funding represents less than one percent of all health spending (WHO, 2019) and will be insufficient to address AMR on its own.

Conceptual framework for OH governance evaluation

Our findings support the development of a conceptual framework for OH governance that informs the design and evaluation of governance systems for AMR surveillance consisting of six governance domains (see Figure 1 on next page).

Figure 1.

On the left side, there are six green circles, each containing a governance domain (participation, collaboration and coordination, management, sustainability, accountability and transparency, and equity). Each circle is connected to the next circle with an arrow to show that they form a cycle. On the right side, the domains are listed on alternating green and white backgrounds and a definition of each is provided, along with two to three examples of factors that facilitate the domain. Equity is slightly separated from the other domains to reflect that it is both a domain, and an essential component of each of the other domains.

For each governance domain, we identify qualitative evaluation questions to assess the extent to which the OH approach has been integrated, building on our findings that connect OH principles to governance evaluation. The proposed questions (see Table 1) can support efforts to distinguish and assess the breadth and depth of OH-ness of governance systems; where breadth refers to the range of actors involved in specific governance domains across human, animal, and environmental health, and depth describes how meaningful that engagement is under each governance domain.

Table 1.

Domain-specific evaluation questions

We conceptualize the relationship between the domains as interdependent and co-constitutive, as certain qualities of a specific governance domain might also relate to a different domain and/or influence each other. For example, meaningful stakeholder participation can positively impact governance systems by fostering trust amongst stakeholders that can lead to more sustainable cooperation/collaboration and lasting participant engagement. Trust can also be generated through effective accountability practices within governance systems, conceived of as an ongoing and dynamic process informed by monitoring and evaluation. The framework is based on a logic model (Figure 2) of how qualitative aspects of a OH-informed governance system that incorporates the domains can contribute to achieving effective OH surveillance of AMR/AMU. In the figure, the inputs that facilitate OH governance principles are listed on the left (inputs to the domain), and their impacts on surveillance systems on the right (outputs of the domain, see Figure 2 below).

Figure 2.

On the left side of the figure are inputs that facilitate implementation of the governance domains. Related inputs are organized in color-coded groups: engagement, buy-in, communication, governance and law, technical and data-related, funding and resources, and equality. In the middle are gray boxes containing the governance domains. The inputs are connected to the governance domains using arrows that are the same color as the input groups. Connections between the governance domains are represented using gray arrows. On the left side are the outputs that are facilitated by the governance domains. These outputs are grouped in the same way as the inputs (minus communication) and connected to the governance domains using arrows that are the same color as the output groups. A gray arrow that connects all the domains surrounds the entire figure.

Consideration of the facilitators/barriers that influence implementation of OH governance of AMR surveillance systems is important. To reduce silos, five barriers should be addressed: a lack of intersectoral communication, a lack of trust, siloed professional education, siloed mandates and funding, and the influence of commercial interests (Johnson et al., Reference Johnson, Hansen and Bi2018). Adequate human and economic resources to support coordinated strategies are crucial as cost can present a barrier to collaborative surveillance, particularly for the environmental and agricultural sectors (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Johnson et al., Reference Johnson, Hansen and Bi2018; Joshi et al., Reference Joshi, Chintu, Mpundu, Kibuule, Hazemba, Andualem, Embrey, Phulu and Gerba2018). Training on systems thinking and community-based and participatory methods can increase the number of OH practitioners able to facilitate and coordinate transdisciplinary collaboration (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015). Tertiary education should include field and cross-cultural experience to reach young professionals before they enter siloed work environments (dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Johnson et al., Reference Johnson, Hansen and Bi2018). Epidemiological data that shows the interconnectivity of human, animal, and environmental health, and the negative impact of not addressing AMR in a cohesive intersectoral manner can increase trust and diminish resistance to change, such that collaborative surveillance is informed by evidence (Wielinga et al., Reference Wielinga, Jensen, Aarestrup and Schlundt2014; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018). Demonstrating the economic benefit of AMR mitigation can also help to reduce the influence of commercial interests, particularly from the agricultural sector, that present a barrier to data sharing across disciplines (Queenan et al., Reference Queenan, Häsler and Rushton2016; Johnson et al., Reference Johnson, Hansen and Bi2018; Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021). To address conflicting priorities between risk-managers and risk-bearers, different agencies or sectors should be responsible for risk assessment and risk management (Wielinga et al., Reference Wielinga, Jensen, Aarestrup and Schlundt2014).

Collaboration and coordination can also be facilitated by removing barriers to data and knowledge sharing and harmonization of protocols and data (Wielinga et al., Reference Wielinga, Jensen, Aarestrup and Schlundt2014; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018; Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Bennani et al., Reference Bennani, Cornelsen, Stärk and Häsler2021; Chua et al., Reference Chua, Verma, Hsu and Legido-Quigley2021; Sumpradit et al., Reference Sumpradit, Wongkongkathep, Malathum, Janejai, Paveenkittiporn, Yingyong, Chuxnum, Vijitleela, Boonyarit, Akaleephan, Manosuthi, Thienthong, Srinha, Wongsrichai, Laoprasert, Athipunyakom, Kriengchaiyaprug, Intarukdach, Numsawad, Somjetanakul, Punnin and Kiatying-Angsulee2021). This could be fostered through participation in regional and global surveillance networks and public-private partnerships, and via technical mechanisms such as the creation of national reference libraries, library networks, or shared laboratories that use standardized methods and a common database (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Mölstad et al., Reference Mölstad, Löfmark, Carlin, Erntell, Aspevall, Blad, Hanberger, Hedin, Hellman, Norman, Skoog, Stålsby-Lundborg, Tegmark Wisell, Åhrén and Cars2017; Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; Sommanustweechai et al., Reference Sommanustweechai, Tangcharoensathien, Malathum, Sumpradit, Kiatying-Angsulee, Janejai and Jaroenpoj2018; Bennani et al., Reference Bennani, Cornelsen, Stärk and Häsler2021; Mader et al., Reference Mader, Muñoz Madero, Aasmäe, Bourély, Broens, Busani, Callens, Collineau, Crespo-Robledo, Damborg, Filippitzi, Fitzgerald, Heuvelink, van Hout, Kaspar, Norström, Pedersen, Pohjanvirta, Pokludova and Amat2022). Adoption of a shared vocabulary and universal guidelines, preferably available in multiple languages with widespread use, may promote data harmonization (Uchtmann et al., Reference Uchtmann, Herrmann, Hahn and Beasley2015; Iskandar et al., Reference Iskandar, Molinier, Hallit, Sartelli, Hardcastle, Haque, Lugova, Dhingra, Sharma, Islam, Mohammed, Naina Mohamed, Hanna, Hajj, Jamaluddin, Salameh and Roques2021). Agreements and frameworks for collaboration and intersectoral data sharing could reduce legal and bureaucratic barriers to data sharing, however, they must balance the obligation to safeguard informed consent and anonymity with the need for useful data (Bordier et al., Reference Bordier, Uea-Anuwong, Binot, Hendrikx and Goutard2018; dos S. Ribeiro et al., Reference dos S. Ribeiro, van de Burgwal and Regeer2019; Rüegg et al., Reference Rüegg, Nielsen, Buttigieg, Santa, Aragrande, Canali, Ehlinger, Chantziaras, Boriani, Radeski, Bruce, Queenan and Häsler2018). Finally, the development of an OH learning platform can support the exchange of information across borders and sectors (Wernli et al., Reference Wernli, Jørgensen, Parmley, Troell, Majowicz, Harbarth, Léger, Lambraki, Graells, Henriksson, Carson, Cousins, Skoog Ståhlgren, Mohan, Simpson, Wieland, Pedersen, Schneider, Chandy, Wijayathilaka, Delamare-Deboutteville, Vila, Stålsby Lundborg and Pittet2020).