1. The Anatomy of the Regime Complex for AMR

AMR is currently governed by a decentralized regime complex. Regime complexes are defined as partially overlapping and sometimes conflicting networks of three or more international regimes that relate to a common issue.⁶ For the multisectoral problem of AMR, it appears that there are at least seven international regimes coalescing around AMR governance, including the human health security, humanitarian biomedicine, animal health, agricultural, trade, development, environmental regimes (Table 1).

These seven elemental regimes, moreover, interact with at least one, but more often many other elemental regimes in the complex through bilateral and multilateral partnerships. For example, the human health, animal health, food, and environmental regimes interact through the WHO, FAO, WOAH, and UNEP’s quadripartite partnerships on AMR, the human health and agriculture regimes interact bilaterally through the WHO and FAO’s joint programmes on food standards and safety.Reference Wernli, Harbarth, Levrat and Pittet⁷ The trade regime interacts with the human health regime, moreover, through the WHO, World Trade Organization (WTO), and World Intellectual Property Organization’s (WIPO) Trilateral Cooperation on Public Health, Intellectual Property, and Trade. It also interacts with the human health, animal health, agricultural regimes through various links among non-binding statements and the WTO’s Agreement on the Application of Sanitary and Phytosanitary Measures (SPS).⁸ Finally, there are also linkages among the trade, human health security, and environmental regimes on matters related to intellectual property rights, access to medicines, and environmental pollution.Reference Barlow, McKee, Basu and Stuckler⁹

Many of the seven elemental regimes have a high degree of overlap in their memberships, but, crucially, there are important divergences in membership across the regime complex. For instance, the WHO and FAO are largely comprised of the same member states; but discrepancies in memberships exist across the trade, development, and biomedical humanitarianism regimes.

And finally, across the regime complex, there are several instances of overlapping and sometimes conflicting principles, rules, norms, and procedures. For example, both the human health security and the trade regimes believe that policy objectives such as promoting health should seek to minimize their impact on trade, while the principles of the human health, food, and animal health regimes all acknowledge the interdependencies among human, environmental, and animal health and the importance of One Health approaches. On the other hand, the trade regime’s principle that intellectual property rights improve health innovation, as well as the rules within the Trade Related Aspects of Intellectual Property Rights (TRIPs) that embody that principle, can often pose challenges for the development and humanitarian biomedicine regimes’ principle of access to medicine as human right.Reference Motari, Nikiema, Kasilo, Kniazkov, Loua and Sougou¹⁰

The following snapshot further elucidates the characteristics of the emerging regime complex for AMR (Table 1).

2. Strengths and Weaknesses of a Decentralized Regime Complex

The AMR governance landscape is currently populated by dozens of actors and institutions, each with their own mandates and initiatives (Table 1).¹¹ As described above, these actors and institutions conflict in some instances, but there are also examples of cooperative synergies and partnerships emerging across them in others. The inherent challenges and opportunities present in the decentralized regime complex for AMR have led some to find the proliferation of actors as problematic for coherent governance, while others see it as an opportunity to mobilize and sustain action on multiple fronts.¹² Indeed, the regime complex for AMR presents both disadvantages and advantages when compared to a comprehensive regime. On one hand, a more centralized regime promises to improve the coherence, consistency, reliability, and efficiency of global AMR governance, while also limiting free riding and gaming.Reference Biermann, Zelli, Pattberg and van Asselt¹³ On the other hand, decentralized regime complexes tend to provide more adaptability, flexibility, and resilience; enable more effective, equitable, and sustainable outcomes at multiple scales; and enhance innovation, learning, and trustworthiness among a greater number of participants.Reference Alter and Raustiala¹⁴

3. Leveraging the Power of Centralization and Decentralization

One could argue that a decentralized regime complex, with its multiple centers of activity and diffuse initiatives, is the best option for generating and sustaining effective action on AMR quickly and meeting the need for more location specific knowledge and stakeholder driven solutions for AMR in the short run. To be sure, however, certain elements of global AMR require a more centralized governance structure to guide action in the long run. For instance, centralized mechanisms through the pandemic instrument could deliver much needed commitments and a global vision for global AMR efforts. It can also raise awareness based on a shared understanding of the issue and its urgency, enable the tracking of progress, distribute responsibilities and benefits equitably, and hold countries accountable to their promises.²²

Considering the benefits offered by both, the best option for a pandemic instrument is to strike a balance between the responsiveness, flexibility, adaptability, and resilience of decentralization and the consistency, reliability, and efficiency provided by centralization. At the national level at least, studies have found that centralized and decentralized governance arrangements often co-exist.²³ Somewhat paradoxically, centralization and decentralization are not exclusive and opposite ends of a spectrum, but are rather compatible and complementary ways of achieving institutional objectives.²⁴

The same holds true for global governance arrangements for complex issues. The enormous regime complex for climate change, for example, has emerged with thousands of multilateral environmental agreements, organizations, and initiatives focused on addressing climate change, but recent efforts through the 2010 Cancún Agreements and, more recently, the 2015 Paris Agreement under the UNFCCC strike a balance between centralization and decentralization.²⁵

The Cancún and Paris Agreements were negotiated against the backdrop of a growing regime complex for climate change and strategically leverage the benefits of decentralization under unified global frameworks to coordinate the global response to climate change.²⁶ By using certain design elements, their architectures acknowledge that mitigating and adapting to the impacts of climate change require a hybrid of top-down centralization on some matters, with room for bottom-up initiatives on others.Reference Bodansky, Brunnée and Rajamani²⁷

For example, the Paris Agreement contains a clear vision and a 2-degree Celsius global target that guides and gauges country behavior without necessarily prescribing it. This goal, in combination with the Paris Agreement’s reliance on individually determined contributions, lets countries determine how they will help meet the goal on their own terms. Put differently, the Paris Agreement provides top-down targets but relies on bottom-up implementation to achieve them.²⁸ Meanwhile, the agreement’s established principles of universal and common but differentiated responsibilities, and its deference to centralized functions of the UNFCCC for matters such as surveillance, transparency, and accountability represent centralized mechanisms that complement its decentralized traits.²⁹

Crucially, in relying on nationally determined, bottom-up initiatives as the main driver of global progress, the Cancún Agreements recognize that some countries require financial support to maximize their ability to address climate change and contribute to the universal global goal. In doing so, the Cancún Agreements established a Green Climate Fund, which, with its limitations notwithstanding, acts as a necessary financing mechanism to support less developed countries in implementing domestic climate action in this hybrid approach.Reference Abbott and Gartner³⁰ The importance of the Green Climate Fund was reaffirmed in the Paris Agreement, which included mechanisms to enhance country contributions to it.

Finally, another key example of a hybrid mechanism embraced by both the Cancún and Paris Agreements are their commitments to the multi-stakeholder forum of the UNFCCC. The forum, as part of the UNFCCC’s Conference of Parties, provides a centralized mechanism and agenda for discussion and dialogue, but is inclusive enough such that many NGOs and interests groups can achieve observer status to attend, monitor, and question states-parties during the conference proceedings, thereby uniting a mix of centralized and decentralized elements.

A pandemic instrument could achieve a hybrid of centralized and decentralized elements by leveraging existing national action plans for AMR, while establishing a global goal against which to assess them and crystalizing a process for ratcheting up their ambition. Moreover, a combination of legally enshrined universal commitments that all countries must undertake, as well as a suite of common but differentiated responsibilities could further enshrine a balance of centralized and decentralized elements within the instrument.³¹ Other substantive items for pandemic treaty that would benefit from more centralization include:

1. 1. Global information sharing and awareness raising mechanisms that are cognizant of location and scale, relevant knowledge, and evidence.

2. 2. A standardized, consistent, and interoperable global surveillance system.

3. 3. Transparency, accountability, and enforcement mechanisms.

4. 4. A diverse and inclusive multi-stakeholder forum.

5. 5. Global financing mechanisms, such as a global pooled fund, for global investments in infection prevention and control, and the innovation and distribution of medical countermeasures including antimicrobials, diagnostics, and alternative therapies. Alternative funding techniques could include a deposit mechanism or multi party-single closing type deals to leverage decentralized funds for AMR initiatives.

6. 6. Global coordination for response to resistant outbreaks.

By adopting similar institutional design elements as the Paris Agreement, a pandemic instrument could provide much needed leadership on these specific issues in need of centralization while also being adequately flexible to encompass and permit location specific initiatives tailored to different national and local circumstances.