1 Introduction
Safeguarding the effectiveness of antibiotics is one of the biggest challenges for global governance in the twenty-first century. Antimicrobial resistance (AMR) happens when microorganisms such as bacteria, viruses, and fungi evolve to become resistant to antimicrobial medicines. AMR is accelerated by the use, and especially the overuse and misuse, of antibiotics in health care and farming. It also worsens through insufficient access to sanitation, clean water, and infection control, increasing its prevalence in low-income countries (Savoldi et al.,
2019). Scientists warn that AMR could lead to a future without effective antibiotics. It directly caused 1.27 million deaths and was associated with a further 3.68 million deaths in the year 2019 (Murray et al.,
2022). The death toll includes 214,000 newborns killed each year by blood infections caused by resistant pathogens (Laxminarayan et al.,
2016). Experts estimate that, in the absence of remedial action, AMR would lead to 10 million annual deaths by 2050, cause an additional 24 million people to become extremely poor, and bring about a global cumulative GDP loss in the order of US$85 trillion during 2015–50 (Ahmed et al.,
2018; Review on Antimicrobial Resistance,
2016).
Drug-resistant bacteria spread easily across borders (Abd El Ghany et al.,
2020; Bokhary et al.,
2021; Frost et al.,
2019). Hence, government policies that exacerbate or mitigate AMR profoundly affect other countries. Maintaining antimicrobial protection is a global public good (Sandler & Arce,
2002). Producing the good involves two types of costs: the cost of developing new antibiotics and the cost of conserving the efficacy of existing antibiotics, which requires fundamental changes in the way they are used in health care and agriculture. Antibiotics have become an integral part of the meat production process, and agriculture lobbies in many countries succeeded in preventing legislation that would restrict antibiotic use in livestock and poultry production (Kahn,
2016). Opposition to the regulation of antibiotic use in humans has been less organized, but highly decentralized antibiotic prescription and sales systems make regulation, monitoring, and enforcement very challenging. Health professionals can refuse to cooperate with attempts to restrict their discretion in prescribing and selling antibiotics for various reasons. Physicians commonly prescribe antibiotics inappropriately due to patient pressure and concerns about complications from “missed” bacterial infections, which may lead to lawsuits (Stivers,
2007). Financial incentives also play a role in many health systems, as the revenues of doctors, pharmacists, hospitals, and other formal and informal health providers are affected by the volume of prescriptions and sales (Blaser et al.,
2021; Kahn,
2016; Kotwani et al.,
2021; Lin et al.,
2020). Interventionist governments face the cost of devoting scarce financial and administrative resources to building and running a complex system for the surveillance and enforcement of a dispersed industry as well as the political cost of discontent with that regulatory system. The benefits of new antibiotics can be excludable if developers are willing and able to enforce intellectual property rights. But no one can be excluded from the benefits of action aimed at conserving the efficacy of existing antibiotics. The relationship between the drivers of resistance and the externalities they produce shows that the domestic and international dimensions of AMR are intimately connected.
This pattern of costs and benefits means that AMR prevention is prone to be undersupplied if governments are left to address the issue unilaterally (Baekkeskov et al.,
2020,
2023; Laxminarayan,
2016; Rönnerstrand et al.,
2022; Smith & Coast,
2003). To overcome this cooperation problem, governments and international organizations have responded to the growing threat of AMR by creating an international regime based on “soft” governance instruments: guidelines that are not legally binding and involve low delegation of monitoring functions and no adjudication functions (Abbott et al.,
2000). The regime lacks both enforcement mechanisms and regular funding for country implementation. Some experts consider this system insufficient to tackle the problem of AMR and advocate higher levels of legalization, notably the adoption of a binding international treaty (Hoffman et al.,
2019a), and there is an ongoing debate about whether and how the international AMR regime should be reformed (Baekkeskov et al.,
2020; Pitchforth et al.,
2022; Rochford et al.,
2018; Rogers Van Katwyk et al.,
2020; Weldon et al.,
2022).
We argue that pessimism about the global soft governance regime to combat AMR is premature. In a first step, we present a theoretical framework specifying the conditions under which international cooperation effectively promotes global public goods. We draw on theoretical building blocks developed by political science, a discipline that has devoted very little attention to AMR.
1 To be effective, international regimes must achieve three things simultaneously: they must demand ambitious policy commitments from governments, attract the participation of all essential countries and achieve a thorough implementation of the commitments that have been made (Barrett,
2008). In principle, this “ambition-participation-implementation triad” could be a “trilemma”: it may be possible to achieve any two of those objectives, but only at the expense of the third. However, we hypothesize that the mix of state preferences and institutional design enables the AMR regime to largely avoid the trilemma and achieve progress on all three elements of the effectiveness triad. We expect the non-binding nature of ambitious commitments to encourage participation, and we predict that the included coordination and monitoring provisions increase governments’ willingness to put those commitments into action within their territories. Formal enforcement mechanisms should not be necessary to ensure implementation because governments do not have incentives to defect once they receive reassurance that most other states are acting as well. However, we also expect that the absence of regular funding mechanisms embedded in the global AMR regime limits its ability to promote national implementation in countries with low bureaucratic capacity.
In a second step, we empirically test these hypotheses by providing the first systematic cross-national analysis of the effectiveness of the global AMR regime. This is an urgent task since, as a recent analytical overview of international AMR policies has summed up the state of knowledge, “it remains unclear what impact the extension of international AMR governance has had at the national and regional levels” (Overton et al.,
2021, p. 10). In line with our hypotheses, we find that the Global Action Plan on Antimicrobial Resistance (GAP) issued by the World Health Organization (WHO) in 2015 prompted widespread adoption of national action plans, that those plans are being implemented in most countries, that implementing national action plans is associated with reduced human use of antibiotics, especially in countries with higher per-capita use, and that countries’ ability to implement the actions they have committed to is linked to their bureaucratic capacity.
These findings are relevant to the debate on reforms of the AMR regime. Most states have committed themselves to take action, and we found little evidence of voluntary defection from such commitments. By contrast, we found that bureaucratic capacity matters for AMR policy implementation. As we note at the end of the article, this finding suggests that the main advantage of a legally binding treaty on AMR over the current institutional design might be the formalization of an obligation of high-income countries to support the capacity of low-income countries and to share the associated financial burden. In contrast, the value-added of formalization in deterring voluntary defection from national conservation measures seems more doubtful.
Our research also has broader relevance beyond debates on global health governance. In recent decades, soft governance institutions have become more popular tools than traditional international law and treaties to address global problems (Pauwelyn et al.,
2014; Reinsberg & Westerwinter,
2021; Roger & Rowan,
2022; Vabulas & Snidal,
2021). While some scholars point at the potential advantages of non-binding agreements and informal international organizations in providing effective solutions to global problems, others are more skeptical (Abbott & Faude,
2021; Morin et al.,
2019; Roger,
2020; Vabulas & Snidal,
2013). Compared to the literature on the effectiveness of international treaties (Hoffman et al.,
2022), less is known about the actual impact of such soft institutions on the problems they are supposed to address, with few studies examining the question systematically (e.g., Böhmelt & Pilster,
2010; Köppel & Sprinz,
2019; Tveit & Tørstad,
2023). We contribute to this debate by developing an analytical framework to understand the effectiveness of the global regime to counter AMR and by testing the effectiveness of a soft governance regime in this important case. In the concluding section, we briefly discuss the implications of our findings for the broader debate on the effectiveness of international soft governance.
2 History and contours of the global AMR regime
Antibiotics have been used since the 1940s and concerns about AMR are nearly as old. Alexander Fleming concluded his Nobel Prize acceptance speech in 1945 by warning that negligent use of the substance he discovered, penicillin, could change the nature of microbes and make them resistant to the drug (Podolsky,
2015, p. 143). The global nature of AMR became evident to doctors in 1953, when an epidemic of penicillin-resistant Staphylococcus aureus spread globally and caused mastitis in breastfeeding mothers worldwide (Gradmann,
2013, p. 560). The WHO’s engagement with AMR conforms to a “punctuated equilibrium” pattern, as detected in the policy process of various international organizations (Lundgren et al.,
2018). The WHO provided a forum for international discussions on AMR among antibiotics experts between the late 1950s and early 1970s, but these discussions did not produce coordinated action across borders (Gradmann,
2013). AMR reacquired salience on the WHO agenda in the late 1990s, and in 2001 the organization published a Global Strategy for Containment of Antimicrobial Resistance, but this remained an “abortive call for action” (Overton et al.,
2021, p. 4). Global action on AMR received a boost in 2015 when the WHO adopted the GAP, which was endorsed by FAO and OIE. The GAP received political backing in 2016 from a Political Declaration adopted by the United Nations following a high-level meeting on AMR of its General Assembly.
The GAP was designed to provide fresh impetus to anti-AMR activities worldwide and to consolidate the One Health principle, whereby human, animal, and plant health are treated as interconnected and needing a coherent governance framework (Hannah & Baekkeskov,
2020). The World Health Assembly urged states “to implement the proposed actions for Member States in the global action plan on antimicrobial resistance, adapted to national priorities and specific contexts” (WHO,
2015b, p. 18), but it did not create a treaty with binding obligations for ratifying states. The AMR regime is a clear instance of soft governance, as its prescriptions are legally non-binding, involve low delegation of monitoring and no delegation of adjudication functions, and are not supported by enforcement mechanisms (Abbott et al.,
2000). This institutional design is typical of global health initiatives, where few legally binding treaties exist (Hoffman et al.,
2019b; Worsnop,
2017).
The GAP prescribes a broad set of costly actions that states should perform, but it does not specify quantitative targets they should aim for. The actions fall under five strategic objectives: improvements in awareness and understanding of AMR; improvements of knowledge and evidence through surveillance and research; reductions of infection through sanitation, hygiene, and infection prevention; optimizing the use of antimicrobial medicines in human and animal health; and increased investment in new medicines, vaccines, and other interventions. Under the GAP-centered regime, states are expected to submit periodic self-assessments based on a standardized questionnaire, whose results are published online (WHO-FAO-OIE,
2022). States also regularly report AMR data to the WHO-led Global Antimicrobial Resistance and Use Surveillance System. The process is managed by a joint secretariat provided by WHO, FAO, and OIE.
3 Theory and hypotheses
To be effective in producing transnational public goods, international regimes must meet three conditions simultaneously: they must demand action that would lead to substantial progress towards reaching the goals of the regime, they must ensure the participation of all countries or at least those whose contribution is most essential, and they must achieve a thorough implementation of relevant commitments (Barrett,
2008). Meeting all three conditions simultaneously can be very difficult. In cases where many states join and comply, this may be because the regime expected very little from them (Downs et al.,
1996). If states expect to have to put ambitious commitments into practice, they may decide not to make them in the first place (Bernauer et al.,
2013; Spilker & Koubi,
2016). If an ambitious regime attracts broad participation, this may be because many adopters do not expect to invest substantial resources to implement it fully (Hironaka & Schofer,
2002).
The difficulty of achieving all three conditions at the same time has led some analysts to ask whether the production of global public goods involves a trilemma, or “impossible trinity”: any two, but only two, conditions for effectiveness can be met at the same time (Dimitrov et al.,
2019; Tørstad,
2020). International institutional design can be conceived as an attempt to push the boundaries of political feasibility and achieve the best possible mix of ambition, participation, and implementation.
2
In the following, we explain why we expect the AMR regime to be largely successful in avoiding the trilemma and achieving progress on all three elements of the ambition-participation-implementation triad. Our expectation centers on the specific mix of state preferences and institutional design features that underpins the regime, while considering also bureaucratic capacity constraints that can affect implementation. We first present the theoretical logic and then show how it applies to the case of AMR.
Building on collective action theory, we posit that international regimes typically face three types of actors: unconditional noncontributors, unconditional contributors, and conditional contributors (Buchholz & Sandler,
2021; Hale,
2020; Martin,
1992; Marwell & Oliver,
1993; Taylor,
1987). Unconditional noncontributors are states who would never contribute to a global public good voluntarily unless they face side payments or sanctions. By contrast, unconditional contributors always contribute. Conditional contributors would contribute to the global public good, provided that enough other actors are also contributing. The group of conditional contributors can be quite diverse in their cooperation thresholds, i.e., the proportion of other actors that need to contribute to make them prefer contributing to not contributing. This diversity of orientations has important implications for the success of cooperation. Initial moves by unconditional contributors may be sufficient to prompt some conditional contributors to join the action. The result can be a snowball effect, where more and more conditional contributors are satisfied with the number of cooperating actors and start cooperating as well (Granovetter,
1978). Finally, the proportion of cooperators may grow large enough to put unconditional contributors under material and moral pressure to follow suit. But even if the snowballing process does not flip all actors from noncooperators to cooperators, the number of contributors may grow enough to reach a critical mass sufficient to produce what can be considered an acceptable level of the public good (Marwell & Oliver,
1993).
How much of a public good will be provided in any given circumstance depends on actor types, benefits, and institutional context. The first factor is the proportion of actors that belong to each of the three types: a higher proportion of conditional and (especially) unconditional contributors facilitates high provision. The second one is whether contributing entails selective benefits for contributors (Buchholz & Sandler,
2021; Hale,
2020). The third factor is the institutional context where the actors find themselves, which we discuss more closely in the following.
As International Relations scholars often note, global cooperation cannot rely on a world government with the authority to compel other actors to contribute to public goods—it is “cooperation under anarchy” (Oye,
1986). The early literature on international regimes focused on their ability to promote cooperation by providing information to states, thereby facilitating reciprocity strategies in response to cooperation or defection by other states (Axelrod & Keohane,
1985; Keohane,
1984; Oye,
1985). Later literature added important dimensions (Simmons,
2010), of which we highlight three. The first is that the deficit of compliance with international agreements is not always voluntary—it can also result from capacity constraints (Chayes & Chayes,
1995; Tallberg,
2002). The second dimension relates to the influence of competing domestic constituencies on governments’ compliance decisions (Dai,
2005). The third dimension concerns the form of the commitments made by states and, specifically, whether they generate a legal obligation (Abbott et al.,
2000; Abbott & Snidal,
2000).
The question of the legal status of the international regime highlights the potential for trade-offs discussed earlier. Current scholarship on international cooperation expects
participation to be higher in international regimes based on soft governance compared to legally binding obligations enshrined in an international treaty (Spilker & Koubi,
2016). This is mainly because soft governance regimes are typically “low-cost institutions” (Abbott & Faude,
2021). Specifically, soft governance institutions tend to have lower transaction costs (fewer diplomatic formalities and less intensive bargaining), domestic approval costs (avoiding hurdles like high-level executive clearance and legislative approval), operating costs (salaries and offices), change costs (modifying features in response to changed conditions or preferences), exit costs (including diminished reputation for reliability) and sovereignty costs (loss of discretionary authority) (Abbott & Faude,
2021). These lower costs increase the likelihood of participation by making policy-makers more willing to create or join them and by placing fewer hurdles along the way. Due to these benefits, informal rule-making has proven more popular among states than formal treaty-making during the past two decades—in health and a variety of other issue areas (Pauwelyn et al.,
2014; Reinsberg & Westerwinter,
2021; Roger & Rowan,
2022; Vabulas & Snidal,
2021; Westerwinter,
2021). By contrast, the trend towards increased delegation observed in formal intergovernmental organizations since 1950 stopped in the 2010s (Lenz et al.,
2022).
Conversely, it is often thought that governments are more likely to
implement commitments made under a hard law regime, since violations of binding agreements can expose governments to costly litigation and censure by judicial bodies, and they are more likely to undermine a government’s international reputation, trigger enforcement measures and attract domestic audience costs than noncompliance with soft commitments (Köppel & Sprinz,
2019, pp. 1863–1865). This view highlights a potential trade-off between the elements of the effectiveness triad. If the choice for soft governance with ambitious demands ensures wider participation, it may do so at the expense of implementation.
We argue that such a trade-off in institutional design does not need to materialize when state preferences are favorably distributed, specifically when a relatively high proportion of conditional cooperators are present. Under such conditions, all three elements of the triad become achievable. First, the regime can be
ambitious in the sense of soliciting demanding commitments. Ambition corresponds to what Downs et al. (
1996) called “depth”:
“the depth of an agreement refers to the extent to which it captures the collective benefits that are available through perfect cooperation in one particular policy area. Given the difficulties involved in identifying the cooperative potential of an ideal treaty, it is most useful to think of a treaty’s depth of cooperation as the extent to which it requires states to depart from what they would have done in its absence” (Downs et al.,
1996, p. 383).
We consider an agreement ambitious when it requires countries to change their policies and perform actions that would substantially contribute to reaching the agreement’s goal (Barrett,
2008, p. 243).
3 Unconditional noncontributors will be wary about joining ambitious regimes if they believe they must honor their commitments. By contrast, unconditional and conditional contributors generally prefer regimes to be ambitious, all else being equal, but for the latter group it also matters who else participates.
Second, an institutional design that combines non-binding commitments with monitoring mechanisms can lead to high levels of participation because it facilitates the snowballing dynamic discussed earlier. The launch of the regime signals to states that a wave of commitments is imminent or underway, and monitoring mechanisms help them ascertain whether this wave has materialized. This signal is especially important for conditional contributors, who seek reassurance that a sufficiently large proportion of other states are also joining. For conditional contributors, the non-binding nature of the regime mitigates the risk of joining: even if they join and others do not, they still retain the option of reneging on their commitments without incurring high costs, at least compared to the consequences of violating international law.
Finally, monitoring mechanisms in regimes promote implementation by helping governments to obtain information on whether other states have put their commitments into practice. For states that are conditional contributors, as opposed to free-riders, reassurance of widespread implementation is sufficient to ensure their own sustained cooperation, provided that they have the capacity to do so. To facilitate a snowballing dynamic, an international institution needs to enable conditional contributors to assess whether enough other countries are taking action to make it worthwhile for them to do the same. By contrast, the typical functions of hard law—raising the international and domestic cost of non-implementation by defining it as a breach of international law and legitimizing retaliatory measures—are less important when the number of unconditional noncontributors is low, and the number of conditional contributors is high.
Our focus so far has been the
choice between implementation and abstaining from it. An influential strand of research on international regimes has emphasized that compliance is not only a matter of choice, but also of capacity (Chayes & Chayes,
1995). Accordingly, the analysis of regime effectiveness should consider both voluntary and non-voluntary sources of implementation deficits.
We now apply this framework to the global AMR regime. As a first step, we explain why we should expect the proportion of conditional contributors to be high in this case. This expectation is based on two features of the global AMR situation. First, levels of AMR prevalence vary considerably across countries. Higher prevalence is partly due to a larger volume of antibiotics used and a higher proportion of clinically inappropriate use of these antibiotics (Hendriksen et al.,
2019; Savoldi et al.,
2019). Hence, “[n]ational efforts to curb the abuse of antibiotics use domestically will prolong the lag phase of resistance beyond that determined by the least global effort to curtail this abuse” (Sandler & Arce,
2002, p. 212). Selective benefits generally mitigate the under-provision of public goods (Buchholz & Sandler,
2021; Hale,
2020).
Second, the selective benefits of acting against AMR make some countries unconditional contributors, but they are insufficient for other countries. An example of an unconditional contributor is the United Kingdom, which adopted a NAP early and started implementing it before any sign that other countries would follow suit (Hopkins,
2016). As we will show in the next section, most other countries acted only as part of a global cascade. The analytical framework suggests that, for each country, the benefit of protective measures increases if other countries implement them as well because it reduces the risk that the type of drug-resistant pathogen prevented domestically is imported from abroad sometime in the future (Abd El Ghany et al.,
2020; Bokhary et al.,
2021; Frost et al.,
2019). AMR containment can be classified as a weaker-link public good (Sandler & Arce,
2002, p. 212).
4 Accordingly, policy-makers are sensitive to the AMR measures put into action by other governments (Rönnerstrand et al.,
2022). Given that implementing changes in the use of antibiotics can entail substantial short- and medium-term economic and political costs, some governments will be ready to pay them only if they can be confident that a sufficiently large proportion of other governments are also taking action. In other words, attempts at countering AMR face a large share of conditional contributors.
This distribution of preferences has implications for ambition, participation, and implementation. Regarding
ambition, the WHO reasoned that most member states would not be interested in having an “empty institution” (Dimitrov,
2020) and that it had the mandate to build a demanding regime. Hence, the GAP asks countries to implement thirty-one key actions to raise awareness, increase surveillance, reduce infection, optimize antimicrobial medicines use, and increase sustainable investment. For instance, the GAP requests the “development and implementation of national and institutional essential medicine lists guided by the WHO Model Lists of Essential Medicines, reimbursement lists and standard treatment guidelines to guide purchasing and prescribing of antimicrobial medicines, and regulation and control of promotional practices by industry” (WHO,
2015a, p. 17). Most states had not already implemented these actions at the time of the GAP’s adoption (Podolsky,
2018).
We also expect the AMR regime to attain high levels of
participation. The regime has all the features of a “low-cost institution”, as defined by Abbott and Faude (
2021), which are suited to attract broad participation. States can demonstrate their commitment to the regime by adopting NAPs that meet the demands of the GAP, but they do not need to fear that lack of implementation will incur penalties. They also have the freedom to adjust the content of their commitments in response to epidemiological, economic, and political development without having to wait for a formal multilateral renegotiation of the rules. Furthermore, the WHO provided a temporal focal point by requesting states to produce the NAP with a two-year deadline, and it publicized information on which states met that expectation.
We further envisage the AMR regime to achieve a high level of voluntary
implementation. The regime is designed to provide exactly the information conditional contributors need to initiate implementation. The regime provides information on how many states have committed to act and to what extent they comply with those commitments. The GAP reduces ambiguity about what AMR action should consist of by providing a framework for the content of NAPs. The WHO, FAO and OIE collect and publishes NAPs, and states are expected to submit periodic self-assessment documents, whose results are published online (WHO-FAO-OIE,
2022). In sum, the regime promotes transparency and facilitates comparisons of commitments and implementation based on standardized reporting categories.
Based on these arguments, we formulate our first hypothesis:
The argument so far has considered the potential lack of implementation that could derive from voluntary defection from commitments. As noted earlier in this section, unwillingness constitutes one of the main potential obstacles to implementation, the other being capacity constraints (Chayes & Chayes,
1995). Involuntary noncompliance due to low capacity is relevant to the case of AMR, because we should expect a state’s administrative capacity to affect its ability to implement a NAP. Implementation involves a wide range of complex tasks requiring high degrees of coordination between multiple agencies and decision-making levels (Anderson et al.,
2019). Many national administrations struggle to perform these tasks. For instance, Shabangu et al. (
2023) interviewed 36 policymakers responsible for developing and implementing AMR NAPs in South Africa and Eswatini and documented significant capacity constraints to implementation. One South African health policy-maker reported that “There is a shortage of qualified microbiologist[s] in the state sector and experienced pharmacists with clinical pharmacy qualification to manage stewardship programs by providing rational antibiotic use interventions to reduce AMR” (Shabangu et al.,
2023, p. 132). Similarly, many AMR policy-makers in Pakistan interviewed by Khan et al. (
2020, p. 979) suggested that “doctors and the pharmaceutical and livestock industries may be too powerful for government agencies to enforce rules on; the latter was presented as under-resourced, poorly organized and lacking in authority to implement the existing regulations.” Lack of resources and expertise in national administrations is a recurring theme in case studies on the development and implementation of NAPs in other countries, such as Bangladesh, Benin, Brazil, Burkina Faso, Ghana, Kenya, Mali, the Philippines, and Tanzania (Ahmed et al.,
2022; Corrêa et al.,
2023; Frumence et al.,
2021; Godman et al.,
2022; Hein et al.,
2022; Lota et al.,
2022; Sariola et al.,
2022; Song et al.,
2022; WHO,
2022a,
c cf. also Thomas & Lo,
2020).
Therefore, we expect implementation to be more challenging in countries with lower bureaucratic capacity.
5 Sandler and Arce (
2002, p. 212) note that the effectiveness of international arrangements for producing weaker-link public goods such as AMR depends on the transfer of assistance from high-income to low-capacity countries. However, the regime does not guarantee financial or technical assistance, and international aid for building countries’ capacity to implement AMR policies is limited and episodic (Micah et al.,
2023). Accordingly, we argue that the regime is less effective in removing obstacles to implementation due to capacity rather than willingness. Thus, we formulate our second hypothesis:
Finally, we test an observable implication of our argument that the AMR regime combines substantial ambition, broad participation, and high levels of voluntary implementation. If that is the case, we should expect considerable progress toward the outcome the regime is meant to attain (Barrett,
2008, p. 243). Specifically, we expect progress towards a key policy outcome that the GAP highlights: the “extent of reduction in global human consumption of antibiotics (with allowance for the need for improved access in some settings)” (WHO,
2015a, p. 17). Accordingly, we formulate our last hypothesis:
5 Conclusion
This article has shown that the global regime to address AMR has prompted wide-ranging national participation through the adoption of NAPs, that bureaucratic capacity constraints slowed down the implementation of NAPs, but they are currently put into practice in most countries, and that implementing NAPs is associated with reduced human consumption of antibiotics. The countries with the largest shares of global antibiotic consumption and the largest per-capita consumers are fully engaged in the regime. Therefore, the global soft governance regime to address antibiotic resistance appears to have been effective at achieving participation and implementation. At the same time, it seems to have been ambitious enough to contribute to a substantial reduction in the consumption of antibiotics—an important step towards producing the global public good of safeguarding antibiotic effectiveness.
We end our study by pointing out some limitations, implications, and directions for future research. One limitation is that the analysis of the implementation of NAPs mainly relied on the information reported by national governments to the WHO, FAO, and OIE. Self-reporting to international organizations can be problematic (Oechslin & Steiner,
2022). However, case studies of NAP implementation in specific countries do not provide reasons to believe that the situation is systematically misrepresented (Ahmed et al.,
2022; Corrêa et al.,
2023; Frumence et al.,
2021; Godman et al.,
2022; Hein et al.,
2022; Lota et al.,
2022; Sariola et al.,
2022; Song et al.,
2022; WHO,
2022a,
c). Nevertheless, we hope that the substantial resources needed to build a nongovernmental monitoring system will be available over the next few years.
Two further limitations should be mentioned. First, our analysis of the effect of NAP implementation on antibiotic consumption covers all antibiotics without distinguishing between the three categories of antibiotics specified by the WHO from 2017 onwards: “access”, “watch”, and “reserve” (the AWaRe framework). Future research could perform a more disaggregated global analysis subject to data availability. Second, the GAP and NAPs promote various outcomes beyond human antibiotic consumption, notably a reduction and modification of the use of antibiotics in agriculture. Subject to data availability, future research could examine to what extent NAP implementation makes a difference for those other outcomes.
As noted in the introduction, several experts advocate institutional changes in the AMR regime, such as the inclusion of legally binding elements (Hoffman et al.,
2019a; Pitchforth et al.,
2022; Rochford et al.,
2018; Rogers Van Katwyk et al.,
2020). In contrast to studies comparing the effectiveness of hard and soft international agreements while controlling for other factors (Böhmelt & Pilster,
2010; Köppel & Sprinz,
2019; Parente,
2022; Tveit & Tørstad,
2023; Zangl,
2008), we cannot empirically assess the counterfactual effectiveness of a legalized AMR regime. However, we can note some implications of our theory and findings for institutional reform. The benefits of legalization need to be assessed carefully because a legally binding agreement may fail to be ratified widely and achieve lower participation compared to the current regime, especially if it were to include penalties for non-compliance, such as trade sanctions, as some have suggested (Hoffman & Behdinan,
2016, p. 532). Our findings are particularly relevant to two provisions that treaty proponents would like to see included. The first is the regulation of antimicrobial prescription and availability for humans (Hoffman & Behdinan,
2016, p. 519). Our research suggests that the existing soft governance regime has made significant progress in getting states to make policy commitments, implement them, and reduce domestic antibiotic consumption. Thus, the added value of legalization for that aspect is unclear. However, legalization could facilitate sustained implementation, for instance, by helping domestic actors who prefer robust public action to overcome opposition and inertia, as has been documented for human rights treaties (Simmons,
2009). Legalization could also make implementation resilient to an increase in ambition, such as the adoption of explicit antibiotic use targets.
11 The other proposed treaty provision is a commitment by high-income countries to support capacity building in low-income countries, including AMR surveillance systems, laboratory capacity, and infection prevention programs (Hoffman & Behdinan,
2016, p. 523). Such funding commitments are sometimes included in international agreements mandating costly contributions to transnational public goods.
12 We found that bureaucratic capacity deficits are associated with significantly less implementation of national action plans, which points to the usefulness of external assistance. Our finding that countries implementing their NAPs account for more than 90% of global consumption of antibiotics (summarized in Fig.
2) may give the impression that current implementation deficits have only local rather than global relevance, but that would be a rash conclusion. As noted earlier, the level of AMR prevention in weaker-link countries disproportionately impacts the success of efforts to preserve antibiotic efficacy globally (Sandler & Arce,
2002). A treaty that made funding streams more sizeable and less volatile—for instance, by mitigating burden-sharing conflicts among donors—could substantially improve the sustainability of global collective action.
Finally, an important implication of our study concerns broader debates about soft governance in international relations. Against suspicions that non-binding initiatives promoted by multilateral organizations amount to inconsequential “blue-washing”, we found that the processes led by the WHO, FAO, and OIE had a real impact on antibiotic consumption. We argued that soft governance is effective in this case because the collective action problem raised by AMR involves many conditional contributors, and the regime includes monitoring mechanisms that allow them to verify the implementation status of other countries. The empirical findings indicate that soft governance can produce meaningful results toward solving global collective action problems under these conditions. In future work, researchers could systematically compare soft governance institutions to determine which proportion of unconditional and conditional contributors is necessary and sufficient for such institutions to bring about successful international cooperation. Climate change is an important example. Researchers usually assume that states have strong incentives to free-ride concerning mitigation efforts, which has led some to interpret global collective action as facing the effectiveness trilemma discussed earlier in this article (Dimitrov et al.,
2019). According to Hale (
2020), however, the incentive structure of climate mitigation has three features—joint goods, preference heterogeneity, and increasing returns—that make it more similar to the AMR cooperation problem than to a straightforward Prisoners’ Dilemma. A systematic comparison of global collective action problems across issue areas would be fruitful, but an assessment of the scope conditions for effective soft governance would also need to take similarities and differences in domestic interests, power distributions, and problem salience into account (e.g., Colgan et al.,
2021). We hope that our work contributes to demonstrating the importance of this research agenda by showing that the ambition-participation-implementation triad does not have to be a trilemma. In the case of AMR, the global soft governance regime has been successful in eliciting commitments and attaining a substantial improvement in the use of antibiotics.