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June 25, 2024 The Honorable Charles Schumer The Honorable Mike Johnson Majority Leader Speaker United States Senate U.S. House of Representatives Washington, DC 20510 Washington, DC 20515 The Honorable Mitch McConnell The Honorable Hakeem Jeffries Minority Leader Minority Leader United States Senate U.S. House of Representatives Washington, DC 20510 Washington, DC 20515 Dear Speaker Johnson, Majority Leader Schumer, Minority Leader McConnell, and Minority Leader Jeffries: The 1,050 undersigned organizations—which represent the full breadth of investments that support all of America, every day—call on Congress to reject arbitrary and damaging funding levels for Fiscal Year 2025 and, at the very least, to fully appropriate the necessary non-defense discretionary (NDD) funds to keep pace with rising costs and demand and keep poison pill policy riders that undercut the priorities of the American people out of the package. Cutting funding from the FY 2024 levels appropriated just three months ago will do little to reduce the national debt and federal deficit but will greatly jeopardize American competitiveness, security, economic strength, and services on which families and individuals rely. Vital domestic and international appropriations are a small part of the federal budget—less than one-sixth—yet they fund a wide range of important services and investments that keep America strong now and in the future. Examples include: scientific and medical research; health care for veterans; federal law enforcement; environmental conservation; home energy assistance; housing and child care assistance for low-income families; mental health and substance use disorder treatment; rural development; K-12 education and skills training; nutrition assistance for young children, families, and older people; financial aid for higher and technical education; infrastructure investments in roads and bridges, sewage treatment, safe drinking water, flood control and navigation improvements; diplomacy, humanitarian aid and development; services for victims of gender-based violence; courts and reentry programs; assistance for small businesses; public safety and other programs for older people; life-saving services for people with disabilities; public health; and much more. Every state and congressional district benefits from NDD investments. Denying NDD programs the increases needed to keep pace with rising costs and provide effective services is a pennywise, pound-foolish way to address the larger fiscal challenges facing our country. As seen with enactment of FY24 appropriations law, there is a strong governing majority for more robust investments. Rather than constraining NDD appropriations to an arbitrary and insufficient funding target, our organizations urge you to avoid poison pill policy riders and invest the amounts needed to meet the needs of our country and protect American competitiveness, economic strength, security, and services critical to families and individuals. Sincerely, 20/20 Vision 3 Daughters and 1000 Sons A New PATH (Parents for Addiction Treatment & Healing) A Safe Place - Lake County, IL A Safe Place - West PA A Woman's Place AACTE AASA, The School Superintendents Association Abuse & Rape Crisis Center Academy for Radiology & Biomedical Imaging Research Academy of Nutrition and Dietetics AcademyHealth ACCESS FAMILY SERVICES., Inc Access Ready Inc. 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AMR GLOBAL LEGISLATORS REPORT Tackling AMR is essential to save lives and contain this threatening health crisis that is quietly unfolding. In this context, political will is key. This report is an incredible tool for politicians and parliamentarians worldwide to speak with the same voice and act efficiently. Professor Agnes Buzyn Professor of Hematology at Paris-Sorbonne University, France The challenge of tackling AMR is one of unique complexity and ever-growing importance. This report focuses on what Parliamentarians around the world can best do to both hold their own Governments to account for progress & keep a political focus on what is too often seen as just a medical issue. If AMR renders all antibiotics powerless to fight infection the world will enter a very dark place indeed with routine medical procedures becoming too dangerous to use. We must avoid this dystopia by working together and holistically to slow the spread of resistant pathogens, discover new treatments & distribute them equally across the globe. Parliamentary accountability will be key to progress in this crucial battle. Dame Angela Eagle DBE, UK MP- Chair, G20&G7 AMR Legislators Grop Hon. Dr Christopher Kalila Member of Parliament Zambia, Former Executive Committee member of the Commonwealth Parliamentary Let us reward Dr.Alexander Fleming( discoverer of Penicillin) by containing AMR. This will require concerted effort and Multisectoral collaboration on a similar scale as we did with HIV and COVID. ANNEX 1 The need for a more systematic and common approach in tackling AMR at both global and national levels REFERENCES ACKNOWLEDGEMENTS 16 Table of CONTENTS PREAMBLE AMR IS A GLOBAL PROBLEM REQUIRING URGENT, EFFECTIVE AND LONG TERM POLITICAL ATTENTION. - Why is it such a complex problem? - Why this initiative? - Why do we need legislators involved in this initiative? - Ensuring Effective Global Action on AMR - Essential Common Tools RECOMMENDATIONS - Enhancing the Role of Global Legislators - Enhance the role of National Legislators - Create Global Benchmarks for Research and Data - Updating the 2015 Global Action Plan and ensuring global convergence in multilateral fora on AMR Action - Sustainable Finance for Research & Product Development 6 7 8 9 12 13 14 11 15 18 22 23 6 7 Preamble AMR is a global problem requiring urgent, effective, and long-term political attention. 1. AMR is a huge and growing problem at the world level, and yet it has not received the same degree of attention as some other global challenges, such as climate change. 2. While there have been significant organizational changes, policy initiatives, and background reports all aimed at tackling the problem they have not yet had the desired impact, and not yet been sufficient game changers. 3. 2028 will mark the centenary of the development of the first antibiotic and yet rising levels of antimicrobial resistance or AMR are attacking our entire ecosystem and are no longer just a health challenge. It is time, therefore, for more integrated inter-ministerial and multi-sectoral collaboration. 4. Despite the wealth of evidence and the creation of countless initiatives on AMR from across all sectors, there seems to be a critical disconnect in translating the challenges posed by AMR into the necessary political messages and actions amongst legislators in governments and parliaments. 5. Indeed, the January 2024 Executive Board Meeting of the WHO confirmed that AMR has not attracted the “sustained political attention it demands”a) and expressed the need for greater urgency on this matter. In order to help address this need, there will be a high-level meeting at the UN General Assembly (HLM UNGA) on 26th September 2024 and at the 4th AMR Ministerial Conference in the Kingdom of Saudi Arabia (KSA) on 14th -16th November 2024. Why is it such a complex problem? 6. AMR is not a disease. It is, however, endemic to the world and is an umbrella term to indicate the growing threat of drug-resistant microbes. This makes it less understood by the public and by political leaders. 7. Antimicrobial medicines such as antibiotics, antivirals, antifungals, and antiparasitics are powerful tools to prevent infections across human, and animal health and food, plant, and environmental ecosystems. In some places, notably in many Low and Middle Income Countries (LMICs), there is still insufficient access to these tools. In other places, however, antimicrobial medicines can be misused or overused, and bacteria, viruses, fungi, and parasites may no longer respond to them. 8. AMR also has a profound impact on illnesses such as Cancer, Tuberculosis, Malaria, HIV/AIDS, and untreatable resistant infections significantly increasing the risks to patients undergoing surgical procedures. Deaths caused by these illnesses are often attributed to them rather than to drug resistance, and AMR is thus often underreported. 9. Bacterial AMR has already been directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths, with children under 5 and people in LMICs, notably in Sub-Saharan Africa, being particularly vulnerable b). AMR is made worse by inadequate infection prevention and control 8 9 Why do we need legislators involved in this initiative? 18. Legislators are in a unique position to influence governments and to draw the attention of citizens to the growing problems caused by AMR at the global level. Legislators can play a critical role in developing policies and comprehensive strategies, writing appropriate laws, allocating resources, ensuring oversight, and promoting international cooperation. 19. The involvement of Legislators thus complements the roles of other actors. National governments are often too focused on the short-term to take the longer-term measures that are necessary to tackle AMR and national policymakers are often working in narrow silos. Civil society organisations are often organized within disease silos and broader-based patient safety issues related to AMR are poorly represented. Experts on AMR in national and international administrations are often talking to each other more than to the wider public. 20. It is essential, therefore, that legislators play a vital role in the development of this initiative and take the necessary steps to ensure both transparency as well as stronger political leadership on these issues. 21. It is also essential to create a common narrative on AMR to promote a wider understanding and joint action among legislators, Ministers of Health, Finance, Agriculture, and Environment. Ensuring Effective Global Action on AMR 22. To address this, the current initiative sets out some essential objectives and some essential common tools for the guidance of legislators. measures in healthcare settings, lack of access to water, sanitation, and hygiene (WASH) and weaknesses in hospital and primary healthcare structures. New environmental threats, notably those caused by climate change, are already having adverse effects on health and on AMR. 10. Unless there are concrete, clear, and actionable measures on AMR, the situation will continue to deteriorate and there will be great damage to human, animal, and plant health as well as to the environment. The world economy, especially in LMICs, will also suffer greatly. The World Bank has estimated that AMR could result in US$ 1 trillion in additional healthcare costs by 2050 and US$ 1 trillion to US$ 3.4 trillion gross domestic product (GDP) losses per year by 2030c). 11. The complex and multi-sectoral nature of AMR is reflected in the complexity of the necessary governance arrangements to respond to the AMR challenge at both national and international levels. Many different actors are involved, and there are many overlapping initiatives, which reduce their impact and visibility. 12. One of many examples of this complexity concerns target setting. Many such targets have already been set (reducing global deaths, reducing levels of antibiotic use for humans and animals, etc), and others may still be required, such as R&D targets for antibiotics and diagnostics. At the same time, target setting is complicated by the absence of appropriate benchmarks, since, for example, in many countries, there is a lack of knowledge on the impact of antibiotics in their agricultural sector and in their water. The ambition should be to avoid the setting of artificial targets and to save more lives by collecting better data on the scale of the problem within the animal, health and water/food supply. 13. A number of actions have been taken at national and international levels, but they have often not been followed up nor adequately financed. There are a large number of National Action Plans, for example, but recent track survey results show that only 17%d) of them are fully funded through a budgetary allocation, others are all funded through ad hoc mechanisms and many are not funded at all. 14. Measures to address AMR are currently insufficient to tackle the scale of this problem. The development of new antibiotics is at its lowest level since 1945, and there are inadequate diagnostic tools. Scientific challenges, low return on investments, and lack of compensating economic support have led to a chronic lack of innovatione). 15. Finally, AMR also greatly reinforces the risks of Sepsis, which causes 13.7 million deaths a year, of which almost 5 million or 36% of the total are associated with, or directly attributable to AMRf). Why this initiative? 16. The current initiative has a twofold purpose. The first is to raise awareness of the AMR crisis among policymakers and regulators at national, regional as well as at global levels and bridge the disconnect between scientists and policymakers. The second is to enlist global legislators to advocate for the necessary measures to tackle AMR and to implement them effectively. 17. The present report puts forward precise recommendations and a model resolution covering each key issue where legislators can have an impact. This is designed to be used by as many actors as possible and aims to ensure a commonality of approach. 10 11 23. he need to set in motion a multiyear process in governments and parliaments, keeping AMR high up the political agenda on a continuing rather than occasional basis, incorporating all countries and regions in that process, reflecting the priorities of legislators as well as of technical experts, and fully taking into account the very differing national contexts 24. The need to create an understanding of what “One Health “means for non-health experts and to promote an integrated approach to this complex multi-sectoral, multi-jurisdictional problem, with human, animal, and plant health components, as well as concern for the environment. 25. The need to balance the excess use of antimicrobials in many contexts against antimicrobial access and affordability problems for the LMICs. 26. The need for essential preventative measures, notably in the areas of clean water, effective sanitation, infection control, vaccines, as well as sustainable production systems for animals and food and good animal husbandry. 27. The need for a more visible and binding framework for future measures on AMR, with sustainable long-term funding. These should be based both on common guidelines at the global level and on appropriate adaptation and implementation of these guidelines at the national level, including cost, well-resourced, and accountable National Action Plans. Essential Common Tools 28. These should include the following: Enhancing the role of global legislators, strengthened research and data, appropriate legislation and regulation, innovative funding, enhanced governance and transparency, and joined-up Communication amongst all sectors and at all levels of policy-making in governments: Key Objectives Balancing Excess and Access Legislative Framework One Health approach Multiyear Process 12 13 Recommendations Enhancing the Role of Global Legislators by: a) Promoting the appropriate set of policies and regulatory framework, including, where necessary, binding, and realistic targets and other measures, whilst recognizing that we cannot apply a “one size fits all” policy. b) Pushing for the necessary funding through Multilateral Organisations and Development Finance Institutes as well as encouraging accompanying funding in national budgets. c) Establishing an independent Science Panel on Evidence for Action against Antimicrobial Resistance to identify evidence and data gaps, on the lines of the IPCC for climate change. Such a panel should propose benchmarks across the one-health spectrum, in order to facilitate effective oversight over national reporting mechanisms. d) Formalizing on a bi-annual basis the role of the periodic High-level Ministerial Conferences on AMR to provide the necessary political impetus for global action and progress on AMR, in collaboration with the WHO, The Joint Quadripartite (FAO, UNEP, WOAH) and the Global Leaders Group on AMR. e) Establishing an annual meeting of national legislators and policymakers for Health, Agriculture, Environment, and Finance. f) Working on a convincing narrative and communicating on AMR both to other policymakers and to the general public concerning the consequences of the crisis and the measures that are being taken to tackle it. g) Empowering the voices of affected communities, including civil society and youth and patient-based organizations, and leveraging their messages to policymakers. h) Intensifying efforts for strengthening early detection, diagnosis, and therapy of Sepsis in the context of AMR, as called by the 2017 World Health Assembly Resolution on Sepsis (WHA70.7), the G7 Health Ministers’ Communiqué of 2022, and the 2023 Berlin Declaration on Sepsisg). Enhance the Role of National Legislators by: a) Ensuring there is integrated decision-making for AMR and intersectoral coordinating mechanisms at the national and international levels, incorporating all the concerned government ministries, and international organizations. b) Pushing for the necessary national funding. c) Using the findings of the proposed International Science Panel, in order to identify priority national actions, monitor progress, and set appropriate indicators. d) Call for an annual hearing and report to be presented to legislators by governments on the funding and implementation of NAPs, as well as on other AMR mitigation measures, such as the provision of clean and adequate sanitation to communities. e) Appointing national AMR envoys to coordinate country and interministerial and sectorial efforts to implement NAPs and to facilitate international exchange of views and experiences. f) Creating an AMR platform for Legislators, in order to share national and regional best practices. g) Holding periodic AMR Summits to bring together international stakeholders from all sectors, to review targets, guidelines and build on commitments, and track their progress from one summit to the next. h) Promoting strong antimicrobial stewardship, both for the prudent and appropriate use of existing antimicrobials and to maximise the effective use of diagnostic tools. Create Global Benchmarks for Research and Data: a) Establish common and global/sectorial benchmarks for data collection, including mapping of hotspots of AMR, maximising the use of existing surveillance mechanisms1 . b) Direct research towards innovative diagnostic tools, and new antimicrobials to meet current and future unmet needs including resistance c) Encourage additional research on the impacts of, and on the more appropriate use of existing antibiotics across the One Health approach d) Provide more research on the causes and impact of drug-resistant infections on account of age, gender 1 For example GLASS, ANIMUSE, and TrACSS. 14 15 Updating the 2015 Global Action Plan and ensuring global convergence in multilateral fora on AMR Action: a) In the coming months the Global Leaders Group and the Quadripartite, the WHO, the G7, the G20, and others preparing the WHA, UN High-Level Meeting on AMR, and the 4th Ministerial Conference on AMR in Saudi Arabia, are all urged to ensure the fullest possible convergence around a concise set of implementable actions and targets to be incorporated in an updated version of the 2015 AMR Global Action Plan. b) Global legislators should now urge that country-specific targets should be better coordinated, clear, and transparent, should be measurable, and be monitored through regularly updated scoreboards. These should be sufficiently flexible to adapt to country-specific needs and be presented in such a way that is easier to communicate with policymakers and with the general public. c) National measures against AMR should complement international guidelines and be enshrined in national legal frameworks to ensure that they are properly funded, implemented, and subject to regular reporting and hence fuller accountability. d) Measures and legislation to tackle AMR should be coordinated between sectors and government ministries, in order to fully embrace the One Health approach. e) National or Regional regulatory bodies should be established or strengthened in areas where enforcement is lacking. f) Fully utilize the portfolio of vaccines that are available, in order to reduce the number of infections in the population and thereby minimise the use of antibiotics. g) Establish a Global Essential Veterinary Medicine and Vaccine List and AWaRe guidance for veterinary medicines as well as working towards an agreed target for antibiotics use in animals. Sustainable Finance for Research & Product Development: a) Develop innovative and blended financing mechanisms to encourage new forms of investments via private/ public partnerships and the support of Multilateral and Regional Development Banks and ensure that there is continuity in funding so that promising projects are not curtailed. b) Include sufficient and predictable long-term funding for push and pull incentives, that are incentivised and driven by governments and supported by the private sector and funders as both mechanisms are required to drive the progress of the antibiotic pipeline. c) Support push funding to sustain R&D and ensure new and existing antibiotics meet all public health needs. Higher income countries (G7+, G20, EU27) should seek to incorporate such funding into their national budgets at the earliest opportunity. d) Push mechanisms also require additional, substantial, long-term global investments, in particular, to support innovative scientific research, to build a robust early-stage pipeline, and to facilitate early access in LMICs. e) When appropriate, enact legislation directing relevant evaluation, procurement, and reimbursement authorities to implement realistic pull incentives. Maximise the use and scope of existing funds rather than prioritize the establishment of a new dedicated AMR Fund. f) Encourage countries to cooperate at a regional level , to develop multi-national pooled procurement mechanisms for antimicrobial tools and diagnostics, in order to strengthen the market environment and access for new and old products. g) Preferentially procure antibiotics that are responsibly made (for example, as certified by the BSIh) or in line with any forthcoming guidelines set by the WHO), in order to reduce manufacturing discharges into the environment. identity and sex, and socioeconomic status. e) Ensure that all R&D actors take into account access considerations as early as possible including shaping clinical development to cater to real-world needs. f) Push for simplified administration, reduction of production costs, and the generation of relevant clinical data and medical evidence to support the appropriate use of approved medicine in diverse settings/ or post-approval 16 17 Annex 1 (a) Whereas AMR is a huge and growing problem at the world level, and yet it has not received the same degree of attention as some other global challenges, such as climate change. (b) Whereas AMR is not a disease but is an umbrella term to indicate the growing threat of drug-resistant microbes, and is endemic to the world; whereas it also has a profound effect on diseases such as Cancer, TB, Malaria and HIV/AIDS, and greatly increases the risks of Sepsis. (c) Whereas AMR is made worse by inadequate infection prevention and control measures in healthcare settings, lack of access to water, sanitation, and hygiene (WASH), and weaknesses in hospital and primary healthcare structures. (d) Whereas measures to tackle climate change and other environmental threats, may also be very useful in the AMR context. (e) Whereas the economic consequences of AMR are also very great. (f) Whereas 2028 will mark the centenary of the development of the first antibiotic and yet few new ones are being developed. (g) Whereas there is now increasing resistance to all antimicrobials, which threatens our entire ecosystem, and is no longer just a health challenge. (h) Whereas significant organizational changes, policy initiatives, and background reports have been taken to tackle the problem, they have not yet had the desired impact, nor been sufficient game changers. (i) Whereas there seems indeed to be a critical disconnect in translating the challenges posed by AMR into the necessary political messages and actions amongst legislators in governments and parliaments. (j) Whereas there now needs to be a renewed global impetus on containing the AMR crisis (k) Whereas unless concrete, clear, and actionable measures are taken on AMR within a genuinely integrated “One Health” approach, the situation will continue to deteriorate and there will be great damage to human, animal, and plant health as well as to the environment. (l) Whereas AMR governance needs to be strengthened since there are so many different actors involved at the national and international levels, and so many overlapping initiatives which reduce their impact and visibility. (m) Whereas there needs to be targeted and monitored reduction in the inappropriate use of antimicrobials in human, animal, and plant health. (n) Whereas action plans at national and international levels need to be properly followed up and adequately funded on a continuing basis (o) Whereas the excess use of antimicrobials in many contexts needs to be balanced against antimicrobials access and affordability problems for the LMICs (p) Whereas it is vitally important to create a common narrative on AMR in order to promote a wider understanding and joint action amongst legislators, governments, international organisations, and all other key actors. (q) Whereas global and national legislators are in a unique position to influence governments and to draw the attention of citizens to the growing problems caused by AMR at the global level. (r) Whereas it is essential, therefore, that legislators play a vital role in the development of this initiative, in developing policies and comprehensive strategies, writing appropriate laws, allocating resources, ensuring oversight, and promoting international cooperation and more generally in ensuring both transparency as well as stronger political leadership on AMR issues. 1. Taking into account the 2015 Global Action Plan on Antimicrobial Resistancei). 2. Taking into account the Muscat Declarationj). 3. Taking into account regional initiatives such as the 2017 EU One Health Action Plan against AMR k) and subsequent resolutions including the EU Parliament resolutions of 2018 l) and 2023m); 4. Taking into account 170 adopted National Action Plansn); 5. Taking into account forthcoming important multilateral meetings on AMR, including the WHA, the Global Leaders Group Summit, the high-level meeting at the UN General Assembly in September 2024, and the 4th AMR Ministerial Meeting in the Kingdom of Saudi Arabia (KSA) in November 2024; MODEL RESOLUTION 07 June 2024 18 19 The need for a more systematic and common approach in tackling AMR at both global and national levels: 1. Calls for the following measures to be taken: 2. Enhance the role of Global Legislators by: a) Promoting the appropriate set of policies and regulatory framework, including, for example, binding, and realistic targets and other measures, whilst recognizing the need for them to be sufficiently flexible to adapt to country-specific needs. b) Pushing for the necessary funding through Multilateral Organisations and Development Finance Institutes as well as encouraging accompanying funding in national budgets. c) Establishing an independent Science Panel on Evidence for Action against Antimicrobial Resistance to identify evidence and data gaps, on the lines of the IPCC for climate change. d) Formalizing on a bi-annual basis the role of the periodic High-level Ministerial Conferences on AMR to provide the necessary political impetus for global action on AMR, in collaboration with the WHO and the other members of the Quadripartite (FAO, UNEP, WOAH). e) Establishing an annual meeting of national legislators and policymakers for Health, Agriculture, Environment, and Finance. f) Fully utilizing the portfolio of vaccines that are available, to reduce the number of infections in the population and thereby minimise the use of antibiotics. g) Intensifying efforts for strengthening early detection, diagnosis, and therapy of Sepsis in the context of AMR, as called by the 2017 World Health Assembly. 3. Enhance the Role of National Legislators by: a) Ensuring that there is integrated decision-making and coordination for AMR at national and international levels. b) Pushing for the necessary national funding. c) Using the findings of the proposed International Science Panel, in order to identify priority national actions, monitor progress, and set appropriate indicators. d) Calling for national measures against AMR to complement international guidelines and be enshrined in national legal frameworks to ensure that they are properly funded, implemented, and subject to regular reporting and hence to fuller accountability. e) Appointing national AMR envoys to coordinate country and interministerial and sectorial efforts to implement NAPs and to facilitate international exchange of views and experiences. f) Establishing or strengthening National or Regional regulatory bodies in areas where enforcement is lacking. g) Calling for an annual hearing and report to be presented to legislators by governments on the funding and implementation of NAPs, as well as on other AMR mitigation measures. h) Creating an AMR platform for Legislators to share national and regional best practices. i) Holding periodic AMR Summits to bring together international stakeholders from all sectors, to review targets and guidelines, and to build on commitments. 4. Create Global Benchmarks for Research and Data by: a) Establishing common and global/sectorial benchmarks for data collection. b) Directing research toward innovative diagnostic tools, on new antimicrobials and towards promoting more appropriate use of existing antimicrobials. c) Providing for more research on the causes and impact of drug-resistant infections on account of age, gender identity and sex, and socioeconomic status. d) Ensuring that all R&D actors take into account real-world needs and access considerations at the earliest stage possible. e) Promoting appropriate use of approved medicine in diverse settings and pushing for simplified administration and reduction of production costs. 5. Create Global Convergence in Multilateral Fora to Update the 2015 Global Action Plan by: a) Calling on the key decision-makers to ensure the fullest possible convergence around a concise set of implementable actions and targets in the official meetings at the world level over the coming months. 20 21 b) Further urging these to be incorporated in an updated version of the 2015 AMR Global Action Plan and ensuring that they are monitored through regularly updated scoreboards. c) Ensuring that measures and legislation to tackle AMR should fully embrace the One Health approach and be coordinated between policy sectors, government ministries, and international organizations. d) Establishing a Global Essential Veterinary Medicine and vaccine list and AWaRe guidance for veterinary medicines as well as working towards an agreed target for antibiotics use in animals. e) Promoting global stewardship through more prudent and better use of existing antimicrobials and maximising the effective use of diagnostic tools. 6. Provide Sustainable Finance for Research & Product Development by: a) Developing innovative and blended financing mechanisms to encourage new forms of investments via private/public partnerships and the support of Multilateral and Regional Development Banks. b) Including sufficient and predictable long-term funding for push and pull incentives, that are incentivised and driven by governments and supported by the private sector. c) Supporting push funding to sustain R&D and ensure new and existing antibiotics meet all public health needs, build a robust early-stage pipeline, and facilitate early access in LMICs. d) Calling for higher income countries (G7+, G20, EU27) to incorporate push funding into their national budgets at the earliest opportunity. e) Calling for legislation directing relevant evaluation, procurement, and reimbursement authorities to implement realistic pull incentives. f) Maximising the use and scope of existing funds rather than prioritizing the establishment of a new dedicated AMR Fund. g) Encouraging countries to cooperate at a regional level to develop multi-national pooled procurement mechanisms for antimicrobial tools and diagnostics, in order to strengthen the market environment and access to new and old products. h) Seeking to reduce manufacturing discharges into the environment through promoting responsible production of antimicrobials. 7. Enhance Transparency and Communication on AMR by: a) Working on a practical, evidence-based and convincing narrative to emphasise the consequences of AMR on human lives across the planet, as well as on animal and plant health and on the environment. b) Communicating clearly on measures that are being taken and will have to be taken on AMR, both to policymakers, without a health portfolio or expertise, and to the general public. c) Empowering the voices of affected patients, farmers and communities by including the civil society, youth and patient-based organizations to empower these messages to policy-makers and legislators. 8. Calls for this resolution to be submitted for the attention of all legislators at national, regional, and international levels. 22 23 References a. 154th WHO Executive Board Agenda Item 13: Antimicrobial resistance: accelerating national and global responses – Global Health Council b. Antimicrobial resistance (who.int) c. Antimicrobial Resistance (AMR) (worldbank.org) d. Special focus: Assessing the landscape of national action plans on antimicrobial resistance | Embracing a One Health Framework to Fight Antimicrobial Resistance | OECD iLibrary (oecd-ilibrary.org) e. Why is it so difficult to discover new antibiotics? - BBC News f. An estimated 1.2 million people died in 2019 from antibiotic-resistant bacterial infections | University of Oxford g. The Berlin Declaration on Sepsis – An Urgent Call for the Enforcement of the WHA Resolution 70.7 and Reinvigorated Global Action on Sepsis — World Sepsis Day - September 13 h. Antimicrobial resistance | BSI (bsigroup.com) i. Global action plan on antimicrobial resistance (who.int) j. Final Version Muscat Manifesto AMR with Annex.pdf (amrconference2022.om) k. 353f40d1-f114-4c41-9755-c7e3f1da5378_en (europa.eu) l. Texts adopted - A European One Health Action Plan against Antimicrobial Resistance - Thursday, 13 September 2018 (europa.eu) m. Texts adopted - Antimicrobial resistance - Thursday, 1 June 2023 (europa.eu) n. Microsoft PowerPoint - AMR MS Briefing 22 Mar 2023 - final.pptx (who.int) Acknowledgements This report was authored by Dame Angela Eagle, DBE, Professor Agnes Buzyn, Hon. Dr Christopher Kalila and Mr Francis Jacobs. We would like to express our deepest appreciation to everyone who supported us with the creation and completion of this report. We would like to thank our Chair and Founder of The G20&G7 Health and Development Partnership (G20/G7HDP) Alan Donnelly and Executive Director Hatice Beton for their expertise and valuable advice in guiding the report creation. We would also like to extend our thank to the team at the G20 & G7 Health and Development Partnership, Luisa Mucci and Marc Muller for their support in organising the hearings and collating information for the report. We thank everyone for their collegiate efforts. We would like to express our utmost appreciation to all experts who have kindly participated in our hearings, shared their insights, and added great value to the report’s content in leveraging the importance of the legislators’ role in advancing concrete actions for AMR. We like to express a special thanks to the International Federation of Pharmaceutical Association (IFPMA) for their support of the initiative and financial contribution and for sharing with us valuable content material and expertise. A special thanks to James Anderson for Chairing the Working Group who supported the organization of the Hearings and contributed to the successful realization of our hearings. We would like to extend our thanks to the Working Group, the WHO Quadripartite for their technical expertise and all the speakers and attendees that attended the hearings. This report would not have been possible without the valuable support of our partners in the G20&G7HDP, our Global Ambassadors and our Academic Partners, all of whom supported this project. We are grateful for the support of Shenel Osman in designing this report. This report is based on evidence heard during the four hearings the G20&G7HDP conducted on NAPs, Funding Mechanism and One Health Approach The G20 and G7 Health and Development Partnership is a not-for-profit advocacy organisation representing over 30+ global health organisations from across the public and private sectors and academia aiming to ensure G20&G7 countries coordinate their current and future health innovation strategies to tackle the growing global burden of communicable and non-communicable diseases and promote the delivery of the United Nations Sustainable Development Goals (UN SDGs) by 2030 with a focus on SDG3 “health and well-being for all” and SDG17 “strengthening partnerships.“ At the heart of its efforts the Partnership aims to build on the narrative that health is a positive investment to socioeconomic growth and supports a sustainable dialogue between health and finance ministers. Since 2017 our partnership emerged as an informal coalition of like-minded organisations and global ambassadors during the G20 Presidency in Germany. Over the last 7 years, we have increased our collaboration with both the G20&G7 Presidencies to reflect the need for increased convergence and stronger multilateral agendas. For more information contact us: office@ssdhub.org g20healthpartnership.com The G20 & G7 Health and Development Partnership @G20&G7Partnership

The Global Health Technologies Coalition (GHTC) welcomes commitments by G7 nations to advancing health research and development (R&D) included in the G7 Apulia Leaders’ Communiqué. GHTC was pleased to see G7 leaders explicitly recommit to ending HIV/AIDS, tuberculosis, and malaria, in particular, through support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as neglected tropical diseases and polio as public health threats by 2030, and to countering the effects of climate change on infectious diseases. While it was encouraging to see this signal of political will at the highest level of government, it was disappointing that leaders fell short of offering new funding pledges or specific plans to realize these aims. We also welcome the expression of support by G7 leaders for the Pandemic Fund, which included a call for expanding the donor base and securing at least US$2 billion in new pledges and cofinancing. Given that the fund could prove a powerful new financial instrument for strengthening R&D and regulatory capacity in low- and middle-income countries, we hope that G7 leaders will follow through and provide new commitments as part of the fund’s replenishment this fall. On antimicrobial resistance (AMR), it was encouraging to see leaders vow to support public-private partnerships and implement push and pull incentives to accelerate the development of new antimicrobials and other tools to combat AMR. We also appreciate the G7 articulating support for an “ambitious” Political Declaration for the United Nations High-Level Meeting on AMR, with concrete targets and an evidence-based panel to drive action. We hope that in the coming months, new R&D targets will be included in the final text to complement the current high-level global targets outlined in the zero draft. While we applaud G7 leaders for voicing their continued support for research initiatives to confront emerging and enduring health threats, we now call on them to match their statements with follow-through and financial pledges to translate these commitments into reality. 

GHTC contributed to Global Health Council's statement below entered into the official record at the 77th World Health Assembly in response to Agenda Item 11.8: Antimicrobial resistance: accelerating national and global responses.AMR is a growing existential threat that requires sustained action and urgent attention. The UN High Level meeting on AMR must prompt Member States to promote infection prevention and control measures, including WASH, and invest in priority, new and improved antimicrobials, novel compounds, diagnostics, vaccines, and other technologies to fight AMR. Innovations should be developed with access in mind, especially for gender minorities, underserved populations, and those in low-resource settings.We also call on countries to accelerate the implementation of national AMR action plans and prioritize a comprehensive, collaborative One Health approach that integrates gender perspectives. Member States should support the resolution on this agenda item and call for the creation of a global AMR laboratory network to strengthen diagnostic capacity.