Policy termination made easy? The emerging trend towards sunsetting antimicrobial resistance national action plans

ABSTRACT

While policy termination is usually more difficult than continuity in domestic policymaking, the international process for addressing antimicrobial resistance (AMR) shows that sustaining commitments can be the more difficult path. Addressing persistent crises requires persistent policy responses across multiple countries. Policy coordination among many countries has gained significant scholarly attention whereas analyses of continuing, longer-term commitments of many countries to crisis response are less common. This paper remedies this shortfall by analysing the commitments of different countries to the international policy process against AMR. It triangulates novel evidence in the form of distinct indicators based on global surveys, content analysis of national action plans (NAPs), and publication patterns of second-generation NAPs. The findings suggest that national commitments to the international process initially reached high levels but are now in decline. Countries are effectively ‘sunsetting’ their NAPs, and thereby ending commitments to the international process for addressing AMR. Many have refrained from renewing their NAPs, and those that do renew rarely show signs of learning or adaptation from previous NAPs. Hence, even in the AMR case, where a global and persistent threat rose high on the international political agenda, long-term commitment to the international response policy process is by no means assured.

KEYWORDS:

• Policy termination
• policy succession
• political commitment
• persistent crises
• antimicrobial resistance
• national action plans
• global action plan

Introduction

Contemporary societies face crises requiring serious policy action from many governments simultaneously. Global warming and biodiversity loss are examples of crises that no individual country can solve by working on its own. Cross-border coordination is one significant political challenge related to managing such crises. Another is sustaining the political commitment necessary for as long as it takes to manage the crisis.

The paper contributes to the policy termination literature (Bardach, 1976; Greenwood, 1997; Kaufman, 1976; Kirkpatrick et al., 1999) and draws on long-standing debates in public policy theory about policy termination and succession (Hogwood & Peters, 1982; Turnhout, 2009) and about policy learning (Dunlop & Radaelli, 2018). It focuses on policy termination and continuity at the international level. Studies of domestic policymaking conventionally show that policy termination is considerably rarer than sustained policy commitments. Factors such as institutional path dependency and powerful vested interests keep policies and programmes alive for long periods, sometimes outliving their original rationales (Hall & Taylor, 1996; Kay, 2003; Moe, 2015). However, this paper shows that internationally coordinated actions can tend towards policy commitments being terminated even when the underlying problem persists. It does so by looking closely at the international policy process of adopting national action plans (NAPs) to curb antimicrobial resistance (AMR).¹ The NAP policy process is a crucial case of international responses to persistent crises because it exemplifies successful short-term cross-border coordination and commitment while offering far less clear longer-term commitments. Almost all countries developed AMR NAPs during the 2015–2020 periods. However, many NAPs had 4 – or 5-year terms, which began to expire in 2020. As of mid-2024, many countries find themselves having to decide whether and how to renew their NAPs. This means that the development of AMR NAPs offers information about government commitment to sustaining the international policy process aimed at combatting AMR.

The paper juxtaposes two explanations of national long-term commitment to the NAP policy process: that such commitment can be functionally problem-driven or politically contingent. From a functional perspective, we would expect policies to be made addressing a major challenge as long as it persists. Following this logic, policy commitments to fighting AMR would be sustained so long as AMR-related crises persist. However, a common theme in policy process theories is how domestic politics shapes policymaking, rather than any functional matching of problems and solutions (Weible, 2023). From this perspective, we would expect policies addressing a major challenge to be made and abandoned based on political dynamics with little relationship to whether the challenge persists. Following this logic, national governments will take up or abandon commitments to fighting AMR based on specific political benefits and opportunities that they face domestically and internationally.

The paper relies on several types of evidence that illuminate long-term commitment to the global AMR policy process, including survey and text analysis. It analyses how many countries claim they intend to renew their NAPs, how many have renewed expired NAPs, and progressions in substance from initial NAPs to subsequent ones. It also reviews a growing literature on national-level policymaking against AMR after countries publish NAPs.

The main finding is that in the choice between sustaining and terminating international AMR policy process commitments, countries have tended to sunset their commitments by allowing their NAPs to expire. Most countries with time-limited NAPs did not renew them when their terms ended. The NAPs that have been renewed often show few links to the experiences and results of the initial NAPs. Moreover, the paper summarises the literature on NAP-related policymaking (so-called ‘NAP implementation’; not to be confused with policy implementation), indicating that many governments have struggled to move beyond the very general strategy expressed in their NAPs. These different kinds of information tend to concur that national commitments to the international NAP policy process are declining. Hence, the global policy process against AMR appears to depend more on domestic political contingencies than on problem-driven decision-making.

The next section outlines the global success in creating momentum against AMR through the 2015 Global Action Plan (GAP) and the subsequent widespread publication of NAPs in more than 170 countries. The section also reviews the burgeoning literature on the subsequent difficulties many countries have faced with NAP-based policymaking. The paper then outlines expectations about longer-term commitments to the AMR GAP–NAP process, followed by methods for assessing them and a discussion of different related analyses and propositions. Finally, the paper analyses evidence relevant to these propositions and discusses findings and conclusions.

National commitments to the international policy process against AMR

AMR is a useful case for developing insights about long-term national commitments to international policy processes aimed at combating persistent crises. AMR persists over time and, hence, demands long-term political commitment (Baekkeskov et al., 2020; Gradmann & Kirchhelle, 2023). AMR undermines antibiotic-based medical treatments, and the World Health Organisation (WHO) estimates that infections from resistant bacteria alone are causing 1.3 million deaths annually (WHO, 2023a). The UN reports worst-case projections of 10 million deaths per year by 2050, a cost to the global economy of $100 trillion, and millions of people forced into extreme poverty (UN News, 2019).

In 2015, WHO, the United Nations Food and Agriculture Organisation (FAO), and the World Organisation for Animal Health (WOAH) jointly developed and issued a GAP on AMR (WHO, FAO, & WOAH, 2015). The UN Environment Program (UNEP) later joined the group, now known as ‘the quadripartite’. The GAP was adopted by the World Health Assembly on 26 May 2015 (World Health Assembly, 2015). One of the key items in its resolutions was that each member state should develop a NAP modelled over the GAP. By November 2023, 176 member states had reportedly developed NAPs (WHO, 2024). In addition, most UN member states annually respond to the quadripartite's AMR Country Self-Assessment Survey (TrACSS) on NAP-based policymaking (FAO, UNEP, WHO, & WOAH, 2023). This annual survey asks countries to report whether they have developed a NAP, what it includes, how ‘implemented’ it is (i.e., whether specific national policies and practices have been aligned with it), and whether countries plan to revise and renew it.

International policy processes rarely enjoy such strong support from national governments. Commitments to the UN initiative on Women, Peace and Security (UN Security Council Resolution 1325), for example, were much more modest, with only 11 national action plans having been developed four years after the call in 2004 (Fritz, 2009). Another UN policy initiative in 2014 to develop national action plans to further the implementation of the UN Guiding Principles on Business and Human Rights also appeared to have limited member-state commitment, with just 21 plans within the first four years (Morris et al., 2018). More than 40 countries never signed the Rome Statute of the International Criminal Court, and some signatory countries (including the USA, Israel, Russia, and Egypt) did not ratify it (Council on Foreign Relations, 2023). By most standards, this global initiative to develop NAPs must therefore be characterised as highly successful.

The 2015 GAP on AMR promoted five strategic objectives: (i) improve awareness and understanding of antimicrobial resistance through effective communication, education, and training; (ii) strengthen the knowledge and evidence base through surveillance and research; (iii) reduce the incidence of infection through effective sanitation, hygiene, and infection-prevention measures; (iv) optimise the use of antimicrobial medicines in human and animal health; and (v) develop the economic case for sustainable investment that takes the needs of all countries into account, and increase investment in new medicines, diagnostic tools, vaccines, and other interventions (WHO, FAO & WOAH, 2015). In turn, most AMR NAPs adopted similar objectives (Munkholm & Rubin, 2020). The meaning of this similarity remains ambiguous and possibly results from isomorphic mimicry (Munkholm & Rubin, 2020). However it does suggest congruence within the process linking GAP and NAP developments; that is, national governments took a relatively coordinated approach to meeting the global AMR challenge through the GAP–NAP process.

However, the great success of the international GAP–NAP process has yet to be followed by the widespread creation and adoption of national policies targeting AMR beyond NAPs themselves. AMR-focused literature often labels this ‘NAP implementation’ (referring to countries aligning domestic policies and practices with their NAPs, rather than conventionally understood policy implementation) (IACG, 2019; WHO, FAO & WOAH, 2021). As of the 2023 TrACSS survey, 166 of 178 self-reporting member states had created NAPs, but just 49 indicated having moved beyond government approval for the NAP to planning for costs and other mechanisms (FAO, UNEP, WHO, & WOAH, 2023, question 2.3). The next section reviews the scholarship on how AMR NAP-based policymaking developed after 2015.

Difficulties in aligning domestic policies and practices with NAPs

Concerns about NAP-aligned policy have triggered numerous academic studies of the extent to which NAP design and development have adhered to the GAP and how NAP implementation has proceeded. These studies have focused on three different levels of aggregation: (i) national, (ii) regional, and (iii) global.

Nation-level studies have usually included in-depth investigations based on qualitative interviews focusing on the challenges of implementing the recommended GAP objectives in specific national contexts. Many such studies have analysed NAP design and policymaking in lower – and middle-income countries (LMICs), which are generally crucial to the global fight against AMR. For instance, through 48 interviews of key stakeholders involved in NAP policymaking in Pakistan, Khan et al. (2020) identified that the objectives and corresponding actions represented in Pakistan's NAP were disconnected from actual practices; local political contestations and power plays hampered policy development. Hein et al. (2022) relied on 13 semi-structured expert interviews to identify that lacking financial resources and integration of AMR policies into the Ghanaian health system were the main impediments to more comprehensive policymaking based on Ghana's NAP. In Tanzania, Frumence et al. (2021) interviewed 111 key informants from the national, district, and health facility levels. They concluded that Tanzania's NAP policymaking suffered from inadequate resources, such as insufficient funding for research or for monitoring progress (Frumence et al., 2021). Similarly, in Bangladesh, Ahmed et al. (2022) found that policy development was constrained by a shortage of trained health workers and inadequate financial resources. Nair et al.'s (2021) study of NAP policymaking in India echoes these findings, identifying lacking financial allocations across states, poor enforcement, and inadequate multi-sectoral coordination as key barriers to achieving India's NAP objectives. Also in India, the prospective regulation of drug production effluents in ‘upstream’ European markets is promising to press producers to clean up production; but national regulation has proven difficult to achieve (Chaturvedi & Kavalakkat, 2023; Mitkidis, 2023). In some African countries, little funding has been forthcoming for realising any of the ambitions of their NAPs (Mpundu et al., 2023). At the regional level, Fuller et al. (2022) relied on data from 20 African countries collected at a 2019 lessons-learned workshop. They found that very few countries in the region appear to have positioned AMR at the highest political level (Fuller et al., 2022). Likewise, Harant (2022) focused on 15 African countries, finding that while most had developed NAPs, policymaking progress was often hampered by inadequate funding allocations.

High-income countries have also faced NAP-related policy challenges. For instance, an analysis of the Australian NAP development process found evidence pointing to political apathy towards AMR and an absence of strategic objectives (Do et al., 2023). The study concluded that while ‘the conceptualisation of strategic vision is necessary, in the current state it is an idealistic hypothetical’ (Do et al., 2023). A comparison of the Australian and British NAP policy processes showed a clearer policy path towards change in the UK due to stronger political mandates (Hannah & Baekkeskov, 2020). At the regional level, Carelli et al. (2023) analysed 27 European NAPs. They found that lower-income countries in the region showed stronger tendencies to emulate the GAP, whereas higher-income countries to a larger extent set their own higher targets and comprehensive strategies independently of the global standards (Carelli et al., 2023). More recently, some of the authors have also analysed 13 updated NAPs in Europe, highlighting an increased focus on One Health and coordination issues in the subsequent NAPs but nevertheless concluding that ‘AMR program development today appears to be driven more by nation states and less by international institutions’ (Carelli et al., 2024, p. 5). Özçelik et al. (2022) combined manual qualitative reviews with natural-language-processing techniques to analyse 21 NAPs from OECD and G20 countries. They found strong alignment between the strategic objectives set out in the GAP and those in the 21 NAPs (Özçelik et al., 2022). Similarly, Chua et al. (2021) found that 10 Southeast Asian NAPs were all well-aligned with the GAP, although the study also concluded that the NAPs required more attention to accountability mechanisms, international collaboration, and the environmental sector (Chua et al., 2021).

For the global level, studies have focused on comparisons of the GAP–NAP links between many countries and regions using quantitative content analyses. Munkholm and Rubin (2020) developed indicators to proxy for NAP policy alignment with the GAP and with other NAPs within regions. They found that, among WHO member states, lower income was associated with greater similarity between NAPs and GAP. In particular, NAP and GAP objectives in poorer countries tended to be worded very similarly, while actions mentioned for achieving these objectives were somewhat similar. Charani et al. (2023) analysed 108 NAPs to assess how well they tackled AMR in the human population. Their systematic review focused on six key domains, such as policy and strategic planning, AMR monitoring, and antimicrobial prescriptions. One key finding was the limited ability of countries to progress from strategies on paper to policy action. The authors concluded that successful NAP implementation would require policymakers and stakeholders with clearly defined roles and backed by financial commitment and political power (Charani et al., 2023). Patel et al. (2023) analysed 114 NAPs by having three researchers independently review and score all of them across multiple dimensions of governance. As in the smaller-scale studies described previously, this review found little tangible budgetary and other support for NAP implementation. Willemsen et al. (2022) manually reviewed 78 NAPs to identify frequently used terms and keywords that would indicate alignment with the five objectives in the GAP, which they related to national GDP levels. The study found no relationship between alignment and GDP. For instance, Belgium, Canada, and Denmark were placed near the bottom in terms of alignment, while Laos, Palestine, and Zimbabwe were all near the top. However, LMICs placed greater emphasis on the need for human and financial resources (Willemsen et al., 2022).

Overall, these studies of NAP policymaking in various forms reveal that many countries have experienced difficulties in progressing from creating NAPs to making aligned national policies or changing local practices. Many poorer countries have paid lip service to the international GAP–NAP process but have yet to dedicate legislative mandates, resources, or organisations to policymaking and practical changes capable of realising the ambitions expressed in their NAPs. Many richer countries have participated in the GAP–NAP process but have forged their own courses even in how they have articulated their NAPs.

Clearly, the international GAP–NAP process enjoyed immense success in converting global agreements into national planning. Equally, pervasive national planning has thus far not meant consistent or deep changes in domestic policies and practices that affect AMR. Some scholars have called this a commitment–compliance gap (Tejpar et al., 2022), the gap suggesting that sustaining the global push to develop plans against AMR is crucial and necessary (albeit insufficient) for mitigating AMR. Without pervasive national commitments to creating and sustaining NAPs, the prospect of real action against AMR seems less likely in many countries.

Termination or continuity – NAP expiry dates as sunset clauses or learning opportunities?

The broad range of studies reviewed here has mainly addressed the short-term national government work in the wake of the international GAP–NAP process. This existing body of evidence points to a substantial discrepancy between, on one hand, the demonstrated engagement of most countries in the international policy process to address AMR in the 2015–2020 period and, on the other hand, national policymaking during the same period directed against AMR within countries (referred to in related reporting as ‘NAP implementation’). Sustained national government commitment to global policy development addressing AMR remains as relevant as ever because AMR persists as a major global challenge. Yet, there is so far little scholarship on longer-term national commitments to the international GAP–NAP process.

Why would something as important as a national strategy to address a persistent or growing threat to human society have an expiration date? End dates for policies or strategies might promote evaluation and revision cycles; hence, creating new ones that improve upon their predecessors. That is, end dates could be intended as opportunities for systematic learning from the experiences of using the initial strategy or policy (cf. Dunlop & Radaelli, 2018). They could be part of explicitly designing for policy succession (Hogwood & Peters, 1982; Turnhout, 2009), where initial policies to address a persistent problem are replaced by policies informed by and modified according to lessons learned.

Alternatively, end dates are potentially designed for systematically terminating national commitments to addressing an issue. A review of policy termination studies in the public policy and administration literature observes that such studies burgeoned after the Carter administration in the USA introduced a slew of ‘sunset legislation’ designed to operate only for a limited time (Greenwood, 1997, p. 2125). While not the norm for legislation, such sunset clauses are often used for emergency rules (Kouroutakis, 2016). They signal a defined end to a government's commitment to implement that set of policies. Hence, having an end date for a policy or strategy allows governments to set it aside, subtly terminating their commitment to addressing the underlying issues. When a NAP has an end date, the possibility of sunsetting the real commitment to fighting AMR clearly exists. Even if such termination is never declared, it can become a reality. The end date then provides an easy exit for a government uninterested in sustaining its commitment to the GAP–NAP process.

Why would a government want to have an AMR NAP with a sunset clause? Describing every possible answer to this question is beyond the scope of this paper (we return to some possibilities in the conclusion). We generally assume that political contingencies provide the answer; political gains and losses for the ruling government could explain the sunsetting of commitments to persistent crises. A temporary strategy allows governments to test their political gains from addressing the issue. They can assess whether the strategy matters to voters or key stakeholders, or if constituents reward the government at the polls or in policy negotiations for adopting the strategy. If the strategy yields gains, then renewing the strategy promises further gains. If not, then sunsetting the strategy and prioritising other policy initiatives holds greater promise. In addition, an expiration date allows a strategy or policy to terminate without active effort to scrap it. Such subtlety may reduce any political risk to the government by avoiding public or parliamentary debate about the underlying issue. Finally, for AMR in particular, the 2015 World Health Assembly declaration on the GAP committed signatories to create AMR NAPs. Countries promised to create NAPs, and the WHO and its partners exercise soft power by keeping track of whether that promise is fulfilled. Yet no deep political commitment to effective domestic policymaking against AMR was required for a country to issue a NAP. In effect, having a NAP expiry date allows countries to minimise messy political debate and quietly drop their commitments.

The alternative logics for how to renew national policy or strategy yield two alternative expectations for whether and how countries are committed to the international GAP–NAP policy process (see Table 1).

Table 1. Short- and long-term commitments to the GAP–AMR policy process.

Short-term record (2015–20)	Longer-term expectations (2020 and onward)
More than 170 member states develop NAPs 95% of WHO member states respond to annual NAP self-assessment surveys.	Learning: sustained national commitments (continuity is more common than termination) OR Sunsetting: declining national commitments (continuity is less common than termination)

One is a ‘learning’ expectation: The AMR threat remains undiminished globally, so long-term commitment to policies against AMR would be logical if most countries are interested in mitigation. This long-term commitment would mean that countries would sustain their engagement in the GAP–NAP process and progress by learning from past experiences and refining their NAPs. Hence, they would renew their NAPs upon expiration, explicitly crafting the new ones on the lessons learned from implementing their old NAPs.

The alternative is a sunsetting expectation. In the wake of many NAPs being created, governments have often not prioritised AMR in their domestic policymaking (reviewed previously); that is, the AMR cause offers no political gains for governments in many countries. Hence, governments doing less on the global stage against AMR could follow, because the political consequences for those governments terminating activity would be few to none. The logical expectation would then be for countries to disengage from the international GAP–NAP policy process after delivering an NAP as promised in international forums. Hence, they would allow their NAPs to expire without being renewed, or they would do little to learn from their previous NAPs if they do publish new ones.

Are these longer-term expectations being met? The next section presents a methodology and specific indicators of whether the learning or sunsetting expectations for the longer-term global fight against AMR are better supported.

Are national commitments to the international GAP–NAP process declining or being sustained? Methods and propositions

The international policy process against AMR is useful for broadening understanding of policy termination and continuity beyond purely domestic policymaking.I AMR is also a crucial case for campaigns to raise persistent crises to global political attention because of its strong short-term success in setting national agendas (described previously). The widespread use of AMR NAPs initially suggested unusually pervasive national commitments to the international GAP–NAP process. If this global response to AMR successfully sustains its hold on many countries’ commitments, then the current global approach to AMR could be a model for responses to other pervasive and persistent crises. As described, this would fit well with the general understanding from public policy theories that policy continuity is the norm. Conversely, if the GAP–NAP process fails to hold on to national commitments, then the difficult process of successfully raising a persistent crisis to the centre stage of international politics is insufficient for effective global responses. As described, this would show that policy termination can be the norm in policy circumstances such as those facing the global fight against AMR.

Measuring long-term national commitments to international policy processes is complex. In their paper on indexing political commitment, Lassa et al. (2019) note how the exercise of measuring political commitment quantitatively is best approached indirectly by developing multiple proxies for commitment. To assess the expectations presented previously, the study has developed four proxies for national commitments to the global GAP–NAP process, which rely on a variety of data (all data can be accessed as a supplementary file). This section presents these data and offers three propositions about how analyses indicate support for one of the expectations or another (see Table 2). The basic methodological approach is triangulation. The robustness of the findings is strengthened by having different proxies, each with its own composition and data weaknesses, point in the same direction.

Table 2. Three propositions and indicators.

Proposition	Indicator(s)	Interpretation
1: Expressed national intention to renew NAPs	Share of WHO Member States responding ‘yes’ on 2022 (N = 166) and 2023 (N = 177) TrACSS questions about NAP renewals (0–100%).	A high share of intending renewals indicates the sustained commitment to the GAP–NAP process (learning). A low share indicates many terminated commitments (sunsetting).
2: Actual national renewal of NAPs	Number of renewed NAPs as a share of the number of expired NAPs (0–100%). N = 150 NAPs in the WHO collection.	A high share of expired NAPs being renewed indicates a sustained commitment to the GAP–NAP process (learning). A low share indicates many terminated commitments (sunsetting).
3: Refinement of subsequent generation of NAPs Based on overlaps with the GAP Based on first-generation NAPs	Percentage of verbatim overlap between the 2015 GAP, first-generation, and later-generation versions of the NAPs. N = 33 NAPs Links between the different editions of NAPs assessed by two analysts; score from 1 to 5 (no link–strong link). N = 33 NAPs.	A decrease in overlap suggests learning and adaptation. No change or increasing overlap suggests the absence of learning, and hence, support for sunsetting. Higher scores indicate stronger continuity between NAP generations, suggesting more sustained commitment (learning). Lower scores suggest weaker commitment (sunsetting).

One crucial source of evidence about longer-term commitments to the global GAP–NAP process is how countries are behaving at the emerging moment of inflection created by the expiration of many NAPs published shortly after the 2015 GAP. Many of the first-generation NAPs had 4- or 5-year terms. Hence, many of these initial plans have now expired or will do so soon. Countries with expired NAPs have needed to develop and approve new ones to still have NAPs with current terms, which offers opportunities for insight. Are countries creating new NAPs or are most letting them lapse? Two types of data on this are now becoming available.

Firstly, starting in 2022, the previously described TrACSS survey has asked countries: ‘if the national AMR plan has/is about to expire, is the country in the process of revising the national AMR action plan or developing a new one?’ (FAO, UNEP, WHO, & WOAH, 2023). This indicates whether countries express an intention to renew their NAPs. Hence:

Proposition 1: A high share answering ‘yes’ to the question would indicate support for the learning expectation (that continued commitment to the global process is more common); a low share would support the sunsetting expectation (that terminated commitments are more common).

Secondly, the present study has considered all actual NAPs uploaded to a WHO-hosted online depository (WHO, 2023b). Several studies have pointed out inconsistencies and methodological difficulties with self-reporting survey data, including TrACSS (Harant, 2022; Munkholm & Rubin, 2020). Hence, additional data are relevant to bolster indications from how countries have answered the renewal question above. Data gleaned from the WHO NAP collection include the period covered by each NAP (if specified) and whether expired NAPs were supplemented by new editions on the WHO website. Comparing the number of expired NAPs to the number of renewed NAPs offers a second indicator of the extent of national commitments to the GAP–NAP process. Hence:

Proposition 2: A high number of renewals compared to expired NAPs would indicate support for the learning expectation (continued commitment to the global process is more common); a low number of renewals would support the sunsetting expectation (terminated commitments are more common).

Thirdly, turning to the few second-generation NAPs produced, one can gauge whether they appear to reflect learning or sunsetting dynamics. If subsequent generations of NAPs are refined based on the specific country context and/or experiences with the implementation of the first-generation NAP, then this would suggest a propensity for learning. If countries appear to be refining their NAP, then it seems fair to assume that they do so based on a long-term commitment to addressing AMR.

Proposition 3: Clear refinements of subsequent NAPs support the learning expectation that a country is sustaining its commitment to the GAP–-NAP process. Conversely, limited refinements support the sunsetting expectation that commitment is weak.

The refining of subsequent generations of NAPs relies on two different measures, both based on an analysis of the next-generation NAPs that have been uploaded to the WHO website as of August 2023 (16 countries; N = 33 NAPs).

The first measure captures the extent to which the country's second NAP is similar to the 2015 GAP. The GAP was written as a general set of guidelines for all countries to follow, meaning that it focused on common global challenges rather than the specific AMR drivers in national contexts. As NAPs are refined over time, we would expect them to be increasingly differentiated and adapted to the specific contextual drivers of AMR; that is, next-generation NAPs should generally overlap less with the 2015 GAP than the first-generation NAPs. Thus, the first measure captures the extent to which later generations of NAPs overlap with the GAP. The study uses the text similarity analysis pioneered by some previous analyses referenced above. Using software originally developed to detect plagiarism, Munkholm and Rubin (2020) measured the degree of verbatim overlap between first-generation NAPs, and then between these NAPs and the GAP. Using the same tool (Plagiarism Checker X, version 8.0.12), the present study focuses on capturing the verbatim overlap between first- and second-generation NAPs, and between these NAPs and the GAP. Learning would suggest that next-generation NAPs would be less similar to the GAP than first-generation NAPs. Conversely, if next-generation NAPs are as similar to the GAP as first-generation NAPs or more, then no NAP refinement is evident, which supports the sunsetting expectation.

The second measure captures the extent to which next-generation NAPs learn from and build further upon earlier generation(s) of NAPs. Qualitative comparisons of the present and previous versions of countries’ NAPs were conducted separately by two analysts. Based on the qualitative review, both analysts also scored each next-generation NAP (1–5) to indicate the degree to which it builds on the earlier version(s) and thus reflected learning. These assessment scores were applied as follows: 1 → no mention of the previous NAPs; 2 → mentions of previous NAPs but with no reference to monitoring and evaluations of previous NAP interventions; 3 → mentions of previous NAPs but with limited reference to monitoring and evaluations of previous NAP interventions; 4 → discussion of monitoring and evaluations of previous NAP interventions; 5 → discussion of monitoring and evaluations of previous NAP interventions together with an outline of a concrete strategy for how to build on the first. To assess intercoder reliability, Cohen's Kappa test was used to assess the extent to which the two analysts assigned the same scores across the NAPs. With a score of 0.95, the measures indicate strong alignment between the analyst scoring of the connections between old and new NAPs. The scores disagreed on three NAPs, but by just one point for each. Scores have been averaged in the results table (Table 5). Finally, the analysts wrote and merged brief qualitative reviews in a consultative process that reflected the agreed score (appendix).

Findings: national longer-term commitments to the GAP–NAP process

To assess temporal commitment to the GAP–NAP policy process and its global extent, this section analyses the previously described evidence from the emerging record on NAP renewals. It focuses on the three propositions presented in the previous section.

Focusing on propositions 1 and 2, how in aggregate are countries proving to sustain or terminate commitments to the GAP–NAP process?

Firstly, as described, the TrACSS survey question 2.3. as asked: ‘If the national AMR plan has/or is about to expire, is the country in the process of revising the national AMR action plan or developing a new one?’ (FAO, UNEP, WHO, & WOAH, 2023). In 2022, 109 countries answered ‘yes’, and 57 countries ‘no’; that is, roughly 34% of the 166 countries reporting on their NAP progress did not intend to renew their NAP. In 2023, 133 answered yes and 44 answered no, so about 25% of the 177 responding countries appear to be uncommitted to the NAP-updating policy process. The subjective self-reporting data offers some support for the ‘learning’ expectation in proposition 1. An argument could be made that 75% of intent to renew is high, particularly because the yes-country number has increased since 2022. However, having 25% of the countries explicitly self-reporting that they are not in the process of renewal (and have no plans to) is substantial, particularly because these types of subjective self-reporting surveys may suffer from social desirability bias (answering what they think the WHO and other UN organisations want to hear). Thus, while the responses seem to be moving towards greater commitment, the number of countries intending to renew NAPs remains well below the 166 reporting that they created NAPs in the first wave.

Secondly, the previously described WHO NAP collection includes first-, second-, and later-generation NAPs from most WHO member states. This enables scrutiny of whether new NAPs really have been written when old NAPs expire, and how they differ from the first generation. In terms of actual renewals on record, there has thus far been fewer than the survey data suggests. The online WHO library contains 150 NAPs from a total of 134 countries (as of late 2023). That is, some countries now have second- or even third-generation NAPs on record. This permits a more detailed analysis of how countries are really progressing in their national planning around AMR (Table 3).

Table 3. Number of countries with renewed and expired NAPs.

WHO Region	Total plans	Renewed	Expired	Net-expired	No expiration date
AFRO	36	3	13	10	5
AMRO	14	1	6	5	4
EMRO	20	0	7	7	8
EURO	42	6	26	20	6
SEARO	12	1	10	9	1
WPRO	26	4	10	6	2
Total	150	15	72	57	26

While most NAPs have a clear expiration date, 26 of the 150 NAPs in the WHO collection do not. NAPs that do not expire remain static plans rather than dynamic documents that allow for updating, but they may still signal an ongoing national commitment. In addition, 51 NAPs have an end date of 2023 or later, meaning that renewal may not yet have been recorded (as of this writing in early 2024). So, for 75 NAPs in the collection, sustained national commitment remains plausible.

The collection also includes 72 NAPs from 70 countries that expired in 2022 or earlier. In turn, it includes 16 s- or third-generation NAPs; that is, of the 134 countries represented in the collection and of the 70 with expired plans, just 16 have renewals on record. This means a 23% renewal rate among countries with expired plans, which is significantly lower than the 66–75% renewal rate that the previously described survey results would suggest. Hence, following proposition 2, this indicator of actual behaviour suggests stronger support for the sunsetting expectation: that longer-term national commitments to the GAP–NAP process are declining.

The results of the analyses for propositions 1 and 2 point in the same direction. While there is room for optimism when considering the TrACSS results, where countries profess their intention to renew NAPs, the number of countries responding that they do not intend to renew their NAPs arguably remains substantial. A sunsetting trend is particularly evident when examining the actions countries have taken, represented by the collection of NAPs. Less than one-fourth of countries with expired NAPs have actually renewed them. Hence, in aggregate, countries are showing declining longer-term commitment to the global process for combatting AMR.

The third and final proposition relates to whether the contents of renewed NAPs indicate refinement from earlier NAPs.

A measure to distinguish whether later-generation NAPs represent contextual adaptation and refinement from first-generation NAPs is the extent to which they overlap with the 2015 GAP. Table 4 shows the results of text similarity analyses for each country with two generations of NAPs in the WHO collection. Overall, there does not appear to be a decline in the NAP–GAP verbatim overlap. Around 8% of both first- and second-generation NAPs contain phrases or sentences that are identical to the GAP. The evidence thus suggests that there is not a substantial movement away from GAP phrases and sentences in the second-generation NAPs, as one would have expected if the NAPs increasingly adapted to the country-specific circumstances over time. This lends some support to the sunsetting expectation regarding commitment to the GAP–NAP process; not only are few countries renewing their NAPs, but the renewed NAPs display the same semantic overlap with the GAP as the first generation.

Table 4. Verbatim overlap between the 2015 GAP, first, and subsequent NAPs.

Country	First NAP/GAP (%)	Second NAP/GAP (%)
Austria	13	8
Belgium	9	5
Cameroon	3	11
China	2	4
Czechia	5	2
Ethiopia	11	9
Fiji	9	8
France	4	4
Indonesia	9	17
Ireland	11	14
Japan	11	10
South Korea	2	3
Mongolia	9	3
Portugal	10	1
Tanzania	18	17
USA	6	6
Average	8	8

Focusing on the learning potential between the different generations of NAPs, two analysts have independently read and scored each of the 17 renewed NAPs from the 16 countries on a 1–5 scale (one country, Ethiopia, had renewed their NAP twice). As described, the score of 1 represents no explicit refinement from first to second NAPs, while 5 represents strong evidence of refinement (see Appendix 1 for the description of each comparison).

The in-depth readings of the existing later-generation plans reported in Table 5 again offer a mixed picture of country-level commitments to the GAP–NAP policy process. This detail reveals nuance in how clearly countries’ AMR strategies have developed between their successive NAPs. Several new NAPs have explicit links to those that preceded them (see also Appendix 1). However, many have little or no clear link to the previous NAP, suggesting that little learning has occurred over the time that the countries have approached AMR through the GAP–NAP framework. Working from the average of the scores assigned by our two analysts, in the aggregate, the scores average 3.2, indicating some explicit but superficial connections between the first and later NAPs. In fact, just six countries scored four and above, suggesting that of the 176 countries initially producing an NAP, only these six countries have explicitly developed new NAPs based upon national achievements in the initial round of NAP implementation. This lends strong support to sunsetting.

Table 5. Refinement between first and subsequent NAPs (analyst scores).

Country	Analyst 1	Analyst 2	Average
Austria	3	3	3
France	3	3	3
Belgium	2	3	2.5
Cameroon	2	1	1.5
China	2	2	2
Czechia	2	1	1.5
Ethiopia	3	3	3
Fiji	4	3	3.5
Indonesia	2	2	2
Ireland	5	5	5
Japan	5	5	5
Korea	5	5	5
Mongolia	4	4	4
Portugal	1	1	1
Tanzania	5	5	5
USA	4	5	4.5
Average	3.3	3.2	3.2

Discussion and conclusions: how to explain declining long-term commitment to AMR and ideas about re-engagement?

This paper has focused on the international GAP–NAP process to fight AMR. This analysis contributes to the wider public policy literature on policy termination or continuity by describing a case where termination is the dominant trend. This finding contrasts with the conventional understanding from studies of policy termination, which is that policy continuity is most likely. In practical terms, the GAP–NAP process is testing whether engaging international organisations and high-level political forums is sufficient for generally creating long-term national commitments to persistent crisis response. The initial apparent enthusiasm among national governments for fighting AMR was expressed by the prolific production of AMR NAPs in the years following the GAP in 2015. These commitments have generally proven not to be sustained when countries need to decide whether to renew NAPs, however. Hence, the prospects for other global fights against persistent crises are dim. Securing broad international backing for responses is a necessary step, but may only set national political agendas for a short period. As policy process frameworks for understanding domestic policymaking suggest (e.g., Baumgartner & Jones, 2010; Kingdon & Stano, 1984; Sabatier, 1988), more and different international steps are perhaps needed to create longer term policy commitments. This final section discusses some possible explanations for the decline in national commitments to the international GAP–NAP process, and ideas about how to re-engage national governments in the global AMR fight.

Analysing the renewal of NAPs against AMR indicates that the number of countries maintaining their early commitments to the GAP–NAP policy process is declining. The subjective evidence did suggest some commitment to the global AMR policy process (66–75% of self-reporting countries answered that they plan to renew). However, our analysis of actual NAP renewals suggests that sunsetting is better supported. Of 70 countries with expired NAPs in the WHO online database, just 16 have renewed plans. Further, many of the renewed NAPs show little or no indication of refinement from the preceding NAPs. The overall pattern, therefore, is sunsetting: National commitments to the GAP–NAP process appear to be declining. Hence, a longer-term global commitment to combatting AMR is not in evidence.

Combatting AMR is therefore not merely a question of lacklustre activity to align domestic policies and practices with NAPs. This paper has shown that long-term national commitments to the international GAP–NAP policy process are also low. In 2018, the UN Interagency Coordination Group concluded that the greatest challenge is not writing national action plans on AMR but rather implementing them and demonstrating sustained action (IACG, 2018, p. 2). Six years later, writing new NAPs has also become a challenge. Borrowing a concept from the Hogwood and Peters (1982, p. 239) paper on policy succession, the NAP policy process appears to have been subjected to partial termination, referring to a substantial reduction in the resources committed to a given programme.

What explains this development, and what can be done to re-engage national governments in the fight against AMR? While answering these questions deserves a longer analysis than this paper can encompass, we can nevertheless offer some possibilities using available evidence and recent arguments.

Firstly, some analyses of ‘NAP implementation’ (i.e., domestic efforts to align policies and practices with NAPs) have suggested that national capability and capacity are crucial issues (Anderson et al., 2019; Mpundu et al., 2023; Neale & Cullen, 2024). The approach implies that less national capacity correlates with less national commitment to the GAP–NAP process. Notably, most countries have demonstrated capacity by developing NAPs. However, the capacity claim deserves closer scrutiny. If we proxy capacity by wealth, countries indicating in the 2022 TrACSS survey that they planned to renew their NAPs were not significantly wealthier than those saying they would not renew (GNI per capita (PPP) 2022).² Nor were their health expenditures per capita significantly higher. Hence, reduced capacity seems unlikely to be driving commitment to the GAP–NAP policy process. Capacity is no doubt essential to fighting AMR. In most cases, however, an important first step (necessary condition) is to ensure that governments sustain their commitments to the international GAP–NAP policy processes. Re-engaging national governments by encouraging them to renew their NAPs certainly is feasible because lower capacity has not hindered such engagement in the past.

Fox et al. (2011, p. 2) note that one challenge when measuring political commitment is ‘the question of how to know whether a leader is genuinely committed to a policy platform or is feigning commitment for strategic reasons or under pressure from external forces.’ The findings of this paper suggest that short-term commitment to the GAP–NAP process might have resulted more from international pressure than genuine national commitment. Downs (1972) introduced the issue-attention cycle to crises with slow onsets, such as AMR. The cycle consisted of five steps: (i) the pre-problem stage, (ii) alarmed discovery and euphoric enthusiasm, (iii) realising the significant cost of progress, (iv) the gradual decline of intense public interest, and (v) the post-problem phase: the twilight realm of lesser attention. Our analysis of the falling commitment to the GAP–NAP policy process suggests that public and political attention may not initially have been high. It is unlikely that the AMR issue has the necessary gravitas to drive strategic commitment independently in many countries amidst the many other health and related challenges facing them. In LMICs, for example, many more people die from limited access to antibiotics than from AMR (Rochford et al., 2018). Thus, for most countries, the NAPs were never written with euphoric enthusiasm or due to alarmed discovery but more probably to fulfil promises made in an international process led by core UN agencies. Political gains linked to intensive public interest and attention never existed. The issue of where to locate and how to mobilise domestic political gains from (re-)engaging with AMR seems to be an important puzzle for long-term response.

Secondly, and relatedly, as with other public issues (Baumgartner & Jones, 2010; Kingdon & Stano, 1984; Sabatier, 1988), political attention and follow-through on AMR depends on the turns of national politics. Hence, while AMR has a lengthy history as a global health issue of concern, it only rose to political prominence between 2010 and 2017 (Gradmann & Kirchhelle, 2023; Rubin & Baekkeskov, 2023). As previously described, this was followed up in subsequent years by more than 170 countries publishing NAPs. This global agenda-setting success was probably a result of significant policy entrepreneurship from a small number of well-placed health officials (Podolsky, 2018; Rubin & Baekkeskov, 2023). But for AMR to remain an important national priority in so many countries, policy-entrepreneurial efforts must occur repeatedly. This probably requires a much broader advocacy coalition of NGOs, private businesses, popular movements, political parties, and government and international organisations than AMR currently commands, perhaps in the mould of how climate change-related advocacy is organised (Rubin & Baekkeskov, 2023; Zaman et al., 2024). Building-wide and deep advocacy coalitions around AMR could at least partly solve how to mobilise political gains for AMR responses.

Thirdly, continual political attention matters because AMR is a persistent and global challenge to modern healthcare and food security. After all, microbial evolution does not stop because governments adopt new priorities, and microorganisms can and often do spread across political borders despite containment efforts. In fact, AMR could accelerate if national authorities grow (even more) lax in their antibiotics and antimicrobial stewardship. This structural condition – the enduring, global, and ever-lurking threat to medicine and food security – is difficult to manage for any political system. However, as the wider public policy literature we have evoked here on policy termination and continuity often shows, long-term challenges have been met many times before in politics by long-surviving policies and programmes. Government or legally codified programmes and institutions exist across a broad range of public threats and keep working to mitigate enduring public problems (e.g., fire departments, national defence, social and healthcare programmes). So, beyond ongoing advocacy, re-engaging governments should be about establishing the kinds of drivers that have often made policy terminations difficult. Hence, the task is to institutionalise effective AMR mitigation, and create vested interests that protect such policies (cf. Hall & Taylor, 1996; Moe, 2015). The hope in generating institutions and vested interests would be that the path-dependency so often associated with these would help to maintain policy commitments to the long-term struggle against AMR. At the global level, repeatedly and routinely renewing the GAP in itself might be an option for re-engaging political leaders around the world. Continuous global-level renewal could re-establish the momentum of the 2015–2020 period.

This study points towards further important research. Persistent global crises such as AMR need persistent responses. The GAP–NAP process has demonstrated that global actors can generate a widespread commitment among key polities to strategise and respond for a period. Yet, this paper has shown how that commitment is declining. The long-term remains a concern, and the persistence of a crisis does not ensure the persistence of commitments from national governments to respond. More can be learned about how and why long-term commitments drop off or are sustained. Future studies should systematically theorise and assess such reasons.

Acknowledgements

We want to thank the three anonymous reviewers for their constructive and valuable comments. Mirko Heinzel and many other participants in an online workshop on AMR policy (May 23, 2023) also provided helpful comments on an earlier version of the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Erik Baekkeskov

Erik Baekkeskov is an associate professor in public policy at Melbourne University.

Olivier Rubin

Olivier Rubin is a professor of disaster research at Roskilde University.

Notes

1 AMR occurs naturally, developing through evolutionary biological processes. Species of microbes (e.g., bacteria, viruses, fungi) can develop resistance to antibiotics and other antimicrobials when exposed to them. A species starts out vulnerable, but when antimicrobials kill off many of its members, it adapts over successive generations as immune organisms survive and procreate, while vulnerable organisms die off. Consequently, after several generations, the resistant microbes predominate, meaning they can survive the antimicrobials that killed their ancestors. Increasing AMR thus renders vital medicines and chemicals ineffectual.

2 The average GNI per capita was USD 22,028 for the group of countries answering ‘yes’ to survey question 2.3.a (n = 104) and $19,988 for the group answering ‘no’ (n = 51). The difference in mean between the groups is not significant (independent t-test: [t(152) =  –5.76, p = 0.28]). The average health expenditures for countries answering ‘yes’ to survey question 2.3.a was $1,376 (n = 104) and $1,251 for the ‘no’ group (n = 54). Again, the difference in mean between the two groups is not significant (independent t-test: [t(156) =  –3.57, p = 0.36). Data extracted from World Development Indicators (World Bank, 2023).