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SSM - Qualitative Research in Health 4 (2023) 100332
Available online 9 September 2023
2667-3215/© 2023 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Between superimposition and local initiatives: Making sense of
‘implementation gaps’ as a governance problem of antimicrobial resistance
Maren Jeleff
a
,
1
, Christian Haddad
b
,
*
,
1
, Ruth Kutalek
a
a
Center for Public Health (Department of Social and Preventive Medicine), Medical University Vienna, Austria
b
Department of Science & Technology Studies, University of Vienna, Austria
ARTICLE INFO
Keywords:
Antimicrobial resistance
Antimicrobial stewardship
Public health policy
AMR mitigation
Institutional superimposition
Austria
ABSTRACT
Mitigating antimicrobial resistance (AMR) is a global imperative. Part of this effort is the translation of the Global
Action Plan into National Action Plans on AMR (NAPs-AMR). However, effective implementation of these plans
remains a governance challenge worldwide.
This study aims to explore the apparent implementation gap as a governance problem in Austria by examining
the situated perspectives of key experts and stakeholders involved in AMR-related policy and practice. Data were
collected through semi-structured qualitative interviews, a focus group discussion, and participation in various
symposia on AMR. Data analysis revealed key themes the experts have identied as decisive factors shaping AMR
governance, which they perceive as insufcient. These include: the absence of a binding legal framework,
incomplete and lacking AMR data, low risk perception, lack of funding mechanisms, and absence of an incentive
system for people working in AMR stewardship.
The interpretation of these ndings suggests policy fragmentation, scattered responsibilities, agenda confor-
mity and a lack of symbolic and material recognition as central features that impede a comprehensive, sus-
tainable and effective AMR-related governance. These insights highlight a tension between local efforts to
precipitate longer-term adaptations to prepare for and mitigate effectively AMR on the one hand, and the current
approach of ‘superimposing’ reforms onto existing institutional structures. Effective and sustainable measures to
address AMR require a fundamental restructuring process of institutional responsibilities, professional routines,
and social practices to prioritize AMR stewardship as a guiding principle.
1. Introduction
The therapeutic power of existing antimicrobial drugs is rapidly
waning, and with it, not only the pillars of modern health care but also
many domains of social and economic life enabled by antimicrobial
drugs. Antimicrobial resistance (AMR) refers to a multifaceted process in
which microbes, such as bacteria or fungi, progressively develop resis-
tance to those agents with which they could previously be effectively
treated (Nahrgang, Nolte, & Rechel, 2018; WHO, 2018; World Health
Assembly 2005). Recognized as growing concern for global health, AMR
has been listed by the WHO as the second major threat after climate
change (WHO, 2019b). Because of its multiple drivers and progressive
proliferation, AMR amounts to a pressing whole-of-society challenge
that requires urgent and coordinated global action (Baekkeskov et al.,
2020; Ghebreyesus, 2019; Hoffman et al., 2015; Podolsky et al., 2015).
While AMR is a global problem that disproportionally affects low
income countries of the so-called Global South (Pokharel, Raut, &
Adhikari, 2019), recent studies assessed that AMR poses a serious public
health problem also in the WHO European Region due to high rates of
resistance and mortality (Antimicrobial Resistance Collaborators, 2022;
European Antimicrobial Resistance Collaborators, 2022). This predica-
ment calls for comprehensive and coordinated stewardship programs,
understood as all the diverse processes of formulating policies and
strategies to deal with AMR (Rubin, 2019).
To tackle the evolution of multi-resistant pathogens, major UN-based
international institutions joined forces to develop a Global Action Plan on
AMR (GAP), which was issued in 2015 (WHO, 2015). Based on a One
Health framework, the GAP provides a blueprint for the creation of
National Action Plans on AMR (NAPs-AMR) with the aim of stimulating
policy diffusion in different countries and across key sectors. As of 2022,
* Corresponding author. Department of Science & Technology Studies, University of Vienna, Universit¨
atsstraße 7/Stiege II/6. Stock (NIG), 1010, Wien, Austria.
E-mail address: christian.haddad@univie.ac.at (C. Haddad).
1
M. Jeleff and C. Haddad have equally contributed to this article (shared rst authorship).
Contents lists available at ScienceDirect
SSM - Qualitative Research in Health
journal homepage: www.journals.elsevier.com/ssm-qualitative-research-in-health
https://doi.org/10.1016/j.ssmqr.2023.100332
Received 25 July 2023; Accepted 4 September 2023
SSM - Qualitative Research in Health 4 (2023) 100332
2
146 countries have issued NAPs-AMR (WHO, 2022a). However, despite
these achievements, there is growing testimony that the NAPs-AMR are
not fully translated into effective policies and action. The lack of pri-
oritization of the suggested measures and the reluctance to translate
them into national law and institutional processes was soon referred to
as the “implementation gap” and was framed as a problem that, in the
eyes of many actors and stakeholders, constitutes a key obstacle to
solving the global AMR crisis (Kirchhelle et al., 2020; Rubin, 2019;
Weldon & Hoffman, 2021; Wellcome, 2020; WHO, 2022b).
To counter the widening implementation gap, the WHO published an
Implementation Handbook for National Action Plans on Antimicrobial
Resistance targeting national and subnational stakeholders working on
AMR to help them “guide and accelerate sustainable implementation” of
NAPs-AMR (WHO, 2022b). Specically, it offers a step-by-step guide
that – fashioned similar to a policy cycle model – starts with questions of
governance, followed by guidance on policy prioritization, cost calcu-
lation, mobilization of resources, implementation in a concrete and
narrow sense and nally concludes with the monitoring and evaluation
of the policy process.
While the handbook serves as a template to support domestic
implementation of NAPs-AMR, it does so on a rather generic level, not
leaving much space to address the context specic factors that shape the
(non-)adoption of such plans. Moreover, framing the issue in terms of an
implementation gap further de-politicizes AMR as a pan-societal chal-
lenge and renders it rather a “technical matter” of governance.
2
Building
on social science literature, we conceive of AMR as a deep-seated soci-
etal problem, positing that tackling AMR is likely to involve political
tensions which touch upon entrenched interests, normalized social
routines, social values and the re-making of institutions (Broom &
Doron, 2020; Broom, Kenny, Prainsack, et al., 2021; Chandler, 2019;
Tompson, Manderson, & Chandler, 2021). This paper offers an in-depth
study of a single country, zeroing in on Austria to explore the imple-
mentation of the National Action Plan on AMR (NAP-AMR) through the
lenses of key experts and stakeholders involved in AMR stewardship or
the design and implementation of AMR-related policies. Empirically, the
paper explores how experts experience and make sense of what they
perceive as an implementation gap in Austria’s AMR policy.
Whilst the academic debate on the “implementation gap” especially
problematizes the performance of low- and middle-income countries
(Pokharel et al., 2019; Wellcome, 2020), Austria is an illustrative case to
the extent that it represents a high-income country with a
well-developed and effective health care system (Bachner et al., 2019).
Moreover, there has been a strong awareness of AMR within the Aus-
trian public health system for a long time. Austria had developed
AMR-specic national strategies before the recent wave of NAPs-AMR
animated by the GAP in 2015. Yet, despite this early turn towards
AMR stewardship in Austria, many experts working in this eld are
highly discontent with the pace and rigor of AMR-related measures and
deplore a glaring implementation gap of Austria’s NAP-AMR, which was
rst issued in 2013. Our qualitative data suggest that while these experts
attribute responsibility to political administration inertia in imple-
menting the NAP-AMR, they equally fault the lack of long-term vision,
nancial and symbolic incentives and an appropriate culture of recog-
nition for stewardship as a major impediment.
2. Global action on AMR: the problem of implementation
Recent years have seen a broad wave of policy diffusion, as evi-
denced by the impressive number of NAPs-AMR issued worldwide.
However, the success of these measures has become clouded by a sub-
stantial implementation decit in countries worldwide. For instance,
88% of the 136 countries that participated in a WHO-led self-assessment
survey reported having developed a NAP-AMR; however, only 20% of
these countries have fully funded the operationalization of their NAPs-
AMR (WHO, FAO, and OIE 2021). “For most countries”, the WHO thus
concludes,
“[…] the greatest challenge is not developing a NAP; rather, it is
achieving NAP implementation that is evidence-based and demon-
strates sustained action.” (WHO, 2022b)
The enforcement issues relating to international policy agendas and
the non-binding character of global guidelines that characterizes many
domains of WHO-led global health policy is often cited in the literature
as a major problem for this implementation decit. For instance, a high-
level stakeholder meeting underscored that an international legal
agreement is urgently needed to lock in long-term standards and norms
across the private and public sectors (Padiyara, Inoue, & Sprenger,
2018; Rochford et al., 2018). Recent inputs to this debate, however,
have put into question the general push for binding international norms
and have instead advocated for strategies to encourage states to comply
(Weldon & Hoffman, 2021) or for a more pragmatic mix of binding and
non-binding governance mechanisms (Ruckert et al., 2020); an
approach that moves a step away from top-down models and notions of
norm compliance and rather involves alternative strategies such as
polycentric or adaptive governance (Rubin, 2019).
Several commentators have pointed to the fact that, especially in in
low- and middle-income countries (LMICs), national authorities are
quick to adopt formal strategies and set in motion policy processes
without having the capacity to actually achieve the outcome (Andrews,
Pritchett, & Woolcock, 2017; Munkholm & Rubin, 2020b). This is a
phenomenon captured by the term “isomorphic mimicry” (Munkholm &
Rubin, 2020a) suggesting that a considerable part of the observed policy
action to date mainly consist in agenda conformity with the GAP, not
least because of lacking budgets for the substantial costs involved with
the establishment and maintenance in cross-sector antimicrobial stew-
ardship programs (ASP), let alone the political challenges in effectuating
far-reaching change in policy and institutional settlements (Broom,
Kenny, Kirby, et al., 2021).
At the same time, the actual evidence-based assessment of NAP-AMR
implementation is further complicated by the fact that the data neces-
sary for monitoring and evaluation is poor and incomplete. Knowledge
on NAP-AMR implementation differentials is generated on a semi-
voluntary self-assessment. This assessment is compiled by each coun-
try on a yearly basis, however, without a proper verication system in
place. These specic data practice – common in several other domains of
international public health governance (Pichelstorfer & Paul, 2022) –
almost by default generates a whole range of problems, and inevitably
includes the possibility of self-report bias (WHO, FAO, and OIE, 2021).
Thus, the state of implementation of NAPs-AMR as well as the factors
that impede implementation is subject to considerable knowledge gaps.
3. Towards a political understanding of AMR governance:
power, values, ignorance
The majority of these accounts operate within a more technical un-
derstanding of governance that shows little conceptual sensitivity to
AMR as a fundamentally political problem, since AMR mitigation and
stewardship always involve delicate (re-)distributive issues and touches
upon unquestioned values and vested political and economic interests
(Elbe & Rushton, 2016; Kelsall, 2023).
The problem of values in AMR mitigation and governance has been
elaborated in several studies. This perspective makes it possible to un-
derstand AMR less as an eruptive crisis befalling society – as, for
example, pandemic preparedness plans typically conceptualize the
threat of emerging infectious diseases – but rather as a structural
2
Of course, modern governance always contains a decidedly technical
component. Here we refer to the tension between the technical and the political
as elaborated by Barry (2001). Accordingly, the foregrounding of the “tech-
nical” always implies a form of de-politicization, transforming a subject from a
matter of concern into a seemingly technical matter.
M. Jeleff et al.
SSM - Qualitative Research in Health 4 (2023) 100332
3
problem of modern societies (Broom, Kenny, Prainsack, & et al, 2021;
Chandler, 2019; Kirchhelle, 2018; Landecker, 2016). Antimicrobials,
and thus antimicrobial resistance, are deeply “embedded within the
cultural fabric of modern societies and the (varied) ways they are
organized economically, socially and politically” (Broom, Kenny,
Prainsack, & et al, 2021). Attention to values exhibit the limitations of
an approach based on individual behavior and discrete technical in-
terventions. Furthermore, according to these authors, default responses
to AMR are shaped by temporal myopia, human exceptionalism, and the
neoliberal duad of individualization and market ideology – a corset of
values that make a comprehensive (and solidarity-based) approach
difcult or even impossible (Broom et al., 2020).
This interplay of entrenched societal regimes, vested interests and
specic values that shape the handling of AMR brings AMR as a political
phenomenon into analogy with climate change (Rogers Van Katwyk
et al., 2020). This applies not only to the high politics of international
agreements and the difcult global governance (Munkholm & Rubin,
2020b; Rochford et al., 2018; Woolhouse & Farrar, 2014), but also to the
way specic reforms are thought about and implemented. As Bhardwaj
and Khosla (2021) show with the example of climate change mitigation
in India, this happens often in a way that leaves existing structures and
long-term goals largely untouched. To capture the problematic nature of
such practices, these authors have coined the term “institutional su-
perimposition” to describe the tendency of bureaucracies with the
intention to address climate objectives, while having only “limited
control over their planning practices and mandates, high levels of
institutional inertia to change existing practices, and multiple other
objectives related to development that dominate agendas” (Bhardwaj &
Khosla, 2021).
As regards knowledge, the stress on lacking data is only one aspect of
pertinent non-knowledge that shapes AMR governance processes,
deecting from other ways in which AMR is known. These knowledge
practices include the categories and tools used to conceptualize and
measure AMR, which also support and channel forms of strategic igno-
rance (Kelly & McGoey, 2018; McGoey, 2012; Paul & Haddad, 2019).
AMR-related ignorance signicantly shapes public health responses
worldwide, and social scientists have examined the forms of
non-knowledge and ignorance that shape AMR and public health and
pandemic preparedness governance more generally (Aarden, 2022;
Dahdah, Falisse, & Lurton, 2021; Kelly & McGoey, 2018; Paul & Had-
dad, 2023; Will, 2020). Specically, social studies on AMR highlight
how the unique features of AMR contribute to strategic forms of
ignoring, sidelining, or downplaying its implications, and to delay, un-
dermine or thwart policy action. AMR is often characterized as a “slowly
emerging disaster” (Littmann & Viens, 2015), somewhat akin to the
global climate crisis (Rubin, 2019), leading to less attention and fewer
affective responses compared to rapidly emerging infectious diseases
(Herrick & Reubi, 2017; Kelly, 2018). Tropes such as “silent” (Daman,
2022) or “invisible” pandemic (WHO, 2019a) are frequently mobilized
in the literature to explain the lack of urgency and resulting policy
inaction.
To summarize, these insights from the extant literature suggests that
AMR governance needs to be conceptualized in political terms
(including a focus on power relations, vested interests and values), and
not primarily as a technical matter of governance (as the framing of an
implementation gap indicates). This, too, extends to the domain of
knowledge, where data gaps – their negative implications on governance
notwithstanding – are only the tip of an iceberg of ignorance that needs
to be addressed in the management of AMR. With these conceptual
sensibilities in place, we now turn to our empirical analysis of how ac-
tors and stakeholders perceive and reect on the implementation of
AMR-related policy measures in Austria.
4. Methodology and research process: towards a situated
analysis
Methodologically, the research process was guided by the basic te-
nets of grounded theory (Corbin & Strauss, 2008), an inductive frame-
work in which data collection and analysis is closely entwined in an
iterative process. Further, this study draws on the tradition of inter-
pretive policy studies (Wagenaar, 2014; Yanow & Schwartz-Shea,
2015). Interpretive here refers to the analytical attention given to
local knowledge and meaning-making and the local contexts in which
policies are made and enacted (Yanow, 2003). Informed by ethno-
graphic sensibility (Prainsack & Wahlberg, 2013), our analysis situates
the actions and articulations of the respondents within broader cultural
contexts of the Austrian political and health care system, its institutional
patterns and idiosyncrasies, while attending closely to their
meaning-making and context-bound agency.
Data generation took place between September 2019 and May 2022
(with a longer break in 2020 due to the COVID 19 pandemic) and started
with the identication of a small number of experts in the eld of AMR
in Austria. Respondents were asked where they locate the main problem
areas regarding AMR in human medicine in Austria.
3
First data analysis
revealed a pervasive focus on political aspects of AMR governance.
Various respondents repeatedly brought up the implementation gap and
how it constitutes an overarching challenge in the human medicine
sector. Hence, this theme was further pursued in subsequent interviews
until theoretical saturation was reached.
Respondents were identied and invited to participate in this study
using a theoretical (purposive) sampling strategy. A total of 12 experts,
involved in AMR-related policy and practice (mainly human medicine,
hospital sector), participated in in-depth interviews via online call or
telephone.
4
(see Table 1) In addition, one focus group discussion took
place with four experts at a non-prot hospital in Vienna (see Table 1).
Further, data generation involved informal conversations and partici-
pation at online events (Table 2). At later stages of theory development,
the empirical data was triangulated by literature research as well as
policy document analysis, including most notably, different editions of
the NAP-AMRs (BMASGK, 2018; BMG, 2014; BMSGPK, 2021) as well as
a recent edition of the AURES report (BMSGPK, 2020). At a nal stage, a
report documenting the main empirical ndings of the study was shared
with two interview partners who validated and provided feedback on
the manuscript in progress. Another follow up-conversation with an
expert resulted from this validation process.
5. Contextualizing AMR in the Austrian health care system
Before addressing the main ndings, the following section outlines
the Austrian context in terms of the healthcare system and historical
developments related to AMR stewardship.
The Austrian health care system is well funded and characterized by
its high quality and institutional development. At the same time, it is
marked by a highly decentralized, federal structure, which often leads to
fragmentation of responsibilities between the federal government and
the Austrian federal states. The federal government [Bund], the states
3
This study focuses on the human medicine sector for reasons of scope.
Clearly, this selective focus is likely to bring to the fore a specic constellation
of AMR governance, with a particular focus on the hospital sector, while
sidelining other important sectors for AMR, such as the agriculture and live-
stock farming. Further research is needed to complement the human-centered
focus with an in-depth study of antimicrobial stewardship in animal health
and agriculture.
4
Conversations lasted between 30 and 60 min. Two respondents were
interviewed twice to elaborate on key aspects and emerging categories. In-
terviews were transcribed and anonymized and text data was analyzed by open,
axial and selective coding with the support of data analysis software Atlas.ti.
M. Jeleff et al.
SSM - Qualitative Research in Health 4 (2023) 100332
4
[L¨
ander] and the social insurance institutions jointly contribute to the
nancing of the system, with the states having the largest share in the
nancing of the hospital sector (Habimana et al., 2019). Moreover, the
Austrian health care system is institutionally divided into intramural
(hospital) sector and extramural sector. Extramural care is mainly
nanced by the social health insurance system. Legislation and
enforcement are the responsibility of the federal government, except for
the hospital sector, where states are responsible for implementation
(Habimana et al., 2019). In an effort to improve the organizational and
nancial structure perceived as overly inert, the Federal Target Setting
Commission was established in 2013 (Habimana et al., 2019). This
decision-making entity comprises representatives from the federal gov-
ernment, the states, and the social insurance system to negotiate health
targets, which are then implemented by commissions at the state level
(Bachner et al., 2019). This patchy and decentralized health system with
distributed tasks and constant political negotiations over nancial and
organizational responsibility makes the implementation of national
health policy agendas, such as the NAP-AMR, a highly complex and
complicated matter.
Austria took important steps towards antibiotic stewardship at an
early stage. These include, for instance, the regulation of antibiotics as
prescription drugs, effectively prohibiting the over-the-counter (OTC)
sales of antibiotics in the primary care sector (Rechtsinformationssystem
des Bundes, 2022). Moreover, initiated by a WHO-sponsored project,
experts at a Vienna-based Community Hospital created the rst strate-
gies for prudent use of antibiotics in hospitals in the 1990s, which is now
considered a precursor to ASP (BMG, 2014; BMASGK, 2018). On the
basis of the ASP guidelines (Dellit et al., 2007), German and Austrian
specialist societies and institutions adapted ASP to the German/Austrian
context in 2013, which is updated every ve years (de With et al. 2016,
2018) and provides the thematic content for a federal quality standard.
In 2013, Austria developed a NAP-AMR – issued one year before the
WHO GAP was released – followed by two updated versions in 2018 and
2021 (BMASGK, 2018; BMG, 2014; BMSGPK, 2021). Well in line with
the “One Health” framing of the AMR challenge underpinning the GAP,
the Austrian NAP-AMR contains a section on veterinary medicine and
agriculture, in addition to its section on human medicine. Throughout
all editions, the section on human medicine exhibits a predominant
focus on the hospital sector, whilst issues pertaining to the primary care
sector and long-term nursing facilities are only touched cursorily (Hall
et al., 2022).
Arguably one of the pertinent accomplishments with regard to AMR
is the issuance of the “AURES report”, published annually since 2005
and which details the overall resistance situation in Austria (BMSGPK,
2020). Since 2012, AURES has been performing resistance screening
according to the European Committee on Antimicrobial Susceptibility
Testing (EUCAST) quality standard. The human pathogen section is
mainly managed by the national reference center for AMR and through
participation in the European Antimicrobial Resistance Surveillance
Network (EARS-Net) (BMSGPK, 2020). While AURES collates important
data that informs expert and policy debates on AMR, critics regret that
the selective data collection practices underpinning AURES signicantly
reduces its potential value for proactive AMR mitigation.
In other respects, there are clear omissions. For instance, whilst the
OTC sale of antibiotics is prohibited, there is to date no legal framework
in place that enforces mandatory ASPs in hospitals. Similarly, partici-
pation in the antibiotic consumption surveillance program provided by
The Austrian Agency for Health and Food Safety (AGES) is voluntary.
Only 24 of 130 Austrian hospitals are registered and 18 actively use this
system on a voluntary basis (AGES, 2019). This non-mandatory
approach engenders several problems, including data gaps that
hamper an evidence-based management of rational antimicrobial use in
hospitals. The absence of these legal provisions distinguishes Austria
from other countries in the EU. Germany, for example, in response to the
European Commission’s 2010 report, created a legal framework in 2011
to make antibiotic consumption monitoring and ASP mandatory (Eu-
ropean Commission, 2010; de With et al., 2013; Bundesministerium der
Justiz and Bundesamt für Justiz, 2011).
6. Findings
6.1. “Paper does not blush” – problematizing the implementation gap
Right from the start, the focus of the interviews was on the NAP-
AMR, a policy document issued in 2013 that sets out the roadmap for
the implementation of various measures in human and veterinary
medicine. Many participants appreciated the NAP-AMR and its specic
content, but criticized its slow uptake and institutionalization at various
levels in the Austrian health system. According to these respondents, few
of the goals dened in the NAP-AMR had been actually implemented to
date or lacked the necessary political, nancial or institutional com-
mitments to be able to adequately address the challenge of AMR.
Table 1
Characteristics of participants.
Overview: Sample of participants (Interviews)
Variable Description No of
participants
Notes
Gender Male 4
Female 9
Relevant
profession
Hospital hygiene
specialist
2 Two participants
interviewed twice
Hospital pharmacist 1
Infectious disease
expert
2
Specialist for hygiene
and/or microbiology
3
General practitioner
(clinical & research)
1
Hospital director 1
Member of the
ministry of health
2 One consent withdrawn
Member of the
medical chamber
1
Overview: Sample of participants (Focus group discussion)
Gender Female 4
Hospital hygiene
specialist
1
Specialist for hygiene
and/or microbiology
1
Hospital pharmacist 2
Overview: Sample of participants (informal conversation)
Gender Female 3
Member of the
medical chamber
1
Virologist 1
Hospital hygiene
specialist
1 (2 informal
conversations with the
same person)
Table 2
Participation in symposia.
Overview: Webinars Date
Symposium on the 14th European Antibiotics Day
(AGES)
18.11.2021,
10:00–17:00 CET
International Symposium on Antimicrobial Stewardship
(AGES)
3.3.2022, 10:00–16:00
CET
CDC AMR Exchange Series—AMR in a Changed World:
Building Resilient Systems for Today and Tomorrow
13.5.2021, 09:30 a.m.
Eastern Time
WHO global webinar series: Strengthening IPC activities
and embedding IPC in AMR NAP implementation
8.9.2021, 10:00 a.m.
Zurich
WHO Global Webinar Series to Support Implementation
of National Action Plans on Antimicrobial Resistance
(AMR)
19.5.2022, 11:00 a.m.
Zurich
Das ¨
osterreichische Gesundheitssystem aus dem Blick
der Prim¨
arversorgung (G¨
OGG)
18.5.2022, 18:00–19:30
CET
M. Jeleff et al.
SSM - Qualitative Research in Health 4 (2023) 100332
5
The notion of a pervasive “implementation gap” has emerged in the
conversations as a dominant, if not the overarching problematization
articulated by interlocutors. When asked about the potential conditions
and causes of this implementation decit, participants suggested a range
of explanations and interpretations. Many respondents lamented the
lack of transparency in the implementation process and attributed the
implementation decits to a mixture of lacking political prioritization,
inadequate governance structures including striking communication
decits, as well as a lack of clarity about the scope of authority and
responsibility of the stakeholders involved. Indeed, the NAPs-AMR list
several stakeholders to be involved in the implementation of various
measures. And although there were many promising initiatives and
working groups initially, little follow-up was done after the adoption of
the action plan and the interaction and communication between the
actors were severed. As one respondent recalls,
“I was invited to the working groups [of the NAP-AMR], but at some
point, I didn’t hear anything anymore. I have no idea about any re-
sults.” (ITV-7)
This stalled process made it difcult for those involved to follow up
on activities and to apprehend the overall state of progress of the plan’s
implementation.
“Well, I’m (XY), but I still don’t know what has actually been
implemented and what still needs to be done and by when. I was
involved twice when it [the NAP-AMR] was developed at the time,
and then a few years later there was a specication or an update, so
to speak, of this NAP-AMR, but I cannot tell you what was actually
implemented in terms of content.” (ITV-5)
These experiences suggest that the lack of implementation – or the
glaring lack of knowledge about the status of implementation – is
essentially a political-administrative failure.
“It is not enough to say that we have published the NAP-AMR on the
Ministry’s website, (…), […] It is not enough to just dene which
measures are necessary, but how do these measures end up with
those who are supposed to implement them. […] and when the
document is nalized, it would actually need someone to take things
into their own hands, and say, ‘now we’re going to start coordinating
these measures’, informing the institutions concerned. And that did
not happen. […] Now we have a nice document, but where do we
start to implement it? “(ITV-13)
For the interviewed experts, the delaying and postponing of a future-
oriented AMR stewardship program poses a great danger to public
health in Austria. Accordingly, this delay in implementation can only be
explained by considering the general perception of the AMR situation in
Austria, namely that AMR is not recognized as an urgent matter in and
for national public health. This perception - and the associated lack of
awareness of the problem - is based on the “relatively low resistance
rate” in Austria. Yet, this apparently prevailing perception of “low risk/
low urgency” rests on a specic and highly selective interpretation of the
available data, on at least two important points. On the one hand, this
perception is content with counting the current situation and conve-
niently neglects the potentially escalating dynamics of the AMR
endemic, as emphasized by international institutions. On the other
hand, the good, stable situation is often justied with reference to other
countries where the AMR situation is much more dramatic. One
respondent pointedly sums up these two interpretive layers:
“I mean we are not Italy and Greece, where the resistances are of
course a real issue. With us, the resistances are more or less under
control. And maybe that’s one reason why people think that’s not top
priority, maybe. But it’s very naïve, because it can catch up with us at
any time and, as we know, the world is now so short-circuited with
mobility and if someone is spreading resistance somewhere, like with
COVID-19 right now, you just have to prepare yourself.” (ITV-3)
Overall, these downward comparisons beg the question why Austria,
one of the richest countries in Europe and worldwide, is only infre-
quently contrasted with other high-income countries, such as Scandi-
navian countries, where AMR control receives much more public and
political attention. According to one respondent, however, policy
makers seem to be satised, with Austria ranking somewhere in the
“middle":
“I don’t see any reason why Austria should be happy that we’re in
mideld. Surely, we could do better. There’s no reason, but anti-
biotic resistance doesn’t have the importance it should have, given
that the WHO and the UN see climate change and antibiotic resis-
tance as the two major problems [ …], but that reects that it is not
the priority of the public health system here.” (ITV-2)
The notion of global mobility and global vectors of contagion is often
invoked to support the view that AMR in Austria is mainly an “imported
problem” brought in from other regions. At the same time, this global
predicament also obliges the public health system to take action: the
present low resistance rate should not serve as a justication to dispense
with AMR prevention activities:
“If we really want to keep this [good] situation, it will take a lot of
effort, because it is quite clear, the multi-resistant pathogens are
pouring in from all sides, people bring it with them from vacation,
they bring it with them from Asia, they bring it from Italy, from
Greece, from Slovenia, wherever they are and we are not immune to
the fact that they will spread, if the hospital hygiene does not work
out.” (ITV-1)
It therefore would be a mistake to complacently rest on these “laurels
of success”, as one respondent put it.
“Among those who are responsible, there are apparently huge
knowledge gaps regarding the scope of the topic and also why it
would be so important to invest in the area […] just don’t rest on the
laurels of the success reports – ‘we have such low resistances
compared to other countries’ – because otherwise it will be too late.
So there are big gaps in understanding [the situation].” (ITV-7)
The frustration of the experts who campaigned for and have engaged
with the topic is obvious.
The pertinence of reforms has been known for a long time and many
measures to address them have already been laid down in the rst NAP-
AMR. In the various interviews, criticism of the implementation gap is
condensed and expressed through the frequent use of paper metaphors:
interviewees stated, “we now have a nice document,” or “we have
produced so much paperwork,” or even “meters of paperwork.” These
metaphors indicate how much work went into drafting the NAP-AMR,
but without adequately imagining how it would be implemented in
practice. The metaphor “paper is patient” indicates that a policy docu-
ment as such does not put pressure on implementing actors if there is no
effective mechanism to push for its implementation. “Paper does not
blush” describes the lack of accountability of the actors who should be
pursuing timely implementation - paper cannot be shamed if it contains
words that are largely of no consequence. One respondent emphasized:
“So I’ve always had the impression up until now that a piece of paper
was created that is beautiful and interesting to read, but it had
actually no consequences whatsoever. Unless you personally show
initiative and do something from your own small area, but I’ve
actually never seen anything done in a structured or targeted way for
the whole Republic.” (ITV-12)
The criticism of the implementation decit and its articulation
through paper metaphors refers to the problem of agenda conformity,
which is discussed in the literature mainly with reference to low-income
countries and will be addressed in more detail in the discussion.
M. Jeleff et al.
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6.2. "Nice documents, but no money attached" – missing legal and
nancial frameworks
Most experts agree that a comprehensive legal framework would be
paramount to foster desperately needed country-wide ASPs and con-
sumption surveillance in hospitals. These are two important elements of
the NAP-AMR that so far have only the status of non-binding recom-
mendations. Moreover, only through legal obligation would it be
possible to create mandatory structures to gather antibiotics consump-
tion data from the primary care sector as well as to link antibiotics
prescriptions with the diagnosis.
According to the NAP-AMR, the implementing entities are them-
selves responsible for putting measures into practice. The working group
of the NAP-AMR – composed of experts of Austrian authorities, specialist
societies and health care institutions – is the key venue where the set of
policy measures are negotiated. When an agreement is reached between
the Federal Ministry of Health and the implementing entities, the Min-
istry delegates activities, yet without making any claims on the imple-
menting bodies. This is primarily a consequence of the voluntary, non-
binding character of the NAP-AMR as well as the GAP, more generally
(ITV-14). It offers recommendations which do not precipitate any legal
or political consequences, if these are not translated into practice. This
shifts the responsibility to the implementing entities who often remain
confused over their concrete obligations as well as the lack of clarity
about who provides nancial resources.
“The nancing of the measures is certainly also an issue. It’s easy to
take part in a working group and say, yes, we now have a nice
document, but the measures simply have money attached to them.”
(ITV-13)
The voluntary character of many measures listed in the NAP-AMR is
both used as an explanation for inaction and as an excuse. For instance,
interviewee 14 suggested that ASPs have not been implemented in all
hospitals so far because there is no legal basis for it. Yet, the mentioning
of the missing legal framework and the corresponding (im)possibility of
a country-wide implementation of the action plan, point to the fault lines
and conicts of a highly federalized system, as in the Austrian context. In
this system, the federal [Bund] and state [L¨
ander] governments are
constantly negotiating competencies, obligations and nancing issues.
Against this background, the elaboration of a NAP-AMR seems to be
the easiest task in a political process, since the main issue for imple-
mentation is to clarify who bears the costs for a given set of policy
measures (ITV-1). This political fact was also raised at the International
Symposium on ASP, held in Vienna in 2022, where one panelist spoke
out on the matter of nancing implementation in Austria as a “sensitive
issue”:
“So it’s all done, so to speak, it was just a matter of implementing it.
That is of course politically sensitive, [ASP] teams that cost some-
thing, you have to implement them, someone has to pay for them,
and so on. And that’s when the whole wheel starts to turn with the
Finanzausgleich
5
and possibly a consultation mechanism, that means,
for those who know their way around politics, I don’t have to say
much more about it. That’s always politically sensitive and here
things often get skewered.” (Notes from International Symposium of
Antimicrobial Stewardship, 3rd March 2022)
As it is difcult to arrive at a binding agreement between the
different parties involved, political maneuvers often seem to seek to
circumnavigate these sensitive issues. The respondents described two
particular ways in which the contentious issue of nancing ASP mea-
sures have been dealt with.
To begin with, from the perspective of the federal ministry, one way
of securing a success in spite of the political difculties relating to
nancing, is to promote the development of a non-binding federal
quality standard. The standard denes the thematic content and the
technical expertise, without, however, making the adoption and its
translation into legal and institutional procedures mandatory. Thus, the
federal quality standard serves as a temporary solution and as an in-
strument to arrive a voluntary agreement with the federal states,
without touching the sensitive issue of legal and nancial responsibility
(ITV-14). Without any actual power of legal enforceability, it creates a
moral economy of responsibilization that invokes stakeholders to
voluntarily take action and reorder their priorities in favor of ASP-
related investments. However, it rather postpones the political deter-
mination of responsibility, hence contributes to the lag in implementa-
tion which is also reected in the delayed adoption of the quality
standard itself.
“The federal quality standard for ASP was written in 2017 and then it
went to the Steering Committee, that means that it is in the Ministry
of Health [ …]. And it’s been there ever since. All ASP agendas are
dened there, for example, the establishment of an interdisciplinary
group, […] who has to be part of this group, what agendas they have,
what training is expected. So that is exactly what is described there,
broken down to Austrian conditions. And nothing has happened
since then (2017)." (ITV-3)
The second example concerns the outsourcing of the implementation
process, as the following interview sequence details:
– "The problem in Austria is when the Ministry says you have to do
something, the [stakeholders tasked with the implementation]
respond: ‘Well, then give me the money for it!’ Of course, no one
wants to do it just like that. That is why the Ministry no longer says,
‘You have to do it!‘, but rather: ‘You have to create the resources so
that it can be done’. That is of course very tricky.”
– “So, that means that the stakeholders themselves have to come up
with the money they need to implement the measures?”
– “Yes, exactly. Of course, that’s difcult now because, for instance,
each house [i.e., hospital] prioritizes. The question is: do I need a
new computer tomography or do I need a doctor who is responsible
for antibiotics stewardship? Well, this is very difcult to resolve, and
there are also different interest groups in a hospital, which all lobby
for different investments that would all make sense, individually.”
(ITV-4)
These tensions are structural in the federally organized Austrian
(healthcare) system, in which the federal states bear two-thirds of the
costs for measures, and this “implementation outsourcing” can create
further confusion over actual responsibility. What’s more, it responsi-
bilizes those actors at the micro level to make the decision and forces
them to evaluate their investment priorities. For instance, the question
arises as to which values and interests are given priority at the institu-
tional level of an individual hospital. For a medical director of a hospital,
it might be more opportune to purchase a new and long-demanded
computer tomography – a tangible, shiny technological product with
which the hospital can publicly advertise – than to invest in ASP infra-
structure and create the position of a hygiene ofcer specialized in AMR.
The costs of establishing appropriate ASP structures are likely to exceed
the mere opportunity costs lost to, e.g., the computer tomography: the
job description of an AMR responsible ofcer is precisely to make
infrastructural decits and problematic professional routines visible.
These shortcomings then call for improvement, which, in turn, generates
further costs in the short and mid-term. Despite these challenging ten-
sions between competing interests that hospital operators have to
manage, they are not mentioned in the NAP-AMR, neither as nanciers
nor as responsible for implementing measures.
Apart from signicantly contributing to the implementation decits,
this unclear nancial situation also negatively impacts the sustainability
5
Technical term for the vertical tax revenue sharing agreement between the
central government and federal states.
M. Jeleff et al.
SSM - Qualitative Research in Health 4 (2023) 100332
7
of AMR-related projects, such as the continuous data collection, the
routinization and professionalization of ASP teams, as well as the
monitoring and evaluation of projects. The excessive focus on thematic
aspects of the NAP-AMR without clarifying budgetary responsibilities is
perceived as a serious problem.
6.3. "In dire need of improvement" - lamenting data gaps
Although this may not be obvious at rst glance, the NAP-AMR de-
pends on the availability of a variety of data to understand the resistance
situation and act accordingly. These include, among others, data sets on
morbidity, datasets that link prescriptions to diagnoses, as well as
regional and local-level data.
Respondents positively referred to the Annual Report on Antimi-
crobial Resistance in Austria (AURES) as a true and early accomplish-
ment in the national action against AMR, as it surveys the AMR situation
and makes data available. However, some respondents lament numerous
gaps in the data situation, especially in terms of the primary care sector.
For instance, the resistance data from the primary care sector dis-
played in AURES reect predominantly data of “problematic infections”
(i.e., drawn from selected samples of infections which cannot be treated
with rst-line antibiotics) but not so much on epidemiologically-
relevant surveillance or morbidity data (ITV-7). Consequently, the
AURES report does not provide a representative overview of pathogen
circulation, and areas of potential concern become only visible once they
have already become clinically problematic (ITV-7). This epistemic
selectivity renders AURES, despite its merits, only a limited tool for
careful and proactive, long-term AMR governance. To provide for a
more comprehensive picture of morbidity data, it was necessary to
establish sentinel practices in primary care that monitor, on a regular
basis, specic infectious diseases (e.g., urinary tract infections or res-
piratory infections) (ITV-7). While similar sentinel systems already exist
for monitoring viral infections managed by the Diagnostic Inuenza
Network Austria (DIN¨
O), they are lacking for bacterial infections for
which another institute would be responsible (informal conversation 3).
Another source of data that feeds into AURES is data on antibiotic
consumption in the primary care sector, which is provided through the
Austrian Public Health Insurance in the form of reimbursed prescription
fees. This data indicates what kinds of antibiotic drugs are prescribed
and what quantity in Austria. Yet, it does not capture the actual con-
sumption. Crucially, the prescription data is not linked to neither the
diagnosis, nor to morbidity data (which is, as mentioned above, largely
non-existing), nor to patterns of known drug resistances. Due to these
gaps resulting from missing links between different types of data, this
information cannot be used for continuously updating guidelines for the
primary care sector or as a basis for ASPs.
“We don’t know what antibiotics are used for in primary care prac-
tices. As with so many other topics, the underlying data is in dire
need of improvement. I can say that much of this specic antibiotic
substance is used in the primary care sector, but I cannot tell for
which purpose. So there is no connection to the diagnosis made. That
is a true impediment. If you are considering to establish an antibiotic
stewardship program somewhere, and want to know where to start,
then you need to know where the antibiotics ow to, and whether
they ow there correctly, based on a proper indication, or not – but
none of us know that.” (ITV-5)
Although a lack of knowledge about the development of resistance
and infection processes in the primary health care sector is well known,
the NAP-AMR only cursorily addresses these problems specically. It
merely states very generally, that an ASP should be implemented in the
primary care sector. When asked how these specic knowledge gaps
were addressed, one respondent replied laconically:
– “Well, this has not been addressed. The problem is that it doesn’t
have to be done. […] Once, the idea was to do a study with a few
doctors who were willing to contribute this data on a voluntary basis.
But that has failed. [ …]”
– “And why did the study fail?”
– “Because you would have needed volunteers to take part. Volun-
teering doctors, who sacrice some of their time, but you won’t nd
any.” (ITV-14, italics added)
The problem of something “not having to take place” hints to both
the lack of political priority, agenda conformity and the lack of legally
binding responsibilities. In the views of another respondent (ITV-7),
these omissions perpetuate a vicious circle between insufcient knowl-
edge and problematic treatment practices. Without robust evidence it
was impossible to update treatment guidelines, so that prescribers can
make evidence-based decisions.
6.4. "Neither the means nor compensation"– Lacking incentive structures
for AMR stewardship
Another less obvious factor which complicates the implementation of
the NAP-AMR and mitigation of AMR in general is the lack of an
incentive system - nancial, social and symbolic recognition but also
providence and availability of education and continued training - for
those engaged in ASP at various levels.
Respondents see a reciprocal relation between a lack of knowledge
(evidence), professional awareness, and the subordinate role of the topic
in academic education and clinical training. Appropriate national action
against AMR would require to properly integrate AMR-related training
into the medical curriculum at the early stages:
“During your studies, you don’t realize how much antibiotic therapy
actually makes up a doctor’s everyday life. Every day, you treat
patients with infections, […], infectiology makes up a large part of
the work – I mean, not even the special infectiological topics, but the
standard therapies which more often than not, also involve antibiotic
treatment. It therefore would make a lot of sense, but it is not suf-
ciently promoted in the curricula." (FGD-1)
This quote captures a broadly shared sentiment among many re-
spondents, who emphasized that insufcient education also impedes
evidence-based antibiotic therapy in clinical practice. Moreover, as one
respondent considered (ITV-12), many physicians are aware of some
lack of knowledge, however, they hardly nd time to properly engage
with the topic. Yet, these gaps in knowledge are structural rather than
personal, and can hardly be xed with sporadic training. To date,
however, most trainings in infectiology that deal with AMR are volun-
tary and thus a matter of personal initiative of the individual physicians,
who have to make choices regarding their training priorities against the
background of scarce time resources and reimbursement opportunities
(ITV-12).
6
In addition to the need for progressive and compulsory training
programs, there is a lack of nancial incentives and symbolic recogni-
tion of professionals who dedicate their time and efforts to AMR-related
activities. As an example, one respondent mentions the absence of any
ofcial certicate or diploma for ASP training:
“In Austria, the training is poorly structured. If you compare that
with Germany where you have consecutive antibiotic stewardship
6
Notable training formats mentioned by respondents include courses pro-
vided by medical societies such as ASP training hosted by the Austrian Society
for Antimicrobial Chemotherapy (¨
OGACH) and the “Toxic Tuesday’’ seminars
hosted by the Austrian Society for Infectious and Tropical Diseases (¨
OGIT). Yet,
respondents shared the view that there is still a great need for structured
courses, starting at a very basic level, as many physicians are deemed lacking
the basics for those existing courses that often start at a rather advanced level
(FGD-1).
M. Jeleff et al.
SSM - Qualitative Research in Health 4 (2023) 100332
8
trainings – course level 1, level 2, level 3 – and then you get a proper
title, which we don’t even have here, yet.” (ITV-4)
A diploma and an ofcial title (“ASP ofcer”) would provide an
incentive and could serve as a tool to recognize the work of those who
implement ASPs.
Symbolic incentivization (e.g., through titles and certicates) is only
seen as one crucial step to value the work of those who invest their time
in ASP. Another one is nancial remuneration (ITV-1). As one respon-
dent critically notes, “We have plenty of titles (…) but they come with no
resources“ (informal conversation 2). Besides the missing personal
valuation of medical professionals, this lack also generates a structural
human resources problem in the long term:
“Hygienists and microbiologists are already becoming a scarce good,
because there are no successors, and no one is being primarily
trained in this eld” (informal conversation 2).
Similarly, another respondent makes the link between lacking
human resources and inadequate nancial incentives:
“We do not nd any successors, we do not nd anyone who is pri-
marily interested in hygiene because there is no special income,
there’s no other allowances, that’s already something that makes it
not very attractive. And that’s certainly going to be a problem in the
long run.” (ITV-9)
Lack of human resources – medical hygiene personnel, ASP ofcers,
infectiologists and microbiologists, who all form part of an ASP team – is
broadly considered by respondents as one of the major impediments for
effective ASP activities in hospitals.
“Antibiotic stewardship a very time-consuming process. Above all,
consulting is always time-consuming, especially if you want to do it
well. You have to advise, train – and that costs an insane amount of
time. There are guidelines on how much personnel is needed, espe-
cially in the ASP guidelines. You know, that can certainly consume
the entire time of a doctor. And probably, another person from the
pharmacy, if you want to do it well (…) It is also difcult to nd
successors.” (FGD-1)
Thus, the missing symbolic and nancial incentivization is a struc-
tural problem just as the aforementioned gaps in education and missing
personnel resources. There is the need for more personnel dedicated to
ASP activities, however, as there is no structurally anchored incentive
system, people, except for idealists, won’t have much reason to pursue a
career in this subject area.
„It’s no wonder there’s a shortage of hygienists and ASP ofcers,
because they have neither the means nor compensation for the
confrontations they often have to endure.” (informal conversation 2)
7. Discussion
This study investigated the question how experts make sense of NAP
implementation gaps and what remedies they suggest to improve AMR
governance in Austria. The ndings show that the implementation
decits are shaped and perpetuated by a variety of (sometimes inter-
linked) issues and features: policy fragmentation with selective priori-
tization; scattered responsibilities without clear mandates; and lacking
incentivization of those experts that assume the main work of effectu-
ating AMR policy. Whilst the implementation gap has mostly been
associated with LMICs (Wellcome, 2020) and explained by a tendency of
“isomorphic mimicry” (Munkholm & Rubin, 2020a), the ndings of this
study point to forms of agenda conformity and policy ignorance also in
Austria. Through these lenses, Austria, a high-income country with a
differentiated and operational administrative and public health system,
also appears to prioritize agenda conformity over actual implementation
of important AMR mitigation measures.
In contrast to its high priority at the international level, AMR has
only received little priority at the national level. According to in-
terlocutors’ accounts, this low priority is due to the perception of a
relatively stable resistance situation in Austria. Mainly, this policy
ignorance was discussed both in terms of data gaps (making evidence-
based long-term planning difcult) as well as a more general reluc-
tance to implement the measures articulated in the NAP-AMR. As con-
cerns the latter, the low perception of risk, arguably, is associated with a
low sense of urgency. Further, the data gaps concern comprehensive
consumption surveillance (in hospitals), the “non-linkability” of data (e.
g. prescription to consumption or diagnosis) and the general data situ-
ation which is predominantly based on clinically relevant “problematic
infections” in the primary care sector. This fragmentary data has a
bearing on the institutional level as a form of policy ignorance. Not only
does the lack of this epidemiological knowledge impede a planned and
prudent stewardship/mitigation plan; also, as a “convenient unknown”
(Paul & Haddad, 2019), sustains a complacent perception of low risk and
low urgency in Austria. As for the role of strategic policy ignorance, its
function seems to be based less on unknowing the reality of AMR as such
than on downplaying its meaning and imminence for Austria. This
strategic tendency is reected in the temporalization of measures:
postponing implementation deadlines and merely repeating measures
already in place.
This deferred implementation complements the point Broom et al.
(2020) made regarding the “temporal myopia” at work in AMR gover-
nance, i.e., the prioritization of short-term, quantiable outcomes
instead of longer-term AMR mitigation actions (Broom, Kenny, Prain-
sack, & et al, 2021). The continued perpetuation of plans envisioned and
existing measures replicated render AMR a constant policy process that
stretches the policy cycle between agenda setting and implementation
(Paul & Haddad, 2023). Moreover, this politics of deferral and post-
ponement was expressed by the various “paper metaphors” used to
polemically describe the implementation decits and reects a lack of
embodied sense of responsibility and accountability from policy makers.
The ndings suggest a prevailing tendency at the national policy level to
wait until the problem is being tackled and resolved through interna-
tional legally binding mechanisms. Only these binding legal standards,
or so it seems to be the view among policymakers, would generate the
necessary pressure for effective implementation.
In sum, the lack of legal obligations (i.e., the largely voluntary nature
of many aspects of the NAP-AMR), the specic distribution of compe-
tence and responsibility in a highly federalized health system, and the
nancial aspects of scattered responsibilities (i.e., the politics of which
investments are prioritized in Austria) shape the implementation decit
in Austria. Not only are budgetary resources generally lacking; what is
also lacking are specic nancial, symbolic, and social incentives for
actors at different levels in the health system to fully commit to AMR
stewardship and make it “their business”. The system of domestic AMR
mitigation and thus implementation of the NAP-AMR has so far relied
mainly on idealists and those who can afford to work on this issue. From
the vantage point of actors in different positions in the healthcare sys-
tem, these lacking incentives pose a concrete practical “values problem”
(Broom, Kenny, Prainsack, & et al, 2021): there is, it seems, always an
investment that seems more important and a training that is of more
immediate relevant to professional practice.
All these tensions and difculties point to the challenge of anchoring
AMR as a priority value in the healthcare system. Not only as an abstract
general principle or ideal of a (health care) system, but also as a prag-
matic and practicable form of valuation, translatable into subjective
preferences and the lived value hierarchies of individuals. This certainly
requires money, but also institutional transformation.
8. Conclusion
The insights gained by closely attending to the experiences of key
actors in the Austrian AMR-related health policy community suggest
M. Jeleff et al.
SSM - Qualitative Research in Health 4 (2023) 100332
9
that institutional and policy fragmentation, scattered responsibilities,
agenda conformity and the lack of incentive structures were at the root
of the problem; a problem of governance of AMR, that was predomi-
nantly framed in terms of an “implementation gap”. While many of those
measures listed in the NAP-AMR (transferred from the WHO’s Global
Action Plan) indeed represent much needed requirements for AMR
governance, these, however, do not sufce. Measures that are being
superimposed on existing institutional forms and practices do not
address structural concerns (e.g., staff shortages), power ties and vested
interests (within a fragmented health care system) nor do they properly
consider those who (must) put these reforms into practice. As a result,
these reforms do not alter the basic principles and standard procedures
of existing societal practices and institutions that are necessary to
confront AMR at its roots (a structural problem of high modernist
societies).
Approaches that seek to “solve” the AMR crisis through distinct and
once-and-for all measures therefore misconceive also the structural
transformation that is under way in the microbial biopolitics precipi-
tated by AMR. As Kirchhelle et al. (2020) emphasize, “AMR is not a
problem to be solved but a phenomenon to be continuously managed”.
This insight demands a comprehensive rethinking of how we as societies
deal with infections, but also how we organize our vital systems and
institutions – from medicine, to food sector and agriculture. This pros-
pect then prompts us as societies to reorganize public health from the
ground up, in terms of its organizational principles, guiding values, and
strategic direction.
Funding
M. Jeleff and R. Kutalek received funding for this study from the
European Union’s Horizon 2020 research and innovation program
(Grant Agreement Number: 825671)
CRediT authorship contribution statement
Maren Jeleff: Research design, data collection, Formal analysis,
data interpretation, development of the conceptual approach, literature
review, Writing – original draft, editing. Christian Haddad: Formal
analysis, data interpretation, development of the conceptual approach,
literature review, Writing – original draft, editing. Ruth Kutalek:
Writing – review & editing, Funding acquisition, Supervision, of Ph.D.
work of M. Jeleff.
Declaration of competing interest
The authors declare that they have no conicts of interests.
Acknowledgements
The authors wish to thank Katharina Paul, Helena Segarra, Marlies
Zuccato-Doutlik, Viktoria Parisot for their valuable feedback and
reection upon data/coding.
Further, the authors greatly acknowledge the contribution of the
participants of the research for their time, openness and feedback.
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