Antibiotics | Policy Makers’ Perceptions on Implementation of National Action Plans on Antimicrobial Resistance in South Africa and Eswatini: A CARRO Framework Analysis

This study systematically analyzed critical challenges in implementing antimicrobial resistance (AMR) national action plans (NAPs) in South Africa and Eswatini using the CARRO framework (Coordination, Accountability, Resourcing, Regulation, Ownership). It revealed significant obstacles including insufficient multi-sectoral coordination, lack of accountability mechanisms, resource constraints, weak regulatory enforcement, and fragmented policy ownership, providing crucial insights for AMR governance in low- and middle-income countries globally.

 

Literature Overview
The article "Policy Makers’ Perceptions on Implementation of National Action Plans on Antimicrobial Resistance in South Africa and Eswatini Using Coordination, Accountability, Resourcing, Regulation and Ownership Framework (2018–2019)", published in the journal *Antibiotics*, reviews and summarizes key policy-maker perspectives and implementation challenges of national action plans (NAPs) on antimicrobial resistance (AMR) in South Africa and Eswatini. Based on the CARRO framework, the study analyzed qualitative interviews with 36 key informants, uncovering critical issues such as incomplete governance structures, poor intersectoral coordination, inadequate financial and human resources, weak regulatory enforcement, and insufficient policy ownership. The research provides systematic evidence for understanding AMR governance realities in low- and middle-income countries, offering significant policy implications.

Background Knowledge
Antimicrobial resistance (AMR) has emerged as a critical global public health challenge, affecting human, animal, plant, and environmental health while threatening global food security and healthcare systems. In 2015, the World Health Assembly (WHA) adopted the Global Action Plan (GAP) on AMR, encouraging countries to develop and implement national action plans (NAPs) using a One Health multi-sectoral approach. Despite both South Africa and Eswatini having established NAPs, implementation progress remains slow, particularly showing significant gaps in resource allocation, interdepartmental coordination, and policy enforcement. This study explores practical barriers encountered by policy-makers during NAP execution in these countries through the CARRO framework (Coordination, Accountability, Resourcing, Regulation, Ownership), revealing systemic challenges in AMR governance for low-income nations, including insufficient financial support, inadequate regulation, and unclear cross-sectoral responsibility allocation. The findings provide empirical evidence for optimizing AMR governance policies and offer actionable references for NAP implementation in resource-limited settings.

 

 

Research Methods and Experiments
This study employed qualitative narrative research methods, collecting perspectives from 36 key informants through semi-structured interview guides based on the CARRO framework. Research sites included KwaZulu-Natal, Gauteng, and Western Cape provinces in South Africa, as well as Manzini and Hhohho regions in Eswatini. Data collection occurred from November 2018 to March 2019, covering five core dimensions: coordination, accountability, resourcing, regulation, and ownership. All interviews were transcribed verbatim and analyzed thematically using NVivo 12 to ensure data reliability and validity.

Key Conclusions and Perspectives

• Both countries have established governance structures (e.g., South Africa's MAC and Eswatini's NAMRCC) for their NAPs, but environmental sector representation remains minimal, hindering comprehensive One Health implementation.
• Clear accountability mechanisms are lacking in policy execution, particularly in primary healthcare and agricultural sectors. Many implementers demonstrate limited awareness of NAPs, causing implementation fragmentation.
• No dedicated national budgets exist for NAPs in either country, with reliance on international funding. Resource limitations severely constrain the sustainability of AMR surveillance, education, and intervention programs.
• Regulatory gaps persist in antimicrobial drug control: In South Africa, conflicting legal systems from 1947 and 1965 enable antibiotic misuse; in Eswatini, although new pharmaceutical regulations exist, ineffective enforcement allows unrestricted over-the-counter antibiotic sales.
• Weak political commitment and delayed implementation occur due to insufficient cross-sectoral ownership mechanisms, impeding sustainable NAP progression.

Research Significance and Prospects
This study identifies structural deficiencies in AMR governance within low- and middle-income countries, emphasizing the importance of multi-sectoral coordination, financial support, and policy consistency. Recommendations include strengthening regulatory systems, establishing dedicated budgets, enhancing policy ownership, and improving environmental sector engagement for effective NAP implementation. Future research should evaluate implementation progress in both countries and explore mechanisms to enhance policy execution efficiency.

 

 

Conclusion
South Africa and Eswatini face significant challenges in AMR governance, including inadequate environmental sector representation in governance structures, absent accountability mechanisms, limited financial and human resources, weak regulatory enforcement, and unclear policy ownership. While both countries have established NAPs, implementation effectiveness remains constrained by heavy reliance on external funding and insufficient national resource support. CARRO framework analysis demonstrates that despite existing coordination mechanisms, insufficient intersectoral integration at execution levels hampers policy implementation. The study emphasizes that combating AMR effectively requires enhanced cross-sectoral collaboration, increased financial investment, and strengthened policy enforcement at the national level. Additionally, improving awareness and responsibility allocation among One Health sectors, reinforcing regulatory legislation, and promoting long-term policy sustainability are critical. Future research should track NAP implementation progress in both countries and assess execution outcomes following policy adjustments.

 

Kholiwe Shabangu, Sabiha Yusuf Essack, and Sinegugu Evidence Duma. Policy Makers’ Perceptions on Implementation of National Action Plans on Antimicrobial Resistance in South Africa and Eswatini Using Coordination, Accountability, Resourcing, Regulation and Ownership Framework (2018–2019). Antibiotics.