Reconsidering middle-Income country approaches to a global antimicrobial resistance (AMR) problem: A case study of Sri Lanka

Antimicrobial resistance (AMR) is a major public health threat, posing serious challenges to the effective management of infectious diseases within local, regional and international contexts. Studying multifaceted bases and the impact of AMR on healthcare in Sri Lanka from 1948 onwards, this study argues that the development and mitigation of AMR is a complex process, representing more than just a narrowly clinical issue. It claims that the problem has been underpinned by the socio-political determinants of antibiotic provision and use, in both Sri Lanka and the wider South Asian subcontinent. Adopting integrated critical historical and health policy approaches, this study is a detailed investigation of the evolution of antibiotics use and supply policies, their connections with the advocacy and politics of primary health care and universal health coverage, and interactions between the World Health Organization (WHO) headquarters, its regional office in South Asia and Sri Lankan administrations at all levels. This mixed methods thesis uses archival research and in-depth interviews to demonstrate how AMR be assessed in all its complexities, using techniques that can allow researchers to overcome several common constraints faced in studying this subject. This is also a study of how WHO structures around the world failed to pay sufficient attention to AMR in the face of rising evidence, from multiple national settings, of resistance to antibiotics in common bacterial strains. Studying the past in all its complexity, this thesis identifies contemporary health challenges in Sri Lanka in which disagreements and debates about policy, political and social pressures about expectations and rights, and economic difficulties and international aid flows helped to shape AMR-related health strategies and budgets on the ground. The thesis concludes by proposing that instead of the current approach of tackling AMR based on narrowly and technologically-oriented frameworks proposed by the WHO, Sri Lanka should look for alternative views and actions, rooted in specific socio-political needs that are transparently studied for the greatest public benefit. I argue that only this can help administrative efforts to effectively contain AMR in the national setting. Understanding this recent history of international actions based on AMR will enable the adoption of more self-critical, historically accurate and policy-relevant concepts of antibiotic provision and use and AMR at all different levels of governance.