 All right, so let's go ahead and that probably are the colleagues who are running in a minute or so. Welcome to this Knowledge Dissemination Dialogue webinar. For us, we changed the schedule, so now we do it twice a month. And one of them is run in the afternoon, hours afternoon in Central Europe, from 3 to 4. And so we changed, we are still all thinking that the lunchtime used to be, but we changed it to accommodate different regions' time zones. And so thank you for joining. And it will keep being that this one morning, the next one will be in the morning, towards the end of the month, morning in Central Europe, any afternoon this one. So welcome. And thank you Francesca. Francesca will be our speaker today to address this interesting topic of corruption in the airman. So I'm very much looking forward to it. Francesca will be addressing the relationship between corruption and AMR. And Francesca is a public health professional. Just finish her Master's in Public Health in UK. So it will be interesting to share with us what she has learned. A couple of housekeeping rules. Please keep your microphone on mute. Rename yourself with your name and organization. And please note that the views presented in this case today by Francesca are her own opinions and not necessarily FAOs. If you post something on the chat referring from, this is your company and any commercial product or brand. And at the end, we always ask the speakers to make their presentations relatively short, about half an hour. And then to have a dialogue, that's why the name of the webinar series to have a dialogue at the end. And please post your questions in the chat and the speaker will try to address them. I'll read them out and then Francesca will address them. Also keep in mind that this meeting is being recorded and afterwards. We always share the link in our dissemination channels. So please keep that in mind. Don't worry about the presentations and the materials. All of that is shared afterwards. So just enjoy the knowledge that Francesca will share with us. So that's it from my side, Francesca. Thank you for making your time available for us. And then for to you. I'll stop sharing. Thank you. Hello everyone. Thank you, Georgie and Dr. Pinto for actually let me go to my PowerPoint and start that presentation. Yes. Okay. Can you guys confirm that you can see my screen. Perfect. Okay. So I'm as Dr. Pinto Farera said, I'm here to talk to you about my summer project for London School of hygiene and tropical medicine, which is about corruption and Amar. And this project, the idea for this project actually sparked from a conversation that I had with Dr. Pinto Farera, and that I thank very much for allowing me to be here and present my research findings. I call a professional and other than Dr. Pinto Farera credits for this project. Go to Dr. Meenakshi Gautham, which is a professor at the school that she's been an excellent supervisor for this year. So let's start. As everyone knows, Amar is a complex problem threatening worldwide public health. Currently around 1.27 million people are affected by resistant pathogens. The environmental management of antibiotics drives a positive selective pressure toward pathogens that are antibiotic resistant, which will make it harder to treat infectious disease as antibiotics are becoming less and less effective. But overuse of overconsumption of antibiotics is just one way of driving Amar for which there is actually an evidence of a dose dependent relationship, meaning that to give an increase in antibiotic consumption corresponds a proportional increase in antibiotic in antimicrobial resistance. However, antibiotic antibiotic resistant pathogens can also be acquired through two other pathways, the direct spread of resistant pathogens from humans to humans or to animal to humans or from animal to animals and environmental spread, which is basically through either hospital wastewater or large wastewater that could be used as fertilizers. The relationship between AMR and antibiotics is not a perfectly linear one, as it lacks backing from observation that reveal a high proportion of AMR in various low and middle income countries, despite lower per capita antibiotic consumption, compared to high income countries. This highlights the fundamental contribution of contagion and environmental spread in driving AMR. All these three pathways, so overconsumption of antibiotics, environmental spread and contagion are taken into account into the five pillars of antimicrobial stewardship, which address both the appropriate use of antibiotics and the intervention to prevent infections and environmental spread. Precisely, the five pillars of AMR are establish and develop national coordination mechanism for antimicrobial stewardship and develop guidelines, ensure access to and regulation of antimicrobials, improve awareness, education and training, strengthen water sanitation and infection prevention and control, and surveillance monitoring and evaluation. These pillars are essential to reduce antimicrobial resistance because they are their aim to prevent the spread of multi-resistant pathogens and maintain efficacy of existing antibiotics. Delving deeper into what causes AMR, determinants are next. To briefly explain what determinants are, I chose this image that shows men from a village that keep falling into the river. Villagers keep throwing lifeboats at them, but unless they remove the slippery stones upstream the river, they will not prevent the fall. Acting upstream, in this case, removing the stones instead of downstream, which are basically the lifeboats, enables the prevention of diseases and not just the cure. The determinants of health are often structural elements of society, like socioeconomic conditions or political situations. For my project, I conducted a quick preliminary review and I found that the upstream determinants of AMR are alkyr per capita expenditure, temperatures, health systems quality and corruption, which is the determinants that I went on to explore. Interestingly, one study from the quickly preliminary review reported a positive association between corruption and AMR, so the higher the corruption, the higher the AMR. I found more ecological studies reporting a link between these two. It is worth mentioning though that they were carried out, this kind of study, the ecological one, they were carried out in high income countries where population level data are abundant and available. So corruption hinders efforts to combat AMR, but we don't know exactly how, which is what I aim to do with my piece of research. But exactly what is corruption? Corruption is a critical concept that is related to adherence to legal principle and societal standards. For my study, I took on with the definition of corruption being the private gain at the public expense. It encompasses both illegal forms of corruption such as fraud, informal payments, theft of drugs, the ground corruption, bribery and embezzlement, and also not necessarily illegal forms just like conflict of interest. Corruption and health care practices exist in both low and high income countries and of course in all domain, but health care is particularly susceptible because of the nature of the patient provided relationship, which is characterized by the asymmetry of information. But going back to the mechanism of action, how does corruption influence AMR? My hypothesis was that corruption may impact AMR by disrupting the strategies of antimicrobial stewardship and undermining their efficacy. For instance, there is evidence that antibiotics are being sold in unlicensed drug shops or by untrained personnel in low and middle income countries, and that health care personnel receive informal payments in exchange for unnecessary drugs or treatment, which is likely to impact antibiotic use. In the same way, if personal protective equipment is stolen from hospitals, it could make it harder to control infections. So to summarize, the objective of my study was to identify corruption mechanism that hinders progress in tackling antimicrobial resistance, which have not yet been documented in literature. More specifically, I went on to explore which corruption manifestation acts on which pillar of AMS and which forces drive it and what are its possible solutions. So I only had three months to complete the summer project, so I had to find a methodology that allowed me to quickly review the literature without it being a full on systematic review because first of all, I only had three months again, and it was just me looking at the literature. I was not a quick word about inclusion criteria. I was not expecting many studies to be here to be there in in the in databases because of the topics. So I included most study types, excluding commentaries, conference papers, preprints and retracted publications. Always due to time constraints, I only focus on human subjects, leaving out animals, and I chose to exclude papers that were reporting manifestation of corruption that were perpetrated by people that weren't aware of cause and harm. The reason for this is that for corruption to fit the definition of corruption, there needs to be a transaction between private gain and public expense. And although one could argue that such transaction still happens, even though the people that perpetrated are unaware, I was still more interested in manifestations that were aware and deliberate. Once done with the systematic research, I ended up having two big clumps of studies, the quantitative, made of mostly ecological studies and the qualitative one. Quality appraisal and data synthesis were performed using different tools according to the study type, which has been challenging because it really doubled the process. Quantitative studies were praised using the CASP tool and analyzed using the rapid best fit framework analysis, which uses a deductive approach of mapping data from the included studies onto a framework. In this case, the five pillars of antimicrobial was my choice. For quantitative studies in that instead I use the access tool for quality appraisal and a narrative synthesis approach because outcome and measurements were comparable, even though there were still two heterogeneous for me to make a meta analysis. So now on to results. Here you can see a Prisma diagram which basically synthesize my systematic search. My systematic search lasted two weeks I explored five databases, and my, the final pool of the initial pool actually about articles with around was about 811. Then it was after the duplication so after removing the duplicates and it was reduced to 541. After the first screening, it was 71 and then the final number of articles was around 25. I performed quality, I performed quality appraisal, but I had to include all 25 papers, even though the quality was not so great, especially for reviews and and cross sectional studies. A bit of study characteristics, a bit of demographics. So, most studies, so the qualitative studies accounted for 40% of the total, followed by ecologic studies at 24%, cross sectional studies at 20% and reviews at 16%. Most articles centered on research conducted in Asia around 48% and Europe around 20%. Just 12% focus on African countries and the rest either did not specify origin or had a global scope. Most studies 60% focused on low and middle income countries and 24% focus on high income countries. Most studies investigated link between corruption and antibiotics access and regulation around 56%, followed by corruption and AMR in general. The studies were mostly conducted in the community and the qualitative finding paint a rich picture of the daily menage of community pharmacies informal drug shops and private practices. Okay, so now let's delve into the meaty part. These are the results from the ecological study they use population level data to study the relationship between AMR and corruption. I, most of the time, indexes were used to estimate AMR and corruption. Overall, all the studies pointed in the same direction that there is a strong association between antimicrobial resistance and corruption. And specifically, there is an inverse correlation between the indexes of control of corruption, governance indexes and corruption perception indexes and the various antimicrobial resistance indexes, meaning that for every improvement of the former, there would be a decrease in the latter. The strength of this inverse correlation seems also coherent. In almost all studies, an improvement of the corruption index of one unit will cause a reduction in the antibiotic resistance index of around 0.4. The most interesting part of the study for me was the qualitative analysis which provided descriptive accounts of various forms of corruption, each affecting one or more pillar of AMS. So overall, the manifestation of corruption that I have identified are over-the-counter sale of antibiotics, the influence of pharmaceutical industry education and training, concept of interest, counterfeit drugs, payment of cash to state official and regulatory capture. Unfortunately, the systematic search found only papers asquavable to the first three pillars of AMS, which are establishment of national guidelines, antibiotic access and increased education and awareness, and I could not find any manifestation of corruption linked to pillar four and five. So here I will present the findings for each pillars of AMS involved, starting with the first one, which is to establish and develop coordination mechanism. Only two qualitative papers reported on how corruption impacts the first pillar. Both studies were recent and reported data from low and middle-income countries, and both mentioned corruption-related barriers to implement WHO-led AMR National Action Plan or not. The first study was carried out in Pakistan and discovered that policymakers were actually reluctant to endorse restriction on powerful professional groups such as doctors or pharmaceutical companies, whereas they had no problem in casting them on informal drug sellers. The authors pinned on powerful healthcare lobbies the lenient regulation on antibiotic prescription, which then impaired the implementation of AMR NAB. The second study was instead conducted in Myanmar, and the authors uncovered complex connection between regulatory agency, state officials and informal drug providers. These letters provide easy access to antibiotics to the population. State officials are aware of this. Nevertheless, some of them require bribes to turn a blind eye. The reason for this seems to be ascribable to their insufficient government salaries, and the government, in turn, tolerates the bribes because it avoids them raising the pay of their officials. Both studies suggest that global policymakers should increase the involvement in the local national context before implementing policies to avoid promoting an over-prescriptive, almost one-size-fits-all policy. Going on with the second pillar, which is to ensure access and regulation to antimicrobials, this one rubbed the majority of the studies retrieved, and a manifestation of corruption identified where the over-the-counter sale of antibiotics counterfeit drugs and conflict of interest, which will explore one by one in more details. We'll start with over-the-counter sale of antibiotics, which is defined as the sale of antibiotics without a prescription. Most of the studies reporting it were predominantly, again, LMIC-based, and authors identified two main drivers. One ascribable to the demand, so on part of patients, and the other one on the offer, on part of drug providers. These two pull-and-push forces are synergic. The push is the growing demand for antibiotics from patients who do not want to consult a physician because of how resource-intensive it is. They need to accommodate time and money, travel long distances, miss one or more days of work, pay for the doctor consultation, and also for the full course of antibiotics. So they will rather go straight to the pharmacist slash informal drug provider and ask for antibiotics. The pull is the fear of losing clients if the antibiotic is denied from doctors or drug providers. Losing clients means decreased revenues for drug shops and pharmacies, a condition worsened by the high market competition. Several authors believe that this is fueled by the meager salaries earned by former and informal drug sellers. In between these push-and-pull forces, there should be the regulatory hand of the government that protect the citizen from exploitation using laws and regulation. However, these laws are reported to be lacking or not even enforced, or even sometimes they seem to fuel the market competition. Counterfeit drugs, which is the next manifestation of corruption associated to this pillar, are drugs that are deliberately and fraudulently mislabeled with respect to identity and source. Two studies, I found two studies that were linked to these manifestations, and in both the studies that were carried in Benin and Laos, almost 60% of the essay drugs were not compliant with quality requirements. Even though, in both cases, the author could not determine if the low quality of the drug was attributable to faulty substandards or decay, or actually was attributable to falsification and counterfeiting. Counterfeit drugs being sold in drug shops and pharmacies is actually an important concern for medical professionals and health workers, as reported in many studies. However, the professionals also report to be aware that even registered drugs could be faulty and substandards, because they think that the quality checks are not actually in place. As a matter of fact, some drug sellers reported that they did not believe they were harming patients by selling them unregistered drugs, but rather they were providing an equal level of service for just a smaller price. A key driver identified by several papers were the high tariffs and taxes that were put on registered drugs in lower middle income countries, which led to increased drug costs, driving down and sending for supply, causing a subsequent scarcity of antibiotics, which is a condition exploitable by counterfeiters that can fill the gap in the market. Other structural drivers are the excessive reliance on international supply chain, which often evades the stringent regulatory supervision of the national supply chain and the lack of quality assurance programs. One of the solutions that were identified to combat this problem was criminalization of falsified medical products, which is a very downstream solution, and the strengthening of the structural flaws in both the supply chain and improve the quality checks. Moving on to the last manifestation of corruption for this pillar, we find a concept of interest, which occurs when personal interest interacts with professional obligations. Hospitals and pharmaceutical industries often exert pressure on providers by incentivizing the sale of antibiotics, jeopardizing the capacity of a provider to make an unbiased decision, and this happens all over the world. Medical representatives are rewarded. This is an example that came from the papers from this review. Medical representatives are rewarded based on number of antibiotics that they are able to sell. And to increase their sales, they share their rewards with drug providers. These relationships gave them access to other networks, which in turn helped them expand their business opportunities. Similarly, they also tried to incentivize prescription of antibiotics by providing doctors with sponsorship to Congress or gifts. Of course, there is no obligation for them to sell the given drug, but it is a very important, not subtle, not so subtle way to influence a prescription. Regarding the drivers, the studies have identified again poor salaries of doctors and drug providers as main driver together with a lack of protective regulation and high market competition, especially in low and middle income countries that see that there is an insignificant out-of-pocket market for their expense and private hospitals. The natural proposed solutions was to decode the couple, the incentives from sale targets to increase ethical practice and to increase also quality controls. Now we are a third pillar of AMS and the corruption manifestation that I found to be associated with that. And this pillar is to improve awareness and education on AMR. So in this topic, I only found two studies, again both conducted in low and middle income countries that dealt with the topic. Both studies identified corruption as the undue influence by the pharmaceutical industry on drug provider education, informal and informal healthcare. Controlling education on antibiotics can lead to biased prescription favoring overuse and ensues. The examples that were given from these two papers was that pharmaceutical company representatives were often the single source of new knowledge, especially for informal health providers, as they often organized meetings, conferences to promote their products among local drug providers, especially in remote areas. From both papers transpires that one of the major drivers is the lack of widespread institutionally provided training, which is independent from pharmaceutical interests. And of course, one of the solutions that were suggested was to actually provide such training. So this is coming to an end. And here I tied all of the knowledge coming from a systematic review in this logic model. If you see on the left column under the inputs, these are all the drivers that are color coded depending on the frequency of retrieval, with insufficient protection law or enforcement being the most common driver that I found throughout the papers. And they are categorized into three groups, so socioeconomic conditions, government and healthcare structural flaws and emerging private interests. Each of them is then linked into the activities, which are the manifestation of corruption that I was able to fetch, and that are linked to the AMS, to the five pillars of AMS, which are then directed toward one or more mechanism of acquiring a resistant pathogen or genes, which then leads to antimicrobial resistance. What this logic model shows is how the structural feature of a country create a fertile soil in which manifestations of corruption persists. For example, poverty is a significant factor that often forces people to prioritize their basic needs over seeking medical attention. Patients in these studies only sought medical help when their conditions were severe, viewing a doctor's visit as a luxury they could rarely afford. Spending money on medicine or food was more critical for them than visiting a healthcare provider. They believed antibiotics are the only cure that could help them recover and return to work in order to supply their family. Antibiotic consumption seems deeply entangled in the daily life of people living in lower middle income countries, and most of all in rural areas and informal settlements, because it is connected to the ability to work and survive in an equitable place. People actually broker their emancipation from an unjust environment through antibiotic use. Before concluding, I'd like to point out a couple of limitations that I had during my research. First of all, there is this big data gap of data that could be retrieved from lower and middle income countries, which were mostly qualitative in high income countries. Because high income countries studies were mostly ecologic and focused on the relationship between corruption and AMR because they had population data that are routinely retrieved because they have high capacity for research, why we don't have the same in lower middle income country. That actually impairs both the research capacity and the data that we're able to get from lower middle income countries and also impacts my external validity, the external validity of this study. The results from this research may only applicable to lower middle income countries. Also, the quality of studies was not always great. Ecologic studies and qualitative studies fared better and had higher scores than reviews or cross-sectional studies. And also, I'd like to point out that since I am a researcher coming from Western countries, I might have actually read the accounts coming from lower middle income countries. Through a Eurocentric and Western lens. So to wrap it all up, I have some take-home messages from my research, which I think are fitting. Corruptic practices in the use of antibiotics in lower middle income countries seems to be filling the gaps left by the government and institutions. Fighting corruption will need to account for country-specific dynamics rather than one-size-fits-all plan. Because the use of antibiotics is deeply rooted in the socioeconomic fabric. Also, there are important gaps in research and I think I advocate for qualitative studies to be done in high-income countries to retrieve the same kind of breach accounts from those countries. And also, a review with similar objectives to this one should be carried out in the food and environmental sector to uncover further mechanisms on corruption that are in their AMR and have the full picture. That's it for me. Thank you so much for your attention and I am open to answer all questions that you shall have. Thank you. Right. Thank you, Francesca. Great presentation. Very clear and very interesting. Many of us do not work in these topics. We don't necessarily think about these connections. So it's great that you made that good pieces together that we usually don't put and think in systems and you went from the salaries of officials to counterfeit drugs. So I found it very, very interesting and it's not surprising that you get many questions in the chat. And I have a couple of myself, but let's first address the ones that came in the chat and then we go to the others. The first one was on the sample size. And I guess in this case it will refer mostly how many papers we looked at because the basis of your study was the liquid review. So the question was how much is the sample in total you addressed in your survey. I guess in this case it would be about the papers that you included. You explained that if you could cover that better. Yeah. So the papers that I included overall were 25. If I can go back to share my screen, I can go back to Prisma Diagram if you want. Let me go just back here. Can you see my screen? Not yet, but maybe. Okay. Yes. Okay. I'm going to go back to the slide in which I had my Prisma. Yes, there it was. Yeah. So the included studies, the overall included studies were 25, but overall the one that I could include because they would be includeable after the first screening, they were 71. But then I had to, I went into the full, I screened them using the full text and then they were not fitting. So it was around 25. Then I had to exclude, I think the inclusion criteria that was more strict was the one regarding the intention of people perpetrating manifestation of corruption because I excluded those papers in which people perpetrating corruption was not aware. So for example, they were selling antibiotics, but they didn't know they were harming patients because of AMR, they didn't know they were fuelling antimicrobial resistance. So I think that if you include them, you might have a higher number of studies, but still there was not much literature on the topic at all. Thank you, 25. Now great. And being biased, I fully agree with your next suggestion of next step, look at one's food and animal protection, being fully biased, being a veterinarian that will be interested in looking at that side. Let's move on into the questions that came up in the chat. One question, are the quantitative studies solely based on correlation? So a question on correlation of your studies. Yes. Yeah, so the quantitative studies that I was able to gather, first of all, they were all the gathered data from Europe and the gather routinely collected data, so population level data, both from AMR and for corruption. Corruption and both AMR and corruption were not like, of course, directly measured, they were estimate from indexes, and they were not, especially from AMR for corruption, they were they were indexes coming from the literature, so it was not, because it's not really measurable as for now, corruption. I had, I found transactional studies, but they were survey based and they were more qualitative than quantitative. So yeah, so the strong quantitative part was mostly based on correlation and they were mostly ecological, which we all know that kind of study have a lot of studies have a lot of fallacies. Great. Thank you for the next question is also on the correlation. So asking if the study you only integrated correlation between the corruption index and AMR, or you use some more refined metrics is like the antimicrobial use per kilogram of biomass, or the amount of counterfeit drug sales. So if you look at the correlation between corruption and AMR or other metrics is like AMU per kilogram of biomass or the amount of counterfeit drug sales. No, I only found the core, I only found papers talking about corruption indexes and AMR indexes, not even just AMR in general just, or like for example, I don't know the burden of the burden of AMR not just AMR indexes and corruption indexes. Regarding counterfeit drug sales, it's really hard to find papers that give you a number because I found these two papers that literally took samples of drugs and put them under, put them into the essay machines and to look for the quality of the drug. But that's it. I couldn't find like many papers talking about counterfeit sales, which I think it's really interesting because I read that there are lots of emergencies, especially with one happening in Nigeria with kids dying from counterfeit drugs. So I think it's an emerging problem in this country and has been for a lot of time in lower million countries. Thank you very much. One interesting about the interviews I guess you addressed because I mean it really triggered a lot of interesting questions and follow ups. One way you had this in mind, a colleague is asking if the study includes interviews on the manufacturers about counterfeit drugs. So I'm assuming that it was basically the literature review. But if you thought about that, including interviews with the manufacturers about the counterfeit drugs. No, it didn't. So the literature review did not. So basically I found some interviews of drug sellers providing counterfeit drugs, but that was as far as the researcher or that primary study went. She did not or she or he did not find any other, she did not find any other manufacturer of counterfeit drugs or any other person involved with the counterfeiting. I think it would be very interesting to ask them about about to ask the manufacturer about counterfeit drugs also to understand to understand like to have more insights on how they try to. They actually escape the quality checks and and how to how they they're able to insert their lots in the in the markets because it is I think one era which has been not discovered yet so many people many authors were saying that they are not really able to understand like how this big lots of counterfeit drugs enter the markets without being without being checked at all. Yeah, we have been doing some work on that thing we did a pilot in each and one of the reasons why it says and been much study comes with many, many challenges to put together the the parts of those drugs and the testing of those drugs. It comes with significant challenges that we were somehow aware when we started, but it became even more when we tried to do it but we will keep moving, but it's it's one of the reasons it the endless challenges to actually analyze those drugs. But very good point on. Next, if your work, if review has already been published, or if it on the way or how are you in the public with it will take some time between the work and the actual publication till you actually have the PDF, and you have it usually go out for dinner to celebrate so tell us how you are in terms of the Yeah, I'm still, I'm still, I'm working toward it, but I've been busy the last few months but now I will work toward the publication of this manuscript as soon as I can. I'm really here to publish it yeah it's been a lot of I think there were many people interested in in reading it and further working on it which is great and then that's one of the purpose of these dialogues is always to trigger collaboration collaboration between the speaker and FAO and colleagues in the chat and that's that's the goal of this to trigger further collaboration of interesting work like like yours. Next question in the case of counterfeit the two week postmark of surveillance. Should we slowly blame it on corruption as you highlighted or just low budget allocation by government. So I guess the question is, why do we have counterfeit time. That's the, the question that we post market of surveillance or corruption or low budget allocation by governments to fight this. Yeah, I think the, I think what it's interesting of this whole work is that corruption is not something to blame at the end of the day, but it's a way that people find to actually broker their emancipation and how it's a way for them to go on with their life and survive, because they're already embedded in a in a fabric which is really unfair. So corruption corruption is just one way that they can use to survive in the case of counterfeit drugs. I think. So counterfeit drugs are a part like our manifestation of corruption right, and I like the studies that were that that I found in my research and my research piece, we're actually blaming. We're actually blaming the high market, the high taxes on drugs so that were not that they did not drive the incentives of government to actually have to actually to actually stock on antibiotics so there was a scarcity of antibiotics in that particular country. And because they weren't enough antibiotics and the one that were in the farm in the pharmacies were actually costing a lot of money. They did a gap. So, a counterfeiters filled the gap by inserting unregistered drugs being sold mostly by unlicensed drug shops. So I think that counterfeit drugs are surely a manifestation of when a government of a government being falling short on something. Very good. About government, the next question relates to the natural action plans, natural action plan on a market. And so the question is, how do you see the impact of your of your leadership review related to the implementation or open open and the civilization. The big work of national action plans so many countries are now, most of them do have a plan that not most of them have a plan. And I'll say most of them are already implementing them. The summer struggling with the funding which is a common problem that they might develop on but they struggle to find the funding to implement it. But how did you ever think about that the connection between your result. And for countries are implementing or even revising the national action plans on the MR. Yeah. So, the, the, the, the WHO led any MR now had several, several recommendations for for countries and one of them, for example, to create a technical group, right. You can see this as being a technical group and actually try to find some leverage in the government to actually strengthen the governance. And I think that is quite tricky for lower middle income countries because this, as long as we stick to the results of my, of my research, the problems is really sometimes lying in the government is itself, which are not improving the salaries of public officials like doctors and pharmacies, which is itself, given incentives for these professionals to promote over the So, so yeah, I think this could be a big problem if you talk about strengthening governance and actually involving government representatives and then actually having them not to talk like you have to have them not to talk about the MR, but first of all, you have to talk to them about giving incentives to people, they're actually working in a frontline of healthcare to be able to, for them to engage in ethical practices, because then what's the purpose of having them talk about a MR if you don't address the structural flaws that you have in the government. And also, for example, there was another suggestion from the NAP that is, again, the funding if you don't allocate, like you need to allocate funding for a MR, you need to allocate funding for for people to be able to do it to promote education awareness but then, then again, like, what can we do if, if they're not allocating funding then to the, to the subsidization of antibiotics so that they don't have antibiotics that are that are sold in a good amount in in pharmacies. So I think it's a problem of structural like, or at least for the lower middle income countries, they should revise their, not that they should revise because I'm no one to say what they should be, but defining my research, they're aiming at saying that probably global policymakers and in should engage more in the local environment before writing up a policy that it's global. All right, very good. The next one, you might want to tear again your screen, because you have a good slide addressing it. If you could please repeat, are you defined corruption? Is it that deliberate behavior to deceive or defraud? And if you looked at the relationship between trust and corruption, so either you can just address it or you might want to Yeah, we can see. Okay. So this is the slide. Let me share it. Yeah. This is light and I defined I use the definition of the private gain at public expense so basically I use this transaction between something that it's private so my own private interest and something that is paid by the public so I'm prioritizing my interest over the common, the common good, basically. And what was the question again other than this one definition. What was your definition of corruption and if you look at the relationship between trust and corruption. No, I didn't. I didn't look into the trust and corrections, I think it would be very interesting because most of the accounts coming from positive papers were actually saying that they did not trust the government, especially when it comes when it came to counterfeit drugs. The same health professionals that were condemning contrafeit drugs were not putting trust in registered drugs because they did not believe the government was able to provide quality checks on registered on registered drugs so I think that would be that is an interesting an interesting questions and that's why I think that it would be interesting also to have accounts, qualitative accounts of corruption coming from high income countries because it's also it's always a taboo topic to talk about corruption in high income countries, while I think that I think that you will see in the future that in countries where the government is trusted, the less there will be a higher levels of corruption, because we don't we just don't trust each other we just we just don't trust the government so we will find our own ways to survive, which is probably legal. The next question, if you may be in this literature review, if you I mean your focus of corruption and EMR and the question from the colleague if you have, how do you think results that you found would align with similar studies on corruption and other health issues to come across some studies on that corruption and other health issues not amr other diseases or any other link between health issues and corruption for no way, but other corruption and other health issues if you if you came across some papers on other not amr I think that I saw a couple of papers focusing not on on amr because in the preliminary review and in there is this general association with corruption and worse health outcomes, but in general, and that's also coming from ecological studies which have the fallacy of being ecological so you just see the bigger the bigger picture you just see the bigger association but if you if you delve deeper than you might see different things. But I did not explore specific like a specific health issues, just the overall outcomes and I think that that's the trend more corruption worse health outcomes. Okay, thank you for the question about and the graphic, the different graphical areas and the different graphic results. And it was very interesting that you highlighted the limitation of your studies, we see it, both of us, for example, European so we would see three the papers with that angle, which is my default bias as much as we tried to control it. And so there was a question of that, did you see any differences between geographical areas for example Asia versus Europe. I wish I could compare them, but unfortunately I don't have data I don't have in my review studies ecological studies coming from Asia, nor I have qualitative studies coming from Europe so I can't really compare the two. I only have qualitative papers for Asia and only have ecological study from Europe. And that's a big gap in knowledge because we shall start collecting, we shall start like collecting, making doing interviews on corruption in Europe so that we have the same amount, the same kind of knowledge and we can we can actually compare them and actually trying to understand which are the underlying the determinants and mechanism that fuel corruption and, of course, and determines the worst health outcomes and worse, in the areas. Thank you. There is also a question on. And I think this is a broader present how do you would improve the health systems so that people do not have to turn into informal markets the issue about counterfeit drugs, or even expired drugs. So I think you touched about a bit about that on the incentives for example, but the question is that how do you think from your literature review, we could improve the health systems, so that people do not turn into the informal markets where they might find the expired or counterfeit drugs. And that's one million dollar question. 30 seconds to answer that. Thank you for the trust but I think that, I don't know, it really comes down to poverty to fighting poverty in some case so I think before trying to strengthen health systems, I think we should, we should focus on combating poverty and trying to tackle the fabric of the country in which corruption lies, because once you fight poverty and once you make sure that people are living in a dignified way, you actually start seeing the health outcomes improve. And, and also yeah incentivizing people that are working in the frontline health care because they're the first defender of the health systems and they don't believe in what they're doing. If they don't engage in ethical practices then that it's going to be less trust on them less trust in the government. They're not going to believe the drugs that we will be giving them. And, and it's going to be just a cascade. So I think fighting poverty and then surely incentivizing the work of first line health care workers. The next one is, if you have a, I think you addressed some of these but maybe you want to emphasize some points or maybe address it both potential recommendations for medical regulatory authorities. In this case in low and medium income countries, and their impact on a mark so it would be the question on recommendations to medical regulatory authorities. I think you address some of these by speaking in general about governments know not just medical regulatory authorities but if you want to address it. And you can address the question. Yes, so one of the solution that were proposed by because I think it's about counterfeit drugs. The one of the things proposed was a very downstream solution which was the criminalization of of counterfeit drugs which I think it's not in place in many countries and that was one of the main issues that others were stating. But I think it's very downstream. I think, again, we should try to strengthen health systems by improving quality checks and by trying to subsidize drugs that are so important as antibiotics and by subsidizing them we allow pharmacies to be able to sell them properly on their prescription but for a price that is actually affordable by many people so that you don't just have to go and go buy it from a provider that is not registered. Thank you for checking. So I'll take the last one before we wrap up and out of and I know that you focus you very clearly said and explained very well that you focus on human papers human related literature. Just to see maybe colleagues that are listening to us would like to follow the other side or one of the other sides on the animal. You recall when you did the first lead to research where there's some other studies on on animals, the environment, use of antimicrobial implants, there was there some literature that you intentionally exclude because it makes elections yet make justice. Did that come across some results or not much was really just humans that you came across. I think they were fairly a good amount that's why I had to exclude them. I would I would have loved to include them, but there was a fairly good amount of correction practices with animals. And because this project only have only happens around across three months I could not include them because alone alone they wouldn't they wouldn't have made a whole systematic review but without but with them, it would have been too long. And I came across them especially for sludge sludge wastewater is used as fertilizers sold for environmental sectors and for for animals, the use of antibiotics and I think the one that that were inserted in in the food for animals I think was one of the big deals. And yeah, it would have been so interesting to complete the picture and have these two other piece of the puzzle so that we can understand how, how everything goes and I could, for me, I could complete the logic model and have have it all on one piece of paper. It would be great. So who knows, you might have the chance to follow up or other colleagues listening to us might be might be willing to reach out to you and I'm sure you'll be knowing you and know that you'll be willing to to getting that feed other colleagues and provide some guidance I think you learned a lot from your research to the matters that you used. And if colleagues are interested in our following up on the annual side. I'm sure we will need to collaborate and support and get. So that's it. Thank you very much. It was excellent Francesca very well done very thankful for you to take time to present to us your results. And we have shared in the chat, the feedback, the question and feedback for the, the question and to let us know what we can do for example, the idea to change the schedule came from the feedback questionnaire. So it's very much and we hope that right now our colleagues in the Americas this schedule is a bit better. And as I said, the next one will be on February 27. And it will be 930 am. So in that case, the colleagues in Asia might be a more decent time to corner to connect in working hours. So please do fill in that and you can for example suggest different topics and different speakers. The goal is that to colleagues, mostly working. We call it data in a broad sense, can be a little bit like Francesca so well presented today, but colleagues that are out there in the regions in the fields in the countries, making complete two different works and we have addressed a broad range of topics. So we are very thankful if you can complete that form and let us know how we can improve. So that's it. Thank you all for joining and thank you Francesca. I wish you all very good rest of the day. Thank you. Thank you. Bye.