Demystifying the commercial determinants of health in antimicrobial resistance through complex system dynamics.

Antimicrobial resistance (AMR) poses a significant threat to public health. The commercial determinants of health (CDoH) play a key role in shaping the development and growth of AMR. It is important to recognise these commercial factors and situate them within the complex system which describes the emergence and transmission of AMR, so that we can begin to evaluate their impact. There are several feedback loops in the AMR system that prevent a linear 'cause and effect' solution presenting itself to policymakers. These factors are all complexly interdependent and a solution requires recognition of this complexity. We take it for granted that one solution alone cannot tackle the issue of the growing threat of AMR. For this reason, we propose the use of complex system dynamics to visualize key interdependencies within the system. By building on existing systems maps of AMR, we propose to explore and highlight the relationships between the CDoH and AMR in order to demonstrate how commercial factors have consequences for and knock-on effects on other elements (and potential policy suggestions) within the system. In short, the proposed systems map is a tool that can be used to (i) represent some of the ways that commercial factors impact on AMR and (ii) visually simplify the complexity of the issue at hand. We provide a map that could act as a starting point to demonstrate our argument and act as a baseline to be developed going forward in collaboration with other research and non-research actors within the system.