Dele Rebstock, The University of California – Santa Barbara
Abstract
Antimicrobial resistance (AMR) is a leading global health crisis that threatens the efficacy of routine clinical care and medical procedures. The World Health Organization’s (WHO) Global Action Plan (GAP) has aided the introduction of National Action Plans (NAPs) against AMR. These plans remain difficult to implement and execute in low- and middle-income countries (LMICs), where the burden of infectious disease is high and diagnostic infrastructure is limited. Prevention and use based policy must integrate diagnostic and surveillance capacity with stewardship efforts. Examining data from WHO Antimicrobial Resistance and Use Surveillance System (GLASS), modeling AMR burden in LMICs, and country case studies from Zimbabwe and Nigeria, show that surveillance completeness is limited by laboratory capacity to generate antimicrobial susceptibility testing (AST) results. Evidence from Zimbabwe and Nigeria’s NAP implementation efforts demonstrate how limited diagnostic capacity and weak surveillance networks limit AMR control. A diagnostics-first approach along with strengthened surveillance capacity allows targeted treatment interventions, and makes stewardship efforts feasible. These findings support sustained investment in laboratory infrastructure, surveillance networks, and rapid diagnostic tools as foundational systems for effective and equitable NAP execution.
- Introduction
Antimicrobial resistance (AMR) has been identified as a top threat to global public health by the World Health Organization (WHO); often described as a “silent pandemic,” antimicrobial resistance threatens the foundation of modern medicine and increases the spread of infectious diseases worldwide. Antimicrobial resistance is a public health issue that has become a global health crisis; pathogens cross borders through travel and trade, amplifying the effects of AMR on a global scale.
Antibiotics are antimicrobial drugs used to treat bacterial infections, often used as a first line of treatment in clinical practice and a necessity for the safety of medical procedures including routine surgery and chemotherapy. When the effectiveness of antibiotic treatment declines, infectious pathogens are able to survive and spread – increasing the number of preventable deaths by infections that were once manageable. Bacteria that have evolved resistance are no longer killed by antimicrobial treatment.
The drivers of antimicrobial resistance differ across health systems and reflect regional medical capacity and systemic practices. The evolutionary pressures of antimicrobial resistance are increased by poor sanitation, under-resourced healthcare systems, and misuse and overuse in humans and animals. Effective AMR control requires equity-centered National Action Plans (NAPs) that integrate prevention and appropriate use with diagnostics and surveillance; without these infrastructures, NAPs cannot shift clinical practice away from broad-spectrum use and disparities will continue to drive AMR. Ultimately, AMR is a crisis of health-system capacity and clinical practice that threatens the efficacy of modern medicine and deepens global health inequities.
- Literature Review/Context
Antimicrobial resistance is a natural evolutionary process that is accelerated by misuse and overuse of antimicrobial drugs, both by individuals and through broad-spectrum prescribing driven by time pressures in clinical care. When pathogens are treated with antibiotics, bacterial populations are under greater selective pressure, and microbes rapidly accumulate genetic mutations. As these adaptive mutations spread, bacterial strains are able to survive antibiotic treatment.
The burden of infectious disease creates ongoing demand for effective antibiotic treatment, reinforcing a dynamic where disease increases antibiotic usage, intensifies selective pressure, and accelerates the spread of resistant strains, making infections more difficult to treat. Public health conditions including lack of access to clean water, inadequate sanitation, and limited awareness all contribute to the spread of infectious disease. The drivers and consequences of antimicrobial resistance disproportionately affect low- and middle-income countries (LMICs) that face higher burdens of infectious disease and under-resourced health systems.
The WHO recommends antimicrobial stewardship (AMS), a systematic approach to educate healthcare professionals on safe and effective prescribing practices of antimicrobial drugs to minimize AMR across health systems. There are limited studies on the effectiveness of stewardship policy implementation in LMICs where there are simultaneous efforts to provide consistent access to antibiotic drugs for medically necessary treatment. Additionally, modeling in high income countries (HICs) has shown that reduced infections, not stewardship, has been the greatest contributor to reducing antibiotic usage in outpatient clinical settings. To reduce the burden of disease, the WHO has emphasized a global need for access to clean water, sanitation, and hygiene (WASH); still, when education and policy-based preventive measures are applied, infectious disease and drug resistant bacterial strains will persist.
The spread of infectious disease is managed through vaccines and WASH measures, and when necessary can be treated through antibiotic and antiviral drugs. When a healthcare provider seeks to treat a patient, it is necessary to know if the infection is bacterial or viral for effective targeted treatment. This determination can be supported through diagnostics such as PCR (polymerase chain reaction) which can detect infectious diseases caused by bacteria, viruses, fungi, and parasites, in addition to a range of genetic diseases. Widespread applications of PCR in diagnostics are seen for the COVID-19 virus, Streptococcus (Strep throat) bacteria, and E. Coli bacteria. In LMICs, lack of reliable access to vaccines and diagnostics increases dependence on antibiotics. Where accessible rapid diagnostics are not available, antibiotic usage is the fallback rather than a targeted treatment.
In an effort to manage AMR, the 2015 World Health Assembly launched the Global Action Plan (GAP) on AMR. The GAP seeks to reduce the prevalence of infectious disease through WASH, optimize use of antimicrobial treatments for human and animal health, increase awareness of AMR through educational resources, continue to monitor and research the impact of AMR, and to invest in the future of all countries through access to medical resources. This plan integrates “The One Health Approach,” an initiative by the WHO to unite global sectors of human and environmental health, systemically applied to managing AMR through policy and stakeholders.
Global frameworks, namely One Health and GAP, create an organized strategy to combat AMR; however, the effectiveness of these plans depends on how they are implemented across health systems. AMR National Action Plans (NAPs) have been facilitated following the GAP, which has identified barriers to implementing antimicrobial stewardship across LMICs. Difficulty with AMR interventions in LMICs is grounded in a lack of knowledge on the issue of AMR and the efficiency of applying stewardship situationally. The conceptual gap of understanding around AMR is reflected in governmental capabilities where cross sector collaboration and professional capacity is limited. Shamas et al. assessed the challenges of stewardship in LMICs, identifying the need for country specific intervention plans for tackling AMR.
Applying antimicrobial stewardship (AMS) interventions used in HIC to LMICs is an ineffective approach, by not considering the inequalities in the infrastructure and capacity between health systems. In LMICs where antibiotic use is directed by individuals who possess varying levels of clinical awareness, stewardship efforts need to be directed to a broader audience. This calls attention to the limitations of current stewardship models. In an evidence review and modeling analysis, Lewnard et al. determined that quality of evidence supporting the effectiveness of existing AMS interventions is insufficient to serve as the primary tools for reducing the global burden of AMR. Researchers based in the European Union, Kaprou et al., have reviewed rapid diagnostic methods that can both detect antimicrobial resistant genes and identify infectious pathogens, emphasizing how fast and affordable diagnostics could guide targeted therapy and reduce broad-spectrum antibiotic use. In this context, successful diagnostic interventions deliver results quickly and with high accuracy through user friendly technology, providing results before clinicians resort to broad-spectrum prescribing. Overall, the existing literature maps the main approaches for reducing AMR across health systems but offers limited evidence on their effectiveness and treats equitable health systems and technological innovation as separate challenges.
- Methods/Approach
A persistent gap in current AMR strategies is assessing policy-based stewardship and prevention efforts through a separate lens from technical advancement of diagnostics and treatment. Prevention and stewardship efforts are recommended by National Action Plans (NAPs) and Antimicrobial Stewardship (AMS) initiatives that focus on standardizing guidelines for low- and middle-income countries (LMICs) that are vulnerable to infectious disease and the burden of AMR. These NAPs are designed to align with the broader global framework of the WHO Global Action Plan (GAP) on AMR, calling for countries to integrate standardized practices and regional needs. However, this is difficult in LMICs that face political instability, underfunded health systems, and limited professional capacity. In contrast, diagnostics and innovation research are focused on efficiency of molecular-based techniques, surveillance methods, and next-generation diagnostics. Research by Kaprou et al. examined AMR detection and diagnostic techniques for performance: speed, sensitivity, and affordability, without explicitly assessing how these tools could support equitable health systems. The concepts of prevention and AMS need to be integrated with rapid diagnostic tools and emerging technologies in the development of NAPs. Assessing surveillance data, modeling of AMR burden in LMICs, and case studies together helps identify where health equity and innovation are misaligned and where more integrated approaches to reducing AMR are needed.
- Analysis/Evidence
Following the 2015 World Health Assembly which enacted the Global Action Plan (GAP) on AMR, the WHO Antimicrobial Resistance and Use Surveillance System (GLASS) was launched as a global monitoring system. Surveillance of AMR involves tracking where resistance is occurring and how it is changing over time, relying on lab testing and epidemiological data. GLASS assesses data on bacteriologically confirmed infections and monitors the maturity of AMR surveillance, to build a comprehensive picture of AMR in all reporting countries. In 2023, the report included data from over 100 countries, representing 70 percent of the global population; this four-fold increase in participation since its origin in 2016 represents a global shift in awareness surrounding AMR as a shared public health crisis. Expanded participation does not result in equally comprehensive surveillance between countries, creating regional disparities in reporting; out of the 104 reporting countries, only 48 were reported to have all WHO recommended surveillance systems.
To assess how nationally representative surveillance data is, reporting countries were scored on completeness, using the criteria: 1) Implementation of national AMR surveillance systems 2) AMR surveillance coverage 3) Availability of data on AMR in all infection types 4) Availability of epidemiological, demographic and clinical information. The global completeness score for the data captured in 2023 was 53.8 percent, indicating persistent challenges in diagnostic and laboratory capacity necessary for comprehensive surveillance. Surveillance completeness depends on laboratory capacity to generate antimicrobial susceptibility testing (AST) results, which identify whether a clinical isolate is resistant to specific antibiotics.
GLASS uses statistical modeling to synthesize reported AST data and estimate the resistance of eight common bacterial pathogens to the 22 different antibiotics used to treat them. This totals 93 different pathogen-antibiotic combinations. The four types of infection these common pathogens are responsible for include: bloodstream, gastrointestinal, urinary tract, and urogenital gonorrhea. The increase in global participation in GLASS is parallel to the growing resistance in bacteria-drug combinations being monitored, which have increased by 40% between 2018 and 2023. GLASS data show that AMR rates are unevenly distributed across regions, countries with limited surveillance often report higher resistance levels, and AMR disproportionately affects LMICs with weak health systems.
GLASS provides a global estimate of AMR, but quality of surveillance data is uneven because diagnostic and laboratory infrastructure vary across health systems. Surveillance gaps are largest in many LMICs, meaning the countries that face the greatest effects of AMR are often those that lack the ability to detect and report it; even among represented countries, the low global completeness score demonstrates that current estimates rely on incomplete epidemiological data. Bacterial infections are estimated to be responsible for approximately 5 million deaths annually, 4.3 million of those occurring in LMICs. Modeling the burden of AMR in LMICs by Lewnard et al. examined the effectiveness of preventive interventions: improved water, sanitation, and hygiene (WASH), infection prevention and control (IPC), and expanded access to vaccines. They estimate that the implementation of these efforts could reduce the burden of AMR by 10 percent. The effectiveness of antimicrobial stewardship interventions was not considered because the evidence of its effectiveness alone is inadequate. When these results are considered in tandem with GLASS data, it is clear that countries with the greatest burden of AMR are those with the least surveillance capacity, and poorest access to prevention and treatment tools. As a result, the extent of AMR in LMICs is likely an underestimate of the real burden. The consequences of surveillance and intervention gaps globally are demonstrated by examining the progress and hindrance of National Action Plans (NAPs) in individual countries.
Zimbabwe is a lower-middle-income country that has a formal NAP and participates in GLASS, yet still struggles with the foundational tools for managing AMR. As one of the first African countries to enlist a NAP, Zimbabwe has created momentum for reducing drug resistance with an emphasis on a “One Health” approach. Following the initial plan from 2017-2021, Zimbabwe is executing its second NAP, designed to be followed from 2023-2027. Progress was made in preventive interventions across human, animal, and environmental sectors during the first NAP. Laboratory advancement with technical training increased surveillance and diagnostic capacities; yet, prescribing data show that diagnostic limitations continue to influence clinical antibiotic use. A study at Harare Central Hospital in Zimbabwe examined clinical records of pediatric inpatients admitted over a three-week period. Out of 130 admitted children, 121 (93%) were prescribed at least one antibiotic, with 84 percent receiving combination therapy. The study found that prescribing practices adhered to national guidelines in only 57.7 percent of children. The authors note that this high antimicrobial usage may reflect infectious disease burden and limited diagnostics to prove or refute bacterial infection, and that use was higher than rates reported in pediatric inpatient settings in HICs. Zimbabwe demonstrates that a NAP with ambitious objectives is not sufficient to fill the gaps in regulation; without effective implementation of policy through community-level awareness, the drivers of AMR will continue.
Mickelsson et al. studied the effectiveness of AMR policy implementation at the community level, to understand how social and economic conditions weaken the efficacy of the NAP. Through participatory workshops with lecturers and students from the University of Zimbabwe and Midlands State University, they identify social, economic, and institutional constraints. Economic uncertainty and food insecurity continue to make antibiotic use in raising livestock a strategy for short-term survival. In many cases, both farmers and consumers remain unaware of how antibiotic use in livestock affects long-term human and environmental health. AMR interventions must be built on community needs, considering economic and educational conditions; this adaptive strategy is described by Mickelsson and Oljans as agile policy. Zimbabwe’s clinical prescribing patterns and community implementation constraints show that NAP execution is dependent on awareness, diagnostic access, and surveillance capacity to make appropriate antimicrobial use feasible.
Comparative work on NAP implementation in African countries highlights community awareness as a crucial part of deploying effective strategies of AMR intervention, particularly for laboratory systems enabling effective surveillance. Nigeria exemplifies a second-generation NAP that formally integrates community engagement as well as emphasizes surveillance, seeking to involve civil society organizations (CSOs) and faith-based groups. Nigeria’s NAP 2.0 reviews weaknesses from NAP 1.0, developing a new plan that incorporates a situational analysis of the current landscape and outlines revised strategies. Within the “Awareness” analysis, the NAP seeks to improve grassroots awareness of AMR, supporting the connection between awareness and resistance as limited understanding sustains patterns of inappropriate antibiotic use even when NAPs exist.
Concurrently, Nigeria’s situational analysis highlights the severity of the increasing rate of resistance detected by the national AMR surveillance network. According to Nigeria’s NAP 2.0: “between 2017 and 2022, out of 12,251 samples from the national AMR surveillance network, 5,601 returned bacterial isolates, with high resistance levels of most isolates to most antibiotics tested.” While surveillance is in place to monitor resistance, the capacity is not yet at the level needed to efficiently reduce AMR and manage use; NAP 2.0 continues to prioritize expanded coverage and strengthened laboratory capacity.
- Discussion
While these approaches clarify the need for country-specific NAPs and local modeling, they also show that awareness and policy design cannot compensate for lacking diagnostic and surveillance infrastructure. Closing the gap requires more than asking for communities and clinicians to implement AMR policies, it demands parallel investment in laboratory capacity, sustained surveillance networks, and rapid diagnostic tools that make advisable antibiotic use possible.
A diagnostics-first approach to stewardship, along with expanded access to safe vaccines and strengthened surveillance systems, creates the capacity for equitable and community-specific NAP design. In many LMICs, broad-spectrum prescribing has become the default in both healthcare and agriculture. Where quick and affordable methods of diagnostics, detection of genetic resistance markers, and antimicrobial susceptibility testing (AST) are not available, antibiotic usage is the fallback rather than a targeted treatment, increasing selective pressures that drive resistant strains.
Review of rapid diagnostic tools demonstrates the need for tests that are sensitive and affordable. Current methodologies involve nucleic acid amplification assays (including PCR-based tests), microfluidic systems, and automated sequencing methods that can identify pathogens and genetic resistance markers. These methods have not been broadly applied in LMICs due to drawbacks of pre-treatment steps which eliminate the “rapid” component that is vital, as well as requirements of stable supply chains and costly equipment. In order for NAPs to be efficient and equitable, diagnostics and emerging technologies must be treated as priorities in LMIC health infrastructure rather than privileges reserved for high-resource systems. Reviews of Zimbabwe and Nigeria exemplify that community engagement and local modeling are necessary for NAP success, but not sufficient. Future NAPs must pair community engagement with investment in laboratories, public health education, and surveillance technology. This shift in NAP development creates the capacity for antimicrobial drugs to be used advisably.
- Conclucion
Global health systems must address antimicrobial resistance (AMR) by prioritizing diagnostics and surveillance in National Action Plans (NAPs) so stewardship can be implemented situationally. Evidence from the WHO Antimicrobial Resistance and Use Surveillance System (GLASS), modeling analyses of AMR burden in LMICs, and country case studies from Zimbabwe and Nigeria show that where laboratory capacity and surveillance networks are limited, resistance is most difficult to detect, and prescribing practices are uninformed. Together, this evidence demonstrates that NAPs cannot operate effectively when surveillance is inadequate and responsibility for proper antibiotic usage is pushed onto communities that lack rapid, reliable diagnostics and care. A diagnostics-first approach paired with strengthened surveillance capacity guides targeted treatment and slows the spread of resistance. The control of AMR and the effectiveness of antimicrobial treatments depend on sustained investment in diagnostic and surveillance infrastructure that can be translated to LMICs, strengthening health systems and protecting global medical advancement.
The Global Affairs Journal 
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