Global AMR Governance & Outcomes: A 2000–2021 Longitudinal Study

A new global evaluation of antimicrobial resistance (AMR) governance across 193 countries is informing updates to the 2026 Global Action Plan, a critical framework for combating the growing threat of drug-resistant infections. The study, published in January 2026 in Global Health, reveals a complex picture of progress and persistent challenges in national responses to AMR, highlighting the need for more effective strategies to curb the rise of resistance.

Antimicrobial resistance occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness, and death. The World Health Organization (WHO) considers AMR one of the top 10 global public health threats facing humanity. WHO fact sheet on AMR

A Longitudinal Assessment of National Policies

Researchers used a longitudinal, country-level design, analyzing data from 2000 to 2021, including 190 United Nations Member States, the Cook Islands, the State of Palestine, and Bermuda. The study constructed an index to characterize national AMR governance across multiple domains, examining changes over time and assessing how governance trajectories relate to AMR-related outcomes. Data sources included national AMR policy documents, the Tracking AMR Country Self-Assessment Survey (TrACSS), and databases maintained by UNICEF, the Global AMR R&D Hub (https://dashboard.globalamrhub.org/), and the Global Antimicrobial Resistance and Use Surveillance System (GLASS).

The study period, 2017-2022, was selected based on the availability of comprehensive TrACSS data. Researchers analyzed 269 national policy documents – 200 National Action Plans (NAPs) and 69 related policies – translating non-English documents using Google Translate. Four researchers independently reviewed these documents, rating governance indicators based on Cochrane Systematic Review standards, with discrepancies resolved through discussion or arbitration.

Key Findings: Progress and Persistent Gaps

The evaluation considered AMR-related outcomes including AMR prevalence, antimicrobial use (AMU) in humans, animals, and agriculture, and AMR-related mortality. The study found considerable variation in governance scores across countries and regions. While many nations have adopted NAPs, the study highlights that simply having a plan isn’t enough. Effective implementation and monitoring are crucial, and these areas often lag behind policy development.

Researchers identified three primary governance domains: policy design, implementation, and monitoring. Within these, 14 subdomains and 46 specific indicators were assessed. The analysis revealed that improvements in governance were not consistently linked to improvements in AMR-related outcomes, suggesting that the quality and effectiveness of governance interventions are more vital than their mere presence.

Data Handling and Methodological Considerations

The study addressed the challenge of missing data, a common issue in global health research. Countries with structurally missing data for animal AMU or agricultural crop-production AMU were excluded from composite AMU score construction to avoid bias. For the remaining 172 countries, missing AMU data were handled using statistical imputation techniques, preserving within-country temporal structure and cross-country heterogeneity. Specifically, human AMU values were projected using autoregressive integrated moving average (ARIMA) models, while animal AMU data were estimated based on each country’s sociodemographic index (SDI) trajectory.

To ensure the robustness of the governance framework, an international expert panel of 38 individuals from diverse fields (clinical medicine, veterinary medicine, environmental science) was convened. Through a two-round Delphi survey, experts refined the framework and identified key indicators, scoring their importance on a five-point Likert scale. Indicators meeting consensus criteria – a mean importance score of 3.5 or higher and a coefficient of variation of 0.25 or lower – were included in the final framework. The panel included a mix of experts from LMIEs (68.4%) and high-income economies (31.6%), with 65.8% based in China and 34.2% in other countries. Sensitivity analyses confirmed that regional and income-related biases were minimal.

What Does This Mean for Global AMR Efforts?

The findings underscore the need for a more nuanced approach to AMR governance. Simply adopting a NAP is not sufficient; countries must prioritize effective implementation, robust monitoring, and data-driven decision-making. The study highlights the importance of considering the interconnectedness of human, animal, and environmental health – the “One Health” approach – in addressing AMR. CDC One Health

The study’s use of a composite index allows for comparisons across countries, but it’s important to acknowledge the limitations of such an approach. Indices can oversimplify complex realities and may not fully capture the unique challenges faced by individual nations. The reliance on data from multiple sources introduces potential for inconsistencies and biases. The researchers acknowledge that the use of Google Translate for non-English policy documents could introduce some inaccuracies, although they employed rigorous review processes to mitigate this risk.

Looking Ahead: The 2026 Global Action Plan and Beyond

The results of this comprehensive evaluation will directly inform the update of the 2026 Global Action Plan on AMR. The plan, originally released in 2015, provides a roadmap for countries to address AMR through five strategic objectives: improving awareness, strengthening surveillance, optimizing antimicrobial use, preventing infection, and developing new diagnostics, therapeutics, and vaccines. The updated plan is expected to place greater emphasis on strengthening governance, improving data collection and analysis, and promoting cross-sectoral collaboration.

Beyond the Global Action Plan, continued surveillance and research are essential to track the evolving threat of AMR. The Global Antimicrobial Resistance and Use Surveillance System (GLASS) plays a crucial role in monitoring AMR trends worldwide, but its coverage remains limited, particularly in low- and middle-income countries. Investing in laboratory capacity, strengthening surveillance systems, and promoting data sharing are critical steps to improve our understanding of AMR and inform effective interventions. The study’s findings too suggest a need for further research to identify specific governance components that are most strongly associated with improvements in AMR-related outcomes, allowing for more targeted and effective interventions.

The next steps involve ongoing monitoring of national action plans, refinement of surveillance systems, and continued investment in research and development. Regular reviews of the Global Action Plan will be essential to ensure that it remains relevant and effective in the face of this evolving global health threat.