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

A comprehensive evaluation of antimicrobial resistance (AMR) governance across 193 countries has revealed a complex landscape of policy implementation and varying levels of success, informing updates to the 2026 Global Action Plan. The study, published in January 2026 in Global Health, utilized a longitudinal, country-level design to assess how national approaches to AMR surveillance and control correlate with actual outcomes.

Antimicrobial resistance—the ability of microbes to withstand the drugs designed to kill them—is a growing threat to global public health. Effective governance, encompassing policy design, implementation, and monitoring, is considered crucial to slowing the spread of AMR. This new research provides a detailed assessment of where countries stand and what factors are associated with progress.

A Global Snapshot of Governance

Researchers constructed an index-based system to characterize national AMR governance, drawing on national policy documents, the Tracking AMR Country Self-Assessment Survey (TrACSS), data from UNICEF, the Global AMR R&D Hub (https://dashboard.globalamrhub.org/), and the GLASS database. The analysis spanned from 2000 to 2021, with data collection completed in November 2024. The study deliberately adopted the World Health Organization’s (WHO) regional classifications to account for differences in AMR governance trajectories, particularly within Asia, where the WHO distinguishes between the Eastern Mediterranean, South-East Asia, and Western Pacific regions.

The core of the assessment focused on 46 indicators across three primary governance domains: policy design, implementation, and monitoring. These indicators were refined through a Delphi consultation involving 38 international experts from diverse fields, ensuring a robust and internationally relevant framework. The Delphi process involved multiple rounds of surveys and discussions to reach consensus on the importance of each indicator.

Linking Governance to Outcomes

The study didn’t just assess governance structures; it sought to determine whether those structures were associated with improvements in AMR-related outcomes. Researchers examined trends in antimicrobial use (AMU) – in humans, animals, and agriculture – as well as AMR prevalence and associated mortality rates. Data on AMR prevalence were sourced from the Global Burden of Disease (GBD) study, supplemented by data from the Institute for Health Metrics and Evaluation (https://vizhub.healthdata.org/microbe/) and WHO Global TB Reports (https://www.who.int/teams/global-programme-on-tuberculosis-and-lung-health/data).

To account for the staggered implementation of National Action Plans (NAPs) – national strategies to combat AMR – researchers employed a difference-in-differences (DID) analysis. This statistical method compares changes in outcomes between countries that adopted NAPs and those that did not, allowing for the assessment of policy effectiveness. The analysis considered potential confounding factors, such as health expenditure and population density.

Data Challenges and Handling

The researchers acknowledged the challenges of working with data from 193 countries over a 21-year period. Missing data, particularly regarding animal and agricultural antimicrobial use, were addressed using sophisticated imputation techniques. For example, animal AMU data, available only for 2020, were backcasted and forecasted based on each country’s sociodemographic index (SDI) trajectory, recognizing the link between economic development and antimicrobial consumption in livestock. Human AMU data gaps were filled using country-specific autoregressive integrated moving average (ARIMA) models.

What the Data Reveals: Trajectories of Change

Joinpoint regression analysis revealed varying trends in AMR prevalence globally and across WHO regions. The analysis identified inflection points – years where the rate of change in AMR prevalence shifted significantly – and related these points to the 2015 release of the WHO’s Global Action Plan on AMR. Latent class growth modeling further categorized countries based on their AMR prevalence trajectories, identifying distinct groups with different patterns of improvement or deterioration.

The study found that countries with stronger governance structures, particularly in the areas of policy implementation and monitoring, tended to show greater improvements in AMR-related outcomes. However, the relationship was not always straightforward, and the effectiveness of specific governance components varied depending on the region, and context.

Implications for the 2026 Global Action Plan

The findings of this study are directly relevant to the upcoming update of the Global Action Plan on AMR. The research highlights the importance of not only developing national action plans but also ensuring their effective implementation and ongoing monitoring. The detailed governance framework developed in this study can serve as a valuable tool for countries to assess their own strengths and weaknesses and identify areas for improvement.

The study also underscores the need for a One Health approach, recognizing the interconnectedness of human, animal, and environmental health in the emergence and spread of AMR. Addressing antimicrobial use in agriculture and promoting responsible stewardship practices across all sectors are crucial components of a comprehensive AMR strategy.

Looking Ahead: Surveillance and Refinement

Continued surveillance and data collection are essential to track progress and identify emerging challenges. Strengthening global surveillance networks, improving data quality, and promoting data sharing are key priorities. Further research is needed to understand the specific governance mechanisms that are most effective in different contexts and to develop tailored interventions to address local needs. The researchers emphasize the importance of ongoing evaluation and adaptation of AMR strategies based on the latest evidence.

The WHO is expected to incorporate the findings of this study into the 2026 Global Action Plan, providing updated guidance and recommendations for countries to combat AMR. Regular reviews of national action plans and ongoing monitoring of AMR-related outcomes will be crucial to ensure that the global response remains effective and responsive to the evolving threat of antimicrobial resistance.