London School of Hygiene & Tropical Medicine

The persistence of antimicrobial resistance (AMR), despite repeated warnings dating back to Alexander Fleming’s Nobel Prize address, suggests that policy responses have either been insufficient or ineffective, at best. Given the compounding effects of AMR on health systems and economies, a re-evaluation of how AMR governance is administered should be a clear and urgent priority. The global threat posed by AMR, combined with the political and economic complexities of health systems, presents challenges that demand robust governance for the effective implementation of AMR policies.

The scientific community is aware of the dire predictions surrounding AMR, which threaten to erode the fragile health and economic gains made in low- and middle-income countries (LMICs) and among vulnerable populations. Even countries that are considered global leaders in AMR response are not finding it easy. A recent audit report of the UK’s 2019-2024 AMR National Action Plan (NAP) revealed that only one of five national AMR targets was on track, despite serious investment and effort. 

The report acknowledged that modifying the behaviours of millions of individuals and thousands of institutions is a massive undertaking. This reality, coupled with recent global cuts in public health funding, underscores the urgency of developing cost-effective and streamlined strategies for managing scarce health resources, even if that requires a complete overhaul of existing systems. AMR is such a profound threat that it touches every corner of medicine. The latest AMR burden report forecasts grim outcomes for LMICs, despite country-level investments in AMR National Action Plans (NAPs). This highlights an unsettling truth: if we approach the problem the same way we always have, we will remain stuck in a cycle of underperformance. While there has been some progress in LMICs, much of it feels stagnant. Certainly, something must change.

Perhaps it is time to reimagine how we structure AMR governance in LMICs. This would involve rethinking how processes, institutions, and accountability mechanisms function, including how power is exercised, how stakeholders participate, and how decision-makers are held accountable. The solution may lie in establishing dedicated AMR agencies, not as instant solutions, but as focused, empowered institutions with clear mandates. A dedicated AMR agency could operate under direct oversight from ministries of health and national leadership. It would have a streamlined mission, a defined annual budget, the capacity to engage directly with donors, and the operational independence to prioritise and execute country NAPs effectively. This contrasts with the current setup in many LMICs, where AMR programs are tucked away within broader national public health institutes (NPHIs), often competing with other health priorities.

While those who defend the current NPHI model argue that it fosters better coordination, the magnitude and urgency of AMR demand a more focused approach. The establishment of standalone AMR agencies would not undermine multisectoral collaboration; it would rather strengthen it. These agencies would be able to plan annually, receive and report on dedicated funding, and coordinate with partners operating at the same institutional levels, giving donors more confidence that resources will be used as intended. Moreover, having a specialised agency with "antimicrobial resistance" in its name would enhance public and institutional normative awareness. 

This could play a key role in addressing one of the most underachieved components of existing AMR NAPs, awareness and understanding, the first objective in most countries' NAPs. Yet awareness levels remain critically low, especially in high-risk, marginalised, and rural populations. This reflects a form of the ‘Inverse Care Law’, where those who need awareness and understanding of AMR the most are least likely to have it. A dedicated agency, visible by name and focused on its purpose, could enhance the visibility of AMR in community outreach, educational campaigns, and public discourse. The impact of a name should not be underestimated, just as one cannot overlook the significance of ‘AIDS’ in the Nigerian ‘National Agency for the Control of AIDS’ or ‘Cancer’ in the ‘National Cancer Institute of Kenya’.

In summary, the current governance structures in many LMICs may no longer be fit for purpose. LMICs should consider creating dedicated, empowered AMR agencies that can enhance accountability, focus resources, and drive multisectoral collaboration to break the cycle of underperformance. The stakes are too high, and the clock is ticking.

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