Antimicrobial resistance (AMR) is one of the most critical global health challenges of the 21st century, undermining decades of progress in the treatment and control of infectious diseases. The World Health Organization (WHO) has identified AMR as one of the top 10 threats to global public health. Low- and middle-income countries (LMICs) bear a disproportionate share of this burden because of their high infectious disease prevalence, limited diagnostic and laboratory capacity, weak health systems, and socioeconomic constraints. The burden of AMR in LMICs extends far beyond the immediate clinical impact on patients. A recent modelling by Lewnard et al., 2024 estimated that improving infection prevention and control programmes in LMIC health-care settings could prevent at least 337,000 AMR-associated deaths while ensuring universal access to high-quality water, sanitation, and hygiene services would prevent about 247,800 AMR-associated deaths and pediatric vaccines 181,500 AMR-associated deaths, from both direct prevention of resistant infections and reductions in antibiotic consumption. Children in LMICs are particularly affected, with AMR contributing to more than a million deaths each year. The economic consequences are also staggering with projections suggesting most severe impacts in LMICs. These losses derive from both direct health-system costs and broader productivity reductions as a result of increased illness and premature mortality. The high prevalence of infectious diseases, frequent empirical antibiotic use, and unregulated access to antimicrobial drugs all compound this growing burden.
Despite its recognised importance, the current status of AMR containment strategies such as surveillance, policy, and stewardship in LMICs remains limited. The WHO’s Global Action Plan on Antimicrobial Resistance (GAP), adopted in 2015, spurred many LMICs to develop National Action Plans (NAPs) that align with global objectives to improve awareness, strengthen surveillance, reduce infection incidence, optimise antimicrobial use, and promote sustainable investment. While the existence of NAPs demonstrates the growing political recognition of AMR, implementation remains uneven with minimal enforcement for prescription-only antibiotics or controlling the sale of antimicrobials in informal markets. Over-the-counter antibiotic access remains common, driven by weak governance, economic incentives, and public demand. Antimicrobial stewardship (AMS) programs, which aim to ensure the rational use of antibiotics, are gradually being adopted in LMIC healthcare facilities. Evidence from a scoping review by Harun et al., 2024 showed that AMS interventions have successfully reduced antibiotic consumption and improved clinical outcomes. Infection prevention and control (IPC) programs and WASH improvements are equally essential to reducing infection rates and thus antibiotic demand.
Progress toward AMR containment in LMICs has been notable but insufficient. More countries now possess NAPs. Hospital-based AMS initiatives have demonstrated measurable improvements in antibiotic prescribing practices and reductions in resistance trends. In parallel, national immunisation campaigns and investments in WASH have indirectly contributed to lowering infection incidence and curbing antimicrobial use. The One Health framework, which integrates human, animal, and environmental health perspectives, is increasingly being recognised and incorporated into LMIC AMR strategies, reflecting a growing understanding that antibiotic misuse in agriculture and environmental contamination play critical roles in the resistance cycle
Despite these encouraging developments, LMICs face several persistent challenges. Health system weaknesses remain fundamental barriers. Laboratory capacity continues to be inadequate, with limited quality assurance, inconsistent supplies, and underinvestment in workforce training. Weak IPC systems and poor infrastructure facilitate infection spread within communities and healthcare facilities. Over-the-counter antibiotic use and self-medication remain pervasive, fueled by the affordability of generic antibiotics and the limited availability of qualified prescribers. In agricultural sectors, antibiotics are frequently used as preventive measures in livestock and aquaculture, often without veterinary oversight. These practices amplify selection pressure and facilitate the dissemination of resistant strains through the food chain and the environment. Although many LMICs have formal policies to regulate antibiotic use, enforcement mechanisms are weak, and surveillance of drug quality and distribution is minimal. Financial constraints are another major obstacle with competing health priorities, limited domestic funding, and reliance on external donors.
Despite this, significant opportunities for LMICs to strengthen their response to AMR exist including scaling up infection prevention and control measures, WASH improvements, and vaccination coverage. Another key opportunity lies in strengthening surveillance and diagnostic capacity building on efforts like the Fleming Fund which played a crucial role in funding laboratory capacity, workforce training, and data-sharing networks generating reliable data across human, animal, and environmental health sectors. Regional collaborations, such as shared laboratories, training programs, and pooled procurement of diagnostic reagents, offer cost-effective solutions for resource-limited settings. Expanding antimicrobial stewardship programs adapted to local contexts can further enhance rational prescribing practices. These programs should include continuous medical education, feedback systems, and integration with IPC activities. Reinforced regulatory frameworks that restrict non-prescription antibiotic sales and monitor agricultural antimicrobial use are essential. Moreover, developing an international accreditation or benchmarking system for stewardship programs could help LMICs maintain accountability and attract support. Integrating human, veterinary, and environmental surveillance can provide a more comprehensive understanding of resistance dynamics and promote coordinated interventions. Environmental monitoring of antibiotic residues and resistant organisms in wastewater, soil, and agricultural runoff could also identify hotspots and guide mitigation efforts.
In relation to financing, innovative models such as public-private partnerships, pooled procurement systems, and global AMR funding mechanisms could support sustainable interventions in LMICs. Promoting equitable access to new antimicrobials, and encouraging innovation in diagnostics and vaccines will also be critical in addition to strengthening data systems for monitoring antibiotic use, resistance rates, and policy outcomes can improve accountability and policy effectiveness. Data-driven decision-making, combined with transparent reporting and international collaboration, will be vital to sustaining progress.
Overall, AMR will continue to threaten health, development, and economic stability, particularly in LMICs amidst high competing priorities and therefore will need continuous investments by national governments to implement evidence-based interventions, including WASH improvements, vaccination, IPC, stewardship. With stronger political commitment, international solidarity, and investment in innovation and infrastructure, LMICs can make substantial strides toward containing AMR and safeguarding global health security.
Denis K. Byarugaba is a Professor of Microbiology at Makerere University in Kampala, Uganda
Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth