Evelyn Wesangula

This paper reflects upon the experience of the Fleming Fund in designing and implementing One Health antimicrobial resistance (AMR) programs in 25 countries and identifies practical lessons for the design of future One Health programs. The Fleming Fund experience highlights key priorities for implementing One Health effectively within AMR programs–though many of the insights should be applicable to other contexts as well, such as emerging infectious diseases and health security. One Health should be treated as an approach to problem framing and action rather than a program output, with flexibility for national adaptation. Meaningful implementation requires sustained investment beyond human health, particularly in animal and environmental sectors, to avoid symbolic engagement. Surveillance systems should consider both the role of the sector and sector-specific needs, supported by capacity for joint interpretation and use of evidence. The costs of multisectoral coordination should be explicitly resourced and both formal governance mechanisms and informal professional networks recognized as essential for building trust, sustaining collaboration, and translating data into policy-relevant action.

This paper examines the Fleming Fund as a major long-term investment in strengthening antimicrobial resistance (AMR) surveillance in low- and middle-income countries. Established by the UK Department of Health and Social Care in 2015, the Fund committed up to £498 million to support surveillance capacity across 25 countries in Africa and Asia through a One Health approach spanning human, animal and environmental health. The paper situates the Fleming Fund within wider global concern about AMR and highlights surveillance as essential for stewardship, policy and international coordination. It describes the Fleming Fund's design logic, governance arrangements, grant architecture and evolving strategic priorities, with particular attention to how the program combined laboratory strengthening, workforce development, data systems, quality assurance, sampling pathways and multisectoral coordination to generate credible and usable AMR data. The analysis also examines the Phase 2 shift from an initial emphasis on data generation toward greater attention to data interpretation, dissemination and use in policy and practice. Drawing on program documentation, evaluation evidence and stakeholder perspectives, the paper presents the Fleming Fund as an important case of large-scale surveillance system strengthening in resource-constrained settings. It argues that the Fund offers wider lessons on the time, coordination and institutional embedding required to move from externally supported capacity building toward sustainable national surveillance functions. These lessons are relevant to future AMR investments and to broader debates on global health security, health systems strengthening and One Health implementation.

Background: Drawing on the Fleming Fund's work to strengthen antimicrobial resistance (AMR) surveillance across Africa and Asia during 2018–2026, this article provides one of the first syntheses of AMR surveillance data use in low- and middle-income countries. Methods: A participatory synthesis for narrative review was conducted to summarize experience across administrative levels (facility, subnational, national, and regional). Results: Data use was most evident at the facility level, in human health systems where resistance patterns, antimicrobial use, and clinical data increasingly informed antimicrobial stewardship, infection prevention and control, and other quality improvement initiatives. Data use in other sectors required different approaches. At the national level, Fleming Fund investments were associated with revisions of treatment guidelines, updates of essential medicines lists, and regulatory measures, primarily through improved governance and policy communities. Regional platforms supported member country data use at the national level. Subnational data use was undertaken in countries with decentralized health systems. Across levels, data use pathways driven by local priorities helped surveillance inform action. Conclusions: Fleming Fund experience suggests that surveillance is more likely to inform action when data use is built into system design. Continued investment will be needed if AMR surveillance is to improve policy and practice in low- and middle-income countries.

Background: Kenya has moved from fragmented, pilot-based antimicrobial resistance (AMR) surveillance toward a coordinated One Health system, and its experience, pathways of change, and remaining gaps are relevant for other low- and middle-income settings working to operationalize One Health AMR surveillance. Methods: Here, we report a narrative overview of programmatic learning using 2018 as the pre-Fleming Fund baseline, drawing on national and global surveillance reports, monitoring frameworks from the Quadripartite indicators, qualitative evidence on governance, implementation and policy evolution across the One Health sectors, and Fleming Fund documentation. Results: Since 2018, AMR surveillance expanded from 2 human health sites to 30 human, animal, and environmental sites by 2025. National reports evolved to integrate AMR, antimicrobial consumption, and antimicrobial use data; routine reporting to global platforms matured; and outputs such as dashboards, reports, and policy briefs informing stewardship, Infection Prevention and Control, regulatory action, and policy decisions. External benchmarks showed improvement in AMR-related capacity, with World Health Organization Joint External Evaluation scores moving from limited to demonstrated capacity for surveillance and multisectoral coordination. Conclusions: Kenya's experience suggests that sustainable progress depends on embedding AMR surveillance within government-led governance structures, technical systems, and coordinated partner support, but sustaining gains will require predictable financing and routine data use.

Background/Objectives: Antimicrobial resistance (AMR) is a critical global health threat, with sub-Saharan Africa disproportionately affected. Antimicrobial stewardship (AMS) programs are essential in combating AMR; however, data on their implementation in resource-limited settings like Zambia remain scarce. This study assessed the post-implementation status of World Health Organization (WHO) AMS core elements in selected public hospitals in Zambia. Methods: A cross-sectional pre- and post-intervention survey was conducted in 11 public hospitals across Zambia’s 10 provinces. Baseline (pre-implementation) and 12-month follow-up (post-implementation) assessments were carried out using the WHO-adapted Periodic National and Healthcare Facility Assessment Tool. The six AMS core elements evaluated included leadership, accountability, AMS actions, education, monitoring, and feedback. Results: The average AMS program score increased from 59% at pre-implementation to 81% at post-implementation. Significant improvements were observed in education and training (+36%) and accountability (+31%). While leadership and monitoring also showed positive trends, gaps persisted in AMS actions (63%) and feedback/reporting mechanisms (68%). Drug and Therapeutics Committee (DTC) functionality improved by 23%, with 90% of facilities now holding regular DTC meetings. Implementation of AMS actions, such as ward rounds, rose from 0% to 73%. Challenges remained in clinical audit feedback, resource mobilization, and prescribing optimization. Variability across facilities highlighted differences in leadership, resources, and technical capacity. Conclusions: AMS implementation in Zambia improved substantially across key domains. However, sustained leadership, adequate financing, and continuous capacity-building are needed to address persistent gaps and ensure long-term success in mitigating AMR.

Background: The World Health Organization (WHO) AWaRe (Access/Watch/Reserve) book gives detailed guidance on the optimal use of antibiotics across primary care and hospitals for adults and children with the aim of improving the quality of use and reducing antimicrobial resistance. Objectives: To develop model sets of appropriate and feasible quality indicators based on the WHO AWaRe system, that are widely implementable across primary care, hospital, and the health care system settings to support optimal antibiotic use. Methods: Indicators from a scoping review were revised to focus on clinical infections in the AWaRe book. They were assessed using consensus techniques through two rounds each of the Global Delphi Technique and RAND/UCLA Appropriateness Method, evaluating appropriateness and feasibility at national and global levels respectively. In Round 1 of each method, panellists rated clarity and suggested revisions or new indicator. Round 2 results are reported. Findings: The AWaRe QIs covered common primary and hospital infections listed in the AWaRe book and general patient and population level indicators. There were 102 quality indicators (Primary Care: 46; Hospital: 39; General: 17) included in Round 2 of the Delphi Technique and 136 indicators (Primary Care: 56; Hospital: 60; General: 20) in Round 2 of the RAND/UCLA method, which are presented as model sets of indicators. Conclusion: These AWaRe model quality indicators can be locally adapted to support optimal use of antibiotics and inform global and national antimicrobial stewardship programs.

Background: Antimicrobial stewardship (AMS) programs optimize the use of antimicrobials and reduce antimicrobial resistance (AMR). This study evaluated the implementation of AMS programs in Africa using a harmonized regional approach. Methods: This was an exploratory cross-sectional study across five countries involving 32 hospitals using an adapted Periodic National and Hospitals Assessment Tool from the World Health Organization (WHO) policy guidance on integrated AMS activities in human health. Results: This study found baseline scores for AMS core elements ranging from 34% to 79% at the baseline which improved to 58% to 92% at the endline. At baseline, Drugs and Therapeutics Committee (DTC) functionality in updating facility-specific medicines and medical devices ranged from 58% to 100%, and this ranged from 79 to 100% at endline. Classifying antibiotics by WHO AWaRe, classification ranged from 33% to 83% at baseline and 64% to 100% at endline. Leadership commitment scores were 47% at baseline and 66% at endline. Education and training scores were 42% and 63% at baseline and endline, respectively. Reporting and feedback scores were 34% at baseline and 58% at endline. Conclusions: Our study showed that understanding context and standardizing regional stewardship approaches enhanced cross-country learning and improved AMS implementation. Although the challenges in Low- and Middle-Income Countries (LMICs) are similar, they vary by country and can be addressed by strengthening AMS regulatory frameworks and surveillance systems.

Background: Antimicrobial stewardship (AMS) programs optimize use of antimicrobi-als and reduce antimicrobial resistance (AMR). This study evaluated implementation of AMS programs in Africa using a harmonized regional approach. Methods: This was an exploratory cross-sectional study across five countries involving 32 hospitals using adapted Periodic National and Hospitals Assessment Tool in WHO policy guidance on integrated AMS activities in human health. Results: This study found baseline scores for AMS core elements ranging from 34% to 79% and improved to 58% to 92% at the end line. At baseline, DTC functionality in updating facility-specific medicines and medical devices ranged from 58% to 100% and ranged from 79 to 100% at endline. Classifying antibiotics by WHO AWaRe classification ranged from 33% to 83% at baseline and 64% to 100% at endline. Leadership commitment scores were 47% at baseline and 66% at endline. Education and training scores were 42% and 63% at baseline and end-line respectively. Reporting and feedback was 34% at baseline and 58% at endline. Conclusions: Our study showed that understanding context and standardizing regional stewardship approaches enhanced cross-country learning and improved AMS implementation. Although challenges in LMICs are similar, they vary by country and can be addressed by strengthening AMS regulatory frameworks and surveillance systems.

Background: The inappropriate use of antibiotics in hospitals contributes to the development and spread of antimicrobial resistance (AMR). This study evaluated the prevalence of antibiotic use and adherence to the World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification of antibiotics across 16 hospitals in Zambia. Methods: A descriptive, cross-sectional study employing the WHO Point Prevalence Survey (PPS) methodology and WHO AWaRe classification of antibiotics was conducted among inpatients across 16 hospitals in December 2023, Zambia. Data analysis was performed using STATA version 17.0. Results: Of the 1296 inpatients surveyed in the 16 hospitals, 56% were female, and 54% were aged between 16 and 50 years. The overall prevalence of antibiotic use was 70%. Additionally, 52% of the inpatients received Watch group antibiotics, with ceftriaxone being the most prescribed antibiotic. Slightly below half (48%) of the inpatients received Access group antibiotics. Compliance with the local treatment guidelines was 53%. Conclusions: This study found a high prevalence of prescribing and use of antibiotics in hospitalized patients across the surveyed hospitals in Zambia. The high use of Watch group antibiotics was above the recommended threshold indicating non-adherence to the WHO AWaRe guidelines for antibiotic use. Hence, there is a need to establish and strengthen antimicrobial stewardship programmes that promote the rational use of antibiotics in hospitals in Zambia.