Timothy Worth

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.

Background/Objectives: Antimicrobial resistance (AMR) surveillance is a cornerstone of national AMR strategies but requires sustained, cross-sectoral financing. While the need for such financing is well recognized, its quantification remains scarce in low- and middle-income countries. This study aimed to estimate the full costs of AMR surveillance across the human health, animal health, and food sectors (2021–2030) in selected facilities in Nepal and generate evidence to inform sustainable financing. Methods: A bottom-up micro-costing approach was used to analyze data from five sites. Costs were adjusted for inflation using projected gross domestic product deflators, and probabilistic sensitivity analyses were conducted to assess uncertainty in laboratory sample volumes under four scenarios. Results: The total cost of AMR surveillance in Nepal was $6.7 million: $3.4 million for human health (50.3% out of the aggregated costs), $2.7 million for animal health (39.8%), and $0.7 million for the food sector (9.9%). Laboratories accounted for >90% of total costs, with consumables and personnel as the main cost drivers. Average cost per sample was $150 (animal), $64 (food), and $6 (human). Conclusions: This study offers the first robust, multi-sectoral 10-year cost estimates of AMR surveillance in Nepal. The findings highlight that sustaining AMR surveillance requires predictable domestic financing, particularly to cover recurrent laboratory operations as donor support declines. These results provide cost evidence to support future budgeting and policy planning toward sustainable, nationally financed AMR surveillance in Nepal.

This study has employed a mixed methods approach that combined qualitative data collected during field visits with quantitative programme data, including sample throughput, procurement records, point prevalence surveys of antibiotic prescribing, and cost data (associated with microbiology and AMR surveillance) collected through the Technical Assistance for Data and Evidence Use Regional Grant (TADE Africa) and the Zambia country grant.

AMR is an escalating One Health threat with major implications for human health and animal production. Surveillance data is essential to monitor trends, guide antimicrobial stewardship (AMS), and inform policy and investment decisions. However, animal health AMR surveillance in low- and middle-income countries (LMICs) is resource-intensive, and sustainability beyond donor support remains a central challenge. This report, prepared as the Fleming Fund concludes in 2026, reviews the effectiveness, cost‑efficiency, and sustainability of different animal health AMR surveillance strategies, including farm-based, abattoir, opportunistic, and wastewater sampling. We have explored these questions through case studies carried out in Zambia and Nepal.

This study has employed a mixed methods approach that combined qualitative data collected during field visits with quantitative programme data, including sample throughput, procurement records, point prevalence surveys of antibiotic prescribing, and cost data (associated with microbiology and AMR surveillance) collected through the Technical Assistance for Data and Evidence Use Regional Grant (TADE Africa) and the Zambia country grant.

Towards a One Health AMR Surveillance System: protocol for active AMR surveillance in commercial broiler and layer chicken populations for the Fleming Fund Grants Programme.

The Fleming Fund has supported antimicrobial resistance (AMR) surveillance capacity building in Zambia since 2018. In the human health sector, this support contributed to substantial improvements in laboratory infrastructure, equipment, workforce development, quality assurance, governance, and the routine use of data. These investments were associated with measurable gains in diagnostic capacity, sample throughput, laboratory performance, and antimicrobial stewardship (AMS) practices. The example of Livingstone Teaching Hospital (LTH), which has benefitted from the programme, illustrates how targeted investments can mature into functional surveillance systems that support clinical decision-making, influence prescribing behaviour, and inform policy. Our analysis shows that surveillance capacity can be established relatively rapidly when investments are well-sequenced and aligned with national priorities. However, sustaining and fully realising these gains is significantly more challenging. Recurrent costs, particularly consumables and equipment maintenance, remain heavily donor-dependent, while procurement failures, staff turnover, uneven engagement by clinicians, and reliance on individual champions reduce system resilience and efficiency. Cost and output analysis across sentinel sites also demonstrated economies of scale, with higherthroughput and more mature laboratories achieving lower costs per sample. Once laboratories move beyond the set-up phase, the principal sustainability challenge is no longer capital investment, but reliable financing for recurrent inputs, particularly consumables, equipment maintenance, and staff time. Without stronger domestic financing and more reliable procurement systems, recent gains risk erosion after donor support ends. At the same time, the Fleming Fund has created durable assets that provide a strong platform for future AMR-related interventions, including functional laboratories, skilled personnel, governance structures, and routine data flows. The central conclusion of this review is that sustainability is not only a financing issue, but a systems-alignment challenge. The long-term value of AMR surveillance depends on whether countries can embed diagnostic services, procurement, stewardship, and data use into routine, trusted, and financed health-system functions.

AMR is an escalating One Health threat with major implications for human health and animal production. Surveillance data is essential to monitor trends, guide antimicrobial stewardship (AMS), and inform policy and investment decisions. However, animal health AMR surveillance in low- and middle-income countries (LMICs) is resource-intensive, and sustainability beyond donor support remains a central challenge. This report, prepared as the Fleming Fund concludes in 2026, reviews the effectiveness, cost‑efficiency, and sustainability of different animal health AMR surveillance strategies, including farm-based, abattoir, opportunistic, and wastewater sampling. We have explored these questions through case studies carried out in Zambia and Nepal.

AMR is an escalating One Health threat with major implications for human health and animal production. Surveillance data is essential to monitor trends, guide antimicrobial stewardship (AMS), and inform policy and investment decisions. However, animal health AMR surveillance in low- and middle-income countries (LMICs) is resource-intensive, and sustainability beyond donor support remains a central challenge. This report, prepared as the Fleming Fund concludes in 2026, reviews the effectiveness, cost‑efficiency, and sustainability of different animal health AMR surveillance strategies, including farm-based, abattoir, opportunistic, and wastewater sampling. We have explored these questions through case studies carried out in Zambia and Nepal.