Evaluation of antimicrobial resistance governance across 193 countries to inform the 2026 Global Action Plan update

Antimicrobial resistance (AMR) poses a major global health threat, yet the effectiveness of national action plans (NAPs) remains uncertain. Here we developed a multidimensional One Health governance index through a structured Delphi expert consultation to evaluate AMR governance across 193 countries (2017-2022), integrating 269 policy documents, expert-weighted indicators and multinational survey and surveillance datasets. Difference-in-differences and joinpoint regression analyses were used to link governance to antimicrobial use, AMR prevalence and AMR-related mortality. Global governance scores improved from 30.7 to 44.5/100, although implementation and monitoring lagged behind policy design, particularly in animal and environmental sectors. A significant increase in AMR prevalence scores was observed only 5 years after NAP adoption (two-stage difference-in-differences, β = 2.43, 95% confidence interval (CI) 1.02-3.85, P < 0.05), underscoring the delayed impact of policy. Multisector engagement (early-adopting countries, β = 0.05, 95% CI 0.02-0.08, P < 0.01) and antimicrobial use surveillance system (early-adopting countries, β = 0.05, 95% CI 0.03-0.07, P < 0.01) showed the strongest associations with improvement in AMR outcomes. As the 2026 Global Action Plan update approaches, sustained financing and integrated One Health surveillance, with stronger environmental and agricultural engagement, are essential for translating NAPs into sustained reductions in resistance.

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Publication Details

Journal
Nature Medicine
Published
2026-03-03
DOI
https://doi.org/10.1038/s41591-026-04257-1
Primary Topic
Antibiotic Use and Resistance
Type
article
Field-Weighted Citation Impact
0.00

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article

Evaluation of antimicrobial resistance governance across 193 countries to inform the 2026 Global Action Plan update

Yongzhang Zhu, J. Utzinger, Emmanuel Kabali, Robert Bergquist et al.
Nature Medicine
Antibiotic Use and Resistance
article

Evaluation of antimicrobial resistance governance across 193 countries to inform the 2026 Global Action Plan update

Yongzhang Zhu, J. Utzinger, Emmanuel Kabali, Robert Bergquist, Xiaonong Zhou, Yige Zeng, Hein M. Tun, Xiaokui Guo, Zile Cheng, Mashkoor Mohsin, Wei Gu, Hong Chen, Weiye Chen, Yung-Fu Chang, Xiao Tan, Chao Lv, Xiaoxi Zhang, Jinxin Zheng, Zhemin Zhou, Chunlei Shi, Guangrui Yang, Jing Wang, Chendi Zhu, Yonghong Xiao, Junxia Song, Tanvir Rahman, Zhaojun Wang, Sheng Chen, Jing Qian, Nan Zhou, Yiwen Chen, Min Li, J. Ross Fitzgerald
article en

Abstract

Antimicrobial resistance (AMR) poses a major global health threat, yet the effectiveness of national action plans (NAPs) remains uncertain. Here we developed a multidimensional One Health governance index through a structured Delphi expert consultation to evaluate AMR governance across 193 countries (2017-2022), integrating 269 policy documents, expert-weighted indicators and multinational survey and surveillance datasets. Difference-in-differences and joinpoint regression analyses were used to link governance to antimicrobial use, AMR prevalence and AMR-related mortality. Global governance scores improved from 30.7 to 44.5/100, although implementation and monitoring lagged behind policy design, particularly in animal and environmental sectors. A significant increase in AMR prevalence scores was observed only 5 years after NAP adoption (two-stage difference-in-differences, β = 2.43, 95% confidence interval (CI) 1.02-3.85, P < 0.05), underscoring the delayed impact of policy. Multisector engagement (early-adopting countries, β = 0.05, 95% CI 0.02-0.08, P < 0.01) and antimicrobial use surveillance system (early-adopting countries, β = 0.05, 95% CI 0.03-0.07, P < 0.01) showed the strongest associations with improvement in AMR outcomes. As the 2026 Global Action Plan update approaches, sustained financing and integrated One Health surveillance, with stronger environmental and agricultural engagement, are essential for translating NAPs into sustained reductions in resistance.

Nature Medicine
Food and Agriculture Organization of the United Nations (IT), Roslin Institute (GB), Hong Kong Polytechnic University (HK), Zhongnan University of Economics and Law (CN), Swiss Tropical and Public Health Institute (CH), Chinese University of Hong Kong (HK), Shanghai Jiao Tong University (CN), University of Basel (CH), University of Colorado Boulder (US), Cornell University (US), Bangladesh Agricultural University (BD), University of Michigan (US), Soochow University (CN), Second Affiliated Hospital of Soochow University (CN), FAO/IAEA Agriculture and Biotechnology Laboratories (AT), National Institute for Communicable Disease Control and Prevention (CN), New York State College of Veterinary Medicine (US), First Affiliated Hospital Zhejiang University (CN), State Key Laboratory of Diagnosis and Treatment of Infectious Diseases, University of Agriculture Faisalabad (PK), Zhejiang University (CN), University of Edinburgh (GB)
National Key Research and Development Program of China
Openalex Percentile: Top 33%
Antibiotic Use and Resistance
DOIOpen Access PDFOpenAlex
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