Environmental Blind Spots in National Antimicrobial Resistance Governance: A Comparative Analysis of Egypt, Pakistan, and the United Arab Emirates Using 2022 WHO TrACSS Data

Background: Antimicrobial resistance (AMR) national action plans are typically evaluated on governance, legislation, and surveillance capacity, while environmental transmission pathways remain comparatively under-assessed. This study compares AMR governance capacity across three WHO Eastern Mediterranean Region (EMRO) countries of differing income classification, using self-reported 2022 WHO Tracking AMR Country Self-Assessment Survey (TrACSS) data. Methods: Indicators spanning governance, legislation, multisector coordination, laboratory/diagnostic capacity, and environmental protection were extracted from official 2022 TrACSS country profile reports for Egypt, Pakistan, and the United Arab Emirates (UAE) and compiled into a structured dataset. Composite readiness scores were calculated per country across governance, legislation, and sectoral domains. Results: UAE (high income) recorded the highest composite AMR readiness score (69%), versus Pakistan (48%) and Egypt (44%), driven largely by stronger legislation coverage (7/9 indicators versus 3-4/9). Despite this gap, all three countries scored 0% across all three environmental indicators assessed, national risk assessment, protective legislation, and water-quality monitoring for antimicrobial contamination, irrespective of income level or overall readiness. Animal Health was the weakest sector for all three countries (mean capacity 1.82-2.00 of 5). Conclusion: Environmental AMR surveillance appears to be a uniform, income-independent gap in national capacity, even where governance and legislative frameworks are otherwise well developed. Environmental monitoring warrants dedicated attention in future AMR national action plan revisions across the EMRO region. Keywords: antimicrobial resistance; TrACSS; One Health; national action plan; environmental surveillance; WHO EMRO