Antimicrobial Resistance (AMR) poses a critical public health problem globally, including in Indonesia. Gender and equity issues are known to drive risk of exposure to AMR and create barriers to diagnosis and recommended use of antimicrobials. However, gender and equity considerations remain marginal within existing policy and implementation frameworks at the global level. Through interviews with key stakeholders in Indonesia, this study sought to summarise the issues relating to gender and equity in Indonesia and gain a comprehensive understanding of the extent to which AMR policy, surveillance, data use, and antimicrobial stewardship incorporate gender and equity considerations, and to identify gaps in the integration of an equity perspective. Interviews were conducted with seven key informants from government, academia, civil society, and non-government organisations.
This study highlights that gender and equity are not adequately addressed in Indonesia’s AMR response. The current National Action Plan on AMR (NAP-AMR) and hospital-level AMR policies do not explicitly address equity dimensions. Efforts to address AMR also remain heavily hospital-centred, with most interventions focused on inpatient care. Where equity is considered, it is often interpreted as equitable access to healthcare services. Monitoring and evaluation rely mainly on hospital accreditation processes, which track technical compliance but do not systematically assess equitable access or gendered patterns of antibiotic use.
Addressing these gaps requires the explicit integration of gender and equity into AMR policy frameworks. Stronger leadership from the Ministry of Health is needed to direct hospitals and AMR programme implementers to adopt equity-sensitive approaches. National policies should be complemented by community engagement strategies, empowering parents and local actors to participate in addressing AMR. Clinical guidelines should embed gender and equity considerations, particularly for conditions such as urinary tract infections, tuberculosis, and HIV, where sex and gender dimensions significantly shape risks and treatment outcomes. Finally, adequate funding and planning are essential to support these efforts, alongside investment in awareness-raising to improve public understanding of AMR across different social groups.
Antimicrobial resistance (AMR) poses a major and growing threat to public health in Uganda, with significant implications across human, animal, and environmental sectors. While Uganda made notable progress in aligning their AMR strategies with global frameworks such as the WHO Global Action Plan and Global Antimicrobial Resistance and Use Surveillance System (GLASS), the integration of gender and equity (G&E) considerations into AMR policy and surveillance remained limited until 2024, when GEAR up supported G&E mainstreaming through the NAP 2.0. This landscape analysis assesses the extent to which G&E dimensions are embedded in AMR frameworks, identifies systemic gaps, and outlines opportunities for more inclusive action.
The analysis draws on a structured review of 12 national AMR policy documents and technical surveillance tools from Uganda. A 12-domain Gender and Equity assessment framework, informed by global guidance, was applied to assess the integration of inclusive principles into AMR governance, surveillance, and implementation. Insights from multisectoral stakeholder roundtables, which focused on gender and equity integration in AMR strategies contributed to the findings.
Findings show that while Uganda has developed technically sound AMR surveillance systems and multi-sectoral governance structures, they have not systematically considered who is most affected by AMR or who participates in designing solutions. Health facilities collect AMR data through routine monitoring and reporting mechanisms – they capture antimicrobial use (AMU) and AMR patterns observed in patients, the type of infection, antimicrobial agents used, and microbiological test results (e.g., pathogen resistance profiles). The surveillance tools rarely capture disaggregated demographic data beyond age and sex, and equity-relevant variables such as occupation, disability status, or caregiving roles are largely absent. While the data is aggregated annually, the analysis often lacks detailed demographic disaggregation, limiting its ability to fully assess the G&E dimensions of AMR. National action plans refer to inclusion in general terms but do not operationalise equity principles in goals or resource allocation.
The November 2024 launch of Uganda’s revised AMR National Action Plan was presented as a direct outcome of G&E engagement processes. Stakeholders noted that the updated NAP reflected a shift from a gender-blind to a more gender-sensitive document. However, the policy still requires further embedding of equity considerations into implementation, in relation to surveillance design, resourcing, and reporting. Women and caregivers, particularly in rural areas, often rely on informal sources for antimicrobials due to barriers such as cost and stigma. Despite this, they remain underrepresented in AMR governance and are rarely engaged in planning or monitoring efforts. Surveillance staff and technical working groups lack training and guidance on applying a gender or intersectional lens to data collection and programme design.
In this short leaflet we summarise the main outputs from GEAR up’s work on antimicrobial resistance. These include webinar recordings, how-to guides, briefs and case studies.
AMR and antimicrobial use surveillance data is routinely collected across many countries, but sex, age, and other social stratifiers are rarely analysed or reported. This case study describes how GEAR Up worked with country partners in Lao PDR, Ghana, Uganda, and Tanzania to apply an equity lens to existing AMR and AMU surveillance data, and developed practical guidance to support others to do the same.
Written by Susan Okioma, Anne Ngunjiri, Jane Thiomi, Cleophas Ondieki, Rosie Steege and Katy Davis.
The WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) 2025 report marks an important milestone in strengthening global antimicrobial resistance (AMR) surveillance. It reflects WHO’s increasing commitment to ensure that AMR responses are inclusive, equitable, and informed by real-world data across human, animal, and environmental health sectors (World Health Organization [WHO], 2025). This reflexivity note acknowledges these advances while identifying opportunities for GLASS to further embed gender and equity as integral elements of effective AMR surveillance.
Conceptual framing: building on a strong foundation
The GLASS 2025 report demonstrates clear progress in recognizing gender and equity as priorities within AMR surveillance. For instance, the term sex appears 20 times in the report, and gender five times, an encouraging start. However, the two terms are often used interchangeably, suggesting limited distinction between biological and social determinants. As a result, gender tends to appear as a supplementary consideration rather than a central factor shaping AMR patterns.
Considering gender and equity in AMR is critical because gender and equity shape exposure, health-seeking behavior, access to diagnostics and treatment, and outcomes of antimicrobial resistance across different populations. Without sex- and gender-disaggregated data, critical inequities remain invisible, limiting the effectiveness of national and global AMR responses. Integrating gender and equity ensures that surveillance data capture the full spectrum of social determinants influencing resistance patterns and treatment gaps, ultimately leading to more inclusive and effective interventions (Okioma et al., 2025).
The One Health framework is robust in addressing ecological connections, spanning humans, animals, and the environment but could be further enriched by integrating social dimensions such as gendered caregiving roles, informal medicine access, and occupational exposures. Expanding this framing would make surveillance more holistic and people-centred, consistent with the principles outlined in the WHO Equity Guidance for Public Health Surveillance (WHO, 2024).
The role of sex in AMR data completeness
In reflecting on the domains that define the completeness of AMR surveillance data, I commend the WHO GLASS 2025 report for explicitly recognising sex as one of the key variables in assessing data completeness. This acknowledgement marks an important step toward strengthening the interpretability and reliability of AMR surveillance globally. From my experience working on gender and AMR integration, I have seen how systematically capturing and analysing sex-disaggregated data can reveal critical differences in infection patterns, care-seeking behaviour, and antimicrobial use between men and women. When such data are missing, these gendered nuances often remain invisible, limiting our ability to design effective, equitable responses. The GLASS 2025 recognition of sex as a core data domain therefore reflects a maturing understanding that equity and data quality are deeply interconnected. It reaffirms that a surveillance system attentive to demographic diversity is one that not only tracks resistance more accurately but also moves closer to protecting all populations equally.
The bugs and drugs syndrome
While the WHO GLASS 2025 report provides an impressive and detailed analysis of pathogens and antimicrobial resistance patterns across drugs, it does not explicitly present disaggregated data by sex or age. As a gender and equity practitioner, this presents a dilemma for me: without such demographic detail, we are unable to clearly identify which populations are most affected by AMR, or how patterns of resistance may vary across different groups. The absence of these insights limits our ability to understand the social dimensions of resistance, who is most exposed, who is most at risk, and who may be left behind by current responses. Nevertheless, I find hope in the report’s recognition of sex as a key domain for assessing the completeness of AMR surveillance data. These signals growing awareness that data are not neutral and that future reports can move beyond collection to deeper analysis unmasking the faces and lived realities of the people behind AMR statistics.
Visibility in data: moving toward inclusive surveillance
The report’s inclusion of sex-disaggregated data is commendable and signals a step toward more inclusive surveillance, however, broadening this to include other equity indicators such as, such as religion, gender identity/expression, place of residence, migration or displacement status, education level, income level, disability status, ethnicity or racial identity, occupation, caregiving responsibilities and level of agency over decision making, and geographic location would help capture the lived realities of populations most affected by AMR. Enhanced disaggregation would strengthen both the analytical depth and the policy relevance of GLASS data.
Progress and alignment: from recognition to practice
Compared to earlier editions, the GLASS 2025 report reflects notable progress in integrating gender and equity concepts and aligning with the WHO Equity Guidance (WHO, 2024; WHO, 2025). The next step is to translate this conceptual recognition into practice through the inclusion of operational tools, case studies, and practical country-level examples. This would help countries operationalise equity in AMR surveillance planning, data collection, and analysis.
Governance and accountability: strengthening inclusion
WHO’s leadership in coordinating global AMR surveillance is well recognised. Strengthening participation from community health actors, women’s networks, and social scientists could make GLASS governance more inclusive and context-responsive. Introducing incentives for countries to report equity-related data, or linking investments to equity-sensitive indicators, would enhance accountability and ensure that national surveillance systems capture diverse
Pathways for a people-centred surveillance system
To build on its achievements, GLASS could continue to evolve by:
Embedding equity and gender as cross-cutting categories across all levels of analysis and reporting.
Expanding metrics beyond sex-disaggregation to include key social and economic determinants of vulnerability.
Supporting member states to capture data from rural, informal, and low-resource settings.
Encouraging inclusive governance by integrating community, civil society, and social science perspectives.
In conclusion the GLASS 2025 report provides a strong platform for advancing inclusive AMR surveillance. By deepening its integration of sex and gender considerations, GLASS can set a global standard for surveillance systems that are not only technically sound but also socially responsive and truly people-centred.
AMR policy has long been gender-blind, and this case study documents our work to change that. In Uganda, GEAR Up partnered with the Ministry of Health to embed gender and equity provisions into the revised National Action Plan 2024–2029. In Bangladesh, a scoping review of existing policy documents informed recommended changes to the National AMR Surveillance Strategy. Both examples offer a practical model for translating WHO guidance on gender and AMR into country-level action.
This case study explores how GEAR Up is building the evidence base on gender, equity, and AMR across two country contexts. In Zimbabwe, surveillance research with key population groups reveals high rates of gonorrhoea misdiagnosis and the urgent need for point-of-care diagnostics. In Bangladesh, qualitative research in Dhaka’s informal settlements uncovers how poverty, gender norms, and limited healthcare access shape antibiotic use, with distinct patterns emerging for men and women.
What drives medicine use in informal settlements, and what does that mean for antimicrobial resistance?
This photovoice study, conducted by LVCT Health as part of the GEAR Up project, puts community members at the centre of the research. Over three weeks in Nairobi’s Raila Village, residents of Mugumoini Ward documented their own experiences of accessing medicine, seeking advice, and managing leftover drugs through photography and narrative.
The findings reveal a complex, highly social picture of health-seeking behaviour: where people get medicine (often without prescriptions), how they decide what to take, what happens when treatments stop working, and how unused medicines are stored and disposed of. Together, these insights highlight the structural, economic, and social drivers of medicine use, and the gendered dimensions of health decisions within communities facing constrained access to formal healthcare.
The study was conducted by LVCT Health and funded by the Fleming Fund through UK aid, as part of the GEAR Up programme to catalyse action on gender, equity, and antimicrobial resistance in low- and middle-income countries.
In this blog Sammy Gachigua and Anne Ngunjiri describe both the crucial role of caregivers in acting on AMR and the realities of life in informal settlements which make medicine use fraught.
Walking through Nairobi’s informal settlements, you cannot miss the resilience of families who raise young children in the midst of immense challenges. Mothers balance small businesses with childcare, fathers juggle daily hustles to feed their households, and grandparents step in when parents are absent. In these crowded environments, where diarrhoea, malaria, coughs, and flu are part of daily life, caregivers are constantly making decisions about when and how to treat illness. At the centre of these choices is the use of medicines, especially antibiotics, which are often seen as the quickest route to recovery.
Yet behind each packet of tablets bought from a chemist or handed out at a health centre lies a complex web of poverty, health system gaps, and cultural practices. We spoke to caregivers of children under five years old in Kibera and surrounding areas to understand these everyday realities. Their stories reveal how antimicrobial use is shaped by the harsh conditions of informal settlements, and how this, in turn, fuels the threat of antimicrobial resistance (AMR).
For caregivers, the health of young children is a constant concern. Diarrhoea, coughs, malaria, and flu-like symptoms dominate conversations. Overcrowded homes, unsafe water, and poor sanitation mean infections spread quickly. A caregiver explained that diarrhoea is frequent because “the environment is dirty” and children are often exposed to sewage and contaminated water. Another parent added that coughs and chest problems worsen whenever the weather changes, forcing children to remain indoors. In these conditions, illness is not an occasional event but part of everyday life. Caregivers spoke of being in and out of hospitals or chemists several times a month. Some rely on public facilities like Otiende Health Centre, while others seek care at smaller NGOs or private clinics nearby.
But hospital visits are not always straightforward. Long queues, stock-outs of essential medicines, and the costs of transport often push families toward pharmacies as their first option.
(Insert image: A crowded waiting area outside a government clinic, with mothers holding babies)
While hospitals are valued for diagnosis and testing, chemists play a much larger role in actual treatment. Parents repeatedly described situations where they go straight to the pharmacy, explain symptoms, and leave with medicine.
One father admitted that when his child falls ill, he often just buys medicine worth fifty shillings to try at home first before considering a hospital visit. Caregivers view pharmacies as accessible and flexible – they are nearby, they do not require consultation fees, and they allow purchases in small amounts. One mother noted that she might buy just two or three tablets of an antibiotic because she cannot afford the full dose. Others described keeping medicines like Panadol at home for emergencies, giving them to children at night when health facilities are closed.
This practice of partial dosing, self-prescribing, and relying on advice from chemist attendants rather than trained clinicians creates major risks for AMR. But for caregivers struggling with poverty and urgent childcare needs, it feels like the only practical solution.
Health choices have financial costs
At the heart of antimicrobial use decisions is money. Caregivers often described weighing the severity of a child’s illness against the cost of treatment. A grandmother caring for her disabled grandchild explained that she sometimes delays treatment until she can borrow money, even if the child has been unwell for days. Another parent said that hospital visits quickly become unaffordable because, even with government insurance schemes, many drugs are unavailable and must be bought out-of-pocket.
Families often rely on informal support systems — borrowing from neighbours, joining community savings groups, or depending on small earnings from odd jobs to cover the cost of drugs. The constant trade-offs mean that children may not always complete full courses of medicine. As one respondent admitted, once symptoms improve, medicines are often stopped early to save the remaining tablets for the next illness.
Interestingly, some caregivers showed awareness of the idea that medicines can stop working if misused. One father explained that frequent use of malaria drugs in his home region had led to a point where “you don’t get cured anymore.” Another caregiver noted that overusing antibiotics could make them act “like poison in the body” instead of curing illness. But even when this awareness exists, it rarely changes behaviour because the immediate priority is making a sick child feel better quickly. The long-term risks of AMR are overshadowed by urgent financial and health pressures.
The voices of caregivers highlight an urgent truth: strategies to combat AMR cannot succeed without addressing the social and economic realities of families in informal settlements. Telling people to complete doses or avoid self-medicating will not work if medicines are unaffordable, unavailable, or only accessible in partial amounts.
Supporting caregivers means ensuring that public facilities are stocked with essential medicines, strengthening regulation of pharmacies, and creating health financing systems that truly reduce out-of-pocket costs. It also means recognising the gendered dynamics of care, where women are often the ones negotiating treatment decisions within households under tight economic constraints.
Most importantly, it means amplifying the voices of caregivers themselves. They understand better than anyone the daily struggles of keeping young children healthy in these environments, and their insights are crucial to designing solutions that are both effective and realistic.
This blog by Sammy Gachigua and Anne Ngunjiri explores how community health workers play a key role in health information on AMR and connecting very vulnerable communities to the health system by creating trusting relationships. It suggests ways in which this role could be formalised and supported by the state.
When you step into Nairobi’s informal settlements, you are struck by how much life happens in tight, unplanned spaces. Narrow paths wind between corrugated iron homes, children chase each other barefoot through alleys, and vendors call out from makeshift stalls. Beneath the vibrancy, however, illness is an ever-present reality. Dirty water pools in open drains, toilets are overcrowded or inaccessible, and the air carries dust and smoke that fuel persistent coughs.
In such settings, health is not only managed in hospitals or clinics. It is managed at home, in conversations between neighbours, and in the quiet interventions of people who are rarely recognised in formal health systems — the Community Health Promoters (CHPs).
These CHPs are local men and women chosen by their communities to support households with health education, referrals, and follow-up. They walk door to door, checking in on pregnant women, monitoring newborns, following up on sick children, and reminding families to complete treatments. They are volunteers, often juggling their own survival with the responsibility of caring for up to 100 households each. And yet, despite being the bridge between health facilities and the communities they serve, their role in combating antimicrobial resistance (AMR) remains almost invisible.
Life on the frontline of illness – What CHPs actually do
The daily reality in informal settlements is that illness is constant. Families talk of diarrhoea, malaria, flu, and skin conditions as part of normal life. Outbreaks of cholera sweep through after the rains, and coughs linger for months in damp, crowded homes. Poverty shapes how people respond. For many, a hospital visit is the last resort – medicines are costly, transport is costly, and queues are long. Public facilities often run out of drugs, leaving families with prescriptions they cannot afford to fill. Instead, residents turn to local chemists. They buy antibiotics or painkillers in small quantities, often just two or three tablets at a time. A CHP explained that people stop treatment when symptoms improve, saving the rest for another day or for another family member with similar complaints. In the absence of money, medicine is rationed like food – stretched as far as possible, even when it means incomplete treatment.
In this fragile system, CHPs become the quiet custodians of health. They are assigned households, but their real work is relational: building trust, offering advice, and persuading families to seek care when they would otherwise delay. They teach handwashing, check immunisation cards, and encourage families to go for antenatal visits. They explain how to take medicine properly, why finishing antibiotics matters, and when to return to hospital.
Their work is critical in the health of the community. One CHP described herself simply as, “the bridge between the hospital and the household.” Without her, she said, many neighbours would never reach formal care. The trust they hold is critical. Families often confide in CHPs before they approach nurses or doctors, especially for sensitive conditions like sexually transmitted infections or reproductive health. They are seen not just as health promoters, but as neighbours who care, who listen without judgment, and who remain available long after hospital staff have gone home.
Barriers to medicine use
A recurring theme in conversations with CHPs is the way that people use medicines ‘improperly’. In the settlements, antibiotics are viewed as cure-alls, used for everything from headaches to stomach pain. Leftover medicines are shared among neighbours. Some parents store antibiotics in case a child falls sick at night. Others buy whatever the chemist suggests, sometimes without prescriptions.
CHPs spoke of families abandoning treatment after just two days when symptoms improved. They see people switching to herbal remedies if illness persists, or turning to traditional healers when modern medicines seem ineffective. Misconceptions are common. Some believe persistent illness is caused by witchcraft, while others think taking too much medicine makes the body “weaker.”
For CHPs, addressing these beliefs is part of their daily work. They remind families that unfinished treatment not only fails to cure the illness but can make medicines stop working in the future. They explain that what feels like poison in the body is actually resistance developing. One CHP put it plainly: “When you misuse antibiotics, it can turn into poison in the body. The illness will not go, and another one will emerge.”
Knowledge without recognition
What is striking is how much CHPs already know about AMR, even if they do not always use that terminology. They see resistance not as a laboratory result, but as lived experience: medicines that used to work no longer do, coughs linger despite repeated treatment, and children relapse after partial courses of drugs. They connect these patterns with incomplete treatment and misuse, and they do their best to intervene with the limited tools they have.
Their approach goes beyond medicine. CHPs emphasise hygiene, clean water, and nutrition. They use local language, stories, and practical examples to make health advice relatable. They rely on persuasion rather than authority, often enlisting respected relatives or community elders to reinforce messages. In this way, they weave health education into everyday life, making it part of conversations rather than lectures.
Despite their dedication, CHPs face enormous challenges. Many households resist their advice, preferring the quick fix of buying drugs from a pharmacy. Some dismiss them as busybodies. Others suspect they are paid to disturb families, when in reality, CHPs receive little or no compensation.
The lack of medicines at government facilities undermines their credibility. When they encourage families to go to the hospital only for patients to be turned away with empty prescriptions, frustration builds on both sides. Trust erodes, not because of CHPs themselves, but because the system they represent feels broken.
In some cases, CHPs face outright hostility. They have doors slammed in their faces, are insulted, or accused of interfering in matters beyond their concern. Yet, despite the resistance, they keep going, driven by the belief that their work saves lives.
Witnessing AMR first-hand
CHPs may not call it AMR, but they recognise its signs. They hear constant complaints that medicines “no longer work.” They notice families trying the same drugs repeatedly without success. They see people turning to herbal remedies after antibiotics fail. They watch as amoxicillin, once effective for many illnesses, becomes less reliable.
Their response is pragmatic. They encourage families to return to hospital, accompany them when possible, and explain the link between misuse and ineffectiveness. They see themselves as educators as much as caregivers, fighting a quiet battle against resistance one household at a time.
The experiences of CHPs make it clear that any effort to address AMR in informal settlements cannot be confined to hospitals, policies, or laboratories. It must begin with the people who influence how medicines are used at household level and that means recognising CHPs.
They are not simply volunteers; they are frontline health workers operating in the hardest-to-reach communities. Yet they lack proper training on AMR, receive little material support, and are excluded from national strategies. Recognising them means equipping them with knowledge, ensuring their advice is backed by reliable access to medicines, and formally including them in AMR responses.
Most importantly, it means listening to them. CHPs provide a window into how communities actually use medicines, insights that policy papers or hospital records cannot fully capture. They are the missing link in the fight against AMR.
CHPs are already acting as change agents, but they are doing so quietly, often invisibly. If their role were formally recognised, supported, and integrated into AMR strategies, they could play an even greater part in preventing resistance.
By investing in their training, providing them with stipends or material support, and ensuring hospitals back up their referrals with reliable services, governments and donors can harness a resource that already exists in communities. Strengthening CHPs is not creating a new system. It is empowering the one that is already holding communities together.
