Uganda

By collecting disaggregated data and involving diverse stakeholders, Uganda is setting a precedent for inclusive, gender-responsive AMR strategies in Africa. In this blog by Susan Okioma, Anne Ngunjiri, Anthony Mwaniki and Rogers Kisame talk about LVCT Health’s recent successful monitoring and evaluation trip to Uganda.

Antimicrobial resistance (AMR) is a silent yet a growing crisis hitting low- and middle-income countries (LMIC) the hardest. AMR disproportionately affects genders differently due to a complex interplay of biological, sociocultural, and systemic factors. Women, children, and marginalised gender groups often face higher risks and greater barriers to accessing effective healthcare, making gender and inclusion critical considerations in AMR response strategies. Without timely, targeted interventions, the human and economic toll of AMR will continue to rise — overwhelm health systems, widening health inequities, and threatening progress towards global health goals.

In response, governments are adopting National Action Plans (NAPs) on AMR – comprehensive blueprints developed in line with the World Health Organisation’s Global Action Plan on AMR. These NAPs outline national priorities for improving infection prevention and control, regulating antimicrobial use, expanding access to quality diagnostics, and strengthening antimicrobial stewardship. Additionally, countries are investing in real-time surveillance systems and stronger laboratory capacity to detect resistance patterns, track antimicrobial use, and facilitate timely, evidence-based interventions.

Uganda is one of the leading African countries in AMR response, having recently launched its second generation 2024/25-2028/29 National Action Plan: Prevent, Slow Down and Control Spread of Resistant Organisms. The NAP sets Uganda apart by explicitly prioritising gender and equity mainstreaming, positioning the country at the forefront of inclusive, multisectoral AMR policy and implementation in Africa.

Through the GEAR UP project, led by LVCT Health as the East Africa regional partner, Phase II of the Fleming Fund is making significant progress in embedding gender and equity considerations into AMR programming. A recent milestone was the LVCT Health team’s monitoring and evaluation visit to Uganda, conducted from 3rd to 7th March 2025. The goal of the meeting was to strengthen monitoring and evaluation (M&E) approaches by integrating gender, equity, and other social dimensions into Uganda’s routine AMR surveillance and program review processes.

The visit achieved the following objectives:  

1. Raised awareness and initiated dialogue on gender and equity in AMR surveillance — particularly in human health and animal health domains.
2. Assessed the integration of gender and equity into surveillance tools and their ability to generate disaggregated data and inform more inclusive AMR prevention, diagnosis, and response efforts.
3. Strengthened capacity across institutions to mainstream gender and equity within AMR surveillance, including enhancing understanding of how to analyse and use sex-disaggregated and equity-relevant data.
4. Promoted the use of sex, gender and equity-disaggregated data to uncover disparities in AMR burden, access to diagnostics, treatment outcomes, and service use.

By doing so, the participating teams gained a comprehensive understanding of the impact of AMR across diverse subpopulations. They also reflected on how AMR programming can be responsive to the needs, rights, preferences, and power dynamics among women, girls, men, boys, and other vulnerable groups in monitoring and evaluation processes.

Insights from the Field

The M&E visit was an enlightening experience that underscored the critical intersection of gender, equity, and AMR surveillance. Hosted by Baylor College of Medicine Children’s Foundation Uganda (Baylor Foundation Uganda),the visit brought together stakeholders from the Uganda One Health platform, who are custodians of various data sets. Participants included pharmacists from key ministries responsible for antimicrobial use and consumption data (AMU/AMC) in both human and animal health, as well as representatives from the Uganda National Health Laboratory Services (UNHLS) and the National Animal Disease Diagnostics and Epidemiology Center (NADDEC).

The LVCT Heath team ran gender and equity capacity strengthening sessions for participants across the One Health space

Gendered patterns in AMR – What UTI data revealed

One of the core activities involved analysing the AMR human health data related to urinary tract infections (UTIs), presenting an invaluable opportunity to explore gendered patterns of infection and resistance from the AMR surveillance data. This analysis was led by Prof. Andy Ramsey from the Liverpool School of Tropical Medicine (LSTM).

Prof. Ramsey guided the team through trends emerging from Uganda’s AMR surveillance data, alongside comparative insights from Tanzania. A notable observation was the overrepresentation of women in UTI cases, particularly those aged 15–54, while men were more frequently affected in the older age group (54 and above). This pattern aligns with global trends, where anatomical and hormonal factors predispose women to UTIs.

For comparison, Prof. Ramsey provided insights from Tanzania, where UTI cases among older men were often associated with prostate-related complications. These cases involved different pathogen profiles than those typically seen in younger populations.

Analysis of the Uganda and Tanzania AMR datasets revealed sex-based differences in both pathogen prevalence and antimicrobial resistance profiles. These disparities may be influenced by factors such as healthcare-seeking behaviors, prior antibiotic use, or underlying comorbidities. These insights prompted important questions about how age, sex, and underlying health conditions influence infection patterns and resistance outcomes.

This finding sparked important questions during the discussions at the Central Public Health Laboratory (CPHL):

• What explains the over-representation of women aged 15–54 in UTI cases?
• What are the predominant pathogens in male versus female UTI cases?
• Are there notable differences in AMR profiles based on sex and age?
• Are there comorbidities, health conditions or characteristics such as age or sex that are associated with particular UTI pathogens or AMR UTI profiles?

The findings and discussions underscored the critical need for gender-responsive and equity-based approaches to AMR surveillance. And the critical need to generate sex- and age-disaggregated data to better understand AMR patterns and inform more tailored, gender-responsive strategies for prevention and treatment in tackling these public health challenges.

Strengthening laboratory capacity for gender- and equity-responsive AMR surveillance and M&E

The visit underscored the importance of building institutional capacity on gender and equity integration into AMR surveillance and monitoring systems across all One Health domains – human, animal and environmental health. The sessions revealed significant gaps in participants’ understanding of how gender and equity intersect with AMR data in each domain. These gaps point to a broader challenge: existing systems may be missing critical patterns and disparities that shape exposure, access to care, treatment outcomes, and risk of resistance among different population groups. Without this lens, AMR responses risk being less effective and potentially inequitable.

However, there was a palpable enthusiasm for learning and change. For instance: during discussions at the Uganda National Health Laboratory Services (UNHLS), participants emphasised the need to disaggregate data beyond sex and age by including other social determinants  /health statifiers like marital status, disability status, geographical location and economic status.  Dr. Susan Nabadda, Director of the Uganda National Health Laboratory Service (UNHLS), requested that the capacity of the laboratory staff be strengthened on gender and equity in AMR programming, and especially in collecting disaggregated diagnostic data that is clear, representative and can be used to inform policy and interventions. This means:

• Ensuring patient-level data includes key variables like sex, age, location, and—where possible—socioeconomic markers (e.g. referral source, facility type).
• Flagging AMR data patterns by analysing the sex-, age- and socioeconomic-disaggregated data in a way that enables meaningful comparisons;
• Collaborating with epidemiologists and data analysts to use those insights to design interventions that address systemic inequities, not just biological differences.

Building this capacity is essential to ensuring that AMR programming is truly inclusive, effective, and equitable—and that it serves all communities, not just the majority or most visible.

LVCT Health team, Baylor Foundation Uganda and the National Health Laboratory and Diagnostic Services partners during the meeting.

Need for a One Health approach in integrating gender and equity

Following the capacity-building sessions with human health laboratory stakeholders, focus shifted to the animal health sector—an essential pillar of the One Health approach. At the National Animal Disease Diagnostics and Epidemiology Center (NADDEC), participants discussed how gender and equity considerations were being reflected in veterinary AMR surveillance. They examined existing AMR surveillance data from the animal health sector, particularly in relation to antimicrobial use (AMU) in poultry farming. The analysis indicated that the data was primarily on large-scale and medium-scale farms, including poultry reared for export, with limited attention given to practices in small holdings. These settings were better monitored and more consistent with veterinary oversight and antibiotic tracking.

They acknowledged gaps in their animal health surveillance systems. Small-scale farmers, many of whom are women, were left out on the surveillance activities, as the focus was on large scale farmers, providing very limited data on antibiotic practices and resistance patterns. This gap meant the experiences and contributions of women in the livestock sector were being missed in both AMR data and policy conversations. Where the data existed, the NADDEC team observed that small- to medium-sized poultry farms managed by women had higher rates of AMR compared to those managed by men. This raised important questions about gendered differences in farming practices, access to veterinary care, and antibiotic usage. Interestingly, this could be linked to the gendered health-seeking behaviour, as women tend to seek veterinary health services more promptly than their male counterparts, leading to frequent antibiotic use, and their cases being more likely to be tested, documented, and reported for resistance patterns. This highlighted a critical need to strengthen surveillance in smallholder settings, expand data disaggregation by gender and farm type, and investigate how social and gender dynamics shape AMU behaviors and AMR risks across farming systems.

Participants from the animal health domain raised a significant challenge in Uganda: the difficulty in obtaining reliable data on veterinary antibiotic use and management (AMU) and biosecurity practices on farms. They noted that many farmers may not fully understand the antibiotics being administered to animals, and in some cases, veterinarians often fail to record what has been administered. For lay farmers, even dewormers might be mistakenly recorded as antibiotics, rendering AMR/AMU data unreliable.

Advancing equity in AMR data collection and use

Our discussions with the human and animal health stakeholders highlighted Uganda’s already existing and robust AMR surveillance framework while also identifying opportunities for enhancement. A notable suggestion was piloting the collection of additional variables related to health equity at selected sentinel sites to capture better how resistance burdens and access to treatment vary across population groups. These variables could include:

• Enhancing data disaggregation: Incorporating gender, socioeconomic status, and geographic variables into AMR surveillance tools, such as Marital status, disability status/type, number of live births (for women), health insurance coverage, and access to antibiotics.
• Household and environmental characteristics: Data on sanitation facilities, access to protected water sources, antibiotic use in livestock rearing, and proximity of waste sites to homes
• Conduct further analysis: Explore associations between comorbidities/characteristics, e.g., occupation, rural residence, and specific pathogens or AMR profiles

By integrating these variables into existing tools like the Microbiology Request Form, we can better understand how social determinants influence UTI risk and AMR patterns

The learning loop: From insight to impact

As the GEAR up lead for East Africa, LVCT Health has embarked on a transformative journey with Uganda as the key technical partner in mainstreaming gender and equity. This collaboration has achieved significant milestones in promoting inclusive, gender-responsive AMR programming. The most notable achievement is the integration of gender and equity into Uganda’s second-generation 2024/25-2028/29 National Action Plan: Prevent, Slow Down and Control Spread of Resistant Organisms, marking the first time a Fleming Fund Phase II national plan has incorporated these critical elements.

A particularly affirming moment was captured in a LinkedIn post by the Baylor Foundation, which reflected on their achievements in their gender and equity mainstreaming journey.

The post reads: “Have you ever done everything right but still wondered why the results aren’t showing? We are often told that, that is a sign that strategy, not effort, needs to be changed. That’s what the Fleming Fund Country Grant II is doing—fine-tuning its approach, tightening the nuts and bolts, and driving impact in the fight against antimicrobial resistance (AMR)—leaving no one behind.”

The post acknowledges that, as a result of the process – a multi-phase, consultative which aimed to mainstream gender and equity into Uganda’s antimicrobial resistance (AMR) response – tangible resultsare now evident. LVCT Health played a key role in this process by providing targeted technical assistance to government institutions and AMR stakeholders. This included:

• Facilitating gender and equity-focused M&E sessions;
• Supporting the review of AMR surveillance data to assess gaps in equity representation;
• Advising on the inclusion of disaggregated indicators within data collection tools

The integration of gender and equity into Uganda’s NAP for AMR, the M&E framework, and the AMR data collection tools marks a significant milestone in the GEAR up project’s efforts to strengthen AMR governance. This achievement reinforces the need for national commitment, stakeholder buy-in, and new entry points for institutional learning across sectors to achieve an inclusive, gender-responsive plan. As we look to the future, we are hopeful that our efforts to address AMR will be effective, targeted, inclusive, and equitable, benefiting all population groups, including women and other underserved populations.

Staff from UNPHL contributing to the M&E review actions

The Road Ahead

Our discussions in Uganda underscored a crucial insight that addressing AMR requires more than just laboratory surveillance; it demands a people-centered approach that considers the social and economic realities of those affected. By embedding gender-transformative methodologies and breaking down data silos, we can ensure that AMR programming is not only effective but also inclusive and sustainable. Uganda’s commitment to integrating gender and equity into AMR surveillance provides a promising foundation for change.

As we move forward, the insights gained during this visit must now translate into actionable policies and refined data management practices that ensure no population is left behind in the response against antimicrobial resistance. With the foundation laid by the second-generation NAP, Uganda is well-positioned to lead the way on gender-responsive AMR programming in the region.

Acknowledgements

We sincerely thank the Ministry of Health Uganda, the Uganda National Health Laboratory Services (UNHLS), NADDEC, and Baylor Foundation Uganda for their collaboration and openness during the M&E visit.

Thanks to Michael Gaitho, Jane Thiomi, Pacific Owoundo, Dr. Cleophas Ondieki, Festus Mutua and Hayley Stewart for their help in reviewing this blog.