In October a diverse group of stakeholders in Indonesia came together for a productive workshop focused on addressing the intersections of gender, equity, and antimicrobial resistance (AMR). The workshop was hosted by the Ministry of Health with support from the Fleming Fund country Grant to Indonesia (FFCGI), and was coordinated by Desrina Sitompul, Senior Technical Programme Lead, FFCGI. As part of a broader discussion on One Health economic assessments and the burden of disease, the workshop explored crucial issues such as how gender dynamics influence AMR patterns, the role of women in AMR stewardship, and antimicrobial use across both human and animal health settings. Here Ralalicia Limato shares five key insights and outcomes from the workshop.

1. Domains of gender equity within AMR

Saraswati, the gender equity lead facilitator for Indonesian country grantee, presented a framework with three main domains for potential research and intervention:

• Gender equity and drug-resistant organisms: The relationship between gender and the prevalence or transmission of AMR, including how specific groups of people are disproportionately impacted by AMR, and how norms, values or underlying beliefs in society maintain or perpetuate the different risks of drug-resistant organisms’ exposure among genders and other intersecting identities.

• Women’s leadership and agency in AMR surveillance and stewardship: Understanding how cultural norms, beliefs and practices hinder or foster women’s meaningful participation; how women, both in healthcare facilities and community settings, are involved in AMR management, AMU decision-making, and how their roles can be strengthened; and how women have the access to and control of resources in AMR containment and stewardship initiatives.

• Antimicrobial use (AMU) in human and animal health settings: Investigating how gender dynamics influence AMU practices in different contexts. This includes examining how cultural norms, beliefs, and practices influence AMU in the community, as well as how health-seeking behaviours differ between men and women and among other intersecting social stratifiers, such as age, socio-economic status, ethnicity and education level. Besides, it is crucial to understand the distinct roles and responsibilities of men and women in the purchasing, use, and administration of antimicrobial drugs

This framework serves as the foundation for further investigation and the integration of gender-sensitive indicators into AMR surveillance in Indonesia.

2. Integrating gender equity into burden of disease data

There is a plan to integrate gender-specific indicators and perspectives into broader burden of disease and AMR data collection. This integration will help capture nuanced insights on how AMR affects different populations, including women and marginalised groups, and how gender influences AMR risk and outcomes. In doing so, a further discussion will take place to plan the quantitative and qualitative data.

3. Stakeholder feedback: insights from both human and non-human sectors

There were initial concerns regarding the relevance of gender equity within AMR research in the Indonesian context. However, in this workshop, stakeholders were overwhelmingly supportive of studying AMR through a gendered lens. They suggested several avenues for further research to better capture the diversity of experiences and risks across different population groups, and emphasised the need for multi-sectoral studies that cut across different population groups and geographical contexts.

• Stakeholders from the Ministry of Health recommended including the clinical aspects, for example, guideline compliance in the research framework. Understanding how gender influences adherence to clinical guidelines could reveal important gaps in AMU and stewardship, which would be crucial for improving treatment outcomes.
• Stakeholders from the Ministry of Agriculture and Ministry of Marine Affairs and Fisheries pointed out the importance of studying farming communities, especially where the majority of farmers are male or female. By examining gender-specific roles in these communities, researchers can better understand the gendered dimensions of AMU and resistance in agriculture and livestock management.
• A recommendation from the Chairperson of the Committee on AMR Control called for comparative studies between urban and rural populations. These studies could help illuminate the disparities in access to antibiotics, healthcare services, and public knowledge of AMR. Such research could provide critical insights into the barriers and opportunities for improving AMR governance and stewardship, especially in underserved or rural areas.

4. Way forward: continued consultation and stakeholder engagement

In light of the valuable feedback received during the workshop, Saraswati and the DAI team have given stakeholders a month to provide further input or specify any domains they wish to explore in more depth. This period will allow for a more comprehensive understanding of the nuances in gender and AMR, as well as refine research questions and methodologies.

Meanwhile, discussions with DAI are set to continue regarding the budget for data collection and analysis related to gender equity. The goal is to ensure that sufficient resources are allocated for gender-sensitive AMR research, allowing for the collection of high-quality data and the formulation of evidence-based policies and interventions.

5. Looking ahead: the One Health approach to AMR

The workshop reinforced the importance of adopting the One Health and gender-sensitive approach to tackling AMR. As AMR continues to threaten global health, it is essential to understand the diverse and often hidden ways in which gender influences both the causes and consequences of AMR. By considering gender alongside other factors like economics, healthcare access, and education, we can develop more equitable and effective strategies for combating AMR.

The next steps in this important work will involve refining the research agenda, collecting data, and continuing to engage with stakeholders from multiple sectors. The workshop has laid the groundwork for a more inclusive and comprehensive understanding of AMR, one that accounts for the lived realities of all affected populations. Stay tuned for more updates on the progress of this initiative.