The AMR footprint: an integrative indicator in the global response to antimicrobial resistance

Abstract

The draft updated Global Action Plan (GAP) on antimicrobial resistance (AMR) for 2026–2035 acknowledges persistent gaps between political commitment and measurable implementation. This Viewpoint argues that progress can be facilitated by a simple, integrative indicator capable of capturing multisectoral action while remaining sensitive to national context. We propose the AMR footprint as a unifying concept to operationalize the updated GAP. Analogous to the carbon footprint, the AMR footprint consolidates and tracks selected AMR-specific and AMR-sensitive indicators across human health, animal and agrifood systems, and the environment, relative to national baselines over time. Anchoring monitoring, evaluation and accountability frameworks around an AMR footprint would shift the global response from aspirational targets towards continuous improvement, transparent benchmarking, and sustained financing. Without such an operational lens, the next decade of AMR action risks repeating the implementation failures of the past.

Gaps in the global antimicrobial resistance response

Antimicrobial resistance (AMR) has become a defining test of global governance, scientifically tractable in principle, yet, persistently resistant to sustained, system-wide implementation.^1,2 Over the past decade, the Global Action Plan on AMR has succeeded in mobilizing political attention and catalyzing National Action Plans in most countries.³ However, this widespread policy adoption has not translated into commensurate reductions in antimicrobial misuse, infection burden, or environmental contamination. The updated Global Action Plan for 2026–2035 openly acknowledges this implementation gap, placing new emphasis on One Health integration, financing, monitoring, and accountability.⁴

A core weakness of the global AMR response has been its reliance on fragmented indicators and headline targets that struggle to capture the cumulative nature of AMR risk. Table 1 summarizes existing global AMR target frameworks and indicator sets, illustrating their sectoral focus and limited integration across One Health domains. Mortality estimates, resistance prevalence and antimicrobial consumption indicators are indispensable, but they are slow to change, highly contextual and poorly suited to driving political accountability on their own.^5–8 What has been missing is an indicator that reflects how human activity across One Health systems collectively shapes AMR. This Viewpoint argues that the AMR footprint can fill that gap.

Table 1.

Suggested indicators to monitor country-level action on AMR

Stakeholder	Selected indicators
United Nations General Assembly5	By 2030: 10% reduction in global bacterial AMR-associated deaths against the 2019 baseline of 4.95 million deaths. 60% of countries have funded NAPs through the mobilization of $100 million. 100% of countries have basic water, sanitation, hygiene, and waste services in all health care facilities. 90% of countries meet all WHO’s minimum requirements for infection prevention and control programmes at national level. 70% of human antibiotic use globally is from the WHO access group. 80% of countries can test resistance in all bacterial and fungal GLASS pathogens by improving access to diagnostics. 95% of countries participate in the annual Tracking Antimicrobial Resistance Country Self-Assessment Survey (TrACSS). Meaningful reduction in the use of antimicrobials in the global agri-food system.
Global Leaders Group on AMR6	By 2030: 10% reduction in global deaths caused by bacterial AMR. 80% of overall human antibiotic consumption is comprised of the access group antibiotics. 30–50% reduction from the current level in the quantity of antimicrobials used in the agri-food system globally. Eliminate the use of medically important antimicrobials (MIAs) for human medicine in animals for non-veterinary medical purposes, or in crop production and agri-food systems for non-phytosanitary purposes. All countries should develop national, outcome-oriented, sector-specific targets with clear goals and timelines, and follow-up on their implementation based on these global targets.
Lancet Commission7	By 2030, achieve: 10% reduction in mortality from AMR. 20% reduction in inappropriate human antibiotic use. 30% reduction in inappropriate animal antibiotic use relative to a pre-pandemic 2019 baseline within a framework of universal access to effective antibiotics.
Global Strategy Lab8	1:10:100 1: Unite the world using a One Health approach to protect human health, animal welfare, agri-food systems, and the environment from the evolution and dissemination of drug-resistant microorganisms and infections. 10: Save 10 million lives by 2040 by preventing and appropriately treating infections without compromising the One Health systems and services that depend on sustained effectiveness of antimicrobials. 100: Ensure that 100% of countries enjoy sustainable and affordable access to antimicrobials that are appropriately used while investing in therapeutic, diagnostic, preventive, and social innovation to secure antimicrobials for the future.

From targets to footprints

The AMR footprint reframes resistance not as a single outcome to be reduced, but as the aggregate consequence of decisions made across health systems, food production, environmental management and governance. Conceptually aligned with the carbon and antibiotic footprints,⁹ it consolidates selected AMR-specific and AMR-sensitive indicators into a composite measure that can be tracked over time. Importantly, it is not designed to impose uniform global thresholds, but to assess direction of travel relative to national baselines.

An AMR footprint might include, for example, changes in the proportion of access antibiotics in national consumption, coverage of infection prevention and control and water, sanitation and hygiene (WASH) infrastructure, reductions in non-therapeutic antimicrobial use in food animals, uptake of farm biosecurity and vaccination, and trends in antimicrobial residues or resistant organisms in wastewater (Figure 1). Individually, these indicators already exist; their value lies in being interpreted collectively as contributors to a single intelligible signal of AMR pressure.

Figure 1.

The AMR footprint. MIA—medically important antimicrobials are antimicrobial classes used in both humans and animals classified as critically important, highly important, or important for human medicine based on the risk of transmitting AMR to humans as a result of non-human use.¹⁰

Unlike outcome-focused composite scores such as the Drug Resistance Index or AMR burden scores, the AMR footprint is intentionally driver- and action-oriented, explicitly integrates human, animal and environmental domains, and prioritizes tracking change over time rather than producing static cross-country rankings. Footprint components would be standardized to national baselines and combined using transparent weighting approaches informed by national priorities.

Why the footprint matters for accountability

The updated Global Action Plan places strong emphasis on governance, financing, and accountability.⁴ Yet, accountability remains the most fragile element of AMR policy. Self-assessment tools and voluntary reporting mechanisms are necessary but insufficient to sustain political attention or justify long-term domestic investment.¹¹

An AMR footprint strengthens accountability by rewarding incremental progress rather than penalizing countries starting from structurally disadvantaged positions. It enables transparent benchmarking based on improvement over time and creates a narrative intelligibility beyond technical audiences. Proposals for AMR accountability indices reflect this recognition.¹² Improvements in reporting systems may initially increase measured AMR pressure and should be interpreted as progress in system maturity rather than policy failure.

Financing AMR through a footprint lens

The most underappreciated value of the AMR footprint may lie in financing. By linking AMR pressure to investments in primary health care, WASH, animal vaccination, waste management, and environmental regulation, the footprint provides a language for mainstreaming AMR into national development planning rather than treating it as a vertical, donor-dependent programme.

The footprint is however not proposed as a sole determinant for performance-based financing but could inform accountability dialogues and funding decisions when interpreted alongside contextual information.

A different path for the next decade

The updated Global Action Plan offers a rare opportunity to reset how progress against AMR is conceptualized and measured. Without a unifying operational metric, the next decade risks reproducing ambitious strategies with uneven implementation. The AMR footprint does not replace existing surveillance or targets; it connects them. It offers a practical pathway from One Health principle to measurable accountability across diverse national contexts.

Transparency declarations

Sabiha Essack is the Chairperson of the Global Respiratory Infection Partnership and a member of the Global Hygiene Council, both supported by unrestricted educational grants from Reckitt (Pty.), Ltd, UK. Sabiha Essack is also a member of the GSK Africa Open Lab Scientific Advisory Board.