Mind the governance gap: a one health scoping review of national AMR performance indicators

Abstract

Despite several initiatives to benchmark national action in responding to antimicrobial resistance (AMR), no comprehensive inventory exists of indicators used across these efforts. We present a scoping review that maps and synthesises existing indicators used to assess national performance in addressing AMR. We conducted a review of academic and grey literature to identify quantitative and qualitative indicators used to assess national AMR performance across animal, environmental, and human health sectors. The academic search was conducted across MEDLINE, EMBASE, and Global Health. The grey literature search was conducted across multilateral organisations (e.g., WHO, FAO, WOAH, UNEP, OECD) and think-tanks. We categorised indicators into a thematic framework spanning 19 subdomains within three overarching domains: Governance & Leadership, Action Areas, and Monitoring & Evaluation. From 184 academic studies, we identified 2311 indicators, and 1406 from 48 grey literature sources. In total, 2101 were in human health, 675 in animal health, 232 in environmental health, and 709 were multisectoral. Within the three overarching domains, 281 were Governance & Leadership, 1907 were Action Areas, and 1671 were Monitoring & Evaluation indicators. When grouping indicators by subdomain, Surveillance & Laboratory (1427), Stewardship (765), and Prevention & Control (365) accounted for the largest volumes, followed by Social Determinants (232), Reporting (141), and Workforce (140), in contrast to Accountability (22), Transparency (22), and Equity (29). This comprehensive scoping review provides a One Health inventory of 3717 indicators used to assess national performance in responding to AMR. While revealing robust Surveillance & Laboratory, Prevention & Control, and Stewardship metrics, we identify critical gaps in Accountability, Transparency, and Equity. These measures comprise the Governance & Leadership domain, which is essential for policy implementation.

Introduction

Antimicrobial resistance (AMR), leading to an estimated 1.14 million deaths worldwide in 2021 alone¹, is a critical, complex public health issue. By 2035, the global economy is projected to incur additional healthcare costs of $412 billion, and losses of $443 billion from reduced workforce productivity².

International efforts to combat AMR have intensified since 2011, when the WHO Regional Office for Europe (WHO Europe) and the European Commission adopted regional action plans for AMR^3,4. This was followed by the WHO 2015 Global Action Plan (GAP) and the 2016 and 2024 United Nations (UN) political declaration on AMR⁵. In 2023, the WHO Europe member states endorsed an AMR roadmap to identify, prioritise, implement, and monitor high-impact interventions to tackle AMR⁶. Despite these initiatives, countries are inconsistent when translating global and regional commitments into practice due to differing political priorities, economic constraints, and healthcare infrastructure capacities⁷.

In response, stakeholders have advocated for target-based approaches, such as the global 10–20–30 targets for 2030, the targets within the 2024 UN political declaration on AMR (UNGA), and the EU’s One Health Action Plan goals^5,8,9. Targets provide specific, measurable objectives that can unify and accelerate country-level efforts, but reliance on targets alone risks oversimplifying the multifactorial drivers of and policy responses to AMR¹⁰. Several initiatives exist that monitor different aspects of AMR national policy, such as the Global Database for Tracking AMR Country Self-Assessment Survey (TrACSS)¹¹, IHR States Parties Self-Assessment Annual Report (SPAR)¹², WHO Infection Prevention and Control Assessment Tool 2 (IPCAT2)¹³ the Joint External Evaluation (JEE)¹⁴, the Global Coalition on Aging and Infectious Disease Society of America AMR Preparedness Index¹⁵, the AMR Governance Framework¹⁶, FAO’s Assessment Tool for Laboratories and AMR Surveillance Systems (ATLASS)¹⁷, and the WOAH Observatory Monitoring Reports¹⁸. However, these initiatives are sometimes conducted and interpreted in isolation, resulting in a fragmented evidence base that limits the ability of policymakers to form a comprehensive, cross-sectoral view of national AMR policy responses.

We conducted a literature review to identify and consolidate existing quantitative and qualitative indicators currently used, or proposed, to compare national performance in addressing AMR. We aimed to highlight best practices, uncover gaps in indicator coverage, and identify candidates for inclusion within a novel proposed One-Health AMR Accountability Index¹⁹. While previous reviews examine selected aspects of AMR policy implementation, this study encompasses academic and grey literature to map indicators across the full One Health spectrum and, to our knowledge, constitutes the most comprehensive resource to date that identifies gaps, reduces duplication, and helps develop balanced, multisectoral indicators to measure national performance in addressing AMR.

Results

Scoping review

Our academic search identified 9361 results (Fig. 1). Following title and abstract screening, 1087 results remained. We further excluded 468 (wrong outcomes), 126 (wrong comparator), and 309 (wrong study design). This resulted in 184 academic studies and 48 grey literature sources. Levels of interrater-reliability observed were substantial, for abstract and title screening (0.78), and fair, for full text screening (0.30). The lower agreement at the full-text stage is consistent with the greater complexity of eligibility decisions required at this level, where a more nuanced judgement was required regarding the inclusion and exclusion criteria. All disagreements were resolved through adjudication by a third independent reviewer (MA).

Fig. 1. PRISMA flow diagram of studies included in scoping review.

Authors’ creation.

Supplementary Table 1 lists grey literature and source links, while Supplementary Tables 2 and 3 summarise the literature included. From these sources, 6645 indicators were initially extracted (Fig. 2). During screening, 2928 indicators were excluded: 1011 (not considered cross-national measures of performance in addressing AMR); 1547 (duplicates); 370 (not specific to AMR). This resulted in 3717 indicators eligible for inclusion.

Fig. 2. PRISMA flow diagram of indicators included in scoping review.

Authors’ creation.

We identified 2311 unique indicators from academic studies and 1406 from grey literature sources (outlined in Supplementary Data 1 and 2). Table 1 provides the number of academic studies, grey literature sources, indicators identified, and example indicators within each AMR policy subdomain. A summary visualisation of indicator density across the 19 subdomains illustrates substantial concentration in Surveillance & Laboratory, Stewardship, Prevention & Control, and comparatively few indicators for Accountability, Transparency, and Equity subdomains (Fig. 3). Since indicators could be grouped under multiple subdomains, in some instances the totals exceed the number of unique indicators identified (n = 3717). Supplementary Figure 1 visualises indicator groupings by sector (animal, environmental, human health, multisectoral). We provide below an in-depth narrative synthesis of indicators grouped under their subdomains, with notable findings. Supplementary Figure 2 displays the distribution of academic studies by publication year; most appeared within the past five years.

Table 1.

Overview of subdomains showing the number of academic studies and grey literature sources reviewed

Domain	Sub-domain	Definition	Academic indicators	Academic studies	Grey literature indicators	Grey literature studies	Example indicator
Monitoring & Evaluation	Surveillance & Laboratory	Indicators that assess the comprehensiveness of surveillance programmes and the capacity and quality of laboratory systems across all sectors.	941	118	486	32	What is the status of the national surveillance system for antimicrobial resistance in live aquatic animals?11
	Reporting	Mechanisms for communicating progress on the national AMR strategy to external stakeholders, including annual progress reports and formal submissions to international and regional surveillance initiatives (e.g., GLASS, ECDC, CAESER, EARS-Net)	56	18	85	12	Does the country report use of antibiotics (ATC classes J01, A07AA, P01AB) and do they report route of administration (oral, parenteral, inhalation, rectal)?63
	Feedback Mechanisms	Indicators that capture the existence and quality of processes for relaying surveillance data and performance information back to regional, organizational, and individual stakeholders	16	6	50	13	Select all that apply: 1) Quality audits of long-term care facilities (LTCFs) include AMR. 2) There is monitoring and evaluation of AMR in LTCFs44.
	Effectiveness	Indicators examine whether structured mechanisms exist at the national level to evaluate if policies or interventions achieve their intended health and economic outcomes.	19	9	17	8	Estimation of the incidence of patients acquiring at least one hospital-acquired infection (HAI) in acute care hospitals per 1000 hospital admissions. Estimation of all types of HAIs per year in acute care hospitals per 1000 hospital admissions13.
Governance & Leadership	Regulations & Legislation	Covers all forms of legislation, incentives, and penalties in place for the containment of AMR.	74	13	54	14	Does the country have legislation in place that limits or prohibits the over-the-counter sale of antibiotics without a prescription?49
	Strategic Vision	Indicators that measure the extent to which there exists a national long-term strategy that has been informed by a situational analysis, with specific, measurable, actionable, relevant and time-bound (SMART) aims for the containment of AMR.	88	26	25	13	Is there a national strategic plan for hospital-acquired infection surveillance (with a focus on priority infections based on the local context) developed by the multidisciplinary technical group?48
	Participation	Indicators that evaluate the extent of inclusive involvement of all relevant stakeholders in development, implementation, monitoring and evaluation of national strategies to address AMR.	47	19	11	7	Who is involved & what is the role for priority setting regarding AMR action and standards?20
	Coordination	Indicators that measure the comprehensiveness of mechanisms in place for coordination across One Health sectors.	30	14	42	16	What is the level of effective integration of laboratories in AMR surveillance in the animal health and food safety sectors?48
	Accountability	Indicators that measure whether responsibility is allocated to deliver objectives and activities listed within the NAP, and whether agreements exist if actions are not undertaken or targets not met.	15	9	7	6	What is the number of focal persons in the network who are reference persons for AMR activities?23
	Transparency	Indicators that measure the extent to which NAPs, progress reports, funding information and other data are publicly available and accessible.	6	6	16	7	Is the information on the national action plan, including progress reports, AMR surveillance data, funding allocation, responsible body, and responsible person/sector within the country, publicly available?75
	Sustainability	Assesses the commitment of relevant stakeholders, the degree to which adequate budgets for present and future activities are allocated, and the consistency with which support is provided for AMR policy development, implementation and monitoring.	18	9	28	14	Is the country’s funding for One Health initiatives in government budget? If Yes, what is the amount of funding? Describe the extent of technical support provided to build capacities to address AMR through support for implementation of international standards and action plans, trainings, and R&D80.
	Equity	Indicators that measure the extent to which AMR policy facilitates equitable access to antimicrobials or mitigates the impact of AMR on disadvantaged and vulnerable populations.	11	3	18	3	Does the country promote equal participation of women, men and other vulnerable groups and/or groups facing discrimination in the multisectoral AMR coordination mechanism and technical working groups?85
Action Areas	Prevention & Control	Measures of the comprehensiveness of IPC programmes, biosecurity mechanisms, and access to clean water, sanitation, and hygiene between countries.	122	35	243	22	Are a minimal set of core indicators for infection, prevention, and control (IPC) within healthcare facilities in the country defined?108
	Social Determinants	Encompass the structural and contextual factors that shape AMR risk between countries, including educational level, climate change, pollution, conflict, nutrition, housing, finance status, demographic trends, technological environments, and individual characteristics.	209	19	23	4	What are the behavioural barriers, including structural barriers, to tackling AMR?32
	Stewardship	Indicators that measure the comprehensiveness of efforts to reduce inappropriate antimicrobial use such as stewardship programmes and guidelines for antibiotic use, and consumption rates and sales of antibiotics	468	80	297	31	Report antimicrobial use for ATC class J01, A07AA, P01AB by AWaRe (Access, Watch, and Reserve) classification (relative use % of Access class antibiotics; relative use % of Watch class antibiotics; relative use % of Reserve class antibiotics)63.
	Community Awareness & Enabling Behaviors	Indicators designed to improve knowledge, shape attitudes, and foster practices that support responsible antimicrobial use.	91	18	18	11	What is the amount of funding mobilised for communication actions on AMR and antimicrobial stewardship per 1000 population?80
	Workforce	Indicators referring to the development, education, and training of teams and individuals across the One Health sectors.	77	22	63	10	Does the country provide training and professional education on AMR to the agriculture (animal and plant), food production, food safety, and environment sectors?11
	Access to Medicines & Health Services	To what extent the population experiences barriers when accessing healthcare services and essential medicines.	70	20	48	11	What is the unmet need for each of the following due to cost, distance, and waiting times? 1) Health care 2) Dental care 3) Prescribed medicines64.
	Research, Innovation, & Digital Technology	Assess whether there is investment in research to examine the drivers of AMR, effectiveness of interventions to mitigate AMR, and whether there are incentives in place that aim to foster innovation.	28	16	22	6	Amount of funding allocated for translational research and late-stage development of AMR medical countermeasures, including clinical trials for antimicrobials80.

The total indicators extracted, and representative example indicators per subdomain. Some indicators and studies appear in multiple subdomains; subdomain sums may exceed the overall total.

Fig. 3. Indicators within 19 government framework subdomains for academic and grey literature.

Figure Notes: Some indicators and studies appear in multiple subdomains; subdomain sums may exceed the overall total. Access to Medicines & Health Services (Access); Community Awareness & Enabling Behaviours (Community Awareness); Research, Innovation, & Digital Technology (Research).

Domain: governance & leadership; subdomain 1: strategic vision

Strategic Vision refers to indicators relating to the adoption of a national long-term strategy informed by a situational analysis, with specific, measurable, achievable, relevant, and time-bound (SMART) aims for addressing AMR. Indicators also measure whether there is a high-level commitment to tackling AMR, e.g., AMR appears in political manifestos or on national risk registers. 88 indicators were extracted from 23 academic studies^20–42; 25 from 12 grey literature sources^{11,13,15,17,43–50} (in particular, from Implementation of WOAH Standards: The Observatory Annual Report 2022)¹⁸.

Indicators include measurements of operational plan comprehensiveness³⁴, zoonotic disease governance²¹, overall National Action Plan (NAP) design²², and specific NAP characteristics (e.g. shared leadership^27,33, advocacy facilitators, functionality, preparedness and response to public health events, and incorporation of the primary healthcare sector)²⁸. While some indicators measure whether countries have adopted a NAP^21,32, and progress with NAP development^29,30,45, most gauge whether specific elements are included, e.g. the implementation of a One Water stewardship framework³⁶, antimicrobial use (AMU) reduction across One Health sectors⁴¹, the integration of long-term care facilities⁴⁴, and sections dedicated to environmental, food and agricultural issues^17,43,46. Certain indicators from the academic literature evaluate the level of political recognition and support that strategies and targets receive^21,25,31.

Indicators also evaluate the degree to which NAPs incorporate international bodies’ priorities. This especially concerns alignment between NAPs and the GAP^{24,35,37,39,42}, on infection prevention control (IPC), AMU and surveillance³⁴, best practices^26,38, support for IPC programmes¹³, and governance training programmes (e.g. provided by Medicines, Technologies, and Pharmaceutical Services (MTaPS)²³. Other indicators consider the standards and criteria for implementation of targets⁴⁰, the existence of a focal point or technical group to lead NAP implementation and monitoring and evaluation (M&E)¹¹, and whether the setting of priorities is based on empirical evidence²⁰.

Domain: governance & leadership; subdomain 2: participation

Participation refers to indicators that evaluate the extent to which the development, implementation, and M&E of national AMR strategies involve stakeholders, e.g., civil society, healthcare professionals, veterinarians, the food and pharmaceutical industries, and subject matter experts. Forty-seven indicators were extracted from 19 academic studies^{20,21,23,27,29,31–33,39,51–60}; 11 from 7 grey literature sources^{15,18,49,61–64}.

Indicators assess ‘participatory’, inclusive and consensus-oriented decision-making at the governmental and inter-governmental level²¹. They also evaluate stakeholders’ level of contribution and participation across One Health sectors⁵² and map the type of persons associated with AMR national-level policy-making^20,54. Other indicators gauge how many stakeholder support activities involve non-state actors³¹, the participation of private-sector entities in AMR-related decision-making, and the safeguards against potential conflicts of interest⁶². Indicators consider participation in international AMR-related initiatives⁵⁵, e.g. campaigns⁵⁶, laboratory training programmes⁶⁰, and surveillance data repositories^{15,29,32,57–60}; and stakeholder participation in facilitating mechanisms, e.g. regional and national-level AMR meetings⁵¹ and joint programmes involving agricultural and veterinarian actors^61,65.

Domain: governance & leadership; subdomain 3: coordination

Coordination refers to indicators that measure the comprehensiveness of mechanisms linking up One Health sectors, e.g. multisectoral committees. Thirty indicators were extracted from 14 academic studies^{21–30,52,53,66,67}; 42 from 15 grey literature sources^{11,13–15,17,43,50,61,62,68–73}.

Multiple indicators, both from the academic and grey literature, assess the extent to which national-level coordination includes all One Health sectors. Studies employ ordinal^11,14,27,30, quantitative²², qualitative⁵³, and multiple-choice⁷² metrics for overall assessments of One Health intersectoral coordination capacity. Other indicators record stakeholder contribution to coordinated initiatives^11,43,52.

One Health initiatives are often included within NAPs²⁹, in addition to collaborative research activities⁶⁶. Other studies consider the level of coordination within sectors (e.g., between agricultural and veterinary stakeholders⁵² or intra-sectoral chains of command)⁶¹. For the human sector, indicators ordinally measure coordination between governments, NGOs and patient groups¹⁵; and institutional linkages between IPC and water, sanitation, and hygiene (WASH) programmes, patient associations, civil society bodies, and medical societies^11,13,30,66.

Nationally and internationally, indicators also evaluate institutional alignment and collaboration, e.g. whether a country’s NAP is linked to or integrated with its other national strategies^11,21; the extent to which national reference laboratories support the integration of peripheral laboratories across the veterinary and agricultural sector⁷⁰; and how decision-making competences are shared between centralised levels of AMR governance⁶². Internationally, indicators measure integration of addressing AMR into other global agendas^24–26, and countries’ collaboration with international research¹⁵ and programmes such as MTaPS²³.

Several indicators assess national mechanisms for facilitating coordinated activity, e.g. whether countries have national, multisectoral coordinating committees^{17,26,28,53,71,72} and the extent to which local and national IPC monitoring, audit and feedback mechanisms are aligned¹³. Other indicators evaluate coordinating mechanisms, e.g. operational documents⁴³, integrated laboratory data-sharing networks⁶⁹, emergency logistics and supply chain management systems⁶⁹, International Food Safety Authorities Network contact points⁷², and information-sharing processes for regulatory bodies⁴³.

Domain: governance & leadership; subdomain 4: accountability

Accountability refers to indicators that assess whether responsibility is allocated to certain individuals or organisations to deliver the NAP’s objectives, and whether sanctions exist if any are unmet. Fifteen indicators were extracted from nine academic studies^{20–23,27,51,66,74,75}; 7 from 5 grey literature documents^{11,13,61,76,77}. In both sets of sources, indicators measure accountability at the national level through overall, quantitative scores^21,22.

Indicators demonstrate the existence of relevant authorities to which responsibility for AMR-related initiatives can be allocated, e.g., focal persons acting as reference persons for AMR activities⁵¹, or focal working groups responsible for M&E and NAP implementation¹¹. Other indicators map the role and scope of authorities and stakeholders, outlining mechanisms for delegating, accrediting, and authorising AMR-related responsibilities^13,61. These mechanisms are evaluated according to their linkage to broader health system governance structures²⁰, and their compliance with national-level policies and regulatory frameworks, concerning, e.g. food policy²¹. Lastly, indicators consider facilitating practices, e.g., institutional audits⁵¹; MTaPS-supported activities for entities addressing AMR²³; the consistent and reliable reporting of information to national or international health authorities^74,77.

Domain: governance & leadership; subdomain 5: transparency

Transparency encompasses indicators that measure the public availability and accessibility of NAPs, progress reports, funding information, and the extent to what degree do AMR policy development, implementation, and evaluation occur in an accessible and open environment. Six indicators were extracted from 6 academic studies^{21,22,27,75,78,79}; 16 from 7 grey literature sources^{17,18,61–63,71,77}. In both sets of sources, indicators measure AMR governance transparency through overall, quantitative scores^21,22 and respondent awareness of AMR risks and response⁷⁹.

Indicators consider whether information (e.g., NAPs^21,75,78, progress reports, surveillance data¹⁷, funding allocations, a log of responsible entities⁷⁵, audits of AMR treatment guidelines⁷¹, risk assessment outcomes)¹⁷ is published and accessible^17,62,63. Other indicators assess whether stakeholders fulfil their obligations to facilitate transparency, either by sharing information⁷⁷ or by consistently and punctually informing other AMR-related stakeholders about sector-specific developments and activities⁶¹.

Domain: governance & leadership; subdomain 6: sustainability

Sustainability encompasses the commitment of relevant stakeholders, the allocation of adequate budgets for present and future activities, and the consistency with which support is provided for AMR policy development, implementation and monitoring through the input of subject matter experts through technical advisory groups. Eighteen indicators were extracted from 9 academic studies^{21–23,26–28,31,34,80}; 28 indicators from 14 grey literature sources^{11,13,15,17,43,44,46,61,69,72,80–83}. Two studies measure sustainability through overall scores²², while another qualitatively assesses the overall sustainability of national veterinary laboratory systems⁶¹.

Indicators assess whether AMR activities are financially sustainable, e.g. ensuring accessibility of funds⁶¹; the appropriate costing of activities³⁴; the identification, mobilisation, and diversification of funding^{15,26,34,43,72,80}; the protection of allocated funds for operating budgets and resources^13,28,81. Other indicators gauge AMR funding and investments’ level of government backing^{15,21,31,44,46,72}. Lastly, indicators consider the existence of other, non-financial support that facilitates sustainable practices, e.g. advocacy mechanisms for International Health Regulation (IHR) implementation⁷²; experts’ participation in a NAP implementation campaign²⁸; MTaPS-supported activities for building technical capacity²³; active Drug Safety Monitoring expert committees⁶⁹.

Domain: governance & leadership; subdomain 7: equity

Equity refers to indicators that measure the extent to which AMR policy facilitates equitable access to antimicrobials or mitigates the impact of AMR on disadvantaged and vulnerable populations. Eleven indicators were extracted from three academic studies^21,22,84; 18 from 3 grey literature sources^11,72,85, in particular from the WHO guidance: addressing gender inequalities in national action plans on AMR⁸⁵.

Indicators include geographic factors that impact access⁸⁶, economic inequality and development measures²¹. Another measures the impact of a country’s poverty gap and public sanitation services on AMR⁸⁴. Other indicators inquire whether national-level data are captured and categorised according to social stratifiers^11,49,87. Grey-literature indicators assess if inclusion of vulnerable groups is promoted across all AMR-related national mechanisms⁴⁹. Indicators also include retrospective reviews of services, policies, and education to identify and reduce gender biases or inequalities^21,49,72.

Domain: action areas; subdomain 8: regulations & legislation

Regulations & Legislation covers legislation, incentives, and penalties in place for the containment of AMR. Seventy-four indicators were extracted from 10 academic studies^{21,22,34,66,88–93}; and 54 from 14 grey literature sources^{11,15,17,44,46,48,49,61,62,69,71,72,77,85}. Three studies generated 49 indicators^18,66,88. Within the grey literature, over half came from WHO’s TrACSS¹¹.

Many indicators focus on oversight of AMU and enforcement of guidelines, laws, and regulatory instruments. To regulate AMU, indicators consider whether legislative frameworks exist to prohibit or severely restrict highly critical antibiotics⁸⁹ in animal health^{34,48,66,77,89}. Indicators also include regulations for antibiotic use in human health, establishing whether over-the-counter (OTC) sales without prescription are banned⁷¹ and OTC prescriptions are written by legally authorised persons^49,77,89. Other indicators focus on elements of antimicrobial supply legislation, e.g. controlling the marketing of pesticides; country-level coverage of drug regulations in the supply chain^21,92. Indicators also consider the potential contribution of regulations that might reduce AMU⁹¹, e.g. taxing antibiotics for livestock use; restricting broad-spectrum antibiotics’ use in growth promotion^15,90.

Several indicators evaluate the existence and adequacy of legislation for safe wastewater treatment and disposal. TrACSS, for example, inquires whether national legislation is in place and enforceable for preventing environmental antibiotic contamination^11,88. Indicators also quantify antibiotic residue according to environmental protection criteria⁴⁹. Other indicators gauge regulation concerning the detection and prevention of substandard and falsified medical products in human⁴⁹ and animal health^61,62. Finally, certain indicators assess other forms of legal or regulatory instruments, e.g. nutrition guidelines²¹, legislation for AMR surveillance^17,80, transnational transport of food, goods, animals and people¹¹, IHR implementation⁷², and contextual factors including rule of law and corruption²¹.

Domain: action areas; subdomain 9: prevention & control

Prevention and control refer to IPC programmes, biosecurity mechanisms, access to clean water and sanitation, and hygiene. 122 indicators were extracted from 33 academic studies^{21,22,24,26,28,30,32,36,40,51,53,55,57,60,66,74,80,84,86,90,93–105}; 243 from 21 grey literature studies^{11–13,15,18,43,44,46,49,61,68,69,71,77,83,106–112}, including 100-plus from IPCAT2¹³.

Indicators for WASH include the proportion of the population with basic or safely managed drinking water and sanitation facilities; access to hygiene installations in communities and healthcare facilities; hand hygiene infrastructure; waste management services; environmental cleaning protocols; and WASH adherence^21,84. Human health IPC indicators cover the existence of national IPC programmes¹¹; focal points¹⁰⁸; budgets⁴⁴; updated and implemented national and facility-level guidelines^13,108; adaptation and implementation of multimodal strategies such as the States Parties Self-Assessment Annual Report¹²; integrated monitoring and audit frameworks linked to AMR and WASH surveillance, microbiological support for healthcare-associated infection (HAI) surveillance, clear reporting lines, timely feedback mechanisms¹³; defined surveillance objectives and benchmarking⁶⁹; capacity assessments such as Joint External Evaluation (JEE) IPC scores^26,55; and institutional policies and training for IPC personnel¹³. Animal health indicators include farm biosecurity measures⁹⁰; livestock density and diversity metrics²¹; animal–human contact rates⁹⁵; inspection and hygiene practices along the farm-to-fork food chain²¹; good manufacturing practices³⁰; manure management²¹; traceability and movement control, zoning and compartmentalisation⁶¹; preparedness plans for containment of resistant pathogens⁶⁸; vaccination strategies for zoonoses^61,68; vector control measures⁶⁹; and monitoring of antibiotic residues and environmental discharges^11,49. Policy and planning indicators encompass the percentage of NAPs addressing WASH⁹⁸; environmental contamination, inclusion of One Health environment sector scorecards, the existence of national strategic plans for HAI and AMR surveillance that are aligned with IHR^12,36,98; vaccination coverage metrics for key pathogens⁶⁸; AMU reduction interventions on farms⁷¹; and stakeholder perceptions of biosecurity improvements¹³.

We observed crossover between indicators for IPC and other domains, including Coordination, Feedback Mechanisms, and Accountability. Multi-domain indicators include presence of IPC M&E plans for NAPs^13,108; consistency and quality of surveillance platform data, national platforms for IPC data-sharing, feedback mechanism for IPC scores, and clarity on responsible entities for IPC performance monitoring¹³; cross-sector linkage of IPC with AMR, WASH, and environmental programmes, regular audits and guideline reviews⁹⁹; training programmes for IPC professionals¹³; outbreak preparedness and response capacity⁶⁸; and health outcome monitoring, e.g., HAI incidence⁴⁰, Clostridioides difficile infections surveillance, sepsis critical care admissions, and measures of population-level intervention impact on infection rates⁵⁷.

Domain: action areas; subdomain 10: social determinants

Social determinants encompass the structural and contextual factors that shape AMR risk within different populations across countries, including educational level, climate change, pollution, conflict, nutrition, housing, financial status, demographic trends, technological environments, and individual characteristics such as gender, age, and ethnicity. A total of 209 indicators were extracted from 19 academic studies^{21,32,36,42,84,86,91,92,94–96,98,101,102,113–117}, with over half of the indicators coming from one study²¹; 23 from 4 grey literature studies^{69,77,109,110}, including 15 from the Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP)¹¹⁰.

Indicators for WASH appeared in both IPC and Social Determinants^{21,94–96,98}. Economic and financial indicators comprise GNI per capita, GDP, public social and education expenditure, unemployment, labour force participation, income inequality, and measures of political stability, corruption perception, and rule of law^21,94,96. Demographic indicators cover urbanisation rates, age distribution, gender and ethnic composition, population growth, migration or refugee ratios, and population density or proximity to water bodies, all of which affect transmission dynamics and healthcare demands^{21,77,96,110,113}. Nutrition and food security metrics such as undernourishment prevalence, stunting in children, anaemia among women of reproductive age, dietary energy and protein supply adequacy, food price indices, and food insecurity ratios highlight vulnerability to infection and influence AMU in agriculture and human health²¹.

Many environmental indicators were grouped within the Social Determinants subdomain (89). These include climate indicators, e.g. average temperature and precipitation, air quality, CO₂ and greenhouse gas emissions, climate risk indices, water stress and renewable water resources, land use factors, pollution scores, and indicators of ecosystem health, all of which affect pathogen emergence, spread, and AMR selection pressures^21,94,96. Housing and living conditions, e.g., quality of housing, overcrowding, and access to electricity, influence infection risk and healthcare-seeking behaviour¹¹⁰. Technological and infrastructure indicators include internet penetration, mobile subscriptions, logistics performance, transport accessibility, electricity access, and technology adoption rates, which shape health communication, surveillance capacity, and distribution of medical and veterinary interventions^21,96. Conflict and governance contexts are captured by political stability, violence and conflict indices, proportions of refugees and internally displaced people, justice system metrics (unsentenced detainees, property rights, press freedom), and governance indicators (public spending, affordability of justice), reflecting how crises and instability disrupt health services, surveillance, and stewardship efforts²¹.

Domain: action areas; subdomain 11: stewardship

Stewardship refers both to indicators that measure the comprehensiveness of efforts to reduce inappropriate AMU, such as stewardship programmes and guidelines for antibiotic use in human, animal, and environmental (aquaculture) health, and consumption rates and sales of antibiotics. A total of 468 indicators were extracted from 78 academic studies^{21,22,24,26,30,32,34,36,40,41,51,53,55,56,60,65,66,79,80,86,90–95,97,100,101,103,105,113,114,116,118–160}; 297 from 31 grey literature studies^{11,14,18,44,46,48,49,63,68,69,71,77,83,107,109,161–170}, with 163 indicators originating from the 9th Annual Report on Antimicrobial Agents Intended for Use in Animals (ANIMUSE)⁴⁸.

Key indicators for Stewardship assess whether NAPs include One Health stewardship frameworks, guidelines, and dedicated governance structures (e.g., antimicrobial stewardship (AMS) committees, AMS focal points, drug and therapeutics committees, auditing and feedback mechanisms)^{28,36,103,129,147}. Human-sector consumption metrics encompass defined daily dose (DDD) and DDD/1000/day (DID) in hospital and community settings, stratified by antibiotic class, access, watch, reserve (AWaRe) categories, age groups, syndromes, and seasonal or regional variation^{63,86,94,101,103,125,127,128,130,143,155,164}. Additional indicators include antibiotic treatment courses per country population,¹⁰³, percentage of hospitals in the country with early switch/discharge protocols⁹⁷, prescribing rates per consultation or population¹⁰³, percentage of prescriptions aligned with guidelines¹⁴⁶, and metrics of outpatient vs. inpatient antibiotic use¹³⁰.

Animal-sector indicators cover antimicrobial consumption^68,165, antimicrobial consumption by Antimicrobial Expert Group (AMEG) categorisation¹⁷⁰, treatment incidence per flock or per production round^100,128,150, proportions of classes used¹²¹, routes of administration¹⁷¹, traceability of medicated feed¹¹⁹, classification of veterinary antimicrobials per WOAH/WHO importance lists^18,119, targets for AMU reduction¹⁶⁸, and projections of future consumption^139,140. Environmental stewardship indicators include monitoring and reduction of antibiotic discharges^97,143, biosecurity practices to optimise AMU¹¹ and minimisation of antimicrobial pesticide use^11,14,71. Broader metrics capture national monitoring systems for sales/use in human and animal sectors^11,77, adoption of AWaRe classification in essential medicines lists^{28,79,103,136,151}, capacity for AMU monitoring³⁰, interaction of livestock antibiotic consumption with GDP¹¹³, and perceived contributions or achievable reductions in sector-specific AMU⁹⁰. Surveillance and evaluation indicators include variation in antibiotic use (DDD/1000/day), trends in consumption rates and costs (EUR/DDD), benchmarking of antibiotic use, and correlation analyses over time^90,127,131. Stewardship implementation metrics also cover rapid diagnostic test availability, feedback on prescriptions, AMS resource presence, training and behaviour-change methodologies, audit and quality improvement activities, integration of AMS into facility accreditation, and feedback loops for prescribers^103,142,147.

Domain: action areas; subdomain 12: community awareness & enabling behaviours

Community awareness and enabling behaviours encompass indicators designed to improve knowledge, shape attitudes, and foster practices that support responsible AMU, including the comprehensiveness and consistency of public awareness campaigns, including educational programmes at school. Ninety-one indicators were extracted from 18 academic studies^{21,22,24,27,28,30,31,40,51,56,66,91,104,117,138,147,172,173}, with 38 indicators originating from a single study³¹; 18 across 11 grey literature studies^{11,15,17,43,49,62,71,77,111,164,168}.

Indicators focused on educational metrics (e.g., students’ participation rates in prudent antibiotic use campaigns and the core concepts of curriculum used^11,173). Others measured public awareness campaign output (e.g. counts of education activities, and the variety of materials produced^24,31). Knowledge and attitude assessments are reflected in government- or survey-derived awareness and understanding scores, personal and political knowledge, attitude, and practice scores, perceived awareness of interconnected issues (climate change, food security, AMR), and perception of priority areas for action^{24,56,117,172}. Indicators also track engagement in national and international campaigns and the existence of formal communication strategies^12,30,147.

Behavioural change metrics include self-reported antibiotic use patterns, public perception of benefits and worries about AMR, and adoption of recommended practices such as obtaining antibiotics by prescription^12,49,111. Capacity-building indicators assess countries’ ability to raise AMR awareness, measured by Global One Health Index (GOHI)-AMR improved awareness and understanding scores and the presence of incentives to promote and monitor public engagement^21,138. Finally, stakeholder mapping and community engagement metrics gauge the number of identified and engaged actors, jointly developed risk communication activities, and the proportion of activities adopted by communities¹².

Domain: action areas; subdomain 13: workforce

Workforce encompasses indicators referring to the development, education, and training of teams and individuals across the One Health sectors. Indicators in this subdomain include staffing and the existence of an overarching, coherent workforce strategy. A total of 77 indicators were extracted from 22 academic studies^{21,22,27,28,30–32,40,53,60,66,90,91,95,99,102,115,119,133,141,174,175}; 63 from 10 grey literature studies^{11–13,15,17,43,49,69,77,108}, with over half originating from IPCAT2¹³.

Academic measures include participation in laboratory training and national training modules, the existence of pre-service and in-service pharmacovigilance curricula, and mandatory IPC training for healthcare workers^99,104. Other staffing-level indicators capture the proportion of the employed population working in agriculture or animal husbandry, ratios of IPC personnel, and estimated numbers of pharmacists and technicians per country^32,95,115. Some indicators measure competency and preparedness via stakeholder knowledge, perceptions, and practices toward AMS^90,174,175; education quality is also tracked^11,21,31. Performance analyses such as correlations between hospital transmission rates and numbers of healthcare workers or practising nurses per 100,000 population that highlight the impact of staffing levels on infection control are also included¹⁴¹. National assessment tools such as GOHI education scores benchmark country progress in workforce development and continuous professional education^23,45,69. These indicators further track the number of professionals trained in joint risk assessment and the integration of AMR content into medical and veterinary curricula^13,43,49. Lastly, indicators encompass IHR workforce readiness during public health emergencies¹².

Domain: action areas; subdomain 14: access to medicines & health services

Access to Medicines & Healthcare Services captures the extent to which the population experiences barriers when accessing healthcare services and essential medicines. Seventy indicators were extracted from 19 academic studies^{21,51,84,86,92,96,101,103,115,120,134,141,176–182}; 48 from 11 grey literature studies^{11,15,44,49,61,64,72,83,106,112,167}. The majority of grey literature indicators (38) were from Universal Health Coverage (UHC) Watch⁶⁴. Academic indicators include both financial metrics and utilisation measures.

Financial metrics include total health expenditure as a percentage of GDP, the ratio of public to private health spending, out-of-pocket payments as a share of national income, and cost estimates per infection^13,76. Utilisation measures here include the proportion of children with cough or fever who visit formal versus informal healthcare providers and the estimated cumulative number of facility visits before age five¹²⁰. Service capacity within this subdomain is gauged by hospital bed density, ICU and IMCU beds per 100,000 inhabitants, hospital admissions per year, numbers of registered medicine outlets, and days antibiotics are out of stock^{51,84,86,134,179,180}. Essential medicines access is tracked via the count of countries approving the WHO essential medicines list ‘Access’, ‘Forgotten’, and pediatric formulations, while GOHI scores assess domestic health expenditure, health service coverage, and UHC service indices for infectious diseases^21,182. Grey literature indicators complement these with measures of financial protection, e.g., households facing catastrophic or impoverishing health spending by consumption quintile; unmet need for healthcare and dental care due to cost, distance, or waiting time; and system resilience metrics (e.g., public spending on health as a share of government and GDP, occupancy rates of acute-care beds, and veterinary service strength)⁶⁴. Trusted and utilised health services under this subdomain are gauged by outpatient contact rates and the continuity of essential health services¹².

Domain: action areas; subdomain 15: research, innovation & digital technology

Research, Innovation & Digital Technology includes indicators that assess whether there is investment in research to examine the drivers of AMR and the effectiveness of interventions to mitigate AMR. This subdomain includes indicators that measure whether incentives exist, in the public and private sectors, that aim to foster innovation with respect to the development of diagnostics and treatments for AMR. Twenty-eight indicators were extracted from 14 academic studies^{21,22,27,31,34,36,51,53,60,66,80,93,183,184}; 22 from 6 grey literature studies^{15,49,62,69,77,112}.

In the case of AMR-related research, different academic studies generated AMR research scores through assessment of countries’ commitment to research and development (R&D) through the development of novel agents, presence of a research budget, and reference to R&D within the NAP. These scores were variously presented (e.g. quantitative²², qualitative⁵³, ordinal, and binary measures)^27,34. Certain indicators evaluate the provenance^15,80, and amount⁸⁰, of funding made available for AMR-related research while others assess the type (e.g. push incentives¹⁵) and scope of this funding^68,82. Studies also consider the adequacy of AMR-related research by measuring the national number of researchers in the AMR field²¹, the number of publications affiliated with a given country^31,51, whether these publications address issues such as irrational AMU¹⁸³, and whether relevant scientific or professional conferences are held³¹. The grey literature in particular focuses on structural factors related to AMR research, e.g. the extent to which national research agendas are informed by global AMR agendas and tailored to national needs⁴⁹ and the degree to which capacity building for the implementation of such research is the product of the collaboration between academia, the private sector, and civil society⁴⁹.

Domain: monitoring & evaluation; subdomain 16: surveillance & laboratory

Surveillance & Laboratory encompasses indicators that assess the comprehensiveness of surveillance programmes and the capacity and quality of laboratory systems across all sectors. A total of 941 indicators were extracted from 115 academic studies^{21,22,26,27,29,30,40,51,53,55,57–60,65,74,80,84,87,91,92,94–96,99,101–105,113,121,124–126,132–134,138,141,144,145,147,148,153,154,160,176–180,185–243}; 486 from 29 grey literature studies^{11–15,17,18,43,44,46,47,49,61,63,69–71,73,77,106,107,109,112,161–165,244}. Over half of the grey literature indicators were from the WHO Global AMR and Use Surveillance System (GLASS)⁶³ (207) and IPCAT 2¹³ (111).

Academic indicators related to surveillance^{21,74,99,138,153}, the representativeness and coverage of surveillance platforms¹⁰⁴, prioritised pathogens or infections²¹⁴, data completeness and consistency, standardised case definitions¹⁰⁴, sampling schemes^53,216, data collection intervals^193,230, data verification and validation processes^27,102,190, and the establishment and integration of surveillance across One Health sectors²¹. Measures of laboratory capacity and quality span assessments of infrastructure and operations (e.g., availability of national reference laboratories, continuity of services, referral pathways, sample transport)^21,53,74, diagnostic methods and techniques (e.g., culture, antimicrobial susceptibility testing (AST) for bacteria and fungi, molecular/genomic testing, pathogen-specific assays)⁸⁶, standardisation of procedures (e.g., adherence to Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines, participation in external quality assurance/proficiency testing schemes)^{53,57,224,233}, data management, and analysis capabilities (e.g., electronic reporting platforms, and interoperability)^{92,113,153,197,214,234}. Many indicators quantify network attributes such as the number and distribution of surveillance sites^{194,202,217,235}, coverage of sentinel sites or industry monitoring systems^58,104, integration of peripheral and reference labs^53,74, and the establishment of national coordinating centres or integrated surveillance strategies^21,138. Quality-related indicators include completeness and timeliness of AST data, frequency and methods of data analysis and dissemination, and metrics on external quality assurance participation^27,53,197.

Surveillance output indicators encompass pathogen-specific resistance rates and incidence densities^{134,194,223,232}, bloodstream infection incidence by age, sex, and clinical setting^{104,187,202,205}, genotype prevalence and molecular epidemiology (e.g., sequence types, resistance genes, virulence determinants)^203,206, environmental surveillance metrics (e.g., antimicrobial resistance gene (ARG) abundance in water, wastewater, food chain)^21,30,228, and outcome measures (e.g. deaths and disability-adjusted life years (DALYs) attributable to AMR)^103,104,205. Further indicators capture temporal trends^201,206,235, correlations between resistance prevalence and antimicrobial consumption^96,141, blood culture positivity rates²¹⁸, and burden estimates¹⁶³. Grey-literature indicators emphasise the establishment of integrated AMR surveillance systems^11,69,70, laboratory network robustness^{11,12,17,70,77}, essential diagnostics lists^11,69, external quality assessment implementation^11,73, AST capacity for critical pathogens^11,13, and reporting to GLASS⁶³. Additional measures assess the presence of sustainable specimen referral and transport systems, biosafety/biosecurity frameworks, laboratory quality management systems, tiered diagnostic network implementation, and early warning surveillance protocols^12,69.

Domain: monitoring & evaluation; subdomain 17: reporting

Reporting refers to mechanisms for communicating progress and data on the national AMR strategy to stakeholders, including annual progress reports and formal submissions to international and regional AMR surveillance initiatives. Fifty-six indicators were extracted from 18 academic studies^{22,27,29,34,53,66,67,75,78,99,104,128,135,153,190,194,197,204}; 85 from 12 grey literature studies^{11,13,15,18,43,45,48,63,71,77,107,244}, with 39 indicators originating from ANIMUSE⁴⁸.

Indicators grouped under Reporting address the existence of governance structures or processes for sharing AMR and AMU data with global and regional databases and regulatory bodies (e.g., evidence of protocols for submission to GLASS, Central Asian and European Surveillance of Antimicrobial Resistance network (CAESAR), European Centre of Disease Control (ECDC), European AMR Surveillance Network (EARS-Net), WHO reports, WOAH AMU/AMR databases, European Food Safety Authority (EFSA), European Surveillance of Veterinary Antimicrobial Consumption (ESVAC))^67,78. Animal health indicators cover registration and reporting of antimicrobial products, submission of AMU and residue data, and integration within One Health reporting frameworks, bacteria–drug combinations, and core data elements^{11,18,48,53,77,128}. Laboratory reporting measures include counts of culture-positive/negative results, proportions of commonly reported pathogens, and frequency of AST result submission^197,204. Grey-literature indicators emphasise reporting NAP status updates^11,15,44,49, annual animal-sector AMU reports to WOAH^11,18,61, participation in GLASS^{15,45,63,71,77}, and the establishment of clear reporting pathways for AMR and AMU information¹³.

Domain: monitoring & evaluation; subdomain 18: feedback mechanisms

Feedback mechanisms refer to indicators that capture the existence and quality of processes for relaying surveillance data and performance information to regional, organisational, and individual stakeholders. Sixteen indicators were extracted from 6 academic studies^{21,22,53,59,80,104}; 50 from 13 grey literature studies^{11,13,17,43,44,49,61,69–71,77,81,108}.

Indicators sought to measure scoping themes from national performance to regional- and hospital-level IPC and stewardship. Sector-specific feedback processes include the establishment of national platforms for sharing pathogen-specific data^13,104. Multisector coordination indicators examine whether data analysed are used for policy advocacy and resource allocation, whether data reviews occur, and whether AMU and AMR surveillance data inform decision-making and policy^11,13,69,71. Metrics of zoonotic events (infection transmission between animal and human species) include the proportion of events evaluated with timeliness metrics or decision tools, joint investigations, and activities implemented based on joint risk assessments⁴³. Key indicators examine the documented use of surveillance data for decision-making, inclusion of monitoring mechanisms in NAPs, and governance responsiveness scores^11,21.

Monitoring and audit frameworks are evaluated for integration of IPC indicators within national systems, tools for systematic data collection (e.g., WHO hand hygiene self-assessment), alignment of national and local monitoring activities, linkage with WASH monitoring, regular collection of IPC monitoring and audit data, facility-level self- or peer- evaluation against standards, and dissemination of monitoring results to drive improvement^13,43. Laboratory feedback is measured by participation in external quality assurance/proficiency testing schemes and whether alternate bodies perform equivalent functions⁷⁰. Indicators also assess whether treatment guidelines undergo regular audit, review, and dissemination, and whether collected data guide action and guideline updates^49,71. Other indicators measure whether surveillance results are systematically distributed to field actors via organised channels¹⁷. Indicators also gauge whether veterinary laboratory quality management systems and risk-analysis capacity routinely inform risk management and communication⁶¹. Finally, the presence of national bodies that review surveillance findings and translate them into recommendations and implemented actions captures the end-to-end feedback process⁷⁷.

Several IPC-related indicators were jointly grouped as feedback mechanism indicators, including the existence of strategic plans for monitoring and feedback, schedules for guideline review, national systems for monitoring adherence with periodic audits, and timely feedback reports to stakeholders on HAI trends, outbreak control, and multidrug-resistant pathogen occurrences^13,43.

Domain: monitoring & evaluation; subdomain 19: effectiveness

Effectiveness indicators examine whether structured mechanisms exist at the national level to evaluate if policies or interventions achieve their intended health and economic outcomes. Nineteen indicators were extracted from nine academic studies^{20–22,27,28,34,36,91,133}; 17 from 8 grey literature studies^{11,13,18,77,109,110,165,245}.

Indicators include metrics, e.g., M&E plan quality by country, aggregate M&E scores, and national evaluation frameworks for IPC and AMR strategies^13,22,34. Governance effectiveness and efficiency are measured via global governance indices; food safety evaluation scores capture the impact of interventions in related sectors across countries^21,22. Perception-based metrics include respondents’ satisfaction with the functioning of AMR multisector coordination committees and perceived impact from policy measures^28,91. Outcome indicators quantify health and economic burdens attributable to AMR, e.g. loss of life expectancy, excess health expenditure, reduced labour participation and productivity due to AMR and broader risk indices²⁴⁵. Burden-of-disease measures such as DALYs attributed to AMR serve to assess the ultimate impact of interventions⁷⁷. Certain indicators also attempt to measure the cost-effectiveness of policies through comparisons between intervention costs and observed reductions in AMR-related morbidity, mortality, or economic losses^13,245.

Discussion

Our scoping review offers a comprehensive, cross‑sectoral inventory of AMR indicators, drawing from quantitative and qualitative sources across the One Health sectors. By systematically cataloguing over 3000 indicators from academic and grey literature, we fill a critical gap in the AMR evidence landscape and provide a foundation for harmonised, One Health-oriented monitoring.

Our findings demonstrate the structural imbalance in indicator development, with limited coverage of Accountability, Transparency, and Equity subdomains, despite their central importance to the Governance & Leadership domain. Strengthening measurement within these areas is essential for effective policy governance, to ensure AMR strategies are properly developed, then implemented, evaluated, and iteratively improved. The paucity of equity-focused indicators is particularly concerning, given recognition that the burden of AMR falls disproportionately on marginalised, disadvantaged populations²⁴⁶. This imbalance extends across One Health sectors: far more indicators are available for human than for animal and environmental health (Supplementary Fig. 1). This lack likely contributes to animal and environmental health’s underrepresentation in national AMR agendas, weakening the multisectoral coordination required for effective AMR control. These findings suggest two priority actions for international organisations such as the Quadripartite and partners: first, develop standardised indicators for underrepresented domains—particularly Accountability, Equity, and Transparency; second, develop indicators for the animal and environmental health sectors comparable to those for human health.

Our work has several limitations. First, we focused our attention on collating existing qualitative and quantitative indicators, but a critical appraisal of the indicators identified fell outside the remit of this review. Further work is planned to use these indicators as input for a consensus process to develop an index that will benchmark national performance in responding to AMR. Second, the comparative, cross‑country inclusion criteria that we used necessarily deprioritised subnational and local indicators, e.g. regional biosecurity protocols and community‑level stewardship initiatives. However, many regional indicators may be relevant to a given country’s specific context, though deemed irrelevant to comparing cross-national performance. Third, restricting our inclusion criteria to studies published between 2014 and 2024 may have excluded earlier efforts to measure national AMR response. However, we deemed studies published pre-2014 as less policy-relevant as they precede the publication of the GAP on AMR. Fourth, our initial focus on English-language publications, subsequently supplemented by non-English studies, may have introduced bias: non-English literature may emphasise different aspects of AMR policy. Fifth, the academic evidence base disproportionately reflects European and high-income country contexts, with 37% of included studies situated in Europe and only 11% in the WHO African Region. This may mean we have captured indicators predominantly from countries with more developed surveillance systems, as these are more likely to report findings publicly, and that the resulting indicator set reflects structural biases in the literature rather than a balanced global perspective. This should be considered when interpreting the indicators and the planned One Health AMR Accountability Index.

Building on the inventory compiled in the current study, we plan to use these indicators to build a novel One-Health AMR Accountability Index to measure national performance in addressing AMR²⁴⁷. Our next step involves screening the indicators identified for inclusion in a Delphi survey. Indicators will be formally screened and prioritised based on feasibility, data availability, and subdomain balancing. Indicators will be removed if the overall theme is duplicated or collinearity is identified. After indicator refinement, we will undertake a multi-stage consensus process with international AMR experts to select and weight indicators for inclusion into a unified AMR Accountability Index. The One Health AMR Accountability Index will be piloted in different international regions to reflect regional differences and different country income classifications.

As a separate exercise, we have created a human-health-focused AMR Accountability Index in conjunction with WHO Europe, anchored in the Roadmap on Antimicrobial Resistance for the WHO European Region 2023–2030. This index will provide composite indicators that cover the Roadmap’s five action areas and six enablers spanning both multisectoral and human health domains. Currently, the human-health-focused AMR Accountability Index is undergoing a piloting process in six WHO European region Member States to ensure the Index reflects structural differences and country contexts. Ultimately, One Health AMR Accountability Index seeks to fill a current gap in global AMR policy efforts by benchmarking national performance, identifying countries requiring technical support, and tracking global progress toward AMR containment goals.

Methods

Literature review

A scoping approach was employed to review and synthesise existing literature to identify and consolidate quantitative and qualitative measures used to assess and compare national performance in addressing AMR. This review encompassed academic and grey literature searches. The academic literature search was conducted between 26 November 2024, and March 2025. Three electronic databases, Medline, EMBASE, and Global Health, were systematically searched to capture peer-reviewed articles in English from 2014 through 2024. This was supplemented by an additional search using the same search terms for non-English studies in January 2025. Where necessary, non-English studies were translated using Google Translate to assess eligibility and extract relevant data. The starting year of 2014 was chosen to coincide with the release of key global policy instruments (e.g., the World Health Assembly resolution that paved the way for the 2015 WHO GAP on AMR), ensuring that pivotal developments in AMR policy and measurement were captured. In parallel with the academic literature search, a thorough grey literature review was undertaken to capture indicators that might not appear in peer-reviewed journals. Grey literature was identified through Google Scholar and targeted searches of major international organisations. Our methods are further outlined within a previously published PROSPERO protocol (CRD42024625477)²⁴⁸.

Academic literature search terms

The search strategy combined terms related to antimicrobials (e.g., “antibiotic*,” “antimicrobial*,” “antifungal*,” “antiinfective*”), resistance (e.g., “resistance,” “resistant”), and policy or performance measures (e.g., “performance,” “benchmark,” “indicator*,” “evaluation,” “governance,” “framework,” “policy,” “rate*”). Further terms specifying national and governmental contexts (e.g., “national,” “country,” “government*”) were included. Boolean operators (AND, OR) were used to generate comprehensive results while minimising irrelevant studies.

Grey literature search details

For Google Scholar, we screened the first 300 results sorted by relevance for each search string. The 300-result cap was used to balance sensitivity and feasibility, as relevance markedly declines beyond this range in Google Scholar indexing¹. Second, relevant websites of major multilateral organisations involved in AMR policy, such as the World Health Organization (WHO)², the World Organisation for Animal Health (WOAH)³, the Food and Agriculture Organization (FAO)⁴, the United Nations Environment Programme (UNEP)⁵, the Organisation for Economic Co-operation and Development (OECD)⁶, and the World Bank⁷, were examined to identify policy documents, reports, and white papers listing or discussing AMR indicators. Additionally, websites of prominent think tanks and professional societies (e.g., the Centre for Global Development, the Alliance for Reducing Microbial Resistance, and the European Society of Clinical Microbiology and Infectious Diseases) were searched for relevant non-peer-reviewed materials. The full list of all grey literature sources with links is listed in Supplemental Table 1. All grey literature records were screened and extracted by two reviewers (BH and EO) manually using the same inclusion criteria and data charting procedures applied to the academic literature. All identified documents were saved in a shared repository, and duplicates were removed.

Inclusion and exclusion criteria

Inclusion criteria were deliberately broad to capture any cross-country comparison of AMR policy or performance that presented either quantitative or qualitative indicators. Inclusion criteria included any article using indicators to measure national performance in addressing AMR. Exclusion criteria included: 1) Wrong study outcome (articles relevant to antivirals, tuberculosis, or vaccines). Tuberculosis was excluded on the basis that TB-specific AMR operates within a largely separate policy, surveillance, and programmatic infrastructure with dedicated international frameworks and accountability structures, and its inclusion risked conflating two distinct policy domains; 2) wrong study design (systematic reviews that identify individual studies in multiple countries focused on developing understanding of AMR, systematic reviews, organisational or regional-level studies of prevalence of AMR or AMU, cost-effectiveness studies, or editorials or conference abstracts); and 3) wrong study comparator (articles measuring regional, organisational, or individual performance and articles used to measure performance in one country in isolation). As the primary purpose of this review was to identify indicators suitable for cross-national benchmarking, single-country studies may reflect idiosyncratic national priorities or data systems that cannot be meaningfully standardised or compared across diverse country contexts.

Two reviewers (US, SR) screened titles and abstracts for relevance, each working separately to apply inclusion and exclusion criteria independently. Any discrepancies were resolved through iterative discussions or by consulting a third reviewer (MA) if consensus could not be reached. Studies that met inclusion criteria at the abstract level were retained for full-text review, after which the same reviewers independently confirmed eligibility with discrepancies again resolved through iterative discussions or by consulting a third reviewer (MA) if consensus could not be reached. Cohen’s Kappa was reported to assess inter-rater reliability for both title and abstract screening as well as full text screening.

Data extraction and thematic synthesis

All peer-reviewed articles and grey literature documents included were collated into a database. Basic bibliographic information (author(s), publication date, title) and details about the identified indicators (description, measurement approach, data sources used, and One Health domain coverage, which included animal health, environmental health, human health, and multisectoral coordination) were recorded for each. Indicators with sectoral overlap were categorised across animal health, environmental health, and human health, depending on the nature of the indicator. For example, indicators relating to meat production, livestock, or animal products were captured under animal health, while indicators relating to food safety, foodborne disease, or human dietary exposure were captured under human health. Indicators relating to soil contamination, agricultural runoff, or AMR in environmental systems were captured under environmental health. If an indicator had multiple metrics or definitions, each variant was noted separately to ensure a comprehensive initial pool of potential measures.

A narrative thematic synthesis was then performed. We employed a framework-based approach, adapting existing frameworks (Roadmap on Antimicrobial Resistance for the WHO European Region 2023–2030⁶ and Anderson et al.¹⁶) to identify relevant domains a priori. We then inductively refined these categories based on the indicators identified. We merged these frameworks to identify 19 AMR subdomain groups under three domains: Governance & Leadership, Action Areas, and Monitoring & Evaluation (Fig. 4).

Fig. 4. Thematic synthesis of AMR policy domains.

Authors’ creation.

Indicator screening and coding

Indicators were excluded if not considered cross-national measures of performance in AMR response, were duplicates (i.e., were identical or had near-identical constructs and measures); not specific to AMR. Four reviewers (US, VK, BH, and SR) independently conducted initial indicator exclusions; two reviewers (MA and EO) evaluated their accuracy and consistency.

Two reviewers coded each indicator according to the framework’s policy domains (Fig. 4); MA and EO reviewed the coding to ensure concordance in approach. Indicators were then examined within each thematic category to highlight commonalities and identify overlap. Finalised extracted indicators must: (1) measure national performance in addressing AMR in two or more countries; (2) be quantitative or qualitative within the scope of AMR; (3) measure performance in any sector across the One Health spectrum; (4) be relevant to AMR.

Author contributions

E.O., M.A., and E.M. participated in conceiving the study, literature search, analysis, interpretation of the data, writing and critical revision of the manuscript for important intellectual content. U.S. and V.K. participated in the literature search, analysis, interpretation of the data, writing and critical revision of the manuscript for important intellectual content. B.H. and S.R. participated in the literature search and critical revision of the manuscript for important intellectual content. D.L., K.K., and E.M. participated in interpreting results and providing critical revisions. All authors read and approved the final manuscript.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s44259-026-00213-8.