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Journal of Pharmaceutical Policy and Practice logoLink to Journal of Pharmaceutical Policy and Practice
. 2026 Oct 20;19(1):2735525. doi: 10.1080/20523211.2026.2735525

Implementing the national action plans on antimicrobial resistance in Jordan: document analysis and policymakers’ perspectives

Raja’a Al-Qudah a,b, Sarah C Willis c, Ellen I Schafheutle b,CONTACT
PMCID: PMC13686185  PMID: 42910335

ABSTRACT

Background

The World Health Organization (WHO) developed the Global Action Plan (GAP) on Antimicrobial Resistance (AMR) in response to its growing threat to human, animal, and agricultural health. Countries worldwide were encouraged to implement National Action Plans (NAPs) to combat AMR. However, low- and middle-income countries (LMICs) face difficulties in implementing NAPs. This study aimed to investigate the implementation of AMR policy in Jordan and assess progress under its NAP.

Methods

Using the Implementation Research (IR) framework, this study involved documentary analysis of five policy documents and 17 semi-structured interviews with policymakers. Guided by the IR framework’s three phases (proof of concept, proof of implementation, informing scale-up), document analysis was conducted deductively, while the interviews were analysed inductively and deductively using thematic analysis supported by NVivo.

Results

Three key themes emerged: implementation challenges, strategy design, and outcome evaluation. Problem identification and context analysis showed that while Jordan's NAP aligns with the WHO's GAP, poor intersectoral coordination, limited stakeholder engagement, and weak enforcement hinder implementation. Participants noted unclear roles for policymakers, creating accountability gaps and inefficiencies. Implementation strategies showed that AMR interventions focus on hospitals, with little attention to other sectors (community pharmacy and primary care). Differences between public and private hospitals led to inconsistent enforcement, while unenforced community pharmacy regulation allowed for unregulated access to antibiotics. Monitoring and evaluating AMR interventions remain key gaps, with a lack of standardised frameworks, fragmented surveillance data, and insufficient monitoring capacity.

Conclusion

Although aligned with WHO’s GAP, AMR policy implementation in Jordan is hindered by systemic barriers: weak enforcement, limited stakeholder engagement, and fragmented accountability. A focus on hospitals left other settings with limited action or reinforcement. The findings highlighted the need for cross-sector coordination and robust monitoring. While context-specific, these insights may inform AMR governance in comparable settings.

KEYWORDS: Antimicrobial resistance, AMR policy, national action plan, implementation research, governance, Jordan, LMICs

Introduction

In 2019, an estimated 4.95 million deaths worldwide were associated with drug-resistant bacterial infections, with 1.27 million directly attributable to antimicrobial resistance (AMR) (Murray et al., 2022). Although AMR impacts populations internationally, the highest burden is observed in low-resource settings (Mitchell et al., 2023).

The WHO Global Action Plan (GAP) on AMR guides countries in developing National Action Plans (NAPs) to implement context-specific strategies (Al-Haboubi et al., 2020; Patel et al., 2023). Yet, the content and implementation of these are highly variable and often inadequate at the country level (Mendelson & Matsoso, 2015; Patel et al., 2023). This may be due to poor alignment with the GAP, limited implementation capacity, poor institutional alignment, reliance on external funding, and low political prioritition of AMR (Willemsen et al., 2022; Zay Ya et al., 2024). A 2020–2021 governance analysis ranked the Arab region lowest in overall AMR governance (Patel et al., 2023). Policy design across the Arab region varies, from weak or non-existent frameworks (e.g. Egypt, Yemen) to moderate progress in AMR policy implementation aligned with the GAP on AMR (e.g. udi Arabia, Jordan) (Patel et al., 2023). Jordan, a LMIC, has been recognised as having relatively advanced AMR policy design and alignment with the WHO GAP (Patel et al., 2023). However, recent Jordan-focused studies continue to identify gaps in translating AMR strategies into practice, including the need to strengthen research-informed policymaking, implementation capacity, and national policy coordination (Al-Tammemi et al., 2025; Momani et al., 2025; Patel et al., 2023; WHO, 2023). These studies provide important evidence on progress and recommendations; however, less attention has been given to how policymakers themselves understand the implementation process, how policy documents frame enforcement and accountability, and where gaps emerge between national strategic commitments and operational practice. This study therefore contributes original evidence by combining document analysis with policymakers’ perspectives to examine AMR NAP implementation in Jordan through an implementation research lens. In doing so, it moves beyond assessing policy alignment or progress alone and examines the governance mechanisms through which AMR priorities are translated, or not translated, into enforcement, monitoring, stakeholder coordination, and practice.

Jordan’s experience reflects a broader trend: effective AMR governance depends not only on policy design but also on good and sustainable implementation and enforcement (Spellberg et al., 2011). Policymakers are central to designing and executing NAPs in alignment with the WHO's GAP on AMR (Spellberg et al., 2011). Evaluating strategic commitments, reviewing policy documents, and establishing the extent to which regulations are enforced is crucial for assessing progress and ensuring the effective translation of policies into practices that mitigate AMR (Byrne et al., 2019; Kotwani & Joshi, 2021; Stewart Williams & Wall, 2019). Nevertheless, policy effectiveness must also be assessed based on its implementation and how policy is upheld, monitored and enforced by those responsible (Ayukekbong et al., 2017). Evidence from LMICs highlights the value of analysing policy documents and engaging policymakers to identify and understand system barriers and facilitators regarding AMR policy implementation. Such analyses reveal regulatory intentions, objectives, and implementation challenges across healthcare settings where antibiotics are accessed, including hospitals, community pharmacies and primary care, thereby informing the design of context-specific interventions (Chua et al., 2021; Lota et al., 2022; Mukoko et al., 2025; Shabangu et al., 2023, 2025). However, in Jordan, these governance dynamics remain insufficiently examined from the combined perspective of policy documents and policymakers involved in AMR implementation.

Study aim

This study aimed to examine the implementation of the AMR NAP in Jordan by analysing national AMR policy documents and exploring policymakers’ perspectives on implementation priorities, enforcement, stakeholder coordination, monitoring and evaluation, and barriers to feguarding appropriate antibiotic use.

Methods

Theoretical framework

This study focused on policy implementation, defined here as ‘the mechanisms, resources, and relationships that link policies to programme action’ (Mthethwa, 2012). It applies Khurana et al.’s Implementation Research (IR) conceptual framework deductively to guide the analysis and interpretation, drawing out the complexities of AMR policy implementation in Jordan’s healthcare system (Khurana et al., 2023). The framework provides a structured approach to analysing AMR strategy execution by examining each of three phases of implementation: proof of concept, proof of implementation, and informing scale-up. The proof-of-concept phase evaluates the feasibility and theoretical foundations. The proof of implementation phase assesses real-world applications, identifying practical challenges and contextual influences. The informing scale-up phase focuses on sustainability and system integration, ensuring the expansion and institutionalition of successful interventions (Khurana et al., 2023). The framework is particularly relevant to AMR governance in Jordan as it accounts for contextual complexities, stakeholder interactions, and systemic barriers influencing implementation outcomes (Khurana et al., 2023). Figure 1 illustrates the components of the IR framework.

Figure 1.

An implementation diagram linking antimicrobial resistance intervention inputs through 3 phases to outcomes for population and systems. The figure shows a horizontal implementation diagram for antimicrobial resistance, divided into 3 sequential phases that sit inside a large right pointing arrow. At the top, 3 adjoining boxes state: Proof of concept with the question Does the intervention work in a controlled research setting question mark, Proof of implementation with the question Does the intervention work in real world settings question mark, and Informing scale up with the phrase Sustained integration within One Health systems. Below, a row of 3 colored headers labels Phase One, Phase Two, and Phase Three. Under Phase One, 2 columns are titled Intervention and Defining the Implementation Challenges. The Intervention column lists Evidence based antimicrobial resistance interventions with programmes, practices, and policies. The Defining column lists Understand context, Identify challenges, and Identify possible strategies to address challenges. Under Phase Two, a header reads Designing the Implementation Strategy. Two columns describe Identify strategies to address challenges with bullet points for actors or stakeholders, actions, targets, temporality, outcomes, and justification, and Strategy areas with bullets for public oversight, organizational provider improvement, individual provider improvement, and community empowerment. Under Phase Three, a header reads Testing the Strategy colon Outcomes. Three columns are titled Target population, System or service, and Implementation. Target population lists improvement in clinical or health status, behaviour change, and decreased morbidity or mortality. System or service lists strengthened surveillance systems for antimicrobial resistance or antimicrobial use, reduction in antimicrobial resistance or antimicrobial use, reduction in costs, and human capital development. Implementation lists acceptability, adaptability, adoption, appropriateness, cost effectiveness, coverage, feasibility, fidelity, and sustainability. A footer bar labels the whole diagram as Implementation Research Conceptual Framework.

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Khurana et al.’s conceptual framework for implementation research (Khurana et al., 2023).

Study design

A qualitative approach was employed, guided by the IR conceptual framework, to provide an in-depth exploration of the context, processes, and perspectives relevant to AMR in Jordan. This approach was implemented in two stages: document analysis and policy interviews. Document analysis provided a foundation for context and policy details, while interviews offered insights into stakeholder perspectives and real-world implementation challenges.

Stage one: document review

Data collection

To explore how AMR is addressed in national governance, a systematic approach to policy documents was used, focusing on the design, implementation, and evaluation of AMR strategies. Documents were included in the review if they addressed AMR and comprised national policies, operational plans, declarations, training manuals, and project propols. The review process mainly focused on governance and policy documents; hence, communication materials unrelated to policy, such as posters used in awareness campaigns, were excluded. Relevant documents were identified through a broad search of government websites, public health organitions, and academic databases using keywords including ‘Jordan,’ ‘antimicrobial resistance,’ ‘policy,’ ‘intervention,’ and ‘strategy.’

No restrictions were placed on the publication dates of the literature, although most of the literature was published from 2017 onwards, aligning with the establishment of the NAP on AMR. Documents were identified from international organitions (e.g. World Health Organition (WHO)), national institutions (e.g. Ministry of Health (MoH), Jordan Centre for Disease Control (JCDC), Jordan Food and Drug Administration (JFDA)), and professional health associations.

Nine AMR-related documents were initially identified. Documents were screened for relevance to national AMR governance, policy design, implementation, or evaluation. Following screening, five documents were included in the analysis presented here because they directly addressed AMR policy frameworks, operational planning, implementation strategies, or monitoring and evaluation (Jordan Center for Disease Control, 2022; Jordan Food and Drug Administration, 2017, 2025; World Health Organization, 2018, 2023). Four documents were excluded because they were communication or awareness materials, general health-system documents, or documents with limited relevance to AMR policy implementation. The selection process is summarised in Figure 2.

Figure 2.

A flowchart diagram linking Jordan AMR policy frameworks to included and excluded national documents from 2017 to 2025 with legends. The figure shows a flowchart diagram summarizing Jordan AMR policy frameworks and related documents. On the left, a vertical box reads Jordan AMR policy frameworks. From this box, three colored branches extend right to three main rectangles. The top rectangle is labeled NAP and Strategic Plans by Ministry of Health. It connects to two stacked boxes on the right labeled 2018 to 2022 NAP and 2023 to 2025 updated NAP, plus a third box beneath them labeled National AMR surveillance report, which is shaded to indicate exclusion. The middle main rectangle is labeled Regulations and Proposals by Jordan Food and Drug Administration. It connects to four boxes: 2017 Medical Prescriptions and Registration Regulation, 2020 Proposal for Adopting the AWaRe, AWaRe categorisation list, and AMR Awareness campaigns booklet and posters, the last of which is shaded as excluded. The bottom main rectangle is labeled Strategy Document by JCDC. It connects to two boxes on the right: 2023 to 2025 Strategy Document and Action Plan and Mapping and Gap Analysis of the National Communicable Diseases Surveillance and Labs Health Information Systems, with the latter shaded as excluded. On the far right, a key defines NAP as National Action Plan, MoH as Ministry of Health, JFDA as Jordan Food and Drug Administration, and JCDC as Jordan Centre for Disease Control, and explains the shading for excluded documents and arrows for derived policies from strategy documents.

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Overview of Jordan’s AMR policy frameworks and strategic documents.

Data analysis

The five included documents were imported into NVivo and analysed using deductive thematic analysis guided by the IR framework. The analysis focused on how each document addressed policy design, implementation mechanisms, stakeholder roles, enforcement, monitoring, and evaluation. Codes were organised under the three IR framework phases: proof of concept, proof of implementation, and informing scale-up.

Stage two: interviews with policymakers

Study setting and participant recruitment

Interviews were conducted to explore AMR policy implementation from the perspectives of stakeholders involved in policy design, implementation, regulation, or evaluation in Jordan. Eligible participants were individuals with professional responsibility for AMR-related guidance, policy, regulation, surveillance, antimicrobial stewardship, or antibiotic access. Initially, participants were purposively selected based on their institutional roles in national AMR governance, and snowball mpling was then used to identify additional eligible stakeholders. This approach was appropriate because AMR policymaking involves a specialised set of actors who may not be fully identifiable from public documents alone. Recruitment sought representation across key stakeholder groups, including the Ministry of Health (MoH), Jordan Food & Drug Administration (JFDA), World Health Organition (WHO), professional associations, and public, military, and private healthcare sectors. Interviews were conducted in person or via Zoom®, depending on participants’ preference and availability. Recruitment and analysis occurred concurrently, and mpling stopped when additional interviews yielded no substantively new themes relevant to the study aim (Frumence et al., 2022).

Development of interview topic guide

The topic guide, informed by the relevant literature and refined iteratively by the research team (Al-Haboubi et al., 2020; Stewart Williams & Wall, 2019; Sun et al., 2022), comprised three sections: (1) participants’ educational and professional background, (2) their views on AMR in Jordan, including priorities and challenges in antibiotic governance, and (3) a closing question inviting additional input on relevant issues.

Data collection

Audio-recorded interviews lasted up to one hour and were conducted in English, with Arabic allowed if preferred, with translated documents (Participant Information Sheet (PIS), consent forms) provided. Audio recordings were securely transferred from an encrypted device to password-protected storage, with the original files deleted. Transcripts were anonymised, removing identifiers and assigning unique IDs known only to the researcher.

Data analysis

Verbatim interview transcripts were managed using NVivo 12 and analysed through thematic analysis. The data analysis combined inductive and deductive approaches, generating themes that provided detailed insights while mapping onto the IR framework (Braun & Clarke, 2006). Connections between themes were explored to identify key patterns, similarities, and divergences. The findings were triangulated through documentary analysis, where data from both sources were mapped onto the IR framework to identify gaps between policy and real-world implementation. Quotes were presented by institutional affiliation to contextualise participants’ roles while protecting anonymity.

Results

Characteristics of reviewed documents

The five eligible AMR-related documents included national policy and governance documents issued by or linked to key institutions, including the MoH, JFDA, and JCDC.

Interview participant employment characteristics

Seventeen officials and members of the NAP committee on AMR were interviewed, as well as representatives from the WHO and government bodies such as the JFDA and the MoH. Stakeholders working for professional associations such as the Jordanian Pharmacists Association (JPA) and the Jordan Medical Association (JMA), and in the healthcare sector, encompassing public, military, and private hospitals, were also interviewed.

Data handling

Following initial coding, data were categorised according to three key themes within the IR conceptual framework: (1) defining the implementation challenges, (2) designing the implementation strategy, and (3) testing the strategy: outcomes. In each section, the analysis begins by presenting the findings from examining policy documents to assess Jordan’s alignment with global AMR frameworks and identify gaps. This is followed by interview data analysis that highlights implementation challenges and facilitators.

Defining implementation challenges

The documentary analysis showed that Jordan’s NAP aligns with the WHO’s GAP on AMR, adopting a One Health approach that integrates human, animal, and environmental health sectors. The plan is structured around five WHO pillars: AMR surveillance, infection prevention and control (IPC), antimicrobial stewardship programmes (ASP), public awareness, and research. However, the reviewed documents provided limited operational detail on implementation mechanisms, particularly regarding enforcement, cross-sector coordination, and accountability. Interview data supported this finding. Some participants described unclear roles within the national AMR committee, the absence of a permanent coordination structure, and limited resource mobilition as barriers to implementation.

I believe one of the most significant problems is governance or the multisector aspect, which was supposed to happen to implement the strategies precisely, but it didn’t occur accurately. The role of the national committee members since 2018 was not clear. There was no secretariat, which was supposed to be responsible for coordinating the meetings and reports, leading to a lack stakeholder alignment, so the multisector approach wasn’t strong, and as I mentioned, resource mobilition didn’t have the necesry resources. (Participant 11, JFDA)

Designing the implementation strategy

Subtheme: policy design and execution challenges

The documentary analysis revealed that Jordan’s NAP prioritises rational antibiotic use through ASP, regulatory measures, and national surveillance. The JFDA and MoH hold complementary regulatory and stewardship roles across healthcare settings. Among these priorities, the regulation of antibiotic use is recognised as a key objective. However, the policy framework lacks clarity on how the policy objective will be achieved. Interventions such as ‘reviewing and amending regulations’ were only described broadly, offering limited details on enforcement strategies or on regulating antibiotic access. While the NAP recognises the importance of cross-sectoral collaboration in policy design, the lack of clearly defined implementation strategies suggests that translating these intentions into practice may be challenging, potentially affecting the consistency or effectiveness of regulatory efforts.

This lack of operational clarity was reflected in most participants’ perspectives, who identified key barriers in the technical, organitional, and resource-related domains, and in the integration and standardition of AMR interventions across governmental, military, and private healthcare facilities, preventing their implementation.

Regarding private hospitals, there’s nothing that connects the hospitals; each hospital is an independent institution. If a patient is admitted, they follow their procedures. For example, in every hospital, there’s an infection control team, but unfortunately, they don’t get involved or even look at the patient until the culture results are out. (Participant 3, JMA)

Some participants reported limited laboratory infrastructure as a barrier to the implementation of effective AMR surveillance and ASP. These participants explained further that limited microbiological testing capacity hinders the identification of resistance patterns, thus delaying the implementation of appropriate clinical decisions. Participants also highlighted the need for advanced equipment to improve the reliability and speed of tests.

One of the challenges we face in deciding which antibiotic to use in treatment is the strength of the microbiology lab. I believe that having greater capability would be beneficial for the speed of bacterial culture growth and for sensitivity to microbes. The lab might be limited by the available kits, so it can’t test all the antibiotics I might need. It only works with certain types of antibiotics, and that’s what we have. So, I must be cautious about resistance. Sometimes, for example, a culture might show no growth in a sick patient, which could happen, but perhaps it would be better if we had more advanced equipment. (Participant 4, JMA)

Most participants emphasised inadequate training for the IPC team, which included healthcare professionals and microbiologists. Many struggled to interpret and implement the AMR guidelines, which affected the effectiveness of ASP.

We even create summaries of these adopted guidelines and train people in the hospital. Unfortunately, some do not know what these guidelines mean, so we train them on it and try to make them understand, especially microbiologists. (Participant 17, MoH)

Participants described how health information systems face difficulties when it comes to broader adoption, particularly within the private health sector, where hospitals use different and non-integrated information systems. As indicated by most participants, this diminishes the uniformity of surveillance data collection, standardition, and analysis across all healthcare settings.

We are witnessing gaps in data and incorporating them into the system, integrating technology. The process of development and testing is long … There is variability among hospitals and healthcare workers in terms of how this system is utilised. The private sector has the freedom to choose which AMR program they want to implement. (Participant 13, Information Health System Institution)

Subtheme: stakeholder engagement and coordination

Although the policy documents outlined relevant stakeholders and assigned broad responsibilities, they did not provide clear mechanisms for sustained engagement, follow-up, or accountability. This documentary finding was confirmed by most interviewees, who reported that technical groups and multisectoral committees were not consistently activated and that coordination across sectors remained limited.

The technical groups [that provide technical advice to support specific strategic and programmatic decisions on AMR management] formed by the ministry, which we technically support, have been established for a long time but were not activated, especially during the coronavirus pandemic … we have tried to activate their roles and update their membership in the committee, as it was not activated in the old plan [NAP 2018–2022], which was due to a lack of coordination. Unfortunately, one of the issues is that when we talk about stakeholders, there is no prioritition of AMR as a national threat and a lack of coordination between different sectors. (Participants 9, WHO)

Subtheme: actions

The document review identified actions aligned with the NAP's five strategic objectives. These actions targeted AMR management across hospitals, community pharmacies, and primary care. Key actions included establishing national surveillance and early warning systems, enforcing antimicrobial use regulations, implementing ASPs, incorporating AMR into health education curricula, and conducting public awareness campaigns. Further measures focused on strengthening IPC and promoting research and innovation in AMR.

Interviewees indicated that implementation activity was primarily in relation to secondary care, particularly hospital-based protocols and ASP-related activities. By contrast, most participants provided limited detail on primary care and community pharmacy interventions, suggesting that these settings were less consistently operationalised within implementation practice.

This committee [national protocol committee] was made up of infectious disease specialists from various hospitals across different sectors. There have been multiple meetings at the Ministry of Health where a roadmap was discussed, focusing on what needs attention and identifying the issues and deficiencies encountered by the doctors themselves, who are part of the committee. We worked with Dr. … , who was employed at … Medical Centre, to develop a plan for implementing the protocols. We created protocols for respiratory tract infections, as they are the most widespread. We started with WHO behavioural change protocols for health centres, in parallel with other protocols for surgery prophylaxis. (Participant 5, MoH)

The document review identified enforcement of antimicrobial-use regulations as a planned action. However, the documents provided limited detail on how enforcement would be operationalised across community pharmacies and other non-hospital settings. This gap was reflected by some interviewees who described the need for efforts to strengthen pharmacy inspections and to introduce penalties for non-compliance with prescription-only antibiotic regulations.

Currently, we are moving towards activating the law and have begun the procedure. We will impose penalties. Since 2017, when we issued this circular and made amendments, we have had pharmacy inspectors. Now, the inspectors check on the pharmacy’s cleanliness, storage conditions, and the health of the medications. But when they inspect pharmacies, they fill out a form noting the infractions and everything. We added to this new form whether antibiotics are being sold under prescription or not as a start. (Participant 8, JFDA)

At the me time, interview data indicated that enforcement was constrained by limited inspection capacity, insufficient human resources, and the absence of integrated systems for tracking antibiotic distribution and dispensing. These constraints limited the ability to verify whether antibiotics were being sold without a prescription and to monitor access across the supply chain.

The inspection committee for antibiotics and their proper dispensing would need no less than 50–70 inspectors, which we currently lack in terms of human resources. There’s another thing: how to perform data generation and archiving for drugs like antibiotics that are sold as subagents. How to trace this means the pharmaceutical company sells to a subagent, who then sells to the pharmacist, thereby breaking the supply chain. In the case of narcotic drugs, this practice is prohibited, but if we want to do something similar for antibiotics, we need to set up a whole new system. (Participant 12, JFDA)

Some participants also noted that strict enforcement could restrict access for uninsured or low-income patients, while persistent prescribing and dispensing of antibiotics without a prescription hinders AMR policy implementation.

Every behaviour change, whether among healthcare providers or patients, faces resistance. Stakeholders have competing interests; some pharmacists expect a prescription, while others want more autonomy. When procedures are imposed forcefully, it can lead to backlash. One of the biggest challenges arises when policies are suddenly applied or favour one group over another. However, if decisions are made collaboratively and consider patients’ financial capacity, given that only 80% of Jordanians have insurance and many cannot afford doctor visits, these issues can be resolved. (Participant 6, JPA)

Testing the strategy: outcomes

Subtheme: assessing the impact of AMR interventions

According to the IR conceptual framework, measuring implementation outcomes enhances understanding of implementation processes, enables strategy comparison, and distinguishes between intervention and implementation failure. Jordan’s NAP on AMR (2018–2022) proposed testing implementation strategies and developing a monitoring and evaluation framework aligned with WHO guidance, with evaluation recommended at three levels of the IR framework: the target population, the system/service, and the implementation process.

The reviewed policy documents included commitments to monitoring and evaluation; however, they provided limited evidence of a fully operationalised, standardised monitoring system. Interview data similarly indicated that AMR monitoring was fragmented, particularly across public and private sectors, and constrained by staff shortages, workload pressures, and the absence of a single integrated data system.

There is no specific measurement tool in place. We considered preparing a questionnaire, but the reality is that we face multifactorial barriers to continuous and systematic monitoring. For example, we have a staffing issue, there is a lot of pressure at work, and we don’t have a single system that controls everything. Many factors hinder implementation, but we have started. For instance, at Al xxx Hospital in xxx, we conducted an awareness lecture that was agreed upon by both the doctors and us. You can’t imagine how difficult it is when you have a large and multi-sectoral team; coordination becomes very challenging. But honestly, we proceeded and worked, [doing a lecture] yet it is not measured because even measuring is not easy. (Participant 2, MoH)

Discussion

This study employed the IR conceptual framework to explore AMR policies and policymakers’ perspectives in Jordan. By combining policy document analysis with policymakers’ perspectives, it provides context-specific insights into the strengths and challenges of AMR governance. While the findings demonstrate that Jordan’s AMR policy framework is broadly aligned with international guidance, they also identify persistent implementation challenges, including weak enforcement, fragmented accountability, limited intersectoral coordination, hospital-centric implementation, and inadequate monitoring and evaluation. These findings are pertinent to Jordan and other resource-limited settings facing similar AMR governance challenges.

This study identified weak enforcement, regulatory gaps, resource constraints, and limited inspector capacity as major barriers to AMR policy implementation. Rather than attributing these gaps to individual policymakers, the findings suggest that they should be understood as issues of institutional accountability and system design. Although policy documents articulated strategic priorities, both documentary and interview evidence indicated that implementation was constrained by unclear responsibilities, limited coordination mechanisms, insufficient resourcing, and weak feedback systems. This disconnect between policy design and execution highlights the limitations of strategic planning without structured mechanisms for stakeholder coordination and accountability (Khan et al., 2020; Momani et al., 2025; Shabangu et al., 2023). Institutional milignment, unclear roles, and fragmented responsibilities remain persistent barriers in LMICs, weakening AMR governance and enforcement (Khan et al., 2020; Shabangu et al., 2023). Political commitment is key to addressing enforcement gaps by ensuring resource mobilition, regulatory oversight, and sustained stakeholder involvement in implementing the NAP (Khan et al., 2020; Khandker et al., 2025; Shabangu et al., 2023; Zayed et al., 2025).

The current study revealed that AMR implementation priorities varied across healthcare settings, with strategic planning focusing on hospitals in the public sector, whereas community pharmacies and primary healthcare received less attention. Similarly, AMR policies differed between private and public hospitals, reflecting structural disparities between these sectors. These inconsistencies in implementation and enforcement contribute to fragmented AMR management and gaps in regulating access to antibiotics (Ruckert et al., 2024). This milignment in AMR governance extends beyond healthcare settings to access-related challenges.

While prescription-only regulation is an important AMR control measure, its implementation raises concerns about equity and access. Strict enforcement may disproportionately affect uninsured or low-income patients who cannot afford timely medical consultation or incur substantial out-of-pocket healthcare costs. Antibiotic access and prescribing are shaped not only by clinical need, but also by socioeconomic conditions, health insurance coverage, pricing, medicine supply, and regulatory arrangements (Do et al., 2021; Klein et al., 2018; Li et al., 2023). In such contexts, community pharmacies may function not only as convenient access points but also as informal substitutes for unaffordable or inaccessible medical services (Li et al., 2023). Therefore, antibiotic regulation should be implemented alongside measures that expand affordable access to clinical assessment, strengthen financial protection and health insurance coverage, and protect timely access to essential antibiotics for patients with genuine clinical need (Klein et al., 2018). Without these feguards, prescription-only enforcement may reduce inappropriate antibiotic dispensing while also creating unintended barriers to treatment for financially vulnerable groups, reinforcing health inequalities (Li et al., 2023; Nortey et al., 2026).

In this study, the lack of a structured monitoring and evaluation system was identified as a key barrier to the effectiveness of AMR policies. Policymakers often prioritise strategy development over the assessment of real-world implementation or impact, limiting opportunities for learning, adaptation, and improvement (Francetic, 2019; Khan et al., 2020; Miner et al., 2025; Shabangu et al., 2023). The findings of this study reflect the policy and implementation context at the time of data collection (2023); both document analysis and interview data indicated limited operational monitoring mechanisms, fragmented surveillance data, and weak integration between public and private sectors. The Monitoring and Evaluation Plan for the Jordanian NAP on AMR (2023–2025), published in 2024, is an important contextual development that may address some of the monitoring and accountability gaps identified in this study. The plan proposes activity implementation reports and coordination through the National AMR Monitoring and Evaluation Committee. However, its impact will depend on implementation capacity, routine reporting, cross-ministerial accountability, private-sector data integration, and sustained resourcing (Jordan Center for Disease Control, 2024).

Unlike previous approaches, the updated NAP integrates data collection through activity implementation reports from key ministries and institutions, coordinated by the National AMR Monitoring and Evaluation Committee (Jordan Center for Disease Control, 2024). This transition from ad-hoc monitoring to institutionalised monitoring is expected to strengthen accountability and evidence-based policymaking (Jordan Center for Disease Control, 2024). Although Jordan’s AMR policy demonstrates progress toward global alignment, its success in translating monitoring insights into actionable reforms, as noted in both policy documents and interviews, depends on implementation capacity, cross-sector collaboration, and continued resource allocation (Al-Tammemi et al., 2025; Momani et al., 2025). If implemented successfully, it could serve as a model for LMICs seeking to improve AMR governance through structured and adaptive monitoring strategies (Jordan Center for Disease Control, 2024).

Practical implications

The findings indicate several practical priorities for enhancing AMR governance in Jordan. Establishing a permanent AMR coordination secretariat would facilitate routine communication, documentation, reporting, and follow-up across sectors. Formalising cross-ministerial accountability through clearly assigned responsibilities, measurable indicators, reporting timelines, and mechanisms for addressing non-implementation is also recommended. Integrating private-sector data into national AMR surveillance and monitoring systems would reduce fragmentation between public and private healthcare settings. Strengthening laboratory infrastructure would improve microbiological testing capacity, support antimicrobial stewardship, and generate timely resistance data. Implementing prescription-only antibiotic regulations should be accompanied by equity-sensitive measures, such as affordable access to medical consultation, expanded health insurance coverage, and feguards for low-income or uninsured patients.

Strengths and limitations

This study has several notable strengths. Only a small number of studies have explored AMR at a systemic or political level, particularly in LMICs, making this research a novel contribution. Moreover, examining policymakers’ diverse perspectives provided valuable insights into AMR management. However, the findings should be interpreted with caution due to the study's limitations. As data were collected in Jordan, the findings may not be transferable to other contexts. Nonetheless, detailed descriptions of settings, methods, and participants enable readers to assess relevance to their regions. Although Jordan’s NAP adopts a One Health approach, which integrates human, animal, and environmental health sectors, this study focused on AMR implementation within human healthcare and policymaking. Perspectives from the animal health, agriculture, food production, and environmental sectors were not captured; therefore, the findings provide limited insight into the full multisectoral implementation of One Health AMR governance. Future research should include stakeholders from these sectors to examine how intersectoral coordination is operationalised across the wider One Health system. Additionally, social desirability bias could have influenced responses, as participants might have shaped their answers to align with perceived expectations (Chua et al., 2021). To mitigate this, the trustworthiness of this qualitative research was ensured through a range of strategies that enhanced its credibility, transferability, dependability, and confirmability (S. K. Ahmed, 2024)

Conclusion

This study used the IR framework to review AMR policies and gather policymakers’ views in Jordan. The findings indicate that existing policies have limited reach and impact beyond public hospital settings, highlighting the need for stronger integration across the wider healthcare system. Key gaps include inconsistent implementation, weak stakeholder coordination, and limited monitoring and evaluation, all of which hinder effective AMR control and equitable access to essential medicines. These challenges are not unique to Jordan and offer valuable lessons for resource-limited settings facing similar policy and implementation gaps. Strengthening AMR governance requires inclusive stakeholder engagement, comprehensive planning, and structured accountability. In addition, the need for adaptive policy development, based on review and evidence-based change, is important for improving intersectoral collaboration, ensuring responsible antibiotic use, and protecting access to affordable essential medicines.

Acknowledgements

I would like to thank all the participants in this study for their time and invaluable contributions. Additionally, I would like to extend my gratitude to those individuals who helped me access the participants and deliver the study materials. I also express my sincere gratitude to Applied Science Private University, which funded this research and provided me with the opportunity to conduct some interviews on its premises.

Funding Statement

This study is part of a PhD research project that was fully funded by Applied Science Private University, Amman, Jordan.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical approval

Ethical approval was provided for interviews by the University of Manchester, Proportionate University Research Ethics Committee (PUREC) Review (reference: 2023-17029-30426).

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