GEAR up: AMR through a gender and equity lens

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A new Regional Grant for phase 2 of the Fleming Fund, GEAR up (Gender and Equity within Antimicrobial Resistance) is led by the Liverpool School of Tropical Medicine (LSTM) in the UK.

GEAR up is catalysing action on gender and equity in antimicrobial resistance (AMR), supporting stakeholders in low- and middle- income countries to understand how AMR affects different societal groups and formulate tailored action plans. LSTM is partnering with: LVCT Health, Kenya; CeSHHAR, Zimbabwe; University of Health and Allied Sciences, Ghana; HERD international, Nepal; and BRAC James P Grant School of Public Health, Bangladesh.

We hear from GEAR up lead, Dr Rosie Steege from the Department of International Public Health at LSTM on the importance of including an equity focus for surveillance data and looking to the community to understand the AMR drivers missed.

AMR is a critical public health threat globally, but its burden is not distributed equally due to the spread of AMR being heavily influenced by social determinants. Adopting an intersectional equity lens in disease prevention and control can support improved public health outcomes and needs to be customary practice in AMR initiatives.

GEAR up is proactively building on Fleming Fund projects and integrating a focus on equity within existing activities and grant structures. We work closely with Kenya, Uganda, Ghana, Sierra Leone, Zimbabwe, Zambia, Bangladesh, Sri Lanka, Nepal, Indonesia, and other supported countries within the Fleming Fund.

AMR social surveillance indicators

The focus of the Fleming Fund is strengthening AMR surveillance capacity. GEAR up will support countries to use their surveillance data to understand broad trends about AMR, gender and equity and define lines of enquiry for further research in this area.

We provide tailored in-person support in countries such as Tanzania and Lao People's Democratic Republic Laos, to help them interrogate their surveillance data with a gender and equity lens. This will help us develop experience-based guidance for all Fleming Fund-supported countries. Developed alongside other case studies, tools and resources, the guidance will increase awareness and inspire further intersectional analysis and action - to catalyse change in policy and practice.

We are also supporting countries to consider how to collect data on other relevant social indicators beyond sex and age that will enable them to take a more intersectional view in the future – see examples in our recent publication – ‘Including intersectional indicators within AMR surveillance’.

These indicators should be collected in all surveillance programmes. Critically, these changes must also be made within the Global Antimicrobial Resistance and Use Surveillance System (GLASS) to avoid the loss of national data disintegration efforts.

Community research

Surveillance data is essential, but it also comes with biases. Structural inequities – for example, within education or household decision-making – shape who can access a health facility or diagnostic testing.

It’s important to remember these gender inequities when discussing equity in AMR, and we also want to encourage researchers and health system staff to look beyond facility-level surveillance data to community-level dynamics.

GEAR up is undertaking community research to explore the structural drivers of AMR, which is underway in Nepal and has just wrapped up in Bangladesh within two urban informal settlements in Dhaka and share these findings soon.

Policy engagement

GEAR up’s recent success in mainstreaming gender and equity through the National Action Plan in Uganda was launched during the 2024 World AMR Awareness Week. This was achieved through a collaborative approach between LVCT Health, Baylor Uganda, the Ugandan Ministry of Health, and other key stakeholders. They held gender and equity workshops to embrace a people-centred and equity-driven approach in AMR surveillance and policy.

This represents a critical step forward from the recent WHO scoping review of 145 National Action Plans found that 125 made no mention of sex or gender.

Additionally, the GEAR up team from BRAC James P Grant School of Public Health recently contributed to incorporating a gender and equity plan into the Bangladesh National AMR Surveillance Strategy currently under development. This is the first time in the country that policy documents for AMR have included a gender and equity focus.

Key lessons for policy engagement were:

• Continuous capacity strengthening and technical support are needed for sustained progress.
• Multi-sectoral collaboration builds shared accountability and sustainability.
• Collaborative document reviews ensure inclusivity and contextual relevance.
• Integrating disaggregated data leads to more actionable insights – acknowledging the inherent biases.
• Gender and equity champions play a vital role for continued integration efforts.

We continue to review and shape national policy documents, for example, in Kenya and Pakistan among other countries. Taking forward the WHO’s recommended actions for addressing gender inequalities in National Action Plans.

Future plans

We are finalising a global review of the evidence base on equity and AMR, which takes an intersectional lens. This will be published soon and contribute to the conceptualisation of the structural inequities driving and shaping AMR to highlight where current interventions could lie and the biases in surveillance data alone.

GEAR up are also supporting AMR surveillance for key populations – such as female sex workers in Zimbabwe - through our partners CeSHHAR, who are uniquely placed to understand patterns of drug-resistant gonorrhoea among this marginalised group.

Finally, we are building Communities of Practice in gender, equity, and AMR across human, animal, and environmental health – looking to encourage ‘South-South’ learning and exchange between the countries we partner with. Please join our Linked in Group if you are interested to learn more here.

Further reading

Addressing gender inequalities in antimicrobial resistance responses