Gender and equity in AMR surveillance

Introduction

This course examines how antimicrobial resistance (AMR) is shaped by both biological and social determinants of health; and what this means for global health policy and practice. You will develop an understanding of the importance of a biosocial approach to health that requires exploration of the social and contextual factors driving and shaping AMR, as well as people’s experiences of AMR and health-seeking across One Health domains.

It is important to identify how social factors create unequal health experiences and outcomes in order to understand how to address these in policies and interventions because they are largely avoidable if the broader social drivers are addressed. You will explore how gender and equity frameworks can be applied to AMR to help you understand and manage inequitable impacts of AMR in your own context.

After completing this course, you will be able to:

• define key terms and concepts related to gender and equity in AMR
• explain how biological factors, including sex, contribute to differences in the effects of AMR
• explain how gender roles, social norms and social determinants influence AMR exposure and experience across different life stages, identifying which social groups may be differently at risk of or impacted by AMR, and how this aligns with key gender equity and human rights mandates
• outline how focusing on equity can strengthen the One Health approach to AMR
• describe the current biases and inequities in AMR data, and explain the importance of disaggregated data in understanding AMR trends across human health, animal health and the environment
• make recommendations for more equitable approaches to AMR interventions and surveillance
• reflect on how gender-responsive and equitable practices in AMR relate to your work.

In order to achieve your digital badge and Statement of Participation for this course, you must:

• click on every page of the course
• pass the end-of-course quiz
• complete the course satisfaction survey.

The quiz allows up to three attempts at each question. A passing grade is 50% or more.

When you have successfully achieved the completion criteria listed above you will receive an email notification that your badge and Statement of Participation have been awarded. (Please note that it can take up to 24 hours for these to be issued.)

1 Why gender and equity matter in global health

1.1 Gender equity is everyone’s responsibility and everyone’s gain

Evidence shows that gender equality is critical to ensuring sustained peace and democracy around the world (UN Women, 2015). Despite gender and equity being one of the sustainable development goals, women’s rights and gender justice are increasingly politicised (IPPF, 2024; Harper et al., 2025). The Fleming Fund has recognised that gender plays a significant role in AMR and antimicrobial use, and has put gender and equity at the heart of their work as a key strategic shift (Collins, 2023). It is therefore critical that, as you make progress through this course, you reflect on:

• your own positionalities
• the position of your institution with regards to gender and equity commitments and your national context
• identifying any small actions you can take to become a champion for equity, which matters now more than ever.

1.2 What is equity?

Everyone has the ‘right to the enjoyment of the highest attainable standard of physical and mental health’ (UN, 1966).

Figure 1 The difference between equality and equity.

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Two pictures that use bicycles to compare equality and equity. In the first picture, labelled ‘Equality’, the same type of bicycle is provided to all four people, regardless of how suitable it is for them or whether it meets their needs. In the second picture, labelled ‘Equity’, each person has a bicycle that is suited to their needs.

Figure 1 The difference between equality and equity.

2 A biosocial approach to health

AMR is more than just ‘bugs and drugs’; it’s important to put AMR within the contexts in which we live, work and play.

The biomedical model of health focuses on biological processes and factors that affect health; however, this does not take into account the social factors that influence health.

It is increasingly recognised that health and ill-health are shaped by social factors, including economic, commercial and environmental factors. Many researchers have explored these social factors and developed explanatory models.

Next we explore some of the social factors that affect your own health.

2.1 The social and structural determinants of health

The social determinants of health (SDHs) are ‘the conditions in which people are born, grow, live, work and age’, including their positions in hierarchies of power and the money and resources available to them (WHO, 2024a). These include specific factors such as:

• income levels
• access to social protection
• education level and opportunity
• job security and working conditions
• food security/insecurity
• access to safe housing
• exposure to harmful environmental factors
• experiences of early childhood development
• stigma and discrimination
• exposure to violent conflict
• access to affordable health services.

These are in turn influenced by broader socioeconomic, political and cultural factors, known as the structural determinants of health, which include:

• race
• gender
• ethnicity
• age
• sexuality
• class
• disability.

Together, these factors intersect and overlap to produce an unequal distribution of health-damaging or facilitating experiences.

The interrelationships between these social factors, and their influence on health, is illustrated in the Dahlgren-Whitehead ‘rainbow’ model (1991) shown in Figure 2.

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Figure 2 The Dahlgren-Whitehead rainbow.

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At the centre of a series of concentric semi-circles is a group of people with the label ‘Age, sex and constitutional factors’. The second semi-circle is labelled ‘Individual lifestyle factors’. The third semi-circle is labelled ‘Social and community networks’. The fourth semi-circle is labelled ‘Agriculture and food production’, ‘Education’, ‘Work environment’, ‘Living and working conditions’, ‘Unemployment’, ‘Water and sanitation’, ‘Healthcare services’ and ‘Housing’. The fifth and final semi-circle is labelled ‘General socioeconomic, cultural and environmental conditions’.

Figure 2 The Dahlgren-Whitehead rainbow.

Activity 3 explores some of the structural determinants of health further.

In summary, prioritising health equity is a basic human right and matter of social justice. A biosocial view of healthcare considers how social factors create unequal health experiences and outcomes and supports the design of interventions and solutions to address the root causes of illness. These SDHs are important because they improve our understanding of the conditions that create unequal health outcomes and experiences. They highlight that these unequal outcomes are largely avoidable if the root causes are addressed.

Optionally, you may like to watch Sir Micheal Marmot discussing the importance of SDHs in social justice (American Public Health Association, 2016).

Later in this course you will explore how SDHs can impact the drivers of AMR, but first you will be introduced to gender as a social determinant of health.

3 Introduction to gender as a social determinant of health

Sex and gender are both determinants of health: sex is a biological determinant of health and gender is an SDH. At a global level, SDHs are a more significant driver of health inequities than biological determinants of health.

Sex refers to the anatomical or genetic attributes that separate males, females and intersex people, and is usually assigned at birth. Someone’s gender identity may differ from their sex. Sex can influence biological susceptibility to infection, immune responses and responses to treatment; for example, urinary tract infections (UTIs) are more common in females for anatomical reasons, but more severe in elderly males. Sexually transmitted infections (STIs) tend to be less symptomatic in women but have greater reproductive impacts.

Gender is a social process that creates and shapes norms and power relations between women, men, boys, girls and non-binary individuals. This includes power imbalances, differential opportunities, cultural roles and discrimination. These processes, in turn, can influence the risk of exposure to infection, health-seeking behaviour, discrimination in health systems and stigma surrounding ill-health.

For example, gastrointestinal infections tend to be more common and more severe in males, due in part to:

• the fact that men are more likely to handle food in contexts and ways that carry a high risk of food-borne diseases (a gender factor)
• biological differences (including hormones) in immune response that place males at a higher risk of poor outcomes (a sex factor) (Dias et al., 2022).

Gender is relational and operates at multiple levels.

You may hear the terms ‘gender norms’, ‘gender roles’, ‘gender relations’ and ‘gender mainstreaming’. These concepts are integral to understanding gender as an SDH. Broadly these terms are defined as follows:

• Gender norms are a sub-set of social norms that describe how individuals are expected to behave in a given social context and as a result of the way individuals or others identify gender, as women, men and non-binary identities. Gender norms intersect with other norms related to age, ethnicity, class, disability, sexual orientation and gender identity – among other factors – and the way in which individuals experience them (ALIGN, n.d.).
• Gender roles are behaviours that are widely considered to be socially appropriate for individuals of a specific sex or gender within a culture, dictated by gender norms.
• Gender relations are the social power relations between people of different genders within households, communities and wider levels.
• Gender mainstreaming is the systematic consideration of gender equity in policies, programming and actions.

Gender analysis frameworks can support our understanding of how gender interacts with other processes, such as poverty.

3.1 Gender analysis frameworks

Gender analysis in health seeks to identify how gender norms and power relations lead to different experiences of health and health systems. Morgan et al.’s framework (2016), summarised in Table 1, shows how gender power relations affect access to resources, division of labour, norms, values, power negotiation and laws and institutions, and how each of these influence health and health systems.

The aspects of gendered power relations in Table 1 are also influenced by other diverse social factors. An intersectional health lens highlights the ways that these social factors (including gender, race and class) interact and overlap to influence health.

3.2 Intersectionality

The SDHs overlap and intersect to create specific experiences.

Intersectionality examines how different social factors and power relationships interact to create different experiences of privilege, vulnerability and marginalisation. The concept of intersectionality was coined by Kimberlé Crenshaw (2013) as a response to what she saw as the ‘tendency to treat race and gender as mutually exclusive categories of experience and analysis’ and to consider interactions between different aspects of social identity (Hankivsky et al., 2009; Crenshaw, 2013). Simpson’s intersectionality wheel (Figure 3) illustrates how every individual is positioned in the centre of multiple, overlapping forms of identity. These are in turn influenced and shaped by broader social and structural processes, including discrimination (Larson et al., 2016).

From the centre outwards the circles in the intersectionality wheel represent:

• an individual’s unique circumstances
• aspects of collective identity
• different types of discrimination, ‘–isms’ and attitudes that impact identity
• larger forces and structures that work together to reinforce exclusion.

The intersectionality wheel is not exhaustive, but it includes illustrative examples within each of the circles.

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Figure 3 Simpson’s intersectionality wheel (Simpson, 2009).

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A figure showing a series of concentric circles labelled with various terms. The centre circle is labelled ‘Unique circumstances of power, privilege and identity’. The second circle is labelled ‘Indigeneity’, ‘Education’, ‘Age’, ‘Gender’, ‘Occupation’, ‘Class’, ‘Caste’, ‘Social status’, ‘Background’, ‘Income’, ‘Geographic location’, ‘Sexuality’, ‘Spirituality’, ‘Life experience’, ‘Skin colour’, ‘HIV status’, ‘Disability’, ‘Refugee status’, ‘Family status’, ‘Housing situation’, ‘Work history’, ‘Experience of racialisation’, ‘Citizenship status’ and ‘Religion’. The third circle is labelled ‘Racism’, ‘Discrimination’, ‘Heterosexism’, ‘Sexism’, ‘Classism’, ‘Ethnocentrism’, ‘Transphobia’, ‘Ageism’, ‘Homophobia’ and ‘Ableism’. The fourth and final circle is labelled ‘Politics’, ‘Globalisation’, ‘Capitalism’, ‘War’, ‘Education system’, ‘Immigration system’, ‘Historical forces’, ‘Social forces’, ‘Economy’, ‘Legal system’ and ‘Colonisation’.

Figure 3 Simpson’s intersectionality wheel (Simpson, 2009).

In Activity 4, you will explore how gender and intersectionality impacts infectious diseases and access to healthcare.

Optionally if you would like to learn more on the origins of intersectionality, you may like to watch Kimberlé Crenshaw’s video on the origins of intersectionality (TED, 2016).

Next let’s explore more about how social determinants influence AMR.

4 The social drivers of AMR

In this section you will explore equity in AMR and link this to a people-centred approach to health.

While AMR is a natural process that happens over time, its emergence and spread is accelerated by human activity or caused by non-completion or non-recommended use of antimicrobials to treat, prevent or control infections in humans, animals and plants.

Socioeconomic challenges and inequities affect people’s experience of AMR, from exposure to infection to diagnosis and treatment. This is illustrated in Table 2, which shows the World Health Organization’s (WHO) people-centred approach to addressing AMR in human health (WHO, 2023). A focus on the social determinants of health is important because it enables an understanding of the AMR-specific health challenges that people face.

Many of these social challenges are equally relevant to animal health, for example in how they affect access to vaccines for animals and animal health worker training on AMR.

The impact of the inequities illustrated in Table 2 can be seen in the global inequitable burden of AMR. Up to 90% of deaths from AMR occur in the Global South (Mendelson et al., 2024). These contexts often experience high rates of infectious disease, challenges in access to healthcare and global inequities relating to the supply of vaccines and antimicrobials.

For example, in sub-Saharan Africa nearly 1 in 1000 deaths are already associated with bacterial AMR, compared with only half as many in high-income countries (Antimicrobial Resistance Collaborators, 2022). Within countries, the AMR burden is also unequally distributed – but there is no detailed data on how due to the absence of analysis of AMR data disaggregated by gender and other equity-related factors at a national level.

You can learn more about the burden of AMR and how it is measured in the course The health and economic burden of AMR.

5 AMR, sex and gender

Sex differences and gender norms both drive and shape AMR. The following two sections unpack this further.

5.1 AMR and sex differences

Sex – the biological differences between males, females and intersex people – can shape susceptibility to infection, including resistant infections (Figure 4). For example, females have a higher risk of developing UTIs because they have a shorter urethra, and UTIs have a high drug-resistance potential (Gautron et al., 2023). Risk of infection also increases around menstruation and pregnancy, which highlights how physiological changes over the life course have implications for exposure and vulnerability (Ghouri and Hollywood, 2020).

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Figure 4 Sex and gender bias in bacterial infections. RTI = respiratory tract infection; UTI = urinary tract infection; STI = sexually transmitted infection (Dias et al., 2022).

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A figure showing a man and a woman with various labels. The face of the woman is labelled ‘Upper RTIs: generally more common in females, e.g. tonsilitis, sinusitis, otitis externa’. The bladder of the woman is labelled ‘UTIs: more common in females but more severe in males’. The sex organs of the woman are labelled ‘STIs: women less symptomatic but more serious reproductive consequences; chlamydia more common in young women’. A lung of the man is labelled ‘Lower RTIs: generally more common and more severe in males, e.g. bronchiolitis, pneumonia, lung abscess, tuberculosis’. The intestines of the man are labelled ‘Gastrointestinal infections: generally more common and more severe in males, e.g. H. pylori infection, V. vulnificus, campylobacteriosis’. The sex organs of the male are labelled ‘STIs: syphilis and gonorrhoea more often seen in men, particularly MSM’. A shin of the man is labelled ‘Sepsis: males more prone to sepsis and septic shock, sex preference in survival unclear’.

Figure 4 Sex and gender bias in bacterial infections. RTI = respiratory tract infection; UTI = urinary tract infection; STI = sexually ...

Biological or sex factors also interact with diverse social factors, including those that relate to gender:

• Healthcare settings can be sites of high exposure to resistant infections, and women often spend significant amounts of time there. This is in part due to sex-related factors such as childbirth but it is also because of common gender norms around women’s role as caregivers.
• Malnutrition can increase susceptibility to infection, including resistant infection. This is also gendered because in many contexts, families experiencing food insecurity may prioritise feeding boy children because of their economic roles.
• Poor water, sanitation and waste management can create conditions that drive the spread of infection, including resistant infections. Women and girls may be particularly affected by this because of the intersection of anatomical factors and their particular exposure to water-borne infections due to their role collecting water for the household (Gautron et al., 2023).

5.2 AMR and gender differences

The specific ways that people are exposed to antimicrobials and resistant infections, experience AMR, and have knowledge of AMR are significantly influenced by biology, gender and other intersectional inequities.

• Susceptibility: Biological susceptibility is affected by malnutrition, co-morbidities and exposure to pollutants and occupational hazards (e.g. mining). For example, high levels of HIV infection among young women in Nigeria increase their biological susceptibility to drug-resistant tuberculosis (TB). These high levels of HIV infection are thought to be due to intergenerational relationships where young women marry older men who are more likely to be living with HIV (Oladimeji et al., 2023).
• Exposure: Exposure to resistant infections can be influenced by gender norms and roles. Frontline health workers are predominantly women (O'Donnell et al., 2010) and consequently they have high exposure to resistant infections (Gautron et al., 2023). Sex workers have a high risk of exposure to resistant sexually transmitted infections and limited ability to negotiate for safer sex with clients (WHO, 2012; Deering et al., 2013). Lack of access to adequate water, sanitation and hygiene (WASH) systems can create environments in which people experience high exposure to resistant infections (Cocker et al., 2023). Research suggests that women are more likely to be prescribed antimicrobials than men (Schröder et al., 2016).
• Access to health services, treatment and continuity: Low-income communities and particularly female-headed households may not have finances to access formal health services or to ensure continuation of antimicrobial treatment for HIV infection or TB, which both require long-term courses of medication (Shembo et al., 2022). This can also intersect with issues of food insecurity because some medications are to be taken on a full stomach (Kiekens et al., 2021; Taylor et al., 2022).
• Health-seeking autonomy: Household power relations can affect health-seeking autonomy. In many patriarchal settings, men or older women have decision-making power over younger women and girls. For example, among pastoralist communities in Tanzania, boys’ health may be prioritised because of their herding duties; girls and women may have to seek the permission of men to seek healthcare (Barasa and Virhia, 2022).
• Impacts: Catastrophic costs associated with healthcare can hit people already living in poverty hardest. People with multi-drug-resistant TB may have to take multiple, long-term treatments that can reduce their ability to work and push them further into poverty (Kaswa et al., 2021). Stigma relating to resistant infections can also be gendered: one study found that UTIs were thought of as illnesses resulting from poor hygiene, which prevented women in particular from seeking early care (Barasa et al., 2022).

Optionally, if you are interested in exploring this area further, you may be interested in reading ReAct’s report Scoping the Significance of Gender for Antibiotic Resistance report by the ReAct group.

Now try Activity 5, which illustrates how SDHs shape susceptibility and exposure to, and the treatment of, AMR.

While gender differences in AMR highlight disparities in exposure, access and care-seeking behaviours, revisiting the broader social and structural drivers explores how these gendered inequities are both shaped by and reinforce systemic AMR risks.

6 Revisiting the social and structural drivers of AMR

As you will have come to understand from your study in the course so far, AMR drivers are about not only antimicrobial practices but also social and structural determinants of health: the underlying societal and environmental factors that create conditions conducive to the development and spread of AMR.

These are explained in Figure 5, which highlights how drivers of antibiotic resistance and barriers to managing antibiotic resistance are shaped by the socio-cultural inequities (such as gender inequity) that exist at multiple levels – from community to national and international. This includes stigma and social norms within communities, but also power structures within national health system structures and the lack of representation of communities and diverse groups in political decision-making. In this way, managing the spread of AMR needs to look beyond people’s knowledge and behaviours.

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Figure 5 An intersectional view of social constructs and antibiotic resistance (ABR) (Charani et al., 2021).

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A figure with the heading ‘Sociocultural imbalances and their effect on ABR’. On the left-hand side of the figure, under the heading ‘As drivers of ABR’, is the following list: ‘The needs and associated risks of specific populations in society not addressed’, ‘Gaps in knowledge, awareness and literacy’, ‘Attitudes towards health, disease, infection and ABR’ and ‘Lack of access to health; over-, under-, mis-use of antibiotics due to access issues’. In the centre of the figure is a series of concentric circles with various labels. The centre circle is labelled ‘Constructs of gender/class/race/caste’. The second circle is labelled ‘Residence/migrant status’. The third circle is labelled ‘Community position and culture’. The fourth circle is labelled ‘Accountability and agency’. The fifth and final circle is labelled ‘Policy and agenda/political economy’. On the right-hand side of the figure, under the heading ‘As barriers to tackling ABR’, is the following list: ‘Lack of representation in policy and decision-making’, ‘Campaigns not targeting diverse populations’, ‘Power dynamics and hierarchies influencing adherence to desired behaviours’ and ‘Lack of access to health; over-, under-, mis-use of antibiotics due to access issues’. The headings at the bottom of the figure read ‘Access to healthcare, including vaccination’, ‘Access to WASH’, ‘Education >> occupation >> wash’ and ‘Positionality: fallback position in family and society, based on gender, religion and culture’.

Figure 5 An intersectional view of social constructs and antibiotic resistance (ABR) (Charani et al., 2021).

Figure 5 highlights that AMR is not an issue of ‘misuse’, but rather of the structures that prevent recommended use. In fact, bans on antibiotic use are often offered as solutions to curb AMR. However, evidence from Mexico shows that these bans do not work, and people will find ways to work around them (Pérez-Cuevas et al., 2014). This is largely because in many contexts, there is an absence of holistic healthcare and antibiotics are seen as a ‘quick fix’ for the systemic disparities in power, resources and opportunities that result from institutionalised biases and practices (Willis and Chandler, 2019). Context, therefore, is critically important; this will be illustrated in the following case study on urban informal settlements.

6.1 A case study on urban informal settlements

Urban informal settlements comprise a key structural inequity and have been described as hotspots for AMR (Nadimpalli et al., 2020). They are a clear case study of why structural inequities drive AMR.

Informal settlements are often deemed to be ‘illegal’ because of an absence of formal governance, leading to poor environmental conditions, a lack of adequate healthcare and, subsequently, a proliferation of informal antibiotic use. Figure 6 illustrates how these conditions can facilitate the spread of AMR and constrain peoples’ abilities to access and use antimicrobials in the recommended ways.

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Figure 6 Transmission of AMR in urban informal settlements (Nadimpalli et al., 2020).

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On the left-hand side of the figure, under the heading ‘Sources of AMR’, is the following list: ‘Domestic animals’, ‘Wastewater from city, industries and hospitals’, ‘Insufficient sanitation for dense population’ and ‘Open sewage drains’. There is an arrow going from this list to the right-hand side of the figure, where, under the heading ‘Human exposure routes’, is the following list: ‘Flies and rats transfer bacteria to food and homes’, ‘Animals track human and animal faeces into homes’, ‘Contaminated drinking water supplies’ and ‘Children play in open drains and soil’. The arrow is labelled with two lists . At the top of the figure, under the heading ‘Slum environment’, is the following list: ‘High risk of flooding and poor drainage allow sewage to pool where residents eat, work and play’ and ‘Mixing of faecal and environmental bacteria in presence of antibiotics may support HGT’. At the bottom of the figure, under the heading ‘Slum residents’, is the following list: ‘Acute overcrowding and poor hygiene exacerbate the spread of AMR among residents and into the environment’ and ‘Antibiotic overuse exerts constant selection pressure’.

Figure 6 Transmission of AMR in urban informal settlements (Nadimpalli et al., 2020).

Now complete Activity 6, which considers a case study of AMR in urban informal settlements.

An intersectional approach helps to show how gender inequality and other overlapping factors like poverty or race amplify health risks faced by those living in informal settlements. Combining this with a One Health approach can highlight the intersections of human, animal and environmental health, and how these are inequitable.

7 One Health, gender and intersectionality

One Health recognises the close links between human health, animal health, plant health and the health of the wider environment (WHO, n.d. 2). One Health emphasises the interactions of the ecosystem, removes binaries and rejects a reductionist approach (Zinsstag et al., 2015). You can learn more about One Health in the course Introducing a One Health approach to AMR.

There is therefore significant overlap between One Health and intersectionality theory, which emphasises how different SDHs and power relations overlap and intersect to create specific experiences. Both One Health and intersectionality highlight how the combination of various factors experienced at individual and group levels is influenced by societal processes and structures of power (Davis et al., 2025 [forthcoming]).

Using an intersectional lens to study AMR is critical to understanding how individuals experiencing multiple forms of marginalisation may face heightened vulnerability. This includes thinking about how people’s physical and social locations shape their vulnerability, susceptibility and experiences of AMR, and how these overlap with other contextual issues such as climate change and conflict.

This course takes a primarily human-centred lens, but there are many ways in which power structures and harmful gender norms intersect with animal health and environmental health. These concepts are explored more in Video 4 from the Just Transition initiative.

7.1 Gender inequities in animal health

The pathways of antimicrobial exposure, the burden of resistant infections and the comprehension of AMR within animal health systems are significantly gendered. This results in distinct experiences for different genders across the animal health sector.

Women farmers may face significant hurdles in accessing vital livestock services. Research in Kenya found that livestock service providers held negative attitudes towards women farmers that meant that, despite women acknowledging the benefits of livestock vaccination, they were less likely to use vaccines due to sexist perceptions and economic gender inequalities (Kyotos et al., 2022).

A study of rural female smallholder farmers in Rwanda and Uganda found that women preferred to care for chickens and goats rather than cattle (Mutua et al., 2019; Mukamana et al., 2022). However, because government vaccination programmes often focus on vaccinating larger livestock for diseases such as Rift Valley fever (Acosta et al., 2022; Mukamana et al., 2022; Tukahirwa et al., 2023), these programmes – which often subsidise cost and remove physical barriers to vaccinations – are less available to women.

Other research found that women had to seek permission from their husbands before purchasing vaccines or accessing resources in general (Mukamana et al., 2022). Additionally, women may lack the required transportation to travel to vaccination places, and doing so may involve a higher personal risk for women than for men farmers due to gender-based violence (Enahoro et al., 2021; Acosta et al., 2022). Despite this, women were active in self-help groups that aided raising funds and providing physical labour and improved their access to livestock vaccinations (Jumba et al., 2020).

In many societies, including pastoralist communities, men may be more likely to carry out animal slaughter work, which brings significant risk of exposure to resistant infections (Barasa, 2019).

Having explored gender and inequity in AMR drivers, you are now going to look at how data disaggregation in AMR surveillance systems has value in understanding inequitable trends in AMR.

8 AMR surveillance and equity

Currently, efforts are being made to strengthen global AMR surveillance data. This is wonderful, and gives a picture of the general burden of disease among populations. But given what you now know about gender and intersectional inequities driving AMR, do you think it’s important to know who is affected by AMR? You’ll explore the need for disaggregated data in the next section.

8.1 The need for disaggregated data

Much of the surveillance data collected about resistant infections at a global level, for example in the WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS) is aggregated data. This means that it is not broken down by factors such as age, sex, geographic location or other equity-related indicators (such as refugee status). Therefore, very little is known about how the burden of resistant infections is spread within countries.

Disaggregated data supports AMR capacity-strengthening in countries because it provides context-specific understandings of burden of disease. Some countries already have data disaggregated by sex and age, and GLASS now lets you report in this way. It is critical that all countries start reporting disaggregated data to allow for an understanding of the burden of resistant infections within countries to understand which groups are most at risk or affected.

8.2 Limits to surveillance data

Equitable AMR surveillance depends on comprehensive data, but persistent limits in surveillance systems often exclude the marginalised communities most affected by AMR. It is also important to consider the limitations of surveillance data and what it currently cannot tell us, including biases in the data that need to be understood.

AMR surveillance also relies primarily on data collected at health facilities. This means that community-level infections are rarely detected, particularly among those who use informal health providers. Additionally, individuals and groups who face specific barriers to accessing formal health services and diagnostics will not be represented in surveillance data.

This highlights the fact that trends in surveillance data cannot be understood without the contextual understandings of the upstream drivers of exposure, health-seeking, use of antimicrobials and animal health, which can be unpacked with qualitative and social science research.

Together, surveillance data and contextual social research can support decision-making and intervention design. Surveillance data needs to be complemented with:

• research to map the burden of resistance among communities and key populations that may be excluded from current surveillance efforts
• qualitative or co-produced research with communities that unpacks structural drivers of AMR and prioritises community knowledge to support context-appropriate intervention design and prevention.

To mitigate these barriers, it’s important to address the equity gaps in AMR.

9 Addressing equity in AMR

Given the significance of inequities (including gender inequity) in AMR and One Health, there is a need to address these inequities in AMR research and interventions. The following extract explores some reasons why gender and equity considerations are important in AMR research.

In Activity 8 you will consider gender and equity data in your own context.

9.1 Incorporating gender considerations into AMR research and interventions

In 2024 the WHO’s National Action Plans and Monitoring and Evaluation team identified several recommendations for addressing equities in AMR. These recommendations are summarised below. Highlights include the need for:

• multisectoral action and coordination that can cut across One Health domains as well as governance of areas such as water, sanitation and hygiene (WASH), housing, health systems and transport
• data disaggregated by key equity indicators, including sex, age, geographic location (at minimum), and ideally other social stratifiers such as (but not limited to) socioeconomic status, ethnicity, refugee status and disability
• incorporation of equity considerations into AMR national action plans (NAPs) and into multisectoral AMR coordination
• (in the longer term) improved access to WASH and essential health services, with the goal of preventing resistant infections in the first place.

9.2 The importance of community engagement in intervention design

As you have seen, AMR surveillance prioritises specific forms of quantitative data, often collected at tertiary health facilities, over qualitative community-level data and perspectives.

Recognising the significance of gender and other intersectional inequities in shaping differential behaviours and outcomes related to AMR, community engagement can serve as a key approach to address the social drivers. It follows the principle of equitable partnership fostering collaboration with communities to co-design interventions or solutions that are contextually relevant, inclusive and just.

Community engagement approaches to research (e.g. participatory video-making and community dialogue approaches [CDA]) centre community voices – particularly those of marginalised and underrepresented groups – to inform decision-making. CDA was applied by HERD International in Nepal as part of the COSTAR project to address the social drivers of AMR and associated behaviours at the community level, with a focus on gender, power relations and other equity indicators. CDA is a community-driven approach that aims to empower communities to identify and implement sustainable and contextual solutions for health. This informed the creation of flipbooks designed to share context-relevant understandings of AMR and recommended use of antibiotics. They were tailored to age, literacy and sociocultural norms. Pictures were created with community input and designed to be inclusive of gender identities. Facilitators from local communities conducted CDA discussions in rural settings, in which community participants discussed their issues, explored challenges, identified solutions and planned action that is relevant to their individual and societal context.

Figure 7 A flipbook with contextualised AMR messages for CDA.

Figure 8 Community facilitators conducting community dialogue sessions using a flipbook.

Next you will explore how these equity issues can be addressed in country AMR national action plans (NAPs).

9.3 Equity in national action plans

There needs to be a gender and equity focus in all efforts to protect and improve population health, as acknowledged in global mandates such as the UN Sustainable Development Goals (UN, n.d. 1) and the UN Women Strategic Plan 2022–2025 (UN, n.d. 2).

A 2024 WHO review of 145 NAPs for AMR found that 125 of 145 publicly available NAPs did not include mentions of sex or gender. Policy and interventions that do not address inequities risk exacerbating equity challenges (WHO, 2020). NAPs are an important entry point to consider and strengthen the gender and equity responsiveness of national efforts to tackle AMR.

Figure 9 illustrates how addressing equity in AMR NAPs can lead to reduction in mortality and morbidity due to drug-resistant infections.

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Figure 9 Theory of change for addressing gender inequalities in NAPs on AMR. AMU = antimicrobial use; ESBL = extended spectrum beta lactamase; MCM = multisectoral coordination mechanism; MRSA = methicillin-resistant Staphylococcus aureus; TWG = technical working group (WHO, 2024b).

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A flow chart of four columns, with an arrow from each column pointing to the next. The first column is headed ‘Problem statement’ and reads: ‘NAPs on AMR do not recognize gender inequalities and their impact on the emergence and spread of AMR’. The second column is headed ‘Pathways of change’ and reads: ‘1. Sex-disaggregated data and research. 2. Equal gender representation in AMR governance structures. 3. Targeted awareness and behaviour change interventions. 4. Addressing gendered barriers to access to health services (prevention, diagnosis and treatment). 5. Gender-responsive legislation, regulations and guidelines.’ The third column is headed ‘Desired outcomes’ and reads: ‘Increased gender responsiveness of NAP on AMR interventions. Increased representation of women in the AMR MCM and TWGs. Increased awareness among targeted populations about AMR. Increased awareness and knowledge among health workers about gender-specific needs in addressing AMR. Increased availability of geographically representative AMR and AMU surveillance data, disaggregated by sex. Increased evidence from research on AMR and gender dimensions. Increased number of new diagnostics for infections affecting women. Reduced maternal mortality due to (drug-resistant) infections, including sepsis. Reduced bloodstream infections due to MRSA and ESBL Escherichia coli. Increased coverage of women and other vulnerable groups in health insurance packages. Decreased number of stockouts of antimicrobials to treat infections affecting women and other vulnerable groups. Increased availability of sex-disaggregated data on diagnostic services for (drug-resistant) infections. Reduced inappropriate use of antimicrobials in the community and healthcare settings.’ The first column is headed ‘Desired impact’ and reads: ‘Strengthen the evidence base on gender and AMR. Reduce gender-related inequalities in the design, implementation and monitoring of AMR interventions. Reduce mortality and morbidity due to (drug-resistant) infections, including sepsis and other pregnancy-related infections.’

Figure 9 Theory of change for addressing gender inequalities in NAPs on AMR. AMU = antimicrobial use; ESBL = extended spectrum beta ...

Examples of good practice come from Uganda and Malawi’s NAPs, both of which mainstream gender considerations.

Now complete Activity 9 to consider the NAP for AMR in your country.

Now you will move on to reflect on how you can take your learning from this course in your work for positive action.

10 Gender and equity in your work

Gender equity is everyone’s responsibility and everyone’s gain. Achieving it will require a collective approach, with a role for everyone. All the small actions that are taken by individuals and organisations will be important.

Before you finish this course this final activity will help you to think about how what you have learned relates to your role.

11 End-of-course quiz

Well done – you have reached the end of this course and can now do the quiz to test your learning.

This quiz is an opportunity for you to reflect on what you have learned rather than a test, and you can revisit it as many times as you like. 

• End-of-course quiz

Open the quiz in a new tab or window by holding down ‘Ctrl’ (or ‘Cmd’ on a Mac) when you click on the link.

12 Summary

In this course you have learned how social and structural inequities come together with biological factors and processes to create a complex picture that shapes and drives AMR risks and disease burden. You have explored the limitations in surveillance data and explored practical steps to move towards more inclusive and representative data and policy making for AMR.

You should now be able to:

• define key terms and concepts related to gender and equity in AMR
• explain how biological factors, including sex, contribute to differences in the effects of AMR
• explain how gender roles, social norms and social determinants influence AMR exposure and experience across different life stages, identifying which social groups may be differently at risk of or impacted by AMR, and how this aligns with key gender equity and human rights mandates
• outline how focusing on equity can strengthen the One Health approach to AMR
• describe the current biases and inequities in AMR data, and explain the importance of disaggregated data in understanding AMR trends across human health, animal health and the environment
• make recommendations for more equitable approaches to AMR interventions and surveillance
• reflect on how gender-responsive and equitable practices in AMR relate to your work.

Now that you have completed this course, consider the following questions:

• What is the single most important lesson that you have taken away from this course?
• How relevant is it to your work?
• Can you suggest ways in which this new knowledge can benefit your practice?

When you have reflected on these, go to your reflective blog  and note down your thoughts.

13 Your experience of this course

You’ve now reached the end of this course. If you’ve enrolled on a pathway, please go back to the pathway page and tick the box to confirm that you’ve completed this course. On the pathway page you’ll see both your progress so far as well as the other courses you need to complete in order to achieve your Certificate of Completion for that pathway.

Now that you have completed this course, take a few moments to reflect on your experience of working through it. Please complete a survey to tell us about your reflections. Your responses will allow us to gauge how useful you have found this course and how effectively you have engaged with the content. We will also use your feedback on this pathway to better inform the design of future online experiences for our learners.

Many thanks for your help.

Now go to the survey.

Further reading and resources

If you are interested in finding out more about some of the areas covered in this course you may like to read some of the following resources:

• More about the social determinants of health: Marmot, M., Friel, S., Bell, R., Houweling, T. and Taylor, S. (2008) ‘Closing the gap in a generation: health equity through action on the social determinants of health’, The Lancet, 372(9650), pp.1661–9 [online]. Available at: https://www.thelancet.com/ journals/ lancet/ article/ PIIS0140-6736(08)61690-6/ abstract (accessed 6 June 2025).
• Using the social determinants of health to design equitable policies for health: Dahlgren, G. and Whitehead, M. (1991) Policies and Strategies to Promote Social Equity in Health: Background Document to WHO – Strategy Paper for Europe, Institute for Future Studies [online]. Available at: https://www.iffs.se/ publikationer/ arbetsrapporter/ policies-and-strategies-to-promote-social-equity-in-health/ (accessed 6 June 2025).
• Integrating equity considerations into research and intervention design for AMR: Lynch, I., Middleton, L., Naemiratch, B., Fluks, L. and Sobane, K. (2023) Practical Pathways to Integrating Gender and Equity Considerations in Antimicrobial Resistance Research, ICARS/IDRC [online]. Available at: https://icars-global.org/ knowledge/ practical-pathways-integrating-gender-and-equity-considerations-in-antimicrobial-resistance-research/ (accessed 6 June 2025).

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Acknowledgements