Antimicrobial resistance (AMR) policy has long had an intuitive objective: reduce unnecessary exposure to antibiotics so that they remain effective when they are needed. That objective addresses only one of two failures that AMR policy must manage. In many health systems, inappropriate antibiotic use coexists with inadequate access to effective treatment. Limited access to quality-assured antimicrobials can lead to inadequate treatment, substandard medicines, or incorrect dosing, while inappropriate use can persist within the same broader health system.
New guidance from the World Health Organization (the WHO) makes that tension much harder for national AMR programs to treat as a secondary concern. The September 2026 guidance provides 20 recommendations for integrating equity across the 13 core interventions in the WHO’s people-centred approach to AMR.1 Its evidence synthesis concentrates on three areas where inequity can influence AMR or undermine interventions intended to control it: water, sanitation, and hygiene; access to health services and essential antibiotics; and surveillance of AMR and antimicrobial use.
The guidance matters less for documenting unequal AMR risk than for asking how AMR interventions themselves distribute access, exposure, and benefit. The WHO asks countries to examine whether stewardship policies, diagnostic systems, prescribing practices, procurement mechanisms, and restrictions on antibiotic sales produce different effects across populations. Equity, in this formulation, becomes something that national action plans (NAPs) need to measure and manage rather than simply acknowledge.
A health system must therefore reduce unnecessary antimicrobial exposure while making effective treatment reliably available to patients who need it. The difficult policy question is how to accomplish both at once.
Why Lower Use Is Not Always Better Use
Global antibiotic-use data illustrate why AMR policy cannot be reduced to a single goal of lowering consumption. The WHO’s Global Antimicrobial Resistance and Use Surveillance System reported a tenfold difference between the highest- and lowest-using countries and territories in its 2022 antibiotic-use data set. The WHO cautioned that these differences require further investigation, but said they point toward both antibiotic overuse and low access. Some low- and middle-income reporting settings also recorded little or no use of reserve antibiotics, which are intended for infections caused by the most drug-resistant bacteria.2
Low antibiotic consumption may reflect successful stewardship, but it can also signal inadequate access. Limited access to health care, weak diagnostic capacity, unaffordable medicines, fragile supply chains, or lack of access to antibiotics needed for particular resistant infections can all suppress use without producing better care.
The 2026 equity guidance places this tension within a wider critique of approaches that concentrate heavily on individual behaviour. The WHO notes that AMR interventions have often prioritized changing what patients and health workers do while paying less attention to structural conditions that shape those decisions. Self-medication, for example, may be linked to lack of health coverage or health insurance rather than simply inadequate awareness of appropriate antibiotic use. The guidance also identifies inadequate living and working conditions and insufficient health-promoting infrastructure among factors that can influence antimicrobial use.
That perspective is consistent with a broader approach to sustainable antibiotic access proposed in the stewardship literature. Many patients in low- and middle-income countries lack effective and affordable treatments, while conventional stewardship programs may be difficult to implement where financial resources, health-system capacity, and specialized personnel are limited. A context-adapted approach still seeks the right antibiotic at the right time and for the right duration, but it adds affordability and practical access to the equation.3
The implication is not that stewardship should become less restrictive wherever access is poor. It is that stewardship has to distinguish inappropriate exposure from necessary treatment rather than treating lower consumption as an adequate proxy for success.
When Restricting Antibiotics Changes Access
One of the most consequential passages in the new WHO guidance concerns a familiar AMR intervention: restricting non-prescription sales of antimicrobials.
Such regulations have a clear stewardship rationale. The WHO’s people-centred framework includes regulation of non-prescription antimicrobial sales among the interventions intended to support appropriate, quality-assured treatment.4
The new equity guidance adds another criterion for judging whether such policies work. Recommendation 20 asks countries to assess the unintended consequences of policies or regulations that reduce non-prescription antimicrobial sales, specifically examining their effects on access to essential antimicrobials among different population groups. It also calls for consideration of fair and equitable access to new antimicrobials.
That recommendation exposes the access paradox in a particularly concrete form. A rule can reduce inappropriate antibiotic purchases and still create a problem if people who previously depended on that channel have no viable route to medical evaluation, diagnosis, prescription, and affordable treatment. The relevant question therefore extends beyond whether fewer antibiotics are sold without prescriptions. Policymakers also need to know whether patients who require those drugs can obtain them through an appropriate alternative pathway.
This does not argue against regulation. It changes what regulators have to evaluate. A restriction designed to improve antibiotic use operates within a health system whose clinics, laboratories, pharmacies, financing mechanisms, and supply chains may be distributed unequally. Applying the same rule to everyone does not guarantee the same effect for everyone.
For AMR policy, unintended access consequences therefore form part of the evaluation of whether an intervention succeeds.
Access Depends on the Health System
Treating antibiotic access as a simple question of whether a product is technically available obscures much of the problem. A drug can be registered in a country and still remain practically inaccessible because diagnosis, financing, procurement, distribution, or local availability fails somewhere along the path to treatment.
The WHO consequently treats access as a health-system issue extending from insurance coverage and diagnostics to procurement and supply continuity. Its recommendations call for health insurance or health-benefit packages to cover AMR-responsive services, including diagnostics and antimicrobials for drug-resistant infections, with particular attention to groups facing the greatest risk of inequity. They also ask countries to identify barriers to quality-assured medicines, including obstacles that push populations away from formal health-care channels and increase the risk of purchasing substandard or falsified antimicrobials.
The guidance extends the same logic into supply planning. Medicine forecasting and procurement should consider local infection epidemiology by sex, gender, age, and at least one health-equity indicator, in part to ensure that relevant antimicrobials are included and stockouts are reduced. Health-care facilities are also encouraged to develop contingency plans that preserve access to essential antibiotics during supply disruptions, including in low-resource, rural, and remote settings.
Recent regional evidence illustrates how varied these failures can be. A 2026 WHO survey of antibiotic access in the African Region was sent to all 47 Member States, with 25 responding. Countries reported barriers spanning stockouts, affordability, supply chains, registration, and public-sector availability. These barriers affected not only newer reserve antibiotics but also more widely used agents, indicating that access problems can occur across the antibiotic portfolio for different reasons.5
Similar problems appear in Latin America and the Caribbean. A 2026 review of reserve antibiotic access identified interconnected barriers involving regulatory approval, manufacturer participation, formulary inclusion, procurement, and health-technology-assessment capacity. It also found greater constraints in public hospitals than in private facilities, illustrating how substantial access inequalities can exist within a single national market rather than only between richer and poorer countries.6
Medicine availability alone therefore provides an incomplete measure of access. Effective treatment depends on a functioning pathway from care and diagnosis through prescribing, financing, procurement, and supply. Weakness at any point can turn nominal availability into practical absence.
The Patients Missing From AMR Surveillance
There is another difficulty with designing equitable AMR policy: some of the populations experiencing the greatest barriers to care may also be the least visible in surveillance systems.
Routine clinical microbiology provides much of the information used to understand resistance patterns. When aggregated, laboratory data can inform empiric treatment guidance, antibiotic procurement, national surveillance, and NAPs. However, those data depend on which patients reach a facility, which patients are tested, and what diagnostic capacity exists once they arrive.7
Those conditions differ substantially across settings. In some low-income countries, microbiological diagnostics are not routinely available. Where cultures depend on willingness or ability to pay out of pocket, laboratories are under-resourced, or patients do not use formal health-care services, the infections captured in routine datasets may be incomplete or unrepresentative. The same analysis notes that groups outside formal health care may be systematically underrepresented in hospital data even when marginalized populations carry substantial burdens of drug resistance.
The consequence extends beyond statistical completeness. If some populations are less likely to enter the diagnostic system, their infections are also less likely to become surveillance observations. Policies built from those observations may therefore describe resistance accurately for the population being tested while offering a less complete picture of the population actually experiencing infection.
The WHO’s equity recommendations respond directly to this limitation. Countries are asked to disaggregate relevant AMR program data, at minimum, by sex, age, and location, with other equity indicators included where feasible. The WHO also recommends defining equity variables within existing AMR and antimicrobial-use surveillance systems and strengthening the capacity of surveillance professionals to analyze inequalities and inequities.
Data disaggregation alone cannot recover patients who never enter the data set. The WHO therefore also recommends periodic reviews of diagnostic services to identify population groups experiencing unequal access to testing for drug-resistant infections.
Equity-responsive surveillance consequently requires two questions. What differences are visible within the data already being collected? And whose infections are missing because the underlying system never captured them?
From Equity Language to Equity Metrics
Many AMR policies already contain language about vulnerable populations, equitable health care, or leaving no one behind. The harder question is whether those commitments affect budgets, indicators, implementation decisions, and evaluation.
An analysis published in 2025 examined NAPs from 14 West African countries using an equity-focused framework. Most plans did not explicitly reference equity, none included equity-related indicators in their monitoring frameworks, and interventions such as hygiene promotion, public-awareness campaigns, and health-worker training were usually generic rather than adapted to marginalized populations. Although stakeholder engagement was often multisectoral, disadvantaged groups were seldom specifically included.8
Those findings cannot be generalized to every national AMR plan, but they highlight the difference between recognizing that inequity exists and building a system capable of acting on it.
The new WHO guidance makes that distinction explicit from its first recommendations. Countries are asked to incorporate equity into the AMR situation analysis used to develop or update a NAP and then carry equity-responsive actions into objectives, prioritized activities, targets, indicators, and budgets. The guidance also calls for the disaggregated data needed to determine whether those measures are reaching different populations as intended.
That is ultimately the document’s most consequential shift. An equity commitment written into a statement of principles may have little influence over implementation. An equity variable in surveillance, a funded activity in a budget, a target in a monitoring framework, or an identified access barrier in procurement creates something that can be acted upon and evaluated.
The same logic reaches clinical stewardship. The WHO calls for prescription audits, treatment guidelines, and antimicrobial-stewardship program documents to be reviewed for evidence that unconscious prescribing bias linked to social, economic, or other characteristics may reinforce inequity. The current evidence base does not establish how frequently such bias occurs across health systems or which populations are most affected. The importance of the recommendation is therefore as a mandate to measure prescribing inequity rather than as evidence of its prevalence.
Equity becomes operational when AMR programs can detect disparities, identify the mechanisms producing them, and determine whether interventions narrow or widen them.
How the Definition of Success Changes
If equity becomes a design and performance criterion, the questions used to evaluate AMR interventions also need to change.
A program designed to reduce inappropriate antibiotic sales would still ask whether those sales declined, but it would also need to determine whether patients who require treatment retained a workable route to appropriate care. A surveillance program would still measure resistance trends, but it would also examine whether the populations contributing specimens reflect the populations affected by infection. Procurement systems would still monitor medicine availability, but they would also ask whether stockouts or shortages disproportionately compromise treatment for particular populations.
The same principle applies to diagnostic coverage and prescribing. Expanding laboratory capacity has limited equity value if some groups remain unable to reach or afford testing. A treatment guideline may be evidence based in its clinical content while still requiring evaluation of whether implementation produces systematic differences in who receives appropriate therapy.
The new guidance does not replace established AMR objectives with a separate equity agenda. It changes how those objectives are judged. Consumption, stewardship adherence, surveillance completeness, medicine availability, and policy implementation remain important, but aggregate performance can conceal substantial differences between populations.
The sustainable-access approach offers a useful clinical endpoint: the right antibiotic, delivered when needed, for an appropriate duration, and at an affordable price.3 Reaching that endpoint may require reducing use in some parts of a health system while expanding effective access in others.
Appropriate use is therefore not necessarily synonymous with less use everywhere. It requires enough information about who is receiving treatment, who is not, and why to distinguish excess from unmet need.
A Better Understanding of Stewardship Success
Equity is not new to the AMR conversation. The WHO has previously addressed gender inequalities in AMR NAPs, and its 2023 people-centred approach already placed equitable access to health services within a package covering prevention, essential services, diagnosis, and appropriate treatment.4
What the 2026 guidance adds is a more operational proposition. Equity appears not only as a principle but in recommendations about surveillance variables, diagnostic access, insurance and health benefits, medicine procurement, supply-chain continuity, prescribing audits, treatment guidance, regulatory policy, targets, indicators, and budgets.
That matters because AMR policy has to solve two failures at the same time. Antibiotics are used when they should not be, accelerating the selection pressure that contributes to resistance. Elsewhere, or even within the same health systems, patients who need effective treatment cannot reliably obtain it.
A stewardship program capable of correcting only the first failure remains incomplete. The more meaningful measure of success is whether a health system can prevent unnecessary antimicrobial use while reliably delivering effective treatment to every patient who needs it.
