Functionality of antimicrobial stewardship program in Ethiopia and the associated performance and institutionalization gaps in health facilities

This study aimed to evaluate the functionality of antimicrobial stewardship (AMS) program and the factors influencing its performance in selected health facilities in Ethiopia through direct observation and verification of evidence related to antimicrobial consumption and key stewardship process measures, including prospective audit, AWaRe classification, microbiology laboratory services, and other essential AMS program components. Among 129 health facilities assessed, 122 (94.6%) started implementing an AMS program, but only 25 (19.4%) met the weighted criteria for AMS program functionality. AMS functionality was significantly higher in comprehensive specialized hospitals than in health centers (AOR: 9.54; 95% CI: 1.01–91.3) and in facilities with active senior leadership engagement in the AMS team (AOR: 3.09; 95% CI: 1.02–9.37). Respondents consistently identified the lack of structured institutionalization as a major barrier to effective AMS implementation. In summary, the findings revealed a substantial gap between starting an AMS program and running a functional one, with fewer than one‑fifth of the health facilities met AMS functionality standards. Integrating AMS into routine clinical practice and existing committee responsibilities could improve program functionality, particularly at the health center level. However, establishing dedicated AMS units and strengthening microbiology laboratory capacity are critical for improving AMS performance and optimizing patient care in hospitals. Not applicable.