Beyond global AMR targets: toward equitable and actionable implementation targets in humanitarian settings

Renewed commitment to address AMR through the 2026 Global Action Plan (GAP) recognized persistent gaps in implementation, financing, and accountability (1,2). While the 2024 United Nations High-Level Meeting established important 2030 targets-including reducing AMRassociated mortality, increasing Access antibiotic consumption, and strengthening testing capacity-these alone are insufficient to translate global ambition into implementation. Intermediate programmatic targets are needed to define feasible pathways and facilitate progress, as emphasized in the updated GAP (1,2). Laxminarayan and colleagues examined their coherence and achievability, Shafaque et al. called for local commitments and measurable targets embedded in national action plans (NAPs), and Essack advocated measuring progress against country-specific baselines (3)(4)(5). Building on these policy perspectives, we examine the targets through an equity and humanitarian lens. As the updated 2026 AMR GAP emphasizes national and regional evaluation frameworks, this is a timely opportunity to ensure that these frameworks are equitable and actionable. Drawing on Medecins Sans Frontieres' (MSF) operational experience, we consider how UN 2030 targets may perform across contexts and propose complementary programmatic targets measuring the enabling conditions needed to achieve them.From a humanitarian perspective, antibiotic targets must capture appropriate use and access in alignment with the disease burden in each context. We agree with Laxminarayan and colleagues that the 70% Access proportion is insufficient to capture prescribing appropriateness. First, the figure can mask inappropriate use in settings meeting the target. For example, at MSF facilities from 2022-2024, Access antibiotics accounted for approximately 75% of overall antibiotic use and 90% of outpatient use. Yet, these apparently favorable proportions mask inappropriate prescribing observed in MSF prescription audits across hospital and outpatient settings [unpublished data]. These figures provide one illustrative example within the substantial variation in Access proportions reported across countries and settings in WHO GLASS antibiotic-use data. (6) Second, the AWaRe global target does not consider the local epidemiology. A recent study estimating optimal antibiotic use proportions based on clinical infection need in each country showed that for low-income countries the AWaRe target should be around 66%, much less than the 89% estimated for high-income countries (7). Finally, the AWaRe target is non-responsive to the supply realities. In settings where essential antibiotics are frequently unavailable, a high Access proportion may reflect restricted treatment options rather than effective stewardship. According to MSF unpublished AMR data from 2025, multidrug-resistant infections were identified in 60% of infected trauma patients across seven MSF hospitals in conflict-affected settings, and in 25%-80% of pediatric and neonatal patients across ten countries. While these microbiological testing data may not be generalizable, as they have been derived primarily from patients with severe infections under specific admission and testing criteria, they nonetheless illustrate the substantial burden of resistant infections encountered in humanitarian clinical settings, consistent with the high resistant rates among priority pathogens reported by WHO GLASS surveillance. (8) These contexts are where effective antibiotics are most needed yet least reliably available. For example, in Gaza in 2025, Access antibiotics were available on average only 58% of the time, and Watch antibiotics 40% of the time, across 14 public and private facilities (9). Similar constraints are seen in Mozambique, Afghanistan, and Sierra Leone, where access to essential antibiotics is compromised on average 40% of the time (10). We therefore support complementary indicators, including a 20% improvement in prescribing appropriateness, antibiotic use targets matching local epidemiology, and reliable availability of essential antibiotics aligned with SDG 3.b.3 (11) We also share the concern about verifying AMR mortality targets in humanitarian settings. AMR-related deaths remain difficult to estimate even in high-resource settings, with limited global guidance for standardized reporting. In humanitarian settings, limited microbiology testing, lack of clinical-laboratory linkage, and high prevalence of underlying vulnerabilities underestimate the true burden of AMR. Patients affected by malnutrition, HIV, and other vulnerabilities independently increase infection and mortality risks, further distorting estimates of AMR's true contribution (12,13). Weak microbiology capacity adds to this: MSF assessments of microbiology laboratories in over 30 projects have identified recurring quality gaps, including weak quality-control systems, expired reagents, absent standard reference strains, misapplication of quality-control rules, non-functional autoclaves, shortages of trained personnel, and adherence to EUCAST or CLSI guidance (14). Beyond laboratory quality, national AMR surveillance systems where they exist, frequently rely on a few sentinel laboratories concentrated in capital cities, limiting their geographical and clinical representativeness (10). The HIV response showed the value of combining an outcome ambition with measurable milestones. Alongside the goal of ending AIDS, the 90-90-90 target drove implementation and improved detection capacity, treatment, and viral suppression (15). Although the HIV target analogy has important limitations in this context, as HIV focuses on a single pathogen, a relatively well-defined population denominator, and standardized testing pathways, the same principle applies to AMR. AMR similarly requires intermediate actionable targets that address the systems needed to measure and reduce mortality including improved access to quality diagnostic microbiology. Therefore, we support MAAP's proposed target that 50% of laboratory capacity meet AMR quality standards and be accessible to 80% of the population (16).Humanitarian crises, including armed conflict, disasters and large-scale displacements, require an additional layer of AMR preparedness. Crises such as conflict can rapidly disrupt antibiotic supply chains, laboratory networks, infection prevention and control (IPC), water and sanitation infrastructure, surveillance systems, and referral pathways as seen in Ukraine and Gaza (17). To ensure global progress on AMR, AMR considerations should be incorporated into emergency preparedness, and their integration monitored through a specific indicator, as reinforced by WHO in a policy brief and guidance (18,19). There are useful precedents for integrating needs that were not historically considered central to immediate life-and limbsaving emergency response. Mental health and psychosocial support, for example, has progressively become embedded across emergency planning, preparedness, and response (20). AMR could follow a similar trajectory and become an integral component of national emergency preparedness and response plans. In practice, this could include incorporating AMR-related risks into emergency assessments; defining a minimum set of IPC, diagnostic, and treatment capacities adapted to the type of care delivered and local resistance epidemiology; and pre-positioning of essential supplies. As cholera kits are maintained for rapid outbreak response and surgical kits for trauma care, emergency preparedness could include AMR-relevant packages with adequate stocks of priority antibiotics, essential diagnostic capacity and IPC supplies and equipment that can be rapidly deployed or adapted when routine systems are disrupted. Existing work on minimum surgical requirements in conflict settings, including that of the ICRC, could provide a useful model for such minimum preparedness packages (21). Preparedness should also include contingency plans specifying how IPC practices, diagnostic testing, and treatment protocols can be adapted when infrastructure is damaged or supplies are disrupted. Existing guidance provides useful examples of this type of adaptation, including the ICRC's Antibiotic Protocol for Weapon Wounded and its Sterilization Guidelines for low-resource settings (22,23). Humanitarian actors, ministries of health and normative agencies should jointly define these minimum requirements and incorporate them into NAPs, national emergency preparedness plans, and humanitarian response frameworks.Amid shrinking fiscal space (24), broad targets that are difficult to measure or drive equitable action are likely to be the slowest to advance and risk being inadvertently deprioritized in settings facing the greatest AMR burden. Global outcome targets should therefore be complemented by context-adapted indicators of prescribing appropriateness, reliable access to essential antibiotics, quality-assured microbiology and AMR preparedness in humanitarian crises. International political mechanisms and declarations, such as those emerging from the 5th global high-level ministerial conference on AMR in Abuja, Nigeria, can help establish a global commitment to advance responses on AMR in humanitarian settings, facilitated by regional-level targets, while countries are encouraged to integrate these targets into their national action plans on AMR. Embedding these targets within national and regional frameworks would preserve global ambition while making pathways to progress more equitable, measurable and actionable.