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proportions mask inappropriate prescribing observed in MSF prescription audits across hospital and outpatient settings [unpublished data].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 suppo