Addressing Gender Inequalities in National Action Plans on Antimicrobial Resistance: Guidance to Complement the People-centred Approach

"National action plans on antimicrobial resistance (AMR) often overlook the critical intersection of gender, despite evidence that exposure and susceptibility to infection, health-seeking behaviours, as well as antimicrobial prescribing and use patterns are all influenced by gender."

This document, published by the World Health Organization (WHO), provides a summary of the evidence on antimicrobial resistance (AMR) and gender and proposes 20 recommendations for policymakers to consider when developing, revising, implementing or monitoring their national action plans (NAPs) on AMR. Designed to complement WHO's people-centred core package of AMR interventions, the objective of this publication and its recommendations is to support countries in addressing AMR through a more comprehensive, people-centred, and gender-responsive approach.

WHO's people-centred approach to addressing AMR places people, and the challenges they face when seeking access to essential health services for the prevention, diagnosis, and treatment of (drug-resistant) infections, at the centre of the AMR response. The approach has four pillars and 13 interventions that are intended to guide policymakers in developing NAPs on AMR (see Related Summaries, below, for more information on WHO's people-centred core package of AMR interventions).

As explained in the document, a review of NAPs on AMR revealed that minimal attention was being given to gender considerations with 125 out of 145 publicly available NAPs not mentioning sex or gender. Yet, AMR is affected by gender inequalities, just as gender affects people's experiences of and access to other health-related services. "AMR is similarly affected by gender inequalities, where gender norms, roles and relations influence exposure and vulnerability to infection (e.g. through occupational and household roles and nutritional status), participation in infection prevention and health-seeking behaviours, access to health care, prescribing patterns and appropriate use of antimicrobials. This relationship is compounded by other intersectional factors that shape the identities of individuals based on social stratifiers such as age, ethnicity, religion, education, occupation, geography and migration status. Ensuring that policy-makers recognize the intersectional gender differences in the risk of infection, and in experiences and health outcomes, is crucial to tailor interventions that can more equitably and effectively mitigate the burden and spread of AMR, while helping to achieve the health- and equality-related Sustainable Development Goals (SDGs)."

Using the four pillars of the people-centred approach as a guiding framework, the document draws on expert opinion and a rapid synthesis of evidence to outline the 20 policy recommendations, as well as monitoring indicators, for countries to support the development and implementation of gender-responsive NAPs on AMR. Key findings from the evidence review, as highlighted in the report, reveal the following: 
 

• Lack of clean water and safe sanitation in the community and in health facilities puts women and girls at an increased risk of exposure to (drug-resistant) infections due to their menstrual hygiene needs and more frequent contact with the health system.
• Women face a heightened risk of contracting (drug-resistant) infections given their responsibility for household water provision and the fact that they represent over 70% of the global health workforce.
• Male-dominated professions, including animal husbandry, industrial farming and slaughterhouses, expose men to antibiotics and (drug-resistant) infections.
• Negative experiences with the health system and stigma can deter both men who have sex with men and women from seeking specialised care to diagnose and treat sexually transmitted and urinary tract infections.
• Perceptions of masculinity, men's role as primary income earners, and occupational time constraints can contribute to men delaying seeking diagnosis and treatment for infections - in particular, for multidrug-resistant tuberculosis.
• Limited financial and decision-making autonomy as well as numerous household responsibilities can impede women from seeking timely health care, especially when additional travel, out-of-pocket expenditure, and childcare costs are involved. These factors can contribute to women purchasing antibiotics from informal markets.
• Overall, women are 27% more likely to receive antibiotics throughout their lifetime than men.
• Female doctors tend to adopt a more conservative wait-and-see approach to prescribing antibiotics compared to their male counterparts.
• Antimicrobial stewardship recommendations made by male pharmacists are more likely to be accepted than those made by their female colleagues.
• Disaggregated data are lacking on AMR surveillance and antimicrobial use to identify gender disparities in the burden of (drug-resistant) infections and in access to quality-assured treatment that can inform tailored AMR interventions.

The recommendations, which include proposed implementation timeframes, are as follows: 

Overarching
1. Capture and disaggregate data on AMR and surveillance of antimicrobial use and other relevant data by, at minimum, sex and age and, where feasible, other social stratifiers (short term).
2. Review existing national plans or strategies in the health sector or other relevant areas, and incorporate policies or actions that strive for gender equality into the national action plan on AMR (short term).
3. Promote research to strengthen the evidence base on the intersections between gender and AMR (medium term).

Effective governance, awareness, and education
4. Promote equal participation of women, men and other vulnerable groups and/or groups facing discrimination in the multisectoral AMR coordination mechanism and technical working groups (short term).
5. Include representation from gender experts in the multisectoral AMR coordination mechanism (short term).
6. Use context-specific messages, language, and images in AMR awareness and education materials that actively address harmful gender norms and promote gender equality (short term).
7. Use different and tailored approaches to raise awareness on AMR among vulnerable groups and/or groups facing discrimination (short term).
8. Strengthen the knowledge of health workers at all levels of health care on gender inequalities in the prevention, diagnosis and treatment of (drug-resistant) infections (medium term).

Strategic information through surveillance and research
9. Report on patients' sex, age and, where feasible, other social stratifiers as part of routine surveillance systems on AMR and antimicrobial use (short term).
10. Analyse, report, and act upon the key gender-related inequalities identified from sex-disaggregated surveillance data on AMR and antimicrobial use (medium term). 
11. Invest in new diagnostics for infections that disproportionally affect women, such as (drug-resistant) urinary tract infections (long term).

Prevention
12. Improve water, sanitation, and hygiene (WASH) and waste management infrastructure in health facilities and community settings to ensure infrastructure is available, accessible, and safe for all genders and that it does not perpetuate stigma and discrimination (medium term).
13. Identify and address gender inequalities in the risk of exposure to (drug-resistant) infections among healthcare workers and in community settings (medium term).  

Access to essential health services
14. Deliver culturally sensitive and gender-responsive health services for the prevention, diagnosis, and treatment of (drug-resistant) infections (medium term).
15. Ensure health insurance and/or health benefit packages cover access to health services, diagnostics, and antimicrobials for the treatment of (drug-resistant) infections without leaving behind vulnerable populations (medium term).
16. Identify and address gender inequalities in access to quality-assured medicines including antimicrobials, focusing on specific groups of women or men who might be at a higher risk of purchasing substandard or falsified antimicrobials (short term).
17. Update and implement standards on the forecasting and procurement of medicines, including antimicrobials, by undertaking an assessment of the local epidemiology of infections based on sex to ensure all relevant antimicrobials are included (medium term).

Timely, accurate diagnosis
18. Conduct retrospective reviews of diagnostic services for different (drug-resistant) infections to identify and address any gender inequalities (long term). 

Appropriate, quality-assured treatment
19. Apply a gender analysis in regular retrospective prescription audits to identify unconscious gender biases or inequalities in prescribing practices (medium term).
20. Conduct a gender assessment of the unintended effect of policies or regulations that aim to reduce over-the-counter sale of antimicrobials on access to essential antimicrobials (medium term).

Click here for the 3-page executive summary in PDF format.