Reimagining Antimicrobial Resistance (AMR) financing for Africa amid global funding crises

By guest contributors Sherin Paul and Mirfin Mpundu

Antimicrobial Resistance (AMR), a silent pandemic, widens health inequalities in Africa by disproportionately affecting the most vulnerable populations. With an estimated 255,000 attributable deaths in 2019, it is one of Africa’s leading cause of mortality. Beyond misuse and overuse of antimicrobials, the key drivers of AMR, Africa faces other unique challenges. These include inadequate Infection Prevention and Control (IPC) measures, poor Water, Sanitation and Hygiene (WASH), suboptimal childhood vaccination rates coupled with inadequate health systems and lack of sustainable access to essential and novel antimicrobials and diagnostics. Besides worsening AMR, these factors lead to inappropriate treatment of diseases, and treatment gaps while addressing resistant cases, pushing up mortality rates. Without appropriate, timely interventions, AMR is projected to result in millions of deaths in Africa and cause more than 5% fall in Gross Domestic Product (GDP) of low-income countries, by 2050. AMR National Action Plans (NAP) have been developed as strategic documents to address the issue. However, implementation has been impeded by funding gaps as most NAPs are not funded. This is further complicated by a strained health financing landscape with drastic reduction in Overseas Development Assistance (ODA) by traditional donor countries.

AMR financing challenges in Africa

AMR is not often perceived as a development issue due to its technical framing and general lack of awareness, resulting in poor domestic funding for interventions. A study on transparency and accountability of AMR NAPs from 15 African countries showed, only one country has made some funding allocation. African countries depend heavily on the global north for the management of maternal and child health, control of infectious diseases and immunization. With the drastic external funding cuts in 2025, implementation of these programs will be affected. Further, an external debt of over $650 billion by the region is forcing nearly 40% of African countries to spend more on debt servicing than healthcare. As focus will shift to these key issues innovative approaches are needed to prioritize AMR.

Innovative financing strategies in AMR

Faced with these challenges, Africa needs to adopt innovative financing mechanisms to bridge the gaps.

Earmarked financing

In earmarked financing, different tiers of government – federal, local or both – earmark an existing or a new revenue stream for a specific cause, in this scenario it can be AMR.

AMR specific taxes and levies: At present, no African country has AMR specific taxes or any fiscal policy in place to tax commercial activities in non-human sectors such as overuse of pesticides that can cause microbial resistance. A few countries have introduced environmental taxes (e.g: carbon emissions levy in South Africa and tax on plastic bags in Senegal) which could be extended to AMR, or taxes imposed on pharmaceutical or health care facility effluents. Similarly the air ticket solidarity levy system in South Korea where approximately $1 is charged on every international flight from the country which is added to the Global Disease Eradication Fund (GDEF) – is  another example that can be adopted for AMR initiatives.

Sin tax or pro health tax for AMR: It has been found that higher the tax-to-GDP ratio, the better the country’s ability to spend on public development projects. One of the ways to achieve this is by raising excise taxes on tobacco, alcohol and sugary beverages. A 50% increase in excise taxes on these items will increase the tax-to-GDP ratio by 0.7%, allowing to earmark the additional income for AMR initiatives..

Policy changes on managing finances

Budgetary allocations: One of the key challenges for specific allocation, is the multi sectoral nature of AMR requiring co-ordination among ministries. A whole-of government budgeting approach can be used, where the budget prioritizes programs aligned to national goals and supplemented by periodic spending reviews. This will foster inter-ministerial collaboration, reduce inefficiencies, and improve outcomes. The performance-based budgeting by many African nations and results oriented outcome-based budgeting are some of the strategies. To prioritize AMR in this approach, lobbying is required to bring it high on national goals.

Delegated financing for AMR: The concerned ministries within a country can be lobbied to start an independent statutory organisation, similar to Joint Programme for AIDS support in Uganda, to receive funds from all sectors including private, philanthropic and international organizations, and developing agencies. If the efforts are too cumbersome, the agencies or ministries could create joint account reserved for AMR initiatives.

Development impact bonds (DIBs): Outcome-based financing instruments like DIBs have been successfully tried in poverty-related programs in Kenya and Uganda. In DIBs, private investors provide money upfront, who are compensated by outcome payers based on specific results. In AMR financing, DIBs can support investment-heavy areas like diagnostic capacity strengthening or IPC infrastructure in healthcare facilities. However, countries must be cautious of the pitfalls perceived with vaccine bonds and should put in appropriate protective measures in place.

Regional financing mechanisms

The African Union, with its tremendous convening power, can explore regional financing mechanisms to support its member nations.

Debt swap for AMR programs: In Africa, 768 million people live in countries where  interest spending exceeds education or health spending. South Africa, the largest economy in Africa, is having a debt equivalent to three quarters of its entire GDP and is rising. This debt distress can be used favorably to fund AMR interventions and action plans using the debt for development swap concept. AMR should be on the table when any conversation on debt restructuring is taking place in any African nation.

African union pooled AMR fund: African Union can set up a pooled AMR fund like the AMR Multi-Partner Trust Fund. However, it should not fall into the trap of foreign aid dependence but should be made with the commitment and contributions from the member nations, development banks, regional economic communities and health agencies. Loans at concessional rates or performance-linked grants for AMR can come from such a fund.

Conclusion

The heavy reliance on external sources exposes the continent’s healthcare to the fluctuations and the interests of the international donors. This has led to non-alignment with local priorities, fragmented efforts, and lack of sustainable domestic financing mechanisms. To strengthen the AMR response, Africa should adopt locally driven strategies, reduce dependence on external funding and create a more resilient financing mechanism.

About Authors

Dr Sherin Paul is a Monitoring and Evaluation Consultant for ReAct Africa and public health physician based in Geneva, Switzerland, with interests and expertise in impact evaluation, ageing policy, palliative medicine and epidemiology. She previously worked as a Professor of Community Medicine and a Consultant, Unit of Pain and Palliative Care at Pushpagiri Institute of Medical Sciences and Research Centre (PIMS&RC), India and as a faculty member of Community Health at the department of RUHSA (Rural Unit for Health and Social Affairs) of Christian Medical College (CMC), Vellore, India. She is currently an Adjunct Faculty at PIMS&RC and College of Public Health, Kent State University, Ohio. LinkedIn profile: www.linkedin.com/in/sherin-susan-paul-n-47a25bba

Prof Mirfin Mpundu is a global health leader with over 25 years of experience in antimicrobial resistance (AMR), and public health policy. Being the Co-founder and Executive Director of ReAct Africa network, he has led transformative initiatives, including AMR policy frameworks for USAID, securing multi-million-dollar funding for health programs in low- and middle-income countries. A passionate advocate for One Health, Prof Mirfin bridges research and policy to strengthen sustainable public health systems addressing infectious diseases, pharmaceutical access, and biosecurity.

An engaging speaker and published author in renowned journals like The Lancet Global Health, Prof Mirfin has presented at the United Nations, World Health Assembly, and AMR Global Summits. He excels in coalition building, uniting governments, academia, nonprofits, and global organizations to drive impactful change. Prof Mirfin is a consultant for the World Bank providing expertise on AMR economic modelling and global public health interventions.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.