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Impact story

Helping the UK Government tackle the global antimicrobial emergency

Our long-term evaluation of the UK Government’s flagship Fleming Fund has informed strategic shifts relating to data use and gender equity to reduce disease, illness and death from drug resistance.


Antimicrobial resistance (AMR) happens when microorganisms such as bacteria, fungi, viruses and parasites evolve and stop responding, or respond less, to treatment.

AMR is a global crisis that has the potential to reverse a century of progress in Public Health. Unless urgent action is taken, drug-resistant infections could kill 10 million people across the world every year by 2050.

Low- and middle-income countries are expected to bear the heaviest consequences of the spread of AMR with up to 90% of all deaths related to AMR anticipated in Africa and Asia.

The Fleming Fund: using evidence for action

Tackling and mitigating the growing threat of AMR requires reliable evidence on the scale of the problem and trends in resistance. Enter the Fleming Fund – a major UK aid programme supporting up to 25 countries across Africa and Asia to tackle antimicrobial resistance. The Fleming Fund seeks to bring evidence and people together to encourage action against drug resistance for a healthier world by supporting low- and middle-income countries to generate, share and use AMR data.

Long-term collaboration for more effective programming

Itad was commissioned as the Fleming Fund’s independent evaluator soon after it was established in 2015.

From 2016-23, we evaluated the Fund’s portfolio of country and regional grants, global projects and fellowship schemes – all of which sought to strengthen AMR surveillance systems. We provided adaptive management support for Mott MacDonald (the Fund’s managing agent) enabling ongoing learning and programme improvement. And we provided an evaluation of the Global Burden of Disease study.

The purpose of our support was both formative and summative: From 2016-20, our evaluation focused on generating real-time learning to enhance the quality of implementation. Then in 2021, the balance shifted to provide a summative assessment of how far the Fund has and is likely to contribute to its intended outcomes and impact.

Throughout, we worked closely with the UK Government Department of Health and Social Care (the Fund manager) and Mott MacDonald to ensure our work was both useful and used.

In August 2023, the UK Government announced that the Fleming Fund would receive £210m to extend its work into a second phase. This represented the largest ever investment in global AMR surveillance by any country.

Such was the success of our long-term collaboration, Itad was recommissioned to be the Fleming Fund’s evaluation partner for phase II.

Shaping the next phase of the Fleming Fund

Our evaluation of phase I of the Fleming Fund was well received by the Fund manager who welcomed the evaluation recommendations and praised the evaluation’s methodological rigour.

In their Management Response to our 2023 Summative Report, the Fund manager said:

The Department of Health and Social Care accept the full range of strategic, design and implementation level findings. The lessons from these findings have already been incorporated into the design of phase II of the programme.”

In developing phase II, the Department of Health and Social Care (DHSC) made a number of key strategic shifts to maximise the effectiveness and value of the Funds’ investments.  Itad made a direct contribution to a number of these shifts, including a renewed focus on data use and adding gender and equity as a new underpinning principle.

AMR is a global crisis that has the potential to reverse a century of progress in Public Health.

Renewed focus on data use for action

The Fleming Fund supports low- and middle-income countries to generate, share and use data to improve antimicrobial use (for example, for clinicians prescribing antibiotics or decision-makers creating better policy) and encourage investment in AMR laboratories, workforce and systems.

As phase I of the Fleming Fund drew to a close over 2021-22, DHSC considered how to build lessons into an improved phase II from 2023. A core reflection was that the Fund’s successful stimulus of surveillance data production in phase I could and should be better linked to action on AMR in order to capitalise on and demonstrate value for phase II investments. DHSC set ‘data use’ as a major strategic shift in its phase II business case, and has since been working to implement this.

The Itad evaluation team worked across a range of processes over 2021-22 to encourage and support this impact. There was a pivotal moment in 2021 when one of our milestone evaluation reports highlighted that the Fund was not so far supporting data use effectively and there was potential to adapt to focus more on influencing policy and behaviour change. This was then elaborated and further evidenced for the phase I Summative Report, for example through formal assessment of data use issues country by country and through collecting local impact vignettes (or stories of change) to address thinking and adaptation towards phase II data use initiatives.

Alongside our work to produce these milestone reports and evidence, the Itad team supported the shift to data use in a range of ways. For example, we consulted and advised on an updated theory of change; we helped DHSC and delivery partners with their business case development; and we collaborated on a series of ‘strategic shift’ workshops over 2022. The workshops culminated in a session on data use at the Development Partners Event in Ghana in September 2022 communicating and securing participative commitment to the relevant changes in phase II.

Putting gender and equity at the heart of the Fleming Fund

Our evaluation from 2016-23 contributed to the addition of gender and equity as a new core principle to underpin and enhance all programme activities in phase II.

AMR is often seen as an issue of ‘bugs and drugs’. However, it is increasingly recognised that there are major differences in the impact of AMR across diverse groups of people due to factors such as sex, gender, age, and socio-economic context. Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance.

Recognising this, DHSC is exploring ways to integrate the gender and equity principle the following domains: in human resources and ways of working; at the programmatic level; in capacity strengthening activities; in AMR surveillance systems; and in the analysis and use of preceding data.

Itad supported DHSC in its decision to add gender and equity as a Fleming Fund principle for phase II through a range of knowledge generation and learning activities.

In 2021-22 we facilitated a series of reflective workshops on gender and AMR in human and animal health. We also conducted a scoping review on the burden and drivers of AMR disaggregated by gender and other socio-economic characteristics. A discussion of this scoping review was subsequently published in the Journal of Health Policy and Planning.

The article’s authors, Juliette GautronGiada Tu ThanhDr Violet Barasa and Giovanna Voltolina, examined how sex and gender compounded by other axes of marginalisation ‘intersect’ to shape the experiences of individuals and groups in relation to AMR. Since being published in November 2023, the article ‘Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries’.  has been viewed more than 3000 times.

Itad also hosted a high profile online event to discuss key issues in addressing gender inequalities in AMR. Event speakers included members of the informal WHO expert working group on gender & AMR and Professor Dame Sally Davies, the first UK Special Envoy on Antimicrobial Resistance.

Building on this work, the World Health Organisation conducted a follow-up evidence review in collaboration with the Global Strategy Lab, and convened an informal Expert Working Group on Gender and AMR (of which our evaluation Deputy Team Leader, Giada Tu Thanh, is an active member) to co-create evidence-based recommendations for countries on how to integrate a gender and equity lens in their AMR National Action Plans.

We are currently supporting DHSC as it prepares to raise awareness of the need to discuss gender inequality at the United Nations General Assembly meeting on antimicrobial resistance in September 2024.

Contributing to global efforts to address antimicrobial resistance

Through our work with the Fleming Fund we are proud to be contributing to global efforts to combat AMR. Our evaluation findings and recommendations are benefitting the Fleming Fund and the programmme delivery partners to work more effectively and achieve a greater return on the Fund’s investments.

Fleming Fund country government partners are benefiting because improved data use and greater equity imply greater adaptation to country context and partner government priorities. This in turn benefits the public in the 23 Fleming Fund countries by significantly strengthening local and national efforts to combat AMR, and by increasing awareness of how AMR response can be made more equitable and effective by addressing the socio-determinants of health and health-seeking behaviours, especially for most disadvantaged genders and groups.

Ultimately we hope that our combined efforts will benefit everyone in the world by undermining the deadly threat of AMR over the longer term.