Published in Globalization & Health, the paper adds important evidence about what the Fleming Fund has achieved. The Fleming Fund is a major UK programme that has invested £475 million over the past decade across more than 20 low- and middle-income countries in Africa and Asia to strengthen their capacity for Antimicrobial Resistance (AMR) surveillance and response. Using WHO country indicator data, the paper shows the Fund has had a transformative effect on how beneficiary countries are responding to AMR. It also suggests that developing countries, especially in South-East Asia, have increasingly taken the lead in driving action on AMR.
The paper results from a collaboration between members of Itad’s independent evaluation team for the Fleming Fund. The team analysed WHO’s Tracking AMR Country Self-Assessment Survey (TrACSS) data from 2019 to 2024 to assess global progress in AMR surveillance governance and whether UK aid through the Fleming Fund has made a measurable difference. With global efforts to renew the Global Action Plan on AMR in 2026, and with the Fleming Fund itself concluding this year, these findings come at a pivotal moment.
Mobilising a serious response to the AMR threat
AMR is projected to contribute to 10 million deaths annually by 2050, with low- and middle-income countries (LMICs) bearing the heaviest burden. Surveillance that systematically tracks resistance patterns is the cornerstone of any response, but its effectiveness depends on governance: the policies, coordination mechanisms, and decision-making structures that turn data into action.
What TrACSS shows about Fleming Fund impact
TrACSS is an annual online questionnaire that allows countries to report their progress on AMR surveillance systems and governance. Countries self-assess across a series of indicators covering laboratories, data systems, One Health coordination and policy frameworks. Launched in 2017, it now gathers responses from more than 130 countries each year, providing a global snapshot of AMR surveillance capacity (though self-reported and evolving).
For this analysis, the Itad team focused on a subset of 15 surveillance‑related topics and compared changes in 22 Fleming Fund-supported countries with a matched group of other ODA‑eligible countries, using descriptive statistics and quasi‑experimental difference‑in‑differences methods. Key findings include:
- AMR surveillance governance has generally improved in LMICs, with the gap narrowing between these countries and high‑income countries.
- Clear global progress appeared in four indicators, largely linked to human and animal health surveillance and regulatory systems.
- Asian countries stood out for their exceptionally strong gains compared to other countries in the region.
- In terms of aid effectiveness, Fleming Fund recipient countries outperformed comparable ODA-eligible nations, reporting a 0.11 higher standardised change score for human health surveillance systems.
- Countries receiving Fleming Fund support were approximately 25% more likely to use animal health surveillance data for administrative decisions, suggesting that the programme is helping translate data into policy.
- There was a strong statistically significant association between Fleming Fund support and improved human health infection prevention and control (IPC) programmes. Duration of support was more closely linked to positive outcomes than the total volume of funding provided.
However, the Fund had limited impact in areas outside its direct scope, such as food surveillance, National Action Plan (NAP) progress and awareness‑raising. Overall, the evidence suggests the Fleming Fund has strengthened foundational systems and encouraged more routine use of surveillance data in decision‑making.
Why AMR surveillance governance still matters as Fleming Fund concludes
Fleming Fund investments have demonstrably strengthened laboratories, protocols and data flows. But TrACSS highlights governance as the “missing middle”: while systems improved, deeper elements such as routine data analysis, cross-sectoral sharing, and stewardship integration progressed more slowly. As phase II ends, this uneven trajectory underscores the importance of governance for long-term sustainability.
External funding can catalyse infrastructure, but domestic budget lines, One Health committees and accountability for data use ultimately determine whether systems endure. South-East Asia’s relative success hints at enabling factors such as political prioritisation, regional peer learning and more integrated NAP implementation.
For donors and governments, the takeaway is clear: in the next phase of global AMR action, governance needs to move from the periphery to the centre. This means shifting from siloed surveillance to data-to-decision pipelines, securing predictable financing and fostering cross-sectoral collaboration.
Itad’s role in the independent evaluation of the Fund
Since 2016, Itad has served as the Fleming Fund’s independent evaluation supplier, delivering real-time learning, strategic reviews and synthesis across Phases I and II. This TrACSS analysis exemplifies Itad’s commitment to innovation in evaluation, demonstrating how global indicators can be used in quasi-experimental analysis, which remains relatively rare in aid monitoring and evaluation, where country case studies often dominate. By leveraging global datasets like TrACSS, Itad aims to bridge the evidence gap on the effectiveness of major aid initiatives in LMICs.
See the full data/code in the Open Science Framework repository
Acknowledgements: The paper was developed with support from the UK Department of Health and Social Care, which funds the Fleming Fund and commissioned Itad as the independent evaluator. It also benefited from the Brunel Talent Marketplace, which enabled postgraduate students from UK higher education to contribute to early data collection and exploratory analysis, as well as from WHO colleagues whose early technical feedback helped refine the analysis.
