Antimicrobial resistance (AMR) is one of the defining global health challenges of our time. When the UK Government established the Fleming Fund in 2015, an influential review had warned that, without action, drug-resistant infections could cause 10 million deaths a year by 2050 and result in up to US$100 trillion in cumulative economic losses.
The response was ambitious. Across two phases, the Fleming Fund supported
low- and middle-income countries to strengthen the laboratories, surveillance systems, workforce and institutions needed to understand and respond to drug resistance.
Itad was appointed as the Fund’s independent evaluation partner in 2016, beginning a ten-year partnership that evolved alongside the programme.
Building the foundations for a stronger AMR response
Many countries supported by the Fleming Fund began with significant gaps in the laboratories, skilled workforce, surveillance infrastructure and systems needed to produce and share reliable AMR data. Our evaluation found important progress, with 10 out of 20 countries reporting increases of 20% or more in core human-health laboratory functions between 2018 and 2020. The Fleming Fellowship Scheme was an important part of this effort, pairing fellows with mentors to build specialist AMR expertise and strengthen institutional capacity. Our learning on getting the most from fellowship schemes identifies what made this model work and what future programmes can learn from it.
By the end of the programme, we were also able to examine the Fund’s contribution at a much larger scale. Using World Health Organization data from 2019 to 2024, our researchers compared 22 Fleming Fund-supported countries with similar aid-eligible countries, providing new evidence about where the programme had accelerated progress.
From collecting data to using it
One of the clearest changes over the Fund’s lifetime was the shift from generating AMR data to putting it to use. Our Phase I evaluation found that, while countries’ capacity to produce surveillance data was improving, more was needed to ensure this evidence influenced policy, practice and behaviour. We brought these findings into analysis, learning and strategic discussions about the next phase.
Data use subsequently became a major strategic focus of Phase II.
In Malawi, data from supported surveillance sites informed national treatment guidance and was being used locally to support decisions about patient treatment.
In Nepal, improved access to surveillance data contributed to revisions to national antimicrobial treatment guidelines and wider policy and regulatory action.
And in Timor-Leste, reliable national AMR data informed updated antimicrobial guidelines reflecting national resistance patterns for the first time.
These stories show the progression from building surveillance systems to using the resulting evidence to improve decisions about antimicrobial use.
Evidence at the moments that mattered
The Fleming Fund changed significantly over its lifetime. Itad’s evaluation partnership spanned two programme phases, changes in the political and funding environment and the COVID-19 pandemic.
That continuity mattered. It gave our evaluators a deep understanding of the programme and the decisions facing the UK Department of Health and Social Care (DHSC) (the Fund Manager) and Mott MacDonald (the Fund’s Managing Agent). As priorities changed, the evaluation could adapt while retaining the independence needed to challenge assumptions.
Findings from Phase I were deliberately timed to inform the Phase II business case. DHSC subsequently accepted the full range of strategic, design and implementation findings, praised the evaluation’s methodological rigour, and confirmed that lessons had already been incorporated into Phase II.
Dr Milena von und zur Muhlen, Policy and Programme Manager for the Fleming Fund, UK Department of Health and Social Care said:
“Having a continuous contract is good value for a large, complex, long-term programme. Itad hasn’t just delivered an evaluation, it’s been a strategic thinking partner.”
For Itad, being a “strategic thinking partner” did not mean stepping into programme management. Maintaining clear boundaries allowed us to bring independent evidence, challenge and learning to the table while DHSC retained decision-making and accountability. Our reflections on the value of long-term evaluation relationships explore what the partnership taught us about continuity, trust and independence.
Jon Cooper, Fleming Fund Evaluation Team Director, Itad, said:
“Working closely with an agency over a long period of time and seeing the programme adapt in response to your findings is really fulfilling for an evaluator.”
Putting gender and equity on the AMR agenda
The evaluation also helped broaden thinking about who experiences AMR and why. people’s exposure to drug-resistant infections, access to healthcare and use of antimicrobials are shaped not only by health systems, but by gender and other inequalities.
In 2021–22, we facilitated reflective workshops on gender and AMR in human and animal health and conducted research into how gender and other forms of inequality intersect to shape people’s experiences of AMR. This work contributed to gender and equity becoming an underpinning principle of Phase II of the Fleming Fund.
Our research also helped take the conversation beyond the programme. It informed a peer-reviewed article on gender, intersectionality and AMR in low- and middle-income countries, and an Itad event brought together international experts, including members of the WHO expert working group on gender and AMR and Professor Dame Sally Davies.
Building on this work, the World Health Organization undertook a follow-up evidence review and convened an expert working group to develop evidence-based recommendations for integrating gender and equity into countries’ AMR National Action Plans. Itad’s Deputy Evaluation Team Leader, Giada Tu Thanh, was invited to join the group.
Lessons for future investment in AMR
Over ten years, the evaluation has generated a substantial body of evidence about what it takes to build effective and sustainable AMR surveillance systems. Our forthcoming article in Clinical Infectious Diseases brings together key findings from a decade of research, drawing out lessons for future investment in AMR surveillance and the wider global response to drug resistance.
Building technical capacity matters. Laboratories need equipment, surveillance systems need data and countries need people with the skills to make them work. But our learning on designing sustainable surveillance systems shows that sustaining these gains also requires domestic financing, institutional ownership, leadership and the ability to adapt to changing contexts.
Our final evaluation and learning work points to the importance of domestic financing, institutional ownership, leadership, cross-sector collaboration and the political and organisational systems needed to turn surveillance data into decisions.
The experience of the Fleming Fund also shows the value of sustained investment. Building national systems and relationships takes time. So does moving from producing better data to routinely using it to inform policy and clinical practice.
After a decade alongside one of the world’s largest investments in AMR surveillance, Itad’s final evaluation, learning briefs and journal articles Diseases leave a substantial body of evidence about what it takes to build stronger, more sustainable surveillance systems and turn better data into action.
If you are looking to strengthen the evidence, learning and impact of a complex global health programme, get in touch with our team to discuss how we can help.
