We've been aware of the threat of antibiotic resistance since the first use of Penicillin. Fleming foresaw a danger, during his 1945 Nobel Prize acceptance speech, he warned that misusing penicillin would inevitably fuel bacterial resistance. Time proved him right. By 1976, the World Health Organization (WHO) convened its first meeting on antibiotic resistance to address the alarming rise in drug-resistant infections. Since then, countries worldwide have struggled to balance regulation with access to ensure these life-saving medications reach those who need them the most without accelerating antibiotic resistance.

Developing new antibiotics is crucial, but they must be affordable and accessible where they are needed. Currently, low-and middle-income countries (LMICs) bear a disproportionate communicable disease burden, with mortality rates and years of life lost ten times higher than those in upper-middle-income countries and high-income countries1,2.Despite this higher disease burden, these countries consume fewer antibiotics, creating a mismatch between medical need and access 3. High infection rates, coupled with inadequate healthcare infrastructure, limited diagnostic capabilities, and economic constraints, drive antibiotic consumption in these countries.

Access to effective antibiotics offers multiple benefits. It helps LMICs manage their infectious disease burden, reduce dependence on counterfeit medications, strengthen primary healthcare systems by enabling the treatment of common infections, and ultimately prevent infections from becoming antibiotic resistant. Innovative distribution approaches have shown promise in reaching vulnerable populations. Uganda's Village Health Team program exemplifies this where specially trained Community Health Workers support treatment for children suffering from life-threatening conditions like diarrhoea and pneumonia while delivering quality antibiotics to communities where traditional healthcare systems fail to reach 4.

LMICs typically allocate minimal funding to healthcare, forcing patients to bear devastating out-of-pocket expenses and catastrophic health expenditures. Ensuring proper access to affordable antibiotics is therefore essential, not only for addressing immediate health needs but also for closing the global health inequity gap. Improved antibiotic access represents a crucial step toward achieving Universal Health Coverage, enabling vulnerable populations to access effective, quality-assured antibiotics where and when they need them without financial hardship. Recognizing this urgent priority, world leaders at the recent United Nations General Assembly High-Level Meeting on AMR committed to " leaving no one behind and reaching the furthest behind first to ensure equitable and timely access to quality essential health-care services including antimicrobials"5. This declaration reflects a growing international consensus that antibiotic access in resource-limited settings must be addressed as both a public health imperative and a matter of global health justice.

Enhancing antibiotic access in LMICs presents significant challenges alongside its benefits. The widespread use of antibiotics in these regions exemplifies what economists call a "tragedy of the commons", perhaps humanity’s most dangerous shared resource dilemma, where individuals, acting in their perceived self-interest, collectively deplete a shared limited resource that benefits everyone6. Though no individual wants antibiotics to lose their effectiveness, the collective behaviour of unrestricted usage accelerates antibiotic resistance. Unregulated access to AWaRe antibiotics compromises the integrity of pharmaceutical supply chains, allowing counterfeit and substandard products to proliferate. This problem becomes particularly severe in LMICs experiencing severe economic instability, where medicine inflation rates have reached as high as 1100% in some cases7. 

Most AMR National Action Plans developed by LMICs acknowledge unregulated antibiotic access as a critical challenge, with comprehensive strategies outlined to regulate informal drug markets. However, the effective implementation and enforcement of these policies leave much to be seen. Given the delicate balance between ensuring necessary access and preventing misuse in resource-limited settings, a balanced approach is essential, one that promotes appropriate antibiotic availability while implementing practical regulatory policies. Although regulatory agencies exist in most LMICs with mandates to monitor informal drug markets and combat counterfeiting, these institutions often lack sufficient resources, coordination, and political support to function effectively. 

The urgency to address this "tragedy of the commons" cannot be overstated. The world needs decisive action not merely because antibiotic misuse harms individuals through organ toxicity or microbiome disruption, but because AMR is a pandemic upon us with disproportionately severe consequences for LMICs. As Laxminarayan et al., (2016), rightly noted, the challenge for LMICs is not one of reducing antibiotic use but rather ensuring access to appropriate antibiotics while simultaneously implementing stewardship measures 8. Without access, we cannot even begin to address resistance, patients simply die from treatable infections before resistance becomes the issue.  

References

1. Pagès, F., Maison, D. and Faulde, M. Current control strategies for infectious diseases in low-income countries. In: Ecology and Evolution of Infectious Diseases: Pathogen control and public health management in low-income countries. Edited by Benjamin; 2018.
2. Klein, EY., Milkowska-Shibata, M., Tseng, KK., Sharland, M., Gandra, S., Pulcini, C., Laxminarayan, R. Assessment of WHO antibiotic consumption and access targets in 76 countries, 2000-15: an analysis of pharmaceutical sales data. Lancet Infect Dis. 2021. doi: 10.1016/S1473-3099(20)30332-7. Epub 2020 Jul 24. PMID: 32717205.
3. Browne, A., Chipeta, M., Haines-Woodhouse, G. Global Antibiotic Consumption and Usage in Humans, 2000-18: A Spatial Modelling Study. Lancet Planet Health.2021 Nov 12;5(12):e893–e904. DOI: 10.1016/S2542-5196(21)00280-1.
4. Musoke D, Gonza J, Ndejjo R, Ottosson A, Ekirapa-Kiracho E. Uganda’s Village Health Teams Program. CHW Central [Internet]. Available from: https://chwcentral.org/ugandas-village-health-teams-program/. Cited 12 March 2025.
5. United Nations. Political Declaration of the High-level Meeting on Antimicrobial Resistance [Internet]. 2024 [Cited 11 March 2025]. Available from: https://www.un.org/pga/wp-content/uploads/sites/108/2024/09/FINAL-Text-AMR-to-PGA.pdf.  
6. World Bank. Drug-Resistant Infections. A Threat to Our Economic Future [Internet]. 2022 [Cited 11 March 2025]. Available from: https://documents1.worldbank.org/curated/en/455311493396671601/pdf/executive-summary.pdf.
7. Bokinni, Y. Antibiotic costs rise 1100% as big pharma exits Nigeria. BMJ. 2024. https://doi.org/10.1136/bmj.q328.
8. Laxminarayan, R., Matsoso, P., Pant, S., et al. Access to Effective Antimicrobials: A Worldwide Challenge. The Lancet. 2016. Vol 387; p168-175.