A recent conversation with a colleague revealed a few inconvenient truths about our medical systems. Some of these truths hit harder for some countries than others. He shared how, while travelling to a Gulf State, he attempted to buy antibiotics for a relative who was a bit under the weather. They walked into a pharmacy, shared symptoms, named the drug that had worked before, and asked for it. ALSO READ: Antimicrobial resistance stands at 30 percent in Rwanda – officials The pharmacist looked at them and said, “no prescription. No drugs.” They tried five more pharmacies—same response. Eventually, they went to a hospital. The doctor listened, examined the patient, and asked questions. His diagnosis? Common flu. No antibiotics were needed. The system worked as intended. Now consider a different context. If this same situation were to play out in your country, particularly if you are from the Global South, would the outcome be any different? Would pharmacies consistently refuse to sell? Would antibiotics be denied without a prescription? Would diagnostics precede dispensing? ALSO READ: What you should know about antimicrobial resistance, an escalating global threat These questions sit at the heart of the global Antimicrobial Resistance (AMR) crisis. Over the past few months, I have been part of several national and continental conversations on AMR, including discussions around continental frameworks and country implementation plans. ALSO READ: RBC warns against drug misuse amid rising antimicrobial resistance Antimicrobial resistance happens when bacteria, viruses and other microbes change over time and no longer respond to the medicines – antimicrobials – that are meant to treat them. Simply put, infections become harder, and sometimes, impossible to treat. AMR is driven by everyday practices: the overuse and misuse of antimicrobials, patients not completing their prescribed treatment, the unnecessary use of antibiotics in farming to promote animal growth, poor hygiene and sanitation, weak infection control in hospitals and clinics, and limited access to proper laboratory tests that guide treatment decisions. One message has been consistent throughout: Africa does not lack policies, frameworks, or guidelines on antimicrobial use. The WHO Global Action Plan on AMR has been in place for nearly a decade. The African Union has strengthened its continental AMR framework, and African countries developed and implemented National Action Plans to control AMR. What we struggle with is action, implementation, regulation, and accountability, often driven by economic incentives that complicate stewardship. Antibiotics generate revenue. Pharmacies operate within competitive markets. Agricultural producers face pressure to maximize output. Healthcare providers work in under-resourced environments with limited diagnostic capacity. The result is a pattern characterized by access without control. It is the gap between policy and practice. Antibiotics are easily sold without a prescription, misused by patients, overused in farming, and poorly regulated across supply chains. Resistance develops. And it spreads from farms to food, from the environment to people, from people to hospitals, and across borders with ease. The consequences are measurable. In 2019, antimicrobial resistance directly caused an estimated 1.27 million deaths globally, with nearly 5 million deaths associated with drug-resistant infections. Sub-Saharan Africa carries the highest mortality burden. In Rwanda, while significant strides have been made in fixing public health systems, AMR remains a significant challenge. Analyses of national data suggest that thousands of deaths in the country each year are linked to antimicrobial resistance. Rwanda ranks among the countries with a high age-standardised mortality rate associated with resistant infections. Surveillance studies in Rwandan hospitals have documented rising resistance among common bloodstream pathogens, including Staphylococcus aureus, Klebsiella pneumoniae and E. coli, with high resistance to antibiotics frequently used to treat them. Information from Rwanda Biomedical Centre indicates that the age categories more affected by anti-microbial resistance in the country are those aged 55 to 64, followed by 15 to 24. High resistance has been reported among common bacteria, such as E. coli and Klebsiella pneumoniae, to widely used antibiotics, such as ceftriaxone. Yet in many settings, these same medicines can still be accessed with limited oversight, sometimes in the absence of both prescription and diagnosis. And herein lies the paradox of access to care in the Global South. Even where regulation is tightened, and prescribers adhere to the set guidelines, many populations struggle to access quality, first-line antibiotics. Supply shortages, cost barriers, and weak manufacturing capacity push patients toward substandard or poor-quality medicines. Both realities fuel antimicrobial resistance. So, if policies exist, if guidelines are written, and frameworks are approved, why is access still uncontrolled? Why does implementation lag behind commitment? And more importantly, who is accountable for changing this status quo? AMR is often framed as a scientific problem requiring new drugs and better diagnostics. These are essential. But increasingly, AMR reveals itself as a governance challenge. Where policies are not implemented, resistance will continue to thrive. Implementation requires more than documentation. It requires consistent enforcement, incentives that prioritize responsible use over sales, investment in diagnostics, and regulatory systems that function in practice, not just on paper. Responsibility sits with all of us. It sits with regulators who must enforce, with healthcare systems that must prioritise diagnostics, with professional bodies that must uphold standards, with agricultural sectors that must ensure responsible antimicrobial use, and with policymakers who must ensure that access to quality first-line antibiotics is both affordable and regulated. Until access is matched with control, enforcement, and shared accountability, antimicrobial resistance will continue to expose the gap between commitment and action. The writer is an award-winning public health communication specialist passionate about using storytelling to make public health issues accessible and impactful.
