Gaps in One Health Strategies for Rational Antimicrobial Use in Eastern, Central and Southern Africa: A Systematic Review

Abstract

Antimicrobial resistance (AMR) is accelerated by inappropriate antimicrobial use across human and animal-health systems, yet the extent to which One Health approaches have informed antimicrobial stewardship in Eastern, Middle, and Southern Africa remains incompletely described. This systematic review synthesized evidence on antimicrobial-use practices, self-medication, prescribing and dispensing, stewardship, and cross-sectoral One Health integration in the region. Peer-reviewed English-language studies published from 2012 to 2024 were identified through bibliographic and supplementary searches and screened using predefined eligibility criteria. Ninety-three unique studies were included. Evidence was concentrated in human-health settings, particularly community and hospital studies, with fewer livestock and veterinary studies and very limited integrated cross-sectoral research. Commonly reported concerns included non-prescription access to antimicrobials, self-medication, empirical prescribing, limited diagnostic support, restricted access to professional veterinary services, and gaps in antimicrobial stewardship and regulatory oversight. Study designs, populations, definitions, and measurement instruments were heterogeneous; therefore, findings were synthesized primarily narratively. The evidence indicates substantial gaps in integrated One Health approaches to rational antimicrobial use and limited intervention evidence. Strengthening coordinated stewardship, surveillance, diagnostic capacity, regulation, and cross-sectoral research is needed to support rational antimicrobial use in the region.