Introduction
When embarking on policy and strategy development, it is imperative to remember that “No man is an island”. Nor for that matter is any action, organisation or outcome. They operate within a wider system, and “systems thinking” helps explain why some policy interventions fail to deliver what they set out to achieve.
Systems thinking is a holistic framework for addressing complex challenges by analysing how interconnected elements shape overall outcomes. It moves beyond isolated problems to uncover root causes, feedback processes, and structural dependencies. In systems thinking, the components are more than the sum of their parts, which enables more effective and sustainable solutions.
One of the most comprehensive and important applications of systems thinking is “One Health”. This is a joined-up, holistic approach that seeks to balance human, animal, plant and environmental health in a sustainable way. The relationships and dependencies between those subsystems are studied and harnessed to create a more comprehensive and multidisciplinary approach to global health security (World Health Organization, 2022).
Few areas more clearly demonstrate the value of a One Health approach than the challenge of antimicrobial resistance (AMR). This is the process by which microorganisms (such as bacteria) evolve to resist the medicines (such as antibiotics) designed to kill them. A recent analysis published in The Lancet estimated that more than one million deaths were attributable to bacterial AMR and that antibiotic-resistant infections could claim over 39 million lives over the next 25 years (Naghavi et al., 2024).
This article examines AMR from a systems perspective with a particular focus on work in Ireland. It highlights some of the key systemic challenges that are inherent in tackling AMR and suggests strategies for addressing these challenges effectively.
AMR in Ireland
In Ireland, the National Risk Assessment (NRA) ranks AMR as among the most likely and impactful strategic risks facing the State across a wide range of potential emergencies (Government of Ireland, 2023; 2024). The third version of the One Health National Action Plan on AMR sets out a multi-system strategy for 2026–2030 (Department of Health, 2025).
This Action Plan builds on two previous versions dating back to 2017. These have already enabled significant progress, including reduced bacterial resistance in food-producing animals and improved prescribing of antibiotics in community settings. Challenges remain, however, including a higher rate of prescribed daily doses of antibiotics per 1,000 population (21) than the OECD average (16) (Organisation for Economic Co-operation and Development, 2025).
The new Action Plan sets out six strategic objectives: These are: 1) improving awareness and empower behaviour change to reduce antimicrobial resistance; 2) enhancing surveillance of antibiotic resistance and antibiotic use; 3) reducing the spread of infection and disease; 4) optimising the use of antibiotics in human and animal health; 5) promoting research and sustainable investment in new medicines, diagnostic tools, vaccines and other interventions; and 6) strengthening multisectoral governance, sustainability, and accountability for a co-ordinated AMR response across all sectors and at all levels (see Figure 1).
Figure 1: Strategic Objectives in the Third Ireland National Action Plan on AMR
The issue of AMR provides an excellent example of why systems thinking is important. For example, it may be tempting to think of AMR as purely a clinical issue caused by the over prescribing of antibiotics. However, it is not just a matter for health professionals, but also those working in animal health, farming and agriculture, environmental management, water management, data surveillance, economics, international trade and, of course, politics and policymaking.
There are a number of challenges inherent in working across such a wide system of determinants and disciplines. This paper will now go onto consider some challenges that cut across the AMR management system and examines ways in which they may be addressed.
Data Integration Challenges
As with any systemic policy challenge, data monitoring and integration is crucial. Different health, animal and environmental surveillance systems cannot be operated in isolation but rather stitched together to form a coherent picture of how components within of the system are interacting. This is never easy when datasets involve a heterogenous mix of data collection methods, outputs, measurement frequencies and digital systems, most of which will have been originally developed in isolation for the purposes of one particular purpose or discipline.
These challenges may be addressed by the application of artificial intelligence (AI). AI-enabled surveillance systems can greatly improve the rapid detection of resistant pathogens and resistance markers, strengthen the analysis of clinical and genomic data, and support real-time surveillance and early warning by integrating diverse data from human, animal, and environmental sources.
Work on AMR to date has only begun to tap into this potential, and further progress will depend on enabling AI applications through standardised data formats, harmonised protocols, and interoperable platforms that support seamless data integration across sectors and regions (Kasse et al.,2025).
Behavioural Challenges
Another key challenge relates to behaviour. The positive impact of surveillance, innovation and regulation is inevitably mediated by the extent to which they are translated into behaviour change. This is undoubtedly an undeveloped factor in work aimed at controlling AMR. A recent systematic review of the evidence found that only a third of studies conducted in the human health sector reported significant pre- to post-intervention decreases in antimicrobial use and a general lack of robust study designs. It also reported a lack of behaviour change evidence in the animal health sector (Craig et al., 2023).
The challenge of behaviour change in AMR is inevitably complicated by the diversity of actors involved in the necessary system. Working cultures, methods, incentives and regulatory systems vary widely across human, animal, environmental and commercial sectors. This makes the development and testing of behavioural interventions very difficult to achieve. Despite this, there are a number of behaviour change models that may have wide applicability across systems and which could be used as a basis for the convergence and synthesis of evidence.
One such model is COM-B (Michie et al., 2011), which brings together the concepts of capability, opportunity and motivation as determinants of behaviour. There are already examples of this model being used to synthesise evidence on behaviour change in AMR across both human and animal health sectors (e.g.: Weeks et al., 2026), as well as in examining AMR-related behaviour in agriculture (Farrell et al.,2023).
Increasingly, public health programmes have gone beyond traditional interventions that focus on individual behaviour and shifted towards place-based, community-led approaches. These acknowledge that behaviour does not exist in a vacuum but is determined by a complex range of social and cultural influences. Community-led approaches convene and resource communities to enact positive changes from within, with professionals adopting a facilitating rather than an intervening role. This serves to equalise power relationships that can hinder trust and empowers influential individuals within a community to drive progress (McNally, 2026).
An example of a community-led approach applied to AMR is the “Community Engagement for Antimicrobial Resistance (CE4AMR)” programme, which is an international and interdisciplinary network focused on tackling drivers of AMR at community level within low-middle income countries (Mitchell et al., 2023).
Socioeconomic Challenges
Efforts to control AMR must inevitably stretch across a diverse range of countries and cultures. Given this, variations in socioeconomic conditions will inevitably influence implementation and outcomes. Review level evidence indicates that remoteness, migration, regional poverty, age, gender and race all have a role in driving AMR (Ljungqvist et al., 2025).
For example, lower income and socioeconomic status were identified as risk factors for self-medication with antimicrobials and for contracting AMR infections. In addition, there is consistent evidence of an association between migration status and AMR, with recent immigration and forced displacement repeatedly identified as risk factors for self-medication, antibiotic storage, and the carriage of infection with drug-resistant organisms.
In relation to agriculture, studies have found that “the challenges of economic vulnerability, tight profit margins, scarcity of funding facilities and limited finance for veterinary consultations, coupled with substandard farming structures and practices and poor infrastructure, contribute to antimicrobial use (AMU) reliance to preserve productivity” (McKernan et al.,2021).
Addressing socioeconomic variation in AMR programmes is a complex challenge. Many of the determinant factors, such as poverty or remoteness are not readily amenable to change. To be effective across geographies, demographics and socioeconomic groups, AMR programmes are likely to require a proportionate universalism approach. While this strategy allows for a comprehensive approach that intervenes across all groups and areas (universal), it varies the intensity or scale in a way that corresponds to the level of need (proportionate) (Marmot, 2010). In relation to AMR, this approach would utilise data on the epidemiology of AMR, as well as on variations in professional practice and environmental characteristics, to focus more time and resources on those groups or areas most at risk.
Coordination Challenges
As is evident in many of the challenges discussed above, the effective management of AMR is dependent on effective stakeholder coordination and collaboration. The levers to reduce resistance sit in different systems with different incentives, datasets and lines of accountability, yet they must move in step.
In Ireland, this challenge is taken up by bodies such as the National Interdepartmental AMR Consultative Committee (cross‑government oversight), the Animal Health Implementation Committee (animal/environment actions) and the HSE AMRIC team (Infection Prevention Control (IPC) and stewardship across health and social care).
A key tool in the management of any complex system is stakeholder analysis. In their study of AMR, Adhikari et al., (2025) examined agency, system roles and power relationships to reveal how a wide range of actors interacted within a complex system. Through a case study of a One Health approach, they demonstrated how this understanding supports more targeted and collaborative actions that reflect stakeholders’ capacities and priorities. They applied a five-pillar framework (agency, system roles, power and influence, alignment, and transformation potential) to demonstrate a structured way to analyse global AMR action plans and identify practical challenges, opportunities and recommendations.
Conclusion
Ireland continues to face up to the challenge of AMR with a new iteration of its national action plan. This guides a complex system requiring coordinated action across human, animal and environmental health. Key challenges will include integrating fragmented data, supporting behaviour change, socioeconomic inequalities and cross-sector coordination.
Strategies that may accelerate progress include the use of artificial intelligence, model-based or community-led interventions and proportionate universalism, informed by structured stakeholder analysis. Together, these strategies provide a practical framework for strengthening AMR management and translating One Health strategies into effective, sustainable action.
About the author
Professor Lisa McNally is a Director of Public Health in the UK and an Honorary Professor in Applied Health Sciences at the University of Birmingham. She is an advisor to the National Institute for Health and Care Research. Lisa and her team have won several national awards for their community development work, including the LGC Public Health Award in 2025.
Follow Lisa on LinkedIn at: https://www.linkedin.com/in/prof-lisa-mcnally-751830244/
Lisa is also author of the 2026 report: Integrating Place-Based and Community Led-Approaches into Ireland’s Public Health System
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