In the climate debate, low- and middle-income countries have often been blamed for rising emissions, while the vastly greater historical contribution of wealthy nations is treated as yesterday’s story.

Something similar has happened with the global antimicrobial resistance (AMR) crisis. Low- and middle-income countries (LMICs) have long been portrayed as the worst offenders of antibiotic overuse, with over-the-counter sales and weak regulation seen as one of the main reasons behind the rise and spread of drug-resistant infections. But a new study now challenges this narrative.

Research published in the Lancet Public Health found that overuse is actually concentrated in high-income settings, with these countries consuming the largest volumes of antibiotics used to treat drug-resistant infections. In contrast, many lower-income countries still lack access to these drugs, despite accounting for more than 80% of the estimated global need.

In other words, the global challenge is not simply a matter of using fewer antibiotics, but rather one of tackling overuse in some parts of the world and underuse in others.

For years, the AMR debate has focused on the dangers of using too many antibiotics. But too few can also contribute to drug resistance. When the right antibiotics are unavailable, infections are more likely to go untreated, increasing their opportunity to spread. Or they may be treated with suboptimal antibiotics.

This not only increases the risk of the treatment failing, but it can also create selective pressure for resistant strains to survive, spread, and become more difficult to treat over time. Tackling AMR therefore requires both the effective stewardship of antibiotics and reliable access to them; one cannot succeed without the other.

In order to achieve this, the focus has to shift away from reducing consumption and more toward ensuring that patients receive the right antibiotic, at the right time, for the right infection. To help guide this, the World Health Organization (WHO) groups antibiotics into three categories through its Access, Watch, and Reserve (AWaRe) framework. Access antibiotics are first-line treatments for common infections and should be widely available. Watch antibiotics are broader-spectrum medicines that carry a higher risk of driving resistance and should be used more carefully. Reserve antibiotics are last-resort treatments for multidrug-resistant infections.

Until now, much of the global discussion has focused on increasing the use of access antibiotics while preserving watch and reserve drugs for situations in which they are genuinely needed. Reflecting this approach, in 2024 the U.N. General Assembly committed to ensuring that at least 70% of global human antibiotic use comes from the access group by 2030.

Encouragingly, the new Lancet Public Health study broadly supports that target. It also provides the first estimates of what optimal antibiotic use should look like in 186 countries, based on their infectious disease burden, levels of antimicrobial resistance, and local context. By doing so, it moves the conversation beyond how many antibiotics are being used to whether countries have access to the antibiotics they actually need.

Their results challenge some long-held assumptions. While the authors found that 77% of antibiotic use worldwide came from the access group — well above the U.N. target — this global figure obscures major inequities between countries, both in terms of the antibiotics they consume and the antibiotics they actually require. When the researchers compared actual antibiotic consumption with their estimates of optimal use, they found that nearly three-quarters of the 67 countries with available data, the majority wealthier countries, were using more antibiotics overall than clinically required. More strikingly, almost all were using more watch antibiotics than needed.

At the same time, countries facing the highest burdens of infectious disease and antimicrobial resistance, predominantly lower-income countries, were estimated to require substantially greater use of watch and reserve antibiotics than wealthier countries. This challenges the widely held assumption that LMICs primarily need access antibiotics, and instead have a disproportionately high need for watch and reserve antibiotics because they face higher burdens of infectious disease and antimicrobial resistance.

These findings suggest that the problem is not simply one of excessive consumption, but of antibiotic use that is poorly aligned with clinical need. This has huge implications for AMR and patient survival. Research that is pending publication by Singapore-based clinical research network ADVANCE-ID, for example, has found that the 28-day mortality of patients with difficult-to-treat but common drug-resistant infections exceeds 50% if they do not receive the optimal reserve antibiotics. The two antibiotics in question are not available in any LMICs.

Global targets are only a starting point. Just as countries face very different pathways to reducing CO2 emissions, they also face very different challenges when it comes to antibiotic use. The Lancet Public Health study supports looking beyond the proportion of antibiotics that fall into each AWaRe category and paying closer attention to total antibiotic use adjusted for infectious disease burden. National AMR action plans therefore need more context-specific targets, reflecting local patterns of infection, resistance, and access, rather than relying solely on global averages.

If we are serious about tackling AMR, we must move beyond simplistic assumptions about who is responsible and focus instead on ensuring that every patient, everywhere, has access to the right antibiotic, for the right infection, at the right time. Like climate change, AMR is a global challenge, but its causes and consequences are unevenly distributed. Recognizing those differences is not a distraction from the solution; it is the only way to find one.

Peter Beyer is deputy executive director of the Global Antibiotic Research & Development Partnership (GARDP).