The DisAMR project investigates how improved sanitation and community-led action can help address environmental antimicrobial resistance (AMR) in urban informal settlements in Makassar, Indonesia. Building on infrastructure installed through the RISE programme, it supports sustainable wastewater management and hygiene practices while generating evidence to inform government policy.
National AMR context
Antimicrobial Resistance (AMR) poses a major public health threat in Indonesia, with 2019 mortality estimates ranging from roughly 34,500 attributable deaths to nearly 134,000 associated deaths. E. coli was the single largest contributor, linked to an estimated 19,000-36,000 deaths, alongside rising resistance in pathogens like K. pneumoniae. Indonesia has a National Action Plan (NAP) aligned with the WHO’s Global Action Plan and participates in WHO’s GLASS surveillance system, but GLASS data comes from only 75 hospitals, meaning the true burden is likely underestimated. Notably, Indonesia’s own NAP identifies it as having one of the highest resistance rates in Asia. A recent review found evidence of resistant pathogens in both hospital and community settings, underscoring gaps in understanding transmission outside clinical environments.
Governance is spread across multiple bodies: the Quadripartite organisations (FAO, WHO, WOAH, and UNEP) supports IPC-WASH initiatives, the Ministry of Health has issued hospital-focused antibiotic policies, and the National AMR Coordinating Committee (NARCC) coordinates five ministries to lead a multi-sectoral One Health approach. Additional sector-specific rules address antibiotic misuse in livestock and fisheries. However, no policy currently addresses environmental AMR specifically, and there is still no strong longitudinal evidence confirming that water and sanitation interventions actually reduce environmental AMR risk, therefore representing a significant gap in both policy and evidence.
Problem
Urban Informal Settlements (UISs) are particularly vulnerable to health risks and function as high-risk hotspots for the accumulation, mobilisation, mutation, and transmission of environmental AMR. This vulnerability stems from a combination of infrastructural, behavioral, and governance factors. Infrastructurally, UISs often lack formal sanitation, leading to untreated fecal waste release, alongside poor drainage, flooding, inadequate road access for service maintenance, substandard housing, and limited access to safe water. Close contact with domestic and wild animals, including vermin and insects, further creates reservoirs for AMR.
Behavioral factors compound these risks: recurrent bacterial illnesses are frequently treated with unprescribed antibiotics, over-the-counter pharmaceutical use is widespread and unregulated, hygiene practices and health/sanitation literacy tend to be low, and poor food hygiene contributes to contamination and transmission. Governance gaps also play a role with weak coordination among local governments and service providers undermining sanitation infrastructure support. There is a lack of evidence-based policy integration addressing the environmental dimensions of AMR in urban health planning.
Despite being a clear priority for AMR risk mitigation, policy responses for UISs remain underdeveloped, largely due to insufficient UIS-specific evidence and a lack of confirmed effective interventions for reducing AMR risk in this population.
Project overview
The DisAMR project (“Disruption of AMR in urban informal settlements: pathways for policy action”) aims to reduce environmental AMR contamination by strengthening wastewater systems, promoting community engagement, improving hygiene practices, and generating policy-relevant evidence in urban informal settlements (UISs). It builds on the existing RISE (Revitalising Informal Settlements and their Environments) program in Makassar, Indonesia (a One Health-based RCT trialling improved sanitation and water management across 12 informal communities with approximately 3,500 residents), half of which have already received infrastructure upgrades. As a separately funded add-on, DisAMR does not fund new intervention installations but instead investigates the broader environmental AMR impacts of these sanitation interventions and supports their continuity.
DisAMR has four core objectives: (1) strengthening community and local government capacity to maintain centralized wastewater and sanitation infrastructure, (2) driving behavior change through hygiene education and community-led AMR prevention, (3) generating evidence on the effectiveness, acceptability, and sustainability of integrated WASH and environmental AMR interventions, and (4) informing government policy and planning at local to national levels with actionable environmental AMR data.
Using a mixed-methods approach, the project will produce practical insights transferable to similar settings, while also examining the potential cost-effectiveness of integrated sanitation and AMR interventions, particularly in low- and middle-income countries.
Intended outcomes
Outcome 1: Communities and the municipality adequately implement WASH practices, appropriate AMU and maintain UIS wastewater and sanitation infrastructure, reducing direct discharge of blackwater (containing AMR genes and bacteria) into the environment
Outcome 2: Government institutions incorporate AMR-related sanitation evidence into local environmental health planning and policy.
