Reframing Antimicrobial Stewardship as Systems Governance: Aligning Regulation, Diagnostics, Antibiotic Use Measurement, and Surveillance to Address Antimicrobial Resistance.

Antimicrobial stewardship (AMS) is often framed as a set of prescribing-focused interventions aimed at optimizing antibiotic selection, dose, route of administration, and duration. In practice, AMS also functions as a systems discipline. Embedded within governance and regulatory frameworks, diagnostic capacity, antimicrobial consumption and use patterns, and surveillance infrastructure, AMS operates within real-world structural and economic constraints, such as resource limitations, conflicting pharmaceutical market incentives, and health system fragmentation. In lower- and middle-income countries, variation in regulatory enforcement, prescribing patterns, diagnostic limitations, and surveillance infrastructure can undermine otherwise well-designed stewardship policies. This paper frames AMS as a systems governance function and proposes the Aligned AMS Systems Governance framework, comprising four core AMS functions-governance and regulation, antimicrobial consumption and antimicrobial use measurement, diagnostic stewardship, and antimicrobial resistance (AMR) surveillance and reporting-within four broader enabling domains: infection prevention and control, public engagement and awareness, environmental stewardship, and One Health coordination. This paper is an analytical narrative review of peer-reviewed literature, global policy frameworks, and implementation guidance. Using India as an illustrative example, we show that inconsistent regulatory enforcement, non-prescription antibiotic access, diagnostic constraints, and pharmaceutical market dynamics interact to complicate stewardship implementation despite the presence of national policies. Effective AMS requires deliberate alignment of these multiple functions and domains through defined responsibilities, routine data collection and sharing across AMS functions, and continuous feedback loops linking findings to coordinated action and subsequent reassessment. Reframing AMS as systems governance clarifies actionable leverage points for implementation and supports more practical, scalable approaches to mitigating AMR across diverse health system contexts.