ECONOMIC EVALUATION OF ANTIMICROBIAL RESISTANCE INTERVENTIONS

Antimicrobial resistance (AMR) is a rapidly evolving global health threat with complex and diffuse effects that challenge the current methods of economic evaluation. Existing analyses frequently do not quantify the indirect and long-term effects of AMR interventions, potentially underestimating their full value and misinforming policy. This thesis develops and applies a framework to guide the choice of scope for economic evaluations in AMR and explores methods for extending economic evaluation time horizons while considering associated uncertainties.
First, a systematic literature review finds that the scope of existing evaluations is commonly restricted to a short time horizon and a narrow geographical scope, often omitting wider impacts across other pathogens and settings. To address this, the thesis introduces the AMR development map: a conceptual framework grounded in the biological and ecological principles of antimicrobial resistance. The map provides a mechanistic rationale for determining the scope of evaluation and highlights the key AMR burden dimensions: time, physical space, One Health sectors, and the wider pathogen pool. Focusing on the temporal dimension, an overview of the literature is then used to structure categories of time horizons, distribution of intervention effects over time and key sources of temporal uncertainty, forming an operational bridge between conceptual insights and applied modelling.
The structured approach is then applied in a policy-relevant case study of a hospital-based screening intervention for carbapenemase-producing Enterobacteriaceae. A cohort-based transmission and cost-effectiveness model is developed and subsequently extended to incorporate longer time horizons and key sources of temporal uncertainty, including spatial transmission dynamics and pathogen evolution. The analysis demonstrates that expanding the analytical scope and its associated uncertainties can alter the cost-effectiveness of an intervention.
This work offers a structured rationale for defining the scope of AMR evaluations and a practical demonstration that choices of scope can have a considerable impact on policy-relevant conclusions.