Antimicrobial Resistance as a Global Stratifying Force: How Differential Containment Capacity Creates Durable Health Hierarchies Between Nations

This scoping review synthesises evidence that antimicrobial resistance (AMR) functions as a stratifying force, a mechanism that does not merely reflect pre-existing global inequalities but actively generates and reproduces durable, self-reinforcing health hierarchies between nations. The central thesis is that differential AMR containment capacity measured across surveillance systems, antimicrobial stewardship, diagnostic infrastructure, governance, and One Health coordination produces and sustains structured hierarchies between countries. These hierarchies are self-reinforcing through identifiable feedback loops that trap nations in low-capacity positions, and the downstream consequences of this stratification extend beyond health burden to encompass economic contraction, geopolitical marginalisation, social inequity, and environmental degradation. While AMR burden disparities are well documented in the literature, no prior scoping or systematic review has articulated this causal architecture, proposed a formal capacity tier typology, modelled the feedback loops that sustain tier positions, or mapped the full system of AMR stratification consequences across multiple domains. This review is designed to fill that conceptual and evidence synthesis gap. The review is guided by three research questions corresponding to key components of the proposed AMR Stratification Framework. The first question asks what evidence documents differential AMR containment capacity across countries, disaggregated by the domains of surveillance, stewardship, diagnostics, and governance. The second question asks what self-reinforcing mechanisms sustain or amplify differential capacity, trapping countries in low-capacity positions. The third question asks what are the demonstrable or projected consequences of AMR stratification for health burden, economics, geopolitics, and environmental systems, with particular focus on sub-Saharan Africa. These questions are designed to progressively build the empirical foundation for the framework, characterise the mechanisms that sustain stratification, and map the consequences that compound and entrench the hierarchy. The methodological approach follows the framework of Arksey and O'Malley as updated by the JBI Manual for Evidence Synthesis, with reporting conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The Population, Concept, Context framework guides eligibility, with countries and health systems constituting the population, AMR containment capacity as the concept, and global or multi-country settings as the context. Sources published in English from January 2015 through May 2026 will be eligible, including peer-reviewed articles, systematic or scoping reviews, narrative reviews, modelling studies, and official reports from WHO, the World Bank, the OECD, and Africa CDC. Studies must address differential AMR capacity, burden, or consequences across at least two countries or jurisdictions. Single country studies without comparative dimensions will be excluded unless they provide direct mechanism level evidence for the stratification framework. Seven databases and repositories will be searched, including PubMed, Scopus, Web of Science, Global Health, WHO IRIS, the GLASS report repository, and the World Bank Open Knowledge Repository. Hand searching of reference lists and author specific searches will supplement database searches. Two reviewers will independently screen titles and abstracts and full texts using Covidence software, with disagreements resolved by discussion or arbitration by a third reviewer. A structured data extraction form, piloted on ten randomly selected sources, will capture bibliographic details, study design, country or region, capacity domain, key quantitative and qualitative data, and framework relevant claims. Evidence will be synthesised using descriptive numerical summary and qualitative thematic synthesis, organised by the three research questions, with evidence for each framework proposition mapped separately and then integrated into the AMR Stratification Framework. No meta-analysis will be conducted given expected evidence heterogeneity. The review is registered on the Open Science Framework prior to data extraction, and all deviations from the protocol will be documented and justified in the final report. The expected outcomes of this review include a comprehensive evidence synthesis documenting differential AMR containment capacity across countries, a formalised AMR Stratification Framework incorporating five self-reinforcing feedback loops and a three tier country typology, a taxonomy of downstream consequences across health, economic, geopolitical, social, and environmental domains, identification of evidence gaps in the current literature, and policy relevant conclusions specifying the five feedback loops as primary intervention targets. The review will also propose a research agenda for future work, including formal quantitative validation of the tier typology and prospective evaluation of stratification reduction interventions. This work makes several novel contributions, including the first synthesis to theorise AMR as an active stratifying force, a coherent causal architecture integrating disparate evidence across multiple disciplines, and an equity focused analysis centred on sub-Saharan Africa as the region with the highest AMR mortality burden and the lowest containment capacity. Findings will be disseminated through peer reviewed open access publication, international conference presentations, a policy brief for global health decision makers, and sharing of all data extraction forms, screening logs, and analysis code via the project repository.