Strengthening Community Antimicrobial Stewardship in Africa: A Systematic Review of the Roles, Challenges, and Opportunities of Community Health and Animal Health Workers.

Antimicrobial resistance (AMR) remains a critical global health challenge, and is mainly due to inappropriate antimicrobial use in human and animal health sectors. This systematic review examines the roles of Community Animal Health Workers (CAHWs) and Community Health Workers (CHWs) in antimicrobial stewardship (AMS) across Africa where AMR burden is highest and AMS programs are limited. Following PRISMA guidelines, this systematic review analyzed 16 studies (2017-2024) from nine African nations. We identified seven key roles of CAHWs and CHWs in AMS: 1) provision of clinical services (13 studies); 2) community mobilization (8 studies); 3) health promotion (7 studies); 4) provision of preventive services (5 studies); 5) epidemiological surveillance (4 studies); 6) advocacy (2 studies), and 7) medical waste management (2 studies). Despite their roles, challenges such as lack of supportive legislation (3 studies), inadequate remuneration (2 studies), and total reliance on foreign funding hinder AMS program sustainability. While most studies (14 studies) indicated that CAHWs and CHWs had received AMS training, their roles in the national AMR strategies remain unclear. CAHW and CHWs could be leveraged in advancing health promotion, raising AMR awareness, supporting AMR surveillance, enhancing integrated management of diseases, and improving waste management within One Health frameworks. To realize this potential, there is a need to formalize CAHW/CHW roles through targeted legislation, specialized training and sustainable funding. This evidence highlights the critical need for policy reforms to harness their potential in strengthening health systems and curbing AMR across Africa. PROSPERO registration number: CRD420251027215.