This mixed‑methods study uses ethnographic approaches within a sequential explanatory design to examine whether regular surveillance of antimicrobial resistance (AMR) and antibiotic use (ABU) in local health systems can improve prescribing practices and patient behaviours to reduce AMR prevalence. Focusing on febrile illness in children under five in Malawi, the study aims to identify factors that optimise ABU and interrupt community-level AMR.

Four research packages (RP) are implemented: RP1 adapts Lot Quality Assurance Sampling (LQAS) to rapidly assess ABU and quality of care (QoC) among febrile children across urban, peri-urban and rural areas; RP2 applies LQAS-based microbiological surveillance and whole genome sequencing to detect key resistant organisms, including MRSA and ESBL-producing Enterobacteriaceae; RP3 uses household surveys and ethnographic methods to explore health system and community-level drivers of ABU and AMR; and RP4 co-develops interventions through community dialogue and stakeholder engagement, supported by ethnographic observation. The study is expected to strengthen health system capacity for sustainable AMR and ABU monitoring, enhance QoC, and support community-driven reforms. This 4-year (2024-2028) study is funded by the National Institute for Health and Care Research (NIHR).