Many people have heard about antibiotics, but do not precisely know what this medicine is and how it works, let alone what antimicrobial resistance (AMR) means. Yet, many have wondered why some infections become difficult to treat, even when antimicrobials are available. Do antimicrobials always work against infections? The fact remains that infectious agents, such as bacteria, do spontaneously develop resistance over time. But this process can be accelerated when bacteria are repeatedly exposed to antimicrobials, including through unnecessary or inappropriate use.

For the past several years, studies have consistently shown that Nepal, like other South Asian countries, experiences excessive and inappropriate use of antimicrobials. In urban areas, one can easily walk into a drug shop, explain symptoms and buy antibiotics, often without a prescription. A patient with a common cold may demand antibiotics even though antibiotics do not work against viruses.

But this is only one side of Nepal’s story. Travel to remote areas, and the problem may be the opposite. For populations in far-flung villages, access to even basic and essential antimicrobials can be difficult. A bacterial infection that could have been treated relatively easily could become severe and complicated. By the time the patient reaches a hospital, treatment can be more complicated and much more expensive.

This is the tension between access and excess. In one place, antimicrobials are easily available and consumed unnecessarily; in another, people who genuinely need them struggle to obtain them. Here lies the unsettling heterogeneity of who becomes vulnerable and who does not, and who needs attention and who, relatively, does not. This is the first premise where community engagement can offer solutions.

Such contradictions in Nepal’s supply side and demand side cannot simply be fixed by bombarding people with recommendations about ‘appropriate antibiotic use’. In such scenarios, stakeholder analysis allows one to explore a multitude of interests and their interactions, understand why people behave as they do, and analyse how health systems, pharmacies, patients, farmers and communities function within their own circumstances and in relation to each other. This is the second premise where community engagement can help resolve the puzzle.

Yet, engagement strategies have sometimes been given unequal weight, particularly with a preference for participatory and dialogue-based activities over approaches that prioritise breadth of engagement. In practice, however, both approaches can and need to coexist, often complementing each other.

Historically, experts developed recommendations at the centre, bureaucracies converted them into programmes, and instructions travelled downward through the health system until they eventually reached communities. Nepal is familiar with this model where a guideline is prepared in Kathmandu, training is provided at the provincial or district level, posters reach health facilities, and communities are told what behaviour should change. Inadequate community buy-in as such can undermine the entire effort.

The one-way nature of vertical engagement has also been rightly criticised. Experts and bureaucrats may prescribe solutions for communities whose everyday experiences are radically different from their own. Recommendations can be technically sound and well-intentioned but also poorly grounded and unrealistic. Imagine telling a person in a remote village that antibiotics must only be taken after consulting a qualified doctor when reaching that doctor requires a day’s walk and considerable expense. Or telling a small poultry farmer to simply reduce antimicrobial use without discussing veterinary access, disease prevention and the possibility that losing chickens may mean losing the household’s income.

Participatory engagement has enormous value. Community members can be involved from the outset, contribute to identifying problems, setting agendas, designing interventions, implementing activities, and evaluating results. Such involvement can garner trust, ownership and produce interventions grounded in local realities. Patients may explain why they avoid health facilities. Farmers may describe why antimicrobials are important for protecting their livestock. These conversations can reveal problems that an expert sitting in Kathmandu may never see.

But enthusiasm for deep participation should not lead us to undervalue another dimension of engagement—breadth. Nepal’s experience with vaccination, mass drug administration and public health campaigns demonstrates the value of reaching hundreds of thousands, sometimes millions, of people. Radio, television, schools, social media, health facilities and community networks can carry simple messages about antibiotics across enormous populations.

Such breadth-based engagement may lack the depth of a small participatory meeting, but its scale is precisely the strength. A community dialogue involving 30 people can uncover why antibiotics are misused in one municipality. A nationwide radio campaign can make hundreds of thousands think twice before demanding antibiotics for a viral cold. Why must one be considered inherently superior to the other?

This is precisely where diagonal community engagement becomes useful. It combines vertical, population-wide strategies with bottom-up, participatory and dialogue-based engagement. This is particularly relevant for Nepal as it is efficient for low- and middle-income countries. AMR is a super-wicked problem. It involves human health, animal health, agriculture, food systems, pharmacies, hospitals, sanitation, environmental contamination, regulation, economics and human behaviour. There will never be one community, one message or one intervention capable of addressing all these dimensions.

Nepal therefore needs engagement that can travel in both directions. Scientific evidence, surveillance, regulation and national communication must move outward from institutions to communities. At the same time, experiences, constraints and solutions emerging from communities must travel back towards policymakers and researchers. Health governance, in other words, should re-orient the approach to reap benefits from a combination of conventional vertical and more recent participatory approaches.

For AMR control, while relevant to many other public health interventions, the idea is to blend these approaches to reach millions at scale and listen deeply to socio-cultural features while identifying and safeguarding vulnerabilities.