Antibiotic Reimbursement as a Policy Lever for Antimicrobial Stewardship: Alignment with WHO AWaRe and Essential Medicines List Recommendations in Albania

Antibiotic misuse, partly resulting from gaps in health policy, is a major driver of antimicrobial resistance (AMR). The World Health Organization developed the AWaRe classification, the Essential Medicines List, and the Essential Medicines List for Children (EML/EMLc) to support appropriate antibiotic use. Reimbursement influences which antibiotics are financially covered. This study developed the Multidimensional Antibiotic Reimbursement Assessment Framework (MARAF) and applied it to Albania's reimbursement system to identify priorities for policy review. A cross-sectional descriptive analysis of antibiotic reimbursement data was conducted. The policy analysis used the 2024 national reimbursement data, the 2023 WHO AWaRe classification and EML/EMLc, national AMR surveillance data, the 2025 reimbursement list, an reimbursed prescription data. Antibiotics were evaluated by International Nonproprietary Name, utilization, AWaRe category, EML/EMLc inclusion, formulation, and strength. Integrating these findings with AMR relevance, changes in reimbursement lists, and geographic distribution enabled the prioritization of antibiotics and counties for further review. In 2024, Access accounted for 62.8% of the total reimbursed quantity, Watch accounted for 37.2%, and no Reserve antibiotics were identified. Amoxicillin-clavulanic acid accounted for 63.5% of the reimbursed Access quantity, while cefaclor, which was absent from the WHO EML/EMLc, accounted for 25.2% of the total reimbursed quantity. Under the alignment classifications, 14 of 28 product entries (50.0%) were classified as fully aligned with WHO recommendations. Structural alignment was similar in the 2025 list, with 21 of 40 entries (52.5%) fully aligned. The prioritization process identified cefaclor as the main priority, while other antibiotics also warranted assessment. Shkodër and Dibër had the highest reported population adjusted reimbursement rates, while Tirana had the highest absolute prescription volume. Assessment across complementary sources identified structural concerns that were not apparent from a single stewardship indicator. MARAF integrates reimbursement, stewardship, AMR, and geographic evidence to establish priorities. It supports reimbursement review within antimicrobial stewardship without evaluating individual prescriptions.