Project ARNA

Duration: 2014-2016
Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine


The non-prudent use of antibiotics is a major risk for antimicrobial resistance. If antibiotics become ineffective, established and newly emerging infectious diseases will increasingly threaten the health of the population. This will lead to increased morbidity, costs, and health care utilization. It has estimated that antimicrobial resistance causes 25,000 deaths annually in the EU and costs health care systems 1,5 billion euro on extra healthcare costs and productivity losses (see ECDC report).

Non-prudent use of antibiotics has several aspects such as over-use because of the prescription of antibiotics for diagnoses where they are not indicated. Moreover, self-medication with antibiotics can be considered as non-prudent use; for example when it is delivered as over-the-counter without knowing the diagnosis or when a citizen uses leftover antibiotics.

While much is known about the volume of prescribed antibiotic use and the types of antibiotics prescribed (see ECDC Technical report), less is known about cross-national variation into appropriate use, i.e. whether or not antibiotics are prescribed for the right indication. Since this information is lacking, there is need for empirical research.



  • Funding: European Comm​ission, Health and Consumers Directorate-General
  • Deliverables: see publications on the right
  • Project partners: University of Antwerp and cosultancybureau TNS-NIPO
  • Nivel involvement: project partner
  • Nivel experts: Prof. Liset van Dijk PhD; John Paget PhD
  • International project website: -

Doel Aims

The ARNA project aims to contribute to a more prudent use of antibiotics in human medicine in Europe, with a specific focus on the use of non-prescribed antibiotics. The overall aim is to assess the non-prudent use of antibiotics in the European Union (EU) and to encourage policies that lead to a more prudent use of antibiotics.

Therefore in the ARNA project we will:

  • Identify key factors that drive the sales and non-prudent use of antibiotics in human medicine obtained without prescription
  • Assess the level of enforcement of legal prescriptions of antimicrobial agents in the EU
  • Document good practices aimed at strengthening a more prudent use of antibiotics
  • Develop policy options for a more prudent use of antibiotics

OrganisatieProject design and planning

The ARNA project consists of six work packages, each with their own methods and products;

WP1: The (non-prudent) use of antibiotics in EU Member States with a special focus on use of non-prescribed antibiotics

WP1 aims to describe the frequency and nature of (non-prudent) use of antimicrobial agents and its variations across the EU. Moreover, key factors explaining this variation will be analysed. It includes five elements:

  • an analysis of literature and existing data on the consumption of antimicrobial agents across the European Union
  • an analysis of the EuroBarometer data in the 28 EU Member States to measure self-medication with antimicrobial agents
  • an in-depth analysis of self-medication with antimicrobial agents in seven countries with high levels of self-medication
  • a survey among general practitioners and pharmacists on self-medication with antibiotics in the same seven countries
  • an analysis of key factors in the different of the health care system explaining cross-country variation
WP2: Questionnaire(s) to Ministries of Health and relevant regulatory authorities

WP2 aims to provide an inventory of:

  • legal provisions that EU Member States have with regard to the prescription of antibiotics in order to guarantee that antibiotics are exclusively sold on a prescription basis only
  • national measures which countries have been taken to reduce non-prudent use of antibiotics (including non-prescription antibiotics)
  • other initiatives that have proved effective in improving the prudent use of antibiotics in their country (for WP3). Data will be collected from Ministries of Health, and other relevant key stakeholders in all European Member States using a mixed-method approach (online combined with written/telephone reminders)
WP3: Literature review on good practices aimed at prudent use of antimicrobial agents

The local and national literature will be reviewed to identify good practices used to enhance a more prudent use of antimicrobial agents, including good practices in reducing/mitigating the consumption of antimicrobial use without a prescription.

WP4: Analysis and policy options

WP4 aims to formulate a set of policy options for EU Member States to promote prudent use of antimicrobial agents given the structural and societal characteristics of each particular country. Also policy options at the EU-level will be explored. Experts in the field of antimicrobial resistance will be invited to participate in a Multi-criteria Decision Analysis (MCDA). MCDA is an approach that aims to come to an overall order of policy options, ranking from the most preferred to the least preferred option by weighing the pros and cons of each particular measure. The good practices set that was established from WP 2 + 3 will serve as the basis for the MCDA-analysis.


WP5: National workshops and a consensus conference

WP5 consists of two elements: national workshops in the seven countries with the highest level of self-medication (see WP1) and a final consensus conference. The national workshops (one for each country) will be held with policy-makers in these countries, as well as with representatives of organizations of health care and general patient organizations. Results will be presented with the rest of the EU as a benchmark. In addition, policy options will be presented and discussed. A short “plan for action” will be formulated. After the workshop each country will receive a short report including figures on its own situation and a report of the workshop including policy options discussed. All conference material and reports containing the main results will also be made publicly available on the ARNA website (see below), within one month after each national conference. The final consensus conference involves key stakeholders at the EU level and representatives from the European Parliament, the European Commission, the ECDC and other key EU bodies, and also WHO EURO.

WP6: Dissemination of results

The ARNA project will disseminate its results in four ways:


  • dissemination of knowledge among policy maker
  • recommendations for actions at the national and European level to enhance prudent use of antimicrobial agents
  • ARNA website/open source
  • final report and scientific publication


A report and a scientific paper (see the publications on the right).
The report is also presented at the EU-site, where each individual chapter can be downloaded; go to Antimicrobial resistance and causes of non-prudent use of antibiotics in human medicine in the EU.

SamenwerkingsverbandProject partners

The project is a collaboration between Nivel, University of Antwerp and TNS-N​IPO. ARNA started on 1st July, 2014, and will run for 2 years. The project is funded by the European Comm​ission, Health and Consumers Directorate-General.

Panels met patiënten, cliënten en burgersNivel project team

The Nivel project team consists of:


DG SANTE (Directorate General for Health and Food Safety) is a Directorate-General of the European Commission (formerly known as the Directorate-General for Health and Consumers). DG SANTE is responsible for the implementation of European Union laws on the safety of food and other products, on consumers’ rights and on the protection of people’s health. Their goal is to make Europe a healthier, safer place, where customers can be confident that their interests are protected.

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Dijk, L. van, Paget, J. Project ARNA. From: [Last update 05-July-2021; consulted on 17-May-2022]. URL: