National Action Plan on Anti-Microbial Resistance (NAPAMR) 2020-2024

1.1 Background 3

1.2 Situational Analysis 4 2 STRATEGIC FRAMEWORKS 7

2.1 Vision 7

2.2 Mission 7

2.3 Guiding Principles 7

2.3.1 Prevention first 7

2.3.2 Access 7

2.3.3 Incremental targets for implementation 7

2.4 GOAL AND OBJECTIVES 8

2.4.1 Goal 8

2.4.2 Strategic Objectives 8 2.4.2.1 Strategic objective one: Increase national awareness and understanding of AMR through education and training 8 2.4.2.2 Strategic Objective Two: Strengthen the Knowledge and Evidence-Based through Surveillance and Research 10 2.4.2.3 Strategic Objective Three: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures. 13 2.4.2.4 Strategic Objective Four: Optimize the Use of Antimicrobial Agents in Human, Animal and Plant Health 16 2.4.2.5 STRATEGIC OBJECTIVE FIVE: Ensure sustainable investment in AMR through Sustainable and equitable financing mechanism and research and development. 20

2.5 Governance 22

2.5.1 Antimicrobial Resistance Focal Point 22

2.5.2 The National Antimicrobial Resistance Secretariat 22 2.5.3 Antimicrobial Resistance multi-sectoral coordinating committee 22 2.5.3.1 Members of Antimicrobial Resistance multi-sectoral coordinating committee 22 2.5.3.2 Roles and Responsibilities of the antimicrobial resistance multi-sectoral coordinating committee 23 2.5.4 Antimicrobial resistance multi-sectoral technical working group 23

2.5.4.1 Membership to TWG 23

2.5.4.2 Roles and Responsibilities of TWG 24

2.5.5 Drugs Therapeutic Committee and Quality Improvement 24 3 IMPLEMENTATION PLAN 25

3.1 Introduction 25

3.2 Objective 25

3.3 Structural Framework 25 1

3.4 Implementation Plan Matrix 26 2 1. INTRODUCTION

1.1 Background Antimicrobial resistance (AMR) is the natural phenomenon that is accelerated by selective pressure exerted by the widespread use and misuse of antimicrobials in humans and animals whereby microbes generate the ability to develop in the presence of an antimicrobial that would normally destroy them or restrict their growth. The spread of antimicrobial residues into marine and terrestrial ecosystems results in antimicrobial use in humans, livestock and agriculture. Antimicrobial products play an essential role in combating infectious diseases in both humans and animals. As much as antimicrobial products have contributed to a reduction of illnesses and deaths related to infectious diseases in the past centuries, the same products are being eroded by the emergence of antimicrobial resistance. Antimicrobial resistance (AMR) has been a growing challenge to the successful treatment of an ever- increasing variety of bacterial, parasite, viral and fungal infections for the past few decades. This has made it hard, expensive or even difficult to treat patients. The scope of the issue is global and impacts on livestock, human health, the climate and, ultimately, the global economy, food and health security. In response to this significant public health issue, at the 68th World Health Assembly in May 2015, a global action plan on antimicrobial resistance was adopted and the Member States agreed on the importance of implementing national action plans (NAPs) aligned with the global plan and integrating the same five strategic objectives1. The resolution also acknowledged the importance of the cooperation of the Member States to ensure synergies in the achievement of the five strategic objectives of the global action plan. In May 2015, the World Assembly of Delegates of the World Health Organization for Animal Health (OIE) also adopted a resolution requiring the Member States to implement the recommendations of the Global Action Plan and to establish national action plans for the use of antimicrobial agents in animals and to work closely with officials of public health. The thirty-ninth conference of the United Nations Food and Agriculture Organization (FAO) adopted a resolution and status report on antimicrobial resistance in June 2015. The FAO resolution encourages members to establish or improve national action plans, policies and international cooperation on food, agriculture and environmental antimicrobial resistance surveillance, monitoring and containment, in close coordination with relevant human health plans. As a result, Rwanda is inspired to develop its own action plan and is now organising the related awareness activities. In addressing this, countries including Rwanda have adopted the global agenda and committed to developing their national action plan on antimicrobial resistance through One Health Approach. 1 68th WHO assembly URGES Member States to have in place, by the Seventieth World Health Assembly, national action plans on antimicrobial resistance that are aligned with the global action plan on antimicrobial resistance and with standards and guidelines established by relevant intergovernmental bodies 3

1.2 Situational Analysis The 2018 Global Health Security Agenda (GHSA) assessment report based on the International Health Regulations (IHR) and the Joint External Evaluation (JEE) tool concluded that antimicrobial resistance is a major public health problem in Rwanda and there are high levels of inappropriate use of antimicrobials in the human and animal sectors. We also noted that, although there are systems for monitoring antimalarial medicines, HIV and TB resistance2 , there is an inadequate system for fully collecting data on antimicrobial resistance (AMR) from both the public and private sectors that are playing an important role in veterinary and human health. Due to its high effect on human and animal health, food protection and the sustainable growth of the agricultural sector, AMR has become a global health priority. In one geographical location or species, resistance can easily spread to other geographical locations or spill over into other species. A study examining a five-year antimicrobial susceptibility trends among bacterial isolates from a tertiary health-care facility in Kigali conducted from year 2009 to December 31, 2013 showed an increase of resistance to Imipenem and Colistin are rising among gram-negative bacteria in Rwanda.(3). Another study conducted in 2012 at a teaching hospital in the Southern province found that antibiotics commonly used for the treatment of Urinary Tract Infections in Rwanda are becoming less effective. Statistics from developed economies worldwide indicate that antimicrobials are commonly used in agriculture and public health. This trend is likely to occur in low- and middle-income countries where rapid growth in infectious disease incidence populations, coupled with high demand for animal proteins derived from intensive farming systems, is leading to increased use of antimicrobials. It is now generally accepted that the pace at which AMR produces and disseminates greatly exceeds the rate at which new antimicrobial drugs are being created. In the livestock sector, Escherichia coli isolates from beef and poultry have been shown to be resistant to tetracycline, Co-Trimoxazole, streptomycin, ampicillin, quinolones and Cephalosporins of the third generation at varying frequencies. Two or three antimicrobials were found to be resistant to some of the isolates. There are surveillance systems for tracking the effectiveness of antimicrobial agents used in TB, HIV and malaria, and these systems must be connected to the national surveillance system for AMR. As foodborne diseases ranging from mild gastroenteritis to life-threatening systemic infections, such as those triggered by non-typhoid salmonella (NTS), it is noteworthy that main antimicrobial-resistant foodborne pathogens (E. coli, Salmonella enterica and Campylobacter spp) have occurred with increasing frequency. These diseases are known as internationally significant public health issues. 2 In 2018, the case detection rate was 84% and the treatment success rate for all forms of TB was 87% 3 Five-Year Antimicrobial Susceptibility Trends among Bacterial Isolates from a Tertiary Health-Care Facility in Kigali, Rwanda; Am. J. Trop. Med. Hyg., 95(6), 2016, pp. 1277–1283 4 Strengths Weaknesses ● The University Teaching Hospitals have an ● There is no national AMR action plan in internal plan for infection control and AMR place. ● Ten laboratories can conduct AMR detection: ● There is no national plan for the National Reference Laboratory; CHUK surveillance of infections caused by laboratory, CHUB Laboratory; King Faisal resistant pathogens. Hospital Laboratory; Rwanda Military ● Priority AMR pathogens have not been Hospital Laboratory; and five district hospital chosen. satellites laboratories in Byumba, Gihundwe, ● There are no designated sentinel sites Gisenyi, Kibungo, and Ruhengeri. for surveillance of AMR pathogens. ● Rubilizi National Veterinary Laboratory is ● There is no national plan for HCAI capable of detecting AMR pathogens in prevention and control. animals. ● There are no designated facilities ● Laboratory capacity exists to detect antibiotic conducting Hospital Acquired residues in some animal products, such as Infections programmes. dairy, honey and meat. ● There is no national plan for ● Potential sentinel sites exist for surveillance antimicrobial stewardship. of infections caused by AMR pathogens. ● There are no designated centres for ● A national epidemic surveillance system is in antimicrobial stewardship. place in both human and animal sectors. ● The draft AMR strategic plan needs to ● Healthcare facilities have individual IPC be finalized and validated. committees and SOPs. ● A minimal or small-scale awareness ● WASH programmes are in place in health campaign on antimicrobial resistance facilities. targeting some but not all related sectors ● Isolation units are in place in district and (animal, agriculture and human) referral hospitals, and there is an isolation stakeholders. Inadequate coordination centre at Rwanda Military Hospital. in AMR awareness programs ● There is a draft AMR strategic plan awaiting ● AMR not included in national Research validation from the Ministry of Health. agenda ● Legislation is in place for inspection and use ● AMR not adequately included in of medicines. training curricula ● SOPs are in place for prescribing antibiotics ● Lack of AMR stewardship programme in teaching hospitals. ● Inadequate regulation on the use of ● A national pharmaceutical policy is in place. antimicrobial products in all sectors ● There is a ministerial order determining the ● Insufficient data on the impact of AMR organization of veterinary pharmacy practice. in the country (mortality, disability or ● Antimicrobial resistance is considered in all morbidity, and economic) strategic documents (health policy, One ● Inadequate IPC programs Health policy, One Health Strategic Plan, ● Insufficient funds and financing HSSP IV) systems for sustainability in new ● Strong political commitment on the part of the medical products including, medicines government of Rwanda (Ministries of diagnosis tools, vaccines and other Agriculture, Health and environment) intervention. 5 Strengths Weaknesses ● Existence of a network of laboratories under ● Veterinary lab satellites are not national reference laboratory equipped enough and able to direct ● National reference Laboratory is accredited AMR. ISO 15189:2012 ● Lack of enough Veterinary lab satellite ● Existence of a national veterinary laboratory technicians trained on AMR detection. and satellite labs ● None veterinary professionals who treat ● Existence of epidemic surveillance systems their livestock. sites including TB, HIV, and malaria ● Existence of a strong vaccination program for humans and animals ● Existence of the One Health Policy ● Existence of coordination mechanisms (One Health Multi-Sectoral Coordination Mechanism) ● Existence of WASH program in all health system including community, ● Existence of Rwanda Food and Drug Authority with clear legislation and regulatory framework in place ● Existence of health/veterinary professional regulatory bodies ● Existence of Drugs therapeutic committees in all health facilities Opportunities Threats ● International organisation commitments ● Limited resources for full ● AMR is a priority in the global health agenda implementation of the NAPAMR ● Existence of mass media to facilitate ● Accelerated emergence of resistant awareness programs strains that are faster than response ● Existence of international health regulation development committee ● Promotion of the use of antibiotics ● Existence of Integrated diseases surveillance agent in for meat and milk production and response system (IDSR) ● Multiple porous borders growing the ● Existence of public Private partnership risk of imported cases initiatives ● Inadequate monitoring and surveillance ● Existence of social Cluster under the Prime systems for counterfeits products Ministry ● Enhanced coordination across sectors ● Development of a coordinated surveillance system ● Increased interest and funding from national and international sources 6 2 STRATEGIC FRAMEWORKS

2.1 Vision To ensure access and use of quality, safe and effective antimicrobials in treatment and prevention of infectious diseases in humans, animals and the environment.

2.2 Mission Embrace the One Health approach in the prevention, slow down and control of the spread of resistant microorganisms while ensuring the availability of safe, effective, and quality assured antimicrobials and their prudent/rational use.

2.3 Guiding Principles The guiding principles define that antimicrobial resistance affects not only human health, but also other sectors such as animal health, agriculture, food security, water and sanitation, and economic development, based on the 68th WHA resolutions. The introduction of NAP management should include all industries and disciplines, including conservation and stewardship initiatives, which are uncertain of the efficacy of antimicrobial medicines by all means. And it requires engagement from the whole of society, including a One Health Approach

2.3.1 Prevention first Each prevented infection is one that requires no care. Infection prevention can be cost-effective and enforced, even where resources are minimal, in all settings and industries. A "best buy" is good sanitation, hygiene and other infection control measures that can delay the production and restrict the spread of antibiotic-resistant infections that are difficult to treat.

2.3.2 Access The goal of preserving the capacity to treat severe infections requires equal access to, and sufficient use of, existing and new antimicrobial medicinal products. The successful implementation of the NAP to tackle antimicrobial resistance also depends on access to, inter alia, health facilities , health practitioners, veterinarians, preventive technologies, diagnostic tools, including those at the ‘point of care’, as well as awareness, education and details. The implementation of the NAP requires adequate investment in all strategies. This requires a good surveillance system, operational research, clear regulation, good laboratories, competent regulatory framework, professional education and training in both the human and animal health sectors well oriented, Political commitment, national and international collaboration as well as a sustainable financial system.

2.3.3 Incremental targets for implementation That NAP constitutes an opportunity for the country to answer the priority issues to achieve each of the global and national strategic objectives. 7

2.4 GOAL AND OBJECTIVES

2.4.1 Goal The overall goal of the action plan is to ensure the ability to treat and prevent infectious diseases with quality, effective and safe antimicrobials medicines.

2.4.2 Strategic Objectives The global five strategic objectives will be operationalized in order to reach the desired targets of this plan. In each strategic objective, the priority actions, strategic objectives, interventions and key activities have been identified. 1. Increase national awareness and understanding of AMR through education and training 2. Strengthen the Knowledge and Evidence-Based through Surveillance and Research Surveillance of antimicrobial resistance for Infection Prevention and Control 3. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures. 4. Optimize the Use of Antimicrobial Agents in Human and Animal Health 5. Ensure sustainable investment in AMR through Sustainable and equitable financing mechanism and research and development.

2.4.2.1 Strategic objective one: Increase national awareness and understanding of AMR through education and training In order to raise awareness of antimicrobial resistance and encourage behavioural improvement, steps need to be taken immediately through public outreach campaigns that address various audiences in the fields of human, animal and plant health. The inclusion in school curricula of antimicrobial agents and resistance would encourage greater understanding and awareness from an early age.. The development of antimicrobial resistance as a core component of professional education, training, certification, continuing education and development in the health, veterinary and agricultural sectors will help to ensure proper understanding and awareness among professionals. AMR's national awareness and knowledge will be improved by setting up an evidence-based public communication health program targeting people, a plant including the food chain; advocating for AMR and conducting campaigns; establishing knowledge management and sharing mechanism at all levels; including AMR as a core component of professional education, training, certification and development. The priority action in this strategic objective is focusing on the follows areas: 1. Awareness-raising and risk communication 2. Coordination framework 3. Education and training 8 Objective 1: Increase national awareness and understanding of AMR through education and training and good coordination: Priority action Strategic Activities areas interventions Awareness- Enhance 1. Conduct baseline assessment of the level of raising and risk Interventions knowledge and practices on AMR among social and communication aimed at professional groups concerning Human, animal and improving public Environment awareness 2. Develop and implement an evidence-based awareness programme/strategy 3. Establish a mechanism for the institutionalization and implementation of an awareness program in order to incorporate more public communication programme for AMR in human and animal health, food chain, plant production, and environment; 4. Undertake AMR awareness-raising activities in primary, secondary and tertiary schools and other learning institutions using specialized materials; 5. Enhance public awareness through dissemination and publication of research findings; 6. Identify and capacitate opinion leaders to champion the AMR agenda in key sectors. 7. Create public awareness on the effective use of antibiotics in the food value chain, human and animals AMR Improve AMR 8. Establish AMR information sharing mechanism in Coordination governance human, animal and environment sectors Framework mechanisms Education and Improve 9. Develop accredited continuing professional training awareness and development (CPD) and in-service training understanding of programmes on AMR including alternative learning AMR through method good 10. Establish a trace-back system in livestock and food of governance, animal origin effective 11. Establish the joint reporting mechanism on AMR communication, education and training Strengthen 12. Include AMR and related topics as a core component education and of professional education, training, certification and training of development human, animal 9 and environmental health professionals

2.4.2.2 Strategic Objective Two: Strengthen the Knowledge and Evidence-Based through Surveillance and Research In order to provide data on the magnitude and patterns of the AMR epidemic, improving awareness and evidence-based on surveillance and analysis is essential. Within the framework of a single health strategy, there is currently no AMR monitoring system in Rwanda, which in turn restricts national efforts to resolve AMR concerns. The AMR surveillance framework will be developed through the multi-sector AMR National Action Plan. For national action to track AMR and its spread, a laboratory-based surveillance system is needed. Equipping laboratories with facilities, reagents and human resources is imperative for reliable microbiological and antimicrobial susceptibility research. Besides, in order to exchange information using a one health approach, a structured system for AMR reporting will be established. The World Health Organization (WHO) approach will be used to assess antimicrobial agent's consumption surveillance in human, livestock, plants and environment. Surveillance and study interventions include the following priority actions areas for action: 1. Surveillance system 2. Laboratory capacity 3. Research and development Strategic Objective 2: Strengthen the Knowledge and Evidence-Based through Surveillance and Research Surveillance of antimicrobial resistance Priority action Strategic Activities areas interventions Surveillance system Support laboratory 1. Establish an AMR surveillance system Surveillance of functioning at all laboratory levels in sectors AMR (animal, Human, Plant, food and environment) and coordinated at national level. 2. Develop/review standards operating procedures (SOPs) for laboratory surveillance of AMR in humans and animals, food, agriculture and environment consistent and harmonized with international standards 3. Build laboratory capacities for AMR surveillance, standardize methods used in testing agencies for livestock, farm-raised aquatic animals and pets. 4. Build capacity of regulatory bodies to perform quality control of tests 10 5. Support the routine use of microbiological culture and sensitivity tests on prioritized microorganisms and antimicrobials in health facilities and on farms 6. Support capacity building for designated laboratories for AMR surveillance supervision to improve availability and reliability of routine microbiology laboratory testing. 7. Enrol the various participating laboratories in national and international external quality assurance programs 8. Analyse, disseminate and share surveillance data and information to facilitate decision making on diagnoses and treatment in clinical public health, veterinary practices, environment and wildlife laboratories and food technologies 9. Establish the joint reporting mechanism on AMR 10. Establish an early warning system and monitor trends to determine the risk factors, drivers of antimicrobial resistance, and its impacts on public and animal health and the economy Support Surveillance 11. Design and implement a national of Antimicrobial use antimicrobial use surveillance plan that defines activities and rules consistent with international surveillance standards in animal and human 12. Develop and implement procedures and methodologies for monitoring antimicrobials imported, used and disposed of. 13. Monitor prescribing practices, dispensing practices, client/community use and consumption patterns in health care settings, veterinary health practice, agriculture, aquaculture, traditional herbalists (indigenous technical knowledge groups) and communities 14. Support collection and sharing of data to evaluate and monitor Strategic objectives 11 aimed to improve appropriate use and access to antimicrobials in humans and animals 15. Monitor and evaluate the impact of pharmaceutical promotion on antimicrobial use Support Surveillance 16. Design and implement a national for Antimicrobial surveillance plan for monitoring Drug Residues in antimicrobial residues in foods and animal Food feeds, 17. Support the use of standard procedures following international Standards including the WHO/FAO Codex Alimentarius for monitoring antimicrobial residues in food 18. Establish collaboration mechanisms with the WHO/FAO Codex Alimentarius and other international efforts to generate and share actionable data 12

2.4.2.3 Strategic Objective Three: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures. In order to limit the production and spread of antimicrobial-resistant and multi-drug - resistant pathogens, better hygiene and infection prevention measures are necessary. Drug-resistant is not only present in the environment of health care, but also at the level of the household. Infection Prevention and Control (IPC) is needed to combat AMR with proper training of health personnel and community-level education. In order to promote infection prevention and control in health care, the national program for infection prevention and control needs to be improved at all levels. To respond to antimicrobial resistance, these efforts should go hand in hand with efforts to improve national linkages and partnerships. The use of vaccines will reduce the incidence of infection and reliance on antimicrobial agents, as well as the risk of developing and transmitting antimicrobial-resistant pathogens across the food chain. Strengthening laboratory and diagnostic infrastructure services to respond to the AMR protocol will be a prerequisite for promoting laboratory and diagnostic infrastructure support, which should include capacity building for laboratory and diagnostic services for antimicrobial agents and timely identification of outbreaks caused by resistant pathogens. Promoting AMR-based competency practices in human and animal health through professional development is also an important and crucial strategic initiative in the field of training and professional development. This can be accomplished by steps such as the setting up of certifiable formal hygiene and infection training programmes. Infection Prevention and Control (IPC) in teaching institutions and in the working environment, through certified competency-based curricula and AMR guidelines. 1. Overall, best IPC practices would lead to greater results in human and animal health outcomes, while reducing the overall treatment cost. Two priority actions have been identified to meet these challenges: Infection Prevention and Control (IPC) 2. Health Waste Management System Priority action Strategic interventions Activities areas Infection Promote Infection 1. Develop and disseminate tools for prevention and Prevention and Control information, education and control(IPC) Practices in Communities communication/behaviour change communication on IPC in communities, including schools and public places. 2. Promote food hygiene practices in all public places and communities. 3. Advocate for access to safe and clean water throughout the country. 13 Priority action Strategic interventions Activities areas Infection Support to improve the 4. Promote safe waste disposal and waste prevention and medical waste treatment practices control(IPC management system 5. Reduce transmission of AMR at the household level Infection Promote Biosecurity 6. Develop and disseminate farm biosecurity prevention and Measures in Agriculture guidelines to different categories of animal control(IPC farms, slaughter facilities, abattoirs and aquaculture facilities. 7. Promote hygiene, sanitation and infection prevention practices on farms. 8. Promote food safety campaigns and programmes good biosecurity practices in the agricultural, livestock and animal production industries. 9. Ensure compliance with minimum standards and promote adoption of advanced standards for infrastructure in animal and agricultural facilities in promoting biosecurity 10. Ensure availability and proper use of infection prevention materials and supplies in agricultural and animal facilities 11. Promote safe waste disposal and waste treatment practices from agricultural and animal facilities. Infection To adopt Collaboration 12. Establish collaboration mechanism with the prevention and and Partnerships WHO, OIE, FAO and other national, control(IPC regional and international efforts focused on the development and implementation of harmonized surveillance and capacity to detect and monitor antimicrobial use and resistance in prioritized pathogens 13. Create mechanisms for national, regional and international communication of critical events that may alert new resistance trends with global One Health implications 14. Adopt national, regional and international quality assurance Standards for a generation of quality data on IPC 14 Priority action Strategic interventions Activities areas Infection Strengthen Infection 15. Maintain up-to-date infection prevention prevention and Prevention and Control guidelines and ensure their availability in control(IPC Programs in Human, all health care facilities animal and environment 16. Institute/strengthen and support minimum standards for infrastructure that promote Infection Prevention and Control. 17. Create and promote specific guidelines for limiting the spread of multidrug-resistant organisms. 18. Support availability and proper use of infection prevention materials and supplies. 19. Encourage timely diagnosis and treatment of drug-resistant microorganisms. 20. Promote hand hygiene and other hygienic practices and behaviours that prevent transmission of infectious diseases. 21. Promote campaigns for infection control in human, animal and environment. 22. Create and strengthen multi-sectoral coordinating entities at all levels. 23. Improve human resource systems, education, and commitment to professionalism. 24. Institute/strengthen and support proper functioning of Infection, Prevention and Control at all levels committees. Increase and Optimize 25. Strengthen vaccination programs in human Use of Vaccines to and animal health. Prevent Infectious 26. Improve coverage of vaccination programs Diseases across the country for vaccine-preventable diseases in humans and animal. Review and strengthen 27. Promote personal hygiene and health waste environmental sanitation in congregate management systems in settings human and animal health 28. Enhance human, zoo-sanitary and sectors phytosanitary inspection services in waste management 29. Empower human, animal health workers on hygiene and safety standards and waste management 15 Priority action Strategic interventions Activities areas Build capacity in medical 30. Strengthen medical waste management waste management system 31. Organize training of animal health workers on hygiene and safety standards and waste management

2.4.2.4 Strategic Objective Four: Optimize the Use of Antimicrobial Agents in Human, Animal and Plant Health Antimicrobial resistance is closely related to antimicrobial use, and 50 per cent or more of antimicrobial use in hospitals is estimated to be inappropriate. The irrational use of antimicrobial agents has been well known in humans and now the issue has spread to animals where drug resistance is induced by non-compliance with the withdrawal period concept. Due to the irrational use of antimicrobials in animals through the food of animal origins such as meat, milk and eggs, the production of drug resistance to humans is growing. There is a need for antimicrobial stewardship programs to be implemented to address this problem. In addition to minimizing improper use, antimicrobial stewardship requires optimizing antimicrobial collection, dosing, route, and length of therapy to optimize clinical cure or infection prevention, while minimizing unintended consequences. By offering evidence-based prescribing and dispensing quality of treatment, it is important to improve stewardship for antimicrobial usage in health facilities. The administration will also track and assess at all levels the use and consumption of antibiotics. The enhancement of the regulatory system for the protection of antimicrobial agents and the revision of policies, regulations, guidelines and directives on the use of antimicrobials in the country are also priority areas for optimizing antimicrobial use. Other measures will include the strengthening of the regulatory framework for the quality control, distribution and usage of antimicrobial agents, including the illegal or uncontrolled use of antimicrobial agents in agriculture. The following priority actions have been established to maximize the responsible use of antimicrobials. 1. Regulatory Framework for Preservation of Antimicrobial Agents 2. Availability and accessibility of antimicrobial Agents in Human and Animal Health 3. Antimicrobial Stewardship Programs Priority action areas Strategic interventions Activities Regulatory Strengthen the 1. Review and strengthen the existing Framework for pharmaceutical quality management system for the Preservation of manufacturing and supply supply of medicines, covering Antimicrobial Agents chain manufacturing, production, storage, transport 2. Strengthen the regulatory mechanisms for access to antimicrobials in human and animal, and plant health 3. Promote the use of standard treatment guidelines for infectious 16 Priority action areas Strategic interventions Activities diseases both in human and animal health Promote Optimal 4. Create mechanisms for coordination Prescribing, Dispensing and support of Antimicrobial and Use in Humans Stewardship and ensuring optimal use 5. Regularly update and ensure availability of prophylactic and treatment guidelines and protocols for infectious diseases in human health. 6. Facilitate continued education and training to promote responsible prescribing practices, dispensing and administration principles for antimicrobials. 7. Institute/strengthen and support the proper functioning of drug and therapeutics committees in all health care facilities. 8. Support the development and dissemination of antimicrobial stewardship working manuals and procedures. 9. Provide up-to-date and unbiased medicine information services to health providers 10. Strengthen supervision of prescribing and dispensing outlets for human and animal-related antimicrobials. 11. Initiate incentives and reward systems for excellence in adherence to best practices and standards. 12. Institute/Strengthen stewardship committees Regulatory Prudent Use of 13. Develop and disseminate Framework for Antimicrobials in prescription guidelines for improving Preservation of Agriculture and appropriate use of antimicrobials in Antimicrobial Agents Veterinary Medicine agriculture and veterinary medicine 14. Support the development and dissemination of antimicrobial stewardship working manuals and 17 Priority action areas Strategic interventions Activities procedures for the agriculture and veterinary sector 15. Restrict broad or generalized use of antimicrobials as growth promoters or as feed additives 16. Strengthen regulation and oversight for the supply chain and use of antimicrobials in agriculture and veterinary medicine Accessibility and Optimize Access to 17. Ensuring the availability of availability of Effective Antimicrobial affordable and accurate diagnostic Antimicrobial Agents Medicines, vaccines and tools for all health facilities in Human and Animal Diagnostics in Human, 18. Enhance systems for financing Health Animal and Plant Health access to antimicrobial medicines or preventative AMR programmes. 19. Enhance and strengthen the supply chain for antimicrobials and distribution coordination for provision of appropriate antimicrobials at the national, regional and local levels to reduce the costs, wastage and inappropriate selection of antimicrobials to human health providers in a timely and efficient way. 20. Enhance capacity and support for local producers/manufacturers of antimicrobials. Promote the quality, safety 21. Strengthen licensing, approval, and efficacy of regulation and oversight over the antimicrobial agents antimicrobial supply chain (pharmaceutical manufacturers, distributors, importation, wholesalers and retailers). 22. Support capacity for regular quality assessment of antimicrobial agents in the Rwanda FDA quality laboratories. 23. Support supervision of pharmacies and ensure adherence to good pharmacy practices in all pharmacy outlets and regulate over-the-counter 18 Priority action areas Strategic interventions Activities availability and self-medication with antimicrobial medicines. 24. Strengthen the regulation of the pharmaceutical companies and adherence to Good Manufacturing Practices and pharmaceutical and antimicrobial waste 19

2.4.2.5 STRATEGIC OBJECTIVE FIVE: Ensure sustainable investment in AMR through Sustainable and equitable financing mechanism and research and development. To better manage the problematic antimicrobial resistance, we must build enough knowledge that will allow us to choose adequate measures to be undertaken to contain it to the best better manage the problematic antimicrobial resistance, we must build a knowledge base that will allow us to decide on the measures to be taken to contain it to the best. We also will need new good medical products to combat news resistant pathogens. Therefore, we will need to conduct surveys and studies to determine resource needs (Human, logistic and financial) as well as the investment required as to unsure the effectiveness in the implementation of the Plan. The international cooperation to promote the study and testing of new advanced medical products and innovations in the respective fields is key for this purpose. Priority action areas Strategic interventions Activities Sustainability of Promote Innovation in 1. Support mechanisms for coordinated Antimicrobial the Search for research and innovation Resistance Alternative Treatments 2. Support academia and other researchers in Interventions and Drug Development product development 3. Support research in alternative treatments for infections and link the traditional technical knowledge (TK) groups to the product development system Sustainability of Promote Innovations in 4. Support investments and collaborations and Antimicrobial Diagnostic Technology strengthen capacity for research, Resistance and antimicrobial development and testing of innovative Interventions resistance detection diagnostic technologies 5. Support validation of point-of-care diagnostics for the detection of infectious diseases and detection of resistance 6. Create linkages and support for Rwanda FDA scientists to take leadership roles in international research partnerships targeting AMR Sustainability of Collaborate with 7. Promote research to identify high-risk and Antimicrobial International Partners in high-burden resistant strains, their Resistance Basic Strategic objective resistance mechanisms and their Interventions Research transmission 8. Promote innovations for new antimicrobial drug development, vaccines, and other innovative therapies. 9. Invest and support collaboration in high- throughput genomics and sequencing technologies that have the potential to enhance product Development 20 Priority action areas Strategic interventions Activities 10. Support research on the burden of AMR to inform policy for investment in the implementation of the strategic objectives. 11. Establish a research innovation fund to support innovations that slow down AMR Sustainability of Enhance Operational 12. Support local research on resistance and Antimicrobial and Health Systems transmission pathways between the Resistance Research at the Local environment, humans, animals and food Interventions Level supply chain 13. Promote local research on antimicrobial use patterns to produce more context-specific stewardship approaches. 21

2.5 Governance

2.5.1 Antimicrobial Resistance Focal Point The One Health approach was adopted by the National Multi-Sectoral Coordinating Committee (MCC) for the development and implementation of the AMR Action Plan. The development of a plan of activities (NAP) as coordinated by MOH/ clinical service Directorate through the Pharmaceutical Services Unit focal point. This will work in collaboration with the AMR secretariat.

2.5.2 The National Antimicrobial Resistance Secretariat The National AMR Secretariat shall include AMR focal point within the ministry of agriculture and animal resources, the Ministry of Health, the ministry of environment/ and any other members nominated by multi-Sectoral Coordinating Committee (MCC). The Roles and Responsibilities of the National Antimicrobial Resistance Secretariat shall include the following: ● Coordinate the implementation of a national action plan for containment of AMR; ● Coordinate the monitoring and evaluation of day to day activities ● Coordination of the development and implementation of the M&E plan; ● Preparation, storage and circulation of documents (e.g. background papers, reports and advisory notes to Multi-Sectoral Coordinating Committee (MCC). ● Build sustained partnerships and work on AMR containment nationally and internationally; ● Identify stakeholders and encourage the development of a multi-sectoral and multidisciplinary MCC; ● Ensure regular data collection and information sharing by instituting effective communication and coordination among all stakeholders, members of the Multi-Sectoral Coordinating Committee (MCC). and their constituencies, sectors and disciplines; ● Coordination of the global monitoring of prevalence and trends of AMR in accordance with the global AMR Surveillance tools

2.5.3 Antimicrobial Resistance multi-sectoral coordinating committee A National Multi-Sectoral Coordinating Committee on AMR is the central National steering body and shall supervise and coordinate all AMR related activities in all sectors. The AMR Action plan operations shall be managed and implemented through the Multi-Sectoral Coordinating Committee. Under the chairmanship of the Medical Officer. Members of the Multi-Sectoral Coordinating Committee include representatives from different sectors and disciplines specifically from the sectors responsible for human, animal, plant, environment health, livestock and food production.

2.5.3.1 Members of Antimicrobial Resistance multi-sectoral coordinating committee Membership to the National antimicrobial resistance multi-sectoral coordinating committee shall include National Medicines and Therapeutic Committee, Global Antimicrobial Resistance Partnership, Focal person from Rwanda Veterinary Services, Director of Crop Development (Plant Health Services), Focal person from Aquaculture, Association, professional Regulatory bodies 22 (medical Pharmacy, Veterinary and allied health professional councils) Rwanda Food and Drug Authority, Pesticides Research Institute, universities ), One Health Coordination committee, Pharmaceutical Manufacturers and wholesalers. Other members from the Ministry of Health and environment should be MCC member. (IDSR; quality assurance Sections; Departments of Curative Services and Policy and Planning; and the National Health Laboratories. Membership also comprises Development Partners and International Organizations’ including the World Health Organization (WHO), Food and Agriculture Organization (FAO), Centre for Disease Control and Prevention (CDC), Management of Science for Health (MSH) and World Organization for Animal Health (OIE). It also includes medical and agriculture universities and professional councils.

2.5.3.2 Roles and Responsibilities of the antimicrobial resistance multi-sectoral coordinating committee The principal role of antimicrobial resistance multi-sectoral coordinating committee is to facilitate and coordinate all national responses to the menace of antimicrobial resistance including: ✔ Development of National antimicrobial resistance action plan and validate it; ✔ Formulation of national programs on antimicrobial resistance; ✔ Monitoring of the integrated implementation of AMR activities in all related sectors (Human, animal health); ✔ Enhancing partnership and networking of all internal and external stakeholders for implementation of antimicrobial resistance national programs/projects in order to ensure effective and efficient use of resources and sharing of information, expertise and resources for inter-sectoral antimicrobial resistance surveillance

2.5.4 Antimicrobial resistance multi-sectoral technical working group The National antimicrobial resistance multi-sectoral coordinating committee has four sub-Technical Working Groups (TWG) which in accordance with the defined Rwanda One Health Policy document and strategic objectives of the Nation Action Plan (NAP) for antimicrobial resistance main objectives. The TWG has a mandate with specific tasks to providing technical input, including conducting situational analysis and in collaboration with MCC development of National AMR Action Plan. The four established sub technical working groups are: (i) Sub technical working group for Awareness, effective communication and Education (ii) Sub Technical working group for AMR Knowledge, Surveillance, Research and sustainable investments (iii) Sub Technical working group for sanitation, hygiene and infection prevention and control (iv) Sub technical Working Groups for Antimicrobial use stewardship

2.5.4.1 Membership to TWG Membership TWG comprises experts from, infectious diseases, microbiology, infection prevention and control, social health, rational, use of medicines, crop and drug regulation, surveillance, environmental health and health promotion. 23

2.5.4.2 Roles and Responsibilities of TWG The MCC has established Terms of References (TORs) for each TWG stipulating specific scope, roles and responsibilities. The Technical Working Groups (TWGs) which are national groups interact with country representatives of the required sectors, as determined by their scope of work and report regularly to the MCC. Activities include to: ✔ Cooperate with MCC in Formulation of NAP and respective operational plans ✔ Develop National AMR Action plan implementation framework ✔ Monitoring and evaluation and report to MCC on the progress to the implementation of the respective strategic objective. ✔ Provide technical day to day update and advice to the MCC and AMR focal persons

2.5.5 Drugs Therapeutic Committee and Quality Improvement There is Drugs Therapeutic Committees (DTC) in each health facility with a mandate to ensure the rational use of medicines including antimicrobial products. Their functions of DTCs may include ✔ Promotion of better use of medical products; ✔ Monitoring all prescribing practices including antimicrobial prescribing, dispensing to the Standard in cording to Clinical protocols in place; ✔ Investigation and prevent on antimicrobial resistance ✔ In-service training and education on medical products rational use; ✔ Lead all activities for infection prevention, control and management in health facilities including antimicrobial related matter ✔ Ensure availability of all basic medical products rational use material for information and education. Those are the Standard Treatment protocol, therapeutic formulary and Essential Medicines List (STG/NTF/ NEML) 24 3 IMPLEMENTATION PLAN

3.1 Introduction This action plan includes a detailed, realistic and cost-effective implementation plan with the specific activities and the planned resources required to carry out the priority activities of the strategic plan. All stakeholders need to be open about their commitment to the fight against AMR in Rwanda, both within their institutions and concerning others, given the complexity of the AMR threat and the response... In order to achieve tangible results, ownership of the strategy by all stakeholders under the leadership of the government of Rwanda is critical. This plan is important in presenting what needs to be done to prevent the emergence and re-emergence of AMR, to enclose its dissemination, and to describe how the Government of Rwanda fits into regional and global efforts to fight resistance. The Government of Rwanda via the One Health Platform will reconstitute the Antimicrobial Resistance committee (AMRC). According to the recommended composition and representation of the ministries concerned, other players in the public and private sectors will contribute to the success of the strategy's implementation. With the support of technical working groups in each region, the AMRC will be responsible for overseeing the implementation of the strategic plan. The Committee shall include, as appropriate, overall strategic guidance and intervention commissions for all stakeholders engaged in surveillance and management of AMR.

3.2 Objective The objective of the implementation plan is to clarify concrete actions that need to be taken in conjunction with each of the strategies described above. Stakeholders will recognize and act to provide support where appropriate and where their resources help them to do so by providing feedback on the specific actions, proposed costs, and outputs. As a results, the implementation plan should be versatile enough to respond to contextual needs while retaining a solid one that ensures accountability and transparency.

3.3 Structural Framework The structural framework of the Implementation Plan is based on the Rwanda FDA faction of evidence and data coming from the population upwards with the Rwanda FDA AMRC providing guidance back to implementing stakeholders. The Rwanda FDA, AMRC, with its multi-sectoral and multi-disciplinary composition, can provide comprehensive and thorough advice back to the Government of Rwanda FDA and other stakeholders on how to better improve the actions being undertaken to address AMR. The Rwanda FDA AMRC will be able to make comprehensive and thorough feedback through independent Technical Working Groups (TWGs), which will comprise multi-disciplinary local experts, who will gather evidence from local implementers to be able to provide an impartial, objective, and balanced view of the realities on the ground. This structure allows for collective ownership of both the evidence, advice, and at the same time driving accountability and action in 25 response to failures and success of the NAP-AMR. The TWGs primary role will be to provide the technical knowledge and guidance necessary for action. Their actions are not limited to but may include baseline studies, consolidation and analysis of data, and/or identification of areas requiring improvement. While the TWGs will continue to refine the required Strategic objective s, and implementation strategies as well as M&E mechanism aimed at improving the outcomes of each strategic objective. By accumulating and documenting the evidence gathered over the lifetime of the NAP-AMR, the following NAP-AMR can be strengthened based on the lessons learned and evidence gathered. In order to promote greater accountability and ownership of the NAP-AMR, Ministry experts and/or implementers may be called upon to serve on the TWGs to provide the evidence for deliberation and evaluation. Since these Government stakeholders will be supporting the District Health Teams in the planning and implementation of the plan at the sub-national and peripheral levels, their active participation will allow financial resources and technical expertise to be provided directly. Combining their expertise and contribution in the development of technical guidance, fruitful carrying out of these proposed Strategic objective s will be able to be more directly integrated into the broader strategy for improving both animal and human health. At the community level, social mobilization through Health workers and other relevant animal health institutions will be used as a means of promoting local contribution and achievement. Gender-specific strategies will be developed to ensure that both men and women are involved in the prevention and control of communicable diseases. At Rwanda Biomedical Centre (RBC) the Epidemic Surveillance and Response (ESR) and the Department of Animal Resources Development (RAB) in collaboration with other departments will be key focal points in providing data and information to the TWGs as well as key recipients of the AMRC’s strategic guidance. The RAMRC and concerned departments will provide technical inspection /supervision to District Directors of Health Services and District Veterinary and Environment Offices. Together with the Rwanda AMRC, the technical working groups and the government departments will coordinate with the private sector on the development and implementation of regulations affecting the program, and for following the plan the implementation. The district level, the information will be fed into the national information system through the national reporting structures. The details of the plan are presented in the implementation matrix table.

3.4 Implementation Plan Matrix The matrix was made in accordance with the WHO AMR related tools for harmonization with the M&E matrix and to compare the plans for different countries. The table describes the activities and sub-activities to be carried out under each proposed strategic intervention in the strategic plan and sets out the unit of measure, the targeted quantities, the timeframe during which the activities are to be carried out, the location or place where the activities are to be conducted, the lead or responsible entity. The TWGs will periodically review the targets by formal data available in the HMIS and collect them through baseline surveys and what can be achieved within a delay. 26 Indicator Quantity Timeline Location Responsible Cost Source of Entity (USD) Funding Strategic objective 1: Increase national awareness and understanding of AMR through education and training Strategic intervention 1.1: Enhance interventions aimed at improving public awareness on antimicrobial resistance

1.1.1 Conduct baseline assessment of the level of knowledge and practices on AMR among social and professional groups in relation to Human, animal, and Environment Sub-activity: 1.1.1.1 Develop the ToRs ToRs for the Technical 1 Year1 National Rwanda One 458 Government of Rwanda for the Sub Technical Working Group Working Group (TWG) Health Multi- /Development Partners (STWG) on public awareness, training, developed sectoral (FAO, WHO, WFP, and Coordinating USAID…) education Mechanism

1.1.1.2 Establish a Sub Technical Technical Working Group 1 Year1 National Rwanda One 500 Government of Rwanda Working Group (STWG) on public established Health Multi- /Development Partners awareness, training, and Education sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.1.3 Prepare and Conduct field survey Report on field survey 1 Year1 Country Rwanda One 50,000 Government of Rwanda on the level of knowledge and practices produced wide Health Multi- /Development Partners on AMR among social and professional sectoral (FAO, WHO, WFP, groups in relation to Human, animal and Coordinating USAID…) Environment Mechanism

1.1.1.4 Conduct a multi-sectoral meeting Report on multi-sectoral 1 Year1 National Rwanda One 10,000 Government of Rwanda to disseminate the findings of the survey meetings available Health Multi- /Development Partners to stakeholders sectoral (FAO, WHO, WFP, 27 Coordinating USAID…) Mechanism

1.1.2. Develop and implement an evidence-based awareness program/strategy

1.1.2.1 Develop AMR communications AMR Communication 1 Year1 National Rwanda One Government of Rwanda strategy based on AMR National Action Strategy developed Health Multi- 30,000 /Development Partners Plan sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.2.2 Print and distribute AMR Number of Copies of the 5,000 Year1 National Rwanda One Government of Rwanda communication strategy to stakeholders AMR Health Multi- 27,778 /Development Partners Strategy disseminated sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.2.3 Publish and disseminate AMR Number of Copies of the 5,000 Year 1 National Rwanda One 15,000 Government of Rwanda communication strategy through various AMR Health Multi- /Development Partners communication channels and media Strategy published sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.2.4 Develop core communication Communication 10 Year 1 National Rwanda One Government of Rwanda messages for different target groups messages developed Health Multi- 10,486 /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 1.1 .3 Establish a mecanism for institutionalisation and implementation of the AMR awareness campaign and mobilise the population for participation 28 1.1.3.1 identify/ generate a list of List generated 1 Year 1 National Rwanda One 5,000 Government of Rwanda institutions to participate in AMR Health Multi- /Development Partners awareness sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.3.2. Develop an annual action plan AMR annual action plan 1 Year 1 National Rwanda One 10,000 Government of Rwanda and tools for the AMR awareness developed Health Multi- /Development Partners campaign sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.3.3 Conduct ToT for district public Number district public 242 Year 1-5 National Rwanda One 40,525 Government of Rwanda health, CHW, environmental specialists health, environmental Health Multi- /Development Partners educators and veterinary officers on the specialists, educators and sectoral (FAO, WHO, WFP, AMR awareness tools veterinary officers trained Coordinating USAID…) Mechanism

1.1.3.4 Conduct communications Number of professionals 4000 Year 2 National Rwanda One 54,210 Government of Rwanda training sessions for public health, trained Health Multi- /Development Partners environmental health and veterinary sectoral (FAO, WHO, WFP, workers on AMR from the community to Coordinating USAID…) district level Mechanism

1.1.3.5 Organise activities to raise public Number of activities 5 Year 1-5 National Rwanda One 15,000 Government of Rwanda awareness during the World Antibiotic carried out Health Multi- /Development Partners Awareness Week sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 29

1.1.3.6 Set up billboards along major Number of billboards set 50 Year 1 Country Rwanda One 41,667 Government of Rwanda travel routes wide Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.3.7 Air radio/TV segments with key TV/Radio 14 Year 2-5 National Rwanda One 19,444 Government of Rwanda messages segments/quarter Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.3.8 Conduct public dramas (at major Number of public Drama 5 Year 2-5 National Rwanda One 6,944 Government of Rwanda national events—Independence Day, per year conducted Health Multi- /Development Partners Labour Day etc.) sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.4 Undertake AMR awareness-raising activities in primary, secondary and tertiary schools and other special needs institutions

1.1.4.1 Identify current primary, Report on the assessment 1 Year 1 National Rwanda One 10,486 Government of Rwanda secondary and tertiary institutions and developed Health Multi- /Development Partners determine the integration of AMR sectoral (FAO, WHO, WFP, courses into the curriculum. Coordinating USAID…) Mechanism

1.1.4.2 Constitute a committee to review Report on the assessment 1 Year 1 National Rwanda One 10,486 Government of Rwanda school curricula in line with AMR developed Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 30

1.1.4.3 Integrate AMR in the curricula, Number of curricula 5 Year 2 National Rwanda One 330,625 Government of Rwanda revised Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.4.4 Support and train One Health One Health students 5,000 Year 2 National Rwanda One 330,625 Government of Rwanda students clubs/other forums at different clubs/other forums Health Multi- /Development Partners levels and sectors of the education supported on AMR sectoral (FAO, WHO, WFP, system Coordinating USAID…) Mechanism

1.1.4.5 Train education partners on Number of Education 1,000 Year 2 National Rwanda One 20,071 Government of Rwanda integration partners trained Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.4.6 Disseminate training materials Number of AMR training 1,000 Year 2 National Rwanda One 5,556 Government of Rwanda and tools to partners materials disseminated Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.4.7 Train media on AMR effective Number of 200 Year 2 National Rwanda One 3,958 Government of Rwanda reporting mechanism Journalist/communication Health Multi- /Development Partners experts trained sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.4.8 Distribute communication Number of Package of 200 Year 2 National Rwanda One 1,111 Government of Rwanda materials and tools to the media training materials Health Multi- /Development Partners distributed sectoral (FAO, WHO, WFP, 31 Coordinating USAID…) Mechanism

1.1.5 Enhance public awareness through dissemination and publication of research findings

1.1.5.1 Identify stakeholders (national 1 Year 1 National Rwanda One 2,000 Government of Rwanda and global) conducting research on AMR list/ number of Health Multi- /Development Partners stakeholders identified sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.5.2 Develop a multi-sectoral AMR Multi-sectoral AMR 1 Year 1 National Rwanda One 5,000 Government of Rwanda research agenda research agenda and Health Multi- /Development Partners developed internatio sectoral (FAO, WHO, WFP, nal Coordinating USAID…) Mechanism

1.1.5.3 Conduct interdisciplinaryNumber of studies on 5 Year 1-5 National Rwanda One 500,000 Government of Rwanda research on AMR AMR available and Health Multi- /Development Partners internatio sectoral (FAO, WHO, WFP, nal Coordinating USAID…) Mechanism

1.1.5.4 Disseminate and publish AMR Number of publications 5 Year 2-5 National Rwanda One 50,000 Government of Rwanda research findings available Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 32

1.1.5.5. Resource mobilisation. Apply Number of grants 2 Year 2-5 National Rwanda One 500,000 Government of Rwanda for grants through RNCST, academic Health Multi- /Development Partners institutional partnerships sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.6. Identify and capacitate opinion leaders to champion the AMR agenda in key sectors. 1.1.6.1 identify relevant opinion leaders Number of opinion 5 Year 1-5 National Rwanda One 10,000 Government of Rwanda leaders identified Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.6.2. Training of Opinion leader on Number of training 5 Year 2-5 National Rwanda One 40,000 Government of Rwanda AMR conducted Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.1.7. Establish awareness mechanism for effective use of antibiotics in the food value chain, human and animals

1.1.7.1 Identify Human and animal food Number of handlers 1 Year-2 National One Health 5,000 Government of Rwanda value chain handlers identified and MCM /Development Partners internatio (FAO, WHO, WFP, nal USAID…)

1.1.7.2 Prepare training documents for Training tools developed 8 Year-2 National One Health 10,000 Government of Rwanda Human and animal food value chain and MCM /Development Partners handlers internatio (FAO, WHO, WFP, nal USAID…)

1.1.7.3 Training of Human and animal Number of participants 250 Year-1-5 National One Health 50,000 Government of Rwanda food value chain handlers trained and MCM /Development Partners internatio (FAO, WHO, WFP, 33 nal USAID… Strategic intervention 1.2: Improve Antimicrobial Resistance governance mechanisms Activity: 1.2.1: Establish antimicrobial resistance information sharing mechanism in Human, Animal and Environment sectors Sub-activity: 1.2.1.1 Develop AMR AMR governance 1 Year 1 National Rwanda One 5,000 Government of Rwanda governance policies policies developed Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism Sub-activity: 1.2.1.2 Disseminate AMR Dissemination meetings 2 Year 1 National Rwanda One 5,000 Government of Rwanda governance policies to stakeholders Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism Strategic Intervention 1.3: Improve awareness and understanding of AMR through good governance, effective communication, education and training Activity 1.3.1: Develop accredited continuing professional development (CPD) and in-service training programmes on AMR, including alternative learning methods

1.3.1.1 Identify professional bodies in List of professional bodies 1 Year 1 National Rwanda One 5,000 Government of Rwanda various sectors Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 1.3.1.2: Develop AMR CPD training Training materials 1 Year 1 National Rwanda One 5,000 Government of Rwanda materials completed and printed Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 34 1.3.1.3: Conduct CPD on AMR for in- CPD implemented 5 Year 2 National Rwanda One 5,000 Government of Rwanda service professionals Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 1.3.1.4: Develop antimicrobial Guidelines developed 1 Year 3 National Rwanda One 5,000 Government of Rwanda stewardship guidelines Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism Activity 1.3.2: Establish a trace-back system in livestock and foods of animal origin 1.3.2.1: Identify abattoirs, and markets List generated 1 Year 1 National Rwanda One 5,000 Government of Rwanda dealing in livestock and agriculture Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 1.3.2.2: Conduct community Number of communities 10 Year 2 National Rwanda One 5,000 Government of Rwanda sensitization and capacity building sensitised Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 1.3.3: Establish the joint reporting Mechanism on AMR

1.3.3.1. Develop an effective reporting AMR reporting document 1 Year 1-5 National Rwanda One 20,000 Government of Rwanda system on AMR (LIMS) developed Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) 35 Mechanism

1.2.3.2 Train technicians on AMR number of trainees 20 Year 1 National Rwanda One 10,000 Government of Rwanda reporting Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.3.4 Establish a national coordination structure for surveillance of AMR

1.3.4.1 Write and approve terms of Developed ToR 20 Year1 National Rwanda One 458 Government of Rwanda reference for a national coordinating Health Multi- /Development Partners centre for AMR surveillance with the sectoral (FAO, WHO, WFP, mandate to oversee the AMR Coordinating USAID…) surveillance programme, including Mechanism collecting, aggregating and sharing data

1.3.4.2. Develop One Health strategic OH plan developed 1 Year1 National Rwanda One 500 Government of Rwanda plan for integrating NPA. Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 1.3.4.3Develop a roadmap for Numbers 20 Year1 National Rwanda One 458 Government of Rwanda implementation of One Health strategic Health Multi- /Development Partners plan sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism Intervention 1.4: Strengthen Education and Training of Human, Animal and Environmental Health professionals

1.4.1 Include AMR and related topics as a core component of professional education, training, certification and development 36

1.4.1.1 Conduct a needs assessment of Number of Needs 1 Year 1 Country Rwanda One 5,000 Government of Rwanda AMR- related gaps in the professional assessment Report wide Health Multi- /Development Partners education system at different levels sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.4.1.2 Disseminate the report of the Educational 100 Year 1 National Rwanda One 556 Government of Rwanda needs assessment findings to relevant and curriculum review Health Multi- /Development Partners educational and curriculum-approval bodies sectoral (FAO, WHO, WFP, bodies Coordinating USAID…) Mechanism

1.4.1.3 Review and update curricula New or updated 100 Year 2 National Rwanda One 5,000 Government of Rwanda based on gaps identified in needs curriculum Health Multi- /Development Partners assessment sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

1.4.1.4 Revise AMR mandatory training Educational Year 2 National Universit Rwanda One 5,000 Government of Rwanda course/programme at an undergraduate and curriculum review ies, Health Multi- /Development Partners and postgraduate level bodies health sectoral (FAO, WHO, WFP, and Coordinating USAID…) veterinar Mechanism y institutio ns and professio nals councils Strategic Objective 2: Strengthen the Knowledge and Evidence-Based through Surveillance and Research Intervention 2.1: Support Laboratory Surveillance of AMR 37

2.1.1 Establish an AMR surveillance system functioning at all Laboratory level in sectors (animal, Human, Plant, food and environment) and coordinated at national level.

2.1.1.1 Development of ToRs for AMR ToRs developed 1 Year 1 National Rwanda One 5,000 Government of Rwanda sub-Technical Working Health Multi- /Development Partners Group (TWG) for Laboratory AMR sectoral (FAO, WHO, WFP, surveillance (SURV TWG) Coordinating USAID…) Mechanism

2.1.1.2 Establish a national sub- SURV TWG established 1 Year 1 National Rwanda One 5,000 Government of Rwanda Technical Working Health Multi- /Development Partners Group (TWG) for Laboratory AMR sectoral (FAO, WHO, WFP, surveillance (SURV TWG) Coordinating USAID…) Mechanism

2.1.1.3 Conduct a baseline survey and Baseline survey report 1 Year 1 Country Rwanda One 15,000 Government of Rwanda needs assessment on Laboratory AMR available wide Health Multi- /Development Partners surveillance system sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.1.4 Develop an integrated Laboratory Integrated AMR 1 Year 1 National Rwanda One 10,057 Government of Rwanda AMR surveillance system and plan Surveillance plan Health Multi- /Development Partners developed sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.1.5 Dissemination of the Laboratory AMR surveillance plan 1,000 Year 1 National Rwanda One 5,556 Government of Rwanda AMR surveillance plan developed and distributed Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 38

2.1.1.6 Select priority surveillance sites List of Laboratory 1 Year 1 National Rwanda One 1,000 Government of Rwanda and surveillance sites selected Health Multi- /Development Partners agree on harmonized surveillance sectoral (FAO, WHO, WFP, methodologies Coordinating USAID…) Mechanism 2 .1.2 Develop/review Standards Operating Procedures (SOPs) for Laboratory surveillance of AMR in humans and animals, animals, food, agriculture, and environment, consistent and harmonized with international Standards 2 .1.2.1 Develop SOPs for Laboratory SOPs developed 1 Year 1 National Rwanda One 10,057 Government of Rwanda AMR surveillance Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1.2.2 Identify priority organisms, List 1 Year 1 National Rwanda One 833 Government of Rwanda samples and testing panels that meet Health Multi- /Development Partners international standards sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1.3 Build laboratory capacities for AMR surveillance, Standardize the methods used in testing agencies for livestock, farm-raised aquatic animals and pets. 2 .1.3.1 Undertake improvements in Renovations 20 Year 2-3 National Rwanda One 4,000,000 Government of Rwanda infrastructure and equipment for Health Multi- /Development Partners microbiological isolation and sectoral (FAO, WHO, WFP, susceptibility Coordinating USAID…) testing in the district, provincial, referral Mechanism laboratories and animal laboratories 2 .1.3.2 Equip laboratories Equipment 20 Year 2 National Rwanda One 4,000,000 Government of Rwanda microbiological isolation and Health Multi- /Development Partners susceptibility testing in the district, sectoral (FAO, WHO, WFP, provincial, referral laboratories and Coordinating USAID…) 39 animal laboratories Mechanism 2 .1.3.3 Improve the supply chain of A national system of the 40 Year 2 National Rwanda One 10,629 Government of Rwanda microbiology reagents and consumables supply chain is Health Multi- /Development Partners for avoiding the stock out-train implemented Training for sectoral (FAO, WHO, WFP, laboratory staff in logistics and supply Laboratory staff Coordinating USAID…) management conducted Mechanism 2 .1.3.4 Procure and install a national LIMS software procured 20 Year 2-3 National Rwanda One 10,000 Government of Rwanda laboratory information management and installed Health Multi- /Development Partners system (LIMS) sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1.4 Build capacity of regulatory bodies to perform quality control of tests 2 .1.4.1 Conduct needs assessment on the Needs assessment report 1 Year 1-2 National Rwanda One 1500 Government of Rwanda capacity of the regulatory to quality Health Multi- /Development Partners control of tests sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.4.2 Provide adequate Laboratory Number of equipped 20 Year 2-3 National Rwanda One 2,000,000 Government of Rwanda infrastructure and equipment for quality laboratories Health Multi- /Development Partners control of tests sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.4.3 Conduct training for regulators of Training report availed 30 Year 2-3 National Rwanda One 1,000,000 Government of Rwanda quality control of tests Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 40 2 .1.5. Support the routine use of microbiological culture and sensitivity tests on prioritized microorganisms and antimicrobials in health facilities and on farms 2 .1.5.1 Re-train clinicians and Training o sample 70 Year 2-3 National Rwanda One 35,000 Government of Rwanda veterinarians on appropriate sample collection conducted Health Multi- /Development Partners collection and transportation sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1. 5.2 Procure consumables for sample Procurement of assorted Year 2-5 National Rwanda One 4,000,000 Government of Rwanda collection, microbiological materials and consumables for sample Health Multi- /Development Partners susceptibility testing panels and reagents collection sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1.6. Support Capacity building for designated laboratories for AMR surveillance supervision to improve availability and reliability of routine microbiology laboratory testing 2 .1.6.1 Procure and make available Procurement of assorted Year 2-5 National Rwanda One 10,000 Government of Rwanda control strains and reference materials Reference materials Health Multi- /Development Partners conducted sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.6.2 Train laboratory staff, Training on QC/QA 100 Year 2-6 National Rwanda One 10,000 Government of Rwanda veterinarians and clinicians on quality conducted Health Multi- /Development Partners control and quality sectoral (FAO, WHO, WFP, assurance Coordinating USAID…) Mechanism 2 .1.7. Enrol the various participating laboratories in national and international External Quality Assurance programs 2 .1.7.1 Accredit the participating Accreditation of the 20 Year 3 National Rwanda One 20,000 Government of Rwanda laboratories participating Health Multi- /Development Partners Laboratories sectoral (FAO, WHO, WFP, 41 Coordinating USAID…) Mechanism 2 .1.7.2 Conduct annual review of SOPs SOPs reviewed 1 Year 3-5 National Rwanda One 10,000 Government of Rwanda Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1.7.3 Undertake regular supervision Plan of Supervision of 14 Year 3 Facility Rwanda One 20,000 Government of Rwanda and mentorship of the hospital Surveillance sites Health Multi- /Development Partners surveillance sites available and sectoral (FAO, WHO, WFP, implemented Coordinating USAID…) Mechanism 2 .1.7.4 Designate national microbiology National Microbiology 4 Year 3 National Rwanda One 1,000 Government of Rwanda reference labs Reference labs designated Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1.8. Analyse, disseminate and share surveillance data and information to facilitate decision making on diagnoses and treatments in clinical public health, veterinary practice, environment and wildlife laboratories and food technologies 2 .1.8.1 Procure and computers and Computers and soft wares 40 Year 2 National Rwanda One 40,000 Government of Rwanda software for data management system for procured Health Multi- /Development Partners sharing and disseminating information to sectoral (FAO, WHO, WFP, partners Coordinating USAID…) Mechanism 2 .1.8.2 Train Laboratory personnel on Training on data 40 Year 2 National Rwanda One 8,000 Government of Rwanda data management and reporting management and Health Multi- /Development Partners reporting conducted sectoral (FAO, WHO, WFP, Coordinating USAID…) 42 Mechanism

2.1.8.3 Share surveillance data locally, Reports Year 2- 5 National Rwanda One 50,000 Government of Rwanda nationally and internally 1 Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2.1.9: Establish the joint reporting Mechanism on AMR 2.1.9.1 conduct a multispectral technical Number 4 Year 1-5 National Rwanda One 20,000 Government of Rwanda meeting to establish effective reporting Health Multi- /Development Partners system on AMR sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.9.2 Establish a TWG with their TORs NA 1 Year 1 National Rwanda One 10,000 Government of Rwanda on the AMR joint reporting system Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.1.9.3 Share data locally, nationally and Reports 1 Year 2- 5 National Rwanda One 50,000 Government of Rwanda internally Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 2 .1 .10. Establish an early warning system and monitor trends to determine the risk factors and drivers of resistance, resistance burden and impacts on public and animal health and the economy 2 .1 .10. 1 Adopt international Standards Adopted International 1 Year 2 National Rwanda One 5,000 Government of Rwanda for AMR early warning Standards for early Health Multi- /Development Partners warning available sectoral (FAO, WHO, WFP, Coordinating USAID…) 43 Mechanism 2 .1 .10. 2. Sensitize laboratory staff, Staff sensitized 100 Year 2 National Rwanda One 5,000 Government of Rwanda clinicians, Health Multi- /Development Partners and veterinarians on identification and sectoral (FAO, WHO, WFP, evaluation of risks Coordinating USAID…) Mechanism 2 .1 .10. 3. Compile and provide Risk events/ System 4 Year 2 -5 National Rwanda One 5,000 Government of Rwanda information on identified risks: Establish compile and provide Health Multi- /Development Partners a system to compile and provide information on identified sectoral (FAO, WHO, WFP, information on identified risks risks established Coordinating USAID…) Mechanism 2 .1 .10. 4. Disseminate AMR data Reports/ System for 121 Year 2-5 Districts Rwanda One 5,000 Government of Rwanda throughout the country including remote dissemination established Health Multi- /Development Partners and hard-to-reach areas/ Establish a sectoral (FAO, WHO, WFP, system for dissemination Coordinating USAID…) Mechanism 2 .1 .10. 5.Train risk registrars Training for Risk 100 Year 2 National Rwanda One 2,014 Government of Rwanda (epidemiologists) to incorporate risk registrars conducted Health Multi- /Development Partners reporting into their registers sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism Intervention 2 .2: Support Surveillance of Antimicrobial Use

2.2.1. Design and implement a national antimicrobial use surveillance plan that defines activities and roles consistent with international Surveillance Standards in animal and human

2.2.1.1 Undertake a baseline survey and Baseline assessment 1 Year 1 National Rwanda One 10,000 Government of Rwanda needs assessment and identify gaps for report Health Multi- /Development Partners implementing an antimicrobial use sectoral (FAO, WHO, WFP, 44 surveillance plan Coordinating USAID…) Mechanism

2.2.1.2 Develop an integrated AMR use Plan 1 Year 1 National Rwanda One 20,000 Government of Rwanda antimicrobial use surveillance plan Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.1.3 Print and distribute antimicrobial Copies 1,000 Year 1 National Rwanda One 5,479 Government of Rwanda use plan Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.1.4 Disseminate the national stakeholders 200 Year 2 National Rwanda One 10,486 Government of Rwanda surveillance of antimicrobial use plan Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.2. Develop and implement procedures and methodologies for monitoring antimicrobials imported, used and disposed of

2.2.2.1 Develop and manual of Manual of Procedures 1 Year 1 National Rwanda One 10,486 Government of Rwanda procedures and methodologies for Health Multi- /Development Partners routine monitoring antimicrobial use sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.2.2. Train hospital, pharmacy and Health, Pharmacy and 1,000 Year 2 National Rwanda One 30,000 Government of Rwanda veterinary staff to collect and share veterinary Health Multi- /Development Partners antimicrobial use data routinely Staff sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism 45

2.2.2.3 Collect, collate and share Reports 1,000 Year 2 National Rwanda One 30,000 Government of Rwanda antimicrobial use data regularly Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.3. Monitor prescribing practices, dispensing practices, client/community use and consumption patterns in health care settings, veterinary health practice, agriculture, aquaculture, traditional herbalists (indigenous technical knowledge groups) and communities

2.2.3.1. Identify antimicrobial use and List of indicators 1 Year 1 National Rwanda One 5,000 Government of Rwanda practice indicators Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.3.2 Develop a manual of procedures Manual of Procedures 1 Year 1 National Rwanda One 30,000 Government of Rwanda for monitoring prescription and Health Multi- /Development Partners dispensing practices sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.3.3 Conduct regular monitoring Monthly Reports Year 2-5 National Rwanda One 20,000 Government of Rwanda prescription and dispensing practices of 12 Health Multi- /Development Partners antimicrobials sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.4. Support collection and sharing of data to evaluate and monitor Strategic objectives aimed to improve appropriate use and access to antimicrobials in humans and animals

2.2.4.1 Undertake regular data collection Reports Year 2-5 Country Rwanda One 20,000 Government of Rwanda on antimicrobial access and use 1,000 wide Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) 46 Mechanism

2.2.4.2 Analyze and share data with Quarterly reports Year 2-5 National Rwanda One 5,000 Government of Rwanda relevant stakeholders 4 Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.5 Monitor and evaluate the impact of pharmaceutical promotion on antimicrobial use

2.2.5.1 Develop tools for monitoring the Tools Year 2-5 National Rwanda One 5,000 Government of Rwanda impact of pharmaceutical promotion 1 Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.2.5.2 Collect, evaluate, and disseminate Quarterly reports Year 2-5 National Rwanda One 5,000 Government of Rwanda data on the impact of pharmaceutical 4 Health Multi- /Development Partners promotion on antimicrobial use sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism Intervention 2.3: Support Surveillance for Antimicrobial Drug Residues in Food

2.3.1 Design and implement a national surveillance plan for monitoring antimicrobial residues in food and animal feeds

2.3.1.1 Undertake a baseline survey and Assessment Report Year 1 National Rwanda One 20,000 Government of Rwanda needs assessment and identify gaps for 1 Health Multi- /Development Partners surveillance of antimicrobial residues in sectoral (FAO, WHO, WFP, foods and animal Coordinating USAID…) feeds Mechanism 47

2.3.1.2 Develop a national plan for Monitoring plan of Year 1 National Rwanda One 20,000 Government of Rwanda monitoring of antimicrobial residues in antimicrobial 1 Health Multi- /Development Partners foods and animal feeds residues in sectoral (FAO, WHO, WFP, Foods Coordinating USAID…) Mechanism

2.3.1.3 Print and distribute national Copies 5,000 Year 1 National Rwanda One 27,397 Government of Rwanda surveillance plan for monitoring residues Health Multi- /Development Partners in sectoral (FAO, WHO, WFP, foods and animal feeds Coordinating USAID…) Mechanism

2.3.1.4 Disseminate the national stakeholders 500 Year 2 National Rwanda One 10,000 Government of Rwanda surveillance Health Multi- /Development Partners plan sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2 Support the use of standard procedures in accordance with international Standards including the WHO/FAO Codex Alimentarius for monitoring antimicrobial residues in foods

2.3.2.1 Develop or adopt international Manual of 1 Year 1 National Rwanda One 10,000 Government of Rwanda Standards for antimicrobial residues in Procedures Health Multi- /Development Partners food sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2.2 Train veterinarians and Veterinary and 50 Year 2 National Rwanda One 10,000 Government of Rwanda laboratory laboratory staff Health Multi- /Development Partners personnel on monitoring antimicrobial sectoral (FAO, WHO, WFP, residues in food and animal feeds Coordinating USAID…) Mechanism 48

2.3.2.3 Identify and prioritize samples List of priority 1 Year 1 National Rwanda One 5,000 Government of Rwanda and Samples Health Multi- /Development Partners antimicrobial residues for testing sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2.4 Provide the appropriate Renovations 2 Year 1 National Rwanda One 800,000 Government of Rwanda infrastructure Health Multi- /Development Partners and renovations for the laboratories sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2.5 Equip national laboratories for Equipment 1 Year 2 National Rwanda One Government of Rwanda monitoring antimicrobial residues Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2.6 Train personnel in laboratory Veterinary and 50 Year 1 National Rwanda One 20,000 Government of Rwanda logistics and supply management laboratory staff Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2.7 Procure laboratory information LIMS software 2 Year 2 National Rwanda One 10,000 Government of Rwanda management system Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.2.8 Procure consumables and procurement assorted Year 2 National Rwanda One 400,000 Government of Rwanda supplies Health Multi- /Development Partners sectoral (FAO, WHO, WFP, 49 Coordinating USAID…) Mechanism

2.3.2.9 Enrol the various labs in national Labs 2 Year 2 National Rwanda One 5,000 Government of Rwanda and international external quality Health Multi- /Development Partners assurance sectoral (FAO, WHO, WFP, programs Coordinating USAID…) Mechanism

2.3.3. Establish collaboration mechanisms with the WHO/FAO Codex Alimentarius and other international efforts to generate and share actionable data

2.3.3.1 Summarise and share data in Reports 12 Year 2 National/R Rwanda One 20,000 Government of Rwanda standardized formats regularly egional Health Multi- /Development Partners sectoral (FAO, WHO, WFP, Coordinating USAID…) Mechanism

2.3.3.2. Hold regular dissemination Stakeholders 100 Year 2 -5 National Rwanda One 10,000 Government of Rwanda meetings Health Multi- /Development Partners for sharing data summaries with sectoral (FAO, WHO, WFP, stakeholders Coordinating USAID…) Mechanism 50 Strategic objective 3. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures Intervention 3.1: Promote Infection Prevention and Control Practices in Communities

3.1.1 Develop and disseminate tools for information, education and communication/behaviour change communication on IPC in communities, including schools and public places.

3.1.1.1 Undertake a survey on the Report on 1 Year 1 national Rwanda One Health 20,000 Government of Rwanda knowledge/attitudes/ perceptions and practices survey Multi-sectoral /Development Partners (FAO, in the community available Coordinating WHO, WFP, USAID…) Mechanism

3.1.1.2. Develop tools for information, Number of 40 Year 2 national Rwanda One Health 20,257 Government of Rwanda education and communication/behaviour tools Multi-sectoral /Development Partners (FAO, change communication on IPC in communities, produced Coordinating WHO, WFP, USAID…) Including schools and public places. Mechanism behavioural change communication strategy

3.1.1.3 Dissemination of information on Report on 500 Year 2- communit Rwanda One 277,778 Government of Rwanda infection control in the community public 5 y level Health Multi- /Development Partners (FAO, awareness sectoral WHO, WFP, USAID…) campaigns Coordinating available Mechanism

3.1.2 Promote food hygiene practices in all public places and communities.

3.1.2.1 Develop minimum Standards for food Guidelines 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda hygiene, handling and preparation developed Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 3.1.2.2Train food vendors and supervisors for Number of 5,000 Year 2- Countrywid Rwanda One Health 27,778 Government of Rwanda proper food handling practices food vendors 5 e Multi-sectoral /Development Partners (FAO, and Coordinating WHO, WFP, USAID…) supervisors Mechanism trained 51 Enforce regular check-ups of food handlers for Food 5,000 Year 2-5 communit Rwanda One Health 72,806 Government of Rwanda infectious diseases of public health importance handlers y level Multi-sectoral /Development Partners (FAO, related to food examined Coordinating WHO, WFP, USAID…) Mechanism

3.1.2.4 Undertake food inspection of foods and Number of 5,000 Year 2-5 Rwanda One Health 138,889 Government of Rwanda food products for public consumption Facilities Districts Multi-sectoral /Development Partners (FAO, inspected Coordinating WHO, WFP, USAID…) Mechanism

3.1.3 Advocate for access to safe and clean water throughout the country

3.1.3.1 Carry out a baseline to obtain Report on 1 Year 1-5 national Rwanda One Health 20,000 Government of Rwanda information on safe water usage in relation to survey Multi-sectoral /Development Partners (FAO, infection control and prevention is concerned available Coordinating WHO, WFP, USAID…) Mechanism

3.1.3.2 Increase safe water coverage in Number of each Year 1-5 Countrywid Rwanda One Health 30,000,000 Government of Rwanda communities new safe comm e Multi-sectoral /Development Partners (FAO, water sources unity Coordinating WHO, WFP, USAID…) established Mechanism

3.1.3.3 Review Standards and guidelines for Guidelines 1 Year 1-5 communit Rwanda One 10,486 Government of Rwanda assessing water safety in the context of AMR assessed y level Health Multi- /Development Partners (FAO, sectoral WHO, WFP, USAID…) Coordinating Mechanism

3.1.3.4 Conduct periodic water safety Water 2,000 Year 1-5 communit Rwanda One Health 114,472 Government of Rwanda analyses at consumption points Consumption y level Multi-sectoral /Development Partners (FAO, points Coordinating WHO, WFP, USAID…) Mechanism 52 Intervention 3.2.Support to improve the medical waste management system

3.2.1 Promote safe waste disposal and waste treatment practices.

3.2.1.1 Promote safe waste disposal and waste Number of 1 Year 1-5 National Rwanda One Health 10,486 Government of Rwanda treatment practices. Review and update IEC IEC Multi-sectoral /Development Partners (FAO, materials on safe materials set Coordinating WHO, WFP, USAID…) waste disposal Mechanism

3.2.1.2 Procure and make available waste Materials assort Year 1-5 Facility Rwanda One Health 2,000,000 Government of Rwanda disposal materials for infectious wastes available ed level Multi-sectoral /Development Partners (FAO, wherever generated Coordinating WHO, WFP, USAID…) Mechanism

3.2.1.3 Conduct training of trainers (TOT) for Number of 121 Year 1-5 National Rwanda One Health 59,831 Government of Rwanda waste handlers ToTs trained Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.2.1.4 Conduct mentorships sessions for Number 1,740 Year 1-5 Facility Rwanda One Health 48,333 Government of Rwanda waste handlers of level Multi-sectoral /Development Partners (FAO, sessions Coordinating WHO, WFP, USAID…) conducted Mechanism

3.2.1.5 Set up health care waste treatment Number of 3,854 Year 1-5 regional Rwanda One Health 19,270,000 Government of Rwanda facilities at each health facility health care Multi-sectoral /Development Partners (FAO, facilities Coordinating WHO, WFP, USAID…) established Mechanism

3.2.2 Reduce transmission of AMR at the household level.

3.2.2.1 Sensitization of the public on AMR Report on 50 Year 1-5 national Rwanda One Health 69,444 Government of Rwanda public Multi-sectoral /Development Partners (FAO, awareness Coordinating WHO, WFP, USAID…) Campaigns Mechanism available 53

3.2.2.2 Contact tracing and management of Number of 1,000 Year 1-5 household Rwanda One Health 138,889 Government of Rwanda patients with drug resistant microorganisms patients with level Multi-sectoral /Development Partners (FAO, drug resistant Coordinating WHO, WFP, USAID…) microorganis Mechanism ms traced

3.2.2.3 Support adherence to antibiotic Number of 1,000 Year 1-5 household Rwanda One Health 138,889 Government of Rwanda treatment at household level individuals level Multi-sectoral /Development Partners (FAO, supported Coordinating WHO, WFP, USAID…) Mechanism Intervention 3.3.: Promote Biosecurity Measures in Agriculture

3.3.1 Develop and disseminate farm biosecurity guidelines to different categories of animal farms, slaughter facilities, abattoirs and aquaculture Facilities.

3.3.1.1 Review and update biosecurity Validated 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda guidelines for different categories of animal guidelines Multi-sectoral /Development Partners (FAO, farms, slaughter facilities, abattoirs and available Coordinating WHO, WFP, USAID…) aquaculture facilities. Mechanism

3.3.1.2 Print and distribute biosecurity Number of 5,000 Year 1 National Rwanda One Health 27,778 Government of Rwanda guidelines to veterinarians and other copies of the Multi-sectoral /Development Partners (FAO, stakeholders guidelines Coordinating WHO, WFP, USAID…) printed and Mechanism distributed

3.3.1.3 Sensitize stakeholders on biosecurity Stakeholders 5,000 Year 1 National Rwanda One Health 97,292 Government of Rwanda guidelines Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.3.1.4 Train district veterinary officers on DVOs 121 Year 1 National Rwanda One Health 23,827 Government of Rwanda biosecurity guidelines Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) 54 Mechanism

3.3.1.5 Promote biosecurity practices on farms Radio/TV 50 Year 2-5 National Rwanda One Health 69,444 Government of Rwanda and animal facilities (e.g. abattoirs) segments Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.3.2 Promote hygiene, sanitation and infection prevention practices on farms.

3.3.2.1 Train farmers in on-farm sanitation and Farmers 5,000 Year 2 National Rwanda One Health 97,292 Government of Rwanda good hygiene practices Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.3.2.2 Undertake regular checks on sanitation Animal 500 Year 2-5 Farm level Rwanda One Health 134,222 GoR, and development Partners and hygiene on animal facilities and farms facilities and Multi-sectoral (FAO, WHO, WFP, USAID…) farms Coordinating Mechanism

3.3.2.3 Regular checks on animal feeds for Report on 2,000 Year 2-5 Farm level Rwanda One Health 114,472 Government of Rwanda contamination feed checks Multi-sectoral /Development Partners (FAO, available Coordinating WHO, WFP, USAID…) Mechanism

3.3.3 Promote food safety campaigns and programmes. Good biosecurity practices in the agricultural, livestock and animal production industries.

3.3.3.1 Sensitize farmers and the general public Public 100 Year 2-5 National Rwanda One Health 55,556 Government of Rwanda on production of safe animals for human awareness Multi-sectoral /Development Partners (FAO, consumption campaigns Coordinating WHO, WFP, USAID…) Mechanism

3.3.3.2 Train farmers in standards animal Number of 5,000 Year 2-5 districts Rwanda One Health 97,292 Government of Rwanda husbandry practices that reduce the need to use farmers Multi-sectoral /Development Partners (FAO, antimicrobial agents trained Coordinating WHO, WFP, USAID…) Mechanism 55

3.3.3.3 Provide regular advisory extension Number of 2,000 Rwanda One Health 55,611 Government of Rwanda services to farmers follow up Multi-sectoral /Development Partners (FAO, Visits Coordinating WHO, WFP, USAID…) conducted Mechanism

3.3.4 Ensure compliance with minimum standards and promote adoption of advanced standards for infrastructure in animal and agricultural facilities in promoting biosecurity 3.3.4 .1 Develop/update standards for farm Number of 1 Year 1 National Rwanda One 10,486 Government of Rwanda infrastructure that promote infection standards Health Multi- /Development Partners (FAO, prevention in animal handling facilities and guidelines sectoral WHO, WFP, USAID…) farms developed Coordinating Mechanism 3.3.4 .2 Print and distribute animal facility and Copies of the 2,000 Year 1 National Rwanda One Health 11,111 Government of Rwanda farm infrastructure Standards guidelines Multi-sectoral /Development Partners (FAO, printed and Coordinating WHO, WFP, USAID…) distributed Mechanism

3.3.4.3 Train district veterinary officers on Number of 121 Year 2 National Rwanda One Health 20,369 Government of Rwanda facility and farm infrastructure Standards DVOs trained Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.3.4.4 Conduct regular advisory/support Report on 2,000 Year 2-5 National Rwanda One Health 55,611 Government of Rwanda supervision/inspection of abattoirs/slaughter facilities Multi-sectoral /Development Partners (FAO, houses and aquaculture facilities inspected Coordinating WHO, WFP, USAID…) Mechanism 3.3.4 .5 Sensitize stakeholders on the need Report on 1,000 Year 2-5 National/di Rwanda One Health 19,514 Government of Rwanda for ante-mortem and post-mortem meetings strict Multi-sectoral /Development Partners (FAO, inspection conducted Coordinating WHO, WFP, USAID…) Mechanism

3.3.5 Ensure availability and proper use of infection prevention materials and supplies in agricultural and animal facilities 56

3.3.5.1 Develop/disseminate guidelines for Number of 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda infection prevention materials for animal Guidelines Multi-sectoral /Development Partners (FAO, facilities and farms developed Coordinating WHO, WFP, USAID…) Mechanism

3.3.5.2 Sensitize farmers and animal facility Report on 1,000 Year 2-5 National Rwanda One Health 19,514 Government of Rwanda operators on the guidelines animal Multi-sectoral /Development Partners (FAO, facility Coordinating WHO, WFP, USAID…) operators Mechanism and farmers available

3.3.6 Promote safe waste disposal and waste treatment practices from agricultural and animal facilities.

3.3.6.1 Conduct a baseline assessment of the Baseline 1 Year 2-5 National Rwanda One Health 20,000 Government of Rwanda current status of animal facility and farm waste report Multi-sectoral /Development Partners (FAO, Disposal available Coordinating WHO, WFP, USAID…) Mechanism

3.3.6.2 Develop/disseminate guidelines for safe Guidelines 1 Year 2-5 National Rwanda One Health 10,486 Government of Rwanda waste disposal for animal facilities and farms developed Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.3.6.3 Sensitize farmers and animal facility Number of 1,000 Year 2-5 National Rwanda One Health 19,514 Government of Rwanda operators on safe waste disposal and treatment farmers and Multi-sectoral /Development Partners (FAO, Practices animal Coordinating WHO, WFP, USAID…) facility Mechanism Operators trained

3.3.6.4 Sensitize stakeholders and farmers on Farmers and 1,000 Year 2- National Rwanda One Health 19,514 Government of Rwanda animal facility and farm waste recycling animal 5 Multi-sectoral /Development Partners (FAO, facility Coordinating WHO, WFP, USAID…) 57 operators Mechanism

3.3.6.5 Procure incinerators for abattoirs and Incinerators 20 Year 2- National Rwanda One Health 400,000 Government of Rwanda sick animals 5 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism Intervention 3.4: To adopt Collaboration and Partnerships

3.4.1 Establish collaboration mechanism with the WHO, OIE, FAO and other national, regional and international efforts focused on the development and implementation of harmonized surveillance and capacity to detect and monitor antimicrobial use and resistance in prioritized pathogens

3.4.1.1 Organize a harmonization workshop Report on Year 2 National Rwanda One Health 10,000 Government of Rwanda with international partners and other workshop 5 Multi-sectoral /Development Partners (FAO, stakeholders on the surveillance tools and available Coordinating WHO, WFP, USAID…) Methodologies Mechanism

3.4.1.2 Participate in regional and global Report Year 2 National/ Rwanda One Health 5,000 Government of Rwanda data-sharing platforms, including GLASS available 5 -5 Internation Multi-sectoral /Development Partners (FAO, al Coordinating WHO, WFP, USAID…) Mechanism

3.4.2 Create mechanisms for national, regional and international communication of critical events that may alert new resistance trends with global One Health implications

3.4.2.1 Identify AMR critical events that are Report Year 2 National Rwanda One Health 5,000 Government of Rwanda consistent with international Standards available 5 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.4.2.2 Institute global reporting mechanisms Report Year 2 National Rwanda One Health 5,000 Government of Rwanda for critical events available 5 -5 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 58

3.4.3 Adopt national, regional and international quality assurance Standards for the generation of quality data on IPC

3.4.3.1 Develop a manual of procedures for Manual of Year 2 National Rwanda One Health 10,000 Government of Rwanda Quality assurance mechanisms for surveillance Procedures 1 -5 Multi-sectoral /Development Partners (FAO, available Coordinating WHO, WFP, USAID…) Mechanism

3.4.3.2 Train personnel in Quality assurance Number Year 2 National Rwanda One Health 10,000 Government of Rwanda mechanisms for surveillance of 100 -5 Multi-sectoral /Development Partners (FAO, laboratory Coordinating WHO, WFP, USAID…) staff Mechanism trained 3.4.3. 3 Enroll all laboratory surveillance Report on Year 2 National Rwanda One Health 5,000 GoR and development partners in relevant quality assurance enrollment 22 -5 Multi-sectoral Partners(FAO, WHO, WFP, mechanisms available Coordinating USAID…) Mechanism Intervention 3.5. Strengthen Infection Prevention and Control Programs in Human, animal and environment

3.5.1. Maintain up-to-date infection prevention guidelines and ensure their availability in all healthcare facilities.

3.5.1.1. Review and Update the IPC policy Report on IPC 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda Policy Multi-sectoral /Development Partners (FAO, available Coordinating WHO, WFP, USAID…) Mechanism

3.5.1.2 Revise IPC manual for infection Report on IPC 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda prevention control guidelines Multi-sectoral /Development Partners (FAO, available Coordinating WHO, WFP, USAID…) Mechanism

3.5.1.3 Print and distribute IPC Guidelines Number of 2,000 Year 2 National Rwanda One Health 10,486 Government of Rwanda copies printed Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) 59 Mechanism

3.5.1.4 Disseminate IPC guidelines at all Number of 2,000 Year 2 National Rwanda One Health 10,000 Government of Rwanda health facilities and Vet clinics copies Multi-sectoral /Development Partners (FAO, disseminated Coordinating Mechanism WHO, WFP, USAID…)

3.5.2. Institute/strengthen and support minimum standards for infrastructure that promote Infection Prevention and Control.

3.5.2.1 Conduct situation analysis of IPC in Report 2,000 Year 2 Facility Rwanda One Health GoR and development Partners health facilities available Level Multi-sectoral (FAO, WHO, WFP, USAID…) Coordinating Mechanism

3.5.2.2 Update guidelines for health care IPC 1 Year 1 National Rwanda One Health 10,486 GoR and development Partners facility infrastructure that support minimum compliant Multi-sectoral (FAO, WHO, WFP, USAID…) IPC standards Infrastructure Coordinating Guideline Mechanism developed

3.5.2.3 Disseminate the guidelines Report 2,000 Year 1 National Rwanda One Health 10,486 Government of Rwanda available Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.5.2.4 Undertake support supervision to Report 2,000 Year Health Rwanda One Health 961,929 GoR and development Partners support implementation of IPC at Human and available 2,3 facility Multi-sectoral (FAO, WHO, WFP, USAID…) Veterinary health facility level Coordinating Mechanism 60

3.5.3. Create and promote specific guidelines for limiting the spread of multidrug-resistant organisms.

3.5.3.1 Setup functional IPC committees with Committees 2,000 Year Facility Rwanda One Health 10,000 Government of Rwanda TORs established 2,3 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.5.3.2 Train IPC committee members on their IPC members 2,000 Year National Rwanda One Health 69,758 Government of Rwanda functions trained 2,3 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.5.4. Support availability and proper use of infection prevention materials and supplies.

3.5.4.1 Regularly undertake performance Report 2,000 Year Human Vet Rwanda One Health 641,193 GoR and development Partners monitoring and mentoring of the IPC available 2,3 health Multi-sectoral (FAO, WHO, WFP, USAID…) committee members facilities Coordinating Mechanism

3.5.5. Encourage timely diagnosis and treatment of drug-resistant microorganisms.

3.5.5.1 Procure and timely distribute tools for Report Year 1- Facility Rwanda One Health 2,000,00 0 GoR and development Partners rapid diagnosis of drug-resistant organisms available 3 level Multi-sectoral (FAO, WHO, WFP, USAID…) Coordinating Mechanism

3.5.5.2 Train health care workers at the facility Number of 2,000 Year 1- Facility Rwanda One Health 38,958 Government of Rwanda/ level on the treatment and management of Health Care 3 level Multi-sectoral Development Partners (FAO, patients with MDR infections Providers Coordinating WHO, WFP, USAID…) trained Mechanism

3.5.5.3 Procure and timely distribute drugs for Report Year 1- Facility Rwanda One Health 3,000,00 0 Government of Rwanda/ the treatment of MDR available 3 level Multi-sectoral Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 61

3.5.6. Promote hand hygiene and other hygienic practices and behaviours that prevent transmission of infectious diseases.

3.5.6.1 Train health care workers at facility Number of 5,000 Year 1- Facility Rwanda One Health 139,447 Government of Rwanda/ level on hand hygiene and other hygienic Health Care 3 level Multi-sectoral Development Partners (FAO, practices and behaviours preventing the Providers Coordinating WHO, WFP, USAID…) transmission of infectious diseases trained Mechanism

3.5.6.2 Undertake health talks to patients about Report 10,000 Year 1- Facility Rwanda One Health 13,889 Government of Rwanda/ IPC behaviours to protect themselves from available 3 level Multi-sectoral Development Partners (FAO, acquisition and transmission of infectious Coordinating WHO, WFP, USAID…) diseases Mechanism

3.5.6.3 Train personnel on the correct use of Number of 14,33 Year 1- Facility Rwanda One Health 79,644 Government of Rwanda Personal Protective Equipment and materials health Care 6 3 level Multi-sectoral /Development Partners (FAO, for standard and transmission-based cautions Providers Coordinating WHO, WFP, USAID…) trained Mechanism

3.5.7. Promote campaigns for infection control in human, animal and environment

3.5.7.1 Train health care workers on IPC Number of 14,336 Year 1- Facility Rwanda One Health 79,644 Government of Rwanda health Care 3 level Multi-sectoral /Development Partners (FAO, Providers Coordinating WHO, WFP, USAID…) trained Mechanism

3.5.7.2 Undertake support supervision visits to Report 3,854 Year 1- Facility Rwanda One Health 79,644 Government of Rwanda reinforce infection control practices available 3 Level Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.5.8. Create and strengthen multisectorial coordinating entities at all levels

3.5.8.1 Establish a communication platform Coordination 3,854 Year 1- Facility Rwanda One Health 107,056 Government of Rwanda among IPC related committees e.g. medicines committee 3 Level Multi-sectoral /Development Partners (FAO, & therapeutics committee, AMR stewardship established Coordinating WHO, WFP, USAID…) 62 Mechanism

3.5.9. Improve human resource systems, education, and commitment to professionalism.

3.5.9.1 Conduct survey on training needs for Report 1 Year 1 National Rwanda One Health 20,000 GoR and development Partners health professionals regarding IPC available Multi-sectoral (FAO, WHO, WFP, USAID…) Coordinating Mechanism

3.5.9.2 Conduct regular continued professional Report 2,000 Year 2- Facility Rwanda One Health 55,556 GoR and development Partners development (CPD) training regarding IPC available 3 level Multi-sectoral (FAO, WHO, WFP, USAID…) Coordinating Mechanism

3.5.9.3 Integrate IPC content in the Report 100 Year 2- National Rwanda One Health 16,871 GoR and development Partners curriculum/ education for all health training available 3 Multi-sectoral (FAO, WHO, WFP, USAID…) institutions Coordinating Mechanism

3.5.10. Institute/strengthen and support proper functioning of Infection, Prevention and Control at all levels 3.5.10.1: Promote environmental sanitation Report Rwanda One Health GoR and development Partners and other hygienic practices and behaviours available Multi-sectoral (FAO, WHO, WFP, USAID…) that prevent transmission of infectious Coordinating diseases. Mechanism 3.5.10.2: Create an integrated AMR courses in Report Rwanda One Health GoR and development Partners the existing undergraduate and postgraduate available Multi-sectoral (FAO, WHO, WFP, USAID…) health professionals programs (human, animal Coordinating and environment health). Mechanism 3.5.10.3: Train in service Environmental Health Number of Rwanda One Health Government of Rwanda/ Professionals on antimicrobial resistance. professionals Multi-sectoral Development Partners (FAO, trained Coordinating WHO, WFP, USAID…) 63 Mechanism 3.5.10.4: Promote knowledge and skills in Report Rwanda One Health Government of Rwanda/ human, animal and environmental health available Multi-sectoral Development Partners (FAO, professionals on prudent antimicrobial use and Coordinating WHO, WFP, USAID…) resistance prevention. Mechanism 3.5.10.5: Incorporate courses on antimicrobial Report Rwanda One Health Government of Rwanda/ resistance into the continuous professional available Multi-sectoral Development Partners (FAO, development curricula for all health, Coordinating WHO, WFP, USAID…) agriculture, animal and environmental health Mechanism professionals with a system of ensuring accountability.

3.6. Increase and optimize the use of Vaccines to prevent infectious diseases

3.6.1. Strengthen vaccination programs in human and animal health

3.6.1.1 Procure vaccine and supply vaccines for Report Year 2- National Rwanda One Health 25,000,0 00 Government of Rwanda/ humans and animals available 3 Multi-sectoral Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 3.6.1. 2 Develop/review regulations for Regulations 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda/ vaccination s for animals with vaccination developed Multi-sectoral Development Partners (FAO, schedules Coordinating WHO, WFP, USAID…) Mechanism

3.6.1.3 Conduct campaigns to provide Report 50 Year 2- Rwanda One Health 69,444 GoR, and development Partners information, awareness and schedules about available 3 Multi-sectoral (FAO, WHO, WFP, USAID…) vaccination Coordinating Mechanism

3.6.1.4 Undertake vaccination of Human and Report 8,000, Year 2-3 Rwanda One Health 100,000,00 Government of Rwanda/ 64 animal against a broader range of diseases available 000 Multi-sectoral 0 Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.6.1.5 Conduct a baseline assessment for Report 1 Year 1 National Rwanda One Health 20,000 Government of Rwanda/ animal and human vaccines program and available Multi-sectoral Development Partners (FAO, services coverage Coordinating WHO, WFP, USAID…) Mechanism

3.6.1.6 Support routine maintenance of a Report Year 2-3 health Rwanda One Health 100,000 Government of Rwanda/ functional cold chain available facility Multi-sectoral Development Partners (FAO, level Coordinating WHO, WFP, USAID…) Mechanism

3.6.1.7 Procure vaccine and supply vaccines for Report Year 1-5 health Rwanda One Health Government of Rwanda/ humans and animals available facility Multi-sectoral Development Partners (FAO, level Coordinating WHO, WFP, USAID…) Mechanism

3.6.1.8 Develop/review regulations for Regulations 1 Year 1 National Rwanda One Health 10,486 Government of Rwanda/ vaccination s for animals with vaccination developed Multi-sectoral Development Partners (FAO, schedules Coordinating WHO, WFP, USAID…) Mechanism

3.6.1.9 Conduct campaigns to provide Report 50 Year 2- National Rwanda One Health 69,444 Government of Rwanda/ information, awareness and schedules about available 3 Multi-sectoral Development Partners (FAO, vaccination Coordinating WHO, WFP, USAID…) Mechanism Activity:3.6.2. Improve coverage of vaccination programs across the country for vaccine-preventable diseases in humans and animal

3.6.2.1 Review and recommend the Updated Year 1 National Rwanda One Health Government of Rwanda/ introduction of new vaccines for both human vaccine list 1 Multi-sectoral 10,486 Development Partners (FAO, and animals Coordinating WHO, WFP, USAID…) Mechanism 65

3.6.2.2 Undertake research to measure the Report 1 Year 2 National Rwanda One Health 100,000 Government of Rwanda/ impact/best methods of vaccinating animals available Multi-sectoral Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism Intervention 3.7. Review and strengthen health waste management systems in human and animal health sectors

3.7.1 Promote personal hygiene and environmental sanitation in congregate settings 3.7.1.1: Review the existing infectious Report 8 Year 1 National Rwanda One Health 50,000 Government of Rwanda/ outbreak guidelines to accommodate the available Multi-sectoral Development Partners (FAO, concept of hygiene and sanitation. Coordinating WHO, WFP, USAID…) Mechanism

3.7.2. Enhance human, zoo sanitary and phyto-sanitary inspection services in waste management

3.7.2.1 Equip zoo sanitary and phytosanitary Report Lump- Year 1 National Rwanda One Health 20,000 Government of Rwanda points with necessary facilities available sum Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.7.2.2. Conduct capacity building to respective Report 4 Year 1 National Rwanda One Health 10,000 Government of Rwanda inspectors available Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

3.7.3. Empower human, animal health workers on hygiene and safety standards and waste management 3.7.3.1: Conduct supportive supervision Report 2 Year 1 National Rwanda One Health 100,000 Government of Rwanda available Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism Intervention 3.8: Build capacity in medical waste management

3.8.1. Strengthen medical waste management system 66 Sub-activity 3.8.1.1: Identify needed waste Report done 1 Year 1 Rwanda One Health Government of Rwanda management equipment Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 3.8.1.1: Procure waste management equipment Number of 1 Year 2 Rwanda One Health Government of Rwanda equipment Multi-sectoral /Development Partners (FAO, procured Coordinating WHO, WFP, USAID…) Mechanism

3.8.2 Organise training of Animal Health workers on hygiene and safety standards and waste management 3.8.2.1: Training of Animal Health workers Reports of 1 Year 1 National Rwanda One Health Government of Rwanda training Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism Strategic objective 4: Optimize the Use of Antimicrobial Agents in Human and Animal Health Intervention 4.1.Strengthen the pharmaceutical manufacturing and supply chain

4.1.1. Review and strengthen the existing quality management system for the supply of medicines, covering manufacturing, production, storage, transport, etc.

4.1.1.1 Develop the ToRs for the Sub Technical ToRs for the 1 Year1 National Rwanda One Health Government of Rwanda Working Group (STWG) on optimising the use Technical Multi-sectoral 458 /Development Partners (FAO, of antimicrobial agents. Working Coordinating WHO, WFP, USAID…) Group Mechanism (TWG) developed

4.1.1.2 Establish a Sub Technical Working Sub 1 Year1 National Rwanda One Health 500 Government of Rwanda Group (STWG) on optimising the use of Technical Multi-sectoral /Development Partners (FAO, antimicrobial agents Working Coordinating WHO, WFP, USAID…) Group Mechanism established 67 4.1.1.3: Review and update the guidelines on Stakeholder Year 2 National Rwanda One Health 30, 000 Government of Rwanda procurement and supply chain for meetings 1 Multi-sectoral /Development Partners (FAO, antimicrobials Coordinating WHO, WFP, USAID…) Mechanism 4.1.1.4: Disseminate the revised guidelines to Copies of Year 2 National Rwanda One Health 20, 000 Government of Rwanda government and private health facilities for revised 1 Multi-sectoral /Development Partners (FAO, humans and animals guidelines Coordinating WHO, WFP, USAID…) printed Mechanism 4.1.1.5: Train human and animal health Number of Year 2 National Rwanda One Health 50, 000 Government of Rwanda workers on the revised guidelines trainings 20 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.1.2. Strengthen the regulatory mechanisms for access to antimicrobials in human, animal, and plant health 4.1.2.1: Review and update the current Consultative 2 Year 2 National Rwanda One Health 50,000 Government of Rwanda regulatory mechanisms meeting Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 4.1.2.3: Disseminate the revised guidelines to Copies of Year 2 National Rwanda One Health 20, 000 Government of Rwanda government and private health facilities revised 1 Multi-sectoral /Development Partners (FAO, guidelines Coordinating WHO, WFP, USAID…) printed Mechanism 4.1.2.4: Train health workers on the revised Number of Year 2 National Rwanda One Health 50, 000 Government of Rwanda guidelines trainings 20 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism 4.1.2.5: Monitor the implementation/ Field 5 Quarter National Rwanda One Health 50,000 Government of Rwanda compliance on all the revised guidelines impromptu ly Multi-sectoral /Development Partners (FAO, Visits Coordinating WHO, WFP, USAID…) 68 Mechanism

4.1.3. Promote the use of standard treatment guidelines for infectious diseases both in human and animal health.

4.1.3.1. Develop/review standard treatment New/ updated 1 Year 1 National Rwanda One Health 100000 Government of Rwanda guidelines for infectious diseases both in human document Multi-sectoral /Development Partners (FAO, and animal health available Coordinating WHO, WFP, USAID…) Mechanism

4.1.3.2. Disseminate the revised standard Copies of 2000 Year 2 National Rwanda One Health 100000 Government of Rwanda treatment guidelines on infectious diseases to updated Multi-sectoral /Development Partners (FAO, government and private health facilities guidelines Coordinating WHO, WFP, USAID…) printed and Mechanism circulated

4.1.3.2. Train health workers on the revised Number of 20 Year 2 Health Rwanda One Health 100000 Government of Rwanda treatment guidelines for infectious diseases trainings facilities Multi-sectoral /Development Partners (FAO, both in human and animal health Coordinating WHO, WFP, USAID…) Mechanism Intervention 4.2: Promote Optimal Prescribing, dispensing and Use in human

4.2.1 Create mechanisms for coordination and support of Antimicrobial Stewardship and ensuring optimal dose

4.2.1.1 Develop the ToRs for the Sub Technical ToRs for the 1 Year1 National Rwanda One Health 458 Government of Rwanda Working Group Antimicrobial Stewardship ASO Multi-sectoral /Development Partners (FAO, and Optimal Use. developed Coordinating WHO, WFP, USAID…) Mechanism

4.2.1.2 Establish a Technical Working Group ASO TWG Year 1 National Rwanda One Health 458 Government of Rwanda (TWG) on Antimicrobial Stewardship and 1 Multi-sectoral /Development Partners (FAO, Optimal Use (ASO TWG) Coordinating WHO, WFP, USAID…) 69 Mechanism

4.2.2 Regularly update and ensure availability of prophylactic, prescribing and treatment guidelines and protocols for infectious diseases in human Health

4.2.2.1 Review and update prescribing Prescribing Every National Rwanda One Health 40,000 Government of Rwanda guidelines/ regulations for formulation and guideline 1 2 years Multi-sectoral /Development Partners (FAO, essential Coordinating WHO, WFP, USAID…) Medicines Mechanism

4.2.2.2 Disseminate the revised prescribing Copies of the Year 1- National/Di Rwanda One Health 3,778 Government of Rwanda guidelines in both print and online to all health guidelines 5,000 5 strict level Multi-sectoral /Development Partners (FAO, facilities Coordinating WHO, WFP, Mechanism USAID…)Partners

4.2.2.3 Training prescribers and dispensers on Prescribers Year 2- National/R Rwanda One Health 70,000 Government of Rwanda the guidelines and 3,000 5 egional Multi-sectoral /Development Partners (FAO, dispensers Coordinating WHO, WFP, USAID…) Mechanism

2.2.2.4 Sensitize regulatory agencies and Regulator Year 1 national Rwanda One Health 5,486 Government of Rwanda policymakers to improve adherence to y bodies 2 Multi-sectoral /Development Partners (FAO, prescribing guidelines Coordinating WHO, WFP, USAID…) Mechanism

4.2.3 Facilitate continued education and training to promote responsible prescribing practices, dispensing and administration principles for Antimicrobials.

4.2.3.1 Conduct a needs assessment to Needs 1 Year 1 National Rwanda One Health 5,000 Government of Rwanda inform AMR-related CME trainings for assessment Multi-sectoral /Development Partners (FAO, relevant professions report Coordinating WHO, WFP, USAID…) available Mechanism

4.2.3.2 Organize ToT sessions for different ToT sessions Year 1 National Rwanda One 50,000 Government of Rwanda professionals 20 Health Multi- /Development Partners (FAO, sectoral WHO, WFP, USAID…) 70 Coordinating Mechanism

4.2.4. Institute/strengthen and support the proper functioning of drug and Therapeutics committees in all health care facilities

4.2.4.1 Develop the ToRs for the Drugs and ToRs 1 Year1 National Rwanda One Health 458 Government of Rwanda Therapeutic Committees (DTCs) at national developed Multi-sectoral /Development Partners (FAO, and health facility levels Coordinating WHO, WFP, USAID…) Mechanism

4.2.4.2 Activate Drugs and Therapeutic MTCs 348 Year 1- Regional Rwanda One Health 70,000 Government of Rwanda Committees (DTCs) at national and health formulated 5 Multi-sectoral /Development Partners (FAO, facility levels with clear TORs Coordinating WHO, WFP, USAID…) Mechanism

4.2.4.3 Train MTCs in their functions MTC Year 2- National Rwanda One Health 20,000 Government of Rwanda members 1,740 5 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.2.4.4 Regularly undertake performance Mentoring Year 1- Facility Rwanda One Health 50,000 Government of Rwanda monitoring and mentoring activities of the sessions for 348 5 Multi-sectoral /Development Partners (FAO, therapeutic Committees MTCs Coordinating WHO, WFP, USAID…) Mechanism

4.2.5. Support the development and dissemination of antimicrobial stewardship working manuals and procedures.

4.2.5.1 Develop the antimicrobial stewardship MOP Year 1 National Rwanda One 10,486 Government of Rwanda working manuals and procedures 1 Health Multi- /Development Partners (FAO, sectoral WHO, WFP, USAID…) Coordinating Mechanism

4.2.5.2 Print and distribute antimicrobial Copies Year 1 National Rwanda One Health 2,857 Government of Rwanda stewardship working manuals to all health 5,000 Multi-sectoral /Development Partners (FAO, 71 workers Coordinating WHO, WFP, USAID…) Mechanism

4.2.5.3 Train healthcare workers on Number of Year 2- National Rwanda One Health 200,000 Government of Rwanda antimicrobial stewardships for both public and Healthcare 1,000 5 Multi-sectoral /Development Partners (FAO, private health workers workers Coordinating WHO, WFP, USAID…) trained on Mechanism antimicrobial stewardship

4.2.6. Provide up-to-date evidence-based medicine information services to human and animal health providers.

4.2.6.1 Ensure that the LIMS database is Updated data Year 1- National Rwanda One Health 20,000 Government of Rwanda regularly updated in the LIMS Month 5 and Multi-sectoral /Development Partners (FAO, ly (12) facility- Coordinating WHO, WFP, USAID…) based Mechanism

4.2.6.2 Share disseminate susceptibility and AST and Year 1- National Rwanda One Health 20,000 Government of Rwanda antimicrobial use data regularly to Antimicrobial Mont 5 and Multi-sectoral /Development Partners (FAO, stakeholders usage data hly facility- Coordinating WHO, WFP, USAID…) shared (12) based Mechanism

4.2.6.3 Provide and share other updated Information Year 1- National Rwanda One Health 20,000 Government of Rwanda scientific and popular literature to improve shared Month 5 and Multi-sectoral /Development Partners (FAO, prescribing practices ly (12) facility- Coordinating WHO, WFP, USAID…) based Mechanism

4.2.7. Strengthen supervision of prescribing and dispensing outlets for human and animal-related antimicrobials

4.2.7.1 Develop a tool system for more efficient Supervision Year 1 National Rwanda One Health 10,486 Government of Rwanda supervision and monitoring of healthcare tool 1 Multi-sectoral /Development Partners (FAO, facilities and pharmacies/drug stores Coordinating WHO, WFP, USAID…) Mechanism

4.2.7.2 Train professional councils and Professional Year 1 National Rwanda One Health 20,000 Government of Rwanda licensing organs on supervision and monitoring councils and 20 Multi-sectoral /Development Partners (FAO, 72 dispensing outlets licensing Coordinating WHO, WFP, USAID…) organs Mechanism members trained

4.2.7.3 Conduct CMEs to improve prescription Health and Year 2 Rwanda One Health 200,000 Government of Rwanda and good pharmacy practice for health and veterinary 1,000 Multi-sectoral /Development Partners (FAO, veterinary prescribers prescribers Coordinating WHO, WFP, USAID…) Mechanism

4.2.7.4 Develop digital/manual tools for Prescription Year 1 National Rwanda One Health 2,000,000 Government of Rwanda tracking and tracing prescriptions at dispensing tracking tool 2 Multi-sectoral /Development Partners (FAO, facilities Coordinating WHO, WFP, USAID…) Mechanism

4.2.7.5 Disseminate the tools for tracking and Shared tools Year 1 Regionals Rwanda One Health 140,000 Government of Rwanda tracing prescriptions 2 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.2.7.6 Train supervisors on the use of the new Number of 20 Year 2 National Rwanda One Health 100000 Government of Rwanda tracking tools trainings Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.2.8. Initiate incentives and reward systems for excellence in adherence to best practices and Standards

4.2.8.1 Develop tools for the Licensing bodies Performance Year 1 National Rwanda One Health 10,486 Government of Rwanda and Professional Councils to track the monitoring 1 Multi-sectoral /Development Partners (FAO, performance of adherence to best practices and tool Coordinating WHO, WFP, USAID…) Standards Mechanism

4.2.8.2 Develop guidelines for the award of Guideline Year 1 National Rwanda One Health 10,486 Government of Rwanda incentives for excellence in prescription 1 Multi-sectoral /Development Partners (FAO, practices Coordinating WHO, WFP, USAID…) 73 Mechanism

4.2.8.3 Establish a budget to incentivize/ Budget Year 1-5 National Rwanda One Health Government of Rwanda reward excellence in prescription developed 1 Multi-sectoral 25,000 /Development Partners (FAO, practices Coordinating WHO, WFP, USAID…) Mechanism

4.2.9. Institute/strengthen stewardship committees

4.2.9.1 Establish stewardship committees at Stewardship Year 1 Health Rwanda One Health Government of Rwanda health care facilities committees 348 facility Multi-sectoral - /Development Partners (FAO, level Coordinating WHO, WFP, USAID…) Mechanism

4.2.9.2 Update National guidelines for MOH Year 1 National Rwanda One Health 50,000 Government of Rwanda handling resistant microorganism to prevent 1 Multi-sectoral /Development Partners (FAO, transmission Coordinating WHO, WFP, USAID…) Mechanism

4.2.9.3 Integrate data from different Integrated 12 Year 1 Health Rwanda One Health 50,000 Government of Rwanda committees (IPC, MTC, QA etc.) to inform best data (mont facility Multi-sectoral /Development Partners (FAO, practices for containment of resistant hly) level Coordinating WHO, WFP, USAID…) organisms at health facilities Mechanism

4.2.9.4 Develop a tool for auditing Audit tool Year 1 Health Rwanda One Health 2,500 Government of Rwanda antimicrobial prescriptions practices at health developed 1 facility Multi-sectoral /Development Partners (FAO, care facilities level Coordinating WHO, WFP, USAID…) Mechanism

4.2.9.5 Conduct audits of antimicrobial Facilities 5 Year 1- Health Rwanda One Health 2,500 Government of Rwanda prescriptions practices at health care facilities adhering to (one 5 facility Multi-sectoral /Development Partners (FAO, prescriptio per level Coordinating WHO, WFP, USAID…) n annum Mechanism guidelines ) Intervention 4.3: Prudent use of antimicrobials in agriculture and veterinary medicine 74

4.3.1 Develop and disseminate prescription guidelines for improving appropriate use of antimicrobials in agriculture and veterinary medicine

4.3.1.1 Develop or update Prescribing Year 1 National Rwanda One Health 100,000 Government of Rwanda Prescribing/treatment guidelines in animals guidelines 4 Multi-sectoral /Development Partners (FAO, and plants Coordinating WHO, WFP, USAID…) Mechanism

4.3.1.2 Print and distribute the prescribing Copies of the Year 1-5 National/ Rwanda One Health 12,778 Government of Rwanda guidelines to all health and drug facilities guidelines 5,000 District Multi-sectoral /Development Partners (FAO, level Coordinating WHO, WFP, USAID…) Mechanism

4.3.1.3 Train veterinarians and agriculturalists veterinarians Year 1 National Rwanda One Health 50,000 Government of Rwanda on new/ updated prescription trained 500 Multi-sectoral /Development Partners (FAO, guidelines Coordinating WHO, WFP, USAID…) Mechanism

4.3.2 Support the development and dissemination of antimicrobial stewardship working manuals and procedures for the agriculture and veterinary sector

4.3.2.1 Develop antimicrobial stewardship MOPs Year 1 National Rwanda One Health 10,000 Government of Rwanda programs for the agriculture and veterinary 1 Multi-sectoral /Development Partners (FAO, practice Coordinating WHO, WFP, USAID…) Mechanism

4.3.2.2 Print and distribute antimicrobial Copies Year 1 National Rwanda One Health 12,857 Government of Rwanda stewardship working manuals 5,000 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.3.2.3 Train veterinary and agriculture Veterinary Year 2-5 National/ Rwanda One Health 100,000 Government of Rwanda practitioners on antimicrobial stewardships for and 500 Regional Multi-sectoral /Development Partners (FAO, both public and private practitioners agriculture and Coordinating WHO, WFP, USAID…) practitioners veterinary Mechanism facilities

4.3.3 Restrict broad or generalized use of antimicrobials as growth promoters or as feed additives 75

4.3.3.1 Conduct a risk assessment on the use of Survey Year 1 National Rwanda One Health 20,000 Government of Rwanda growth promoters and use of antimicrobial Report 1 Multi-sectoral /Development Partners (FAO, agents as feed additives available Coordinating WHO, WFP, USAID…) Mechanism

4.3.3.2 Develop regulations/guidelines on the Regulations Year 1 National Rwanda One Health 20,000 Government of Rwanda use of growth promoters and use of microbial finalised 1 Multi-sectoral /Development Partners (FAO, agents as feed additives Coordinating WHO, WFP, USAID…) Mechanism

4.3.3.3 Print and distribute the Copies of the Year 1 National/ Rwanda One Health 12,778 Government of Rwanda regulation/guidelines on growth promoters and guidelines 5,000 District Multi-sectoral /Development Partners (FAO, feed additives level Coordinating WHO, WFP, USAID…) Mechanism

4.3.3.4 Sensitize farmers/animal health Farmers/ani Year 2-5 Regional Rwanda One Health 55,000 Government of Rwanda professionals and feed producers on growth mal health 1,000 Multi-sectoral /Development Partners (FAO, promoters professionals Coordinating WHO, WFP, USAID…) and feed Mechanism producers

4.3.4. Strengthen regulation and oversight for the supply chain and use of antimicrobials in agriculture and veterinary medicine.

4.3.4.1 Conduct a situational analysis of the Baseline Year 1 National Rwanda One Health 50,000 Government of Rwanda existing regulations and their implementation status 1 Multi-sectoral /Development Partners (FAO, /enforcement Coordinating WHO, WFP, USAID…) Mechanism

4.3.4.2 Train drug distributors and animal Trained Year 2-5 Rwanda One Health 50,000 Government of Rwanda health workers on distribution mechanisms of animal health 500 National/di Multi-sectoral /Development Partners (FAO, antimicrobials workers strict Coordinating WHO, WFP, USAID…) and drug Mechanism distributors Intervention 4.4: Optimize access to affective antimicrobial medicines , vaccines and diagnostics in human and animal health 76

4.4.1 Ensuring availability of affordable and accurate diagnostic tools for all health facilities

4.4.1.1 Procure adequate diagnostic resources Procured Year 1-5 National Rwanda One Health 3,200,000 Government of Rwanda (equipment, supplies, services, human diagnostic assorte and Multi-sectoral /Development Partners (FAO, resources) for infectious diseases at both public supplies and d facility- Coordinating WHO, WFP, USAID…) and private facilities for human and animal equipment based Mechanism health including Point of Care diagnostics

4.4.1.2 Establish a subcommittee that Committees Year 1 National Rwanda One Health 5,000 Government of Rwanda evaluates/recommends appropriate/affordable at health 348 and Multi-sectoral /Development Partners (FAO, and accurate diagnostic tools facilities facility- Coordinating WHO, WFP, USAID…) based Mechanism

4.4.1.3 Strengthen laboratory quality Enrolment 10 Year 1-5 National Rwanda One Health 20,000 Government of Rwanda management systems onto and Multi-sectoral /Development Partners (FAO, accreditation facility- Coordinating WHO, WFP, USAID…) schemes based Mechanism

4.4.2 Enhance systems for financing access to antimicrobial medicines or preventative AMR programmes.

4.4.2.1 Identify optimal financing mechanisms budget funds Year 1 National Rwanda One Health 50,000 Government of Rwanda for antimicrobial medicines or preventive secured 1 Multi-sectoral /Development Partners (FAO, AMR programs Coordinating WHO, WFP, USAID…) Mechanism

4.4.2.2 Lobby for financing for adequate Lobbying 5 Year 1-5 National Rwanda One Health 50,000 Government of Rwanda antibiotics at all health care facilities activities Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.4.3 Enhance and strengthen the supply chain for antimicrobials and distribution coordination for provision of appropriate antimicrobials at the national, regional and local levels in order to reduce the costs, wastage and inappropriate selection of antimicrobials to human health providers in a timely and efficient way. 77

4.4.3.1 Establish guidelines on the supply and Guidelines in Year 1 National Rwanda One Health 75,000 Government of Rwanda distribution of antimicrobials. place 1 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.4.3.2 Train suppliers of antimicrobials at National Year 1 National Rwanda One Health 20,000 Government of Rwanda national levels in efficient supply chain supplies 50 Multi-sectoral /Development Partners (FAO, management managers Coordinating WHO, WFP, USAID…) trained Mechanism

4.4.3.3 Train health facility procurement Facility Year 1 National Rwanda One Health 20,000 Government of Rwanda officers in procurement management of Procurement 348 Multi-sectoral /Development Partners (FAO, antimicrobials officers Coordinating WHO, WFP, USAID…) to ensure the availability of appropriate trained Mechanism antimicrobials and related supplies

4.4.3.4 Train facility pharmacists in Trained Year 1 National Rwanda One Health 20,000 Government of Rwanda antimicrobial chain management and pharmacists 348 Multi-sectoral /Development Partners (FAO, forecasting of need antimicrobials at their Coordinating WHO, WFP, USAID…) facilities Mechanism 4.4.3.5 support the supervision of health Field visits Year 1-5 National Rwanda One Health 100,000 Government of Rwanda facilities in the implementation of the 348 Multi-sectoral /Development Partners (FAO, guidelines on supply and distribution of Coordinating WHO, WFP, USAID…) antimicrobials Mechanism

4.4.4 Enhance capacity and support for local producers/manufacturers of antimicrobials.

4.4.4.1 Establish guidelines on local production Guidelines in Year 1 National Rwanda One Health 75,000 Government of Rwanda and distribution of antimicrobials. place 1 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.4.4.2 Expand support to existing incentive Funds Year 1 National Rwanda One Health 500,000 Government of Rwanda structures for local production of provided 5 Multi-sectoral /Development Partners (FAO, 78 antimicrobials and compliance with Standards Coordinating WHO, WFP, USAID…) of current good manufacturing practices Mechanism

4.4.4.3 Train local producers of antimicrobials Drug Year 1 National Rwanda One Health 50,000 Government of Rwanda in compliance with Standards of current good manufacturer 100 Multi-sectoral /Development Partners (FAO, manufacturing practices s trained Coordinating WHO, WFP, USAID…) Mechanism

4.4.4.4 Train local producers of antimicrobials Drug Year 1 National Rwanda One Health 50,000 Government of Rwanda in compliance with Standards of current good manufacturer 100 Multi-sectoral /Development Partners (FAO, manufacturing practices s trained Coordinating WHO, WFP, USAID…) Mechanism 4.4.4.5 support the supervision of health Field visits Year 1-5 NationalRwanda One Health 100,000 Government of Rwanda facilities in the implementation of the 348 Multi-sectoral /Development Partners (FAO, guidelines on production and distribution of Coordinating WHO, WFP, USAID…) antimicrobials Mechanism Intervention 4.5: Promote the Quality of, Safe and Efficacious antimicrobial agents

4.5.1 Strengthen licensing, approval, regulation and oversight over the antimicrobial supply chain (pharmaceutical manufacturers, distributors, importation, wholesalers and retailers)

4.5.1.1 Expand support to and recruitment of Recruitment Year 1-5 National Rwanda One Health 186,111 Government of Rwanda professionals in Rwanda FDA to improve 100 and Multi-sectoral /Development Partners (FAO, efficiency in regional Coordinating WHO, WFP, USAID…) their oversight and regulatory function Mechanism

4.51.2 Expand support to an automated system Automated Year 2-5 National Rwanda One Health 1,500,000 Government of Rwanda for improving processes system 6 and Multi-sectoral /Development Partners (FAO, effectiveness regional Coordinating WHO, WFP, USAID…) Mechanism

4.51.3 Sensitize private providers of antibiotics Private Sector Year 2-5 National Rwanda One Health 2,000,000 Government of Rwanda of Rwanda FDA regulations to increase awareness on 5,000 and Multi-sectoral /Development Partners (FAO, compliance regulations regional Coordinating WHO, WFP, USAID…) 79 Mechanism

4.5.2 Support capacity for regular quality assessment of antimicrobial agents in the Rwanda FDA quality laboratories.

4.5.2.1 Perform field visits to benchmark on the Visit report Year 1 National Rwanda One Health 5,000 Government of Rwanda equipment necessary for testing quality of 2 Multi-sectoral /Development Partners (FAO, antimicrobials. Coordinating WHO, WFP, USAID…) Mechanism

4.5.2.2 Procure supplies and equipment for Supplies and Year 2-5 National Rwanda One Health 5,000 Government of Rwanda testing quality of antimicrobials equipment assort Multi-sectoral /Development Partners (FAO, ed Coordinating WHO, WFP, USAID…) Mechanism

4.5.2.3 Collaboration with external laboratories MOUs Year 2- National Rwanda One Health 5,000 Government of Rwanda for quality assurance testing of antimicrobials 5 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.5.2.4 Undertake/subscribe to routine QA/QC QA/QC Year 2-5 National Rwanda One Health 20,000 Government of Rwanda checks for sustained compliance to WHO Renovated 4 Multi-sectoral /Development Partners (FAO, prequalification in chemical analysis and facilities Coordinating WHO, WFP, USAID…) relevant international Standards Mechanism

4.5.2.5 Undertake infrastructure improvements Renovated Year 2-3 National Rwanda One Health 200,000 Government of Rwanda for Rwanda FDA quality control lab facilities 1 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.5.2.6 Procure and install a laboratory Information Year 2 National Rwanda One Health 10,000 Government of Rwanda information management system (LIMS) management 1 Multi-sectoral /Development Partners (FAO, system Coordinating WHO, WFP, USAID…) Mechanism

4.5.3 Support supervision of Pharmacies and ensure adherence to good pharmacy practices in all pharmacy outlets and regulate over-the-counter availability and 80 self-medication with antimicrobial medicines

4.5.3.1 Conduct inspections on pharmacies Reports on Year 1- National Rwanda One Health 40,000 Government of Rwanda against GPP and establish compliance to over Pharmacies quarte 5 and Multi-sectoral /Development Partners (FAO, the counter (OTC) and self-medication inspected rly regional Coordinating WHO, WFP, USAID…) prescribing Mechanism

4.5.3.2 Enforce compliance to OTC dispensing Reports on Year 1- National Rwanda One Health 40,000 Government of Rwanda guidelines Facilities quarte 5 and Multi-sectoral /Development Partners (FAO, inspected rly regional Coordinating WHO, WFP, USAID…) Mechanism

4.5.4 Strengthen regulation of the pharmaceutical companies and adherence to good manufacturing practices and pharmaceutical and antimicrobial waste

4.5.4.1 Establish Harmonization mechanisms MOUs Year 1 National Rwanda One Health 20,000 Government of Rwanda with WHO and Rwanda FDA on the 3 Multi-sectoral /Development Partners (FAO, compliance assessments for pharmaceutical Coordinating WHO, WFP, USAID…) companies Mechanism

4.5.4.2 Develop guidelines for disposal of Guidelines Year 1 National Rwanda One Health 9,999 Government of Rwanda pharmaceutical and antimicrobial waste by the 1 Multi-sectoral /Development Partners (FAO, health facilities and general public Coordinating WHO, WFP, USAID…) Mechanism

4.5.4.3 Print and disseminate disposal Copies of the Year 1 National Rwanda One Health 10,000 Government of Rwanda guidelines guidelines 500 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

4.5.4.4 Sensitize pharmacies and drug dealers Pharmacies 500 Year 2- nationalRwanda One Health Government of Rwanda on pharmaceutical waste disposal and Drug 5 Multi-sectoral /Development Partners (FAO, handlers Coordinating WHO, WFP, USAID…) Mechanism Strategic objective 5: Ensure sustainable investment in AMR through Sustainable and equitable financing mechanism and research and development. 81 Intervention 5.1: Promote innovation in the search for alternative treatments and drug development

5.1.1 Support mechanisms for coordinated research and innovation

5.1.1.1 Develop the ToRs for the Sub Technical ToRs of 1 Year1 National Rwanda One Health 458 Government of Rwanda Working Group (STWG) on research and STWG Multi-sectoral /Development Partners (FAO, innovation developed Coordinating WHO, WFP, USAID…) Mechanism

5.1.1.2 Establish a Sub-Technical Working STWG 1 Year 1 National Rwanda One Health 1000 Government of Rwanda Group (TWG) on Research and Innovation Multi-sectoral /Development Partners (FAO, (STWG) Coordinating WHO, WFP, USAID…) Mechanism

5.1.1.3 Provide hands-on training to Number of 100 Year 1-5 National Rwanda One Health 10,000 Government of Rwanda researchers on grant writing Researchers Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

5.1.1.4 Advocate, lobby and share information Report Year 1 National Rwanda One Health 10,000 Government of Rwanda and RFPs for funding of AMR research contin Multi-sectoral /Development Partners (FAO, uous Coordinating WHO, WFP, USAID…) Mechanism

5.1.1.5 Sensitize researchers on intellectual number of 100 Year 1-5 National Rwanda One Health 10,000 Government of Rwanda property rights and patenting researchers Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

5.1.1.6 Apply for grants on innovation and Grant 2 Year 1 National Rwanda One Health 10,000 alternative drug discovery proposals Multi-sectoral Coordinating Mechanism

5.1.2. Support academia and other researchers in drug development 82

5.1.2.1 Provide seed funding for proposal Research 100 Year 1-5 National Rwanda One Health 100,000 Government of Rwanda development groups Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

5.1.2.2 Post calls for funding opportunities Posts done contin Year 1- National Rwanda One Health Government of Rwanda onto institutional websites and mailing lists of uous 5 Multi-sectoral - /Development Partners (FAO, stakeholders Coordinating WHO, WFP, USAID…) Mechanism

5.1.2.3 Establish a database of biological Database 1 Year 1- Countrywid Rwanda One Health 200,000 Government of Rwanda materials, including plants, fungi, and other created 5 e Multi-sectoral /Development Partners (FAO, compounds with suspected antimicrobial Coordinating WHO, WFP, USAID…) properties Mechanism

5.1.2.4 Support the establishment of Number of 5 Year 1- Internation Rwanda One Health 10000 Government of Rwanda international collaborations in high-throughput MoUs 5 al Multi-sectoral /Development Partners (FAO, screening of antimicrobial compounds Coordinating WHO, WFP, USAID…) Mechanism

5.1.3 Support research in alternative treatments for infections and link the traditional technical knowledge (TK) groups to the product development system

5.1.3.1 Explore and share innovative ideas workshop 2 Year 1- National Rwanda One Health 10,000 Government of Rwanda about alternative treatments to infectious 5 Multi-sectoral /Development Partners (FAO, diseases Coordinating WHO, WFP, USAID…) Mechanism

5.1.3.2 Carry out a country-wide survey of survey 1 Year 1 National Rwanda One Health 20,000 Government of Rwanda indigenous knowledge on antimicrobial Multi-sectoral /Development Partners (FAO, solutions Coordinating WHO, WFP, USAID…) Mechanism Intervention 5.2: Promote Innovations in Diagnostic Technology and antimicrobial resistance detection

5.2.1 Support investments and collaborations and strengthen capacity for research, development and testing of innovative diagnostic technologies

5.2.1.1 Conduct a baseline survey and needs Survey done 1 Year 1 National Rwanda One Health 150,000 Government of Rwanda 83 assessment to identify the opportunities and Multi-sectoral /Development Partners (FAO, challenges in innovative diagnostics Coordinating WHO, WFP, USAID…) Mechanism

5.2.1.2 Enhance the capacity of national Number 5 Year 1 National Rwanda One Health 25,000 Government of Rwanda regulatory bodies to assess and approve of Multi-sectoral /Development Partners (FAO, potentially innovative antimicrobial diagnostic Trainings Coordinating WHO, WFP, USAID…) technologies conducted Mechanism

5.2.2 Support investments and collaborations and strengthen capacity for research, development and testing of innovative technologies for antimicrobial resistance detection technologies

5.2.2.1 Conduct a baseline survey and needs Survey 1 Year 1 National Rwanda One Health 150,000 Government of Rwanda assessment to identify the opportunities and conducted Multi-sectoral /Development Partners (FAO, challenges in antimicrobial resistance detection Coordinating WHO, WFP, USAID…) technologies Mechanism (OH MCM

5.2.2.2 Enhance the capacity of national Number 5 Year 1- National Rwanda One Health 25,000 Rwanda One Health Multi- regulatory bodies to assess and approve of training 5 Multi-sectoral sectoral Coordinating antimicrobial resistance detection technologies conducted Coordinating Mechanism (OH MCM Mechanism (OH MCM

5.2.3 Support validation of point-of-care diagnostics for the detection of infectious diseases and the detection of resistance.

5.2.3.1 Assess the point of care diagnostics in Assessment Year 1 National Rwanda One Health 20,000 Government of Rwanda different stages of development Report 1 Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

5.2.3.2 Sensitize stakeholders on regulatory Number of 100 Year 1- National Rwanda One Health 10,000 Government of Rwanda systems and processes for approval of stakeholders 5 Multi-sectoral /Development Partners (FAO, diagnostic technologies sensitized Coordinating WHO, WFP, USAID…) Mechanism

5.2.3.3 Train regulatory agency staff in Number/cate 20 Year 1- National Rwanda One Health 5,000 Government of Rwanda 84 approval processes for diagnostics gory of 5 Multi-sectoral /Development Partners training done Coordinating (FAO, WHO, WFP, Number of Mechanism USAID…) staff trained

5.2.4 Create linkages and support for Rwanda FDA scientists to take leadership roles in international research partnerships targeting AMR.

5.2.4.1 Identify and disseminate opportunities Opportunities TBD Year 1- National Rwanda One Health 5,000 Government of Rwanda for scientists in international research / MOU signed 5 Multi-sectoral /Development Partners (FAO, partnerships and offer mentorship Coordinating WHO, WFP, USAID…) Mechanism

5.2.4.2 Provide seed funding to support Researchers TBD Year 2 National Rwanda One Health TBD Government of Rwanda Rwanda FDA n scientists in research in Multi-sectoral /Development Partners (FAO, leadership leadership Coordinating WHO, WFP, USAID…) Mechanism Intervention 5.3: Collaborate with International Partners in Basic Strategic objective Research

5.3.1 Promote research to identify high-risk and high-burden resistant strains, their resistance mechanisms and their transmission.

5.3.1.1 Organize workshops to share Number of 4 (1 Year 1- National Rwanda One Health 5,000 Government of Rwanda knowledge on high-risk and high-burden workshops per 5 Multi-sectoral /Development Partners (FAO, resistant strains conducted year) Coordinating WHO, WFP, USAID…) Mechanism

5.3.1.2 Expand seed funding provided for pilot Pilot studies TBD TBD National Rwanda One Health TBD Government of Rwanda studies of new antimicrobials done Multi-sectoral /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

5.3.2 Promote innovations for new antimicrobial drug development, vaccines, and other innovative therapies.

5.3.2.1 Identify and disseminate opportunities Stakeholders 100 Year 1- National Rwanda One Health 5,000 Government of Rwanda for participation in the development of 5 Multi-sectoral /Development Partners (FAO, antimicrobials, vaccines, and other innovative Coordinating WHO, WFP, USAID…) 85 therapies Mechanism

5.3.2.2 Identify and twin local laboratories with MOUs 5 Year 1- National Rwanda One Health 5,000 Government of Rwanda foreign laboratories to support the local 5 Multi-sectoral /Development Partners (FAO, production of vaccines Coordinating WHO, WFP, USAID…) Mechanism

15.3.2.3 Establish and maintain microbial Biologica 1 Year 1-5 National Rwanda One Health 5,000 Government of Rwanda collections and other biological resources for l Multi-sectoral /Development Partners (FAO, research and development of AMR solutions Resource Coordinating WHO, WFP, USAID…) Centres Mechanism

5.3.3 Invest and support collaboration in high-throughput genomics and sequencing technologies that have the potential to enhance product development

5.3.3.1 Undertake a baseline survey and needs Assessment 1 Year 1 National Rwanda One Health 5,000 Government of Rwanda assessment to identify current capabilities and Report Multi-sectoral /Development Partners (FAO, gaps in high-throughput genomics and Coordinating WHO, WFP, USAID…) sequencing in the country Mechanism

5.3.3.2 Establish a National Genomics and Genomics 1 Year 1-5 National Rwanda One Health 3,000,000 Government of Rwanda Bioinformatics Centre to support AMR Centre Multi-sectoral /Development Partners (FAO, research Coordinating WHO, WFP, USAID…) Mechanism

5.3.3.3 Identify and facilitate collaboration MOUs signed 1 Year 1-5 National 500 Government of Rwanda with international Centres of excellence /Development Partners (FAO, WHO, WFP, USAID…)

5.3.4 Support research on the burden of AMR to inform policy for investment in the implementation the strategic objectives.

5.3.4.1 Undertake research to examine the Report done Year 1 National Rwanda One Health Government of Rwanda burden of AMR in the country 1 Multi-sectoral 150,000 /Development Partners (FAO, Coordinating WHO, WFP, USAID…) Mechanism

5.3.5 Establish a research innovation fund to support innovations that slow down AMR. 86

5.3.5.1 Advocate and lobby for funding Research 1 Year 1 National Rwanda One Health 5,000,000 Government of Rwanda support for research innovations from and Multi-sectoral /Development Partners (FAO, government and pharmaceutical companies innovation Coordinating WHO, WFP, USAID…) fund Mechanism Intervention 5.4: Enhance Operational and Health Systems Research at the Local Level

5.4.1 Support local research on resistance and transmission pathways between the environment, humans, animals and food supply chain 5,4.1.1 Organize One Health workshops to Report(s) 1 Year 1 National Rwanda One Health 5,000 Government of Rwanda identify priorities for research on resistance done Multi-sectoral /Development Partners (FAO, and transmission pathways Coordinating WHO, WFP, USAID…) Mechanism

5.4.1.2 Identify and disseminate opportunities Report(s) Year 1-5 National Rwanda One Health 5,000 Government of Rwanda for One Health research funding done contin Multi-sectoral /Development Partners (FAO, uous Coordinating WHO, WFP, USAID…) Mechanism

5.4.2 Promote local research on antimicrobial use patterns to produce more context-specific stewardship approaches.

5.4.2.1 Identify priorities for research to workshops 1 Year 1 national Rwanda One Health 5,000 Government of Rwanda establish and improve antimicrobial Multi-sectoral /Development Partners (FAO, prescription and use patterns Coordinating Mechanism WHO, WFP, USAID…)

5.4.2.2 Conduct research to assess behavioural, research 5 Year 1-5 national Rwanda One Health 200,000 Government of Rwanda cultural and anthropological practices on Multi-sectoral /Development Partners (FAO, antimicrobial use in society, prescription Coordinating Mechanism WHO, WFP, USAID…) practices and motivators Total 17,915,999 87