National Multisectoral Action Plan on antimicrobial resistance for Micronesia 2019-2023

64. Mr. Semes Silbanuz – Pohnpei State Department of Resources & Development We also sincerely acknowledge the technical assistance provided by the following World Health Organization technical experts and advisors: Page 5 of 36

1 — Mr. Asaeli Raikabakaba – Technical Officer, WP/ACO/PIC – WHO Sub-regional

1. Mr. Asaeli Raikabakaba – Technical Officer, WP/ACO/PIC – WHO Sub-regional Office (Suva)

2 — Dr. Eunyoung KO – Country Liaison Officer – WHO CLO for Northern

2. Dr. Eunyoung KO – Country Liaison Officer – WHO CLO for Northern Micronesia Region (FSM)

3 — Dr. Socorro Escalante – Coordinator, EMT and acting DHS – WHO Regional

3. Dr. Socorro Escalante – Coordinator, EMT and acting DHS – WHO Regional Office for the Western Pacific (Manila) The development of this National Multisectoral Action Plan on Antimicrobial Resistance for the Federated States of Micronesia was fully supported by the World Health Organization. Page 6 of 36 Table of Contents Foreword by His Excellency President of the Federated States of Micronesia .............................................. 2 Joint Foreword by Department of Health & Social Affairs and Department of Resources & Development . 3 Acknowledgement .......................................................................................................................................... 4 Table of Contents ........................................................................................................................................... 7 Acronyms ....................................................................................................................................................... 8 1.0 Introduction .............................................................................................................................................. 9 2.0 Summary of brief Situational Analysis on Antimicrobial Resistance in FSM ........................................10 3.0 Governance of Antimicrobial Resistance in FSM ...................................................................................12 Proposed AMR Governance Structure ......................................................................................................13 FSM National AMR Committee – National level .....................................................................................14 Development Partners/Technical Advisors/Observers ..............................................................................14 Draft Composition and Term of Reference: ..............................................................................................14 State AMR Committee – State level ..........................................................................................................15 Draft Composition and Term of Reference: ..............................................................................................15 4.0 Goal .........................................................................................................................................................16 4.1 Strategic Objectives .................................................................................................................................16

1 — Establish and ensure governance, sustainable investment and actions to combat antimicrobial

1. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance ...................................................................................................................................................16

2 — Improving awareness and understanding of antimicrobial resistance across all institutions and sectors

2. Improving awareness and understanding of antimicrobial resistance across all institutions and sectors ...................................................................................................................................................................16 3. Strengthen surveillance, diagnostic capacity and research on antimicrobial resistance ........................16

4 — Reducing incidence of antimicrobial resistance through effective infection prevention and control

4. Reducing incidence of antimicrobial resistance through effective infection prevention and control measures, food safety and hygiene ............................................................................................................16

5 — Optimize the use of antimicrobial medicines in human and animal health ...........................................16

5. Optimize the use of antimicrobial medicines in human and animal health ...........................................16 5.0 FSM National AMR Operational plan (Years: 2019-2023).....................................................................18

1 — Establish and ensure governance, sustainable investment and actions to combat antimicrobial

1. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance ...................................................................................................................................................18 2. Improve awareness and understanding of antimicrobial resistance across all institutions and sectors..19 3. Strengthen surveillance, diagnostic capacity and research on antimicrobial resistance ........................21

4 — Reduce incidence of antimicrobial resistance through effective infection prevention and control

4. Reduce incidence of antimicrobial resistance through effective infection prevention and control measures, food safety and hygiene ............................................................................................................22

5 — Optimize the use of antimicrobial medicines in human and animal health ...........................................25

5. Optimize the use of antimicrobial medicines in human and animal health ...........................................25 Annex 1: A resolution of the 24th Micronesian Islands Forum on Antimicrobial Resistance………………28 Page 7 of 36 Acronyms AMR Antimicrobial Resistance AST Antibiotic susceptibility testing CSA Country situational analysis EQA External quality assessment FSM Federated States of Micronesia IEC Information, Education, and Communication IPC Infection prevention and control MTC Medicines & Therapeutic Committee M&E Monitoring and evaluation NAP National Action Plan on AMR NCD Non communicable disease NGO Non-governmental organization PPE Personal Protective Equipment QMS Quality management system TB Tuberculosis TOR Terms of Reference TWG Technical Working Group WASH Water, Sanitation and Hygiene WHO World Health Organization Page 8 of 36 1.0 Introduction In 2014, the World Health Organisation (WHO) declared antimicrobial resistance as a global health threat that requires urgent collaborative action. High rates of resistance to hospital and community-acquired infections have been reported globally, with some of the highest rates reported in the Western Pacific Region. Antimicrobial Resistance (AMR) has become one of the biggest threats to global health and affects both human and animal health. The World Health Assembly in 2015 endorsed the Global Action Plan on Antimicrobial Resistance 1 that urges Member States to develop national AMR plans by May 2017. The commitment from member states to develop their national action on AMR has been overwhelming. In the Federated States of Micronesia, many common infections are becoming resistant to antibiotics and few alternative treatments will be available soon. Hence, FSM has identified AMR as an important and priority health agenda that needs to be addressed by all states. Three multi-stakeholder meetings were convened to discuss and develop this National Multisectoral Action Plan on AMR with integrated activities to combat AMR in the FSM. This National Multisectoral Plan on AMR is aligned to the priority actions listed in the Action Agenda for Antimicrobial Resistance in the Western Pacific Region 2 and the Global Action Plan on Antimicrobial Resistance that focuses on four main principles of the global action plan; 1) whole-of-society engagement, 2) prevention first, 3) access to effective treatment, and 4) sustainability. 1 WHO (2015), Global Action Plan on Antimicrobial Resistance, Available at: https://www.who.int/antimicrobial-resistance/global-action-plan/en/ 2 WHO (2015), Action agenda for antimicrobial resistance in the Western Pacific Region, Available at: https://iris.wpro.who.int/handle/10665.1/10898 Page 9 of 36 2.0 Summary of brief Situational Analysis on Antimicrobial Resistance in FSM The FSM Department of Health and Social Affairs regularly published the leading causes for hospitalizations and out-patient visits to health services. While hypertension and diabetes are major causes of morbidity, illness caused by infectious agents outnumbers those caused by hypertension and diabetes combined. Infections of the upper respiratory tract, urinary tract, gastro-intestine and ear infections account for a high burden of disease in FSM. There is a relatively high incidence of tuberculosis (TB) and sexually transmitted infections caused by chlamydia and to a lesser extent gonorrhoea. FSM laboratories have published summary reports of antibiotic resistance patterns from the bacteria isolated from clinical specimens. While the laboratories do not have the capacity to test for all antimicrobials and all infectious agents; the laboratory reports clearly show an increasing amount of antimicrobial resistance. Methicillin resistant S. aureus is commonly isolated from both in patients and outpatients. There is a high proportion of enteric bacteria isolated that demonstrate resistance to a number of commonly used antibiotics. In some cases, resistance has been noted to all first and second line antibiotics. Additionally, FSM has experienced two outbreaks of multi-drug resistant TB in 2007 and

2009 — These laboratory reports confirm the serious situation of antibiotic resistance in

2009. These laboratory reports confirm the serious situation of antibiotic resistance in FSM that needs to be addressed urgently. Unfortunately, the impact of AMR in the FSM has not been fully established, especially in the animal health sector, and the country self-assessment, which was completed in May 2017, reveals that important improvements were made in many areas, but some weaknesses still remain. The results of the survey highlighted the need to have: a) a national comprehensive AMR plan with a formed committee, clear reporting structure between national and state level and champions to drive the country’s AMR agenda; b) a dedicated budget to support the implementation of the AMR plan in all states; c) national laboratory surveillance to track AMR in humans and animals in all states; d) specific regulation to regulate, enforce and promote the rational use of antimicrobials in both human and animal health; e) an antimicrobial stewardship programme mainly in state hospitals; f) effective procurement and supply chain management in order to ensure the availability and accessibility of quality antimicrobials; g) infection prevention and control activities and programmes in all sectors, including food safety; h) a well-trained workforce on how to combat AMR; i) continuous awareness campaign on AMR targeted at the public and health professionals, including vaccinations; and Page 10 of 36 j) proper waste management of antimicrobials. In summary, brief country situation analysis has identified areas that need strengthening such as: 1) Awareness raising on AMR in all areas; 2) Formulation of national comprehensive plan on antimicrobial resistance; 3) Coordinated national surveillance systems to monitor AMR and antimicrobial use in all states; and 4) Organized regulatory framework and governance to implement the AMR plan. Page 11 of 36 3.0 Governance of Antimicrobial Resistance in FSM i. High level endorsement of NAP and relevant policies and legislation ii. National AMR Committee (newly formed) shall provide briefings and updates to President and Congress on progress of AMR NAP implementation in all FSM states with further recommendations for consideration and endorsement. Act as advisor to the President from time to time. Provide technical guidance to state AMR committees as when required in relation to the implementation of state AMR plan. Direct/guide FSM response (planning) to AMR related activities. Coordinate external assistance and funding to support the implementation of AMR activities in each state. FSM National AMR committee will be co - chaired by FSM Department of Health and Social Affairs and the Department of Resource and Development. Chairmanship will be rotated between the two co-chairing departments. iii. State AMR Committee shall coordinate, implement and monitor state AMR plan and provide reports/feedback to National AMR committee and State Governors, when needed. Page 12 of 36 Proposed AMR Governance Structure PRESIDENT 'j\ w ➔1 FSM NATIONAL AMR SECRETARIAT (FSM COMMITTEE < Department of Health and Social Affairs) 'j\ '1 STATES’ AMR COMMITTEES ➔1 SECRETARIAT (States’ < Departments of Health Services) Page 13 of 36 FSM National AMR Committee – National level Suggested Members: (Secretaries/Heads of the relevant departments/organizations)  FSM Department of Health and Social Affairs  FSM Department of Resource and Development (Agriculture; Quarantine; Forestry & Fisheries; Trade & Investment)  College of Micronesia - FSM (Public Health & Nursing Program; Cooperative Research & Extension)  FSM Department of Education  FSM Department of Finance & Administration  One Rep from each state – chairperson of state AMR committee Development Partners/Technical Advisors/Observers  WHO  FANGO (umbrella organization for all national NGOs)  SPC  Representative from the Medical Association Draft Composition and Term of Reference: • Membership should reflect all sectors involved in containing AMR at the national level • Committee will be co-chaired by the FSM Department of Health & Social Affairs and the FSM Department of Resource & Development; Chairmanship will be rotated between the two co-chairing departments • Committee will meet four times a year and or as necessary • Coordinate all efforts to address AMR in all FSM states • Oversee the development and review of national AMR plan • Coordinate external assistance and funding to support the implementation of AMR activities in each state. • Develop policies and strategies pertaining to the AMR Action Plan and monitoring • Report to the President • Supported by State AMR committee Page 14 of 36 State AMR Committee – State level The States shall establish their own multisectoral AMR committee with the suggested members: (Directors/Heads of the relevant departments/sectors)  Department of Health Services  College of Micronesia state extensions  Department of Resource & Development (Agriculture, Quarantine, Forestry & Fisheries)  Department of Education  Department of Finance & Administration  Department of Marine Resources  State Environmental Protection Agency  Private Pharmacy and Medical Clinics  Umbrella organization for each state NGOs (observers) (ex: PANGO for Pohnpei State)  Medical Associations  Member from EpiNet Team Draft Composition and Term of Reference: • Membership should reflect all sectors involved in containing AMR at state level • Committee will be co-chaired by the Department of Health Services and the Department of Resource and Development • Coordinate the implementation of the National AMR plan in the States • Committee may meet four (4) times a year or as necessary; • The committee may create technical working groups or a secretariat as it deems necessary • Provide progress / updates/ feedbacks to the National AMR Committee and State Governors when needed • Develop strategies and interventions to address specific challenges in the implementation of the AMR plan at the state level Page 15 of 36 4.0 Goal To maintain a healthy population in the Federated States of Micronesia by ensuring the availability and accessibility of effective antimicrobials 4.1 Strategic Objectives

1 — Establish and ensure governance, sustainable investment and actions to

1. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance • Establish AMR governance structure for finalizing and implementing the national action plan • Ensure political commitment on the implementation of the national action plan • Development and enforcement of appropriate legislations in all sectors • Ensure sustainable investment in combating AMR

2 — Improving awareness and understanding of antimicrobial resistance across

2. Improving awareness and understanding of antimicrobial resistance across all institutions and sectors • Promote information sharing on the situation of AMR and use of antimicrobials across institutions and sectors • Raise awareness on AMR to health-care workers and veterinarians

3 — Strengthen surveillance, diagnostic capacity and research on antimicrobial

3. Strengthen surveillance, diagnostic capacity and research on antimicrobial resistance • Develop a national AMR surveillance system with a reference laboratory • Strengthen food safety capacity to combat AMR • Strengthen research and information sharing on AMR

4 — Reducing incidence of antimicrobial resistance through effective infection

4. Reducing incidence of antimicrobial resistance through effective infection prevention and control measures, food safety and hygiene • Establish a national infection prevention and control programme • Implement the Water, Sanitation and Hygiene (WASH) program to promote safe water and hygiene practices • Promote good infection control and bio security practices in animal husbandry • Implement Good Hygienic Practices (GHP) and Hazard Analysis and Critical Control Point (HACCP) in food handling and processing • Strengthen vaccination program in human sector

5 — Optimize the use of antimicrobial medicines in human and animal health

5. Optimize the use of antimicrobial medicines in human and animal health • Strengthen regulations to promote responsible use of antimicrobials Page 16 of 36 • Establish and develop national guidelines and programs to control the use of antimicrobials • Strengthen procurement and supply of antimicrobials • Strengthen the capacity of pharmacovigilance system in human health Page 17 of 36 5.0 FSM National AMR Operational plan (Years: 2019-2023) SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR

1 — Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance

1. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance 1.1 Establish AMR governance structure for finalizing and implementing the national action plan 1.1.1 Formalize the establishment of a National and State AMR committee Establish a AMR committee in both National and State level Mar 2020 Secretary for Health AMR committee formalized State Directors and endorsed by President Identify reporting structure and communication channel for the AMR Mar 2020 Secretary for Health AMR committee structure committee in both National and State level State Directors established Develop a clear terms of reference for the AMR committee Mar 2020 Secretary for Health ToR developed State Directors 1.1.2 Develop a National Action and Operational Plan for AMR Develop the draft national action and operational plan for AMR for both National – Aug 2019 Secretary for Health National and State action and National and State Level State – Dec 2019 State Directors operational plan endorsed by President Establish technical working group (TWG) to implement the AMR plan Mar 2020 Secretaries and TWG established State Directors 1.1.3 Develop a budget for implementation of the action plan and identify funding sources Consultation with key stakeholders for costing the AMR activities outlined in Jun 2020 National AMR committee Costing completed the AMR plan Formal submission of costed plan to the President for endorsement Jun 2020 National AMR committee Costed plan endorsed by President Conduct consultation meeting with key partners for the identification of Jun 2020 National AMR committee Funding sources identified funding sources 1.1.4 Regular monitoring and evaluation of the implementation of the national action plan Hold a quarterly meeting to discuss implementation of the national action Quarterly National AMR committee Meeting minutes disseminated plan Meeting for M&E of AMR plan implementation and making amendments to Jun 2022 National AMR committee Review conducted the plan Page 18 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Conduct cost analysis on AMR Jun 2020 National AMR committee Assessment completed and report submitted 1.2 Ensure political commitment on the implementation of the national action plan 1.2.1 Establish a high level commitment between national and state level Develop a AMR memorandum of understanding between key sectors Mar 2020 Secretary for Health MoU signed by different State Directors sectors 1.3 Development and enforcement of appropriate legislations in all sectors 1.3.1 Develop and strengthen legislation of AMR in both human and animal sector Review/amend existing legislation(s) and ensure it incorporate clauses Dec 2023 Secretary for Health Legislation revised and related to AMR in both human and animal health State Directors endorsed 1.4 Ensure sustainable investment in combating AMR 1.4.1 Create an enabling environment for access to effective antimicrobials (e.g. infrastructure, roads, supply chain) Strengthen policy and legislation to support the availability and accessibility Ongoing National AMR committee Policy/legislation of antimicrobials to both human and animal health strengthened/updated to support availability & accessibility of antimicrobials Submit budget proposal for AMR Jan 2020 National AMR committee Budget proposal submitted 1.4.2 Invest in appropriate human resources and infrastructure to ensure sustainable implementation of the national action plan Ensure one dedicated staff for AMR secretariat and identify AMR champions Mar 2020 Secretary for Health AMR secretariat and in both National and State level State Directors champions identified and endorsed Identify and assess all facilities to ensure its adequate to prevent, control and Dec 2020 National AMR committee 100% of facilities assessed respond to AMR Develop human resource and training plan for staff to sustain the Dec 2020 National AMR committee Human resource and training implementation of AMR plan plan developed and endorsed

2 — Improve awareness and understanding of antimicrobial resistance across all institutions and sectors

2. Improve awareness and understanding of antimicrobial resistance across all institutions and sectors 2.1 Promote information sharing on the situation of AMR and use of antimicrobials across institutions and sectors 2.1.1 Develop awareness raising materials and conduct awareness activities Develop/revise IEC materials on AMR for the general public and policy Annually National AMR committee IEC materials printed makers All key stakeholders Page 19 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Conduct regular AMR advocacy and awareness using all means of Quarterly National AMR committee 4 awareness raising communication/ mass media aligning to the strategic risk communication All key stakeholders communication conducted plan. annually Hold annual awareness campaign to celebrate World Antibiotic Awareness Annually National AMR committee Awareness week campaigns Week All key stakeholders conducted in November per year Conduct regular AMR awareness raising for farmers, importers, exporters, 6 monthly National AMR committee 2 awareness raising food processors, and animal production officers including antibiotic All key stakeholders communication conducted withdrawal period annually Engage & train community leaders, NGO’s, civil societies, churches, sports 6 monthly National AMR committee 2 training session conducted groups and youth groups to raise awareness on AMR All key stakeholders 2.1.2 Promote effective sanitation and hand hygiene in the community setting Participate in the world hand hygiene day Annually National AMR committee Hand hygiene day celebrated Develop promotional materials to raise awareness of hand hygiene and Annually National AMR committee IEC materials printed and effective sanitation in the community disseminated 2.1.3 Develop an educational programme for schools (all levels) on AMR and rational use with key targeted messages Incorporate the education curriculum to capture AMR, basic sanitation and Dec 2020 National AMR committee Curriculum incorporated hand hygiene awareness raising in primary and secondary schools Department of Education 2.2 Raise awareness on AMR to health-care workers and veterinarians 2.2.1 Include AMR as core component of professional education, training for health-care professionals and veterinarians Ongoing continuous professional development on AMR for health-care Quarterly National AMR committee 4 CPD sessions per year workers and veterinarians/livestock officers Department of Health Department of Resource and Development Re-train health-care workers and veterinarians/livestock officers on any On-going National AMR committee 20% of health-care workers and AMR online or in-service course offered on POLHN, regular training session Department of Health veterinarians/livestock officers or from other relevant institutions Department of Resource and completed online course and Development receive certificates per year Conduct baseline survey on perception of health-care workers and Dec 2019 National AMR committee Perception survey completed veterinarians/livestock officers on AMR Department of Health and report submitted Department of Resource and Page 20 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Development

3 — Strengthen surveillance, diagnostic capacity and research on antimicrobial resistance

3. Strengthen surveillance, diagnostic capacity and research on antimicrobial resistance 3.1 Develop a national AMR surveillance system with a reference laboratory 3.1.1 Strengthen laboratory staff capacity for training on microbiology and quality antimicrobial susceptibility testing Build capacity of laboratory staff in microbiology testing and analysis of On-going National AMR committee All laboratory staff trained antibiogram Department of Health State hospital laboratory Continuous participation in EQA for AMR Annually National AMR committee All state laboratories fully Department of Health enrolled on EQA State hospital laboratory 3.1.2 Strengthen laboratory capacity and infrastructure for AMR surveillance Identification of a reference laboratories for AMR in human and animal On-going National AMR committee Reference laboratories health for further genotyping Department of Health identified Department of Resource and Development State hospital laboratory Review standard operating procedures for antibiotic testing and quality Annually National AMR committee SOP's updated and endorsed management system in all laboratories Department of Health State hospital laboratory Implement QMS and EQA programmes in all laboratories that conduct On-going National AMR committee EQA & QMS conducted antibiotic susceptibility testing Department of Health annually State hospital laboratory Equip all the state laboratories to conduct antibiotic testing for human health Dec 2020 National AMR committee State conducting laboratory test Department of Health for all sectors State hospital laboratory Strengthen the electronic laboratory information system for AMR reporting Jul 2021 National AMR committee Electronic system fully and surveillance in all state laboratories Department of Health operational in all laboratories State hospital laboratory Page 21 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Ensure consistent availability of laboratory consumables and reagents Ongoing National AMR committee 100% availability of supplies Department of Health State hospital laboratory 3.2 Strengthen food safety capacity to combat AMR 3.2.1 Promote random and regular testing on meat and other food product for AMR pathogens and antibiotic residues Undertake random sample collection and testing for AMR pathogens and Ongoing National AMR committee 2 samples randomly selected antibiotic residues. Department of Health and tested per year Establish a mechanism for testing antibiotic residues on meat Dec 2020 National AMR committee Reference laboratory identified Department of Resource and Development 3.3 Strengthen research and information sharing on AMR 3.3.1 Promote collaborative surveys and conferences on AMR in human and animal health and the environment Include AMR session in PBMA, APNLC meetings annually Annually National AMR committee Annual conference held Conduct antimicrobial consumption survey Dec 2020 National AMR committee AMC survey completed and Department of Health report submitted State hospital pharmacy 3.3.2 Conduct bacteria susceptibility survey/profile Develop and continue sharing antibiogram with all states Ongoing National AMR committee Antibiogram data for all states Department of Health available State hospital laboratory 3.3.3 Ensure sharing of AMR surveillance and use data Regular sharing of AMR surveillance and antimicrobial consumption to key Ongoing National AMR committee AMR data available for sharing stakeholders, including regional and international Department of Health State hospital laboratory Strengthen mechanism for reporting AMR in all states and national level On-going National AMR committee AMR standard template and across all sectors Department of Health mechanism in place State hospital laboratory

4 — Reduce incidence of antimicrobial resistance through effective infection prevention and control measures, food safety and hygiene

4. Reduce incidence of antimicrobial resistance through effective infection prevention and control measures, food safety and hygiene 4.1 Establish a national infection prevention and control programme 4.1.1 Endorse the national infection control policy Page 22 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Establish/strengthen state infection control committees June 2020 National AMR committee Endorsed TOR, Formed Department of Health Committee members, & Quarterly meeting minutes Review the national infection prevention and control policy and guidelines Dec 2019 National AMR Committee National IC policy reviewed Department of Health and endorsed and implemented Update the infection prevention and control guidelines based on new policy June 2020 State IPC committee IPC guidelines endorsed in each state hospitals and clinics Print and disseminate the national infection prevention and control policy and June 2020 National AMR Committee 100 copies printed for each guidelines to key stakeholders state hospital and clinics Conduct regular infection prevention and control audit in state hospitals Quarterly State IPC Committee Audit reports submitted Conduct training on infection prevention and control policy and guidelines Annually State IPC Committee 2 trainings per year targeting patients, health care workers and health administrators 4.1.2 Disposal of expired drugs and non-registered drugs and medical waste Develop guidelines on disposal of unused antibiotics and other medicines Dec 2020 Department of Health Medicine policy and Guidelines (including veterinary medicines) endorsed Assess and strengthen incineration of medical waste in all state hospitals Dec 2020 National AMR Committee All state hospitals incinerator Department of Health fully functioning State Hospitals 4.2 Implement the Water, Sanitation and Hygiene (WASH) program to promote safe water and hygiene practices 4.2.1 Develop the WASH program in communities and schools Conduct consultation to communities, schools, health facilities, households, Jun 2020 National AMR committee 1 consultation per state commercial and service establishments, churches, public health events and Department of Health WASH program endorsed by Sakau markets on WASH program in all states Department of Resource and all concerned parties Development Department of Education Develop a WASH program and guidelines for communities, schools, health Jun 2020 National AMR committee WASH program and guidelines facilities, households, commercial and service establishments, churches, Department of Resource and endorsed public health events and Sakau markets in all l states Development Health Department of Education Implement WASH program in communities, schools, health facilities, Jun 2020 National AMR committee WASH program implemented households, commercial and service establishments, churches, public health Department of Resource and events, and Sakau markets Development Department of Education Page 23 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Department of Health Conduct awareness training on WASH program in communities, schools, Quarterly National AMR committee 4 trainings per year health facilities, households, commercial and service establishments, Department of Resource and churches, public health events and Sakau markets Development Department of Education 4.3 Promote good infection control and biosecurity practices in animal husbandry 4.3.1 Strengthen infection prevention and control in animal husbandry Develop infection prevention and control policy specific for animal farms Dec 2019 National AMR committee IPC policy endorsed and clinics Department of Resource and Development Conduct training on infection prevention and control policy Dec 2019 National AMR committee IPC training completed Department of Resource and Development Print and distribute infection prevention and control policy to all key Dec 2019 National AMR committee 100 copies printed for each stakeholders Department of Resource and state hospital and clinics Development Promote use of personal protective equipment (PPE) in hospitals & animal Ongoing National AMR committee 100% availability of PPE health Department of Health supplies Department of Resource and Development 4.4 Implement Good Hygienic Practices (GHP) and Hazard Analysis and Critical Control Point (HACCP) in food handling and processing 4.4.1 Establish GHP and HACCP program Conduct consultation to states and communities on GHP and HACCP Ongoing National AMR committee 1 consultation meeting per state program Department of Health Department of Resource and Development Develop a GHP and HACCP program and guidelines in all states Ongoing National AMR committee GHP & HACCP program and Department of Health guidelines endorsed Department of Resource and Development Implement GHP and HACCP program Ongoing National AMR committee GHP & HACCP program Department of Health implemented Page 24 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Department of Resource and Development Conduct awareness training on GHP and HACCP program in communities Ongoing National AMR committee 4 trainings per year Department of Health Department of Resource and Development 4.5 Strengthen vaccination program in human sector 4.5.1 Implement vaccination program in human sector Conduct awareness to public on vaccination program Quarterly National AMR committee 4 awareness per year Department of Health

5 — Optimize the use of antimicrobial medicines in human and animal health

5. Optimize the use of antimicrobial medicines in human and animal health 5.1 Strengthen regulations to promote responsible use of antimicrobials 5.1.1 Enforce the use of prescription on antimicrobials in the human and animal sector Draft and endorse medicine legislation (law and regulations) to cover the Dec 2020 National AMR Committee Legislation and regulations prescribing and use of antimicrobials in both human and animal health Department of Health drafted/ updated and endorsed Conduct awareness on medicine legislation to veterinarians, medical doctors Jan 2021 National AMR committee Awareness conducted and other key health workers in all states Department of Health Print and disseminate the updated medicine legislation to key stakeholders Jan 2021 National AMR committee Legislation printed and Department of Health distributed Conduct inspection on pharmacy, medical clinic and animal clinic on the Annually Department of Health Inspection conducted and report counter sales of antimicrobials (updating of the inspection Checklist) submitted 5.2 Establish and develop national guidelines and programs to control the use of antimicrobials 5.2.1 Develop and finalized antibiotic guidelines based on country antibiogram, medicine policy and essential medicine list for human and animal use Review the national antibiotic guidelines for human use Ongoing – every 2 National AMR committee Guidelines published years Department of Health Develop a national antibiotic guideline for animal use Dec 2020 National AMR committee Guidelines published Department of Resource and Development Update the national essential medicine list for both human and animal use Ongoing – every 2 National AMR committee EML updated and published using AWaRe classification years Department of Health Department of Resource and Development Page 25 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Review the national medicine policy to ensure the rational use of medicines Dec 2021 National AMR committee Medicine Policy updated including antimicrobials Department of Health Monitor the adherence of antibiotic guideline and rational prescribing of On-going National AMR committee 1 auditing per year veterinarians, medical doctors and health assistants in all states Department of Health Department of Resource and Development 5.2.2 Strengthen border control for detection of imported antimicrobials Ensure that medicine legislation will cover the declaration of all Dec 2020 National AMR committee Boarder control legislation antimicrobials that enters the country including the ban on the use of Department of Resource and updated antibiotics on animal feed as growth promoters Development 5.2.3 Strengthen Antimicrobial Stewardship Program & role of Medicines Therapeutic Committee in hospital Develop basic antimicrobial stewardship (AMS) program and framework in Dec 2020 National AMR committee Basic AMS program developed all state hospitals Department of Health and implemented Develop policy on the use of restricted antimicrobials at all state hospitals Dec 2019 National AMR committee Policy on use of restricted Department of Health antimicrobials endorsed by State Hospitals MTC Establish and strengthen the state medicine therapeutic committee Dec 2020 Department of Health MTC meeting quarterly Review and endorse the ToR of the Medicine and Therapeutic Committee Sep 2019 National AMR Committee ToR updated and endorsed (MTC) to ensure that it cover AMR at the national and state level Department of Health MTC Conduct training workshops for MTCs members on their role on AMR Dec 2019 National AMR Committee 1 training completed Department of Health AMS team to conduct auditing of antibiotic use in state hospitals Ongoing - 6 monthly National AMR Committee Audit report submitted MTC 5.3 Strengthen procurement and supply of antimicrobials 5.3.1 Strengthen prequalification of antimicrobials to ensure quality assured antimicrobials Develop process of market authorization (MA) and registration including Dec 2021 National AMR committee MA and registration of prequalification of antimicrobials Department of Health antimicrobials in place Conduct training on product assessment and physical verifications to Dec 2021 National AMR committee 2 trainings conducted pharmacy inspectors, customs, para-vet in all states Department of Health Build relationship with other stringent regulatory authority and using any sub Ongoing National AMR committee MoU in place regional platform to access information on quality of antimicrobials 5.3.2 Ensure the availability and accessibility of quality antimicrobials Page 26 of 36 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Conduct in depth assessment of the medicine supply system in all states Dec 2021 National AMR committee Assessment report completed Department of Health Develop a procurement and supply strategies of antimicrobials in both human Dec 2022 National AMR committee Procurement plan developed and animal sector in all states Department of Health Review the donation regulation and policies of medicines Dec 2020 National AMR committee Procurement & Donation Department of Health regulation and policies updated and endorsed 5.4 Strengthen the capacity of pharmacovigilance system in human health 5.4.1 Strengthen the monitoring system to detect, assess, prevent adverse effects of antimicrobials Develop the system on pharmacovigilance of antimicrobials including other Dec 2021 National AMR committee Database and guideline on essential medicines Department of Health pharmacovigilance system developed Page 27 of 36

Annex 1: A resolution of the 24th Micronesian — A resolution of the 24th Micronesian

Annex 1: A resolution of the 24th Micronesian Islands Forum on antimicrobial resistance A RESO LUTION OF T HE 24th M ICRO NESIA N ISLAN DS FORU M Rillph OLG~ To,ru Conce rning tue streng thenin g of USAPI health depart Govet'nOt ', CNHI ment capaci ties and system s to effecti vely addres s the health sec urity threat of an timicro bial resista nce (AMR ) WHER EAS , the United States- Affilia ted Pacific lslands (USAPTs) includi ng Guam, the Comm onweal th of Northe rn Marian a Islands (CNMl ), the Republ ic of the Marsha ll Islands (RMl). the Republ ic of Palau, the Federa ted States of Micron esia (FSM) - Pohnpe i, Chuuk , Yap, and Kosrae , Americ an Samoa and the Micron esian Islands Forum (MlF) Region al Health Comm ittee (RHC) is compri sed of the Ministe rs. Secreta ries and Thoma• Re men'Jes.t .U Jr. D irectors of Health of the six USAPl s, who are also the govern Pres1den ~ Rep. of Palau ing body of the Pacific Islands Health Officer s Associ ation (PCHOA). which serves as the Secreta riat of the Mff RI IC; WHER EAS, PIHOA 's mission is to improv e the health and well- being of commu nities in the USAPl s by provid ing, through consen sus, a unified credibl e voice on health issues of regiona l import ance; EPJ l WHER EAS, the USAPi s are home to more than 500,00 0 people who live on hundre ds of islands and atolls spanni ng million s of square miles of ocean and crossin g five Pacific time zones. an area signific than the contine ntal United States: WHF.R EAS, USAPI pvpula tions are geogra phicall y , antly larger dispers ed and have resourc e-limit ed health system s impact ing their abili ty to provide M.-rc.Jo K.. Peterson compr ehensi \e and effectiv e health service s across an array Gove.mo r, Pohnpd St1tte of special ty clinica l. public health and ancilla ry discipl ines; and N Governor , State, of Yap WHER EAS, critical resourc e limitat ions in USAPI popula incl11de , but are not limited to: the lack of trained and qualifi in special ty clinica l, public health and ancilla ry service insuffi cient financi al and other resourc es lO recruit and retain health staff. and inadequ ate/ins ufficient infrastr ucture to tions ed health stafJ dis cipline s, these qualifie d ensure adequa te Page 28 of 36 access co quality and comprehensive services to highly dispersed, rural populations and those with specialty healthcare needs; and WHEREAS, antimicrobial resistance (AMR) is a broad term encompassing microbes (bacteria. parasites, viruses, fungi) developing resistance to drugs that treat infections. including TB, HJV, gonorrhea, extended spectrum B-lactamase producing enterobactetia, etc.; and, that the leading causes of AMR are: 1) patient non-compliance to recommended treatment regimens; 2) irrational use of medications, including self-medication and lack of regulatory monitoring of public consumption of over-the-counter and other restricted medications; 3) medical provider lack of adherence to treatment guidelines or over- prescribing; 4) poor or inconsistently enforced infection control, hygiene and sani1.::rion standards in healthcare faciHties; :5) poor quality of medications procured, including monitoring of dmg efficacy and safety standards: 6) irrational use of antibiotics in agricultural producti.on and animal feeds; 7) inadequate AMR surveilJance and testing capabilities; 8) overcrowding, poor sanitation standards, and access to proper waste management at the community level; and 9) the return of referral patients with nosocomial infections contracted in hospitals in countries in southeast Asia with higb incidence of resistant organisms; and WHEREAS, AMR is a critical health security risk for the USAPrs given existing human, financial and infrastructure constraints, including significant impacts on individual and population health outcomes and cost of healthcare services del.ivery to treat increasingly resistant strains of infectious and other diseases, NOW THEREFORE BE IT RESOLVED, that the Leaders endorse, in principle and as a matter of priority, strengthening national/state systems and capacities for cost-effective and efficient healthcare facilities management encompassing all public healthcare facilities (hospitals, community health centers, outer-island dispensaries, and public health clinics), including appropriate training and certification of relevant local staff. which is one of several critical steps to address AMR through improved health facilities management. monitoring of antimicrobial use pa11.ems. surveillance. sanitation. and infection control : aod NOW THEREFORE BE IT RESOLVED, that the Leaders recognize and support Pll·IOA executive leadership endorsement of the U. S. Departrnellt of Interior's Concept Brief entitled Healthcare /nfrastmcture Management Jniticaire for the Insular Areas (see Attachment I), and will aim to support, through fonding and/or other resource allocations to local health departments as feasible. to ensure the effective and timely implementatfon of this initiative: and Page 29 of 36 BE IT FURTHER RESOLVED, the Leaders support USAPl health department efforts to develop. resource, implement and monitor national/state AMR plans, including: I) expansion of laboratory diagnostic capabilities to detect and monitor AMR: 2) strengthening of local and regional surveillance systems and capacities for AMR surveillance; and, 3) support expansion of in-region laboratory capacity spearheaded by the Guam Department of Health and Social Sen ices· Public Health Laboratory and DiYision of Environmental Heall.h's Mosquito and Food Safety Laboratory for those USA Pis who may v. ish to access such services: and BE IT l' URTHER RESOLVED. I.be Leaders will actively support USA PI health department efforts to coordinate, with the appropriate agencies such as cheir respective local departments/ministries of agriculture, environmen t. and commerce, to ensure appropriate sharing of resources and information 10 detect and monitor AJvfR; and BE IT FURTHER RESOLVED, that the Leaders support mobilization and allocation of financial and other resources. including healthcare provider incentives and training programs, to establish standards and to strengthen healthcare staff competencies for improved hygiene, sanitation, and bio-waste management in all local healthcare settings; and BE IT FURTHER RESOLVE D, that tile Leaders hold accountable appropriate government authorities to enforce national and state regulations around phannaceutical procurement, drug safety and distribution, including regulatory monitoring and enforcement of public and private healthcare provider rational use and prescription of drugs; and B E IT FURT HER RESOLVED, that the Leaders further task its Secretarial to disseminate this resolution to the appropriate USAPI health departments/ministries, relevant USA Pf government agencies. and regionaVintemational technical agencies such as the US Health and Human Services. World Health Organi;,.ation. Pacific Community, etc. Signed this 11 1h Day of July. :!0 19 at the 24th Micronesian lslands' Forum in Chuuk.. Federated States of Micronesiau. Page 30 of 36 ATTACHMENT l Healthcare Infrastructure Ma.oagewenl l nitiative (H[Ml) for the Insular Areas Office of CnsuJar and lnternationaJ Affairs US Department of rnterior As Amended by the U.S.-Affiliuted Pacific Islands Health Leadership Backgro11nd The Office offusular Affairs (OTA) serv~ the four ten-ilories of U.S. Virgin Islands, Guam, CNMI, American Samoa and the three freely aswciated states of Marshall Islands, Palau. and 1hc Fedt::rated States of Micronesia. Combined. rhese insular areas maintain twelve publjc hospitals, six fcderally- qualifitd Community Health Centers (FQCHCs), and numerous out-patient clinics, and rural and outer- island health di.~pcnsarics scrving approximately 700,000 residwl~. A key component of an effective hcallh can: system includes nOl only capiLal invcsunc11t in physical health facilities. but also sy~tcm~ supporting continuous managcmcnr of these facilities to ensure a prop<,-r cnviroruncnl fo1 patient care and successful hcald1 outcomes. Overview ofRealtbcare Facilities Management Jkaldlcan: facility management is constantly needed to maintain clean and l1ca.lthy environments conducive to achieving tile best possible health outcomes. AJI ht:althcare facilities musr t:osure service requests are responded to quickly and efficiently, preventive maintcmancc schedules arc set lip in order to maintain operations without interruption. and adminjstraliw processes run ctlicientJy to suppon timely and co~1-1!ffectiv1: facilities management. An effective health facilities management team should be comprised ofbt-allhcare facility managers, administrators (e.g. finance, procurement, and HR, especially), engineers, a:n:hitecl,;, conslructors. occupational ha1..ard and infection control specialists, and maoy olhas involved wich planning, aecution, and monitoring/maintenance of safe working and healing cnvirorunents. While this is a divcrsi; ~t.il'f witb varying skills sets and areas of expertise. team members share a dcclic.1tion to optimi1Jng cxhting healthcare facilities to ensure the best be:1ltl1 outcome for the communilics thcy scrve, including working environments that arc conducive to good health practices and d'ficient service delivery. Project Rationale Achieving this ideal concept of effective healthcare fadlitics management is a challenge across all insular area healthcare facilities (hospitals. community bcalth cenwrs. and <lispensark-s). Pa:it of the challenge stems from the harsh i1,land environments affecting durability of buildings, remote locations impacting rimd) access to and cost ofsupplies, lack of a trained workforce to impleincnt core hospita.1/bcalth facility management techniques, and inefficient administrative processes. Unlike d1e States, 1be discipline of hospital/health fa_l;ility management has nm matured into an essential component of the insular ,ire11S' hcalth facility management plans. TI1is is not for a lack of effort or desire hy the respective insular areas. but more due to an inability to inet,rporate thi:) ~ki!Jsct need into healthcare workforce development and planning. l he acadc1ruc cnvironmcnL.'- which .:n: alr:.:ady burdened Ii.> support healthcare providers, have not had the bandwidth to support a p1pclinc in this specialized art-.1 of health faciliry managemcnt. And, tl1ere hasn't bcc!n significant investment in allocating sufficient financial resources to recruit and rcr.ai.n qualifkd staff. Good healthcare facilities managers and adm.inislrntors, be th~y from the insular areas or expatriate. are in demand generally across the LJS and abroad. and more often, salary packages offcri;d by the insular areas are not competitive enough to attract and!or retain qualified healthcare facilities managers and administrators. OIA has awarded millions over the last live years for insular hcallhcarc capital improvemcnt through a combination of remodeling 30+ year old facilitit:s and building new facilities. It is prudent for OIA to Page l of 4 Page 31 of 36 considcr methods 10 ensure th1.: long-tenn valut: of these sizable capital investments through ao investment in facility management and administration workforce development. Overarching Project Goal 'lb.is pr0posal aims to initiate a phased plan focm;ed on devdoping a sustainable facility management and administration program for all insular area public hospitals and othcr hcallb facilities implemented lhrough lot.al staff. Timmgh thL~ program, OTA aims to haw at leasr one local, certified h.:alth facili1y manager at each of the 10 public hospitals, at a minimum, within two years. Year I Project Methods Executive project sponsorship and resources include: • Project sponsorship by the Assistant Secretary Insular and International Affairs, Doug Domenech: • I'articipation/consultation, scoping, and shaping of concept through inpu1 from insular area health l~d<.:TShip and other governmental n:prcscntativcS; • Rdmbursable service agreement with the U.S. Health and lluman Services (flJT-S) for int.:r- dcpartmental technical assismncc to cover salary, benefits, and associated tnivcl cx~'tlscs; • Service agreements with other (nou-HHS) technical providers as may he idcorifo:d and requested by insular area health leadership, including, but not limited to the American Society for Tlcalth Care Engineering of the American Hospital Assaciation (ASHE). Yale Global Ht:alth Leadership TnstiluCC (for Hospital Administrators). U.S. Army und Navy Corps of Engineers, and other U.S./intcniational technical assistance providers; and • Subject to availability, OIA financial assistance to pay for local staft'to undergo healthcare facility managt.:r and administrativt training and certification. Year l Objectives • Joint stau.mcnt by the Assistant Secretary and Govcroor/Prcsid,mt to kick offthi:. injtiative; • Coordinate and conduct oosite assessments and written documentation of au in~ular ari.:a hospitals, FQClJCs. and other outpatient clinical facilities/dispcnsari..:-s operated by the insular area health departments. The assi.:ssmcnt :)hould include, but not limited to: o Nwnbcr. age, and location of facilities o Dares of major n.-novatioru; and typt:s of materials used o Whether specific facilities, or pm·ts of facilities, warrant rcnovatio11 or replacement o List of cum:ot assets in each facility such as a major c4uipmcnt requiring special consideration for n:novation/consrruction planning (e.g. radiology equipment, morgue frcc-i.ers, lab equipment requiring special do~cd-~ystem vt:ntilatioo. boi.l)ital kitchen and laundry machinery, ctc.) o Energy audir of currenr and futun: power acc~-ss and usage needs • In consultation with local insular area lcadersb.ip and relevant govemm-c111 agency staff. develop a wriucn plan to address immediate facilities issu~:s and associated modali1ics/opportuni1ies for facility maoagemcm worlctbrcc ttaining antl dcvi;lopmcnt; • In consultation with local insular ar.!a lca1krship and relevant government agency staff, develop additional written plans to address intcrmcdiaw and longcr-1em1, non-urgent facilities management issues and associated modalities for Longer-term workforce devdopmcnt planning and training; • Assist insular area ht:alth leadership aad relevant health staff to rcvi1:w and program existing maimenanet: plans and budg.:ts, and to di:::.ign. execute and mooilor a program of regular maintenance and cost management; • Through tb1.: ousitc assessment, consult and support insular area health leadership and rel.cvant staff to identify appropriate candidates to he trnincd in health facilities management and Page 2 of4 Page 32 of 36 admini!>traLion methods, including discussion of appropriare modalities for training and workforce development (onsilc. remote, hybrid onsi1e-rcmotc, coupled wilh onsite longc~tcnn coaching and mentoring. etc.), appropriate training/technical assistance providers, certi fication/licensurc requirements and proc1.:sscs. and planning for on-going techni~I support. a.\ needed; • Conduct a review and written assessment of available hospiml/hcalth facility management and administration training providers wrucb can be leveraged. through separate co111rnc!UaJ arraogcmc:nts, to provide on-island health facility management and administra1ion trainfog and on-going coaching. mcnroriog and troubleshooting technical assistance; • Conduct a review and writtai assessment nf the potential for a partncrsb.ip between U.S. and/or intcmatiunal-bascd profCS-sional health facilities/administration managcmcnl organiz.uions. universities. and otJ1cr relevant training/technical assistance insti1ut1;s; and, where tea.,iblc. link such pro,idcrs to local island communil} colleges who can serve as longcr-tl..mi providers for workforce development needs idimtified undcr Ibis initiative; and • Provide lcchnical assistance for healthcare opcrations as mutually identified by OLA. and tb1.: insulai an:a. lmntediate Neit Steps • Review of pilot proposal within OlA • Review of approved OJA proposal within 111-1~ • ldcnlification of poccntial technical a&.istance soum.-{s) o WithinlIHS • Office of the As.~istant Secretary for I h:a1lh • Public I leaJch Servi<.-.: • H..:alth Re:.oW'\.."t'.~ and Services Administration Indian Jleahl1 Service: • Centers for M..xlicaid and Medicare Services • Centers for Disease Control and Prevention o External USG • National Indian Ilea.Ith Board (OC) • American Sociccy for Health Care Engineering of the American Hospital Association (AS! IE) llnivcr-:;icy of llawai"i Queen~ Health S)'stcms • <,uam Regional Medical Center • Anny and Navy Curps of Lngineer, American Colkgc of J h:althcare Executives • Triplcr Army Medical Center lndo-Pacific Command - Medical Surgcon·s Office Yale Global I lcalth uadcrship lnscinm.: for Hospital Administrators • Finalize Year 1 project scope imrlcmcn1:11iou anJ evaluation plan Insular Are.i Hospitals and Other Rco.llh facilities under the Jt.1.annecme nt Authority of the Insular Arca Health DepartmenWMin_istrics US Virgio lslunds I. Gov. Juan F. Lui, 1lospit.il and Medical C..:ntcr 2. Schndder R\!gional Medical Center American Samoa 1. l .BJ 1 ropical Medical Center 2. American Samoa Department of Heal ch - Public Ikalth Out-Patient Clinic in Fnga•alu 3. FQCI IC~ io Tafuna. Amouli. Leone and Mdllu·a bland, (i11clut!cs the dc:partmrot"s onl~ Public llcallh Laboratory al the TaJWUl CJJC) Page 3 of 4 Page 33 of 36 Guam I . Guam Memorial Hospital 2. Guam Deparlll'.lcnt of Public Health and Social St:rvices - Public Ifealth Out-Patient Clio it: and Public Health Laboratory in Mangilao 3. FQCI !Cs in Dcdcdo and Inarajan Northern Mariana Islands I. Commonwealth 1lcalthcare Corpordtion Hospital 2. Health Dispensaries in Rom and Tinian Palau I. Belau National Hospital 2. f'QCHC in Koror 3. Health Dispensaries in Koror.13ablt:daob and Pclcliu Marshall Islands I. Lciroj Ebeyc Medical Hospital 2. Ebcyc FQCl IC 3. Majuro Hospital 4. Outer-Island Health Dispensaries Federated States of Micronesia I. Kosrac State Hospital, Department of Public Ilcallh °' Poh11pci State llospital, Department of Public HealthOut-Pa1 j1mt Clinic, and Kosrac fQCI IC 0\ll-Patienl Clinic. Kolonia FQCIIC, and Municipal I lc.'llth Dispensaries 3. Cbuu.k Stntc ITo.spital, Department of Public Ilea.Ith Out-Paticnt Clinic, Chuuk FQCJ IC, and Outer-Island Health Dispcnsaric~ 4. Yap S~ Ilo~ita L Department of Publicllcalth Out-Patient Clinic, Wa'ab rQCHC, and Ourcr-Island r lcalth Dispcnsarics Page4 of 4 Page 34 of 36 LOt; lEOX GL"ERER.RO Go-:cfflO! Go"'2f'tl0f Comnanw ulth o! th~ ti.~-Tm.toryof GIID'l'I ;l;crtb..m ~ ~bmi D..\YID W.P..t.\"'lliO 1\~:i t F~_a s ara «~!it:rmru •.\:! ':-mEW 1 trod zri !nt:m.-!l Afaif', Par?r~it t Hilei Hii.nj Ee. D. Raprj)lic « ~ Ml!'11ull :Sl=:h ~= Gonmo r :?ohn~ Stm, FS!~f HE\"RY F•.\L.\.."'I GO\~ Y2.i ~im, F3?.i Page 35 of 36 Department of Health and Social Affairs P.O. BOX PS 70 Palikir, Pohnpei, FM 96941 Email: health@fsmhealth.fm

National Multisectoral Action Plan on antimicrobial resistance for Micronesia 2019-2023

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