Monitoring and Evaluation (M&E) Plan for the National Action Plan (NAP) for Combating Antimicrobial Resistance (AMR) 2023-2025

2024. These sources collectively lay a robust evidence base for understanding the achievements and challenges in combating AMR. Situation Analysis The situational analysis of AMR in Jordan is informed by multiple national assessments conducted by various stakeholders, both national and international, providing a comprehensive overview of the current AMR landscape and underscoring the critical need for a coordinated approach to address this growing public health threat. The Jordan National AMR Surveillance System, established in 2017 by the Jordanian Ministry of Health, operates through a network of 42 clinical microbiology laboratories across all twelve governorates. The system's second national report3, published in 2022, covered data from 49,044 patients across 42 surveillance sites (public, RMS, University, and private sectors) from 2018 to 2022. This report provided detailed statistics on antimicrobial resistance, showing current levels and trends of antimicrobial susceptibility and resistance in Jordan, indicating a representative sample of the Jordanian population. However, caution in interpretation is advised. The report highlights the need for national-level coordination in implementing the antimicrobial resistance plan, suggesting more substantial budget allocations and enhanced training across sectors. It emphasizes improving cooperation under the One Health approach, linking national efforts with sector-specific plans, and focusing on training healthcare providers to increase awareness and effective management of antimicrobial resistance. Under its national public health institute mandate, the Jordan CDC has taken on a critical role in overseeing the development and implementation of AMR control strategies and coordinating M&E initiatives to ensure national efforts effectively meet global AMR objectives. Despite challenges in data availability for the 2018-2022 AMR NAP, its comprehensive evaluation was crucial for aligning strategies with international efforts to combat AMR. The Jordan CDC adopted a comprehensive methodology for the 'end-term evaluation' and released its first evaluation report in 20234, aimed to measure the implementation status of the AMR NAP 2018-2022, track activity progress, and inform future strategic decisions. Key performance indicators aligned with the NAP's five objectives were scrutinized, integrating the 'One Health' concept across multiple sectors, including human health, animal health, plant production, food production, and the environment. 3https://www.moh.gov.jo/ebv4.0/root_storage/ar/eb_list_page/jordan_national_amr_surveillance_report_2022_(final).pdf 4 Antimicrobial Resistant National Action Plan (2018-2022): Degree of Progress and Implementation-‘End-Term Evaluation Report’ (Unpublished) 19 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC The evaluation provided significant insights, identifying both achievements and areas needing improvement. Findings include a notable deficit in executing multisectoral activities, particularly in awareness and surveillance, with the animal health sector lagging in involvement and integration. The lack of comprehensive strategies was evident in the absence of national surveys, robust public awareness initiatives, and educational strategies. The evaluation also emphasized the need for a cohesive policy framework, strategic human resource development, enhanced laboratory services, and better infection control practices. The WHO mission report on Strengthening Jordan's Response to AMR 20245 aims to evaluate the quality of AMR surveillance data, assess laboratory systems, expand the Antimicrobial Stewardship Program (ASP), and analyze the integration of IPC with AMS, detail a comprehensive evaluation and provide insights into both achievements and areas needing improvement. The report concludes that Jordan has laid solid foundations for addressing AMR and IPC but notes that enhancing leadership and managerial capacities at both national and facility levels is crucial for further progress. It recommends the development of clear terms of reference for AMR committees, improving M&E systems for AMR and IPC, and strengthening education on IPC and AMS among healthcare professionals. In terms of specific areas, the report highlights the need for improvements in laboratory services such as training, quality control, and supply chain management. It also suggests better integration and coordination of IPC measures across all healthcare system levels. It emphasizes the importance of revising committee memberships in antimicrobial stewardship programs to include diverse professionals. Additionally, it advocates for the creation of national guidelines for diagnostic stewardship and the enhancement of the use of diagnostic data. The Tracking Antimicrobial Resistance (AMR) Country Self-Assessment Survey (TrACSS) 2023 report for Jordan6 highlights the country's efforts and challenges in combating AMR across various sectors. Jordan has made significant progress in developing and implementing its NAP on AMR and is revising it to address emerging needs. The human health sector has integrated AMR awareness and stewardship into training for healthcare workers, and IPC programs are in place nationwide. However, Jordan lacks a robust national monitoring system for AMU and a formalized multisector coordination mechanism, which hinders cohesive action against AMR. Laboratory and diagnostic capacities for AMR surveillance need enhancement. In the animal health sector, AMR awareness is included in veterinary training, but national surveillance systems for animals are not standardized. The agriculture and food production sectors require more investment in training and data generation. Environmental aspects of AMR are not adequately addressed due to insufficient legal and regulatory frameworks. To address these gaps, Jordan needs to strengthen multisector coordination, enhance national monitoring systems, and promote awareness campaigns, which are crucial for effective AMR control and a sustainable 'One Health' approach. 5 Strengthening Jordan’s National Response to Antimicrobial Resistance – WHO two levels mission – Amman/Jordan – Mission Report 6 https://amrcountryprogress.org/download/profiles/2023/english/EN_JOR_TrACSS_2023_Jordan.pdf 20 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC In summary, Jordan has made progress in combating AMR but faces critical gaps that need addressing. Key areas for improvement include establishing robust national coordination, enhancing surveillance systems, and promoting a 'One Health' approach. There is a need for better laboratory services, expanded ASP, and improved IPC measures. A coordinated multisectoral effort, supported by strong leadership, adequate funding, and continuous M&E for informing policies and decision-making, is essential for effectively controlling AMR in Jordan. These insights will guide the enhancement of the NAP to meet current and future challenges in AMR management. Theory of Change (ToC) The ToC for the AMR NAP 2.0 (2023-2025) is a strategic framework that delineates the pathway from the current situation to the desired outcomes in the fight against AMR in Jordan. This section outlines the linkages between the key components, from the activities to the impact level, and the assumptions supporting achieving the expected outcomes that will eventually lead to the NAP's objectives. The aim is to reduce the incidence of AMR in Jordan by strengthening national and sector-specific capacities, enhancing surveillance systems, promoting rational antimicrobial use, and fostering a 'One Health' approach across human, animal, and environmental health sectors. Through an in-depth analysis of the challenges in Jordan, six outcomes have been identified as crucial for achieving long-term impact:

1. Increase awareness through effective communication, education, and training.

2. Strengthen knowledge base and evidence on AMR through surveillance.

3. Reduce infection rates through preventive measures, infection control, and general hygiene.

4. Optimal use of antimicrobial medicine in the fields of human, animal, and environmental health.

5. Enhance investment in activities, research, and innovations related to AMR.

6. Strengthen governance and resource mobilization. The ToC Statements for each objective at the output-outcome level are as follows: 21 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Outcome 1: Increase awareness through effective communication, education, and training. If awareness is raised and behaviors are changed through the implementation of SBCC programs about antibiotics, and political commitment to AMR is promoted, assuming political and institutional commitment through ministries' interest in national awareness campaigns for World Antimicrobial Awareness Week )WAAW(, the establishment of sub-committees representing various sectors to collaborate on executing the NAP for AMR, availability of experts and a national multisectoral committee with a dedicated liaison officer, trained teams in SBCC within the Health Communication and Awareness Directorate, active community participation through Community Health Committees, presence of a school health education program, a reliable digital database for social media and the MOH's website, and widespread internet availability for community awareness activities, then awareness will be increased through effective communication, education, and training. Outcome 2: Strengthen the knowledge base and evidence on AMR through continuous surveillance. 22 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC If the antimicrobial resistance surveillance system is in alignment with one health approach is enhanced, assuming a national database for antimicrobial-resistant microbes is used to generate periodic reports, the National Coordination Center for Surveillance, which works in collaboration with the Technical Committee for the Surveillance and Research Axis of AMR, is formed, and public sector institutions have collaborated, and If enhanced laboratory capabilities are achieved, assuming the implementation of a surveillance system for monitoring antimicrobial resistance in 42 reporting centers, a surveillance system for hospital- associated infections and antimicrobial resistance at 14 sites, the existence of the Central Public Health Laboratory as a national reference laboratory, and the presence of modern diagnostic automated systems, then the Strengthening of the knowledge base and evidence through continuous surveillance will be achieved. Outcome 3: Reduce infection rates through preventive measures, infection control, and general hygiene. If an effective program for IPC is developed, environmental sanitation programs are improved, and evidence-based practices and consistent standards for IPC in the livestock sector are ensured at the national level, assuming the availability and active implementation of committees, teams, and programs for preventing and controlling infections in healthcare institutions, availability of human and financial resources, established and followed national reference policies for infection control, endorsement of the healthcare system by political leaders, collaboration between the MOH, the MOA, and other relevant sectors, existence of healthcare quality standards supporting IPC, a robust surveillance system for AMR microbes, operational surveillance systems for monitoring HAI in various hospitals utilizing information technology, regulated and enforced hospital waste management practices, support from international organizations for veterinary programs, availability of safe water in health institutions, and implementation of vaccination campaigns during epidemic outbreaks, then infection rates will be reduced through preventive measures, infection control, and general hygiene. 23 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Outcome 4: Optimal use of antimicrobial medicine in the fields of human, animal, and environmental health. If systems and regulations aimed at dispensing antimicrobials are enhanced and amended, evidence-based treatment guidelines for infectious diseases and protocols for optimal use of antimicrobials at the national level are developed, the implementation of the AMS program is expanded to ensure optimal antimicrobial use, healthcare providers' qualifications on antimicrobial use and the AMS program are developed and enhanced, and a unified national database for antimicrobial use is developed for assessment and studies, assuming the presence of activated regulations and laws, stakeholder support, the commitment of committee members to efficiently join meetings, a budget for training and AMS program implementation, qualified human resources, and an efficient Electronic Health Solutions (EHS) system with valid Antimicrobial Consumption (AMC) data, then optimal use of antimicrobial medicine in the fields of human, animal, and environmental health will be achieved. Outcome 5: Enhance investment in activities, research, and innovations related to AMR. If periodic policy guidance based on country research is provided, assuming global and national attention to AMR, political support for combating AMR, engagement of international 24 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC organizations such as WHO, FAO, and OIE in supporting related initiatives, scientific community interest and support for research, presence of local experts and specialists enhancing national expertise, and coordinated scientific research around integrated health, then investment in activities, research, and innovations related to antimicrobial resistance will be enhanced. Outcome 6: Governance and resource mobilization will be established and strengthened. If governance is strengthened at all levels and resources are mobilized for AMR, assuming broad sector representation with participation from healthcare, agriculture, pharmaceutical, academia, and policy-making sectors in workshops and meetings, ensuring a comprehensive approach to AMR containment, mechanisms for follow-up actions and implementation of recommendations and strategies, an active national sub-technical committee with regular meetings to track progress and ensure accountability, the national AMR M&E focal points periodically reporting workshop outcomes and meeting minutes to relevant stakeholders, institutions prioritizing funding for AMR prevention and containment, and sustainable funding and global cooperation, including support from FAO and WHO, are essential for effective AMR management, then governance and resource mobilization for AMR will be established and strengthened. Under each outcome area, specific outputs and interventions (activities) are designed to contribute to the desired outcomes. The pathways of change are detailed in Annex (4). 25 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC The ToC statement at the outcome-impact level is as follows: A reduction in the burden of AMR in Jordan contributed to improved public health outcomes, safer healthcare environments, and a robust, sustainable 'One Health' system that effectively addresses AMR. If awareness is increased through effective communication, education, and training; and if knowledge base and evidence are strengthened through continuous surveillance; and if infection rates are reduced through preventive measures, infection control, and general hygiene; and if optimal use of antimicrobial medicine is achieved in human, animal, and environmental health; and if investment in activities, research, and innovations related to antimicrobial resistance is enhanced; and If governance and resource mobilization are established and strengthened, assuming reliable and comprehensive data on antimicrobial use and resistance patterns is available for informed decision-making, functional and accurate data collection and reporting systems, sufficient and sustained financial resources, adequate technical expertise and human resources, effective public awareness campaigns, and effective multisectoral collaboration with clear roles and responsibilities among stakeholders, then the burden of antimicrobial resistance will be reduced, and health outcomes for humans, animals, and the environment will be enhanced. 26 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Figure (3). AMR Theory of Change Diagram for the National Action Plan on Antimicrobial Resistance (AMR) in Jordan Impact Reduced burden of AMR and enhanced health outcomes for humans, animals, and the environment. 1: Increase awareness 2. Strengthen the 3: Reduce infection rates 4: Optimal use of 5: Enhance investment in 6: Governance and through effective knowledge base and through preventive antimicrobial medicine in the activities, research, and resource mobilization Outcomes fields of human, animal, and innovations related to will be established and communication, evidence through measures, infection control, education, and training. continuous surveillance. and general hygiene. environmental health. antimicrobial resistance. strengthened. 1.1: Raise awareness 2.1: Enhanced 3.1: Developing an effective 4.1: Enhance and amend systems and 5.1: Periodic 6.1: Governance Outputs and change behaviors antimicrobial program for infection regulations aimed at dispensing policy guidance strengthened at all through the resistance prevention and control. antimicrobials and imposing deterrent based on country levels implementation of surveillance system penalties for violence. research. Social and Behavior in alignment with 3.2: Improving environmental 6.2: Resources Change Communication the one health sanitation programs. 4.2: Develop Evidence-based treatment mobilized for AMR (SBCC) programs to guidelines for infectious diseases and approach. 3.3: Ensuring the availability raise awareness about protocols for optimal use of antibiotics. 2.2: Enhanced of evidence-based practices antimicrobials at the national-level. laboratory and consistent standards at 1.2: Promoting political the national level for infection 4.3: Expanding the implementation of commitment to the capabilities. prevention and control in the AMS program to ensure the optimum issue of antimicrobial livestock sector. antimicrobial use. resistance. 4.4: Develop and enhance health care providers qualifications on antimicrobial Assumptions use and AMS program.

1. Reliable and comprehensive data on antimicrobial use and resistance patterns is available for informed decision-making.

2. Data collection and reporting systems are functional and accurate. 4.5: Develop unified national database

3. Sufficient financial resources are available and sustained throughout the program.

4. Adequate technical expertise and human resources are accessible for program activities. for antimicrobial use for assessment and

5. Public awareness campaigns are effective in educating the population about AMR and promoting behavior change. developing studies.

6. Multisectoral collaboration is effective, with clear roles and responsibilities among stakeholders. 27 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC VII. National AMR M&E Plan • Leadership and Accountability: A dedicated national entity should oversee the National AMR M&E Plan, ensuring a sustainable accountability link to a higher government health body. The Jordan CDC will take on this leadership role with its board chaired by the Prime Minister and including relevant ministers (Health, Agriculture, Water and Irrigation, and Environment). The Jordan CDC will monitor, review, and update the National AMR M&E Plan as necessary. • Support and Development: The Jordan CDC will assist the ministries in developing the next multi-year AMR plan, with support from the WHO. This collaboration will ensure the plan is comprehensive and aligned with international standards. • Revised NAP: The revised NAP should identify priority actions tailored to the country's context and needs. Sector-specific activities should be prioritized, cost, budgeted, and financed based on available resources. These activities should be linked to a clear timeline and include indicators for M&E to ensure effective implementation. Table (1). AMR NAP indicator in Jordan INDICATOR YEAR VALUE Operational integrated multisectoral AMR plan at One Health approach 2018 Yes Operational integrated multisectoral plan that includes the integration of specific 2023 Yes AMR activities at all levels VIII. AMR Governance and Coordination in the Jordanian Context Effective governance and coordination are critical for successfully implementing Jordan's NAP for Combating AMR. To tackle AMR effectively, Jordan has established a robust governance structure that ensures both vertical (within a sector) and horizontal (between sectors) coordination and collaboration. This structure comprises national and subnational AMR multisectoral coordinating mechanisms that oversee ongoing work and secure the necessary leadership commitment. These multisectoral mechanisms are accountable to an inter-ministerial group, which may also oversee other related issues such as zoonoses and food safety. This inter-ministerial group is responsible for aligning efforts with national One Health approaches, promoting cross-cutting activities, and avoiding duplication of efforts. IN JORDAN: High-Level Coordination High-level coordination has been established among key ministries, including the MOH, MOA, MOEnv, and MWI. This inter-ministerial collaboration ensures a unified approach to addressing AMR challenges and implementing the NAP. 28 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC AMR Steering Committee The MOH established the National AMR technical committee in 2017, which was updated in 2019 to include members from the MOEnv and MWI. This committee meets regularly to discuss progress, challenges, and strategies related to AMR. Including environmental and water sectors in the committee highlights Jordan's commitment to a One Health approach, recognizing the interconnectedness of human, animal, and environmental health. Focal Points In 2017, the MOH appointed the national AMR focal point for human health, and the MOA appointed a similar position for animal health. Subsequently, the MOEnv and MWI nominated their AMR focal points in response to a request from the MOH. The focal point for human health also heads the IPC department in the MOH and the Technical Working Group (TWG) on IPC. Additionally, there are focal points from international organizations such as WHO and FAO, ensuring global best practices are integrated into national efforts. National Technical Sub-committees Established in 2018, the MOH formed technical sub-committees focusing on awareness, surveillance, IPC, and the rational use of antimicrobials. These sub-committees work under the guidance of the national AMR technical committee to ensure sector-specific activities are aligned with the overall NAP objectives. Committee Mandates The mandates, authority, reporting, and terms of reference (TORs) of the National Committee are linked to targets and key performance indicators (KPIs). This linkage ensures accountability and facilitates the monitoring of progress against the defined goals of the NAP. National AMR M&E Committee The National AMR M&E Committee led and hosted by Jordan CDC, is responsible for overseeing the implementation of the AMR NAP. This committee ensures that activities are on track, outcomes are measured, and any necessary adjustments are made based on monitoring data. Jordan has achieved significant milestones in AMR governance, as indicated by the following key indicators: Table (2). Key Indicators of Milestones Achieved in AMR Governance and Coordination. INDICATOR YEAR VALUE Operational national multisectoral commission, agency, or mechanism to oversee AMR 2017 YES engagement National multisectoral commission, agency, or mechanism to oversee AMR engagement, 2022 YES policy coherence, and accountability of sectors beyond health National multisectoral commission, agency, or mechanism to oversee AMR had a well- 2023 YES identified TOR and met regularly AMR National focal point for human health 2016 YES 29 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC AMR National focal point for animal health 2016 YES AMR National focal point for environmental health and the water sector 2023 YES A unit/branch/department with responsibility for AMR M&E 2023 YES Working group focal point for each objective 2023 YES Working group for each objective had identified its TOR 2023 YES Working group for each objective active and met regularly 2023 YES IX. Roles and Responsibilities Implementing the M&E Plan for the AMR NAP 2023-2025 entails clearly defined roles and responsibilities for all collaborators. National stakeholders across various sectors collaborate to establish routine systems for collecting relevant data on established indicators. Table (3). Roles and Responsibilities of Key Entities in Implementing the AMR M&E Plan. Entity Responsibilities Jordan CDC Team - Provide guidance on implementing the M&E Plan. - Train the country's technical working groups in M&E processes, including data collection, analysis, usage, and presentation. M&E Focal Point - Implement the M&E Plan. (Representatives) of the - Build the capacity of stakeholder staff. AMR Technical Working - Revise reports and supervise general M&E approaches, practices, Groups and tools. - Work with the MOA, MOEnv, MWI, and JFDA technical staff to ensure indicators and information are reported as required. M&E Focal Points (MOA, - Support the AMR technical working group in maintaining a system MOEnv, MWI, JFDA) to monitor performance based on data from performance indicators. National AMR M&E - Oversee the M&E Plan to ensure it meets the project's needs. Committee - Respond to information requests from the inter-ministerial committee. - Ensure high standards are maintained, and activities align with best practices in the field. Table (4). Monitoring Activities, Frequency, and Responsible Entities for AMR M&E Implementation. Activity Frequency Responsibility Collection of data on performance Continuous AMR Technical Sub-committees Provision of data for quarterly National AMR M&E Committee, AMR Quarterly meetings to review progress. Technical Sub-committees National AMR M&E Committee, AMR Site visits. As required Technical Sub-committees National AMR M&E Committee, AMR Identification of success stories. Annually Technical Sub-committees Reporting of performance results to the National M&E AMR Committee, National AMR M&E Committee, AMR Semi-annually Jordan CDC board, ministries, and Technical Sub-committees related institutes. 30 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Assessment of data quality. Annually Jordan CDC M&E TWG Table (5). National AMR M&E Committee Roles and Responsibilities Personnel Entity Responsibilities Chairman of the Jordan CDC President - Provide leadership to the M&E Committee, ensuring Committee alignment with AMR NAP objectives. - Oversee implementation of M&E activities, ensuring compliance with protocols and standards. - Assure the coordination of efforts with stakeholders, including government agencies, healthcare institutions, research organizations, and other partners. - Approve the develop comprehensive M&E Plans, outlining key performance indicators, data collection methods, timelines, and responsibilities. - Facilitate communication and collaboration among committee members and stakeholders during the committee meetings. - Support the training needs and opportunities for capacity building. - Continuously review and refine M&E processes. Rapporteur of Jointly between Jordan - Prepare agendas and distribute minutes of the Committee CDC and MOH meetings. - Manage correspondence to and from the A representative from the Committee. Directorate of Institutional - Follow up on the implementation of Committee Development and Quality decisions. Control - MOH - Prepare quarterly progress reports in coordination with the Chairman. A representative from the - Maintain all documents related to Committee Jordan CDC to coordinate activities. cooperation - Coordinate logistical arrangements for Committee activities. Vice-Chairman Director of Epidemiology - Represent the Committee in the absence of the Administration - MOH Chairman. - Communicate with entities on behalf of the Committee. Key Members National AMR M&E - Collaborate with stakeholders and coordinate Committee efforts with other teams. - Provide expertise and knowledge in resistance and antimicrobials. - Act as liaison between the Committee and their respective sectors. - Ensure accurate data management for evidence- based decision-making. - Ensure that regular reports on AMR control efforts are prepared, highlighting achievements, challenges, and areas for improvement. 31 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC M&E Representatives and focal - Act as representatives of the sub-technical Coordination points from each objective committees for each objective and their sectors. Group Members and sector - Provide reports on data and activities carried out by the operational technical team. - Contribute to discussions and share experiences. Jordan CDC M&E Prevention Directorate, - Develop M&E Plans outlining goals, objectives, TWG Epidemiological methodologies, indicators, and timelines. Surveillance Directorate, - Facilitate feedback and learning from M&E activities. Research, Policies and - Analyze data to assess progress and identify areas Training Directorate, for improvement. Laboratory Directorate - Prepare regular reports on M&E findings. - Ensure data quality through rigorous quality assurance processes. X. Data Flow AMR reports and data will flow from the district level through provincial structures to the national level and then to the AMR Focal Person and Technical Working Group. This M&E Plan recognizes that the One Health sectors have different structures, from health facilities to the national level. However, this does not affect the direction and levels through which data and reports flow. The simplified reporting and data flow chart is illustrated in Figure (4). Human health data for AMR will come from two primary sources: laboratory data and other reports. Laboratory data will be generated from the source (patient) and then sent to the laboratory for processing. After processing, it will be sent back to the clinician for decision-making. Hospitals generate and collect numerous clinical and AMR data for routine patient care. This data can also be utilized to create cumulative antibiograms and monitor antimicrobial resistance locally at the facility level. 32 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Figure (4). Data Flow and Reporting Structure for AMR National Data 33 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Data Collection: The Health Data Analytics (HDA) program, developed and implemented by EHS through the Hakeem platform in public and RMS, facilitates the extraction of reliable information on AMR data from hospital electronic medical records (EMR). Additionally, designated focal points at participating surveillance sites, including private and university hospitals, are responsible for submitting AMR data annually to the AMR Surveillance Data Management Department at MOH. The submitted AMR data encompasses microbiology, clinical information, and demographic details were available and technically feasible. The reporting protocol is in strict alignment with the Jordan National AMR Surveillance Protocol. It adheres to global reporting standards for AMR surveillance as outlined by the WHO Global Antimicrobial Resistance Surveillance System (WHO-GLASS) in 20157. Table 6 provides an overview of the 42 surveillance sites across various governorates responsible for generating and collecting AMR surveillance data. This data is then reported to the Jordanian Committee for AMR Surveillance. The clinical and microbiology data collected from these surveillance sites serve as the foundation for the national AMR surveillance report. Table (6). AMR surveillance sites by Governorates (2023)8. Facility Type Surveillance sites Amman 17 Irbid 6 Zarqa 2 Jarash 1 Ajlun 2 Mafraq 3 Balqa 3 Madaba 2 Tafileh 1 Karak 2 Ma'an 2 Aqaba 1 TOTAL 42 Laboratory personnel enter data collected at these sites into the national database, where it becomes accessible at the national level. Additional reports on AMR are generated at the facility level and submitted according to established reporting timelines and deadlines. This structured approach ensures comprehensive and timely data collection and reporting, contributing to the ongoing national efforts to monitor and combat AMR. 7 World Health Organization. (2015). Global antimicrobial resistance surveillance system: manual for early implementation. World Health Organization. 8 https://www.moh.gov.jo/ebv4.0/root_storage/ar/eb_list_page/jordan_national_amr_surveillance_report_2022_(final).pdf 34 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC XI. Monitoring Plan The implementation of the AMR NAP will be guided by a comprehensive and systematic monitoring system designed to track progress toward achieving the targets outlined in the results framework. This monitoring system will primarily rely on data from activity implementation reports from various ministries and affiliated institutions. The National AMR M&E Committee will be responsible for compiling, analyzing, and synthesizing this data to ensure accurate tracking of the plan’s progress. Monitoring Activities The M&E focal point within the AMR TWG will lead the monitoring activities, which are scheduled bi-annually and annually. Additionally, periodic supportive site supervision visits will be conducted to offer technical assistance and verify the data's accuracy and quality. The M&E focal point will be tasked with consolidating and generating bi-annual and annual narrative reports encompassing all reportable indicators and summarizing quantitative achievements. Detailed site visit reports and routine monitoring outputs will complement these reports. The detailed reporting frequency for each indicator is outlined in the results framework table (Annex No. 3). The TWG is responsible for submitting narrative and quantitative performance reports to the National AMR M&E Committee. These reports will highlight key achievements, identify challenges, and provide recommendations for course correction where necessary. Success stories and other communication materials, incorporating personal stories, will be developed to illustrate the program’s activities, outcomes, and impact. Local Monitoring and Data Collection Effective local monitoring will necessitate the active participation of facility-level personnel and other relevant stakeholders. The M&E focal point within the TWG will oversee data collection on performance indicators, ensuring that interventions are on track to meet their respective targets. This process will be conducted closely with the Jordan CDC's M&E technical team, ensuring consistency and adherence to national standards. Review Meetings To ensure continuous improvement and adaptation, the National AMR M&E Committee will convene regular review meetings to evaluate the progress and activities concerning the established targets. These review meetings will be held quarterly and bi-annually, following established guidelines on procedures, areas of focus, and participant involvement. During these meetings, performance will be assessed, and adjustments to the implementation strategies will be made as needed to maintain alignment with the overall goals of the AMR NAP. XII. Evaluation Plan The AMR NAP evaluation is a critical process designed to systematically and objectively assess the plan's design, implementation, and outcomes. The primary goal of this evaluation is to determine whether the intended objectives have been achieved and to inform strategic decisions moving forward. 35 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Evaluation Process Designated M&E experts will evaluate the progress made in Jordan's response to AMR annually. These evaluations will be discussed in management and national committee meetings to ensure that the findings inform ongoing implementation and decision-making. The initial evaluation will include a mid-term assessment, which will provide a comprehensive review of the progress made in the implementation. This mid-term evaluation will enable adjustments to the NAP, the M&E framework, and targets as necessary. The final evaluation, conducted at the end of the NAP's implementation period, will align with the Global Action Plan on Antimicrobial Resistance (GAP-AMR) objectives. The Jordan CDC will lead this evaluation in collaboration with the National AMR M&E Committee and will apply the following key evaluation criteria: • Efficiency: Assessment of how effectively the NAP's inputs (materials, financial, and human resources) have been transformed into outputs and results, with attention to time and cost efficiency. • Effectiveness: Measurement of the extent to which the NAP has achieved its stated objectives. • Relevance: Evaluation of the alignment between NAP interventions and AMR priorities. • Impact: Analysis of NAP implementation's positive or negative effects on technical, institutional, and environmental factors, including direct, indirect, and multiplier effects. • Sustainability: Determination of the likelihood that the benefits or outcomes of the NAP will continue beyond the implementation period (2023-2025). Evaluation Timeline Mid-Term Evaluation: The mid-term evaluation is scheduled for mid-2024. This evaluation will provide an interim assessment of the progress made towards the NAP objectives and will be crucial in making necessary adjustments to the plan, M&E framework, and targets. Final Evaluation: The final evaluation will take place at the end of the NAP implementation period in

2026. This comprehensive assessment will evaluate the overall effectiveness, impact, and sustainability of the AMR NAP interventions. Evaluation Focus The evaluation will focus on several key areas, as outlined in the table below: 36 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Table (7). Evaluation Focus and Responsibilities. Evaluation Key Questions Data Sources Frequency Responsibility Focus Progress toward Were the targets of Monitoring Mid-term and Internal and targets and the AMR NAP reports, final evaluation external intermediate achieved? evaluation data evaluators results Did the program from mid-term attain its and final intermediate results? evaluation Reporting Were all the Review of Quarterly National AMR requirements necessary reporting reporting plan M&E Committee requirements and schedule fulfilled? Budget Was there a budget Review of budget Quarterly National AMR management allocated? spending M&E Committee The evaluation will address the following overarching questions: Table (8). Proposed Evaluation Questions a) Relevance - Do the activities and outputs of the program support the overarching objectives and goals of the NAP? - Are the activities appropriate for addressing the challenges of AMR? - Is there sufficient coverage per activity to effectively tackle AMR challenges? - Should specific interventions have been terminated earlier or extended? b) Effectiveness - To what extent were the objectives of the NAP achieved? - What were the major factors influencing the achievement or non- achievement of the objectives? - Were there any coordination issues impacting the achievement of objectives? c) Efficiency - Were NAP activities accomplished at minimal cost? - Were NAP objectives achieved within the specified timeframe? - Was the NAP implemented in the most efficient manner compared to alternative approaches, considering both time and cost factors? d) Impact - What changes occurred as a result of NAP implementation? - Are there discernible differences attributable to NAP implementation compared to the baseline situation? - Who may have been affected by these changes? - What would have been the outcomes if the NAP had not been implemented? e) Sustainability - To what extent will the benefits or outcomes of the NAP persist beyond its duration in 2025? - Are there measures in place to ensure the sustainability of benefits or outcomes beyond 2025? - What are the primary factors influencing the sustainability or lack thereof of the NAP? 37 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Dissemination of Evaluation Findings The findings from both the mid-term and final evaluations could be disseminated through the following forms, Evaluation Reports, Executive Summaries, Workshops and Presentations, Publications and Briefings. Target Audience The primary recipients of the evaluation findings will include: • Jordan CDC Board and National AMR M&E Committee: To inform strategic decisions and policy adjustments. • Relevant Government Ministries (MOH, MOA, MOEnv, MWI, JFDA): To ensure that findings are integrated into future action plans and policy frameworks. • International Partners (WHO, USAID, FAO): To align Jordan’s AMR strategies with global standards and expectations. • Healthcare Institutions and AMR Focal Points: To improve on-the-ground implementation and capacity building. • Academic and Research Institutions: To encourage further research and innovation in AMR management. • Public Health Community: To share best practices and insights for combating AMR globally. XIII. Learning Plan The Learning Plan within the AMR NAP is designed to facilitate continuous improvement through systematically collecting, analyzing, and disseminating data related to activities, outputs, and outcomes. This process aims to establish accountability and equip stakeholders with the necessary information to assess the program's effectiveness, efficiency, impact, and sustainability. Learning Activities and Events To promote knowledge sharing and collaboration, the AMR NAP will incorporate various learning activities, including bi-annual and annual review meetings, exchange visits, and targeted learning events. These gatherings will be platforms for stakeholders to share key achievements, best practices, challenges, and lessons learned across the One Health sectors. For instance, the Jordan CDC AMR Review Report 2023 identified several critical areas needing development, such as inconsistent and insufficient funding, which poses a significant barrier to the sustained implementation of AMR strategies. The report emphasizes that local financial capacity is currently inadequate to support national-level activities; however, it also highlights the potential for securing diverse funding sources through international partnerships to support the implementation of the NAP. Exchange visits within and between sectors will offer valuable opportunities for stakeholders to observe and share successful practices. Depending on the availability of resources, these exchange 38 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC visits may also extend to other countries actively implementing AMR NAP interventions, fostering international collaboration and learning. The National AMR M&E Committee will lead in organizing and managing all learning activities, ensuring that insights gained are effectively integrated into ongoing and future actions. Table (9). Activities and Approaches for Learning Knowledge Activities and Stakeholder consultations, mapping, after-action reviews, reflections, generation and interventions learning networks, learning events, expert panels, assessments, capture special studies, success stories, reports (training reports, quarterly performance progress reports), newsletters Who to involve MOH, MOA, MOE, MWI, JFDA, Jordan CDC, AMR Technical Working Group Sharing what is Who will benefit from MOH, MOA, MOE, MWI, JFDA, Jordan CDC, AMR Technical Working learned learning Group Format Informal discussions, formal meetings, presentations, reports, briefs or updates, tools, guidance, policy, reports, pictures, stories Using what is The kind of change to Understanding context, development of hypotheses, project design, learned which learning can activity design, mechanisms, partnerships or roles, internal or national contribute policy, impact assessment, M&E, quality of data Updating Periodicity Quarterly, semiannual, annual learning Means Continuous monitoring, surveys, evaluation, after-action reviews, reflections, learning events, expert panels, assessments, special studies, success stories, reports (training reports, quarterly performance progress reports), newsletters XIV. Reporting and Communication The reporting and communication plan for the AMR NAP is designed to systematically and effectively document and disseminate progress toward meeting the plan’s targets to ensure that all relevant stakeholders, both internal and external, receive timely and accurate information to support decision-making, policy development, and program adjustments. Reporting Structure and Responsibilities Internally, AMR NAP implementing entities, including the AMR Sub-committees, MOH, MOA, MOEnv, MWI, and JFDA, will receive data from designated delivery points. The M&E focal point of the AMR Sub-committees will aggregate performance indicators and submit comprehensive reports to the National AMR M&E Committee. Data collection will focus on 42 surveillance sites across Jordan, encompassing public sector facilities (MOH and RMS), university hospitals, and private hospitals. Due to the necessity of 39 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC maintaining data quality and the relatively short implementation timeline, the plan will be executed in stages: • Stage One (Ending in 2025): Focuses on 10-15 hospitals from different sectors. • Stage Two: Expand the implementation to the remaining selected hospitals. The MOH’s Data Analysis Department will compile and analyze hospital data, producing an annual report with epidemiological insights and recommendations for improvement. Additionally, data on antimicrobial use will be integrated from the Pharmacy Directorate and the JFDA. Technical staff, including epidemiologists, will analyze this data to generate reports that inform national policies, protocols, systems, and legislation. Collaboration with other sectors, such as the animal and environmental sectors, will include collecting and uploading data to designated global platforms. The environmental sector, in particular, will implement recommendations from previous monitoring projects during the 2018- 2022 action plan. Table (10). Reporting Schedule TARGET REPORT TYPE PURPOSE OF USE FREQUENCY Summary of progress on Promote coordination, Jordan CDC milestones and targets, collaboration, and evidence- Semi-annual board next steps based policy guidance Summary of progress in Facilitate coordination and International achieving milestones and collaboration and assess Quarterly Organizations targets, next steps progress in meeting targets Progress in achieving all Program monitoring, evaluation, Ministries and outputs and outcome reporting, and internal Quarterly Institution Team indicators assessment of data quality Program monitoring, evaluation, National AMR Progress in achieving all reporting, and internal Quarterly M&E Committee output indicators assessment of data quality The National M&E Sub-coordination Committee of the AMR Technical Working Group will be responsible for submitting quarterly reports to the National AMR M&E Committee and semi-annual reports to the Ministries and committees. These reports will include details on progress toward defined outputs and outcomes, next steps, and any emerging issues. Ensuring timely dissemination of these reports is critical to maintaining momentum and enabling prompt decision-making. Communication Strategy Effective communication is essential for conveying clear and consistent messages regarding the AMR NAP’s targets and progress. The communication strategy will utilize various channels, including written reports, success stories, quarterly summary reports, speaking events, and social 40 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC media platforms. The TWG will analyze data in context, identify influencing factors, and assess outputs to support informed decision-making aimed at improving AMU. Reports will integrate both quantitative and qualitative data, accompanied by narratives that provide a comprehensive picture of activities, outcomes, and impacts. These narratives will highlight key achievements, challenges, and lessons learned, helping to contextualize the numerical data. Final NAP Evaluation report The final evaluation report at the conclusion of the NAP will include: • An assessment of performance throughout implementation, measured against established indicators. • An analysis of whether progress or results met, surpassed, or fell short of expectations, with explanations. • Recommendations for future actions, including considerations for program continuation and sustainability. • Lessons learned during the implementation period. AMR NAP Reporting Template Data on AMR NAP implementation will be collected and reported using specifically designed tools. Data collected at service delivery points will be centrally compiled and reported using the AMR NAP reporting template, which will include: • Implementing government institution • Sector (human, animal, or environment) • Reporting period Narrative Summary Components Each narrative summary report will include: • Achievements: A detailed account of accomplishments during the reporting period, including any unplanned activities. • Challenges: An overview of constraints that limited progress, along with actions taken to address them. • Lessons Learned: Insights that validated or necessitated modifications to the implementation approach. • Success Stories: Illustrative examples of successful interventions or outcomes. • Upcoming Activities: A preview of significant activities planned for the next reporting period. • Completed Activities: A summary of completed activities during the reporting period. • Concluding Remarks: Final observations and recommendations for future support or changes. 41 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Performance Indicator Reporting For each performance indicator, the reports will include: • Reporting Frequency: Specification of how often the data is reported. • Results: Summary of results for the current reporting period. • Explanations: Clarification for any unmet targets. • Actions: Strategies to ensure future targets are met. XV. Data Management This section outlines the processes and protocols for data sourcing, analysis, privacy, utilization, and quality assurance to ensure that the data collected is accurate, secure, and effectively used for decision-making. Data Sources Data will primarily be sourced from service delivery point registers across participating institutions. All stakeholders involved in AMR prevention and containment will have controlled access to relevant data. In cases where secondary data sources do not align directly with indicator definitions, the team may conduct assessments and surveys to gather primary data. Standardized templates will be developed to ensure consistency in data recording, storage, and aggregation. Additionally, all reports and evaluations will be systematically documented, with a plan in place to capture and disseminate lessons learned to both internal and external audiences. Data Analysis AMR data will be regularly analyzed to generate actionable insights for policymakers and other stakeholders. The analysis will employ a variety of quantitative and qualitative techniques tailored to specific information needs. These techniques will include, but are not limited to, descriptive statistics, comparative analysis, and trend analysis. The goal is to provide comprehensive and timely information that supports evidence-based decision-making. Data Privacy To safeguard the privacy of AMR data, access will be restricted to authorized users as determined by the National AMR M&E Committee. Strict protocols will be implemented to ensure that data is handled in accordance with national privacy standards, with access granted only to individuals with a legitimate need to know. Data Utilization A key objective of the AMR NAP is to foster a culture of data-driven decision-making at all levels. The AMR M&E Committee will establish mechanisms to promote the effective use of data across the various stakeholders involved in the plan’s implementation. Regular meetings will be held to 42 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC interpret data, prioritize issues, develop solutions, and enhance overall performance. This approach will support the development of multi-level, multi-stakeholder teams dedicated to continuous improvement. Data Quality Assurance Ensuring data quality is a central component of the AMR NAP’s data management strategy. The National AMR M&E Committee will integrate data quality assessments into its technical support activities for implementing institutions. These assessments will focus on key dimensions of data quality, including timeliness, accuracy, completeness, and validity. During supportive supervision visits to both human and animal health facilities, the AMR M&E team, along with the Jordan CDC technical team, will monitor data quality regularly in a participatory manner. Additionally, the AMR M&E team will conduct at least one rapid data quality assessment annually at selected facilities. This assessment will evaluate the completeness, consistency, and accuracy of reported data, identify potential issues in data collection, reporting, or entry, and recommend corrective actions as needed. Data Storage and Security Data collected from service delivery points will be centrally stored in a secure, password-protected system. Access to the data will be limited to personnel responsible for data management, including surveillance focal points, data analysts, and information technology staff. These individuals will be trained in the appropriate handling and management of sensitive data to ensure its integrity and security. XVI. References ▪ Ethiopia: Third One Health strategic plan on antimicrobial resistance prevention and containment 2021- 2025, https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-spc-npm/nap- library/ethiopia-amr-strategic-plan-2021_2025.pdf?sfvrsn=8ef921ca_3&download=true ▪ World Health Organization, UNEP United Nations Environment Programme, & World Organisation for Animal Health. (2023). Guidance to facilitate monitoring and evaluation for antimicrobial resistance national action plans. World Health Organization. ▪ World Health Organization. (2019). Monitoring and evaluation of the global action plan on antimicrobial resistance: framework and recommended indicators. ▪ World Health Organization. (2022). Malawi national action plan on antimicrobial resistance: review of progress in the human health sector. 43 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC XVII. Annexes Annex No. 1 H.E. Minister of Health Official letter No. Epidemics/2023/90, dated 31/5/2023 44 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Annex No. 2 National AMR Activity Prioritization Tool for Jordanian Context Importance Impact (The (The impact Difficulty to Cost importance the activity implement (The costs assigned by has on (The level of required to Activity Total score Ranking stakeholders reducing the difficulty to implement to prioritize development implement the and implement and spread the activity) activity) the activity) of AMR) 1 - Low 1 - Low 1 - High 1 - High The activities Once the total importance impact to difficulty to cost to with the highest scores have assigned by reduce AMR implement implement total scores been calculated, stakeholders 2 - Medium activity activity should be the the activities 2 - Medium impact to 2 - Medium 2 - Medium ones to will importance reduce AMR difficulty to costs to prioritize for automatically be assigned by 3 - High implement implement implementation. categorized into stakeholders impact to activity activity "High," 3 - High reduce AMR 3 - Low 3 - Low "Medium," and importance difficulty to cost to "Low." assigned by implement implement Activities stakeholders activity activity categorized as "High" should be prioritized for implementation, followed by "Medium"- categorized activities. 0 Low 0 Low 0 Low 0 Low 0 Low PRIORITIZATION MATRIX FOR AMR NAP ACTIVITIES STRATEGIC OBJECTIVE: 45 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Annex No. 3 AMR NAP Result Frameworks Monitoring Matrix Tool Responsible agency or organization + relevant unit and Users Target 2024- Period person in (audience) Data Target 2024 Target 2025 2025 (End of Results Data and charge of the and use of Indicators collection Baseline (2023) (non- (non- project/progra statement source(s) frequen indicator. the method(s) accumulative) accumulative) m, cumulative, cy Means and information total) resources to generated support data collection and processing Impact: Reduced burden of AMR and enhanced health outcomes for humans, animals, and the environment Annual trends AMR Surveillance Annual 82% Reduction Reduction Reduction MOH Decision for percentage surveillanc ly makers, of isolates e annual TBD TBD TBD multidrug- report Ministries, resistant (%MDR) for Jordan non- CDC fermenting Gram-negative National rods,r AMR M&E Acinetobacter Committee spp. . Annual trends AMR Surveillance Annual 38% Reduction Reduction Reduction MOH Decision for percentage surveillanc ly makers, of isolates e annual TBD TBD TBD multidrug- report Ministries, 46 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC resistant (%MDR) for Jordan Gram-positive CDC bacteria,e.facie um National AMR M&E Committee . Prevalence of Tricycle Survey Annual Reduction Reduction Reduction MOA ESBL genes of report ly E-coli in poultry TBD TBD TBD Objective no. 1 Outcome 1: Number of HCAD Social Media Annual No. of posts: No. of posts: No. of posts: No. of posts: MOH: Decision Increase people who Facebook Reports ly 3, 8, 12, 20, Awareness makers, awareness interacted with Page design and of AMR the digital Reach: 11817, Reach: Reach: Reach: production MOH – through campaign's 150.000, 200.000, 350.000, unit – Head HCAD, effective awareness Engagement: of the Unit communica materials on 150 Engagement: Engagement: Engagement: National tion, social media 2500 3500 6000 AMR M&E education, conducted on Committee and the HCAD . training. social media page through (likes, views, shares, comments, etc...) Number of Report Reports Annual 0 100 150 250 MOH: Decision schools (within from provided by ly School makers, the age group School school health health 12-17 years) in Health service directorate MOH – which the Directorate providers to HCAD, topic of AMR directorate was included in School their routine health 47 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC health directorate education , topics National AMR M&E Committee . Number of Report Social Media Bi- Listening Listening Listening Listening MOH - Decision advocate from MOH Reports, annual reports: 1, reports: 2 reports: 2 reports: 4 HCAD makers, recommendati – HCAD Focus group reports, reports, reports, ons and MOH – community Number of HCAD, listening advocate Number of Number of Number of reports on the recommenda advocate advocate advocate National issue of AMR. tions: 1 recommenda recommenda recommenda AMR M&E tions: 2 rec. tions: 2 rec. tions: 4 rec. Committee Output 1.1: Raise awareness and change behaviors through the implementation of Social and Behavior Change Communication (SBCC) programs to raise awareness about antibiotics. Prepared Report Report Annual 0 0 1 1 Health MOH – communicatio from HCAD ly Communica HCAD, n plan on AMR. tion and Awareness National Directorate, AMR M&E Committee Awareness committee Number of Report Report Annual 1 1 1 2 Health MOH – digital from HCAD ly Communica HCAD, awareness tion and campaigns Awareness National about AMR Directorate, AMR M&E conducted on Committee the social Awareness media committee platforms of the 48 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC MOH/HCAD and partners' social media pages. Number of Report Electronic Bi- 6569 6300 6500 12800 Health MOH – awareness from HCAD Report annual Communica HCAD, lectures tion and conducted by Awareness National community Directorate, AMR M&E health Committee committees Awareness about hygiene committee and the rational use of antibiotics in human and animal health fields. Number of Report Report Bi- 0 100 200 300 School MOH – awareness from the annual health HCAD, activities School directorate targeting Health National schools. Directorate AMR M&E Committee Output 1.2: Promoting political commitment to the issue of antimicrobial resistance. Number of Health Report Bi- 0 1 1 2 Health MOH – reports communic annual Communica HCAD, prepared ation and tion and included the awareness Awareness National results of Directorate Directorate, AMR M&E community / Committee listening and community Awareness monitoring of health committee social media committee rumors about s and social antimicrobials. 49 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC media platform Number of lists Health Report Bi- 0 1 One same list 2 Health MOH – of experts and Communic annual Communica HCAD, partners was ation and tion and identified to Awareness Awareness National help advocate, Report Directorate, AMR M&E develop, and Directorate Committee enforce / Awareness policies and Awareness committee legislation on Committee antimicrobial report resistance. Implement Number of MOA Report on Annual 0 50 200 250 MOA: Minister, ation of farmers directorate the ly field educated / field visit awareness One Health Assistance orientation about the report form for the and S.G in visits for rational use of optimal use Zoonotic animal farmers antibiotics and of antibiotics Diseases sectors, regarding the by Email- Departmen vaccination, importance of WhatsApp t, S.G (to biosecurity, good animal for 2024/ for assess feed husbandry 2025 EIDSS Animal awareness additives, practices. Health capacity in water Departmen each purification, t, directorate and the use , redirect of Poultry awareness antibiotics, Health effort, among Departmen cross- other t - MOA reference topics. Directorate this data s with the data collected for the 50 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC surveillanc e) Objective no. 2 Outcome 2: Number of Tricyclic Annual 0 TBD TBD TBD MOH: CPHL NGOs, Strengthen facilities that Project ly the implemented report MWI: Policy knowledge the recommenda laboratories makers base and recommendati tions and quality evidence on derived affairs through from the continuous Tricyclic Project MOA: surveillance laboratory . Percentage of MOH Surveillance Annual 33.10% TBD TBD TBD Data the non- surveillanc ly analysis duplicate e department diagnostic isolates Percentage of samples analyzed for detection of AMR pathogens from human health sentinel site Output 2.1: Enhanced antimicrobial resistance surveillance system in alignment with the one health approach. Number of MOH, Recommend Annual 0 0 1 1 MOH: CPHL NGOs recommendati ation ly ons adapted MOE, checklist MWI: Policy according to laboratories maker the Tricycle MOA and quality project data to affairs enhance multisectoral MOA: laboratory 51 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC collaboration report. Number of Data Report Annual 1 1 1 2 Data Public Annual reports Manageme disseminatio ly Manageme health on resistance nt n nt profession patterns Departmen Departmen als and developed and t, t, decision- disseminated makers to relevant Communic Communica sectors able ble Disease Disease Directorate Directorate Establishing Number of Animal Number of Depen Around 400 400 400 800 Micro Lab Farmers, a system animal sample health tests is d on samples at different for test results for central recorded and the directorate veterinaria monitoring antibiotic laboratory compiled freque s ns, antimicrobi susceptibility (microbiolo into annual ncy of al-resistant reported from gy lab) reports by receivi animal microbes in the Animal relevant ng the health animals Health Central Peripheral health and cases workers. similar to Lab (passive labs. veterinary the system surveillance). authorities. & Sharing existing in with other humans. ministries (MOH, MOEnv) and internation al (WOAH) Output 2.2: Enhanced laboratory capabilities. Number of labs CPHL Developed Bi- 10 sites 18 Sites 28 CPHL, MOH that adhere to assessment annual CLSI guidelines tool results Jordan CDC National in testing analysis AMR M&E performance Committee 52 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC and reporting results. Number of labs CPHL Formal Bi- 10 sites 18 sites 28 CPHL MOH with an letters and annual uninterrupted template National supply chain. AMR M&E Committee Developing Number of labs CPHL Filled forms Annual PRESENT Developed Developed Developed CPHL MOH and revising implementing for the ly BUT NOT (1) a quality the quality NEQAS REVISED (0) National assessment assessment AMR M&E program to program Committee be applied to all laboratories participatin g in the monitoring system (internal and External Quality Assessment EQA participatio n). Number of labs CPHL and NEQAS Bi- TBD 10 18 28 CPHL MOH that were Surveillanc assessment annual assessed for e Sites result tool National quality AMR M&E assurance. Committee Standardizi Number of Data from Regular Annual 0 1 1 2 Ministry of Policymak ng the laboratories in the audits to ly Agriculture, ers, national the animal Ministry of ensure laboratory sector that Agriculture laboratories Departmen livestock standards have t of farmers, 53 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC and general developed central comply with Microbiolog guidelines (SOPs) in laboratorie SOP y, veterinaria according accordance s ns, to with (CLSI) Departmen internation guidelines to t One and public al improve Health health standards (AMR) officials. (Clinical and detection and Laboratory surveillance Standards capabilities. Institute, etc.): Including members from all relevant sectors and holding regular meetings. - Preparing a summary - Printing - Training staff - Providing sites with (CLSI) and monitoring their implementa tion and application of Vitek system Objective no. 3 54 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Outcome 3: Decreased rate AMR Electronic Annual 22.7% 0% 3% decrease 3% decrease MOH, MOH, Reduce of Blood Surveillanc AMR ly infection Stream e Surveillance (0.7 point) (0.7 point) Surveillance Jordan rates Infection (BSI) Focal Point CDC, through caused by preventive Carbapenem- RMS, measures, resistant infection organism University control, and (CRO) Hospitals general hygiene Output 3.1: Effective program for infection prevention and control developed. 3.1.1 Improving and developing the organizational structure of the personnel in the infection prevention and control program. Establishing Percentage IPCAT2 Self- Annual 82% 82% (2024) 86% 4.87% MOH - IPC IPC the increase of the Assessment ly (2025) increase Departmen Departme presence of annual score of tool – (4 points) t nt, infection national IPC National control program level IPC units and assessment in Committee directly IPCAT 2 , connecting them to (The average National higher of 3 indicators AMR M&E administrati with 23 sub- Committee ons within indicators) the organizatio nal structure of all healthcare institutions. Determinin Percentage IPCAT2 Self- Annual 56% 56% 81% 44.64% MOH - IPC IPC g the increase of the Assessment ly (2024) (2025) increase Departmen Departme staffing annual score of tool – (25 points) t nt, ratios for IPC guideline 55 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC the assessment in National IPC infection IPCAT 2 level Committee control , units within (The average healthcare of 4 indicators National institutions with 16 sub- AMR M&E based on indicators) Committee the size and nature of the services provided. 3.1.2 Improving the training and education levels for infection control teams and healthcare personnel. Conducting Percentage IPCAT2 Self- Annual 28% 28% 37% 32.14% MOH - IPC IPC specialized increase of the Assessment ly (2024) (2025) increase Departmen Departme training annual score of tool – (9 points) t nt, workshops IPC education National on infection and training level IPC control assessment in Committee procedures. IPCAT 2 , (The average National of 4 indicators AMR M&E with 17 sub- Committee indicators) 3.1.3 Expanding the surveillance system for healthcare-associated infections in hospitals. Developing Percentage IPCAT2 Self- Annual 80% 80% 88% 10% increase MOH - IPC IPC unified increase of the Assessment ly (2024) (2025) (8 points) Departmen Departme policies for annual score of tool – t nt, healthcare- surveillance National associated assessment in level Hospital infection IPCAT 2 administra surveillance tion, processes (The average and aligning of 6 indicators IPC them with with 30 sub- Committee case indicators) , definitions. 56 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC National AMR M&E Committee Output 3.2 Improving environmental sanitation programs 3.2.1: Improved regulatory programs on water sources and sewage networks. Updating Percentage Wash Fit Facility level/ Annual 69% 69% 76% 10% increase Electronic At MOH guidelines increase of assessmen all hospitals ly (2024) (2025) (7 points) dashboard, level: for healthcare t/ JMP and PHC at (Average of regulatory facilities having MOH all facilities) Focal point (Epi- programs basic services Self- at the Administra on water of water. assessmen hospital tion, and sewage t at facility level sources and (The average level (representa Environme networks. of 3 indicators) tives from ntal Health the IPC, Departme Public nt, Health & Service IPC Maintenanc departmen e unit) t, Services managem ent units), National IPC Committee , National AMR M&E Committee Issuing Percentage Wash Fit Facility level/ Annual 22% 22% 35% 59% increase Electronic At the annual increase of assessmen all hospitals ly (2024) (2025) (13 points) dashboard, MOH level: reports to healthcare t/ JMP 57 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC indicate the facilities having and PHC at Focal point (Epi- extent of basic services Self- MOH at the Administra commitme of sanitation. assessmen hospital tion, nt by health t at facility level directorate (The average level (representa Environme s to of 7 indicators) tives from ntal Health implement the IPC, Departme control Public nt, programs. Health & Service IPC Maintenanc departmen e unit) t, Services managem ent units), National IPC Committee , National AMR M&E Committee 3.2.2: Enhanced safe disposal and management of medical waste to achieve a safe and green environment. Updating Percentage Wash Fit Facility level/ Annual 22% 22% 37% 68% increase Electronic At the the increase of assessmen all hospitals ly (2024) (2025) (15 points) dashboard, MOH level: instructions healthcare t/ JMP and PHC at related to facilities MOH Focal point (Epi- the implanting Self- at the Administra manageme basic services assessmen hospital tion, nt of of medical t at facility level medical waste level (representa Environme waste. management. tives from ntal Health the IPC, Departme Public nt, 58 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC (The average Health & of 2 indicators) Service IPC maintenanc departmen e unit) t, Services managem ent units), National IPC Committee , National AMR M&E Committee 3.2.3: Improved environmental hygiene in healthcare institutions. Involving Percentage Wash Fit Facility level/ Annual 57% 57% 72% 26.3% Electronic At the employees increase of assessmen all hospitals ly (2024) (2025) increase dashboard, MOH level: in the healthcare t/ JMP and PHC at (15 points) infection facilities having MOH Focal point (Epi- control field basic services Self- at the Administra by of hygiene. assessmen hospital tion, formulating t at facility level contracts (The average level (representa Environme with service of 1 indicator) tives from ntal Health companies. the IPC, Departme Public nt, Health & Service IPC maintenanc departmen e unit) t, Services managem ent units), 59 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC National IPC Committee , National AMR M&E Committee Percentage Wash Fit Facility level/ Annual 30% 30% 50% 66.6% Electronic At the increase of assessmen all hospitals ly (2024) (2025) increase dashboard, MOH level: healthcare t/ JMP and PHC at (20 points) facilities having MOH Focal point (Epi- basic services Self- at the Administra of assessmen hospital tion, environmental t at facility level cleaning. level (representa Environme tives from ntal Health (The average the IPC, Departme of 2 indicators) Public nt, Health & Service IPC maintenanc departmen e unit) t, Services managem ent units), National IPC Committee , National AMR M&E Committee 60 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Output 3.3 Ensuring the availability of evidence-based practices and consistent standards at the national level for infection prevention and control in the livestock sector. Improving Number of Reports Inspection Annual 10 10 10 20 Municipaliti Policymak hygiene slaughterhous from MOA- from ly es include ers, practices in e inspections slaughterh slaughterhou private slaughterho to ensure ouse ses report sectors, veterinaria uses compliance departmen ns, with Biosafety t Greater and biosecurity inspection Amman Jordan practices reports Municipality CDC, according to accepted , slaughterhous for National e inspection biosafety Ministry of AMR M&E forms. and Municipal Committee biosecurity Affairs, measures. JFDA food, microbiolog y labs, and the slaughterho use department . Objective no. 4 Outcome 4: Percentage of JFDA Antimicrobial Annual TBD Less than 40% Less than 40% Less than 40% JFDA: AMC JFDA-AMC Optimized Antibiotics database consumption ly team, team, antimicrobi consumed Excel sheet al utilization from WATCH MOH National in human group as per AMR M&E and animal AWaRe Committee healthcare classification. 61 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Number of PCPD Formal Annual 8 2 5 7 MOH National hospitals that letters/ ly AMR M&E have active communicati Committee AMS on tools committees. Percentage of Pre- and Questionnair Annual - 75% 85% 80% MOH National trained Health post- e ly AMR M&E Care Providers training Committee who showed a questionna change in their ire (TBD) knowledge post-training. Output 4.1: Enhance and amend systems and regulations aimed at dispensing antimicrobials and imposing deterrent penalties for violence. Number of Meetings Committee Annual 1 decision 1 decision 1 decision At least 2 JFDA National decisions minutes meetings ly AMR M&E taken (checklist) Committee regarding rational use of antibiotics. Number of WHO-EML Through a Every 1 list updated 1 list updated Based on 1 list updated JFDA - RDU JFDA, updates made technical two frequency Q 2 department to the essential committee years years, it will M&E focal National medicine list, based on not be point AMR M&E categorizing WHO-EML updated in Committee antimicrobials for 2025 according to registered the global medications classification, AWaRe classification, and circulating it. 62 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Number of Meetings Committee Bi- 3 3 4 7 MOH National recommendati minutes meetings annual AMR M&E ons of the (checklist) Committee national AMS committee Output 4.2: Develop Evidence-based treatment guidelines for infectious diseases and protocols for optimal use of antimicrobials at the national level. Number of MOH Formal Annual 12 2 4 6 MOH National treatment database letters ly AMR M&E protocols and Committee guidelines developed or updated Number of MOH Formal Annual 2 2 2 4 MOH National policies database letters ly AMR M&E reviewed and Committee updated on prescribing and dispensing antibiotics to standardize procedures at the healthcare institution and national levels. Output 4.3: Expanding the implementation of AMS program to ensure the optimum antimicrobial use. Number of Hakeem Formal letter Annual 0 1 0 1 MOH National electronic system ly AMR M&E tools within Committee EHS/ Hakeem to monitor dispensing antimicrobials on the hospital level. 63 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Number of Clinical Formal Annual 15 5 10 15 MOH: National healthcare pharmacy letters ly Clinical AMR M&E hospitals that directorate pharmacy Committee have AMS records directorate committees. Output 4.4: Develop and enhance health care providers' qualifications on antimicrobial use and AMS program. Number of Clinical Formal Annual 6 3 4 7 MOH National training pharmacy letters ly AMR M&E sessions and directorate Committee workshops records Number of Clinical Attendance Annual 500 200 200 400 MOH: National HCPs received pharmacy sheet ly Clinical AMR M&E the training. directorate pharmacy Committee (Emphasizing records directorate the demographical characteristic) Output 4.5: Develop unified national database for antimicrobial use for assessment and developing studies. Number of JFDA Report Annual 0 1 1 2 JFDA National scientific database, ly AMR M&E studies AWaRe Committee published classificatio regarding AMC n and AWaRe classification to assess compliance with recommendati ons and guidelines. Objective no. 5 64 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Outcome 5: Percentage of National Review of Annual 0 0 0 0 M&E focal Decision Enhanced funding budget financial ly persons of makers, investment investments documents records. sector in activities, for AMR , ministries institutions Jordan research, implementatio or and AMR CDC, and n and research departmen TWG innovations provided ts National related to through the responsible AMR M&E antimicrobi national for Committee al budget research, resistance national research institutes, and internation al organizatio ns. Output 5.1: Periodic policy guidance based on country research. Number of Academic Count of Bi- 4 6 8 14 M&E focal Decision annual AMR- research research annual persons of makers, related studies sector publications published institutions Jordan for research and AMR CDC, studies TWG conducted in National Jordan AMR M&E Committee Number of Director of Review of Bi- 0 1 2 3 M&E focal Decision training Research, Attendance annual persons of makers, sessions policy and registers, sector provided to training pre- and institutions Jordan researchers to directorate post-training and AMR CDC, support in Jordan surveys, TWG methodical CDC interviews or scientific focus 65 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC research in the groups, National field of AMR participant AMR M&E certificates, Committee training reports, quarterly performance progress report Number of AMR Review of Bi- 0 2 4 6 M&E focal Decision multisectoral Research meetings annual persons of makers, meetings Committee minutes sector conducted to in Jordan institutions Jordan facilitate AMR- CDC and AMR CDC, related data TWG access National AMR M&E Committee Number of AMR Email Bi- 0 2 2 4 M&E focal Decision editorial Research Tracking annual persons of makers, boards Committee System, sector contacted in Jordan Contact Log institutions Jordan CDC Forms, or and AMR CDC meetings TWG minutes. National AMR M&E Committee Objective no. 6 Outcome 6: Governance and resource mobilizatio n established 66 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC and strengthens Output 6.1: Governance strengthened at all levels. Percentage of Relevant Governance Annual 0 TBD TBD TBD AMR Focal Decision valid and sectors checklist ly point for makers, relevant MOH, each sector recommendati MOA, (WHO, Jordan ons adopted Jordan MOA, JFDA, CDC from advocacy CDC, JFDA, MWI, MOE, workshops/me MOEnv, Jordan National etings and and MWI. CDC) AMR M&E shared with all Committee sectors in AMR containment. Output 6.2: Resources mobilized for AMR. Percentage of Relevant Financial Annual 0 TBD TBD TBD AMR Focal Decision institutions sectors checklist ly point for makers, &international MOH, each sector organizations MOA, (WHO, Jordan allocate Jordan MOA, JFDA, CDC budget for CDC, JFDA, MWI, MOE, AMR MOEnv, Jordan National prevention and and MWI. CDC) AMR M&E containment. Committee 67 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Annex No. 4 ToC statements at the Activity-Output level Objective 1: Increase awareness through effective communication, education, and training. Output 1.1: Raise awareness and change behaviors through the implementation of SBCC programs to raise awareness about antibiotics. If a communication plan regarding antimicrobial resistance is prepared and developed, an annual digital campaign on social media in collaboration with the MOH/HCAD is launched, community health awareness lectures through Community Health Committees focusing on public hygiene and the responsible use of antibiotics are implemented, and awareness activities targeting school students, teaching staff, and administrative personnel are conducted, assuming the MOH's vested interest in national awareness campaigns for WAAW, knowledgeable experts, professors, and scientists are available, a national multisectoral committee on antimicrobial resistance with a dedicated liaison officer is established, a trained team in SBCC within the Directorate of Health Education and Information is available, active community participation through Community Health Committees is ensured, health awareness personnel are extensively deployed, a school health education program exists, a reliable digital database for social media and the MOH's website is available, and the internet is widely available to aid in community awareness activities, then awareness can be effectively raised and behaviors changed through the implementation of SBCC programs, ultimately increasing awareness about antibiotics and promoting their responsible use. 68 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Output 1.2: Promoting political commitment to the issue of antimicrobial resistance. If in the human health sector, a report is prepared that includes the results of community feedback and monitoring of prominent rumors on social media regarding AMR, and experts and partners are identified to help advocate, develop, and enforce policies and legislation on AMR, and if in the animal health sector, field orientation visits for farmers regarding vaccination, biosecurity, feed additives, water purification, and the use of antibiotics, among other topics, are implemented, assuming strong political commitment, strategic investment in global awareness and commitment with a dedicated focus on awareness activities during WAAW, availability of experts, professors, and scientists knowledgeable in AMR in Jordan, facilitating coordination for a unified national effort in communication and media outreach to raise awareness, a national multisectoral committee on AMR with a dedicated liaison officer, a trained team in SBCC within the Directorate of Health Education and Information for media campaigns, active community participation through Community Health Committees, a reliable digital database for social media and the MOH's website, and widespread internet availability aiding in community awareness activities, then political commitment to the issue of AMR will be promoted. 69 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Objective 2: Strengthen the knowledge base and evidence through continuous surveillance. Output 2.1: Enhanced antimicrobial resistance surveillance system in alignment with the One Health Approach. If in the human health sector, the committee's responsibilities are reviewed and modified, a technical working team is formed to evaluate and improve data quality, issue and review the annual report before presenting it to the committee, collaboration between sectors is enhanced and all partners are integrated through regular meetings, regular reports are shared among relevant sectors, national-level data analysis capabilities are built and enhanced, and an annual report on resistance patterns at the national level is issued, assuming the existence of valid data from the Jordanian AMR surveillance system (JARSS), collaboration of specialized epidemiologists from different sectors, and a national database for antimicrobial-resistant bacteria to generate periodic reports, and if in the animal health sector, a system for monitoring antimicrobial-resistant microbes in animals similar to the one in humans is established, assuming the formation of the National Coordination Center for Surveillance in collaboration with the Technical Committee for the Surveillance and Research Axis of AMR, conducting laboratory tests for AMR to veterinary antibiotics, and operating a laboratory for the surveillance of pharmaceuticals and veterinary pesticide residues, then an enhanced antimicrobial resistance surveillance system in alignment with the One Health Approach will be achieved. 70 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Output 2.2: Enhanced laboratory capabilities. If National Reference Laboratory staff are trained to supervise peripheral laboratories and detect new infectious diseases, training workshops are conducted to enhance the capabilities of laboratory technicians in central and peripheral laboratories, kits and supplies are provided to major hospitals, the Vitek system is provided and linked to the Hakeem computing program in selected hospitals, field visits are conducted to sites with lower quality assessment ratings, and the quality assessment program is improved by developing a mechanism to apply it to all participating laboratories, assuming the appointment of competent staff for continuous education and training, building a comprehensive surveillance system that includes human health, animal health, and the environment, coordination from the National Coordinating Center for Surveillance with the Monitoring and Evaluation committee in WAJ Laboratories, provision of diagnostic devices and kits for testing antimicrobial resistance bacteria in wastewater samples, availability of advanced molecular biology techniques at the national reference laboratory, implementation of an internal and national quality control system in most microbiology laboratories, existence of a national program accrediting hospitals and laboratories, operation of a laboratory for the surveillance of pharmaceuticals and veterinary pesticide residues, conducting laboratory tests for AMR to veterinary antibiotics, collaboration between public sector institutions, and the presence of a specialized unit for genetic sequencing in the central reference laboratory, then laboratory capabilities will be enhanced. 71 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Objective 3: Reduce infection rates through preventive measures, infection control, and general hygiene. Output 3.1: Developing an effective program for infection prevention and control. If infection control units are established and directly connected to higher administrations within the organizational structure of all healthcare institutions, staffing ratios for these units are determined based on the size and nature of services provided, specialized training workshops on infection control procedures are conducted, and standardized policies for monitoring HAIs are developed and aligned with case definitions, assuming the availability and active implementation of committees, teams, and programs for IPC in healthcare institutions, established and followed national reference policies for infection control, a robust surveillance system for AMR microbes, operational surveillance systems for monitoring HAIs in government, private, and university hospitals utilizing information technology, and continuous IPC training programs for IPC practitioners, then an effective program for infection prevention and control will be developed. Output 3.2: Improving environmental sanitation programs. 72 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC If guidelines for regulatory programs on water and sewage sources and networks are updated, annual reports are issued to assess health directorates' commitment to implementing these regulatory programs, instructions related to the management of medical waste are updated, and infection control professionals are involved in the development of contracts with service providers, assuming that committees, teams, and programs for preventing and controlling infections are available and actively implemented in healthcare institutions, national reference policies for infection control are established and followed, the healthcare system is endorsed by political leaders, collaboration exists between the MOH, the MOA, and other relevant sectors, standards for healthcare quality that support infection prevention and control are in place, and hospital waste management practices are regulated and enforced, then environmental sanitation programs can be significantly improved. Output 3.3: Ensuring the availability of evidence-based practices and consistent standards at the national level for infection prevention and control in the livestock sector. If biosecurity and biosafety practices at slaughterhouses are improved, assuming the availability of PPE in all its forms, national reference policies for infection control are established, collaboration between the MOH, the MOA, and other relevant sectors, support from international organizations such as the FAO and WOAH for veterinary programs, and the availability of safe water, then evidence-based practices and consistent standards at the national level for IPC in the livestock sector will be ensured. 73 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC Objective 4: Optimal use of antimicrobial medicine in the fields of human, animal, and environmental health. Output 4.1: Enhance and amend systems and regulations aimed at dispensing antimicrobials and imposing deterrent penalties for violence. If the previously established regulations for dispensing antibiotics without a prescription are reviewed and amended, making compliance mandatory across all sectors, and compliance with antimicrobial manufacturing residue disposal instructions is monitored with enforced penalties for violations, assuming the presence of active laws and regulations to control the prescription and dispensing of antibiotics, the existence of a committee to review and update these regulations, and available human resources to conduct audit visits to pharmacies, then systems and regulations aimed at dispensing antimicrobials and imposing deterrent penalties for violations will be enhanced and amended. Output 4.2: Develop Evidence-based treatment guidelines for infectious diseases and protocols for optimal use of antimicrobials at the national-level. If regular meetings of the AMS national committee, comprising all relevant sectors, are conducted to formulate recommendations and make decisions regarding the use of antimicrobials in accordance with local needs; the list of essential medicines is reviewed and regularly updated, categorizing antimicrobials according to global and Aware classifications and circulated; protocols and guidelines for prescribing and dispensing antimicrobials are reviewed, updated, and developed at the national level; and policies on prescribing and dispensing antibiotics are reviewed and updated to standardize procedures at the healthcare institution level, assuming the commitment of committee 74 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC members to attend meetings regularly, the presence of financial support for the AMS national committee meetings, stakeholder support, the presence of a new essential medicine drug list, and endorsement from policymakers, then evidence-based treatment guidelines for infectious diseases and protocols for optimal use of antimicrobials at the national level will be developed. Output 4.3: Expanding the implementation of AMS program to ensure the optimum antimicrobial use. If the national technical team to oversee AMS is formed, an AMS program is established in hospitals that have not yet implemented it, AMS committees are developed to implement stewardship programs in primary healthcare facilities, hospitals are provided with clinical pharmacists to implement AMS programs, the ASP is incorporated into the national infection prevention and control guidelines, an AMS innovation center is established to oversee the implementation of the AMS program in health facilities and an electronic tool within EHS/Hakeem is developed to monitor antimicrobial dispensing at the hospital level, assuming stakeholders' support and engagement, the presence of human and financial resources, and the development of a new infection prevention and control guideline, then the implementation of the AMS program will be expanded to ensure optimal antimicrobial use. Output 4.4: Develop and enhance health care providers qualifications on antimicrobial use and AMS program. If training sessions and workshops for healthcare providers are conducted, awareness sessions about the AWaRe classification are implemented, and a twinning program between experienced and 75 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC non-experienced hospitals is established, assuming the presence of qualified trainers, stakeholder support, and the availability of financial and human resources, then healthcare providers' qualifications on antimicrobial use and the AMS program will be developed and enhanced. Output 4.5: Develop unified national database for antimicrobial use for assessment and developing studies. If AMC data is continuously updated at the national level and collected at the sector level, assuming the presence of a valid electronic system for AMC data, then a unified national database for antimicrobial use for assessment and developing studies will be developed. Objective 5: Enhance investment in activities, research, and innovations related to antimicrobial resistance. Output 5.1: Periodic policy guidance based on country research. If an advisory research committee affiliated with the AMR NAP is reformed and activated to oversee implementation and monitoring, tasks are defined and access to relevant local data is facilitated, funding is leveraged and government grants, private sector investments, and international collaborations are coordinated to support AMR research and development, a central committee is established to monitor grants, investments, and partnerships, and to prepare reports, proposals are developed to improve policies that incentivize private sector investments in antimicrobial resistance research and development in consultation with government authorities, training and technical 76 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC assistance are provided to researchers, communication with funding agencies is established to prioritize AMR/One Health, existing research entities are identified and policies are developed to facilitate researchers' access to data, and communication with editorial boards of national medical and agricultural journals is maintained to encourage the publication of research, assuming global and national attention to AMR, political support for combating antimicrobial resistance, engagement of international organizations such as WHO, FAO, and OIE, scientific community interest and support, presence of local experts, and coordination of scientific research around integrated health, then periodic policy guidance based on country research will be provided. Objective 6: Governance and resource mobilization will be established and strengthened. Output 6.1: Governance will be strengthened at all levels. If advocacy workshops and meetings are conducted, and reports and meeting minutes are shared with all sectors related to AMR containment, assuming broad sector representation with participation from healthcare, agriculture, pharmaceutical, academia, and policy-making sectors, mechanisms for follow-up actions and implementation of recommendations and strategies developed during the workshops and meetings, an active national sub-technical committee with regular meetings, and periodic reporting by national AMR monitoring and evaluation focal points to relevant stakeholders, then governance will be strengthened at all levels. Output 6.2: Resources will be mobilized for AMR. If institutions and international organizations allocate budgets for AMR prevention and containment, assuming the urgency of AMR is recognized and prioritized for funding by these institutions, then resources will be mobilized for AMR. 77 | National AMR Monitoring & Evaluation Plan 2023-2025 | Jordan CDC