The National Action Plan on Antimicrobial Resistance 2021–2026

1.1 Global context .................................................................................................................................................................................... 1

1.2 Regional context ............................................................................................................................................................................... 2 1.3 Policy and Strategic fit: Highlights on AMR and Sustainable Development Goals (SDGs) Agenda 2030 .... 3 1.3.1 Sustainable Development Goal # 3: Ensure healthy lives and promote wellbeing for all at all ages ........ 3

1.3.2 Sustainable Development Goal # 6: Ensure availability and sustainable management of water and sanitation for all. ...................................................................................................................................................................................... 3

1.4 Organization of the plan ................................................................................................................................................................ 4 CHAPTER II –DEVELOPING THE PLAN (PROCESSES AND METHODS) ............................................................................ 5

2.1 The process......................................................................................................................................................................................... 5

2.2 The Tripartite support ................................................................................................................................................................... 5

2.3 The methods....................................................................................................................................................................................... 6

2.3.1 The instruments ............................................................................................................................................................................ 6

2.4 Governance ......................................................................................................................................................................................... 6 CHAPTER III – KEY STRATEGIC ELEMENTS ................................................................................................................................ 8

3.1 The Goal ............................................................................................................................................................................................... 8

3.3 Key activities ...................................................................................................................................................................................... 9

3.4 Strategic planning matrices ....................................................................................................................................................... 10 Matrix 3.4.1: SO1-Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. ............................................................. 11 Matrix 3.4.2: SO2-To strengthen knowledge and evidence-base through surveillance and research .............................................................................................................................................................. 12 ii | P a g e Matrix 3.4.3: SO3- To reduce the incidence of infection through effective hygiene and IPC measures............................................................................................................................................................. 14 Matrix 3.4.4: SO 4 -To optimize the use of antimicrobial medicines in human and animal health ................................................................................................................................................................... 16 Matrix 3.4.5: SO5: To develop the economic case for sustainable investment that takes account of the national needs and increase investment in new medicines, diagnostic tools, vaccines and other interventions .............................................................................................................. 18 CHAPTER IV –FINANCIAL RESOURCE REQUIREMENTS ...................................................................................................... 19

4.1.1 NAP-AMR Costing Process ...................................................................................................................................................... 19

4.1.2 Costing Assumptions................................................................................................................................................................. 19

4.1.3 Limitations to the costing approach ................................................................................................................................... 19 4.1.4 Estimating resource requirements: Activity Based Costing (ABC) approach ................................................... 20

4.2 Costing results ................................................................................................................................................................................. 20 4.2.1 Projected Budget requirements by Strategic Interventions ..................................................................................... 22 4.2.1.1 Strategic Interventions 1.1-1.3; Education and Awareness .................................................................................. 22 4.2.1.2 Strategic Interventions 2.1-2.4; Surveillance and Research ................................................................................. 22

4.2.1.3 Strategic Interventions 3.1-3.5 Hygiene and IPC....................................................................................................... 24 4.2.1.4 Strategic Interventions 4.1-4.5; Antimicrobial use in Animal and Human Health ...................................... 25

4.2.1.5 Strategic Intervention 5.1; Research and Investment ............................................................................................. 26 4.2.1.6 Distribution of Cost Estimates by Strategic Interventions-A summary ........................................................... 26

4.2.1.7 Budget requirements by Implementing Agency ........................................................................................................ 27 CHAPTER V – MONITORING AND EVALUATION FRAMEWORK ....................................................................................... 28

5.1 Introduction ..................................................................................................................................................................................... 28 5.1.1 AMR indicators and Sustainable Development Goals (Global context) ............................................................... 28

5.2 Methodology .................................................................................................................................................................................... 28

5.2.1 Selection of indicators .............................................................................................................................................................. 28

5.3 The Indicator Framework .......................................................................................................................................................... 30

5.3.1 Indicator listing by thematic areas ..................................................................................................................................... 30

5.4 Performance Monitoring............................................................................................................................................................. 32

5.4.1 Routine data Collection ............................................................................................................................................................ 32 5.4. 2 Integrated supportive supervisions (routine supervisions) ................................................................................... 32

5.5. Evaluation and Surveys .............................................................................................................................................................. 32 5.5.1 Embedded Implementation Research (Operational Research) .............................................................................. 33 iii | P a g e

5.6 Feedback mechanisms ................................................................................................................................................................. 33

5.7 Limitations to the M&E Framework....................................................................................................................................... 34

5.8 Indicator Matrix .............................................................................................................................................................................. 35 Annexure ................................................................................................................................................................................................... 38 Annex 1: The Operational Planning Matrix-EDUCATION AND AWARENESS .............................................................. 38 Annex 2: The Operational Planning Matrix-SURVEILLANCE AND RESEARCH ........................................................... 42 Annex 3: The Operational Planning Matrix- INFECTION, PREVENTION AND CONTROL ....................................... 44 Annex 4: The Operational Planning Matrix-ANTIMICROBIAL USE AND REGUALTION .......................................... 46 Annex 5: The Operational Planning Matrix-INVESTMENT, RESEARCH and DEVELOPMENT .............................. 49 Annex 6: LIST OF COUNTRY PARTICIPANTS ............................................................................................................................. 50 References ................................................................................................................................................................................................ 52 iv | P a g e LIST OF TABLES AND FIGURES LIST OF TABLES Table 1: Distribution of cost estimates by thematic areas ...................................................................................... 21 Table 2: Estimated budget requirements by strategic interventions-Education and Awareness ........................... 22 Table 3: Estimated budget requirements by strategic interventions-Hygiene and IPC ........................................... 24 Table 4: Estimated budget requirements by strategic interventions-Antimicrobial use ......................................... 25 Table 5: Estimated budget requirements by strategic interventions-Research and Investment ............................ 26 Table 6: Estimated budget requirements by implementing agencies ..................................................................... 27 Table 7: Estimated budget requirements by cost categories .................................................................................. 27 Table 8: The programme logical framework ........................................................................................................... 29 Table 9: Indicator listing – (Education and Awareness) & (Surveillance and Research).......................................... 30 Table 10: Indicator listing-(IPC, Hygiene, Sanitation and Bio security) & (AM use and regulation) ........................ 31 Table 11: Indicator listing-Crosscutting indicators among thematic areas ............................................................. 31 Table 12: Feedback platforms for accountability on results.................................................................................... 33 Table 13: Indicator Matrix ..................................................................................................................................... 35 LIST OF FIGURES Figure 1: Ministry of Health Commitment ................................................................................................................. x Figure 2: Ministry of Water Commitment ................................................................................................................. xi Figure 3: Ministry of Agriculture, Food Security and Nutrition ................................................................................ xii Figure 4: Ministry of Tourism , Environment and Culture ....................................................................................... xiii Figure 5: Development process for Lesotho NAP........................................................................................................5 Figure 6: Governance Structure ..................................................................................................................................7 Figure 7: Costing process ......................................................................................................................................... 19 Figure 8: Distribution of cost estimates by strategic interventions ........................................................................ 21 Figure 9: Distribution of cost estimates by years of implementation ..................................................................... 21 Figure 10: Percent distribution of cost estimates by strategic interventions .......................................................... 26 Figure 11: Indicator levels ....................................................................................................................................... 30 v|Page ABBREVIATIONS AND ACRYNOMS AMR Antimicrobial resistance AMU Antimicrobial use CHAL Christian Health Association of Lesotho DGHS Director General Health Services DVO District Veterinary Officer DVPH Director Veterinary Public Health DWA Department of Water Affairs FAO Food and Agriculture Organization of the United Nations GAP Global Action Plan GHSA Global Health Security Agenda HRM Human Resources Manager IDSR Integrated Disease Surveillance and Response IHR International Health Regulations IPC Infection prevention Control M&E Monitoring and Evaluation MAFS Ministry of Agriculture and Food Security MDP Ministry of Development MOF Ministry of Finance MOH Ministry of Health NHTC National Health Training College NRL National Reference Laboratory NUL National University of Lesotho OIE World Organization for Animal Health PHN Public Health Nurse PPT Principal Pharmacy Technician PRO Public Relations Officer PU Planning Unit SCPO Senior Crop Production Officer SPHCC Senior Primary Health Care Coordinator SVO Senior Veterinary Officer WHA World Health Assembly WHO World Health Organization vi | P a g e KEY DEFINITIONS Antimicrobial: an agent such as a drug that destroys or inhibits the growth of a microorganism (National Department of Health, 2014) Antimicrobial Resistance: The ability of a microorganism to withstand treatment with an antimicrobial drug (National Department of Health, 2014) Strategic Objective: This is the aim that should be achieved by the project during the years of its implementation (WHO, 2015) Strategic Intervention: This is the key health measure that will contribute to achieving at least one objective. It includes several activities and sub-activities that need to be developed and/or implemented (WHO, 2015) Key activity: This is the action that contributes to implementing a strategic intervention (WHO, 2015) Sub activity: An activity making up part of a larger activity Indicator: Is a quantitative metric that provides information to monitor performance, measure achievement and determine accountability (UNAIDS) Target: The objective a program/intervention is working towards, expressed as a measurable value; the desired value for an indicator at a particular point in time. Logical Framework: Management tool used to improve the design of interventions. Surveillance: Ongoing systematic collection, analysis, and interpretation of outcome specific data for use in planning, implementing and evaluating public health policies and practices (WHO, 2006) Cost element: Economic value or price of resources that are sacrificed for attaining a particular objective. Operational Plan: process of planning strategic goals and objectives to technical goals and objectives. vii | P a g e ACKNOWLEDGEMENTS The National Multi-sectoral Committee on Antimicrobial Resistance (AMR) wishes to acknowledge the significant support from the collaborating ministries towards development of Lesotho National Action Plan (LNAP) on AMR. The contributions from academia, through National University of Lesotho, National Health Training College and Lesotho Agricultural College are highly recognized, throughout the process. The efforts from development partners cannot be overlooked. Gratitude is extended to WHO, FAO and OIE for continued technical and financial support from the inception phase of the process until production of final LNAP with cost estimates. The multi sectoral AMR Technical Working Groups (TWGs) are also acknowledged for technical expertise in the development of the plan, through active involvement and participation in the successive workshops held from the beginning up to the end. A special thanks is extended to the following AMR Regional Experts who facilitated in-country workshops aimed at spearheading the AMR Situational Analysis as part of developing the NAP on AMR for Lesotho. • Dr. Walter Fuller, AMR Technical Expert- WHO Africa Regional Office, Brazzaville • Dr. Emmanuel Kabali, AMR Technical Officer at Food and Agriculture Organization- FAO SFS • Dr. Olafur Valsson, AMR Programme Officer-World Organization for Animal Health (OIE) Southern Regional Office • Dr. Sekesai Zinyowera, WHO- AMR Consultant • Kapona Otridah- AMR Coordinator Zambia The authors would like to specifically thank Honorable Ministers and the Principal Secretaries for the participating ministries in the development of NAP. Their leadership and support since the inception of AMR initiative in Lesotho is highly valued and recognized. viii | P a g e FOREWORD Lesotho has a National Multi-Sectoral Steering Committee (NMSC) on Antimicrobial resistance (AMR) that provides a strategic direction towards combating antimicrobial resistance in Lesotho as recommended in the Global and regional agenda on AMR. The committee comprises of Principal Secretaries from collaborating Ministries namely Ministry of Health (MOH), Ministry of Agriculture, and Food Security (MAFS), Ministry of Tourism Environment and Culture, Ministry of Water, Ministry of Finance (MOF) as well as Implementing and Development Partners to Government of Lesotho. In response to the Global agenda, Lesotho has therefore put efforts in place to develop a 5-year costed multi- sectoral action plan on AMR, to be implemented from 2020/21 to 2025/26 fiscal year. The plan provides a description of key interventions on the subject of human health, animal health, plants and environment required to combat AMR in Lesotho. The LNAP is further guided by instruments such as World Health Assembly (WHA) resolutions, 2001 Global Strategy on AMR, Africa CDC Framework for AMR 2018-2023, World Organization for Animal Health (OIE) Strategy on Antimicrobial Resistance (2016), FAO-WHO-OIE Manual for Development of National Action Plans on AMR, The National Health Policy, (NHP 2017) and Environment Act 2008. The objectives outlined in the plan address each of the objectives in the global action plan and have been expressed in the current plan according to the following domains; 1) Education and Awareness 2) Surveillance and Research 3) Hygiene, Infection Prevention and Control 4) Antimicrobial Use and Regulation and 5) Investment, Research & Development (R&D) on AMR. The plan further defines the financial resources required for undertaking each of the proposed objectives, strategic interventions and underlying key activities. With a total of about M 270,853,622 million (US$16,928,351) required for financing the plan, we call for active involvement of all stakeholders in resource mobilization as well as mapping for all the resources that the Government of Lesotho (GOL) and her partners would have to inject for implementation. The plan further sets out the mechanism for accountability through the use of Monitoring and Evaluation (M&E) framework which is developed as part of the country’s National Action Plan. The M&E framework aligns to the Global monitoring framework for AMR and Sustainable Development Goals (SDGs) indicator Framework on AMR. As such, we urge all the implementing agencies and partners to commit towards continual availability of timely information and knowledge exchange for effective accountability of results. Finally, the NMSC on AMR commits to work collaboratively with the line ministries to ensure integration of the NAP into the annual work plans for different ministries as a sustainable measure and effective stakeholders’ engagement in the process of implementation. We wish you all, a successful resource mobilization and hence implementation. Hon. Minister of Health Hon. Minister of Water Selibe Mochoboroane Mohlomi Moleko Hon. Minister of Agriculture, Food Hon. Minister of Tourism Environment Security and Nutrition and Culture Thabo Mofosi Letsema John Adonts’i ix | P a g e STATEMENTS OF COMMITMENTS Figure 1: Ministry of Health Commitment x|Page Figure 2: Ministry of Water Commitment xi | P a g e Figure 3: Ministry of Agriculture, Food Security and Nutrition xii | P a g e Figure 4: Ministry of Tourism, Environment and Culture xiii | P a g e EXECUTIVE SUMMARY The Government of Lesotho took an initiative to develop a 5-year multi-sectorial National Action Plan on AMR (2020/21-2024/25) as a response to the Global agenda on combating antimicrobial resistance globally, regionally and at local settings. The development process was led by a National Multi-Sectoral Steering Committee (NMSC) with the support from development partners. The process began with AMR situational analysis where local data on on-going interventions was collected, analyzed and therefore used as a basis for developing the National Action Plan. The plan will be implemented in accordance with ‘One health approach’; a strategic approach in bringing together all relevant sectors1 and disciplines across the human, animal and environment in order to achieve better health outcomes. Development process The process was initiated in 2019 with conducting of situational analysis on AMR in Lesotho, and was completed with a 2 stage validation process conducted in November 2019 and August 2020, prior to endorsement. The product is guided by global, regional and local instruments such as World Health Assembly (WHA) resolutions, 2001 Global Strategy on AMR, Africa CDC Framework for AMR 2018-2023, World Organization for Animal Health (OIE) Strategy on Antimicrobial Resistance (2016), FAO-WHO-OIE Manual for Development of National Action Plans on AMR, National Health Policy (NHP 2017), National Strategic Development Plan (NSDP II 2018/19-2023), National Health Strategic Plan (2019-2023), Water and Sewage Company (WASCO), Water Safety Plan 2017 and Environment Act- 2008. The multidisciplinary inter-ministerial Technical Working Groups (TWGs) on different thematic areas (Education and Awareness, Surveillance and Research, Hygiene, Infection Prevention and Control, Use of antimicrobials, Research and Development) were formed and mandated to provide technical expertise in the development of the plan. Technical and financial support to the TWGs was sought from the tripartite (WHO-FAO-OIE) through facilitation of workshops since the inception phase. The tripartite support further aimed at building the capacity of the country in developing sound and implementable action plan using one health approach. The oversight role in the development process was executed by the National Steering Committee (NSC) and its supporting arm known as National Multi-sectorial Steering Committee (NMSC). Implementation arrangements and accountability The NSC and NMSC will provide the overall coordination, leadership and strategic approach towards continuous resource mobilization throughout the implementation. The line ministries attached to specific interventions in the plan will be responsible for implementation and reporting on progress to the NMSC and NSC. The TWGs in each thematic area, will serve as link between the 1 World Organization on Animal Health (OIE), defines relevant sectors as those sectors, disciplines, stakeholders, or ministries that are essential to addressing the health threat to be addressed using a multi-sectoral, One Health approach. xiv | P a g e NMSC, NSC and the line ministries responsible for implementing the interventions specific to each Ministry. Guided by monitoring and Evaluation Framework for the plan, structured reports on progress towards implementation will be sought from the implementing agencies for onward sharing with the NSC, NMSC and other stakeholders. Strategic elements (Objectives, Strategic Interventions and Key activities) The five strategic objectives from the Global Action Plan (GAP) agreed at the World Health Assembly in May 2015, were adopted to formulate the country’s objectives which are defined in the plan as the Strategic Objectives (SOs) as listed below; • SO1: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. • SO2: To strengthen knowledge and evidence-base through surveillance and research • SO3: To reduce the incidence of infection through effective hygiene and IPC measures • SO4: To optimize the use of antimicrobial medicines in human and animal health • SO5: To develop the economic case for sustainable investment that takes account of the national needs and to increase investment in new medicines, diagnostic tools, vaccines and other interventions. In line with the Logical Framework Approach (LFA), the plan provides the Strategic Interventions (SIs) for achieving each Strategic Objective (SO), key activities for achieving each Strategic intervention and sub-activities linked with each key activity. Nearly 20 strategic interventions and 75 underlying key activities have been proposed for the duration of the Plan. The table below provides the quantitative summary of the strategic elements. Table 1: Strategic Objectives, interventions, and activities-A quantitative summary Thematic Area SO# Strategic No. of SIs No. of key Interventions activities Education and Awareness 1 1.1-1.3 3 11 Surveillance and Research 2 2.1-2.4 6 22 Hygiene, Infection Prevention 3 3.1-3.5 5 18 and Control Antimicrobial Use 4 4.1-4.5 5 20 Investment, Research and 5 5.1 1 4 Development Financial resource requirements The National Action Plan on AMR was costed using the Activity Based Costing (IBC) approach, where the cost of all the inputs were defined, categorized according to the overall strategic objectives, strategic interventions, key activities and sub-activities,. The aggregated indicative costs therefore showed that nearly LSL 270,853,622 Million (US$16,928,351) is required across 5 thematic areas xv | P a g e to support implementation during a 5 year period. A larger proportion of budget (LSL 156.8 Million (US$9,818,443) is required in the first year of implementation accounting for more than 50% of the total cost estimates. The costs were further disaggregated by the thematic areas (equivalence of strategic objectives) and the analysis has revealed that hygiene, infection prevention and control constitutes a higher proportion of the total costs estimates (37%) among the 5 thematic areas for the duration of the plan, with more resources required in the first year of implementation. Generally, it is further noted that higher costs in the first year of implementation is due to acquisition of new diagnostic tools on AMR, initiation of new projects under hygiene, infection prevention and control , development of policy and regulatory frameworks, and strengthening of country Monitoring and Evaluation system for accountability of results at national, regional and global level. The table below provides a summary of indicative costs over a five year period. Table 2: Total cost of Lesotho NAP on AMR YR1 (2020/21)-YR5 (2024/25) Total Cost of Lesotho NAP-AMR 2020 -2025 by Program Areas LSL(Millions) Program Areas 2020/21 2021/22 2022/23 2023/24 2024/25 Total Yr1-Yr5 Education and Awareness 3,657,850 1,506,088 1,307,106 1,068,328 1,134,714 8,674,087 Surveillance 16,331,800 15,998,641 16,516,199 16,674,224 12,624,769 78,145,633 and Research Hygiene, Infection 92,528,830 1,684,022 2,934,281 1,279,508 3,171,027 101,597,668 prevention and control Antimicrobial use and 43,728,400 9,925,492 3,707,973 8,120,597 14,275,859 79,758,321 regulation Investment, Research & 581,200 448,288 899,226 591,640 157,559 2,677,913 Development Grand Total 156,828,080 29,562,531 25,364,786 27,734,298 31,363,927 270,853,622 Monitoring and Evaluation of the Plan In order to ensure accountability throughout implementation, the M&E framework was developed with a One Health perspective to reflect the inter-sectorial nature of AMR, as guided by 2017 WHO framework on Monitoring and Evaluation of AMR National Action Plans. Other instruments that guided the process for developing the framework include; The 2019 WHO, FAO and OIE Monitoring and Evaluation of the Global Action Plan on antimicrobial resistance; Africa CDC Framework for AMR 2018-23 and The 2018 Report on AMR indicators and Sustainable Development Goals. Monitoring Progress A total of 39 indicators have been selected to monitor progress towards implementation of 5 Strategic Objectives, 20 strategic interventions, 75 key activities and their underlying sub activities. xvi | P a g e Six (6) indicators are at impact level, 15 at outcome while the remaining (18) will be used to track the processes. The data collection methods for generating data on selected indicators will be based on the existing ministerial routine data collection platforms. This includes the use of District Health Information System_2 (DHIS2) used in the MOH, Laboratory Management Information System (LMIS) in the MOH and Integrated Financial Management Information System used across collaborating Ministries. Evaluation Using information generated from monitoring, programme evaluations will be conducted at mid- way (between year 2 and year 3) and by the end of year 5 to measure the impact of proposed interventions in the implementation framework. It is also proposed that the baseline assessment on newly proposed indicators will be conducted and such information will serve as a guide towards routine monitoring, and programme evaluations (mid-term and end term). Limitations • Due to unavailability of Lesotho specific data (through research) on AMR related interventions, there is no enough evidence on the country’s current situation on AMR. • Unavailability of global targets on AMR, from which the country could draw own targets. • AMR is a missing topic in the global agenda on Sustainable Development Goals and hence difficulty for the country to ensure proper alignment of M&E for AMR with existing country level M&E frameworks drawn in line with the SDGs Framework. • Unavailability of baseline information for majority of indicators proposed indicators could affect mid-term review and reporting based on targets in the first year of implementation. • There was no standard price used by Government on cost of items for procurement purpose. Therefore other cost estimates emanates from already costed strategic plans for the country. • The costing did not have information on the available financial resources, hence funding gap could not be easily determined. xvii | P a g e CHAPTER I – INTRODUCTION Emergence of antimicrobial resistance is a result of the use, overuse and misuse of antimicrobials both in humans and animals. The current National Action Plan on Antimicrobial Resistance (NAP- AMR) details the country’s response towards global initiative in combating Antimicrobial resistance. The plan sets out the multi-sectoral key interventions that will be undertaken over a 5 year period (2020/21-2024/25) in an attempt to prevent and contain antimicrobial resistance in the country.

1.1 Global context There is a global consensus in the literature that Antimicrobial resistant (AMR) organisms are increasingly threatening to render existing treatments ineffective against many infectious diseases. Conceptually, the drug resistant strains of fungi, bacteria, parasites, and viruses prolong illness, increase case-fatality, facilitate transmission, and increase treatment costs. According to 2018-2023 Africa CDC Framework for AMR, globally drug resistance causes an estimated 700,000 deaths each year and if remains unattended to, could result in over 10 million deaths per year with over 100 trillion USD as a lost output due to AMR by the year 2050 (African Union, 2018) Following the 51st World Health Assembly resolution on Antimicrobial Resistance in 1998, efforts were put in place by WHO to develop the 2001 Global Strategy on AMR. The strategy aimed to provide a framework of interventions for all member states in order to; stimulate the prevention of infection; slow the emergence of resistance and reduce the spread of resistant microorganisms; reduce the impact of resistance on health and health care costs, while improving access to existing agents and encouraging the development of new agents. The 2001 WHO Global Strategy on AMR depicts that deaths from acute respiratory infections, diarrheal diseases, measles, AIDS, malaria and tuberculosis account for more than 85% of the mortality from infection worldwide. Resistance to first-line drugs in the pathogens causing these diseases ranges from zero to almost 100%. The 2010 WHO Global Report on Surveillance and response shows that, about 440 000 new cases of multidrug-resistant tuberculosis emerge annually, leading to at least 150 000 deaths per year. In cognizant of the need for global response on AMR, and recalling further the resolutions from 39th, 47th, 51st, 54th , 58th, 60th, and 67thWorld Health Assembly (WHA)2 meetings the 68th WHA adopted the Global Action Plan on AMR and further urged Member States to: 1) Implement the proposed actions for Member States in the global action plan 2) Adapt the global action plan in to the 2 WHA39.27 and WHA47.13 on the rational use of drugs, resolution, WHA51.17 on emerging and other communicable diseases: antimicrobial resistance, resolution, WHA54.14 on global health security: epidemic alert and response, resolution, WHA58.27 on improving the containment of antimicrobial resistance, resolution, WHA60.16 on progress in the rational use of medicines and resolution and WHA67.25 on antimicrobial resistance 1|Page countries’ contexts; (3) Mobilize human and financial resources through domestic, bilateral and multilateral channels for implementation of plans and strategies in line with the global action plan on AMR.

1.2 Regional context Recently, sub-Saharan Africa (sSA) has been identified as the region with the most limited implementation of antimicrobial surveillance strategies, alongside limited infection prevention and control programmes (Williams PCM, Isaacs D, Berkley JA., 2018). The problem of AMR in sSA is set against a background of an ongoing high incidence of acute respiratory infections, diarrhoeal diseases, parasitic and invasive bacterial infections as well as chronic conditions such as HIV, tuberculosis and malnutrition which increase the demand for both preventative and therapeutic antimicrobials (Williams PCM, Isaacs D, Berkley JA., 2018). Since 2006, the African Region has witnessed the increasing emergence of multidrug-resistant TB (MDR-TB) and extensively drug- resistant TB (XDRTB) which is a severe form of drug resistant TB (Ndihokubwayo JB et al, 2013). A study conducted in Lesotho in 2015 among 984/3441 (28.6%) persons who had data available for analysis showed that MDR-TB was present in 24/773 (3.1%) of new and 25/195 (12.8%) of retreatment TB cases (Maama-Maime LB, Mareka M, Ershova JV, et al, 2015). It was further concluded that 81/773 (10.5%) of the new TB patient isolates in Lesotho had M. tuberculosis isolates resistant to at least isoniazid or rifampin. HIV Drug Resistance is a type of AMR and minimizing the emergence and transmission of drug- resistant HIV is a critical global response to AMR (WHO, 2019). The 2013 report on surveys conducted at sentinel clinics providing ART in several countries in the African Region estimated that HIV resistance to all drug classes was less than 5% and this is likely to increase as more patients are placed on treatment (Ndihokubwayo JB et al, 2013). Generally, NNRTI resistance have been greatest in eastern and southern Africa, where the prevalence of pre-treatment NNRTI resistance was found to be above 10% (WHO, Preventing and responding to HIV drug-resistance in the African Region: regional action plan 2019-2023., 2019). In response the WHO Global Action Plan on HIVDR (2017– 2021) was developed to align with the WHO Global Action Plan on AMR as part of the global effort to address AMR. Evidence from the 2018 study on HIV DR conducted in Lesotho has shown the overall prevalence of any ARV drug resistance of 17.6%, which was higher among women (19.0%) than men (14.7%). The youngest group, ages 18-24 years, had the highest drug resistance prevalence (24.1%) and the oldest group (>= 45) had lowest prevalence at 14% (ICAP, 2018). Despite unavailability of data on mortality rates attributable to AMR in Lesotho, comparative analysis of estimated deaths by 2050 due to AMR revealed 390,000 annual deaths in Europe, 4,730,000 in Asia, 22,000 in Oceania, 317,000 in North America and approximately 4,150,000 in the African region (UK Government , 2014). In the 2014 report on global economic impact of antimicrobial resistance prepared by KPMG LLP, mortality rates for resistance to TB treatment was 28.3% in the African region higher than in 2|Page America 15.9%, Eastern Mediterranean 20.1%, Europe 23.9%, South East Asia 25.4%, and Western Pacific 16.3%.

1.3 Policy and Strategic fit: Highlights on AMR and Sustainable Development Goals (SDGs) Agenda 2030 Availability of a healthy, educated, and skilled workforce has been emphasized in the 2018/23 National Strategic Development Plan (NSDP) II as key drivers in enhancing productivity and attracting private investment (Government of Lesotho, 2018). The development of NSDP II has taken in to consideration the 2030 Agenda on Sustainable Development Goals during its development. It is argued in the literature that achieving majority of Sustainable Development Goals (SDGs) is dependent on addressing antimicrobial resistance effectively. It is believed that with effective antimicrobials, maternal, neonatal and childhood deaths can be prevented and epidemics of communicable diseases, such as HIV gonorrhea and tuberculosis, can also be managed (D. Jasovsky et al, 2016).

1.3.1 Sustainable Development Goal # 3: Ensure healthy lives and promote wellbeing for all at all ages The global statistics shows that about 214,000 neonatal sepsis deaths annually are directly attributable to drug-resistant pathogens and this severely impacts on plans to reduce neonatal mortality to less than 12 per 1,000 live births under SDG target 3.23 (Laxminarayan R, Matsoso P, Pant S, Brower C, Røttingen JA, Klugman K, et al 2016, 2016). It is further revealed that emerging resistance to treatments for communicable diseases such as HIV and tuberculosis (TB), will create significant obstacles for the achievement of SDG target 3.34.

1.3.2 Sustainable Development Goal # 6: Ensure availability and sustainable management of water and sanitation for all. As antibiotic residues can be carried by water and through sediments and soil, gradients of different antibiotic concentrations will form, and even very low antibiotic concentrations may be enough to select for highly resistant bacteria. Lack of access to clean water and sanitation also facilitates the spread of bacterial diseases, leading to increased morbidity and mortality, especially in children. Despite these implications of SDGs and targets on AMR, some of the findings conclude that; Generally, AMR remains a missing topic in the Sustainable Development Goals (Cars D and Jasovsky O, 2014). Complementary to the finding, the 2018 analytic support by McKinsey & Company has 3 Target 3.2 : By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births. 4 Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases 3|Page shown that there was not any explicit mention of AMR in the SDG’s beyond the preamble and not a single indicator is specific for tracking AMR. It is also mentioned that around 40% of indicators in the SDGs are only relevant for antimicrobial resistance. The report further recommends on the following actions to better anchor AMR within the SDGs; (1) Leveraging existing indicators and engaging with custodial agencies to anchor AMR in implementation (2) Leveraging on existing indicators and explicitly calling out AMR and (3) Adding new AMR-specific indicators to existing Monitoring and Evaluation Frameworks.

1.4 Organization of the plan The plan has been organized into 5 interconnected chapters which provides summary of the rationale behind developing the plan (foundational basis), methodological approaches, strategic goals and objectives and how the interventions will be monitored. Chapter I; Introduces the plan and provides a summary of the situation analysis looking at global, regional, country context and serves as a rationale for development of the plan. Chapter II; Provides detailed processes for development of the plan and the main critical instruments employed during the process. Chapter III; Presents the strategic model that defines the Strategic Objectives (SOs) and their underlying interventions. The interventions are further broken down (in a matrix form) into several key activities which have been assigned indicators for measuring the performance. Chapter IV; Details the financial resource requirements for operationalizing the strategic interventions. The key activities under each strategic intervention have been costed and their respective costs were used as basis for estimating the total financial resource requirements for the strategy. Chapter V; Elaborates process for Monitoring and Evaluation of the plan. The chapter categorizes the Key Performance Indicators required for effective monitoring Annexure; Provides detailed information about other components of the plan which were not part of analysis, but serve as important point of reference. 4|Page CHAPTER II –DEVELOPING THE PLAN (PROCESSES AND METHODS)

2.1 The process The development process started with the assessment of the country’s status on AMR (situational analysis) conducted in June 2019, and was completed with costing of planned interventions in September 2020. The figure below details some steps that were key in the development of the costed plan. Figure 5: Development process for Lesotho NAP

2.2 The Tripartite support The development processes were supported technically and financially by World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE). The Organizations have joined hands to form a tripartite and developed a harmonized approach to minimize the emergence and spread of AMR globally. The tripartite support aimed at building capacity of the country in the development of AMR action plan, promote ownership and provide technical guidance in the alignment of the plan with Global and Regional commitments on preventing the spread of AMR. 5|Page

2.3 The methods

2.3.1 The instruments Desk review of local data on the country’s situation on AMR was conducted to inform the key strategic interventions in combating the spread of AMR in the country. Policy and strategic frameworks at global, regional, and at country level were employed and used as the main instruments to guide the development of the plan. The documents that were used include; WHA resolutions, the 2001 Global Strategy on AMR, Africa CDC Framework for AMR 2018-2023, Lesotho National Strategic Development Plan 2018/19-2022/23, The National Health Policy (NHP) 2011, and the National Health Strategic Plans (2019-2023), 2016 Antimicrobial Resistance Manual for developing National Action Plans, Water and Sewage Company (WASCO) Water Safety Plan 2017, Environment Act 2008.

2.3.2 Interactive working sessions and stakeholders’ feedback meetings Support was solicited from WHO, FAO and OIE through facilitation of workshops on; situational analysis (5 days), development of zero draft plan (5 days), further refinement of the plan including consensus building meeting on elements of the plan (5 days), and costing of the plan (5) days. The recommendations from the stakeholders’ consensus meetings, and other consultative meetings with managers in different sectors were therefore incorporated into the draft plan during the costing session. Further consultations with TWGs were conducted to ensure that recommended interventions were feasible and relevant to the collaborating sectors.

2.4 Governance In line with ‘One Health Approach’ towards containment of AMR, Lesotho has formed a National Steering Committee-consisting of Principal Secretaries (PSs) from the collaborating ministries to provide a stewardship in the development and implementation of the country’s National Action Plan. The committee also includes the development and implementing partners, Director General of Health Services, Chairperson of Multi Sectoral Coordination Committee and AMR Secretariat. The Ministries involved are; Ministry of Health (MOH), Ministry of Agriculture and Food Security (MAFS), Ministry of Water, and Ministry of Tourism Environment and Culture. A Multi-Sectoral National Coordinating Committee was also formed to serve as a link between the stewards and the implementing structures which are coordinated through established TWGs. The inter-ministerial collaboration is governed by Memorandum of Understanding (MOU) which commits the Principal Secretaries to collaborate in the prevention, control and monitoring of AMR in Lesotho. The figure below depicts the structures within which the AMR NAP will be governed; 6|Page Figure 6: Governance Structure Lesotho Governance Structure for Combating and containment of AMR National Steering Committee (NSC) ____________________ __________________________________ National Multi-sectoral Coordinating Committee (NMCC) __________________ __ ____________________________ ______ National Technical Working Groups (TWGs) TWG-Education TWG-Surveillance TWG-Hygiene, TWG-Antimicrobial TWG-Investment, and Awareness and Research IPC and use and Regulation Research and Biosecurity Development 7|Page CHAPTER III – KEY STRATEGIC ELEMENTS

3.1 The Goal The overarching goal of the plan is to contribute towards reduction of morbidity and mortality due to antimicrobial resistance in human and animal. The goal will be achieved through the 5 Strategic objectives outlined below. The plan further defines the Strategic Interventions (SIs) linked to each of the 5 objectives.

3.2 Strategic Objectives (SOs) Strategic Objective 1: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. Understanding of antimicrobial use, resistance prevention and containment can be achieved only through raising awareness, effective communication, coordination, collaboration, education and training. The key interventions outlined in details in the strategic planning matrix are as follows: SI 1.1) Establish evidence based public communication programs targeting audiences in the human, animal health and plant production sectors SI 1.2) Develop communication strategies, messages and materials to promote AMR awareness SI 1.3) Develop and pilot a one Health AMR related curriculum and skills content. Strategic Objective 2: To strengthen knowledge and evidence-base through surveillance and research The plan has proposed the following strategic interventions in order to achieve the objective; SI 2.1) Strengthen laboratories capacity to detect, and analyze AMR at all sectors SI 2.2) Strengthen quality management systems to provide consistent diagnostic standards by National Reference Laboratories and other potential laboratories. SI 2.3) Build One Health antimicrobial resistance surveillance system that integrates data sharing from human, water, environment and agricultural sectors SI 2.4) Foster Multi-sectoral collaboration for research implementation in various aspects of Antimicrobial use and resistance in humans, animals and plants. 8|Page Strategic Objective 3: To reduce the incidence of infection through effective hygiene and IPC measures In order to achieve the objective, the country has put forth the following strategic interventions which are summarized in matrix form in the next chapter. These are: SI 3.1) Strengthen biosecurity measures on hatcheries, farms, aquaculture establishments, slaughter houses, and food processing establishments for pathogen risk reduction. SI 3.2) Strengthen ports of entry control mechanisms to reduce trans-boundary of human, animal and plant disease occurrence transmission SI 3.3) Accelerate vaccination campaigns to enhance prevention and control of diseases and infections in human and animal health Strategic Objective 4: To optimize the use of antimicrobial medicines in human and animal health Strategic interventions: SI 4.1) Establish antimicrobial stewardship programs specific and sustainable SI 4.2) Promote the use of Policies and Legal framework on antimicrobials for humans and animals. SI 4.3) Optimize access and availability of quality antimicrobials and diagnostics for human, animal and plant use SI 4.4) Promote optimal prescribing and dispensing in humans and animals SI 4.5) Conduct post-marketing surveillance on antimicrobials Strategic Objective 5: Increase R&D on new medicines, diagnostics, vaccines and other interventions related to priority pathogens Strategic interventions: SI 5.1) Strengthen the research base to generate reliable data for planning and sustainable financing on alternative medicines and alleviation of the AMR burden

3.3 Key activities Using the logical framework approach outlined in Chapter V, the plan outlines the key activities connecting to each of the strategic interventions. The key activities will be implemented over a 5 year period and have been annualized for ease of monitoring the strategic interventions. 9|Page Key performance indicators at outcome level have been defined under each strategic intervention to enable Monitoring and Evaluation of the strategy. A detailed description of such indicators is provided in Chapter V.

3.4 Strategic planning matrices The strategic planning matrix below follows the logical framework and provides a summary of Strategic Objectives, underlying interventions for each objective and the key activities to be performed for achieving each intervention. 10 | P a g e Matrix 3.4.1: SO1-Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. Table 3: Strategic Planning Matrix- Strategic Objective 1 STRATEGIC INTERVENTIONS 1.1: Establish evidence based public communication programs targeting audiences in the human, animal health and plant production sectors KEY ACTIVITIES EXPECTED OUTPUT INDICATOR RESPONSIBLE TIMELINES IN YEARS AGENCY YR1 YR2 YR3 YR4 YR5

1.1.1 Undertake baseline study (KAP) on AMR Baseline study on AMR Baseline study report X awareness, in the general populace and undertaken TWG-E&A professionals in relevant sectors (animal, human health, crops, and environment.)

1.1.2 Develop and disseminate national Developed National Availability of X X communication strategy for AMR Communication National TWG-E&A Strategy for AMR Communication EDUCATION AND AWARENESS Strategy for AMR STRATEGIC INTERVENTIONS 1.2 Develop communication strategies, messages and materials to promote AMR awareness

1.2.1. Adopt IEC materials to the Lesotho IEC materials adopted Number of IEC TWG-E&A X context and language materials

1.2.1 Develop and disseminate IEC materials for IEC materials Number of IEC TWG-E&A X diverse stakeholders in human, animal and developed materials environmental health sectors disseminated

1.2.2. Conduct advocacy and sensitization Advocacy and Number of meetings TWG-E&A X X X X X meetings for parliamentarians, local sensitization meeting conducted government, chiefs at national, district and conducted chiefdom levels non-governmental organizations, Civil Society Organizations

1.2.3. Conduct awareness campaigns amongst Awareness campaigns Number of TWG-E&A X X X X X stakeholders, including during WAAW amongst stakeholders campaigns held conducted

1.2.4. Capacitate media on reporting on AMR Media trainings and Number of trainings TWG-E&A X X X X X and dissemination of key messages. briefings held conducted

1.2.5. Commemorate Antimicrobial Awareness WAAW Availability of TWG-E&A X X X X X Week Commemorated WAAW report STRATEGIC INTERVENTIONS 1.3 Develop and pilot a One Health AMR related curriculum and skills content 11 | P a g e

1.3.1. Advocate for the integration of AMR and AMR and related Number of meetings TWG-E&A X X X X X related topics in formal and informal education topics included in held at all levels curriculum

1.3.2. Engage professional registration bodies CPE a pre-requisite for Number of TWG-E&A X X X X X for inclusion of AMR CPE as pre-requisite for Retention Professional bodies retention engaged

1.3.3 Conduct in-service training programs on In-services training Number of trainings TWG-E&A X X X X X AMR for professionals in the human health, conducted conducted veterinary, environmental and agricultural Matrix 3.4.2: SO2-To strengthen knowledge and evidence-base through surveillance and research Table 4: Strategic Planning Matrix-Strategic Objective 2 STRATEGIC INTERVENTION 2.1: Strengthen laboratories capacity to detect, and analyse AMR at all sectors KEY ACTIVITIES EXPECTED OUTPUT INDICATOR RESPONSIBLE TIMELINES IN YEARS AGENCY YR1 YR2 YR3 YR4 YR5

2.1.1 Procure diagnostic equipment and supplies Diagnostic Availability of X X X for antimicrobial determination equipment and equipment and supplies procured supplies TWG-Surveillance SURVEILLANCE AND RESEARCH

2.1.2 Capacitate laboratory and pharmacy Laboratory and Number of people & Research X X X X X professionals on detection and analysis of AMR pharmacy trained and reporting of antimicrobial medicines Professionals consumption &/ use patterns trained STRATEGIC INTERVENTIONS 2.2: Strengthen quality management systems to provide consistent diagnostic standards by all laboratories. 2.2.1Develop collaboration mechanisms between Collaboration X X X X X the national and external laboratories on AMR mechanisms diagnostics developed 2.2.2Develop/adopt quality management system Quality management Availability of TWG-Surveillance X X X X X guidelines in all laboratories guidelines quality management & Research developed guidelines

2.2.3 Advocate for use of approved (WHO, OIE- Availability of SOPs Availability of SOPs X X X X X FAO) SOPs for optimal detection of AMR KEY ACTIVITIES EXPECTED OUTPUT INDICATOR RESPONSIBLE TIMELINES IN YEARS AGENCY YR1 YR2 YR3 YR4 YR5 12 | P a g e STRATEGIC INTERVENTIONS 2.3: Build One Health antimicrobial resistance surveillance system that integrates data sharing from human, water, environment and agricultural sectors

2.3.1 Establish multi-sectoral AMR surveillance Multi-sectoral AMR Availability of Multi- TWG- X X X X X reporting and information sharing system surveillance sectoral AMR Surveillance & system established surveillance system Research

2.3.2 Advocate for incorporation of AMR issues AMR issues Availability of AMR TWG- X X X X X into DHIS2 incorporated in indicators in DHIS2 Surveillance & DHIS2 Research

2.3.3 Develop national guidelines for surveillance Surveillance System Availability of TWG- X X systems Guideline developed guidelines Surveillance & Research

2.3.4 Develop reporting frameworks for AMR Reporting Availability of TWG- X X X X X frameworks Reporting frameworks Surveillance & developed Research

2.3.5 Develop Mechanisms to participate in Global Mechanisms TWG- X X X X X Antimicrobial Resistance (GLASS) developed Surveillance & Research

2.3.6 Develop and adopt standards for antibiotic Standards adopted Availability of TWG- X residues in waste generated from farms, factories, and developed standards Surveillance & human health care, veterinary care Research Strategic Intervention 2.4 Promote Multi-sectoral collaboration for research implementation in various aspects of Antimicrobial use and resistance in humans, animals and plants

2.4.1 Develop AMR research agenda for AMR agenda Availability of AMR in TWG- X incorporation into research agendas of all incorporated into sectoral Research Surveillance & relevant sectors (humans, water, environment sectoral Research agenda Research and agriculture) agenda

2.4.2 Advocate for academic institutional research AMR research topics Number of academic TWG- X X on AMR incorporated in research studies Surveillance & academia conducted Research

2.4.3 Capacitate practitioners (professionals) on Capacity building Number of people TWG- X X basic and operational research in antimicrobial conducted trained Surveillance & use and resistance Research

2.4.4 Establish platform (conference or Information sharing Number of TWG- X X symposium) for regular information sharing on platform established dissemination for a Surveillance & antimicrobial resistance research. held Research 13 | P a g e Matrix 3.4.3: SO3- To reduce the incidence of infection through effective hygiene and IPC measures Table 5: Strategic Planning matrix-Strategic Objective 3 STRATEGIC INTERVENTION 3.1 Strengthen biosecurity measures on hatcheries, farms, aquaculture establishments, slaughter houses, and food processing establishments for pathogen risk reduction KEY ACTIVITIES EXPECTED INDICATOR RESPONSIBLE TIMELINES IN YEARS OUTPUT AGENCY YR1 YR2 YR3 YR4 YR5

3.1.1 Conduct situation analysis of sanitary and Situation analysis Availability of TWG - IPC X X phytosanitary measure and biosecurity conducted Situation analysis report

3.1.2 Develop guidelines and protocols for Guidelines and Availability of TWG - IPC X X X IPC, HYGIENE, SANITATION AND BIOSECURITY biosecurity measures for pathogen risk reduction protocols for guidelines and biosecurity protocols for measures biosecurity developed measures

3.1.3 Capacitate Famers on biosecurity measures Famers capacitated Number of TWG - IPC X X X X X for pathogen risk reduction famers trained STRATEGIC INTERVENTION 3.2 : Strengthen ports of entry control mechanisms to reduce trans-boundary of human, animal and plant disease occurrence transmission

3.2.1 Develop integrated Protocols, guidelines and Integrated tool Availability of TWG - IPC X X reporting framework on animal trans-boundary developed integrated animal/plant disease occurrence transmission protocols

3.2.2 Advocate for recruitment of border control Border control Number of TWG - IPC X X X X X officers at all designated ports of entries officers recruited border control officers

3.2.3 Strengthen border patrols Border patrols TWG - IPC X X X X X officers deployed STRATEGIC INTERVENTION 3.3 Accelerate Vaccination Campaigns to enhance prevention and control of diseases and infections in human and animal health

3.3.1 Review vaccination programs in animal and Vaccination Availability of TWG - IPC X human health programs reviewed reviewed programs

3.3.2. Intensify sensitization of people on the use of Sensitization Number of TWG - IPC X X X X X preventive medication (Vaccines). Meetings Held meetings held 14 | P a g e KEY ACTIVITIES EXPECTED OUTPUT INDICATOR RESPONSIBLE TIMELINES IN YEARS AGENCY YR1 YR2 YR3 YR4 YR5

3.3.3 Capacitate Professionals on prevention and Professionals Percentage of TWG - IPC X X X X X control of diseases in human and animal capacitated professionals capacitated IPC, HYGIENE, SANITATION AND BIOSECURITY

3.3.4 Conduct Vaccination Campaign for various Vaccination Percentage of TWG - IPC X X X X X health threats campaigns conducted animals and people vaccinated STRATEGIC INTERVENTION 3.4 Protect health and environment against AMR

3.4.1 Develop legal framework (in line with One- Legal framework Availability of TWG - IPC X X Health Approach) developed legal framework

3.4.2 Promote Open Defecation Free (ODF) ODF initiative Number of TWG - IPC X X X X X communities implemented communities with ODF STRATEGIC INTERVENTION 3.5 Develop waste management strategy

3.5.1 Establish sewage Pre-Treatment Facilities at Sewage Pre- Availability of TWG - IPC X X X hospital level Treatment Facilities sewage Pre- established Treatment Facilities

3.5.2 Develop protocols and guidelines on Pre- Pre-Treatment Availability of TWG - IPC X X X Treatment Facilities Facilities developed Guidelines

3.5.3 Establish sewage Pre-Treatment Facilities at Sewage Pre- Percentage of TWG - IPC X X X hospital level Treatment Facilities hospitals with established Pre-Treatment Facilities

3.5.4 Develop protocols and guidelines on Pre- Pre-Treatment Availability of TWG - IPC X X X X X Treatment Facilities Facilities developed Pre-Treatment Facilities 15 | P a g e Matrix 3.4.4: SO 4 -To optimize the use of antimicrobial medicines in human and animal health Table 6: Strategic Planning matrix-Strategic Objective 4 STRATEGIC INTERVENTIONS 4.1: Establish antimicrobial stewardship programs specific and sustainable KEY ACTIVITIES EXPECTED OUTPUT INDICATOR RESPONSIBLE TIMELINES IN YEARS AGENCY YR1 YR2 YR3 YR4 YR5

4.1.1. Review the EML &STGs based on Reviewed STGs and Availability of updated STGs MOH X X antimicrobial resistance data and EML and EMLs incorporate AWaRe classification of antibiotics

4.1.2 Formulate regulations and Regulations and Availability of Regulations and MAFS X guidelines for use of veterinary medicine Guidelines Guidelines for Veterinary developed Medicine ANTIMICROBIAL USE AND REGULATION

4.1.3 Review existing policy drafts Reviewed policies Number of policies that MOH,MAFS X X (animal and human health) to include incorporate AMR AMR issues

4.1.4 Resuscitate Therapeutics Therapeutic Percentage of health facilities MOH X Committees at National and health facility committees with functional therapeutic levels with TORs that incorporate AMR resuscitated committees Stewardship activities

4.1.5 Develop and disseminate AMR AMR guidelines Percentage of health facilities MOH X X X stewardship guidelines developed with AMR guidelines

4.1.6 Establish the one health regulatory Regulatory Availability of functional one MOH,MAFS,M X Authorities Authority health Regulatory Authority TEC,MODP established

4.1.7 Establish pharmaceutical quality Pharmacovigilance Percentage of health facilities MOH X control laboratory guidelines with pharmacovigilance developed guidelines

4.1.8 Develop and Disseminate Pharmacovigilance Availability of MOH X Pharmacovigilance Guidelines Guidelines pharmacovigilance guidelines developed and disseminated

4.1.9 Strengthen AMR Coordination at MOH X X X X X district level 16 | P a g e STRATEGIC INTERVENTIONS 4.2 Establish antimicrobial stewardship programs specific and sustainable KEY ACTIVITIES EXPECTED OUTPUT INDICATOR RESPON TIMELINES IN YEARS SIBLE YR1 YR2 YR3 YR4 YR5 AGENCY

4.2.1.1 Advocate for Enactment of Advocacy for Medicine and Availability of Medicines and MOH X the Medicine and Medical device Medical device control bill Medical Device Control Act Control Bill conducted

4.2.1.2 Advocate for enactment of Advocacy for Animal Availability of Animal MAFS X Animal Production, Health and Production, health and Production, Health and Welfare welfare draft bill welfare draft bill conducted Act Strategic intervention 4.3: Promote the use of Policies and Legal framework on antimicrobials for humans and animals ANTIMICROBIAL USE AND REGULATION

4.3.1 Capacitate healthcare Healthcare personnel trained Percentage of facilities with at MOH X personnel on use of EML and STGs on STGs (antimicrobials). least one personnel trained on (antimicrobials). use of STGs

4.3.2 Capacitate Agriculture Agriculture personnel Percentage of Agricultural MAFS X personnel on use of Animal trained on Animal treatment resource centers trained on treatment guidelines. guidelines Animal treatment guidelines Strategic intervention 4.4: Optimize Access and Availability of quality antimicrobials and diagnostics for human, animal and plant use

4.4.1 Revive Veterinary Drug Veterinary Drug Committee Availability of functional MAFS X X X committee revived Veterinary Drug Committee

4.4.2 Resuscitate Therapeutics Therapeutics Committees Percentage of health facilities MOH X Committees at National and health resuscitated with active Therapeutics facility levels with TORs Committees Strategic Intervention 4.5: Promote optimal prescribing and dispensing in humans and animals

4.5.1. Capacitate Health Personnel Health Personnel capacitated Percentage of facilities MOH X on Rational prescribing and on rational prescribing and prescribing antimicrobials with dispensing of antimicrobials dispensing at least 80% compliance with the Guidelines Strategic Intervention: 4.6 Conduct post-marketing surveillance on antimicrobials

4.6.1 Establish Pharmacovigilance District Pharmacovigilance Percentage of Districts with MOH X committees (PVCs) at District level. committees Established functional Pharmacovigilance committees

4.6.2 Review Pharmacovigilance Pharmacovigilance tools Availability of MOH X X X X X tools reviewed Pharmacovigilance tools 17 | P a g e Matrix 3.4.5: SO5: To develop the economic case for sustainable investment that takes account of the national needs and increase investment in new medicines, diagnostic tools, vaccines and other interventions Table 7: Strategic Planning matrix-Strategic Objective 5 STRATEGIC INTERVENTIONS 5.1: Strengthen the research base to generate reliable data for planning and sustainable financing, on alternative medicines and alleviation of the AMR burden KEY ACTIVITIES EXPECTED INDICATOR RESPONSIBLE TIMELINES IN YEARS OUTPUT AGENCY YR1 YR2 YR3 YR4 YR5

5.1.1 Advocate for Multi-sectoral Number of TWG-Research X INVESTMENT AND RESAERCH collaboration for research on alternative academic and medicines in various aspects of Antimicrobial institutions Investment use and resistance in humans, animals and conducting plants research

5.1.2 Mobilize resources required for research Proposals for Number of funding TWG-Research X X X X X on alternative medicines and for the funding proposals and implementation of the AMR NAPs developed developed Investment

5.1.3 Undertake expenditure tracking analysis Expenditure Availability of TWG-Research X X X in human and animal acquired infections tracking analysis Expenditure and conducted tracking report Investment

5.1.4 Conduct Out-of-Pocket Expenditure OOP study Availability of TWG-Research X X X (OOP) on AMU in relation to animal, plant, conducted survey report and environment and human health Investment 18 | P a g e CHAPTER IV –FINANCIAL RESOURCE REQUIREMENTS This chapter describes in detail the level of resource requirements for implementation period. It outlines the methodology used in costing the strategy, and the estimates of financial resource requirements for the duration of the strategy. The costs have been determined for each of the 5 key strategies outlined in chapter III.

4.1 Costing approach The aim of this costing is to provide a broad framework on resource requirements as a means of informing donor and government allocations in support of its implementation. The proposed activities and their underlying sub-activities formed a basis for costing each of the strategic objectives. In obtaining cost estimates for subsequent years, a 6% increase in prices year-on-year basis was assumed. These estimates include costs of developing or updating relevant policies and strategies; developing relevant norms, standards, guidelines and tools. A desk review of relevant documents such as strategic plans and operational plans from different Ministries were reviewed to gather information of the unit costs of cost drivers identified under each strategic objectives and their underlying interventions. The consolidated costing was reviewed iteratively by TWGs, managers from different ministries who provided technical inputs.

4.1.1 NAP-AMR Costing Process Technical Two training 5 Days Costing Presentation Working Group sessions on Costing Workshop for of costing Tool, Costing results to TWG Formed reorientation on Methodology stakeholders Costing Tools Figure 7: Costing process

4.1.2 Costing Assumptions ✓ The US$ rate to local currency of US$1 to LSL16.00 ✓ An annual inflation rate of 6% for determining cost estimates in the subsequent years

4.1.3 Limitations to the costing approach ✓ The costs estimates have not been disaggregated by the levels of implementation such as district and national so as to estimate the financial resource requirements at implementation and policy making level. 19 | P a g e ✓ There was no standard price list used by Government to guide unit costs under budget categories such as office equipment, stationery and meeting packages; therefore other cost emanates from existing costed strategic plans at National and Ministerial level. ✓ The costing did not have information on the available resources, hence funding gap could be easily determined.

4.1.4 Estimating resource requirements: Activity Based Costing (ABC) approach The National Action Plan on Antimicrobial Resistance (NAP-AMR) was costed using Activity Based Costing (ABC) approach. This costing approach is defined as costing and monitoring of activities which involves tracing resource consumption and costing final outputs. Resources are therefore assigned to activities, and activities to cost objects based on consumption estimates (CIMA, 2008). The ABC uses a bottom-up, input-based approach, indicating the cost of all inputs required to achieve the targets for NAP on AMR during the financial years 2020/21 – 2024/25. The cost over time for all the respective inputs were aggregated into overall costs for individual key activities, strategic interventions and finally aggregated into the Strategic Objectives (SOs) in line with the logical framework used in Chapter III. The estimated resources required for achieving each of the SOs in chapter III provides important details that will initiate debate between GOL and partners on priority setting and effective resource allocation.

4.2 Costing results A detailed analysis of budget requirement was conducted and the data being disaggregated by SOs and their respective interventions over a 5 year period. The table below provides the summary of cost estimates by SOs. Table 8: Estimated budget requirements by Strategic Objectives Strategic Objectives Year 1 Year 2 Year 3 Year 4 Year 5 Grand Total SO(1): Improve awareness and understanding of antimicrobial resistance through effective 3,657,850 1,506,088 1,307,106 1,068,328 1,134,714 8,674,087 communication, education and training SO (2): To strengthen knowledge and evidence-base through 16,331,800 15,998,641 16,516,199 16,674,224 12,624,769 78,145,633 surveillance and research SO (3): To reduce the incidence of infection through effective 92,528,830 1,684,022 2,934,281 1,279,508 3,171,027 101,597,668 hygiene and IPC measures SO(4): To optimize the use of antimicrobial medicines in 43,728,400 9,925,492 3,707,973 8,120,597 14,275,859 79,758,321 human and animal health SO (5): To develop the economic case for sustainable investment and increase investment in new 581,200 448,288 899,226 591,640 157,559 2,677,913 medicines, diagnostic tools, vaccines and other interventions Grand total 156,828,080 29,562,531 25,364,786 27,734,298 31,363,927 270,853,622 20 | P a g e The Government of Lesotho requires LSL 270,853,622 Million (US$16,928,351) over a 5-year period in order to implement the strategy and hence achieve the intended targets. The SO3 that addresses issues on hygiene and IPC requires a larger share of the budgets accounting for (38%) of the total proposed budget. The main cost drivers for interventions under SO3 include; Promotion of Open Defecation Free (ODF) communities; Promoting free access to water targeting communities in 10 districts as shown by figure 4 below. Generally, a bigger proportion of the budget is required during the 1st year of implementation and this is due to initiation of new activities directly related to AMR, review of legal frameworks and implementation of newly proposed projects under SO3 (hygiene and IPC). Figures 3, 4 and table 9 below provides more details of the analysis. Cost Estimates by Strategic Objectives: Cost Estimates by Years of Implementation: Strategic 2020-2025 Strategic 2020-2025 objective 5(SO5) Objective 1% 1(SO1) Year 5 Strategic 3% Year 4 12% Strategic objective objective 10% 4(SO4) 2(SO2) Year 3 29% 29% 9% Year 1 Strategic 58% Objective Year 2 3(SO3) 11% 38% Figure 8: Distribution of cost estimates by strategic interventions Figure 9: Distribution of cost estimates by years of implementation Table 1: Distribution of cost estimates by thematic areas Total Cost of Lesotho NAP-AMR 2020 -2025 by Program Areas LSL(Millions) Thematic Areas 2020/21 FY 2021/22 FY 2022/23 FY 2023/24 FY 2024/25 FY Total EDUCATION AND AWERENES 3,657,850 1,506,088 1,307,106 1,068,328 1,134,714 8,674,087 SURVELLIANCE AND 16,331,800 15,998,641 16,516,199 16,674,224 12,624,769 78,145,633 RESEARCH HYGIENE AND IPC 92,528,830 1,684,022 2,934,281 1,279,508 3,171,027 101,597,668 AM USE IN ANIMAL AND HUMAN 43,728,400 9,925,492 3,707,973 8,120,597 14,275,859 79,758,321 HEALTH RESEARCH AND INVESTMENT 581,200 448,288 899,226 591,640 157,559 2,677,913 Grand Total 156,828,080 29,562,531 25,364,786 27,734,298 31,363,927 270,853,622 21 | P a g e

4.2.1 Projected Budget requirements by Strategic Interventions

4.2.1.1 Strategic Interventions 1.1-1.3; Education and Awareness As reflected in the strategic planning matrix in the previous chapter, 3 strategic interventions have been proposed under Education and Awareness thematic area. These were therefore costed in line with methodology outlined in 4.1.4 above. The table below provides the cost estimates; Table 2: Estimated budget requirements by strategic interventions-Education and Awareness Total estimated Budget: 2020 -2025 LSL(Millions) % of Interventions Year 1 Year 2 Year 3 Year 4 Year 5 Grand Total Total Cost SI(1.1):Establish evidence based public communication programs 2,687,700 0 0 0 0 2,687,700 31.0% targeting audiences in the human, animal health and Plant Health sectors SI (1.2) :Develop communication Strategies, messages and 516,450 362,000 140,450 148,877 157,810 1,325,587 15.3% materials to promote AMR awareness SI(1.3): Develop and pilot a "One Health" AMR 453,700 1,144,088 1,166,656 919,451 976,905 4,660,800 53.7% related Curriculum and Skills content Total 3,657,850 1,506,088 1,307,106 1,068,328 1,134,715 8,674,087 Of the total budget proposed under education and awareness, nearly 53.7% of the estimated budget under Education and awareness is proposed for development and piloting of “One Health” AMR related curriculum as one of the priority strategic interventions. The underlying costed key activities include under this intervention are as follows; integration of AMR and related topics in formal and informal education at all levels; Engagement of professional registration bodies for inclusion of AMR Continuing Professional Education (CPE) as pre-requisite for retention; and implementation of in-service training programs on AMR for professionals in the human health, veterinary, environmental and agricultural.

4.2.1.2 Strategic Interventions 2.1-2.4; Surveillance and Research There are 4 Strategic Interventions proposed under surveillance and research thematic area. Strategic Interventions (2.3) on establishment of One Health antimicrobial resistance surveillance system that integrates data sharing from human, water, environment and agricultural sectors has been costed in the first year only, requiring around M 754,000. These costs include procurement of equipment such as computers and technical assistance for incorporation of AMR data elements in to the DHIS2 platform. 22 | P a g e Table 11: Estimated budget requirements by strategic interventions-Surveillance and Research Total estimated Budget: 2020 -2025 LSL(Millions) % of Interventions Year 1 Year 2 Year 3 Year 4 Year 5 Grand Total Total Cost SI(2.1 & 2.2): Strengthen laboratories 58,901,169 capacity to detect, and analyze AMR at 10,991,800 11,352,641 12,021,799 11,910,160 12,624,769 all sectors; Strengthen quality management systems to provide 75% consistent diagnostic standards by all laboratories SI(2.3): Build One Health 754,000 antimicrobial resistance surveillance 754,000 system that integrates data sharing 0 0 0 0 1% from human, water, environment and agricultural sectors 18,490,464 SI (2.4): Promote Multi-sectoral 4,586,000 4,646,000 4,494,400 4,764,064 collaboration for research 24% 0 implementation in various aspects of Antimicrobial use and resistance in humans, animals and plants 16,331,800 15,998,641 16,516,199 16,674,224 12,624,769 78,145,633 Total SI 2.1 and 2.2 were aimed at improving the use of diagnostic investigations to guide better management of diseases. The interventions constituted a higher proportion (75%) of the total estimated budget for all activities under surveillance and research. 23 | P a g e

4.2.1.3 Strategic Interventions 3.1-3.5 Hygiene and IPC Table 3: Estimated budget requirements by strategic interventions-Hygiene and IPC Total estimated Budget: 2020 -2025 LSL(Millions) % of Total Interventions Year 1 Year 2 Year 3 Year 4 Year 5 Grand Cost Total SI(3.1): Strengthen biosecurity measures on hatcheries, farms, 1,673,200 2,418,212 2,335,519 7,811,306 aquaculture 651,900 732,475 establishments, slaughter 7.7% houses, and food processing establishments etc., for pathogen risk reduction SI(3.2): Strengthen ports of entry control 207,750 589,784 47,191 50,023 53,024 947,772 mechanisms to reduce 0.9% trans-boundary of human, animal and plant disease occurrence transmission SI(3.3):Accelerate Vaccination Campaigns to 202,500 214,650 227,529 241,181 255,652 1,141,511 enhance prevention and 1.1% control of diseases and infections in human and animal health SI(3.4):Protect health and 90,230,580 90,486,232 environment against 255,652 AMR 0 0 0 89.1 % SI(3.5):Conduct 214,800 227,688 241,349 255,830 271,180 1,210,848 monitoring and supervision of the IPC 1.2% initiatives 92,528,830 1,684,022 2,934,281 1,279,509 3,171,027 101,597,669 Total The table above shows the estimated cost for each Strategic Intervention under Hygiene, Infection Prevention and Control. SI 3.4 aiming at protecting health and environment against AMR accounts for nearly 89% of the total estimated budget for Hygiene and IPC, with most of its financial resources needed in the first and final years of implementation. 24 | P a g e

4.2.1.4 Strategic Interventions 4.1-4.5; Antimicrobial use in Animal and Human Health Table 4: Estimated budget requirements by strategic interventions-Antimicrobial use Total estimated Budget: 2020 -2025 LSL(Millions) % of Total Cost Interventions Year 1 Year 2 Year 3 Year 4 Year 5 Grand Total SI(4.1):.Establish 13,354,300 10,193,389 37,052,892 antimicrobial 5,091,600 2,426,976 5,986,627 stewardship 46.5% programs specific and sustainable SI(4.2): Promote the use of Policies and Legal 1,333,600 2,930,972 2,494,212 7,933,658 framework on 9.9% 578,997 595,877 antimicrobials for humans and animals SI(4.3): Optimize Access and Availability of quality 27,503,100 27,508,900 34.5% antimicrobials and diagnostics for human, animal 5,800 and plant use 0 SI (4.4): Promote optimal 1,195,120 3,619,471 prescribing and 4.5% 702,000 836,093 886,258 dispensing in humans and animals 0 SI(4.5): 3,643,400 Strengthen post- 835,400 702,000 702,000 702,000 702,000 marketing 4.6% surveillance on antimicrobials 43,728,400 9,925,492 3,707,973 8,120,597 14,275,859 79,758,321 Total The table above shows the estimated costs for SI 4.1-SI 4.5 under AM Use in Animal and Human Health (Strategic Objective 4). Close to half of the estimated budget (47%) under this strategic objective is proposed to support establishment of antimicrobial stewardship programs. Similar to other strategic objectives, a larger portion of the proposed budget will be required in the 1st year on implementation. 25 | P a g e

4.2.1.5 Strategic Intervention 5.1; Research and Investment Table 5: Estimated budget requirements by strategic interventions-Research and Investment Total estimated budget: 2020 -2025 LSL (Millions) Interventions Year 1 Year 2 Year 3 Year 4 Year 5 Grand Total SI(5.1):Strengthen the research base to generate 581,200 448,288 899,226 591,640 157,559 2,677,913 reliable data for planning and sustainable financing on alternative medicines and alleviation of the AMR burden Only one (1) strategic intervention has been proposed and hence costed under research and investment as shown in strategic planning matrix in chapter 3 and table 14 above. The total estimated budget for the duration of the plan is approximately M 2.67 million. The costed key activities include; Expenditure tracking analysis exercise in human and animal acquired infections and conducting Out-of-Pocket Expenditure study on antimicrobial medicines.

4.2.1.6 Distribution of Cost Estimates by Strategic Interventions-A summary Figure 10: Percent distribution of cost estimates by strategic interventions Distribution of Cost Estimates by Strategic Intervention:2020-2025 SI 4.4 SI 4.5 SI 5.1 SI 1.1 SI 1.2 SI 1.3 1% 1% 1% 1% 0% 2% SI 4.2 SI 4.3 3% 10% SI 2.1 22% SI 4.1 14% SI 2.2 0% SI 2.3 7% SI 3.5 0% SI 3.4 SI 3.1 33% SI 3.2 3% 0% SI 3.3 0% The figure above shows the percent distribution of the estimated cost by each strategic interventions in percentages. SI 3.4 under hygiene and IPC constitutes a larger proportion of the estimated budget (33%) in comparison with other strategic interventions across all the objectives or thematic areas. SI 2.1 (under Surveillance and Research) aimed at improving appropriate use of 26 | P a g e diagnostic investigations to identify pathogens is the second highest accounting for about one fifth of the overall cost of implementing the action plan.

4.2.1.7 Budget requirements by Implementing Agency As indicated in the methodology in chapter 2, preventing emergence and spread of AMR requires a multi sectorial response. As a result, the cost estimates were further disaggregated by the responsible agencies for implementing the interventions outlined in chapter 3. Table 6: Estimated budget requirements by implementing agencies Agency Total estimated budget Implementing Agency: 2020 -2025 LSL (Millions) % of Year 1 Year 2 Year 3 Year 4 Year 5 Total Grand Total Cost MOH 62,921,050 27,037,985 22,144,751 26,287,571 27,237,333 165,628,690 61.2% MAFS 3,788,950 2,432,546 3,092,034 1,446,726 4,126,595 14,886,852 5.5% NUL 90,000 92,000 0 0 0 182,000 0.1% MOWA 90,028,080 0 0 0 0 90,028,080 33.2% LMDPC 0 0 128,000 0 0 128,000 0.0% Grand Total 156,828,080 29,562,531 25,364,786 27,734,298 31,363,927 270,853,622 As shown in the table above, a larger share of the budget (nearly 61%) is proposed to support activities under Ministry of Health (MoH) and 33% is proposed to support activities in the Ministry of Water Affairs (MOWA). Ministry of Agriculture and Food Security will need 5.5% of the estimated budget for implementation of the proposed interventions and their underlying activities.

4.2.1.8 Budget requirements by Cost Categories Table 7: Estimated budget requirements by cost categories 27 | P a g e CHAPTER V – MONITORING AND EVALUATION FRAMEWORK

5.1 Introduction This chapter introduces mechanisms for Monitoring and Evaluation of the National Action Plan and provides an indicator framework to monitor the Plan. The indicator framework provides a list of indicators at output, outcome and Impact level selected by the stakeholders to track progress towards implementation of Strategic Objectives, Strategic interventions, key activities and underlying sub activities. The Impact level indicators will measure progress towards fulfilment of Strategic Objectives (SOs); Outcome level indicators will track progress towards achieving the Strategic Interventions (SIs) while the key activities and their underlying sub-activities will be tracked using output indicators.

5.1.1 AMR indicators and Sustainable Development Goals (Global context) The UN Political Declaration of the High-Level Meeting of the General Assembly on antimicrobial resistance further concluded that antimicrobial resistance challenges the sustainability and effectiveness of the public health response towards health and development and the attainment of the 2030 Agenda; Yet the Sustainable Development Goals (SDGs) do not have a single indicator specific to antimicrobial resistance. In the 2018 McKinsey & Company analysis of AMR Indicators and their relevance to the SDGs and targets, it is further revealed that; ✓ The SDG indicator framework is not specific, but sensitive and highly relevant to AMR. ✓ The SDG framework is very relevant to AMR GAP and nearly 70% of SDGs include indicators relevant to the GAP (covering on average 75% of GAP objectives). ✓ SDGs Indicators relating to human health in the GAP are nearly 2-3 times more common than those relating to animal health, plant health or the environment.

5.2 Methodology The M&E framework was developed with a One Health perspective due to the multi-sectorial nature of the National Action Plan. The Monitoring and Evaluation of Lesotho National Action Plan follows the logical framework adopted from 2017 WHO framework on Monitoring and Evaluation of National Action Plans on AMR. The framework reflects on the causal pathways connecting the plan’s inputs, activities and outputs with the desired outcomes and impact goals.

5.2.1 Selection of indicators Five (5) multi-disciplinary teams were formed according to the thematic areas outlined in the implementation framework (Education and Awareness; Surveillance and Research; Hygiene Sanitation and Biosecurity; Antimicrobial use and Regulation; Investment, Research and 28 | P a g e Development). Each team was provided with a set of tools to facilitate development of newly proposed indicators and adoption of already existing indicators from the regional and global Monitoring and Evaluations Frameworks on AMR. The tools include; 2017 WHO framework on Monitoring and Evaluation of National Action Plans on AMR; 2019 WHO, FAO and OIE Monitoring and Evaluation of the global action plan on antimicrobial resistance; 2018-23 Africa CDC Framework for AMR; 2018 Report on AMR indicators and Sustainable Development Goals. The implementation framework for the current National Action Plan was further used as the primary guide for development and selection of output, outcome and impact indicators in line with Strategic planning matrix in chapter 3. The selection process was also based on the criterion outlined in the 2019 M&E Framework for the GAP, where following are the factors that were considered; (1) Indicator relevance to the Strategic Objectives, Strategic Interventions and key activities (2) Availability of data for reporting at midterm and end term, (3) Feasibility of data collection and (4) Sensitivity of indicators to change at midterm and end term. In order to check on indicator relevance and availability of data for future reporting, Indicator- Objective Mapping tool was developed and used to guide the process in each thematic area. The developed Indicator-Objective mapping tool was used to facilitate categorization of indicators by indicator levels (output, outcome, impact).

5.2.2 The Logical Framework-What causes what? Table 8: The programme logical framework 29 | P a g e The 2016 WHO guidelines on Monitoring and Evaluating digital health interventions defines the logical framework as a management tool that summarizes what a project intends to do and how, what the key assumptions are, and how outputs and outcomes will be monitored and evaluated. Using the strategic implementation matrix in Chapter 3, the Logical Framework in table 17 above shows a causal relationship between selected inputs, outputs, outcomes and the ultimate impact. It further provides guidance in relation to the type of indicators to be used for tracking performance.

5.3 The Indicator Framework A total of 39 indicators have been selected to monitor progress towards implementation of the planned strategic interventions and corresponding key activities. The indicator levels follow a pyramid shape, where majority of the indicators are at output level (at the base) with only few impact level indicators at the apex. The figure below depicts the scenario; Impact level Indicators Outcome level indicators Output level indicators Figure 11: Indicator levels

5.3.1 Indicator listing by thematic areas Table 9: Indicator listing – (Education and Awareness) & (Surveillance and Research) 1. Education and Awareness 2. Surveillance and Research • Percentage of targeted population with knowledge on • Prevalence levels of ESBL in commensal E. coli risk and proper use of antimicrobial from food producing animal species • Percentage of AMR focal sites (community council • Out of pocket expenditure on AM Offices, schools, public and private health facilities) • Percentage of laboratory investigations displaying key messages on AMR conducted prior to prescription of AMs (Culture • Percentage of schools implementing curricula that Sensitivity Tests) includes AMR and related topics • Percentage of new TB cases with multi-drug • Percentage of schools implementing curricula that resistant TB includes AMR and related topics • Total number of antimicrobial susceptibility tests • Percentage of health professionals who meet minimum in plant and animal health CEP points on AMR required upon application for • Availability of active multi sectoral AMR retention Surveillance system 30 | P a g e • Percentage of health facilities with at least one • Availability of updated MOH research agenda personnel trained on AMR that include AMR as priority topic • Percentage of health facilities trained on STGs • Percentage of facilities with AMR diagnostics • Availability of Curricula that include AMR and related tools topics • Percentage of laboratories with functional • Availability of National communication strategy for diagnostic equipment for detection of drug AMR resistance • Total number of planned AMR sensitization meetings • Total number of Operational research studies on with community leaders5 AMR Table 10: Indicator listing-(IPC, Hygiene, Sanitation and Bio security) & (AM use and regulation) 3. IPC, Hygiene, Sanitation and 4. Antimicrobial use and Regulation Biosecurity • Percentage of population using safely • Availability of Legislation on Medicine and Medical device managed sanitation services, including a control bill hand-washing facility with soap and water • Percentage of new-borns with suspected severe bacterial (SDG6) infection who receive appropriate antibiotic therapy • Percentage of commercial farms that have • Percentage of farms, compliant with standards for proper use implemented a biosecurity programme of antimicrobial in animals • Vaccine coverage in human and animal health • Antimicrobial (AM) use per capita in human health • Percentage of hospitals prescribing antimicrobials for surgical prophylaxis with >80% compliance with guidelines • Percentage of inspected medicines that met required WHO standards • Rate of readmissions due to surgical site infection • Total number of reported adverse drug reactions • Percentage of retail pharmacies inspected that comply with standards • Percentage of facilities with active committees ( therapeutic , AMS) • Percentage of AMR focal sites with AMR guidelines (DHMT, rural water supply, department of environment) • Percentage of facilities reporting stock outs (non-availability) of specified antibiotics Table 11: Indicator listing-Crosscutting indicators among thematic areas • Proportion of GOL budget allocated for research • Proportion budget allocated for AMR interventions (GOL, Donors) • Mortality attributable to AMR infections • Morbidity due to AM 5 parliamentarians, local government, chiefs at national, district and chiefdom levels non-governmental organizations, Civil Society Organizations 31 | P a g e

5.4 Performance Monitoring

5.4.1 Routine data Collection The data collection methods for generating data on selected indicators will be based on the existing ministerial routine data collection platforms. This includes the use of District Health Information System_2 (DHIS2) used in the MOH, Laboratory Management Information System (LMIS) in the MOH and Integrated Financial Management Information System used across collaborating Ministries. The primary source documents will also be used as the point of reference for data elements generated in different sectors but are not ultimately aggregated and reported at district and national level. Such data will be collected at agreed time intervals in line with the reporting requirements in the indicator matrix. The use of existing platforms to generate and report data on AMR indictors is a sustainability measure in the M&E system for combating AMR in Lesotho. 5.4. 2 Integrated supportive supervisions (routine supervisions) In line with the One Health Approach, a multi-sectoral integrated supportive supervision will be conducted on quarterly basis from national to the lower level using the developed supervision check list as a guide. The checklist will be developed in line with the proposed output level indicators, where progress towards fulfilment of planned sub-activities will be monitored. The data elements which are not reported through routine data collection platforms but are a requirement for reporting on progress will be collected during supervision visits. This includes adherence to the guidelines, stock levels on antibiotics in AMR focal points and functionality of AMR committees at lower level of implementation.

5.5. Evaluation and Surveys Using information generated from monitoring, programme evaluations will be conducted at mid- way in the implementation of the National Action Plan and also by the end of the duration of the plan. It is also proposed that the baseline assessment on newly proposed indicators will be conducted and such information will serve as a guide towards routine monitoring, and programme evaluations and mid-term and end term. Targeted surveys will be conducted to inform indicators which data may not be possible to generate through routine data collection platforms and integrated supervisions. The surveys will be conducted mainly on indicators tracking the behavioural patterns from the demand side (general population) and supply side (AMR focal sites) of interventions on prevention of the spread of AMR. Such indicators include; knowledge on AMR among the population, Out of pocket expenditure on antibiotics/antimicrobials, adherence to prescription guidelines in AMR focal points and adherence to the use of agreed standards by the private practitioners including retail pharmacies. These indicators will be informed by surveys such as, Lesotho Demographic and Health Survey (LDHS)- 32 | P a g e every 5 years, Multiple Indicator Cluster Survey (MICS)-every 2 years, Accreditation of Health facilities survey-every 2 years.

5.5.1 Embedded Implementation Research (Operational Research) Following successful activity monitoring through reporting and conducting of integrated supportive supervisions, it is envisaged that at least one operational study will be conducted in each year for the duration of a plan. The priority topics listed in the MOH research agenda will also be considered while initiating an operational research.

5.6 Feedback mechanisms The information from supervision report, targeted surveys and operational research will be harmonized in to one monitoring report which will be consolidated into the National Report on AMR produced quarterly, semi-annually and annually. The quarterly and semi-annual reports will focus on activity monitoring while the annual reports will track outcomes and reflect on strides towards achievement of impact indicators. Existing country level platforms will be used to communicate the achievements and challenges in the implementation of the National Action Plan. Such platforms include; Health Sector District Based Quarterly reviews, Health Sector Annual Joint Reviews (AJR), and reporting to Social Cluster Investment Committee (Quarterly). The table below provides a summary of different reporting platforms targeting both external and internal stakeholders. Table 12: Feedback platforms for accountability on results Reporting Reporting platform Frequency of reporting hierarchy Quarterly Semi- Annually Biennial Annually Global World Health Assembly X OIE AMR Technical meeting X Country Progress Monitoring on AMR X in 6 WHO Regions Regional SADC Antimicrobial TWG X Africa CDC meetings X ReAct Africa Annual Conference X Country Health Sector-Annual Joint Review X level (AJR) Social Cluster Investment Committee X X Ministerial Capital projects progress X X reporting 33 | P a g e

5.7 Limitations to the M&E Framework • Unavailability of global targets on AMR, from which the country could draw own targets. • The Global SDGs monitoring framework adopted by the country does not have indicators specific to AMR, hence difficulty for the country to ensure proper alignment of M&E for AMR with existing M&E frameworks across the sectors. • Unavailability of baseline information for majority of indicators proposed in the indicator matrix, of which realistic target setting and reporting based on targets may be a challenge in the first year of implementation. 34 | P a g e

5.8 Indicator Matrix Table 13: Indicator Matrix Ind. # Indicators M0easures Baseline Targets in years Indicator Data Frequency Strategic 2021 2022 2023 2024 2025 level Source of reporting Objective 1. Mortality attributable to AMR infections SO.1-SO.4 TBD TBD TBD TBD TBD TBD Impact Survey 5 years 2. Morbidity due to AM SO.1-SO.4 TBD TBD TBD TBD TBD TBD Impact Survey 5 years 3. Percentage of targeted population with SO. 1 TBD TBD TBD TBD TBD TBD Impact Survey Biennial knowledge on risk and proper use of antimicrobials 4. Prevalence levels of ESBL in commensal SO.1-SO.4 TBD TBD TBD TBD TBD TBD Impact Survey 5 years E. coli from food producing animal species 5. Out of pocket expenditure on AM SO.1-SO.5 TBD TBD TBD TBD TBD TBD Impact Survey Biennial 6. Percentage of population using safely SO.4 TBD TBD TBD TBD TBD TBD Impact Survey 5 years managed sanitation services, including a hand-washing facility with soap and water (SDG6) 7. Percentage of AMR focal sites SO. 1 TBD TBD TBD TBD TBD TBD Outcome ISS- Bi-annual (community council Offices, schools, Reports public and private health facilities) displaying key messages on AMR 8. Percentage of schools implementing SO.1 TBD TBD TBD TBD TBD TBD Outcome ISS- Annually curricula that includes AMR and related Reports topics 9. Percentage of health professionals who SO.1 TBD TBD TBD TBD TBD TBD Outcome Annually meet minimum CEP points on AMR required upon application for retention 10. Percentage of new-borns with suspected SO.4 TBD TBD TBD TBD TBD TBD Outcome H/Facility Annually severe bacterial infection who receive Records appropriate antibiotic therapy 11. Percentage of commercial farms that SO.4 TBD TBD TBD TBD TBD TBD Outcome ISS- Biennial have implemented a biosecurity Reports programme 12. Percentage of farms, compliant with SO.4 TBD TBD TBD TBD TBD TBD Outcome standards for proper use of antimicrobial in animals 35 | P a g e 13. Vaccine coverage in human and animal SO.4 TBD TBD TBD TBD TBD TBD Outcome DHIS2 Annually health 14. Antimicrobial (AM) use per capita in SO.1, SO.2 TBD TBD TBD TBD TBD TBD Outcome H/Facility Annually human health Records 15. Percentage of hospitals prescribing SO.4 TBD TBD TBD TBD TBD TBD Outcome H/F Biennial antimicrobials for surgical prophylaxis survey with >80% compliance with guidelines 16. Percentage of inspected medicines that SO.2 TBD TBD TBD TBD TBD TBD Outcome H/F Biennial met required WHO standards survey 17. Rate of readmissions due to surgical site SO.2, S04 TBD TBD TBD TBD TBD TBD Outcome H/Facility Annual infection Records 18. Total number of reported adverse drug SO.2, S04 TBD TBD TBD TBD TBD TBD Outcome H/Facility Quarterly reactions Records 19. Percentage of retail pharmacies SO.2 TBD TBD TBD TBD TBD TBD Outcome ISS- Quarterly inspected that comply with standards Reports 20. Percentage of laboratory investigations SO3, S04 TBD TBD TBD TBD TBD TBD Outcome H/Facility Quarterly conducted prior to prescription of AMs Records (Culture Sensitivity Tests) 21. Percentage of new TB cases with multi- SO.3, SO.4 TBD TBD TBD TBD TBD TBD Outcome Survey Biennial drug resistant TB 22. Percentage of facilities with active SO.4 TBD TBD TBD TBD TBD TBD Output ISS- Quarterly committees ( therapeutic , AMS) Reports 23. Percentage of AMR focal sites with AMS SO.4 TBD TBD TBD TBD TBD TBD Output ISS- Quarterly guidelines (H/Fs, Agric resource Reports centres, sub-centre, water blenkers) 24. Percentage of AMR focal sites with AMR SO.4 TBD TBD TBD TBD TBD TBD Output ISS- Quarterly guidelines (DHMT, rural water supply, Reports department of environment) 25. Percentage of facilities reporting stock SO.4 TBD TBD TBD TBD TBD TBD Output H/Facility Quarterly outs (non-availability) of specified Records antibiotics 26. Availability of Legislation on Medicine SO.4 N/A 1 N/A N/A N/A N/A Output MOH Quarterly and Medical device control bill reports 27. Percentage of health facilities with at SO.4 TBD TBD TBD TBD TBD TBD Output MOH Quarterly least one personnel trained on AMR reports 28. Percentage of health facilities trained on SO.4 TBD TBD TBD TBD TBD TBD Output MOH Quarterly STGs reports 36 | P a g e 29. Total number of antimicrobial SO.3, SO.4 TBD TBD TBD TBD TBD TBD Output MOH Quarterly susceptibility tests in plant and animal reports health 30. Availability of active multi sectoral AMR SO.2 TBD TBD TBD TBD TBD TBD Output MOH Quarterly Surveillance system reports 31. Availability of updated MOH research SO.2, SO.5 TBD TBD TBD TBD TBD TBD Output MOH Quarterly agenda that include AMR as priority reports topic 32. Percentage of facilities with AMR SO.2,SO.5 TBD TBD TBD TBD TBD TBD Output ISS- Quarterly diagnostics tools Reports 33. Percentage of laboratories with SO.2,SO.5 TBD TBD TBD TBD TBD TBD Output ISS- Quarterly functional diagnostic equipment for Reports detection of drug resistance 34. Total number of Operational research SO.2,SO.5 TBD TBD TBD TBD TBD TBD Output MOH Quarterly studies on AMR reports 35. Availability of Curricula that include SO.1 N/A TBD TBD TBD TBD TBD Output MOH Quarterly AMR and related topics reports 36. Availability of National communication SO.1 N/A TBD TBD TBD TBD TBD Output MOH Quarterly strategy for AMR reports 37. Proportion of GOL budget allocated for SO.2,SO.5 TBD TBD TBD TBD TBD TBD Output MOH Annually research reports 38. Proportion budget allocated for AMR SO.5 0% TBD TBD TBD TBD TBD Output MOH Annually interventions (GOL, Donors) reports 39. Total number of planned AMR SO.1 TBD TBD TBD TBD TBD TBD Output MOH Quarterly sensitization meetings with community reports leaders6 6 Parliamentarians, local government, chiefs at national, district and chiefdom levels non-governmental organizations, Civil Society Organizations 37 | P a g e Annexure

Annex 1: The Operational Planning Matrix-EDUCATION AND AWARENESS KEY ACTIVITY 1.1.1.: Undertake baseline study (KAP) on AMR awareness, in the general populace and professionals in relevant sectors (animal, human health, crops, and environment.) SUB ACTIVITIES EXPECTED OUTPUT RESPONSIB COST (LSL) YR1 TIMELINES IN YEARS LE Q1 Q2 Q3 Q4 YR2 YR3 YR4 YR5 1.1.1.1 Stakeholders Sensitization Meeting Sensitization Meeting TWG-E&A 22,000 X (Ministry Directors, CHE, NGOs, Das, DSCs) Held 1.1.1.2 Develop Research Protocol for Research Protocol TWG-E&A 59,600 X submission to the ethics committee developed 1.1.1.3 Develop Questionnaires for different Questionnaires TWG-E&A 44,700 X Target audiences (Consumers, Prescribers & Developed Dispensers, Media, Local Authorities, etc.) 1.1.1.4 Procurement of Tablets for data Tablets procured TWG-E&A 150,000 X collection (Android) 1.1.1.5 Conduct Training for data collectors Trained Enumerators TWG-E&A 352,500 X (Enumerators)for KAP and Rapid Assessment for both KAP and Rapid Assessment 1.1.1.6 Pretesting of Questionnaires Questionnaires Tested TWG-E&A 185,500 X 1.1.1.7 Data Collection Data collected TWG-E&A 935,000 X 1.1.1.8 Data presentation and analysis Data analyzed TWG-E&A 740,100 X 1.1.1.9 Results validation Validation done TWG-E&A 123,300 X 1.1.2.0 Printing Printed report TWG-E&A 10,000 X 1.1.2.1 Report launch and Dissemination Report launched and TWG-E&A 55,000 X X disseminated 38 | P a g e KEY ACTIVITY 1.1.2.: Develop and disseminate national communication strategy for AMR 1.1.2.1 Introductory Meeting for TWG and other Introductory Meeting TWG-E&A 10,000 X stakeholders Held 1.1.2.2 Develop Communication Strategy AMR Communication TWG-E&A 139,200 X Strategy Developed (Zero Draft) 1.1.2.3 Validation of AMR Communication Validated AMR TWG-E&A 105,250 X Strategy Communication Strategy 1.1.2.4 Printing of AMR Communication Strategy Printed AMR TWG-E&A 100,000 X communication strategy 1.1.2.5 Launch and dissemination of AMR Communication TWG-E&A 37,000 X X Communications Strategy Strategy launched and developed KEY ACTIVITY 1.2.1: Develop and disseminate IEC materials for diverse stakeholders in human, animal and environmental health sectors 1.2.1.1 Review, localize and Adopt Existing IEC IEC materials adopted TWG-E&A 21,000 X Materials and develop new material (WHO, FAO, and developed OIE) 1.2.1.2 Pre-testing of IEC materials by type IEC material tested TWG-E&A 104,250 X 1.2.1.3 Validation and adoption of IEC Materials IEC materials TWG-E&A 104,250 X validated 1.2.1.4 Print IEC materials IEC Materials Printed TWG-E&A 704,637 X 1.2.1.5 Distribution of IEC Materials IEC Material TWG-E&A 704,637 X X Distributed KEY ACTIVITY 1.2.2.: Conduct advocacy and sensitization meetings for parliamentarians, local government, chiefs at national, district and chiefdom levels non-governmental organizations, Civil Society Organizations 1.2.2.1.1Hold Sensitization Meetings for various Sensitization Meeting TWG-E&A 215,123 key informants held KEY ACTIVITY 1.2.3.: Conduct awareness campaigns amongst stakeholders, including during WAAW. 39 | P a g e 1.2.3.1 Conduct Awareness Campaigns for Awareness Campaigns TWG-E&A X X Stakeholders in the human, animal, plant health conducted and environment KEY ACTIVITY 1.2.4.: Capacitate media on reporting on AMR and dissemination of key messages 1.2.4.1 Hold Sensitization Meetings with Media Sensitization Meeting TWG-E&A 8,200 X owners and editors held 1.2.4.2 Conduct Training for Journalist and Journalists Trained TWG-E&A 236,300 X Reporters on AMR 1.2.4.3 Run Annual competition on AMR AMR Reportage TWG-E&A X Reportage and award best stories Awards Held 1.2.4.4 Formulate Terms of Reference for the ToR developed TWG-E&A 3,100 X Awards Panel 1.2.4.5 Appoint a panel of judges for Media Panel of Judges TWG-E&A 338,226 X Awards appointed 1.2.4.6 Hold Awards for Journalists Reporting on Media Awards Held TWG-E&A 177,005 X AMR KEY ACTIVITY 1.2.5: Commemorate Antimicrobial Awareness Week 1.2.5.1 Commemorate Antimicrobial Awareness AMR week TWG-E&A 340,481 X X X X X Week commemorated 1.2.5.2 Hold national symposium on AMR National symposium TWG-E&A 2,572,241 X X X X X on AMR held KEY ACTIVITY 1.3.1: Advocate for the integration of AMR and related topics in formal and informal education at all levels 1.3.1.1 Conduct advocacy meetings with Meeting held TWG-E&A 142,274 X X X X X stakeholders for mainstreaming AMR and related issues in curricula 1.3.1.2 Conduct a desk review of existing Baseline survey data TWG-E&A 15,000 X curricular on curricula 1.3.1.3 Develop AMR manuals and SOPs for Manuals/ SOPs TWG-E&A 42,000 X inclusion in Curriculum developed 1.3.1.4 Develop, Validate and Print teaching Printed training TWG-E&A 21,000 X materials packages 1.3.1.5 Distribute training materials Training Packages TWG-E&A 0 distributed 1.3.1.6 Mainstream the curricula, manuals, and AMR Curricular taught TWG-E&A 0 SOPs in schools 40 | P a g e KEY ACTIVITY 1.3.2.: Engage professional registration bodies for inclusion of AMR CPE as pre-requisite for retention 1.3.2.1 Conduct advocacy meetings with Advocacy Meetings TWG-E&A 27,000 X stakeholders for inclusion of AMR CPE as pre- held requisite for retention 1.3.2.2 Develop AMR CPE manuals AMR CPE Manuals TWG-E&A 138,000 X Developed (Draft 1.3.2.3 Validate AMR CPE Manual AMR CPE Manuals TWG-E&A 85,600 X validated 1.3.2.4 Administer AMR CPE AMR CPE TWG-E&A 0 Administered KEY ACTIVITY 1.3.3.: Conduct in-service training programs on AMR for professionals in the human health, veterinary, environmental and agricultural 1.3.3.1 Develop AMR In-service training AMR In-service TWG-E&A 171,250 X manuals training manuals developed 1.3.3.2 Administer AMR In-service training Training conducted TWG-E&A 85,600 X 1.3.3.3 Develop AMR Pre-Registration AMR Pre-Registration TWG-E&A 4,600 X Examination tool Examination tool conducted 1.3.3.4 Validate AMR Pre-Registration AMR Pre-Registration TWG-E&A 6,400 X Examination tool Examination tool developed 41 | P a g e

Annex 2: The Operational Planning Matrix-SURVEILLANCE AND RESEARCH KEY ACTIVITY 2.1.1.: Strengthen laboratories capacity to detect, and analyze AMR at all sectors SUB ACTIVITIES EXPECTED OUTPUT RESPON COST (LSL) YR1 TIMELINES IN YEARS SIBLE Q1 Q2 Q3 Q4 YR2 YR3 YR4 YR5 2.1.1.1 Procure diagnostic equipment and Diagnostic equipment and TWG- 56,370,929 X X X X X supplies for antimicrobial determination supplies procured S&R 2.1.1.2 Capacitate laboratory professionals on Laboratory Professionals TWG- 1,614,271 X X X detection and analysis of AMR trained S&R KEY ACTIVITY 2.1.2.: Strengthen quality management systems to provide consistent diagnostic standards by all laboratories 2.1.2.1Develop collaboration mechanisms Collaboration TWG- 627,169 X X X between the national and external laboratories mechanisms developed S&R on AMR diagnostics 2.2.1.2Develop quality management system Quality management TWG- 276,000 X guidelines in all laboratories guidelines developed S&R 2.2.1.3 Advocate for use of approved (WHO, Advocacy done TWG- 12,800 X OIE-FAO) SOPs for optimal detection of AMR S&R KEY ACTIVITY 2.3.1.: Strengthen quality management systems to provide consistent diagnostic standards by all laboratories 2.3.1.1 Develop collaboration mechanisms Linkages developed TWG- 627,169 X X X between the national and external laboratories S&R on AMR diagnostics 2.3.1.2 Develop quality management system Guidelines developed/ TWG- 276,000 X guidelines in all laboratories guidelines adopted S&R 2.3.1.3 Advocate for use of approved (WHO, SOPs administered TWG- 12,800 X OIE-FAO) SOPs for optimal detection of AMR S&R KEY ACTIVITY 2.4.1 Build One Health antimicrobial resistance surveillance system that integrates data sharing from human, water, environment and agricultural sectors 2.4.1.1 Establish multi-sectoral AMR Multi-sectoral AMR TWG- 50,000 X surveillance reporting and information sharing surveillance reporting S&R and information sharing system established 42 | P a g e 2.4.1.2 Advocate for incorporation of AMR AMR issues incorporated TWG- 64,000 X issues into DHIS2 or Incorporate AMR into in DHIS2 S&R DHIS2 2.4.1.3 Develop reporting frameworks for AMR Reporting frameworks TWG- 128,000 X developed S&R Mechanisms developed 2.4.1.4 Develop national guidelines for National guidelines TWG- 240,000 X surveillance systems developed S&R 2.4.1.5 Advocate for participation in Global Mechanisms developed TWG- 140,000 X Antimicrobial Resistance GLASS) S&R 2.4.1.6 Develop and adopt standards for Standards adopted and TWG- X antibiotic residues in waste generated from developed S&R 132,000 farms, factories, human health care KEY ACTIVITY 2.5.1 Promote Multi-sectoral collaboration for research implementation in various aspects of Antimicrobial use and resistance in humans, animals and plants 2.5.1.1 Develop AMR research agenda for AMR agenda incorporated TWG- 40,000 X incorporation into research agendas of all into sectoral Research S&R relevant sectors (humans, water, environment agendas and agriculture) 2.5.1.2 Advocate for academic institutional TWG- 182,000 X X research on AMR S&R 2.5.1.3 Capacitate practitioners (professionals) Capacity building TWG- 17,300,464 X X X X on basic and operational research in conducted S&R antimicrobial use and resistance 2.5.1.4 Establish platform (conference or Information sharing TWG- 968,000 X X symposium) for regular information sharing on platform established S&R antimicrobial resistance research. 43 | P a g e

Annex 3: The Operational Planning Matrix- INFECTION, PREVENTION AND CONTROL KEY ACTIVITY 3.1.1.: Conduct situation analysis of sanitary and phytosanitary measure, IPC and biosecurity. SUB ACTIVITIES EXPECTED OUTPUT RESPONSIBL COST (LSL) YR1 TIMELINES IN YEARS E Q1 Q2 Q3 Q4 YR2 YR3 YR4 YR5 3.1.1.1 Conduct workshop with stakeholders on Workshop TWG- S&R 1,665,300 X X X sanitary and phytosanitary measure, IPC and conducted biosecurity. 3.1.1.2 Conduct validation meeting Validation meeting TWG- S&R 685,681 X X X held 3.1.1.3 conduct meeting for situational report Meeting held TWG- S&R 910,855 X X X writing 3.1.1.4 Disseminate situational analysis report Report disseminated TWG- S&R 460,506 X X X KEY ACTIVITY 3.1.2.: Develop guidelines and protocols for biosecurity measures for pathogen risk reduction 3.1.2.1 Conduct stakeholders workshop on Guidelines and TWG- S&R 685,681 x x x development of guidelines and protocols protocols developed 3.1.2.2 Conduct validation meeting on Validation meeting TWG- S&R 415,472 x x x biosecurity measures for pathogen risk conducted reduction 3.1.2.3 Dissemination of guidelines and Guidelines and TWG- S&R 136,000 x protocols protocols disseminated KEY ACTIVITY 3.1.3 Capacitate Famers on biosecurity measures for pathogen risk reduction 3.1.3.1 Train farmers on biosecurity measures Training conducted TWG- S&R 2,851,812 x x x x KEY ACTIVITY 3.2.1 Develop integrated Protocols, guidelines and reporting framework on animal trans-boundary animal/plant disease occurrence transmission 3.2.1.1 Conduct workshop with stakeholder to Number of TWG- S&R x develop protocols, guideline and reporting tools workshops 249,895 conducted 3.2.1.2 Conduct validation meeting on protocols, Validation meeting TWG- S&R x guideline and reporting framework held 151,209 3.2.1.3 Disseminate Protocols, guideline and Protocols and TWG- S&R x reporting on animal trans-boundary guidelines 144,160 animal/plant disease occurrence transmission disseminated KEY ACTIVITY 3.2.2: Advocate for recruitment of border control officers at all designated ports of entries 44 | P a g e 3.2.2.1Develop TORs for Border control officers TORs developed TWG- S&R 102,750 x 3.2.2.2 Advocate for deployment Border control Border control TWG- S&R 21,000 x officers officers deployed KEY ACTIVITY 3.2.3: Strengthen border patrols MOH, MAFS 3.2.3.1 Conduct meetings with stakeholders Number of meetings TWG- S&R 278,758 x x x x x inclusive of security agencies held KEY ACTIVITY 3.3.1: Review vaccination programmes in animal and human health 3.3.1.1 Conduct a review workshop Review workshop TWG- S&R 1,141,511 x x x x x conducted KEY ACTIVITY 3.4.1: Develop legal framework (in line with One-Health Approach) 3.4.1.1 Review existing laws TWG- S&R 458,152 x x KEY ACTIVITY 3.4.2.: Promote Open Defecation Free (ODF) communities and free water accessing communities 3.4.2.1 Engage contractor to build toilets and Contractor engaged TWG- S&R 90,028,080 x install water lines in rural communities identified KEY ACTIVITY 3.4.3: Conduct follow-ups for IPC initiatives and report-write-ups 3.4.3.1 Undertake field and sites visits Field and site visits TWG- S&R 933,503 x x x x x conducted 3.4.3.2 Write reports on field and sites visit Report produced TWG- S&R 277,345 x x x x x 45 | P a g e

Annex 4: The Operational Planning Matrix-ANTIMICROBIAL USE AND REGUALTION KEY ACTIVITY 4.1.1.: Review the EML &STGs based on antimicrobial resistance data SUB ACTIVITIES EXPECTED OUTPUT RESPONSIBL COST (LSL) YR1 TIMELINES IN YEARS E Q1 Q2 Q3 Q4 YR2 YR3 YR4 YR5 4.1.1.1 Hold Review meetings on EMLs and STGs Number of meetings MOH 2,590,082 X held 4.1.1.2 Hold a 2 day stakeholders validation Number of meetings MOH 415,391 X X meetings held 4.1.1.3 Hold dissemination meeting Number of meetings MOH 535,303 X X held 4.1.1.4 Monitor use of STGs and EML Number of studies MOH X X conducted KEY ACTIVITY 4.1.2: Formulate regulations and guidelines for use of veterinary medicine 4.1.2.1 Hold meeting on development of Guidelines and MAFS X Guidelines and Regulation regulation 129,900 developed 4.1.2.2 Hold a 2 day stakeholders validation Validation meeting MAFS X 110,000 meetings held 4.1.2.3 Hold Dissemination Meeting Dissemination MAFS X 81,900 meeting held KEY ACTIVITY 4.1.3.: Review existing policy drafts (animal health) to include AMR issues 4.1.3.1 Hold review meeting on existing policy Review meeting MAFS, MOH 99,500 X drafts held 4.1.3.2 Hold a 2 day stakeholders validation Validation meeting MAF, MOH 110,000 X meetings held 4.1.3.3 Hold Dissemination Meeting Dissemination MAFS, MOH 1,852,969 X X X X X meeting held KEY ACTIVITY 4.14: Resuscitate Therapeutics Committees at National and health facility levels with clear TORs MOH 4.1.4.1 Hold meeting with therapeutics Terms of Reference MOH 97,500 X committee to draft terms of reference for developed National, Health facility level committees 4.1.4.2 Hold orientation meeting with DHMT Orientation meeting MOH 93,600 X and Hospital Management on the terms of held references 46 | P a g e KEY ACTIVITY 4.1.5: Develop and disseminate AMR stewardship guidelines 4.1.5.1 Hold meeting on Development of AMR AMR guidelines 262,000 X X guidelines developed 4.1.5.2 Hold a 2 day Validation meeting Validation meeting 39,000 X X held 4.1.5.3 Train and dissemination AMR guidelines AMR guidelines 304,800 X X X X X disseminated KEY ACTIVITY 4.1.6: Establish the one health regulatory Authorities 4.1.6.1 Twining with SADC countries with Availability of report MOH, MAFS, 0 X stringent Regulatory Authority ,MTEC 4.1.6.2 Hold Stakeholders meeting on Stakeholders MOH, 0 X establishment of one health regulatory meeting held MAFS,METC, Authority M ODP KEY ACTIVITY 4.1.7: Establish pharmaceutical quality control laboratory 4.1.7.1 Procure Pharmaceutical Laboratory Minilabs procured MOH 5,000,000 X quality control Minilabs 4.1.7.2 Construction and equip the Quality control MOH 21,937,600 X Pharmaceutical Quality Control Laboratory laboratory constructed KEY ACTIVITY 4.1.8.: Establish the one health regulatory Authorities 4.1.8.1 Twining with SADC countries with Availability of report MOH, MAFS, 0 X stringent Regulatory Authority ,MTEC 4.1.8.2 Hold Stakeholders meeting on Stakeholders MOH, 0 X establishment of one health regulatory meeting held MAFS,METC, Authority M ODP KEY ACTIVITY 4.1.9.: Develop and Disseminate Pharmacovigilance Guidelines 4.1.9.1 Hold a meeting to review the Review meeting MOH 131,000 X Pharmacovigilance guidelines held 4.1.9.2 Hold validation meeting with Validation meeting MOH 115,600 X stakeholders on Pharmacovigilance guidelines held and reporting tools 4.1.9.3 Train health facility personnel on Training conducted MOH 225,740 X Pharmacovigilance guidelines and reporting tools (dissemination) KEY ACTIVITY 4.1.10.: Strengthen AMR Coordination at district level 4.1.10.1 Hire AMR district focal persons AMR focal persons MOH 12,176,122 X X X X X X X X hired 4.1.10.2 Procure a vehicle Vehicle procured MOH 4,200,000 X 47 | P a g e 4.1.10.3 Conduct Antimicrobials Use Survey AMU survey MOH 1,538,093 X X conducted KEY ACTIVITY 4.2.1.: Capacitate healthcare personnel on use of EML and STGs (antimicrobials). 4.2.1.1 Hold workshop on use of EML and STGs Training conducted MOH 1,827,220 X X X X (Training of updated EML and STGs) 4.2.1.2 Develop tool to monitor AMR Use in Tools developed MOH 99,500 X Lesotho 4.2.1.3 Conduct AMR Review meetings for the Review meeting MOH 620,080 X X X X X Multi -sectorial Coordinating Committee and 5 conduct TWGs KEY ACTIVITY 4.3.1.: Revive Veterinary Drug committee 4.3.1.1 Hold meeting with Veterinary Drug Number of meetings 5,800 X X X X X X committee members held KEY ACTIVITY 4.3.2.: Resuscitate Therapeutics Committees at National and health facility levels with clear TORs MOH 4.3.2.1 Hold meeting with therapeutics Terms of Reference MOH 97,500 X committee to draft terms of reference for developed National, Health facility level committees 4.3.2.2 Hold orientation meeting with DHMT Orientation meeting MOH 93,600 X and Hospital Management on the terms of held references KEY ACTIVITY 4.4.1.: Capacitate Health Personnel on Rational prescribing and dispensing of antimicrobials 4..4.1.1 Hold workshop on rational prescribing Workshop held X 451,000 and dispensing 4.4.1.2 Conduct Supportive supervision and Number of X X X X X 1,342,492 mentorship biannually workshops held KEY ACTIVITY 4.5.1.: Establish Pharmacovigilance committees (PVCs) at District level. 4.5.1.1 Hold meeting with National Terms of Reference 39,800 X Pharmacovigilance Committee to draft terms of developed reference for PVCs at district level 4.5.1.2 Hold orientation meeting with DHMT Orientation meeting 93,600 X and Hospital Management on the terms of held references 4.5.1.3 Supervise and mentor human and animal Number Supportive MOH and 702,000 X X X X X health professionals on pharmacovigilance supervisory visits MAFS reporting conducted 48 | P a g e

Annex 5: The Operational Planning Matrix-INVESTMENT, RESEARCH and DEVELOPMENT KEY ACTIVITY 5.1.1.: Advocate for Multi-sectoral collaboration for research on alternative medicines in various aspects of Antimicrobial use and resistance in humans, animals and plants SUB ACTIVITIES EXPECTED OUTPUT RESPONSIBLE COST YR1 TIMELINES IN YEARS (LSL) Q1 Q2 Q3 Q4 YR2 YR3 YR4 YR5 5.1.1.1. Liaise with other external academic Research activities TWG-RI&D 13,400 X X X X institutions to undertake some of the research undertaken activities KEY ACTIVITY 5.1.2: Mobilize resources required for research on alternative medicines and for the implementation of AMR NAP 5.1.2.1Solicit assistance from funding Availability of funding TWG-RI&D 703,513 X X X X X X X X organizations and development partners KEY ACTIVITY 5.1.3.: Undertake expenditure tracking analysis in human and animal acquired infections. 5.1.3.1Develop protocol and assessment tools Availability of tools TWG-RI&D 686,000 X 5.1.3.2Train stakeholders (data collectors) on Trained data collectors TWG-RI&D 200,000 X the use of data collection tools 5.1.3.3Data collection Availability of data TWG-RI&D 168,000 X 5.1.3.4Data analysis and report writing Availability of the TWG-RI&D 70,000 X report KEY ACTIVITY 5.1.4.: Conduct Out-of-Pocket Expenditure on AMU in relation to animal, plant, environment and human health 5.1.4.1Develop protocol and assessment tools Availability of tools TWG-RI&D 343,000 X 5.1.4.2Train stakeholders (data collectors) on Trained data collectors TWG-RI&D 100,000 X the use of data collection tools 5.1.4.3Data collection Availability of data TWG-RI&D 168,000 X 5.1.4.4Data analysis and report writing Availability of the TWG-RI&D 70,000 X report 49 | P a g e

Annex 6: LIST OF COUNTRY PARTICIPANTS Ministry/Organization Participant’s Name AMR Education and Awareness Technical Working Group 1. Ministry of Health-Public Relations Office Mateboho Mosebekoa 2. Ministry of Health - Health Education Department Nkareng Mosala 3. Ministry of Health -Health Education Department Ntsebo Moremoholo 4. Ministry of Health -Pharmaceutical Department Lerato Kholokholo 5. Ministry of Agriculture and Food Security -Agriculture Neo Mokoara Information Services 6. National University of Lesotho-Agriculture Department Professor Philip Makama 7. Ministry of Water-Water Commission Matebele Setefane 8. Ministry of Agriculture and Food Security- Department of Crops Lesetla Makoae 9. Media Institute of Lesotho Boitelo Rabele 10. World Health Organization (WHO) Thato Mxakasa AMR Surveillance and Research Technical Working Group 11. Ministry of Health -Disease Control Directorate –HIV Keletso Sealiete Surveillance 12. Ministry of Health–Research Unit Dr. Kyaw Thin 13. Ministry of Health – Health Planning and Statistics Unit Masebeo Koto 14. Ministry of Health – National Reference Laboratory (AMR Focal Mahloli Ratsiu Point) 15. Ministry of Health – Manager National Reference Laboratory Mathabo Mareka 16. Ministry of Agriculture and Food Security – Laboratory Makalo Mabusetsa 17. Ministry of Water-Department of Water Affairs-Laboratory Ntiea Letsapo 18. Ministry of Agriculture and Food Security –Epidemiology Dr. Marose Molomo 19. Ministry of Health-Pharmacovigilance Marelebohile Mabuzela 20. World Health Organization (WHO) Mohlakola Hlabana 21. National University of Lesotho-Pharmacy Department Molungoa Sello 22. National Health Training College Rapelang Leluma 23. Lesotho Agricultural College Thabo Matsepe Hygiene, Infection Prevention and Control & Biosecurity Technical Working Group 24. Ministry of Health–Pharmacy Hospital Services Motaba Sebotsa 25. Ministry of Tourism, Environment and Culture- Pollution Kobeli Ts’asanyane Control 26. Ministry of Health – Director - Nursing Services Directorate Mpoeetsi Makau 27. Ministry of Health -Nursing directorate ‘Mathaabe Raseleso 28. Ministry of Health - Environmental Health Department –WASH Mosepeli Ratikane 29. Ministry of Health -Environmental Health Department- Food Motsamai Mahahabisa Safety 50 | P a g e 30. Ministry of Tourism, Environment and Culture- Pollution Samuel Zwakala Control 31. Ministry of Health -International Health Regulations Ntsoaki Mokete 32. Ministry of Health -International Health Regulations Lisemelo Zachia 33. Ministry of Agriculture and Food Security – Veterinary Public Dr. Tabitha Seeiso Health 34. Ministry of Health-Quality Assurance Nthekeleng Mots’oane Antimicrobials Use, Regulation and Harmonisation Technical Working Group 35. Ministry of Health -Medicine Regulation and Policy Germina Mphoso 36. Ministry of Health -Medicine outlets Inspections and Licensing Neo Khoarai 37. Ministry of Health -Medicines Importation and Exportation Bokang Lefaso 38. Ministry of Agriculture and Food Security -Department of Dr. Mpaliseng Matlali Livestock (AMR Focal point) 39. Lesotho Medical and Veterinary Council Dr. Gerard Mahloane 40. Ministry of Health- Clinical Service/ Epidemiology Dr. Tsepang Lekhela 41. Ministry of Health-Family Planning Program Mangose Sithole 42. Ministry of Health-PMTCT Program Seipati Motsei 43. Ministry of Health- Mohale’s Hoek District Health Manager Dr. Mahlape Tiiti 44. Ministry of Health-Dental department Dr. Joelle Mianda Kalambay 45. Ministry of Health – Director Clinical Services Dr. Lucy Mapota- Masoabi 46. Lesotho Medical Dental and Pharmacy Council Dr. Moji 47. Christian Health Association of Lesotho Matseliso Noe Investment, Research and Development Technical Working Group 48. Ministry of Health – National AMR Coordinator (AMR Focal Nteboheng Tjobe Point) 49. Ministry of Development Planning Mantheka Lekatsa 50. Ministry of Health – Health Planning and Statistics Unit – Matlotlo Mohasi Monitoring & Evaluation 51. Ministry of Finance Mabusisiwe Mosito 52. Ministry of Health – Health Planning and Statistics Unit - Makoae Mathaha Research 53. Ministry of Health-Human Resource Manager Rethabile Topo 54. Ministry of Health – Health Planning and Statistics Unit – Policy Kelumetse Moletsane and Strategic planning 55. Ministry of Agriculture and Food Security -Planning Unit Mothibeli Mojaje 56. Ministry of Health -International Health Regulations Khotso Mahomo 57. Ministry of Development Planning Nkeletseng Molahlehi 58. Food and Agriculture Organization (FAO) Mohlophehi Maope 59. Clinton Health Access Initiative (CHAI) Tholoana Masupha 60. Clinton Health Access Initiative (CHAI) Thatohatsi Sefuthi 51 | P a g e References African Union. (2018). Africa CDC Framework for Antimicrobial Resistance, 2018-2023. Retrieved from http://www.africacdc.org/resources/strategic-framework Cars D and Jasovsky O. 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Preventing and responding to HIV drug-resistance in the African Region: regional action plan 2019-2023. Brazzaville: WHO Regional Office for Africa. Retrieved from https://www.afro.who.int/sites/default/files/2019-04/HIV_DrugRes_FINAL_01_04_19_online.pdf Williams PCM, Isaacs D, Berkley JA. (2018). Antimicrobial resistance among children in sub-Saharan Africa. Lancet Infectious Diseases, 18(2). doi: 10.1016/S1473-3099(17)30467-X 53 | P a g e