Pakistan National Action Plan on Antimicrobial Resistance 2.0

i Implementing Agencies I. Ministry of National Health Services Regulation and Coordination II. Ministry of National Food Security and Research III. Ministry of Climate Change IV. Pakistan Council of Research in Water Resources (PCRWR) V. Environmental Protection Agency / National Agricultural Research Centre /Aquaculture ii Abbreviations AHC – Animal Health Center AMC – Antimicrobial Consumption AMR – Antimicrobial Resistance AWaRe – Access, Watch, Reserve (antibiotic classification) CRE – Carbapenem-Resistant Enterobacteriaceae CSSD – Central Sterile Services Department DAI – Development Alternatives, Inc. DRAP – Drug Regulatory Authority of Pakistan DTLs – Drug Testing Laboratories EML – Essential Medicines List EQA – External Quality Assurance FAO – Food and Agriculture Organization GAP – Global Action Plan (on AMR) GLASS – Global Antimicrobial Resistance and Use Surveillance System HCAI – Healthcare-Associated Infections HEC – Higher Education Commission HRI – Health Research Institute IHME – Institute for Health Metrics and Evaluation IPC – Infection Prevention and Control JEE – Joint External Evaluation LMICs – Low- and Middle-Income Countries M&E – Monitoring and Evaluation MDR – Multidrug-Resistant MoNHSRC – Ministry of National Health Services, Regulations, and Coordination MRSA – Methicillin-Resistant Staphylococcus aureus iii NAP – National Action Plan NDM-1 – New Delhi Metallo-beta-lactamase-1 NEQAS – National External Quality Assurance Scheme NIH – National Institute of Health NRL – National Reference Laboratory PASS – Pakistan AMR Surveillance System PDR – Pan-Drug Resistant PHRC – Pakistan Health Research Council PPS – Point Prevalence Survey SDGs – Sustainable Development Goals SWOT – Strengths, Weaknesses, Opportunities, Threats TrACSS – Tripartite AMR Country Self-Assessment Survey TWG – Technical Working Group UNEP – United Nations Environment Programme UNGA – United Nations General Assembly VPDs – Vaccine-Preventable Diseases VRE – Vancomycin-Resistant Enterococci WASH – Water, Sanitation, and Hygiene WHO – World Health Organization WOAH – World Organisation for Animal Health (formerly OIE) XDR – Extensively Drug-Resistant iv Foreword Antimicrobial resistance (AMR) poses one of the most urgent and complex public health challenges of our time, threatening to undermine decades of medical progress and jeopardizing global health security. In Pakistan, the growing burden of drug-resistant infections demands immediate, coordinated, and multisectoral action to safeguard the health of our people, animals, and environment. This National Action Plan on Antimicrobial Resistance (NAP-AMR 2024– 2028) represents Pakistan’s steadfast commitment to combating AMR through a One Health approach, aligning with global frameworks while addressing our unique national priorities. The Government of Pakistan recognizes that AMR is not just a health issue but a socioeconomic threat that requires collaboration across human health, animal health, agriculture, and environmental sectors. Building upon the achievements of NAP-AMR 2017–2022, this updated plan integrates lessons learned, emerging evidence, and innovative strategies to strengthen governance, surveillance, infection prevention, and antimicrobial stewardship. Our vision is clear: to preserve the effectiveness of antimicrobials for future generations while ensuring equitable access to safe and effective treatments for all. We extend our gratitude to all stakeholders, federal and provincial governments, international partners, healthcare professionals, researchers, and civil society, for their invaluable contributions in shaping this plan. The Ministry of National Health Services, Regulations & Coordination (MoNHSRC) will ensure full support for its implementation, working closely with the National Institute of Health (NIH), Drug Regulatory Authority of Pakistan (DRAP), and other key institutions including provincial health departments. However, success depends on collective action, national, provincial, academicians, public health workers, animal health workers, policymakers, practitioners, and the public must all play their part in reducing unnecessary antimicrobial use, improving hygiene practices, and fostering responsible behaviours. As we embark on this important journey, let us reaffirm our commitment to a resilient and sustainable health system. By prioritizing AMR prevention and control, we not only protect our citizens but also contribute to global efforts in combating this silent pandemic. Together, we can turn the tide against antimicrobial resistance and secure a healthier future for Pakistan. Director General Health Ministry of National Health Services, Regulations & Coordination Government of Pakistan v Acknowledgement The Ministry of National Health Services, Regulations and Coordination (MoNHSR&C) and the National Institute of Health (NIH) acknowledge with deep appreciation the dedicated engagement and valuable contributions of all stakeholders who actively participated in the NAP 2.0 development process from May 2024 to February 2025. We extend our gratitude to the Ministry of National Food Security and Research, Ministry of Climate Change, Pakistan Council of Research in Water Resources (PCRWR), National Agricultural Research Centre (NARC) including the National Veterinary Laboratory (NVL) and Aquaculture Division, Environment Protection Agency (EPA), Animal Husbandry Commission, Federal and Provincial Food Safety Authorities, and academic councils for their technical expertise and commitment. We also recognize the vital support and collaboration of our development partners— the World Health Organization (WHO), Fleming Fund Country Grant, Food and Agriculture Organization of the United Nations (FAO), and Integral Global, whose technical and financial assistance was instrumental in shaping a robust, multisectoral, and One Health–aligned National Action Plan. Their sustained involvement and coordinated efforts were essential in ensuring that NAP 2.0 reflects both national priorities and global commitments in the fight against antimicrobial resistance. Table of Content Executive Summary 1 Background 2 1. Introduction 2 Global Trends 2 The burden and extent of AMR in Pakistan 2 One Health approach for AMR containment 3 People centred approach to addressing antimicrobial resistance in human health 4 Addressing gender inequalities 5 2. Relatives’ assessment and Situation Analysis 6 Building on Evidence for NAP 2.0 6 Joint External Evaluation 2023: Key Progress and Gaps 6 TrACSS Reporting: Trends in Multisectoral Engagement 7 NAP 1.0 Progress Review: Achievements and Missed Opportunities 8 3. SWOT Analysis: Cross-Sectoral Insights for Strategic Planning 11 Aligning National Priorities with Global AMR Commitments 12 4. Methods and Process of NAP 2.0 development 13 NAP AMR 2.0 16 6. National Operation Plan 18 NAP AMR 2.0 Costing Estimates 33 Key Interventions and Resource Allocation 36 Implementation Framework for NAP 2.0 38 7. Monitoring, Evaluation, and Learning (MEL) System 39 8. Implementation Roadmap and Way Forward 39 Human Health 42 Animal Health 44 Environment Sector 45 1 EXECUTIVE SUMMARY Antimicrobial resistance (AMR) represents a growing and urgent public health threat in the country. In 2019, an estimated 59,200 deaths were directly attributable to AMR and 221,300 were associated with it (IHME). The age-standardized AMR related mortality rate placed Pakistan 176th out of 204 countries globally, and 5th highest among the five countries of South Asia. Over the past decade, Pakistan has demonstrated sustained commitment to addressing AMR. Milestones include the formulation of the AMR Strategic Framework, the first National Action Plan on AMR (2017–2022), a PC1 worth 361.93 million for the implementation of the NAP and two Joint External Evaluations (JEE) conducted in 2016 and 2023. These efforts reflect Pakistan’s alignment with the Global Action Plan on AMR and its determination to uphold international health security commitments. The National Action Plan for AMR 2024–2028 (NAP 2.0) builds upon these foundations and offers a comprehensive, multisectoral roadmap for the next five years. Developed through a One Health approach, the plan brings together human health, animal health, agriculture, and environmental sectors to ensure a unified and holistic response. The development process was informed by inputs from national experts and technical support from international partners including the WHO Eastern Mediterranean Regional Office, DAI Fleming Fund, and ReAct Africa. The NAP 2.0 outlines, an assessment of current AMR challenges, progress made under NAP 1.0, a strategic framework organized around six core objectives, including governance as a cross-cutting enabler, clearly defined intervention streams, priority actions, and responsible stakeholders and a robust monitoring and evaluation (M&E) framework to guide implementation and assess the impact. This document reflects Pakistan’s continued dedication to preserving antimicrobial effectiveness, safeguarding health systems, and contributing meaningfully to the global fight against AMR. Through this plan, Pakistan affirms its resolve to protect the health of its population, its animals, and its environment—ensuring a safer, more resilient future for all. 2 BACKGROUND 1. INTRODUCTION GLOBAL TRENDS Each year, an estimated 7.7 million deaths are attributed to bacterial infections, with 4.95 million linked to drug- resistant pathogens and 1.27 million caused by bacteria resistant to available antibiotics [1]. A recently published systematic analysis of burden of AMR has estimated that 1·91 million deaths attributable to AMR and 8·22 million deaths associated with AMR could occur globally in 2050 if no ameliorative actions are instituted [2]. In the updated estimates deaths from AMR decreased by more than 50 % among children below 5 years yet increased by over 80 % for adults 70 years and older [3]. Only 6 bacterial pathogens are responsible for >70% of the AMR burden with methicillin-resistant Staphylococcus aureus as the major contributor globally [4]. Two third (75%) of the global burden of Health Care Associated Infections (HAIs) is attributed to the drug-resistant infections, resulting in terrible patient suffering, high health and economic burden [5]. The main driver of increased AMR is the global misuse, or overuse of antimicrobials, particularly in LMICs. Global antibiotic consumption rates have risen from 9.8 to 14.3 defined daily doses (DDD) per 1000 population per day from 2000 to 2018 [6]. However, rationalizing the use and access to second line antibiotics can prevent the number of deaths due to AMR. COVID-19 is one of such examples where antibiotics were used to relieve Covid symptoms. During its peak time, an estimated 92% of coronavirus patients admitted to intensive care units around the world received some type of antibiotic treatment [7]. THE BURDEN AND EXTENT OF AMR IN PAKISTAN In Pakistan, antimicrobial resistance (AMR) has emerged as a major public health challenge, placing a growing strain on the health system and contributing to poor treatment outcomes. The country faces significant threats from drug-resistant infections, which undermine routine medical care and limit the effectiveness of essential medicines.[8] Pakistan has the 3rd highest antibiotics use prevalence in EMRO, at 65.8%, after Iraq and Sudan. Approximately, 70% of patients are prescribed antibiotics with more than 3 drugs per patient. Half (50%) of the population practice self-medication - a key driver of resistance in Pakistan. [9,10] In Pakistan, five antimicrobial resistance (AMR) pathogens account for a significant number of deaths: Klebsiella pneumoniae (34,400 deaths), Escherichia coli (31,300), Staphylococcus aureus (28,600), Salmonella Typhi (23,300), and Streptococcus pneumoniae (20,300) (IHME, 2019). These pathogens commonly cause bloodstream infections, lower respiratory tract infections, and other related infections of the thorax, peritoneum, and intra- abdominal regions. Over the years, a steady increase in AMR rates has been observed in Pakistan, with moderate to high resistance levels reported against third-generation cephalosporins, fluoroquinolones, and cotrimoxazole.[11] Pakistan reported the first outbreak of XDR Salmonella Typhi in Hyderabad in November 2016.[12] In that outbreak zone, approximately 66% of culture‑confirmed typhoid cases were XDR.[13] 3 Urinary Tract Infection (UTI) is the most clinically reported infection in Pakistan, accounting for 16.1% of cases. E. coli was identified in 28 (30.11%) cases, showing high resistance to first-line antibiotics. Methicillin-resistant Staphylococcus aureus (MRSA) was found in 49% of the total S. aureus cases reported.[14] Carbapenem-resistant Enterobacteriaceae (CRE) are on the rise in Pakistan, particularly those producing the NDM-1 enzyme. Among Enterobacteriaceae, more than 51% of reported E. coli and Klebsiella pneumoniae isolates were Multidrug Resistant (MDR), with 2.1% and 6.7% possibly being Pan Drug Resistant (PDR), respectively.[15] Significant bacteria of both human and animal concern, including Escherichia coli, Salmonella spp., and Enterococcus spp., have been reported from multiple federal and peripheral sentinel laboratories across Pakistan. Alarmingly high levels of resistance were observed, particularly to critical antimicrobials identified by the World Health Organization. In poultry, E. coli resistance to quinolones (ciprofloxacin and nalidixic acid) exceeded 80%, and resistance to tetracycline and ampicillin was above 90%. Similar trends were noted in large ruminants, where E. coli resistance to ampicillin reached 92%, and resistance to third-generation cephalosporins (e.g., cefotaxime) exceeded 70%. In Salmonella spp., high resistance to tetracycline, ciprofloxacin, and ampicillin was observed across both poultry and ruminants. Enterococcus isolates from both animal groups also exhibited resistance to critical antimicrobials such as vancomycin, with vancomycin-resistant enterococci (VRE) detected at high levels in some provinces. [16] Major causes of the spread of AMR in environmental settings include (i) poor sanitation and sewage effluents; (ii) effluents from pharmaceutical industries; (iii) discharges from healthcare facilities; (iv) use of antimicrobials and manure in agricultural production; and (v) effluents and waste from animal production. These factors are particularly concerning in low- and middle-income countries (LMICs) like Pakistan, where limitations in wastewater treatment infrastructure and access to clean water exacerbate the spread of AMR. Approximately 56% of wastewater globally is released into the environment without adequate treatment, posing significant public health risks (UNEP, 2022b). Human exposure to environmental AMR can occur through contact with contaminated water, consumption of contaminated food, and inhalation of airborne resistant organisms (UNEP, 2022c). Despite the recognized importance of environmental factors in AMR, surveillance and monitoring in environmental settings remain limited. Integrated surveillance systems that encompass environmental, human, and animal health sectors are needed, in line with the 'One Health' approach to effectively address AMR (UNEP, 2022a). ONE HEALTH APPROACH FOR AMR CONTAINMENT The One Health approach, adopted by the World Health Organization (WHO) and endorsed by all its Member States, is an integrated, unifying framework aimed at sustainably balancing and optimizing the health of people, animals, and ecosystems. It is rooted in the recognition that the health of humans, domestic and wild animals, plants, and the wider environment are inextricably linked. Consequently, interventions to prevent, detect, and respond to antimicrobial resistance (AMR) must be multipronged and rely on strong collaboration between human health, animal health, agricultural, and environmental sectors. [17] AMR is, in part, a natural evolutionary mechanism, driven by the constant competition for resources within the microbiome—even against naturally occurring secondary metabolites that resemble today’s antibiotics. 4 However, the discovery and widespread use of antibiotics in human and veterinary medicine have dramatically altered the conditions for resistance development, creating unprecedented selection pressures. These pressures have significantly impacted the microbiomes of humans, domestic animals, and environments heavily contaminated with antimicrobial residues, facilitating the transfer of antibiotic resistance genes (ARGs) to a broad range of clinically significant bacterial species. Since both bacteria and ARGs can cross species and environmental boundaries, understanding the interconnectedness of human, animal, and environmental health under the One Health concept is critical. [18] Transmission of resistant bacteria from animals to humans can occur through multiple pathways, including the food chain, direct contact with animals, and environmental exposure. Studies have detected AMR organisms in soils and water bodies—including surface and groundwater—often linked to antibiotic use in agriculture, aquaculture, pharmaceutical manufacturing, and human healthcare.[19,20,21] wastewater treatment plants have also been identified as significant reservoirs and dissemination points for AMR .[19] Recognizing the environmental dimension, the United Nations Environment Programme (UNEP, 2017) has classified AMR as one of the most critical pollution challenges. This has been echoed by the O’Neill Report, WHO, and various scientific studies, all of which highlight the importance of integrating environmental surveillance into AMR control strategies. [22,23,24,25] In line with the global principles and scientific evidence, the development of Pakistan’s NAP 2.0 has fully embraced the One Health approach as its guiding framework. This holistic perspective has been embedded throughout the planning process by ensuring the active engagement of all relevant stakeholders at both national and provincial levels. Representatives from human health, animal health, agriculture, food safety, and environmental sectors along with academic institutions, civil society, and development partners have contributed their expertise to ensure that the plan reflects an integrated and coordinated national response. By adopting this collaborative, multisectoral model, NAP 2.0 aims to deliver sustainable and context-specific interventions that address AMR across all interconnected domains. The One Health approach adopted by the WHO and all its member states is an integrated, joined up and unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. One health approach is rooted in the recognition that the health of humans, domestic and wild animals, plants, and the wider environment are intertwined. Therefore, interventions to prevent, detect and respond to AMR must be multipronged and inevitably involves collaboration across human, animal, and environmental health sectors. PEOPLE CENTRED APPROACH TO ADDRESSING ANTIMICROBIAL RESISTANCE IN HUMAN HEALTH Incorporating a people-centred approach is essential to ensuring that AMR containment strategies in the human health sector are not only evidence-based but also socially equitable and responsive to the needs of diverse populations. As outlined in the World Health Organization’s 2023 guidance on applying a people-centred lens to AMR, this perspective reframes AMR as a challenge shaped by the lived experiences, care-seeking behaviours, and systemic barriers individuals face—particularly when dealing with drug-resistant infections. It calls for interventions that are tailored to people’s needs, preferences, and contexts across the continuum of care, from community settings to tertiary hospitals. Priority actions include improving access to clean water and sanitation, strengthening infection prevention and control, ensuring availability of quality diagnostics, and providing safe, effective, and affordable treatment. This approach also underscores the importance of inclusive governance, 5 public awareness, and health education, thereby aligning AMR containment with the principles of Universal Health Coverage (UHC), health equity, and pandemic preparedness. By placing people at the centre of policymaking and service delivery, Pakistan’s NAP 2.0 aims to ensure that no one is left behind in the fight against AMR.[26] The people-centred approach … recognizes that before people become patients, they need to be informed and empowered in promoting and protecting their own health. There is a need to reach out to all people, to families and communities beyond the clinical setting. In addition, health practitioners are people, and healthcare organizations and systems are made up of people. Their needs should also be considered, and they must be empowered to change the system for the better. That is, a people-centred approach involves a balanced consideration of the rights and needs as well as the responsibilities and capacities of all the constituents and stakeholders of the health-care system [and beyond]. WHO ADDRESSING GENDER INEQUALITIES In recent years, gender dimension of AMR has surfaced as a key concern in growing literature on AMR. Though men and women share many of the AMR-associated risks, there are biological and occupational factors that increase women’s vulnerability to infections. For example, childbirth, abortion and sanitary health expose women to a considerably large spectrum of infections.[27] More significantly, women are 27% more likely to receive an antibiotic prescription compared to men.[28] This gendered reality calls for a greater focus on gender dimension within the broader people-centred approach to tackling AMR. A review of NAPs on AMR has confirmed the minimal attention to gender considerations; 125 out of 145 publicly available NAPs did not mention sex or gender.[27] Despite this lack of attention to gender, research indicates that exposure and susceptibility to infections, health-seeking behaviours, as well as patterns of antimicrobial prescribing and use are all influenced by gender considerations. Gender may also affect those who have the resources and decision-making power to access appropriate care and treatment for (drug resistant) infections, which contributes to differences in the quality of care received and patient outcomes. AMR is similarly affected by gender inequalities, where gender norms, roles and relations influence exposure and vulnerability to infection (e.g. through occupational and household roles and nutritional status), participation in infection prevention and health-seeking behaviours, access to health care, prescribing patterns and appropriate use of antimicrobials. Furthermore, in AMR, sex and/or gender disaggregated data are scarce, and disentangling the individual effects of gender and sex on risk of infection or health outcomes is challenging. National action plan 2.0 on AMR explicitly integrates gender as a cross-cutting theme, recognizing its critical influence on exposure, access to care, and health outcomes. By incorporating gender-responsive strategies, the plan aims to ensure equitable interventions that address the unique vulnerabilities and needs of all population groups underscoring the severe impact of hard-to-treat resistant infections—particularly among vulnerable populations. 6 2. RELATIVES’ ASSESSMENT AND SITUATION ANALYSIS BUILDING ON EVIDENCE FOR NAP 2.0 The formulation of Pakistan’s National Action Plan on AMR 2025–2029 (NAP 2.0) was deeply informed by a comprehensive set of relative assessments and situational analyses. Key among these were the Joint External Evaluation (JEE) 2023, periodic TrACSS reporting, a performance review of NAP 1.0, and a cross-sectoral SWOT analysis. Each of these tools provided critical insights into Pakistan’s AMR response capacities, highlighting measurable progress as well as persisting gaps—particularly in areas like multisectoral coordination, infection prevention and control (IPC), and the integration of environmental and agricultural sectors. NAP 1.0, while foundational, faced significant implementation challenges—many of which were exacerbated by the COVID-19 pandemic, including diverted resources, reduced inter-sectoral collaboration, and limited surveillance expansion. Despite these barriers, the evidence generated through these assessments created a strong base for designing NAP 2.0 with clearer priorities, stronger accountability, and a One Health-aligned approach to ensure comprehensive AMR containment over the next five years. These evaluations not only benchmarked past performance but also illuminated the structural and operational adjustments required to transform planning into measurable outcomes. JOINT EXTERNAL EVALUATION 2023: KEY PROGRESS AND GAPS AMR JEE indicators showed improvement from 1 to 2 in multisector coordination and optimal use of antimicrobials in human health from 2016 to 2023. According to the 2023 JEE, progress has been made since the 2016 evaluation with the development of a national action plan and coordinating mechanism for AMR in line with the WHO GAP. However, provincial operational plans for AMR have not yet been developed. Effective actions in human and animal health, such as the expansion of quality assured surveillance sites and good practices in some facilities, have been observed. The country has aligned data reporting of AMR to the global platforms including AMR GLASS, AMC, TrACSS and World Organization for Animal Health (WOAH), but data has not been used to inform evidence-based policies within the country. Facility-based stewardship programs have not been implemented, and WHO guidance has not been translated for national/facility antimicrobial stewardship programs in both human and animal sectors. While AMR surveillance and diagnostic capacities have improved, widespread implementation of existing plans and procedures remains a challenge. For IPC focus, IPC Programs improved to 2, while HCAI Surveillance, previously part of prevention, remains at 1. The new indicator for a safe environment in healthcare facilities also stands at 1. Significant investments have been made in IPC areas. IPC initially covered by one indicator under AMR technical area with a focus on HCAI program. Following the 2016 JEE, Pakistan progressed in developing National IPC Guidelines and standardized IPC training modules for doctors, nurses and Housekeeping Staff and conducted capacity building initiatives. NIH has recently initiated a National IPC program at federal and provincial level. JEE 2023 Recommendations are guiding the current plan for establishment of surveillance of healthcare associated infections in tertiary hospitals and implementing IPC and WASH standards in health care facilities and communities. The scores correspond from No to Limited country core capacities in respective domains and needs to be strengthened through development of a robust NAP revision for next five years. 7 TRACSS REPORTING: TRENDS IN MULTISECTORAL ENGAGEMENT TrACSS is the Global dataset that provides insights into country progress on AMR. Advancing the implementation of one health agenda, NAP implementation is periodically monitored through TrACSS. From 2020 to 2024, Pakistan reported incremental scores that varied compared to global averages. The country displayed higher scores in human health indicators than in animal health. However, scores in food and agriculture, environment, legislation, and One Health sectors were weak. This indicates a lack of a comprehensive approach to NAP implementation, with some indicators scoring well while others performed poorly. For multisectoral coordination Pakistan scored below average through reported literature analysis of AMR NAP. Later efforts to systematically monitor and evaluate the effectiveness and cost-effectiveness of these policies were relatively poor. Sustained action has been achieved only in the development of AMR NAP. The first AMR NAP reported low in adopting and facilitating equity approach.[29] 8 NAP 1.0 PROGRESS REVIEW: ACHIEVEMENTS AND MISSED OPPORTUNITIES Implementation of Pakistan’s NAP on AMR has revealed significant gaps in financial sustainability, regulatory frameworks, prudent antimicrobial use (AMU), and interventions beyond the livestock sector. While NAP 1.0 made notable progress in human and livestock health, it paid limited attention to other critical areas such as plant health, aquaculture, companion animals, food and feed production, and the environment. Data on AMR prevalence in Pakistan’s environmental sector remains scarce, limiting evidence-based policymaking in this domain. Although NAP 1.0 incorporated provisions for adopting waste management practices aligned with the Pakistan Environmental Protection Act (1997), progress in enforcement has been slow. For instance, the Punjab Poultry Production Act (2016) was introduced to regulate waste disposal from poultry farms, but its implementation remains at an early stage, underscoring the need for stronger compliance mechanisms and cross-sectoral engagement in future AMR strategies.[30] 1st Strategic Priority: Development and implementation of a national awareness raising & behavioural change strategy on AMR. Several awareness raising activities were implemented by all OH institutions and partners during the implementation of NAP 1.0. Nonetheless, sector specific reviews noted that these activities were mainly concentrated in the urban areas. Moreover, these activities were conducted in the absence of an overarching and integrated strategy and with limited mechanisms for assessing the effectiveness of these initiatives in fostering knowledge transfer and behavioural change. Notable achievements against this strategic priority are, Celebration of World Antibiotic Awareness Week every year in the form of seminars, competitions, mass media campaigns, engagements with farmers, and public 9 awareness events, regular publication and dissemination of National AMR Newsletters and capacity strengthening initiatives across the human and animal health sectors targeting professionals, allied staff, students, and institutions. 2nd Priority: Establishment of an integrated national AMR surveillance system (human, animal usage and resistance monitoring) Significant progress has been achieved in strengthening Pakistan’s AMR surveillance system in line with NAP priorities, with regular data sharing to WHO GLASS and WOAH. Through a consultative process with stakeholders and development partners, Pakistan has developed the following strategies: a) Pakistan AMR Surveillance Strategy – Human Health (2024) b) National Surveillance Strategy for AMR in Healthy Food Animals c) National Surveillance Strategy for AMR in Bacterial Isolates from Diseased Food Animals (2022) d) National Surveillance Strategy for AMR in Aquaculture e) National Surveillance Strategy for AMR in the Environment Sector These strategies will guide the quality implementation of NAP 2.0. In 2018, Pakistan’s AMR Surveillance System (PASS) was launched, which is supported by National Reference Laboratories (NRLs) and sentinel sites in both human and animal health sectors. National and provincial focal persons have been notified, and Pakistan is enrolled in GLASS with 33 participating laboratories. In the animal health sector, pilot AMR surveillance in healthy food animals (poultry and large ruminants) is underway, with data gathered on E. coli and Enterococcus, and expanded to Salmonella and Campylobacter. The diagnostic harmonization efforts include capacity building for NRLs and sentinel sites, with regular participation in national and international External Quality Assurance (EQA) programmes. Under NEQAS, reference laboratories extend EQA support to provincial AMR labs. With partner support, antimicrobial consumption studies, antibiotic footprint analyses, and Point Prevalence Surveys for poultry and dairy AMU have been conducted, along with a meta-analysis of AMR in the animal health sector. These efforts collectively strengthen the evidence base for targeted AMR interventions. The NAP1.0 included the environment sector in all strategic priorities; however, activities were limited or insufficiently specified. AMR surveillance in the environment sector—part of the strategic priority on establishing an integrated national AMR surveillance system—did not progress as envisaged. Other environmental priorities, such as creating a conducive environment for infection prevention and control (IPC) in healthcare settings and communities, were included but require more comprehensive operationalization in the revised plan. 3rd Strategic Priority: Improve prevention and control of infections in health care, community, animal health, food, agriculture, and environment. Under this priority the National IPC guidelines were also introduced in 2020 followed by notification of an IPC technical working group and several National capacities strengthening training around IPC practices were arranged. Federal and provincial livestock departments continue to promote good husbandry practices, farm biosecurity, and vaccination through farmer days, training courses, seminars, extension services, and disease prevention 10 programs. The AHC office and provincial livestock departments, according to disease situations, issue guidelines and awareness material for the control of prevalent/emerging livestock diseases. While efforts to promote good agricultural practices and biosecurity in livestock production have been initiated, they have not yet reached their full potential, particularly in rural and smallholder farming communities. The NAP addressed the integration of waste management practices consistent with the Pakistan Environmental Protection Act 1997. Punjab Poultry Production Act 2016 regulates the disposal of waste from poultry farms. However, other provinces have no regulations for disposal of poultry/livestock waste. Additionally, the use of untreated cattle and poultry manure as a nutrient source for fish production and as crop fertilizer is a common practice, which contributes to the emergence and spread of AMR. 4th Strategic Priority: Update and enforce regulations for human and veterinary antimicrobial utilization. The Drugs Act 1976 and the DRAP Act 2012 outline the legal standards for the manufacture, import, export, quality control, marketing, and sale of antimicrobials. However, in Pakistan, the regulation of antimicrobial use in human, livestock and poultry sectors is inadequate due to the ineffective enforcement of existing laws and a lack of coordination among key stakeholders. The federal government is tasked with establishing the national AMR regulatory framework, whereas provincial governments have the power to develop their own regulations independently. Nonetheless, there is no national mechanism for evaluating how well provincial regulations align with national standards or for overseeing their enforcement. In 2022, the Drug Regulatory Authority of Pakistan (DRAP) shared the import data for the raw materials used in antimicrobial production into GLASS. With support from technical partners, DRAP is currently working on developing a software for estimating the Antimicrobial Consumption patterns in Pakistan. DRAP has also issued guidelines on responsible use of antimicrobials and a regulatory directive in relation to banning the use of antimicrobials as growth promotors. The AHC office is reporting information on AMU in animals, mostly qualitative, to WOAH since 2016. Pakistan has also initiated the submission of quantitative AMU data to WOAH. The data was classified according to antimicrobial class and use type (medical or growth promotion) but lacked details on animal species, production settings, and methods of administration. The animal health sector has mapped the AMU supply chain to trace the flow of antimicrobials from import and production to farm use, highlighting the roles of various regulatory agencies and the AMU data collected at each stage. There are no national systems for tracking veterinary prescriptions or collecting AMU data at the farm level, apart from limited farm surveys conducted for specific projects. The data on the total sale of antimicrobials at national or provincial level and annual reports documenting trends in AMU in animals are not available. Inappropriate use of antimicrobials has been observed among veterinarians and farmers, with 50% prescribing antibiotics for unsuitable conditions, including viral diseases,[30] highlighting the need for antimicrobial prescription guidelines. However, the absence of antimicrobial susceptibility testing data presents a significant challenge to their development. Additionally, three National Point Prevalence Surveys on AMR, covering major tertiary care hospitals across the country, were completed in 2019, 2023, and 2025. These surveys highlighted the irrational use of antibiotics in hospitals and aimed to estimate the prevalence of antimicrobial utilization among hospitalized patients. 11 5th Strategic Priority: Phase out use of Antimicrobials as Growth Promoters and provide appropriate alternatives. WHO has defined critically important antimicrobials (CIAs) for humans, which are extensively used in the animal health sector. Farm-level studies have shown that 60% of antimicrobial use (AMU) in broiler production and 42% in dairy cattle production involve CIAs, as classified by the WHO. These antimicrobials are excessively used for prophylaxis and as growth promoters in animals, poultry, and aquaculture, with no regulations in place regarding their use for these purposes. Ciprofloxacin has been banned in the poultry and livestock sectors. In Punjab, efforts are underway to limit the use of antibiotics as growth promoters, with the province developing a list of antimicrobials approved for this purpose. DRAP has also issued guidelines on the responsible use of antimicrobials and a regulatory directive banning their use as growth promoters. 6th Strategic Priority: Integration of AMR in all public health research agendas including research on vaccines and diagnostics. There is limited support from the government for AMR research. A national AMR research agenda has not yet been developed. The Health Research Institute (HRI) at NIH is seen as an important opportunity in advancing AMR research agenda and facilitating funding for new research projects on AMR. Review of progress against this priority in other sectors indicates that limited activities have been carried out under this strategic priority. The provincial livestock departments have the capacity to produce vaccines for major livestock diseases such as s foot and mouth disease, haemorrhagic septicaemia, anthrax, peste des petitis ruminants (PPR), and Newcastle Disease. In addition, the livestock departments also implement vaccination programs/campaigns for important livestock diseases. Pakistan has initiated a PPR eradication program with the aim to eradicate PPR by 2030. Full potential of these efforts could not be harnessed due to challenges like limited resources, inadequate infrastructure, and knowledge gaps among livestock farmers leading to inadequate vaccination coverage and persistent disease outbreaks. 7th Strategic Priority: Promote research on estimation of health and economic burden of AMR. Financial sustainability of Pakistan’s AMR containment efforts is identified as a major challenge. The AMR NAP progress has significantly benefitted from external funding, without sufficient internal financial commitments from the government.[30] Research addressing the economic consequences of AMR and the promotion of prudent AMU in the livestock sector is conspicuously missing. Research in this area would be helpful in developing the economic case for policy makers to get more funding to sustain AMR mitigation activities in Pakistan. The NIH is currently working on a research study to determine the financial burden of AMR in Pakistan and tracking trends of antimicrobial resistance against 12 blood pathogens. 3. SWOT ANALYSIS: CROSS-SECTORAL INSIGHTS FOR STRATEGIC PLANNING SWOT analysis was undertaken through a consultative process. The analysis involved discussions and deliberations with technical experts, members of the technical working group, onsite visits, desk reviews, and meetings with key informants and stakeholders from different sectors. Pakistan’s AMR response in the human health sector shows strong institutional foundations, including a national surveillance network, IPC guidelines, 12 and sectoral coordination mechanisms. However, implementation challenges persist due to limited governance capacity, gaps in treatment guidelines, insufficient stewardship programs, and fragmented provincial action. In animal health, national surveillance frameworks and laboratory infrastructure are partially in place, with active global reporting and outreach efforts. Still, enforcement gaps, over-the-counter antibiotic sales, and limited veterinary training constrain sustainable AMR control. The environmental sector demonstrates early institutional engagement through technical labs and collaborative pilots, yet faces systemic limitations including lack of surveillance frameworks, policies on antibiotic pollution, and critical human and financial resource gaps (Detail of the SOWT analysis is annexed). ALIGNING NATIONAL PRIORITIES WITH GLOBAL AMR COMMITMENTS Pakistan’s National Action Plan on AMR (NAP 2.0) has been developed in alignment with key global commitments, including the WHO Global Action Plan (GAP) on AMR, the Tripartite+ (WHO, FAO, WOAH, UNEP) recommendations, and the Sustainable Development Goals (SDGs)—particularly SDG 3 on good health and well- being, and SDG 17 on global partnerships. In addition, the plan reflects Pakistan’s endorsement of the United Nations General Assembly (UNGA) Political Declaration on AMR, which calls for urgent and sustained political action to tackle AMR through a coordinated One Health response. In line with the UNGA Declaration, NAP 2.0 places governance and coordination at the forefront of national priorities, making it the first strategic objective. This reflects a recognition that robust, inclusive, and accountable governance mechanisms are fundamental to effective AMR containment. The plan emphasizes strengthening multisectoral coordination, institutional leadership, and policy coherence at both national and subnational levels. It also incorporates guidance from the WHO’s People-centred approach to addressing antimicrobial resistance in human health and “Addressing Gender Inequality in National AMR Action Plans,” ensuring that principles of equity, sustainability, and access are fully embedded. Through regular participation in global platforms such as GLASS and TrACSS, and alignment with international monitoring and evaluation standards, Pakistan aims to ensure that its AMR response is not only contextually grounded but also globally responsive. NAP 2.0 promotes harmonized strategies such as integrated surveillance, responsible antimicrobial use, capacity building, and whole-of-society engagement, reflecting both global best practices and national imperatives. 13 4. METHODS AND PROCESS OF NAP 2.0 DEVELOPMENT The Ministry of National Health Services, Regulations and Coordination (MoNHSRC), in collaboration with the National Institute of Health (NIH), adopted a multisectoral and consultative approach for the development of Pakistan’s second National Action Plan (NAP 2.0) on Antimicrobial Resistance (AMR). This inclusive process ensured active engagement of key federal ministries, provincial departments of health, livestock and environment, and all relevant One Health stakeholders. The process was led by MoNHSRC and technically and financially supported by key development partners including the World Health Organization (WHO), the Fleming Fund Country Grant, the Food and Agriculture Organization (FAO), and Integral Global. Phase 1: Stakeholder Mapping and Technical Working Group (TWG) Formation The first step in the process was a comprehensive mapping of stakeholders across human health, animal health, agriculture, food safety, and the environment sectors to ensure robust national coordination for AMR containment. Subsequently, a multisectoral Technical Working Group (TWG) was constituted in May 2024. This TWG comprised representatives from federal and provincial governments, development partners, academia, private sector entities, and civil society organizations. Phase 2: Review of NAP 1.0 and Situational Analysis Between May 2024 and February 2025, several TWG meetings were convened to review the implementation status of NAP 1.0. A detailed sector-wise SWOT analysis was conducted to identify strengths, weaknesses, opportunities, and threats across each of the five strategic objectives. This phase also involved the development of a time-bound operational plan, monitoring and evaluation (M&E) framework, and preliminary costing of the proposed interventions under NAP 2.0. AMR Secretariat at NIH led a situational analysis by synthesizing existing data sources, including WHO’s Global Antimicrobial Resistance and Use Surveillance System (GLASS), Antimicrobial Consumption (AMC) data, the Tripartite AMR Country Self-Assessment Survey (TrACSS), and findings from the Joint External Evaluation (JEE) 2023. This was supplemented by key informant interviews with national stakeholders to contextualize AMR priorities, achievements, and implementation gaps of NAP 1.0. 14 Phase 3: Provincial Consultations and Activity Prioritization To ensure local relevance and ownership, sector-specific SWOT findings were validated through two dedicated TWG meetings led by NIH, followed by extensive provincial consultations. These consultations aimed to gather deeper insights and enable contextual prioritization of activities across provinces using WHO’s Activity Prioritization Tool. Two provincial consultative workshops were held—one focused on human and environmental health, and the other on animal health sectors. Costing Process of NAP 2.0 The costing methodology for the NAP-AMR 2025–2029 was designed to ensure robust, transparent, and actionable financial planning, tailored to Pakistan’s unique context. The process utilized the WHO AMR NAP Costing Tool, emphasizing a detailed, bottom-up approach that broke down objectives into actionable steps, aligned with operational realities and resource availability. This methodology ensured that all cost components, from resource estimation to prioritization, were systematically addressed. Process emphasized a detailed breakdown of activities, defining them by implementation steps, responsible entities, quantities, and timelines. Costing inputs were derived from: ● Human resources: Salaries and allowances based on government pay scales and required levels of effort. ● Equipment: Prevailing market rates for essential lab and operational equipment. ● Infrastructure: Civil works costs, including construction and refurbishment of AMR laboratories. ● Technical assistance: Costs for consultants and specialized technical support. ● Operational needs: Logistics, training, and monitoring requirements. Validation and Customization Workshops and validation meetings led by the TWG were conducted to review and refine costing assumptions, ensuring alignment with national priorities and operational feasibility. Assumptions regarding inflation rates, market trends, and implementation timelines were carefully reviewed to enhance accuracy. The WHO AMR Costing Tool was customized to reflect Pakistan’s national context, including local currency adjustments, government budget classifications, and region-specific cost parameters. The costing outputs were developed to facilitate analysis and policy formulation, with key parameters including: ● Annual activity-level funding requirements for the five-year NAP implementation period. ● Costs broken down by strategic objectives, interventions, and funding sources. ● Categorization by funding status (funded, partially funded, unfunded). ● Allocation by cost components, such as human resources, technical assistance, and infrastructure. Phase 4: Finalization of NAP 2.0 A national multisectoral consultative workshop was convened to review and finalize the draft NAP 2.0. The workshop brought together stakeholders from across sectors and provinces to validate the operational plan and M&E framework. In addition, three-day intensive provincial consultations were also conducted to ensure bottom-up validation and alignment of the national plan with subnational priorities. 15 Stakeholder Engagement Across the Development Process Stakeholder involvement spanned across: ● Federal line ministries (Health, Livestock, Environment, Education) ● Provincial health and livestock departments ● National Reference Laboratories and AMR Surveillance Units ● Development partners (WHO, FAO, Fleming Fund, Integral Global Health) ● Academia and research institutions ● Civil society and private healthcare providers 16 NAP AMR 2.0 The AMR Operational Plan is structured around six key objectives, each supported by targeted interventions and detailed activities. Objective 1 focuses on strengthening governance and coordination through three interventions (e.g., establishing AMR governance mechanisms) with 10 activities, including revising the National AMR Steering Committee and strengthening regulatory frameworks. Objective 2 aims to improve AMR awareness via two interventions (e.g., awareness campaigns and education integration) with 12 activities, such as incorporating AMR into school curricula and conducting training for professionals. Objective 3 enhances AMR surveillance with four interventions (e.g., genomic surveillance, IPC strengthening) and eight activities, including establishing reference labs and integrated surveillance systems. Objective 4 targets infection reduction through five interventions (e.g., IPC policies, vaccination) and 22 activities, such as improving water sanitation in healthcare facilities. Objective 5 optimizes antimicrobial use via four interventions (e.g., stewardship programs, AMU monitoring) and 14 activities, including updating essential medicine lists. Objective 6 promotes research investment with two interventions (e.g., priority-setting, capacity-building) and four activities, such as mapping research resources. Each activity aligns with clear responsibilities, indicators, and cost estimates, ensuring measurable progress. 5. STRATEGIC OBJECTIVES Objective 1: Governance and Coordination ▪ Intervention 1: Establishment of AMR governance and financing mechanisms ▪ Intervention 2: Coordination and harmonization of activities on AMR ▪ Intervention 3: Strengthening existing rules and regulations across sectors to address AMR Objective 2: Improve awareness and understanding of antimicrobial resistance through effective communication, education, and training. ▪ Intervention 1: Establish and implement AMR awareness and behaviour change strategy ▪ Intervention 2: Establish and promote AMR in education and training on AMR for professionals Objective 3: Strengthen AMR surveillance across sectors to generate quality data for policy actions. ▪ Intervention 1: Strengthening AMR coordinating centres and reference laboratories in all sectors ▪ Intervention 2: Strengthening integrated AMR surveillance ▪ Intervention 3: Genomic surveillance and healthcare associated infections surveillance 17 ▪ Intervention 4: Ensuring quality through SOPs and EQA systems in health sector Objective 4: Reduce infection through effective water, hygiene, and sanitation, vaccination, and infection prevention and control (IPC) measures. ▪ Intervention 1: Create a formal organizational structure for development and implementation of IPC policies and strategies ▪ Intervention 2: Availability of trained human resource at all levels ▪ Intervention 3: Enable conducive environment for IPC in health care settings and in the community following People- Centred approach. ▪ Intervention 4: Strengthen animal health and agricultural/agrifood/aqua and environment sector IPC practices ▪ Intervention 5: Prevention of infections through better Water sanitation and hygiene including waste management and improved vaccination coverage Objective 5: Optimize the use of antimicrobial medicines in human and animal health. ▪ Intervention 1: Strengthening existing rules and regulation on manufacture, prescribing, sales and use of antimicrobials ▪ Intervention 2: Measuring antimicrobial (human/ veterinary/agrifood/environment/aqua) use ▪ Intervention 3: Implementation of antimicrobial stewardship program at HCFs ▪ Intervention 4: Rationalize use of antimicrobials as growth promoters & prophylaxis aligned in veterinary, agriculture, and aquaculture Objective 6: Develop economic case for sustainable investment based on research studies focused on country needs ▪ Intervention 1: Mapping of AMR research landscape and priority setting ▪ Intervention 2: Capacity building and designing and conducting research in priority areas 18 6. NATIONAL OPERATION PLAN Objective1: Strengthen governance and coordination Intervention 1: Establishment of AMR governance and financing mechanisms No Activity Responsibility Indicator Cost Estimates 01.01 Revision of multistakeholder National AMR Steering Committee to include all Quadripartite partners. MoNHSR&C, NIH No of quadripartite partners participating. No of policies endorsed & implemented by multistakeholder steering committee 01.02 Constitution of national/ One Health Technical Working Groups (TWGs) for AMR surveillance, IPC, Optimized AMU, AMS, and Research Ministry of NHSR&C, NIH, NFS&R & Climate Change, MoWR, Fed & Provincial EPAs No of operational TWGs & representative members No of recommendations /policies developed by TWG 01.03 Strengthening the capacity of the National AMR secretariat with defined TORs and replication at provincial level Ministry of NHSR&C, NIH, NFS&R & Climate Change % increase in budget allocation for the AMR secretariat. # of Information sharing products/publications (Newsletter, Fact sheet/tools) 01.04 Mapping of AMR in health financing at national/provincial levels Ministry of NHSR&C, NIH Amount and allocation of AMR fundings at National /provincial level 01.05 Inclusion of AMR in other programme plans and strategies (immunization, Tb, HIV, malaria etc.) MoNHSR&C, NIH #Briefs on cross-collaborations Intervention 2: Coordination and harmonization of activities on AMR 19 Update Mapping of high-level stakeholders’ platforms/forums at national/provincial level within the core mandate of One Health Ministry of NHSR&C/NIH, MoWR, MoCC, MoNHSR&C, DOH Federal and provincial EPAs. No of Platforms/forums mapped. No of Meetings held 01.07 Review meeting for high level engagement and Advocacy for federal/provincial secretaries, DGs, administrative heads and political leaders to seek commitment Ministry of NHSR&C/NIH, MoWR, MoCC, MoNHSR&C, DOH Federal and provincial EPAs. No of meetings conducted. No of declarations/MoUs signed Intervention 3: Strengthening existing rules and regulations across sectors to address AMR 01.08 Legislation to strengthen drug sales in all relevant sectors. DRAP/ Ministry of NHSR&C, NIH, NFS&R, Health & Livestock Provincial Departments, Ministry of Law & Justice Division No of amendments Reduction in inappropriate use of antimicrobials 01.09 Advocacy for regulatory oversight for enforcement of Drug Act 1976 and DRAP Act 2012 DRAP/ Ministry of NHSR&C, NIH, NFS&R, Health & Livestock Departments/manufacturers No of advocacy meetings for stockholders conducted. 01.10 Legislations to monitor pesticide residue. NFS&R & Climate Change, No of provinces with legislations in place OBJECTIVE 2: IMPROVE AWARENESS AND UNDERSTANDING OF ANTIMICROBIAL RESISTANCE THROUGH EFFECTIVE COMMUNICATION, EDUCATION, AND TRAINING. Intervention 1: Establish and implement AMR awareness and behaviour change strategy No Activity Responsibility Indicators Cost Estimate 02.01 Development of National strategic plan for communication on AMR Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, WHO, % of planned activities conducted. % dissemination activities formed and planned. 20 academia, MoCC, Fed and Provincial EPA 02.02 Adapt, develop, and disseminate AMR awareness raising materials, including at community level, targeting the public, health professionals (incl. pharmacists, nurses, medical doctors) and policymakers. Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, WHO, academia, MoCC, Fed and Provincial EPA Number of communication materials developed. Level of awareness measured by surveys 02.03 Conduct awareness campaigns aligned with the World AMR Awareness Week and other health days (such as Clean Hands, hand hygiene, patient safety) Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, WHO, MoCC, Fed and provincial EPAs No of campaigns conducted. No of people reached with awareness campaign No of organizations involved in awareness week 02.04 Advocacy and IEC campaign for behaviour change on misuse of antimicrobials for prescribers and consumers Ministry of NHSR& C, NIH, DRAP, NFS&R, DOH, Relevant HDPs Knowledge level measured by surveys. social media reach 02.05 Engaging communicating leaders/religious clan, media influencers and civil societies in AMR awareness-raising campaigns Ministry of NHSR&C, NIH, Ministry of religious affairs, No. of groups engaged. No of programs conducted 02.06 Include basics of AMR prevention in high-school curricula. Ministry of NHSR&C, NIH, Education, Depts. of Education, HEC, federal and provincial educational boards No of provinces that included AMR/IPC in curriculum. % of education institutions implementing the curriculum Awareness levels among school children 02.07 Include content on AMR/IPC in college/university curriculum Ministry of NHSR&C, NIH, Education, Depts. of Education, No. of universities with AMR/IPC in curriculum. 21 HEC, federal and provincial educational boards Universities, Colleges, No of trainings sessions conducted for university faculties Awareness levels among college/university students 02.08 Incorporation of AMR related questions into existing national surveys, DHS, and readiness assessments Ministry of NHSR&C, NIH. National Institute of Population Studies (NIPS) No. of Surveys incorporating AMR related questions. Awareness among populations. No. of reports generated and published on AMR awareness. Frequency and reach of press briefings/releases disseminating AMR data and situation updates. Intervention 2: Establish and promote AMR in education and training on AMR for professionals 02.09 Develop/adapt and include AMR in professional education (preservice) and training programs for HCPs, environment professionals, veterinarians and agricultural/aquaculture extension workers and officers PMDC; PVMC; PNC; Pharmacy Council No. of councils adapting the curriculum No. of training programs, certificate courses, and diplomas No. of institutions using AMR curriculum for education and training No. of people enrolled in these programs and courses 02.10 Development of customized training modules on AMR for One Health professionals Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, WHO No. of Modules developed and implemented. 22 02.11 Refresher training of practitioners in public & private HCFs including hospitals, community (Health and Veterinary sectors) Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, WHO No. of trainings conducted. No. of people trained/attended CMEs. % of trainees with appropriate knowledge and skill. 02.12 Education and training on antimicrobial stewardship programs for healthcare professionals Ministry of NHSR&C, NIH, professional councils No. of trainings conducted. No. of people trained/attended CMEs. % of trainees with appropriate knowledge and skill. Objective 3: Strengthen AMR surveillance across sectors to generate quality data for policy actions. Intervention 1: Strengthening AMR coordinating centres and reference laboratories in all sectors No Activity Responsibility Indicators Cost Estimate 03.01 National & provincial AMR surveillance coordination centres in all sectors (Health, Veterinary, Agriculture & Environment) Ministry of NHSR&C, NIH NFS&R, CC/ EPA, Ministry of water resources, Provincial Health, Agriculture &Livestock Departments, WHO, NIH No. provinces with AMR coordination centres No. notified centres 03.02 Notification and strengthening of National, provincial, and regional reference/ referral labs in all sectors Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, Ministry of climate change, Ministry of water resources No. of Labs as per relevant ISO standards No. of Functional labs Intervention 2: Strengthening integrated AMR surveillance 23 03.03 Sector specific AMR surveillance plans in alignment with national strategies for all sectors Ministry of NHSR&C, NIH, NFS&R, CC/EPA, Provincial Health & Livestock Departments, WHO, Ministry of climate change, Ministry of water resources No. of Sector specific plans, Strategies available and disseminated. Lists of Priority MDRO pathogens 03.04 Strengthening of AMR sentinel laboratories for human health, Veterinary sectors, Food and agriculture aquaculture, and environment Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments Functional AMR surveillance sites in each sector 03.04 Integrated AMR surveillance capacities Ministry of NHSR&C, NIH, NFS&R, Provincial Health & Livestock Departments, WHO Ministry of climate change, Ministry of water resources No. of sectors participating No. of Focal persons nominated across sectors No. of AMR surveillance sites No. of sectors with regular data sharing No. of MOU, Sectors and SOPs available and used updated priority pathogens list Intervention 3: Genomic surveillance and healthcare associated infections surveillance 03.05 AMR Genomic surveillance for selected priority pathogens at NRLs Ministry of NHSR&C, NIH, NFS&R, CC/EPA, No. of pathogens No. of studies No. of NRLs for AMR Genomic surveillance 03.06 HAI Surveillance Ministry of NHSR&C, NIH No. of sentinel HAI sites HAI indicators 24 Intervention 4: Ensuring quality through SOPs and EQA systems in health sector 03.07 Development of standardized Lab diagnostic guidelines/ SOPs for Antimicrobial Susceptibility Testing (AST) bacteriology, and mycology protocols in all sectors National Reference Labs, (NIH, NVL, NRLPD) EPA, PCRWR, Provincial Health & Livestock Departments No. of Functioning sites No. of SOPs No. of sites following SOPs EQA results 03.08 Strengthening EQA/NEQAS in all sectors NRLs No of EQA labs EQA results No. of Assessments Reports No. of Trainings conducted No. of Personnel trained Objective 4: Reduce infection through effective water, hygiene, and sanitation, vaccination, and infection prevention and control (IPC) measures. Intervention 1: Create a formal organizational structure for development and implementation of IPC policies and strategies No Activity Responsibility Indicators Cost Estimate 04.01 Strengthening national IPC unit in the human health sector. Ministry of NHSR&C, NIH No. of TORs No. of meetings with minutes of meetings available. 04.02 Establishing national biosafety/ biosecurity Committee for livestock, fisheries and aquaculture sectors established. Livestock Departments No. of TORs No. of meetings with minutes of meetings available. 04.03 Establishment of provincial/regional IPC Units Ministry of NHSR&C, NIH, Provincial Health & District Management No. of IPC Units established at each level, No. of notification and No. of meetings, No. of TORs and No. of committees finalized. 25 04.04 Establishment of provincial/regional In Farm biosafety biosecurity Committees Livestock Departments No. of Provincial InFarm committees. No. of TORs No. of meetings with minutes of meetings available at various levels. 04.05 Functional IPC teams and committees with focal persons in tertiary care public hospitals. Ministry of NHSR&C, NIH, NFS&R, Provincial Health departments. No. of tertiary care hospitals with IPC control teams and committees. No. of joint meetings 04.06 Development, revision/dissemination, and implementation of national IPC guidelines Ministry of NHSR&C, NIH, NFS&R, Provincial Health No. of healthcare facilities implementing the national IPC guidelines. Compliance with the IPC guidelines /SOPs across healthcare settings. 04.07 Development, revision/dissemination, and implementation of farm biosafety/ biosecurity guidelines Livestock Departments /DOH, EPAs. Intervention 2: Availability of trained human resource at all levels 04.08 Availability of IPC trained healthcare workers in healthcare facilities. Ministry of NHSR&C, NIH / DOH % of tertiary facilities with full-time IPC HCWs No. of tertiary facilities with1 IPC nurse per 150-200 beds. % of secondary and primary facilities with trained IPC HCWs 04.09 Availability of infectious diseases (ID) professionals in every teaching hospital. Ministry of NHSR&C, NIH/ DOH % of teaching hospitals with dedicated ID physicians/ID trained physicians % of teaching hospitals with ID trained clinical pharmacists 26 04.10 IPC structures at HCFs Ministry of NHSR&C, NIH/ DOH No. of HCFs with core structures as per ToRs Intervention 3: Enable conducive environment for IPC in health care settings and in the community following People- Centred approach. 04.11 Regular mapping and monitoring availability of clean water supply systems for drinking and clinical purposes in all HCFs Ministry of NHSR&C, NIH, DOH/ Provincial allied departments, WASA and local government (e.g.CDA in Isb) No. of water quality assessments conducted in healthcare facilities % of healthcare facilities with clean water supply systems 04.12 Strengthen sterilization and disinfection/CSSD (as per standards (WHO/CDC) as appropriate to levels of care DOH, Regulatory bodies, Healthcare commission No. of healthcare facilities with operational CSSD and isolation facilities. No. of HCFs with dedicated HR and supplies for CSSD, sterilization & disinfection. 04.13 Strengthen the enforcement of isolation protocols/high containment rooms/areas inn hospitals DOH No. and % of hospitals where containment /isolation facilities area available 04.14 Develop, adopt and enforce and apply IPC building codes for health care facilities Ministry of NHSR&C, NIH/ IPC FP/ NIH/ DOH, EPA, Building and Works Department No. of inspections or audits conducted to ensure adherence to IPC building codes No. of healthcare facilities that have adopted IPC building codes. % compliance with IPC building codes across healthcare facilities. 04.15 Improving IPC and waste management practices Ministry of NHSR&C, NIH, NFS&R, Health & Livestock Departments, Federal and provincial EPA’s, Academia No. of inspections or audits conducted to ensure adherence to Hospital Waste Management rules 27 % compliance with Hospital Waste Management rules. 04.16 Monitoring of occupational and HCWs safety DOH % of Vaccination coverage No. &% of HCWs infections No. &% of HCAI infections Intervention 4: Strengthen animal health and agricultural/agrifood/aqua and environment sector IPC practices 04.17 Implementation of farm biosafety biosecurity guidelines in livestock, poultry, aquaculture Ministry of NFS&R/L&DD No. sectors with guidelines No. and % of animal health workers vaccinated No. provinces with vaccine producing units 04.18 Development & Implementation of Safe production/hygienic standards of food from animal origin Ministry of NFS&R, Livestock Departments, Federal and Provincial EPA’s, Local Governments % of slaughterhouses with standard hygiene practices 04.19 Zoonotic and food borne outbreaks detection, response, and containment. Ministry of NFS&R Agriculture & Livestock Departments, FAO, WHO Food Safety Authority No. of quarantine facilities at checkpoints No. and % of food storage units following SOPs Intervention 5: Prevention of infections through better Water sanitation and hygiene including waste management and improved vaccination coverage 04.20 Water treatment and quality monitoring WASA/ local gov WASA/ Municipality/ District Governments /DOH, EPA - Federal and Provincial PCRWR % of household with safe water supply e. coli load from water samples 04.21 Solid and infectious waste segregation. WASA/ DOH/ Ministry of Climate Change, Local % HCFs with colour coded bins % HCFs following SOPs. 28 Government, fed, Federal and provincial EPAs. % HCFs with trained HCWs on waste segregation %HCFs following waste disposal as per SOPs 04.22 Use of vaccines for VPDs to minimize antimicrobial use in both human and animal sector Ministry of NHSR&C, NIH, NFS&R, Health & Livestock Departments, WHO, FDI, Provincial EPI No. of new vaccines added to national immunization programmes Vaccination coverage Objective 5: Optimize the use of antimicrobial medicines in human and animal health. Intervention 1: Strengthening existing rules and regulation on manufacture, prescribing, sales and use of antimicrobials No Activity Responsibility Indicator Cost Estimate 05.01 Review and update Access, Watch and Reserve (AWaRe) & National essential medicines list (EML) supported by local data DRAP, Ministry of NHSR&C, NFS&R, Health & EML list AWaRe classification in EML AWaRe share, % Access, Access: Watch ratio 05.02 Standardize record keeping mechanism for antimicrobial sale and use at all levels (pharmacies, medical & veterinary hospitals/ GPs) DRAP/ Ministry of NHSR&C, NFS&R, Health & Livestock Departments, % inspections conducted in point of sales and use %adherence to record keeping norms 05.03 Strengthening of quality testing facilities testing laboratories (DTLs) for antimicrobials DRAP (federal and provincial)/ DOH No. of DTLs accredited for antimicrobial drug testing No. of ISO certified drug testing labs % spurious, falsified, and substandard medicines 05.04 Improving availability, quality, and affordability of antimicrobials DRAP (federal and provincial)/ DOH No. of reported shortages No. of spurious and substandard, and falsified antimicrobials drugs Affordability and availability 29 % HCFs reporting availability of EML antibiotics as per AWaRe list Intervention 2: Measuring antimicrobial (human/ veterinary/agrifood/environment/aqua) use 05.05 Development of AMU surveillance plan at national and provincial levels across sectors DRAP/ Ministry of NHSR&C, NFS&R, Health & Livestock Departments, Surveillance plan with timelines No. of M& E Indicators No. of Tools No. of Materials developed No. of Training No. of Skilled HR No. of provinces reporting and regularly using M&E indicators No. of Annual reports 05.06 Capacity building on generating and use of data at national and provincial levels across sectors 05.07 Regular monitoring of antimicrobial use at national and provincial levels across sectors No. of Data available on antimicrobial product registrations No. of import versus export of AWaRe composition GLASS AMU, ANIMUSE, INFARM reporting National level joint dashboards Annual report on consumption 05.08 Regular monitoring of antimicrobial use at HCFs Provincial MoH and provincial DRAP No. of HCFs using the M&E plan % HCFs with regular data collection % HCFs with regular review meetings Intervention 3: Implementation of antimicrobial stewardship program at HCFs 05.09 Development/adaptation antimicrobial stewardship implementation guidelines at national level No. of Antimicrobial stewardship Guidelines No. of training /workshop No. of training tools developed/adapted 30 05.10 Development of facility specific antibiotic use guidelines for tertiary care Ministry of NHSR&C, NFS&R, Health & Livestock Departments, WHO, Health Care Commissions/priva te sector No. of HCFs with antibiotic use guidelines % adherence to guidelines % empirical versus targeted antimicrobial use No. of facilities generating antibiograms Antibiotic use prevalence AWaRe use % top 5 antimicrobial use Level of appropriateness of antimicrobials use. 05.11 Establishing ASP at tertiary level hospitals DRAP, Ministry of NHSR&C, WHO, Health Care Commissions No. of hospitals conducting ASP Assessment scores No. of antimicrobial use prevalence AWaRe use % Top 5 antimicrobials used. 05.12 Programme for appropriate antibiotic use at the Primary care. Ministry of NHSR&C, Departments, WHO, Health Care Commissions/priva te sector/professional associations No. of PHCs conducting PPS/prescription audit antimicrobial use prevalence No. of prescribers using mobile application No. of HCWs adopting guidelines AWaRe use % Top 5 antimicrobials used. Intervention 4: Rationalize use of antimicrobials as growth promoters & prophylaxis aligned in veterinary, agriculture, and aquaculture 05.13 Baseline survey on usage of antimicrobials as growth promoters in animal feed industry including assessment of feed (utilization audit) DRAP/ Ministry of NFS&R, AHC No. of List and quantity and antimicrobial used No. of surveys 31 05.14 National strategy for the control of antimicrobials usage as growth promoters and prophylaxis in veterinary/agriculture/ aqua /industry sector DRAP/ Ministry of NFS&R/ DOH, AHC PL&DD, PL&DD, AHC, Provincial Livestock Departments No. of phasing out of critically important antibiotics from non-human sectors Objective 6: Develop economic case for sustainable investment based on research studies focused on country needs Intervention 1: Mapping of AMR research landscape and priority setting No Activity Responsibility Indicator Cost Estimate 06.01 Mapping of available resources for AMR research Ministry of NHSR&C/ Ministry of NFS&R/ PHRC/ DOH/ HRIHEIs/Focal Person from each Province No. of resources identified No. of priority list for AMR research 06.02 Development of national AMR research priority setting No. of AMR studies and publications No. of AMR research proposals AMR and AMU data Intervention 2: Capacity building and designing and conducting research in priority areas 06.03 Capacity building on AMR research Ministry of NHSR&C/ Ministry of NFS&R/ PHRC/ DOH/HRIHEIs/Focal Person from each Province No. of AMR studies and publications No. of AMR research proposals No. of workshops No. of fellowships No. of grants 06.04 Design and conduct studies as per global, regional and national priorities Ministry of NHSR&C, NFS&R, No. of AMR studies and publications No. of operational research 32 Health & Livestock Departments, WHO, FAO DRAP/P&D/PSWR/ Provincial Health Department HEC/ Academia/ DOH/P&D/NIH/ AMRN No. of research used in policy changes 33 NAP AMR 2.0 COSTING ESTIMATES The overall aggregate cost for AMR NAP is PKR. 13,258.8 million. As compared to the later years, approximately 50% of the total NAP costs are allocated to Years 2026 and 2027, reflecting the peak investment period driven by major activities such as strengthening AMR surveillance, infection prevention measures, and system-wide interventions. The initial year (2025) primarily focuses on foundational investments, including governance setup, awareness campaigns, and capacity building (Tool with full detail of costing is attached Annex-1). The outer years (2028 and 2029) reflect a gradual shift toward operational costs, sustainability measures, and research-related activities (Detail of costing sheet is attached as annex- 2). Objective wise Breakdown The following table provides a year-wise breakup of NAP costs (amount in Million PKR) across its key objectives: Sr. No. Objectives 2025 2026 2027 2028 2029 Total Cost 1 Governance and Financing 1 140 154 152 166 613 2 Awareness and Education 32 89 74 66 23 284 3 Strengthen AMR surveillance across sectors 855 1,268 1,304 1,456 1,374 6,257 4 Reduce infections through WASH, vaccination, and IPC 27 1,559 1,597 1,726 972 5,880 5 Optimize use of antimicrobial medicines 12 72 22 7 2 115 6 Develop an economic case on research 2 13 24 60 9 109 This allocation reflects a phased approach, prioritizing critical infrastructure and interventions in the earlier years while ensuring continuity and operational efficiency in subsequent years. The NAP has six objectives, each addressing a key area of the AMR response for Pakistan. However, based on the activities identified under each area, Objectives 3 (Strengthen AMR Surveillance across sectors) and 4 (Reduce infections through WASH, vaccination, and IPC) account for nearly 85% of the overall NAP 34 response. This is largely driven by civil works for laboratories, procurement of equipment, and staffing and operational expenses required to enhance AMR surveillance and reduce infections effectively. Objective 1 (Governance and Financing) focuses on improving coordination mechanisms and supporting the establishment of an AMR secretariat at the National Institute of Health, the designated AMR focal point for Pakistan in the Human Health sector. This objective accounts for a smaller portion of the budget as it primarily focuses on governance and coordination efforts. At the federal level, Objectives 5 (Optimize the use of antimicrobials in human and animal health) and 6 (Develop an economic case for sustainable investment based on research) are largely comprised of costs for technical assistance in specific areas. Hence, their cost estimates are significantly lower compared to other objectives. Figure 1 illustrates the percentage of NAP costs by objective. As noted earlier, the NAP costs have been categorized into specific cost categories, detailed in the methodology section. Technical assistance makes up about 2.8% of the total NAP cost. The key requirements for technical assistance include expertise in the Animal Sector, Public Health, Environmental Health, Senior Epidemiology, Surveillance, Data Analysis, and Financial Management. Training, seminars, and meeting costs are estimated based on the projected number of participants expected to attend capacity development workshops, trainings, seminars, and meetings. This category contributes to 2% of the total cost and includes facilitator fees, venue costs, meals, and other miscellaneous expenses. Approximately 9.5 % of the total cost has been allocated to the Human Resource category. Based on discussions with key stakeholders, cost estimates for the addition of new staff assume their recruitment as permanent government employees with remuneration set according to GOP pay scales. The total cost for 0 2,000,000,000 4,000,000,000 6,000,000,000 8,000,000,000 10,000,000,000 12,000,000,000 14,000,000,000 Objective wise Yearly Cost Summary 2025 2026 2027 2028 2029 Total 35 human resources is estimated at PKR 7,131 million Key HR categories include National Coordinator, Epidemiologists, Microbiologists, Laboratory Staff, Data Analysts, and support personnel. In terms of hospital and laboratory support, approximately 85% of the total NAP cost has been allocated for the procurement activities which includes refurbishment and civil works of AMR reference laboratories, including procurement of new laboratory equipment. The "Others" category, which includes courier costs for specimen transport, preparation and dissemination of IEC material, software maintenance, monitoring visits, and AMR secretariat costs, constitutes approximately 3 % of the total NAP cost. Sectoral Investment Breakdown Given the One Health nature of AMR, the financial framework supports interventions across multiple sectors to address the interconnectedness of antimicrobial resistance in human, animal, and environmental health. The distribution of costs across these sectors is as follows: Sector Total Cost (PKR Million) % of Total Budget Human Health 2,002 15% Animal Health 202 2% Environmental Health 1.8 0.05% Multisectoral Interventions (One Health) 11,052.22 83% Total 3,303.72 100% The predominant allocation to multisectoral interventions (83%) highlights the integrated governance, surveillance, and stewardship strategies necessary to combat AMR at a national level. Investments in human and animal health ensure rational antimicrobial use, enhanced diagnostics, and regulatory reforms, while environmental health interventions focus on antimicrobial residues, waste management, and pollution control. 0% 10% 0%1% 85% 3%1%0% Category Wise Cost Estimates Field visit HR Meeting Other Procurement Technical assistance Training Workshop 36 KEY INTERVENTIONS AND RESOURCE ALLOCATION The financial estimates include specific, high-impact interventions, ensuring strategic deployment of resources across core AMR response areas. The financial plan also includes the upgradation of 10 hospitals and 15 laboratories, ensuring enhanced diagnostic capacity, infection prevention, and surveillance capabilities across Pakistan. Objectives and Interventions 2025 2026 2027 2028 2029 Total Objective 1: Governance and Financing 0.9 140.1 153.7 152.0 166.4 613.1 Intervention 1.1: Establishment of AMR governance and financing mechanisms 0.4 134.5 142.2 150.5 165.6 593.2 Intervention 1.2: Coordination and harmonization of activities on AMR 0.5 1.2 0.6 1.4 0.8 4.6 Intervention 1.3: Strengthening existing rules and regulations across sectors to address AMR 0.0 4.4 10.9 0.0 0.0 15.3 Objective 2: Awareness and understanding through communication and education, 32.2 88.9 73.7 66.2 23.2 284.2 Intervention 2.1: Establish and implement AMR awareness and behaviour change strategy 32.2 51.8 40.3 29.4 21.9 175.7 Intervention 2.2: Establish and promote AMR in education and training on AMR for professionals 0.0 37.0 33.4 36.7 1.3 108.5 Objective 3: AMR surveillance 855.4 1,268.0 1,304.0 1,455.8 1,373.6 6,256.8 Intervention 3.1: Strengthening AMR coordinating centres and reference laboratories in all sectors 841.5 997.3 1,125.5 1,286.4 1,333.6 5,584.4 Intervention 3.2: Genomic surveillance and healthcare associated infections surveillance 0.0 266.9 169.2 159.2 28.9 624.1 Intervention 3.3: Ensuring quality through SOPs and EQA systems in health sector 13.9 3.8 9.2 10.2 11.2 48.3 Objective 4: AMR – Infection prevention and control (IPC) measures 26.5 1,558.8 1,597.1 1,725.8 971.9 5,880.2 Intervention 4.1: Create a formal organizational structure for development and implementation of IPC policies and strategies 7.8 36.5 34.1 36.6 40.3 155.3 Intervention 4.2: Availability of trained human resource at all levels 18.7 9.8 9.1 8.8 0.7 47.0 37 Intervention 4.3: Enable conducive environment for IPC in health care settings and in the community following People- Centred approach. 0.0 1,512.2 1,509.8 1,655.3 910.1 5,587.4 Intervention 4.4: Strengthen animal health and agricultural/agrifood/aqua and environment sector IPC practices 0.0 0.0 35.4 21.9 20.8 78.1 Intervention 4.5: Prevention of infections through better Water sanitation and hygiene including waste management and improved vaccination coverage 0.0 0.4 8.7 3.2 0.0 12.3 Objective 5: AMS - Antimicrobial Medicines in Human and Animal Health 12.3 72.2 22.2 6.6 1.8 115.0 Intervention 5.1: Strengthening existing rules and regulations on manufacture, prescribing, sales, and use of antimicrobials 3.3 19.3 0.0 0.0 0.0 22.6 Intervention 5.2: Measuring antimicrobial (human/veterinary/agrifood/environment/aqua) use 0.9 24.8 12.2 0.7 0.8 39.5 Intervention 5.3: Implementation of antimicrobial stewardship program at HCFs 0.0 4.5 9.9 5.9 1.0 21.4 Intervention 5.4: Rationalize use of antimicrobials as growth promoters & prophylaxis in veterinary, agriculture, and aquaculture 8.0 23.5 0.0 0.0 0.0 31.5 Objective 6: Sustainable Investment Based on Research Studies 2.4 13.4 23.9 60.3 9.4 109.5 Intervention 6.1: Mapping of AMR research landscape and priority setting 2.4 6.5 0.0 0.0 0.0 8.9 Intervention 6.2: Capacity building and designing and conducting research in priority areas 0.0 6.9 23.9 60.3 9.4 100.5 Total 929.8 3,141.4 3,174.7 3,466.6 2,546.3 13,258.8 Expenditure Categories The distribution of costs across expenditure categories ensures a balanced allocation between infrastructure development, capacity building, and operational sustainability: 38 Cost Category Total Cost (PKR Million) % of Total Budget Procurement 11,267.7 85.0% Human Resources 1,261.1 9.5% Technical Assistance 407.0 3.1% Training & Capacity Building 211.6 1.7% Workshops & Meetings 100.5 0.9% Field Visits & Operational Support 1.67 0.05% Total 13,258.8 100% ● Over 85% of the total budget is allocated to procurement, ensuring the availability of critical hospital, laboratory equipment, and Office related equipment, IPC supplies, and infrastructure upgrades. ● 9.5% is dedicated to human resources, emphasizing the need for trained personnel, capacity building, and intersectoral workforce development. ● 3.1% is allocated to technical assistance, covering policy development, research, and expert consultations to strengthen evidence-based decision-making. IMPLEMENTATION FRAMEWORK FOR NAP 2.0 Roles and Responsibilities of Key Stakeholders The implementation of Pakistan’s National Operational Plan 2.0 for AMR involves a broad range of key stakeholders, each with defined roles and responsibilities to ensure effective, multisectoral coordination. The Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) and the National Institute of Health (NIH) serve as central coordinating bodies, overseeing governance, surveillance, awareness, infection prevention, and antimicrobial stewardship activities across human health. The Drug Regulatory Authority of Pakistan (DRAP) is responsible for strengthening legislation, regulating the manufacture, sale, and use of antimicrobials, and ensuring the quality of medicines. The Ministry of National Food Security & Research (NFS&R) and provincial livestock and agriculture departments lead interventions in veterinary, agriculture, and aquaculture sectors, including biosecurity, vaccination, and reduction of antimicrobials as growth promoters. The Ministry of Climate Change and federal/provincial Environmental Protection Agencies (EPAs) address AMR risks in the environment, including water, waste management, and pesticide residue monitoring. Professional councils (PMDC, PVMC, PNC, Pharmacy Council) integrate AMR into professional education and training. Provincial and district health departments implement AMR, IPC, and stewardship programs at subnational and facility levels. Academia and research institutions contribute to AMR research, capacity building, and innovation, while WHO, FAO, and other development partners provide technical guidance, capacity support, and facilitate global reporting. Civil society, media, and community leaders are engaged to promote awareness, behaviour change, and community participation in AMR prevention efforts. Together, these stakeholders ensure a One Health, coordinated, and evidence-based approach to containing antimicrobial resistance in Pakistan. 39 7. MONITORING, EVALUATION, AND LEARNING (MEL) SYSTEM The monitoring and evaluation (M&E) of Pakistan’s National Action Plan on Antimicrobial Resistance (NAP AMR 2.0) (2025-2028) follows a structured Results-Based Framework aligned with WHO guidelines. Governance is led by the National AMR Secretariat, supported by Technical Working Groups (TWGs) across One Health sectors. Key indicators track progress in governance, awareness, surveillance, infection prevention, antimicrobial use optimization, and research. Data will be collected annually or biennially, based on national and provincial priorities and reporting system through government reports, surveillance systems, and implementation reviews, with responsibilities assigned to relevant ministries and departments along with development partners. Baseline and target values will help to ensure measurable outcomes, such as increased regulatory measures, trained professionals, and improved surveillance etc. Regular reviews and stakeholder engagement enhance accountability, ensuring effective implementation and adaptive management of the NAP AMR 2.0 (Detailed M&E plan is annexed at annexture-2). 8. IMPLEMENTATION ROADMAP AND WAY FORWARD The implementation of Pakistan’s NAP 2.0 will follow a phased approach to ensure systematic progress, institutional strengthening, and sustainable impact. In the foundational phase (short term, 1–2 years), the National Institute of Health (NIH), as the federal coordinating body, will focus on strengthening governance structures, operationalizing the Multistakeholder Intersectoral Steering Committee (MISC), formalizing Technical Working Groups, and enhancing the capacity of AMR focal points at federal and provincial levels. This phase will prioritize the integration of AMR/AMU data systems, the development of national guidelines, and the initiation of high-impact awareness campaigns. In the consolidation phase (medium term, 3–5 years), the focus will shift to expanding surveillance coverage across human, animal, and environmental sectors; implementing antimicrobial stewardship programs in tertiary and secondary care hospitals; integrating AMR into veterinary and environmental monitoring systems; and scaling up laboratory capacity for AMR diagnostics. NIH will coordinate implementation through regular MISC and TWG meetings, joint work planning with provincial health departments, and close collaboration with partner ministries, academia, and civil society to address intersectoral dependencies such as data sharing, laboratory networks, and joint capacity building. Resource mobilization will combine domestic budget allocations with external funding from development partners, leveraging project-based proposals aligned with NAP objectives. Monitoring and evaluation will track milestones at each phase, enabling mid-course corrections, documenting best practices, and ensuring alignment with the One Health approach to contain AMR in Pakistan. 40 References: 1. Alara, J.A. and O.R.J.I.D.-D.T. Alara, An overview of the global alarming increase of multiple drug resistant: a major challenge in clinical diagnosis. 2024. 24(3): p. 26-42. 2. 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Antibiotics. 2024 Feb 22;13(3):206. https://www.who.int/health-topics/one-health https://doi.org/10.1093/jac/dkw054 42 ANNEXURES ANNEXURE-1: SWOT analysis Human Health STRENGTHS WEAKNESSES ▪ Existing NAP as a guiding document for NAP 2.0 ▪ Multisectoral coordination mechanism. ▪ PC-1 developed for National AMR&IPC Program since 2020. ▪ Biannual AMR newsletter, covering all three sectors. ▪ AMR Surveillance Strategies for Human Health (2024). developed and disseminated by NIH. ▪ Quality assured network of laboratories in place. ▪ National data of AMR surveillance from 26 labs, since 2017. ▪ National AMC data reporting in GLASS from 2023. ▪ Substantial MDR-TB data available. ▪ HAI’s surveillance piloted in 6 tertiary care hospitals. ▪ Drug Act 1976 and DRAP Act 2012 in place. ▪ 4 out of 11 DTLs WHO pre-qualified. ▪ Quality control boards for control of spurious and falsified medication. ▪ National IPC Guidelines in place. ▪ National TWG on IPC and Provincial committees in place. ▪ Public Health Act on IPC. ▪ Extensive HCWs training during COVID-19 ▪ Antimicrobial stewardship program established in few private hospitals. ▪ National Guidelines for hospital waste management in place ▪ Few private hospitals exhibit optimal compliance with cleaning and sterilization 1. ▪ NAP lacks mechanisms for governance and monitoring of long-term behaviour change. ▪ Provincial action plans not yet developed ▪ Weak coordination between national and provincial levels, and between sectors too. ▪ No Standardized surveillance approach. ▪ No regular Surveillance system in environment sector ▪ Culture testing preferred in cases with treatment failure for improved representativeness of data. ▪ Adoption of standard MDROs list needed. ▪ No SOPs for MDROs management. ▪ Lack of national antibiogram and national AWaRE list. ▪ No standard National Treatment Guidelines for antimicrobials use present. ▪ Lack of infrastructure to implement an electronic record of antibiotic prescription and retail invoice. ▪ Stewardship programs in only few private sector hospitals. ▪ No specific regulations for growth promoters, medicated feeds, and pesticides ▪ Water chlorination required to ensure safe water supply. ▪ Suboptimal regulation of private sector. ▪ Lack of standardization in sterilization services ▪ Lack of AMR topics in medical and paramedical curriculum. OPPORTUNITIES 2. THREATS ▪ Collaborative projects for AMR surveillance under One Health umbrella. ▪ Expansion of AMR, NEQAS, and AMC surveillance sites and strengthening on data reporting. ▪ Provincial Health Care Commissions (Punjab, Sindh, KP, Baluchistan, and ICT) are in place and can be leveraged. 3. ▪ Lack of sustainable indigenous resources and funds for smooth execution of AMR program. ▪ Non-availability of dedicated, domestic funding for AMR. ▪ Shifting of focus and political will to other competing political and economic priorities. ▪ High cost for existing and new diagnostics and limited access to expensive diagnostics. 43 ▪ Engaging NGOs and civil societies for community awareness and education on AMR. ▪ Incorporate people centred and gender focused lens. ▪ Using new media platforms (social media, podcast etc.) for awareness, education, and training of AMR. ▪ Politicians and policy makers can be further sensitized and continually engaged to improve political ownership and governance of the AMR agenda. ▪ Enhancing the scope of AMR research by engaging different academic institutes. ▪ Highlighting National AMR success stories at international level to seek political interest. ▪ Development partners supporting the public sector to strengthen the AMR surveillance network. ▪ ▪ Interests of professionals and pharmaceutical industry may not align to AMR agendas. ▪ Reluctance in data sharing due to devolution of health sector. ▪ Time-limited and project-focused funding can affect long term planning. ▪ Shrinking fiscal space. ▪ Import of substandard equipment and supplies. 44 Animal Health STRENGTHS WEAKNESSES ▪ NAP 2.0 includes most livestock-related activities recommended by WOAH and FAO. ▪ National AMR surveillance strategies for healthy and diseased animals, aquaculture, and food-animal- environment are developed and partially implemented. ▪ Well-established National Reference Labs for veterinary (NVL) and poultry (NRLPD) sectors with Quality Management Systems. ▪ Enrolment of AMR sites with quality assurance (NEQAS). ▪ Coordination mechanism established at the national level. ▪ The National Laboratory Networking Group for the animal health sector has been established and notified by MoNFS&R. ▪ AMR/AMU surveillance data is shared with the AMR Secretariat and published in the AMR newsletter at NIH. ▪ Pakistan has enrolled in InFARM (FAO) and regularly submits AMU/C data to Animuse (WOAH). ▪ Seminars, competitions, and media campaigns and farmers engagement during World Antimicrobial Awareness Week. ▪ National veterinary laboratory policies and guidelines are developed. ▪ Antimicrobial use prescription guidelines for veterinarians in Pakistan developed. ▪ Vaccines for key animal diseases available. ▪ AMR surveillance dashboard has been developed for the KP and Sindh provinces. 4. ▪ Lack of surveillance strategies for provinces. ▪ Effective multisector coordination. ▪ Lack of sensitization and harmonization of SOPs among public and private laboratories. ▪ No legislation to govern over-the-counter sale of antimicrobials in the animal health sector. ▪ Updated veterinary curriculum regarding AMR not available. Veterinarians lack adequate training. ▪ Stewardship programs lacking. ▪ Lack of effective regulations for antibiotics used as growth promoters and in medicated feed. ▪ Insufficient AMR research and training programs. ▪ Unregistered medicines and falsified antimicrobials used extensively at the farm level. ▪ There is a lack of evidence-based research for effective interventions and therapeutics as alternatives to antimicrobials. OPPORTUNITIES 5. THREATS ▪ The Animal Health Act 2022 has been submitted to the cabinet for approval. ▪ Collaborative projects for AMR surveillance (e.g., Tricycle and CRE projects) implemented at national and provincial levels under the One Health umbrella. ▪ AMR and prudent antimicrobial use incorporated into para-veterinary and farmer training programs. 6. ▪ Farmers and veterinarians may prioritize economic gains over responsible antimicrobial use. ▪ Inadequate enforcement of antimicrobial use regulations at the provincial level could hinder progress. 45 ▪ Established health and livestock infrastructure can support the surveillance system. Environment Sector STRENGTHS WEAKNESSES ▪ Technical Working Group (TWG) for AMR surveillance strategy has been constituted. ▪ Under Pak- EPA, the Central Laboratory of Environmental Analysis and Networking (CLEAN) for microbial analysis of environmental samples i.e. Water (Drinking, waste, surface, ground, stream and reservoirs) and air present. ▪ The CLEAN lab has well qualified microbiologists and technical staff. ▪ Pakistan Council of Research in Water Resources (PCRWR) is having a well-established laboratory (National Water Quality Laboratory-NWQL) for detection of pathogens in water. ▪ Facilities of Culture sensitivity available at PCRWR molecular lab. ▪ Executing One health collaborative projects as tricycle. ▪ PCRWR has necessary infrastructure/equipment for monitoring of antibiotics residues. 7. ▪ Lack of policy guidelines for prevention of antibiotics pollution. ▪ No standardized framework/strategy for environmental AMR surveillance in drinking water, wastewater. ▪ Non-existence of designated national reference laboratory for environmental surveillance of AMR ▪ The lack of funds and advanced laboratories for AMR monitoring (Pak-EPA and Provincial EPAs). ▪ The scarcity of trained human resource and financial constraints at PCRWR laboratories. OPPORTUNITIES 8. THREATS ▪ Implementation of Environmental Samples Rules, 2001 established under Section 31 of PEPA act 1997. ▪ Broadening the scope of research on microbiological analysis of environmental samples. ▪ Designation of environmental AMR surveillance sites. ▪ Enrolment of environmental AMR surveillance sites to NEQAS, and national antimicrobial surveillance system. ▪ Planning of similar One health projects as tricycle and CRE. ▪ Monitoring and reporting on antibiotics residues. 9. ▪ Political instability, governance ▪ Non-sustainability of resources (financial and trained human resource) ▪ Climate change/ global warming ▪ Catastrophes like flooding, drought. ▪ Ever increasing human population. 46 ANNEXURE-2: M&E Plan [Pakistan] [NAP version no2.] [NAP 2025-2028] Results Based M&E Framework SN Type of Indicato r (Result) Activities Indicator (title/small description) Data source (including collection methods) Frequency of data collection Responsibilit y (key entity, if there are more than one) Assu mptio ns Baselin e Overa ll Target Actual/ achievement Objective 1: Enhance governance, coordination, and regulatory frameworks for AMR 1 Long term outcom e Advocacy for regulatory oversight for enforcement of Drug Act 1976 and DRAP Act 2012; Legislations to include pesticides/fungici des/insecticides; Monitor pesticide residue Number of legal or regulatory or policy measures taken based on the recommendations of SC Government circulars/notifications on legal regulatory or policy measures Annually DRAP/ Ministry of NHSR&C, NFS&R, Health & Livestock Provincial Departments , Ministry of Law & Justice Division 0 4 legal or regula tory measu res Improved regulation of antimicrobial use in all relevant sectors Decrease in the inappropriate use 47 and growth promoters 2 Short/ medium outcom e Inclusion/integra tion of AMR in other programme plans and strategies (Health systems, immunization, TB, HIV, malaria, pandemic preparedness etc.) Number of programs (e.g., immunization, XDR Typhoid, TB, HIV, malaria, NTDs etc.) that incorporate AMR in their reports Review of program reports that incorporate AMR Annually MoNHSR&C, NIH 0 4 progra ms Improved cross- collaboration 3 Short/ medium outcom e Mapping of AMR financing at national/provinci al levels Percentage change in allocation of government budget towards AMR initiatives at the national and provincial levels Annual tracking of government budgets allocated to AMR- related activities at the national and provincial levels Annually MoNHSR&C Provincial Health Departments PC-1 approv ed for 3 years, extend ed twice At least 5% annua l increa se based on prece ding year's Sustainable funds for execution of National Action Plan 2.0, Increased awareness and targeted allocation of resources for public decision making. 48 alloca tion 4 Output Revision of multistakeholder National AMR Steering Committee to include all relevant stakeholders; Conduct regular (annually) meeting of National AMR steering committee and provide recommendation s for improvement of policies and legislation based on Committee monitoring and evaluation reports and surveillance data Multistakeholder National AMR Steering Committee formally constituted with clear TORs and operationalized, ensuring regular meetings are held in alignment with the TORs Official government notification, meeting minutes to confirm the operational status of the SC Annually MoNHSR&C NIH SC exist and 3 SC meetin gs held Notify revise d MSC4 MSC meeti ng (annu al) Improved AMR coordination and collaboration. Better coordination between national and provincial AMR Secretariat cell and focal persons 5 Output Constitution of national/One Health Technical Number of thematic technical working groups (TWGs) Official government notifications, meeting minutes, and the ToRs Bi-annually Ministry of NHSR&C; NFS&R & No TWGs exit Notify 4 thema Sustained and strategic AMR governance. 49 Working Groups (TWGs) for Awareness & education, AMR surveillance, IPC, AMU, AMS, and Research with functionalization & clear ToRs constituted with clear TORs and made functional at the national level to verify the constitution and functionality of TWGs Climate Change, MoWR, Fed & Provincial EPAs tic TWGs 32 (2 meeti ngs per TWG per year) Enhanced coordination and collaboration among sectors 6 Output Strengthening the capacity of the National AMR secretariat with defined TORs and replication at provincial level; Mapping of AMR financing at national/provinci al levels Number of National and Provincial AMR Secretariats established and/or strengthened, as evidenced by government notification, availability of dedicated staff with defined TORs, and allocation of government budget Government circulars, appointment letters of dedicated staff with TORs, and govt budget documents Ministry of NHSR&C, NFS&R & Climate Change 4 (1 nationa l, 3 provinc ials in KP, GB, and Sindh) 3 (Punja b, Baluc histan , AJK) Enhanced AMR coordination for implementatio n and information sharing. Increased implementatio n of AMR activities at all levels 7 Output Update and enforce implementation of Prescription monitoring & drug sales in all relevant sectors; Number of monitoring visits conducted related to prescription monitoring, drug sales, and pesticide residues Monitoring reports and monitoring data Bi-annually DRAP PRAs HCCs NIH 0 32 (4 visits per year) Improved regulation of antimicrobial use in all relevant sectors Decrease in the inappropriate 50 Monitor pesticide residue and growth promoters use. Improved pesticide residue monitoring at high-risk areas 8 Output Meeting for high- level engagement and Advocacy for federal/provincia l secretaries, DGs, administrative heads, and political leaders to seek commitment; Inclusion/integra tion of AMR in other programme plans and strategies (Health systems, immunization, TB, HIV, malaria, pandemic preparedness etc.) Number of advocacy materials (e.g., presentations, briefs, information products, reports, newsletters) developed and disseminated Advocacy toolkits, presentations, and briefs shared with stakeholders Biannually NIH Newsle tter dissemi nated nationa lly/pro vinciall y 60 (12 per year) Strengthened multisectoral/ One Health collaboration. Improved cross- collaboration Commitment from political and administrative leaders 51 Objective 2: AMR Education and Awareness 1 Impact Development of National strategic plan for communication on AMR; Advocacy and IEC campaign for behaviour change on misuse of antimicrobials for prescribers and consumers; Conduct awareness campaigns aligned with the World AMR Awareness Week and other health days (such as Clean Hands, hand hygiene, patient safety) Percentage change in the prevalence rate of AMR in healthcare settings and the community Laboratory surveillance data and healthcare facility reports on AMR trends annually MoNHSR&C, NIH, Hospital administrati on 2 Long term Include basics of AMR prevention in high-school Number of educational institutions that Curriculum documentation and reports from need based HEC, FBISE, Provincial boards, AMR topic not Inclusi on of AMR/I Improve knowledge and awareness 52 outcom e curricula. Include content on AMR/IPC in college/universit y curriculum, Develop/adapt and include AMR in professional education (preservice) and training programs for HCPs, environment professionals, veterinarians and agricultural/aqua culture extension workers and officers incorporate AMR prevention and IPC content into their curricula educational institutions to confirm the inclusion of AMR topics in high school and college/ university programs Ministry of NHSR&C, Education, Depts. of Education, PMDC; PVMC; PNC; Pharmacy Council include d in curricul a yet PC conte nt in school , colleg e and univer sity curric ula among school, college and university students leading to behavioural change practices, Increased availability of trained professionals/s killed professionals 3 Short/m edium outcom e Education and training on antimicrobial stewardship programmes for healthcare professionals; Advocacy and IEC campaign for Percentage of trained healthcare professionals adhering to antimicrobial stewardship practices PPS and compliance audits on antimicrobial stewardship annual Ministry of NHSR&C, professional councils few private sector hospita ls are implem enting ASP Functi onal ASP in 30- 40% of major tertiar y care Better use of antibiotics 53 behaviour change on misuse of antimicrobials for prescribers and consumers progra m hospit als Short/m edium outcom e Develop/adapt and include AMR in professional education (preservice) and training programs for HCPs, environment professionals, veterinarians and agricultural/aqua culture extension workers and officers; Refresher training of practitioners in public & private HCFs including hospitals, community (Health and Percentage of trained professionals demonstrating improved knowledge and skills in AMR practices Evaluated through pre- and post-training assessments and feedback surveys collected from participants after training sessions biennial Ministry of NHSR&C, NFS&R, Provincial Health & Livestock Department s, WHO no AMR specific trainin g module s develo ped yet 30% HCPs traine d on modul es Improved knowledge and better practices Standardizatio n of practices 54 Veterinary sectors) 4 Output Conduct awareness campaigns aligned with the World AMR Awareness Week and other health days (such as Clean Hands, hand hygiene, patient safety) Advocacy and IEC campaign for behaviour change on misuse of antimicrobials for prescribers and consumers. Adapt, develop, and disseminate AMR awareness- raising materials, including at community level, targeting the general public, health professionals Number of awareness and advocacy campaigns conducted to promote AMR awareness and behaviour change Campaign reports and attendance records to quantify the number of campaigns and evaluate engagement levels Annually NIH, Ministry of NHSR&C, NFS&R, Provincial Health & Livestock Department s, WHO, MoCC, Fed and provincial EPAs, DRAP, DOH, Ministry of religious affairs WAAW comme morate d every year at federal level, and in few provinc es countr y wide celebr ation Improved knowledge and awareness among the public and district health committees, Improved behaviour and social norms in prescribers and consumers regarding misuse of antibiotics 55 (incl. pharmacists, nurses, medical doctors) and policy- makers; Engaging communicating leaders/religious clan, media influencers and civil societies in AMR awareness- raising campaigns. 5 Output Incorporation of AMR related questions into existing national surveys, DHS, and readiness assessments Number of national surveys and assessments that include AMR-related questions Review of survey instruments and reports from national health authorities to confirm the inclusion of AMR questions in national surveys and assessments NIH PSB DOH Developmen t partners Improved awareness and access to data on AMR 6 Output Education and training on antimicrobial stewardship programmes for healthcare professionals Number of healthcare professionals trained on antimicrobial stewardship Training modules, training attendance records, and training reports annual Health department s, professional councils, hospitals zero level, no trainin g module s trainin g modul es devel oped and Rational use of antimicrobials 56 develo ped trainin gs condu cted 7 Output Develop/adapt and include AMR in professional education (preservice) and training programs for HCPs, environment professionals, veterinarians and agricultural/aqua culture extension workers and officers; Development of customized training modules on AMR for One Health professionals; Refresher training of practitioners in public & private HCFs including hospitals, Number of professionals trained on AMR in health, veterinary, environment, and agriculture sectors using customized training modules Training modules, training attendance records, and training reports Ministry of NHSR&C, NFS&R, Provincial Health & Livestock Department s, WHO Improved knowledge and skills. Standardizatio n of practices 57 community (Health and Veterinary sectors) Objective 3: Strengthen AMR surveillance across sectors to generate quality data for policy actions 1 Long term outcom e Strengthening integrated AMR surveillance; Integrated AMR surveillance capacities Percentage change in the prevalence rate of AMR in healthcare settings and the community(impact) Laboratory surveillance data and healthcare facility reports on AMR trends 2 Long term outcom e Strengthening integrated AMR surveillance; Genomic surveillance and healthcare- associated infections surveillance Percentage change in AMR-related morbidity and mortality rates in the population (JEE score as impact (rephrase - -) Health department records and mortality statistics, measured by the change in rates over time 3 Short/m edium outcom e Integrated AMR surveillance capacities Percentage of reported AMR cases from integrated surveillance systems Surveillance reports from coordinating centres, measured by comparing pre- and post-intervention reporting rates annual NIH, NVL, EPA, PCRWR, provincial health Human and animal health reporti ng separat all sector s report ing surveil 58 depts, sentinel labs ely, environ ment at 0 lance data 4 Short/m edium outcom e Strengthening EQA/NEQAS; Development of Lab diagnostic AST SOPs according to GLASS/bacteriolo gy/mycology protocols and international standards (CLSI; EUCAST) Percentage/number of laboratories/AMR sentinel sites achieving satisfactory scores in EQA/NEQAS assessments EQA/NEQAS assessment reports, measured by calculating the percentage of Amr sentinnel sites that obtain satisfactory results in external quality assessments conducted within a specified period annual NIH, NVL, provincial health depts, sentinel labs 40 laborat ories enrolle d for NEQAS all AMR sentin el sites enroll ed in NEQA S gener ating satisfa ctory result s Enhanced quality assurance. Improved data quality 5 Short/m edium outcom e HAI Surveillance Number of HAIs reported and monitored over time Hospital infection control data, measured by the count of HAIs tracked through hospital records monthly NIH, provincial health depts, hospital Piloted in 6 tertiary care hospita ls 100 tertiar y care hospit als Improved HAI surveillance Reduced HAI incidence, mortality Reduced length of stay and cost of care 6 Output National & provincial AMR surveillance Number of provincial AMR surveillance coordination centres/ Government notifications by relevant health departments annual Ministry of NHSR&C, NFS&R, CC/ NIH from human one health AMR Robust AMR Surveillance Functional 59 coordination centres in all sectors (Health, Veterinary, Agriculture & Environment) mechanism established across One Health sectors across one health sectors at the provincial levels EPA, Ministry of water resources, Provincial Health & Livestock Department s, NIH health & NVL from animal health surveil lance coordi nation centre s notifie d and functi onal in all provin ces national & provincial coordinating centres Improved AMR data 7 Output Development of Lab diagnostic AST, SOPs according to GLASS/bacteriolo gy/ mycology protocols and international standards/ (CLSI; EUCAST). National, provincial, and regional reference/ referral labs in all sectors Number of provincial reference laboratories across One Health sectors accredited and operational as per international standards Accreditation documents and operational reports, measured by the count of labs certified to operate according to national standard annual Ministry of NHSR&C, NFS&R, Provincial Health & Livestock Department s, Ministry of climate change, Ministry of water resources NIH (ISO 15189), NVL, and NRLPD (ISO 17025) accredi ted all provin cial and region al refere nce labs notifie d and accred ited Improved quality control in surveillance Improved AMR data 60 8 Output Sector specific AMR surveillance plans in alignment with national strategy for all sectors Number of sector- specific AMR surveillance plans/strategies developed at the national and provincial levels Sector-specific AMR surveillance plans/ strategies from relevant govt departments annual Ministry of NHSR&C, NFS&R, CC/EPA, Provincial Health & Livestock Department s, WHO, Ministry of climate change, Ministry of water resources Human and animal health (health y and disease d animal, livestoc k) surveill ance strategi es develo ped strate gy for enviro nment and aqua cultur e, agrifo od and for provin ces availa ble Robust integrated AMR surveillance Functional AMR surveillance Strategy Lists of Priority MDRO pathogens 9 Output Percentage of reference laboratories adopting integrated surveillance methodologies across OH sectors Surveys and laboratory reports, measured by the percentage of laboratories confirming the adoption of integrated approaches(delete) 10 Output HAI Surveillance National HAI surveillance protocol/plan developed, disseminated and public sector Hospital infection control reports, measured by the count of hospitals reporting adherence to HAI protocols annual Ministry of NHSR&C, NIH piloted in 6 tertiary care hospita ls plan imple mente d in 100 tertiar Improved HAI surveillance Reduced HAI incidence, mortality Reduced length 61 hospitals across the country implementing HAI surveillance protocols. across Pakista n y care hospit als of stay and cost of care 11 Output Strengthening EQA/NEQAS Percentage of AMR sentinel sites participating in EQA/NEQAS programs EQA participation records, measured by the percentage of AMR sentinel sites enrolled in external quality assessment programs annual NIH, NVL, provincial health depts, sentinel labs 28 AMR sentine l sites enrolle d with NEQAS Inclusi on of all new AMR sentin el sites in NEQA S Output AMR Genomic surveillance for selected priority pathogens at NRLs number of national reference labs in all sectors performing genomic surveillance of priority pathogens genomic surveillance project reports, published papers, annual Ministry of NHSR&C, NIH, NFS&R, CC/EPA, capacit y in Human health sector All nation al refere nce labs equip ped and functi onal AMR Genomic surveillance Biobank /repository of priority pathogens of concerns 62 Objective 4: Reduce infection through effective water, hygiene, and sanitation, vaccination, and infection prevention and control (IPC) measures 1 Long term outcom e Functional IPC teams with dedicated focal persons for implementing IPC in tertiary care public hospitals; Implementation of national IPC guidelines; Strengthen the enforcement of isolation protocols/high containment rooms in hospitals Number of HCFs reporting reduction to HCAIs National AMR surveillance reports 2 Long term outcom e Regular mapping and monitoring of clean and safe water supply systems in HCFs; Water treatment and quality monitoring Percentage of healthcare facilities and communities implementing improved water sanitation and hygiene practices Public health reports and environmental health assessments annual WASA/ local gov WASA/ Municipality / District Government s /DOH, EPA -Federal and Provincial PCRWR Improved water supply Reduced infections 63 3 Short/m edium outcom e Functional IPC teams with dedicated focal persons for implementing IPC in tertiary care public hospitals; Implementation of national IPC guidelines Percentage of healthcare facilities compliant with national IPC guidelines Facility assessment reports and IPC compliance evaluations annual Ministry of NHSR&C, NFS&R, Provincial Health Standardized IPC practices implemented nationwide, leading to improved infection control outcomes. Infections in humans reduced. 4 Short/m edium outcom e Implementation of biosafety biosecurity guidelines in livestock, poultry, and aquaculture sectors; Prevention of zoonotic and foodborne infections transmission from animals to humans Percentage of livestock and aquaculture farms adhering to safe production and biosecurity standards Inspection reports from agricultural and animal health authorities annual Ministry of NFS&R, Livestock Department s, Federal and Provincial EPA’s, Local Government s Quality vaccines available Improved IPC and waste management Protection of health workforce Prevention of spread of transmission. Safe Slaughtering & milk practices Prevention of spread of 64 infection to humans 5 Short/m edium outcom e Prevention of zoonotic and foodborne infections transmission from animals to humans; Development & Implementation of Safe production/hygie nic standards of food from animal origin Number of zoonotic and foodborne disease control measures implemented in the animal health and food sectors Zoonotic disease surveillance reports and food safety inspection data annual Ministry of NFS&R Agriculture & Livestock Department s, FAO, WHO Food Safety Authority Prevention of transboundary disease transmission Improved food storage conditions Reduced spread of infections. 6 Output Strengthening national IPC unit in the human health sector with dedicated budget; Establishing national biosafety biosecurity Committee/TWG for livestock, Number of national and provincial IPC units and biosafety/biosecurity committees/TWGs formally established (measured by dedicated staff, defined TORs, and dedicated budget) Government notifications and meeting minutes will be reviewed to verify the establishment of units and committees annual Ministry of NHSR&C, Provincial Health & District Managemen t Livestock Department s NIH design ated as Nation al focal point for IPC Functi onal and region al IPC and biosaf ety units in all provin ces and Functional provincial and regional IPC units, biosafety/ biosecurity Committee at the national level. 65 fisheries and aquaculture sectors under AMR IPC steering committee; Establishment of provincial/region al biosafety biosecurity Committees region s 7 Output Functional IPC teams and committees with focal persons in tertiary care public hospitals. Availability of IPC trained healthcare workers in healthcare facilities. Availability of infectious diseases (ID) professionals in every teaching hospital. Number of healthcare facilities with trained IPC teams and focal persons deployed Facility records and HR rosters, training records annual Ministry of NHSR&C, NFS&R, Provincial Health department s. IPC teams/ commi ttees in few private tertiary care hospita ls IPC teams /com mittee s with comp etent staff establi shed in 30% of tertiar y care hospit als Improved IPC practices in healthcare facilities. Enhanced capacity to manage and control infections within teaching hospitals. Reduced HAIs. 66 8 Output Development, revision/dissemin ation, and implementation of national IPC guidelines. Functional IPC teams with dedicated focal persons for implementing IPC in tertiary care public hospitals; Strengthen the enforcement of isolation protocols/high containment rooms/areas in hospitals. Number of tertiary care public hospitals implementing national IPC guidelines and isolation protocols Hospital compliance audits and IPC implementation reports biennial Ministry of NHSR&C, NIH, NFS&R, Provincial Health department s, hospitals Nation al IPC guideli nes develo ped in 2020 Revisi on and disse minati on of Natio nal IPC guidel ines Standardized IPC practices implemented nationwide, leading to improved infection control outcomes. Infections in humans reduced. 9 Output Development, revision/dissemin ation, and implementation of farm biosafety/ biosecurity guidelines. Implementation of biosafety biosecurity Number of biosafety and biosecurity guidelines developed and disseminated for livestock, poultry, and aquaculture sectors Sectoral reports and field inspections annual Livestock Department s /DOH, EPAs. Infections in animals reduced. 67 guidelines in livestock, poultry, and aquaculture sectors; 10 Output Regular mapping and monitoring of clean and safe water supply systems in HCFs; Strengthen sterilization and disinfection/CSSD as per standards (WHO/CDC) appropriate to levels of care Number of healthcare facilities regularly monitored for clean and safe water supply systems Monitoring reports and water quality assessments from healthcare facilities annual Ministry of NHSR&C, DOH/ Provincial allied department s, WASA and local government (CDA in Isb) Improved hygiene and IPC in HCFs Improved access to clean water 11 Output Improving IPC and waste management practices Number of healthcare facilities compliant and implementing healthcare waste management practices Hospital waste management records. Number of assessments visits /no of assessment report annual Ministry of NHSR&C, NFS&R, Health & Livestock Department s, Federal and provincial EPA’s, Academia Improved healthcare waste management 68 Objective 5: Optimize the use of antimicrobial medicines in human and animal health 1 Long term outcom e Development of AMU surveillance plan at national and provincial levels across sectors. Regular monitoring of antimicrobial use at national and provincial levels across sectors Number of sectors (human, veterinary, agrifood, aqua, environment) annually regularly contributing AMU data to national databases National AMU database logs, sector-specific data collection reports; percentage calculation based on sectoral data submission Annually DRAP (National data base), Animal husbandry commission, Provincial Government s MoNFS&R, Health & Livestock Department s, Isolate d data availabl e, data base current ly under develo pment (DRAP) Data base devel oped and functi onal, receivi ng data from all sector s regula rly Regular submission of actual amc/use data from all sectors. Better understanding of antimicrobial use /trends of antimicrobial utilization patterns 2 Long term outcom e Development/ad aptation antimicrobial stewardship implementation guidelines at national level. Percentage of tertiary care and primary care facilities adhering to antimicrobial stewardship guidelines Compliance audits of stewardship programs at tertiary and primary care levels; percentage of facilities in compliance with guidelines every three years DRAP, IHRA, PROVINCIAL Health care commission s, NIH Zero status Major tertiar y care hospit als Improved antimicrobial stewardship and better use of antibiotics at HCFs. 3 Short/m edium outcom e Standardize record keeping mechanism for antimicrobial sale and use at all levels Proportion of licenced retail outlets (Pharmacies, Wholesalers/distribu ters, medical store) (medical/veterinary/ inspection reports and audit documents; percentage of standardized systems in place as per inspections On the basis of renewal of licence (every two years) Drug Control administrati on, DHO ICT manual data mainte nance of sale only, data of prescr iption s agains Better data on antimicrobial sales Better monitoring of 69 (pharmacies, medical & veterinary hospitals/ GPs) agriculture) implementing standardized record- keeping for antimicrobial sales and use Drug sales rules are in place t sale of antimi crobia ls availa ble. 25- 30% Licenc ed retail outlet s with Stand ardize d record - keepi ng for antimi crobia l sales and use. antimicrobial sales 4 Short/m edium outcom e Regular monitoring of antimicrobial use at HCFs Percentage of healthcare facilities conducting regular monitoring and reporting of Healthcare facility AMU reports: percentage of facilities regularly Annually DRAP, provincial department s of health, private amu data from 50-60% public 100% health care faciliti es Reporting of AMU data to GLASS. Consumption pattern and 70 antimicrobial use data submitting monitoring data health care facilities, any other administrati ve body healthc are facilitie s reporte d in 2024 on excel sheets report ing data via electr onic syste m trend available at HCF level Audit and feedback to improve use 5 Short/m edium outcom e Capacity building on generating and use of data at national and provincial levels across sectors Percentage of trained personnel applying AMU data generation and analysis techniques in their respective sectors Post-training evaluations, monitoring reports from trained sectors; percentage of trained personnel using new skills, % of trained personnel reporting data as per WHO methodology Annually DRAP, provincial department s of health, private health care facilities, any other administrati ve body No Trainin gs conduc ted so far for health care facilitie s on data genera tion and analysi s AMU data report ing as per WHO metho dolog y from traine d HCF Standardized amu data Available. Enhanced capacities for generating quality data. Better use of data 6 Output Review and update Access, Watch and Reserve (AWaRe) Number of updated rules, regulations, and guidelines on antimicrobial quality Official government publications and notifications of revised regulations; count of As required DRAP, NIH, Provincial department s of health, Certain rules and regulat Guidel ines for priorit Published and notified Guidelines for prioritized 71 & National essential medicines list (EML) supported by local data. Improving availability, quality, and affordability of antimicrobials. testing, prescribing, sales, use published and national aware list published updates notification of rules and regulations Pakistan medical association ions are in place. Sales rules, rules for assurin g quality of drugs ized qualit y testin g of antimi crobia ls, prescr iption /treat ment are requir ed to be formu lated, harmo nizati on of sales rules quality testing of antimicrobials, prescription/tr eatment and harmonized sales rules resulting in improved use Improved availability and affordability of quality assured antimicrobials at healthcare facilities 7 Output Strengthening of quality testing facilities testing laboratories (DTLs) for antimicrobials Number of quality testing facilities for antimicrobials strengthened (e.g., with updated equipment, trained staff) Government records/reports and facility assessments; count of facilities with new infrastructure or personnel improvements, number Biennial DRAP, provincial department s of health 6-7 labs are WHO prequa lified 50- 60% Labs to be iso certifi ed Improved quality of antibiotics 72 of accredited drug testing labs 8 Output Development of AMU surveillance plan at national and provincial levels across sectors Number of national and provincial AMU surveillance plans/strategies developed across human, veterinary, agrifood, environment, and aqua sectors National/provincial surveillance plans/ strategies, and official government notifications; count of approved plans across sectors annual DRAP, MONFS&R, MoNHSR&C, MOCC, AHC, Provincial health. Department s AMU surveill ance plan for human health develo ped AMU one health surveil lance plan AMU surveillance plan continuously monitored, evaluated, and improved. Better data on antimicrobial use 9 Output Capacity building on generating and use of data at national and provincial levels across sectors Number of personnel trained on generating and using AMU data at national and provincial levels across sectors Training completion reports, attendance sheets; count of trained individuals. biennial DRAP/ Ministry of NHSR&C, NFS&R, Health & Livestock Department s, No Trainin gs conduc ted so far for health care facilitie s on data genera tion and analysi s AMU data report ing as per WHO metho dolog y from traine d HCF Enhanced capacities for generating quality data. Better use of data 73 10 Output Regular monitoring of antimicrobial use at national and provincial levels across sectors Number of sectors (human, veterinary, agrifood, and aqua) producing regular monitoring reports (biannually or annually) on antimicrobial use at the national and provincial levels Government records/reports on AMU; Number of sectors producing regular reports Annually (human & animal) DRAP, MONFS&R, MoNHSR&C, MOCC, AHC, Provincial health. Department s Report s from a few sectors availabl e (DRAP, AHC) Stand ardize d AMU DATA FROM huma n and anima l health sector , initiati ng the data collect ion in enviro nment sector Regular annual reports available from all Possible sectors 11 Output Development of facility specific antibiotic use guidelines for tertiary care Number of tertiary care hospitals with facility-specific antibiotic use guidelines in place in accordance with aware and local antibiogram Hospital records and reports; count of hospitals that have developed and implemented guidelines Biennial Ministry of NHSR&C, NFS&R, Health & Livestock Department s, WHO, Health Care Commission No nationa l standar d treatm ent guideli nes Natio nal guidel ines availa ble as per antibi ogram Better treatment protocols Appropriate use of antibiotics 74 s/private sector availabl e and aware 11 Output Programme for appropriate antibiotic use at the Primary care. Number of primary care facilities with programs for promoting appropriate antibiotic use Primary care facility reports, health department audits; count of facilities implementing appropriate use programs Biennial Ministry of NHSR&C, Department s, WHO, Health Care Commission s/private sector/profe ssional associations ZERO 25- 30% activel y imple menti ng the progra m appropriate antibiotic use guidelines available in all PHC. Appropriate use of antibiotics promoting use of Access antibiotics. 12 Output Establishing ASP at tertiary level hospitals Number of tertiary care hospitals with established antimicrobial stewardship programs (ASP) Hospital compliance audits, facility reports; count of hospitals with functioning ASPs Biennial DRAP, Ministry of NHSR&C, WHO, Health Care Commission s ASP establis hed and functio nal in some private tertiary care hospita ls (2) Functi onal AMS progra m major tertiar y care hospit als across the countr y Improved stewardship practices Appropriate use of antibiotics 13 Output Baseline survey on usage of antimicrobials as Number of surveys conducted on antimicrobial usage Survey reports from animal feed and veterinary departments; Biennial DRAP/ Ministry of NFS&R/ a few surveys Regul ar survey Improved understanding of use of 75 growth promoters in animal feed industry including assessment of feed (utilization audit). National strategy for the control of antimicrobials usage as growth promoters and prophylaxis in veterinary/agricu lture/ aqua /industry sector as growth promoters in animal feed industries count of completed surveys DOH, AHC PL&DD, PL&DD, AHC, Provincial Livestock Department s availabl e s in all provin ces and region s antibiotics in non-human health sector Objective 6: Develop economic case for sustainable investment based on research studies focused on country needs 1 Long term outcom e Development of national AMR research priority setting Number of AMR research findings integrated into national and provincial policies, programs, or guidelines Policy and program review reports; count of findings incorporated into national strategies Ministry of NHSR&C/ Ministry of NFS&R/ PHRC/ DOH/ HRIHEIs/Foc al Person from each Province Understand the research gaps. Advocacy on research needs 76 2 Long term outcom e Capacity building on AMR research Number of national institutions /one health partners conducting AMR research on a regular basis Research institution/ one health partners activity reports; count of institutions with ongoing AMR research Ministry of NHSR&C/ Ministry of NFS&R/ PHRC/ DOH/HRIHEI s/Focal Person from each Province Increased pool of AMR researchers. Increased research products 3 Short/m edium outcom e Design and conduct studies as per global, regional and national priorities Number of instances of national participation in regional or global AMR research initiatives Conference participation records, international initiative reports; calculate the number of instances of Pakistan's participation 4 Short/m edium outcom e Development of national AMR research priority setting; Mapping of available resources for AMR research Percentage of national and provincial research priorities reflected in newly designed AMR research studies Research proposals and reports; proportion of studies aligned with set priorities Ministry of NHSR&C/ Ministry of NFS&R/ PHRC/ DOH/ HRIHEIs/Foc al Person from each Province Resource gaps identified. Advocacy for pooling and mobilization of resources Pooling of available resources for development of new vaccines, diagnostics & 77 antibiotic alternatives 5 Short/m edium outcom e Design and conduct studies as per global, regional and national priorities Number of high- quality AMR research publications produced annually by national research institutions/ One health partners Peer-reviewed journals, research institution/ One health partners reports; count of publications Ministry of NHSR&C, NFS&R, Health & Livestock Department s, WHO, FAO DRAP/P&D/ PSWR/ Provincial Health Department HEC/ Academia/ DOH/P&D/N IH/ AMRN Improved understanding on the AMR burden Improved understanding on cost effective interventions Improved advocacy for resource allocation for AMR Better estimates of AMR Better prescription practices, stewardship programmes, and reduced use of antibiotics 6 Output Development of national AMR Number of AMR research priority- setting exercises Government and research body reports; Ministry of NHSR&C/ Ministry of Understand the research gaps. 78 research priority setting /workshops conducted at the national and provincial levels count of completed exercises/WORKSHOPS NFS&R/ PHRC/ DOH/ HRIHEIs/Foc al Person from each Province Advocacy on research needs 7 Output Capacity building on AMR research Number of personnel trained in AMR research methodologies and techniques Training completion reports, and attendance sheets; count of participants trained in relevant research areas Ministry of NHSR&C/ Ministry of NFS&R/ PHRC/ DOH/HRIHEI s/Focal Person from each Province Increased pool of AMR researchers. Increased research products 8 Output Design and conduct studies as per global, regional and national priorities Number of AMR research studies designed and conducted based on national, regional, or global priorities Research reports; count of research projects completed Ministry of NHSR&C, NFS&R, Health & Livestock Department s, WHO, FAO DRAP/P&D/ PSWR/ Provincial Health Department Improved understanding on the AMR burden Improved understanding on cost effective interventions Improved advocacy for resource allocation for AMR 79 HEC/ Academia/ DOH/P&D/N IH/ AMRN Better estimates of AMR Better prescription practices, stewardship programmes, and reduced use of antibiotics 80 Output Design and conduct studies as per global, regional and national priorities Number of AMR research collaborations established between national and international stakeholders Memoranda of understanding (MoUs), agreements signed; count of collaborations established Ministry of NHSR&C, NFS&R, Health & Livestock Department s, WHO, FAO DRAP/P&D/ PSWR/ Provincial Health Department HEC/ Academia/ DOH/P&D/N IH/ AMRN Improved understanding on the AMR burden Improved understanding on cost effective interventions Improved advocacy for resource allocation for AMR Better estimates of AMR Better prescription practices, stewardship programmes, and reduced use of antibiotics