Afghanistan National Action Plan on Antimicrobial Resistance 2017-2021

National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 1 | P a g e Ministry of Public Health, Afghanistan Directorate of Curative Medicine National Action Plan on Antimicrobial Resistance (NAP-AMR) 2017 – 2021 May 2017 Afghanistan National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 2 | P a g e Government of Afghanistan May 2017 National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 3 | P a g e Contents: Abbreviations and acronyms Message Executive Summary 1. Background 1.1 Introduction 1.2 AMR and its containment in Afghanistan 1.2.1 AMR in man and animal 1.2.2 Awareness and understanding of AMR 1.2.3 Surveillance of AMR 1.2.4 Infection prevention and control 1.2.5 Use of antimicrobials 1.2.6 Research and innovation 1.2.7 National response 2. Developing the National Action Plan on AMR 3. National Action plan on Antimicrobial Resistance 3.1 Goal 3.2 Objectives 3.3 Strategic priorities 3.4 National Action Plan on AMR – Interventions, activities and outputs 3.5 Monitoring and evaluation plan References Annex 1: governance committees/groups for AMR Annex 2: Operational plan and budget (Template) National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 4 | P a g e Abbreviations and acronyms AMR Antimicrobial Resistance ARB Antibiotic resistance breaker CWG-AMR Core Working Group on AMR DADF Department of Animal Husbandry Dairy and Fishing ESBL extend spectrum beta-lactamase FAO Food and Agriculture Organization of the United Nation GAP-AMR Global Action Plan on Antimicrobial Resistance GHSA Global Health security Agenda HAI Health care Associated Infection HICC Hospital Infection Control Committee ICC-AMR Intersectoral Coordination Committee on AMR IPC Infection Prevention and Control KAP Knowledge, attitude and practice MAIL Ministry of Agriculture Irrigation and Livestock MoIC Ministry of Information and culture MoHE Ministry of Higher Education MoE Ministry of Education MoF Ministry of Finance MoPH Ministry of Public Health MoT Ministry of Trade MRSA methicillin resistance staphylococcus aureus NAP-AMR National Action Plan for Antimicrobial Resistance NACP National Aids Control Program National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 5 | P a g e NCDC National Center for Disease Control NEPA National Environment Protection Authority OIE World organization for Animal Health (Office International des Episooties) TAG-AMR Technical Advisory Group on AMR UNEP United Nation Environment Program UNICEF United Nation Children’s Fund WHA World Health Assembly WHO World Health Organization National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 6 | P a g e National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 7 | P a g e National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 8 | P a g e Executive Summary The threat posed by antimicrobial resistance (AMR) to public health as well as global health security has been reiterated in numerous World Health Assembly (WHA) resolutions. AMR is also prioritized under the Global Health Security Agenda (GHSA), and Afghanistan is one of the contributing countries. The Ministry of Public Health (MoPH) identified AMR as one of the top Priorities for the ministry’s collaborative work with WHO. In May 2015, sixty-eight World Health Assembly endorsed the Global Action Plan on Antimicrobial Resistance (GAP-AMR) – including antibiotics resistance, the most urgent drug resistance trends. The WAH resolution urges member state to align their National Action Plan on AMR with GAP-AMR by May 2017. Commitment by Global leaders to combat AMR was further strengthen at the High Level Meeting on AMR at the United Nation General Assembly on 21 September 2016 The Ministry of Public Health notified three governance mechanisms in 28 November 2016 to address the challenge. These include the Intersectoral Coordination Committee, Technical Advisory Group, and Core Working group on AMR for technical coordination and oversight. The Core Working Group has been drafted the National Action Plan during orientation workshop on Antimicrobial Resistance by Nation focal point-AMR (NF-AMR), drafted National Action Plan was further reviewed at the national workshop on Development of National Action Plan on AMR that included members from Core Working group and the Technical Advisory Group. The starting objectives of NAP-AMR are aligned with the global action plan based on national needs and priorities, and in additional to the 5 priorities of GAP-AMR, Afghanistan has a sixth priority that is Afghanistan’s specific dealing with Afghanistan’s leadership on AMR – including international, national and sub-national collaboration on AMR. Six strategic Priorities have been identified under the NAP-AMR (i) improving awareness and understanding of AMR through effective communication, education and training (ii) strengthening knowledge and evidence through surveillance (iii) reducing the incidence of infection through effective infection prevention and control; (iv) optimizing the use of antimicrobial agents in health, animals and food; (v) promoting investments for AMR activities, research and innovations; and (vi) strengthening Afghanistan’s leadership on AMR. Strategic priorities focuses on improving awareness and understanding of AMR through effective communication, education and training, and has 2 focus areas – first is communication and information, education, communication (IEC) resources to raise awareness amongst all stakeholders, and second focus area is education and training to improve the knowledge and behavioral of professionals in all sectors. Strategic priorities 2 aims to strengthen knowledge and evidence through surveillance of AMR, with 2 focus area strengthening laboratories in human, animal, food and environment sectors, as well as ensuring surveillance of antimicrobial resistance in human, animal, food and environment sectors. Strategic priority 3 attempts to reduce the incidence of infection through effective infection prevention and control in healthcare to reduce the burden of infection, in animal health and food to reduce spread of AMR and antimicrobial through animals and food, and in community and environment to reduce the spread of AMR and antimicrobials in the environment. Strategic priority 4 shall optimize the use of antimicrobial agents in health, animals and food through strengthening National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 9 | P a g e regulation, ensuring access and surveillance of antimicrobial use, antimicrobial stewardship in healthcare as well as animal health and agriculture. Strategic priority 5 aims to promote investment for AMR activities, research and innovations through new medicine and diagnosis, innovation to develop alternative approaches to manage infectious diseases, sustainable financing to ensure adequate resources for containment of AMR. Strategic priority 6 focuses on strengthening of Afghanistan’s leadership on AMR through international collaborations to ensure Afghanistan contribution toward global efforts to contain AM, national collaboration to facilitate collaboration among vertical disease control programs and national stakeholders, and state level collaborations to ensure action at the ground level against AMR. Within each strategic priority and focus area, strategic interventions, key activities and outputs have been defined with tentative responsibility and timelines – short (within 1 year), medium (between 1 and 3 years)and long-term (between 3and 5 years). National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 10 | P a g e Background AMR is one of the Key priority of the global health security agenda action package, as well as it is one of the commitments of Ministry of Public Health Afghanistan to combat AMR. In Afghanistan because of war and some other political issues the borders of the country are not well secured and well controlled therefore control of smuggling of medicine is a big challenge in front of the rational use of medicine. Lack of knowledge (professionals and public), poor economic state, conflict of war, presence of remote areas and etc…. are the other main challenges for this to won the battle of combating AMR. Misuse and over use of ATB is very common among the society, everyone is able to buy ATB and other medicine without prescription. In majority of cases professionals prescribe without proper diagnosis and in every prescription you can see ATB at first line and even two or three Antibiotics as combination, Smuggling and inappropriate or inadequate quality control of drug, caused presence of big number poor quality medicine in the markets, there for it may cause long term treatment, failure of treatments and finally Antibiotics resistance. Other big issue is unsafe and insecure transportation of medicine, lot of companies using nonstandard containers and stocks, which facilitates the appearance of medicine to high degree of temperature. MoPH Afghanistan highlights the problem of antimicrobial resistance and calls for a rapid standardization of guidelines regarding antibiotic use, limiting the use of antibiotics as over the counter medications, banning or restricting the inclusive usage of antibiotic in the hospital and community. In addition, the MoPH has also identified AMR as one of the key strategic priorities. Therefore, we are committed to implement, monitor and evaluate the NAP - AMR in our country. National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 11 | P a g e 1.1. Introduction In May 2014, the World Health Assembly requested the development of a global action plan (GAP) on antimicrobial resistance, in resolution WHA67.25, reflecting a global consensus that antimicrobial resistance poses a profound threat to human health. The WHO secretariat led the development of the Global Action Plan on AMR (GAP-AMR) that takes into account the commitment, perspectives and roles of all relevant stakeholders. And in which everyone has clear and shared ownership and responsibilities. In May 2015, the sixty-eight world Health Assembly endorsed GAP- AMR to tackle antimicrobial resistance including antibiotic resistance, the most urgent drug resistance trend. The WHO resolution also requests Member States to align their national action plans with GAP-AMR by May 2017. The Global Action Plan on AMR provides a broad framework for combating AMR. The of GAP AMR is to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality assured, used in a responsible way, and accessible to all who need them. The FAO Acton Plan on AMR has 4 strategic objectives that are aligned with GAP-AMR. To achieve it is goal, the global action plan sets out five strategic objectives, to: 1. Improve awareness and understanding of antimicrobial resistance; 2. Strengthen knowledge throw surveillance and research; 3. Reduce the incidence of infection; 4. Optimize the use of antimicrobial agents in health, animal and food sectors; and 5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions. The strategic objectives of the NAP-AMR are aligned to the GAP-AMR based on notional needs and priorities. 1.2. AMR and its containment in Afghanistan 1.2.1. AMR in man and animals The AMR is a major public health concern in Afghanistan. Some small steps are getting towards containment of AMR like some Infection prevention and control programs in some tertiary hospitals of some cities, and preparing some treatment guidelines for some hospitals, this framework will serve as a starting point for cohesive engagement and mobilization of all who are accountable for action on antimicrobial resistance and use. Given National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 12 | P a g e the global nature of this issue, the Action Plan, in line with the one – health concept, highlights the need for Afghanistan to work with international organization and groups to develop solutions applicable to domestic production and use and importation from global market. 1.2.2. Awareness and understanding of AMR The GAP-AMR states that the first strategic objective in effectively containing AMR is to improve awareness and understanding of AMR through effective communication, education and training. The strategy envisions that the awareness building has to proceed on several fronts at the same time. On one hand it has to leverage public communication programs to encourage behavior change in target population-namely stakeholders in human health, animal health and agriculture; and on the other there needs to be concerted efforts to incorporate AMR as core component in the professional education of medical and veterinary professional. The need to focus on awareness building, both in consumers and providers, was highlighted by the results of the multi country public awareness survey that was conducted by WHO in 2015. The finding of the study highlighted important deficits in the understanding of what antibiotics are, how they should be used and when to take them. There is ample evidence to suggest that there is some pressure from patients which forces medical practitioners to overprescribe antibiotics, especially for conditions like viral illness, upper respiratory tract infections and diarrhea, for which antibiotic therapies are not the recommended first line of approach. Given the financial incentives to prescribe antibiotics and the role of the pharmaceutical industry in encouraging prescription of antibiotics in Afghanistan, there is a need to approach the process of awareness generation with additional legislative support. Internationally there is evidence that awareness generation campaign in combination with other interventions that are organized at the national level may be successful to reduce antibiotic use. There is also a need to increase the awareness about the need of contain AMR at the higher levels of policy making, so that it may emerge as a priority in the health policies of the nation. 1.2.3. Surveillance of AMR Afghanistan has previously instituted of the emergence of drug resistance in disease causing microbes in the context of vertical programs, like the Revised National Tuberculosis Control Program (RNTCP), and the National AIDS Control Program (NACP), to name a few. However, a cross cutting program dealing with antimicrobial resistance across multiple microbes has been lacking. National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 13 | P a g e Historically, AMR has not received adequate focus and attention in Afghanistan. However recent trends clearly illustrate the growing MoPH commitment at the highest levels to have a coherent response in place that can the necessary gravitas for nationwide surveillance and stewardship for containment of AMR. Efforts are also being made to incorporate the one health approach into these plans. The Ministry of Health has recently notified 3 governance mechanisms towards this – an intersectoral Coordination Committee, a Technical Advisory Group and a Core Working Group on AMR. The recent political declaration/UN resolution on AMR fallowing the high level meeting on AMR at the United Nations General Assembly is an opportunity for the technical leadership in Afghanistan to leverage the current conducive policy environment for effective action against AMR. 2. Developing the Nation Action Plan on AMR 2.1. Governance mechanism The Government of Afghanistan is strongly committed to tackling AMR in the country and led the global and regional AMR agenda. Governance mechanisms are essential for effective intersectoral coordination of activities to combat AMR. They are also important to engage key stakeholders in the development of NAP-AMR to ensure their ownership during the implementation phase. Governance mechanisms need political support and authority to take actions, and are more likely to be effective with clearly defined terms of reference. The following AMR committee/groups (Figure 1) were notified. Intersectoral coordinating committee Technical advisory group Core working group Figure 1: key governance mechanisms for AMR National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 14 | P a g e 2.1.1. Intersectoral Coordination Committee on AMR The purpose of Intersectoral Coordination Committee on Antimicrobial Resistance (ICC AMR) is to oversee and coordinate policy decision for activities related to antimicrobial resistance in all sectors in alignment with AMR related public health goals. The ICC-AMR shall lead and facilitate the coordination of the national (along with sub national and international) response to the threat of AMR; ensure information sharing to reinforce AMR-related activities among all sectors; review and revise term of reference of the technical advisory group on AMR; ensure coordination of health system and other sectors to achieve the AMR- related public health goals; facilitate and synergies existing and new initiatives to achieve to goal of combating AMR in Afghanistan; facilitates collaboration with internal and external agencies and organizations for AMR related public health activities; endorse national action plan on AMR, and ensure adequate logistic and resource mobilization to cover any funding gap; and oversee progress of efforts to combat AMR and ensure program planning and implementation. 2.1.2. Technical Advisory Group on AMR The purpose of the Technical Advisory Group on Antimicrobial Resistance (TAG-AMR) shall be to the approach and initiatives for combating AMR in Afghanistan and make recommendations on technical issues. The TAG- AMR shall provide technical advice and reports to the ICC- AMR; technically review and revise the draft national action plan on AMR; provide technical oversight for existing and new initiatives to combat AMR in Afghanistan; and review and revise the terms of the core working group on AMR. 2.1.3. Core Working Group on AMR The Core Working Group on Antimicrobial Resistance (CWG- AMR) shall provide technical and operational inputs to the designated national coordinating center for AMR in Afghanistan i.e. National Center for Disease Control (NCDC) to develop and implement the National Action Plan on Antimicrobial Resistance (NAP- AMR) The CWG- AMR shall identify and map stakeholders for AMR- related activities; lead the development of the national action plan on AMR in Afghanistan with involvement of all stakeholders; ensure regular data collection and information sharing; coordinate national activities for establishing/strengthening surveillance systems; develop and disseminate national AMR reports; and facilitate and monitor/evaluate the overall implementation of NAP- AMR. The details of these committees/groups are provided in annex 1. The Technical Advisory Group and Core Working Group are specific for governance mechanisms in the human health sector. Similar groups are needed in the other sectors to coordinate their response in tackling AMR. National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 15 | P a g e 3. National Action Plan on Antimicrobial Resistance 3.1. Goal The overarching goal of the National Action Plan on Antimicrobial Resistance (NAP-AMR) is to effectively combat antimicrobial resistance in Afghanistan, and contribute towards the global efforts to tackle this public health threat. It shall establish and strengthen governance mechanisms as well as the capacity of all stakeholders to reduce the impact of AMR in Afghanistan. The scope of the NAP- AMR focuses primarily on resistance on in bacteria. 3.2. Objectives The following are the specific objectives of the NAP- AMR: 1. Define the strategic priorities, key actions, outputs, responsibilities, and indicative timeline and budget to slow the emergence of AMR in Afghanistan and strengthen the organizational & management structures to ensure intra- & inter sectoral coordination with a One Health Approach; 2. Combat AMR in Afghanistan through better understanding and awareness of AMR, strengthen surveillance, prevention of emergence and spread of resistance bacteria through infection prevention and control, optimize use of antibiotics in all sectors and enhance investments for AMR activities, researches innovation; and 3. Enable monitoring and evaluation (M&E) of the NAP- AMR implementation based on M&E framework. 3.3. Strategic Priorities The NAP- AMR outline the priorities and interventions planned to implemented over 2017-2021 to tackle the public health challenge of AMR in Afghanistan. The first 5 strategic priorities of NAP- AMR (figure 2) are aligned with the Global Action Plan on AMR and the sixth strategic priorities highlighted Afghanistan’s role in containment of AMR at the international level with other countries and organization, national disease control programs and at the sub- national/state level through development of state action plans on AMR to ensure action at the ground level. 1. Improve awareness and understanding of AMR though effective communication, education and training 2. Strengthen knowledge and evidence through surveillance 3. Reduce the incidence of infection through effective infection prevention and control 4. Optimize the use of antimicrobial agents in health, animal and food 5. Promote investments for AMR activities, research and innovations Strengthen Afghanistan leadership on AMR National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 16 | P a g e Figure 2: Priorities of NAP- AMR A harmonize approach across various sectors to address the use of and resistance to antimicrobial agents in human health, animal health, agriculture, food products and the environmental is critical to address these strategic priorities. The focus areas of the six strategic priorities of NAP- AMR (figure 3) are: 1. Improve awareness and understanding of AMR through effective communication, education, and training a. Communication, IEC resources – to raise awareness amongst all stakeholders, including policy makers, general public and formers b. Education and training – to improve the knowledge and behavior of professionals 2. Strengthen knowledge and evidence through surveillance a. Strengthen laboratories – in human, animal, food and environment sectors – for evidence-informed policy making b. Surveillance of antimicrobial resistance in human, animal/food and environment sectors for evidence informed policy making 3. Reduce the incidence of infection through effective infection prevention and control a. Health care - to reduce the burden of infection b. Animal health/food – to reduce spread of AMR and antimicrobials through animals and food c. Community and community environment – to reduce the spread of AMR and antimicrobials in the community and environment 4. Optimize the use of antimicrobial agents in health animal and food a. Regulations, access and surveillance of antimicrobial use – to ensure rational use without affecting access to antimicrobials b. Antimicrobial stewardship in healthcare – to optimize use of antimicrobials in humans c. Animal health, agriculture – to optimize use of antimicrobials in animal and food sectors 5. Promote investments for AMR activities , research and innovation a. New medicine and diagnostics – to ensure availability of effective diagnosis and drug to treat infections b. Innovations – to develop alternative approaches to manage infectious disease c. Financing – to ensure sustainable recourses for containment of AMR 6. Strengthen Afghanistan’s leadership on AMR a. International collaboration – to ensure Afghanistan’s contributions towards global efforts to contain AMR b. National collaborations – to facilitate collaborations among vertical disease control programs and national stakeholders c. State level collaborations – to ensure action at the ground level against AMR National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 17 | P a g e Figure: 3 focus areas of NAP- AMR strategic priorities The National Workshop on Development of National Action Plan on AMR was organized by MoPH, AMR National Focal Point, Glass Focal Point and WHO – Afghanistan on 28 December 2016 in Kabul by Participation of representatives of different related departments. In this Workshop about the topics of what is AMR, How does Antimicrobial spread, Why Antimicrobial is a global concern and information about the Global Antimicrobial Surveillance system presented by the related Focal points, The National Action Plan, primary perpetrations has been done by the sub groups of the Core Working Groups, was extensively reviewed by the Technical Advisory Group and Intersectoral Coordinating Committee suggestions and inputs from the Technical Advisory Group on AMR and Intersectoral Coordinating Committee on AMR have also been incorporated. 3.4. National Action Plan on AMR – interventions, activities and outputs The interventions, activities and key outputs under specific objectives of key focus areas of the strategic priorities are elaborated in the subsequent pages. Each activity has a timeline, which is classified as short term (S) with an expected achievement in one year, medium term (M), with an expected horizon of 1-3 years and long term (L) with a 3-5 years’ timeline. 1. Awareness & understanding 2. Knowledge & evidence 3. Infection prevention & control 4. Optimize use 5. Innovation R&D 6. Leadership Communication & IEC Laboratories Healthcare, HAI Regulation, access, AM use New medicine, diagnostics International collaborations Education, training Surveillance of AMR – human, animal, environment Animal health Antimicrobial stewardship in human health Financing National collaboration Community & environment AMS in animals, agriculture Innovations State level Collaborations National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 18 | P a g e Strategic priority 1 Improve awareness and understanding of AMR through effective communication education and training Awareness and communication Objective 1.1 Increase awareness and improve communication regarding AMR in Afghanistan Strategic interventions and activities 1.1.1 Assess understanding knowledge and awareness of antimicrobial resistance (AMR) and antimicrobial use (AMU) amongst key stakeholders/target groups 1.1.1.1 Consolidate the existing available KAP ( Knowledge attitude and practice) studies across general population, professional in health, veterinary, pharmaceutical and environment, farmers and food processing sector (MoPH, MAIL) S 1.1.1.2 Conduct behavioral studies and KAP surveys amongst general population(as a priority),health professionals, veterinary professionals, pharmaceutical industry, environment professional, food processing sector and formers (MoPH, MAIL) S Key out put  Baseline and trends in knowledge, attitude, practice and behavioral of different segment of population on AMR and its use, in general population, farmers, professionals and industry 1.1.2 Document the existing communication and information resources and products on AMR 1.1.2.1 Identify and consolidate existing communication/information resources/products on AMR in various sectors/stakeholders groups (MoHE, MoPH,MAIL, NEPA,) S o Consolidate AMR resources; identify and list national/international partners (best practices/learnings) towards consolidating the AMR database on communication 1.1.2.2 Map the expertise of stakeholders, individual and organizations to develop communication strategy (MoHE, MoPH,MAIL, NEPA,) S Key output  Consolidated communication and information resources on AMR available  Stakeholder map of communication expertise on AMR developed 1.1.3 Utilize communications to promote AMR awareness targeting key stakeholders National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 19 | P a g e 1.1.3.1 Develop a cross-cutting and sustained communication program on antimicrobial resistance and use, at national, state, district and sub-district levels o Evidence-based communication program with a focus on general population predominantly, followed by famers & dairy/poultry/meat/fish suppliers and all stakeholders to promote rational use of antibiotics; focus on infection prevention through hand hygiene, clean water, sanitation, biosafety in animal farms, etc.; high impact IEC content e.g. related stories from the general population in form of videos etc.; incorporate awareness raising and behavior change as essential component of any public policy; adapt and adopt features of successful AMR communication program from other countries (individual sector); government may consider a Health Cess to fund health campaigns on AMR ( MoPH, MoF, MAIL, MoIC, communication agency/agencies identified by Media and communications unite of MoPH,) S 1.1.3.2 Implement AMR communication program targeting general population and key stakeholders in all sectors, throw partnership and collaborative approach including NGOs and private sectors (Communication agency/agencies identified by Media and communication unite of MoPH, MAIL, MoIC, NEPA, MoE, MoHE) S-M-L Key output  Cross-cutting, comprehensive and sustained communication program for AMR containment at national, state, district and peripheral level Education and training Objective 1.2 Improve knowledge and capacity of key stakeholders regarding AMR and related topics Strategic interventions and activities 1.2.1 Strengthen and consolidate AMR and related topics as core components of professional education and training 1.2.1.1 Review and revise curricula of professionals in human health (MoHE, MoPH etc.) S 1.2.1.2 review/revise curricula of professionals in Animal health 1.2.1.3 Review and revise curricula of professionals in food industry, agriculture and environment (MAIL, MoHE, MoPH etc.) S 1.2.1.4 Review and develop curricula and resources for in-service training of different professionals and allied services (MAIL, MoHE, MoPH etc.) S M National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 20 | P a g e  Develop a module on AMR to bring together the segmented knowledge being imparted under different subjects (microbiology, pharmacology, medicine, etc.) Key outputs  Professional curricula revised  Training module developed on AMR (for in-service and training s) 1.2.2 Introduce concept of AMR and appropriate use of antimicrobials as part of school curriculum 1.2.2.1 Develop module on AMR and appropriate use of antimicrobial for school children (MoE, etc.) M Key output  Module on AMR and antimicrobials developed for school children 1.2.3 Strengthen capability and skills of key stakeholders 1.2.3.1 Conduct Training Needs Analysis (TNA) across all sectors (MoPH, MAIL, NEPA) S 1.2.3.2 Develop training resource (including online courses) on antibiotic resistance and use for capacity development among professionals S (overall responsibility MoPH, NACP)  Human health (MoPH)  Animal health (MAIL)  Food Industry (MoPH)  Agriculture (MAIL)  Environment (NEPA) 1.2.3.3 Implement training of AMR for all key stakeholders has an essential component of the phased NAP implementation S-M (MoPH)  Clinician  Microbiologist  Pharmacologist  Public Health  Veterinarians  Food industries  Social workers and civil society activists  Academic institutions Key output  National training plan and information products developed for key stakeholders and human health, animal health, food industry, feed industry, agriculture, environment and pharmaceutical industry National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 21 | P a g e 1.2.4 Improve inter-departmental as well as intersectoral communication 1.2.4.1 Develop a strategy towards enabling the institutions to ensure communication and data sharing among their microbiologist and clinicians (antibiotic policy etc.) MoPH S 1.2.4.2 Design AMR training/orientation programs to train composite group of representatives from all sectors (MoPH) M 1.2.4.3 Develop a strategy towards enabling communication, interaction among different sectors influencing AMR (MoPH, Media and communication unit of MoPH, MAIL, NEPA) S Key output  Mechanisms establish for interdepartmental and intersectoral communication Strategic Priority 2 Strengthen knowledge and evidence through surveillance Laboratory capacity Objective 2.1 Invent and Strengthen microbiology laboratory capacity for AMR surveillance in human, animal, food and environmental sectors* Strengthen interventions and activities 2.1.1 Strengthen capacity for laboratory- based surveillance of AMR in humans, animals, food and environment 2.1.1.1 Develop national strategy based on system/lab assessments to strengthen microbiology (including private sector) for antimicrobial susceptibility testing (AST) in medical labs, ensuring SOPs, quality assurance and community data (MoPH) S-M 2.1.1.2 Develop national strategy based on system/lab assessments to strengthen microbiology (including private sector) for antimicrobial susceptibility testing (AST) in animals, food, ensuring SOPs, quality assurance and community data (MAIL) S-M 2.1.1.3 Develop national strategy based on system/lab assessment to strengthen microbiology laboratories (including private sector) for antimicrobial resistance and antimicrobial residues in the environment, including waste from farms, factories and healthcare settings (MoPH, MAIL) S 2.1.1.4 Strengthen capacity for laboratory-based surveillance of AMR with species level identification of bacteria in humans during health and National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 22 | P a g e disease; surveillance lab under national network including private sector (MoPH) S  (<1 year): 5-10 labs; M (1-3 year): 10-20 labs; L (>3 years): >30 labs 2.1.1.5 Strengthen capacity for laboratory based surveillance for AMR in animals, food and environmental M  Animal sector (MAIL)  Food sector (MAIL, MoT)  Environmental sector (NEPA) 2.1.1.6 Establish routine EQAS for all surveillance laboratories M L  Human labs (MoPH)  Animal labs (MAIL)  Food Labs (MAIL, MoPH)  Environment Labs (MoPH, NEPA) 2.1.1.7 Organize joint training workshops for bacterial identification, antimicrobial susceptibility testing (AST) and data harmonization S-M  Humans (MoPH)  Animals (MAIL)  Food (MAIL, MoPH)  Environmental ( NEPA, MoPH) Key out puts  Strategic plan developed to strengthen microbiology laboratories for AMR surveillance in humans, animals, food and environment  Training workshops held for AST in medical and food labs and environment labs 2.1.2 Designate national reference laboratories for AMR surveillance in humans (also in animal, food and environmental sectors) as pre-requisite for enrolment in GLASS 2.1.2.1 Identify and strengthen national reference laboratories for confirmation and detailed characterization of target pathogens and external quality assessment scheme for AMR organized in human health (MoPH) S 2.1.2.2 Identify and strengthen national reference laboratory(ies)for confirmation and detailed characterization of target pathogens and external quality assessment scheme for AMR in animal and food sector (MAIL, MoPH) S 2.1.2.3 Afghanistan enrollment in GLLAS – Global AMR Surveillance System (MoPH) S-M Key outputs National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 23 | P a g e  National AMR reference labs designated  Afghanistan enrolled in GLASS Surveillance of AMR Objective 2.3 Strengthen Surveillance for AMR in humans, animals, food and environment Strategic interventions and activities 2.3.1 Establish standard and coordination mechanisms for national surveillance of AMR 2.3.1.1 Establish an intersectoral experts group on integrated AMR surveillance (MoPH, MAIL, NEPA, MoHE, MoE) S 2.3.1.2 Define comprehensive standards for national coordination of AMR surveillance – including surveillance standards at various healthcare levels, drug-bug combination - in a phased approach for strengthening AMR surveillance (MoPH) S  Humans include private sector (MoPH, WHO)  Animals (MAIL, OIE)  Food (MAIL, MoPH,FAO)  Environmental ( NEPA, MoPH, UNEP) 2.3.1.3 Organize annual consultation to strengthen AMR surveillance (MoPH) S-M-L  Humans include private sector (MoPH, WHO)  Animals (MAIL, OIE)  Food (MAIL, MoPH, FAO)  Environmental ( NEPA, MoPH, UNEP) 2.3.1.4 Organize annual national consultation to strengthen the AMR surveillance program in humans, animals, food and environment (MoPH, MAIL and NEPA, WHO, FAO) S-M-L Key outputs  National AMR surveillance standards establish in human, animal, food and environment 2.3.2 Standard data analyses and information management for AMR surveillance 2.3.2.1 Define mechanisms and modalities for data collections, collection and analysis and information management at central, state and district level ( including urban, rural, governmental, private and unorganized sector) to increase health intelligence for AMR in human (MoPH, WHO) S 2.3.2.2 Define mechanisms and modalities for data collections, collection and analysis and information management at central, state and district level for AMR surveillance in animals and food (MAIL, FAO) National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 24 | P a g e 2.3.2.3 Define mechanisms and modalities for data collections, collection and analysis and information management at central, state and district level for AMR surveillance in environment (NEPA, MoPH UNEP) S Key outputs  National mechanisms for data analysis/information management for AMR surveillance implemented in humans, animals, food and environment 2.3.3 Strengthen AMR surveillance data/information management in human, animals, food and environment 2.3.3.1 Implement mechanisms to collate and analyses AMR surveillance data into useful information and make an online database available to all stakeholders (MoPH) S-M-L  Humans include private sector (MoPH, WHO)  Animals (MAIL, OIE)  Food (MAIL, MoPH, FAO)  Environmental ( NEPA, MoPH, UNEP) Key outputs  AMR surveillance database available in human, food and environment  Annual report of national AMR surveillance with data from all sectors published 2.3.4 Establish surveillance of antimicrobial residues/containment in food and environment 2.3.4.1 Develop national framework for surveillance of antibiotics residues and containment in food animals (MAIL, MoPH, FAO, OIE, WHO) S 2.3.4.2 Develop national framework for surveillance of antibiotics residues and containments in environment including waste from farms, factories (pharmaceutical industries, making animal feed, processing meat, dairy, fish), veterinary and human health care settings (MAIL, MoPH, MoT, FAO, OIE, WHO) M 2.3.4.3 Develop standards for antibiotics residues in food from animals such as chicken, eggs, milk and fish (MAIL, MoT,) S 2.3.4.4 Develop standards for antibiotics residues in industrial effluents and waste from farms, human health care and veterinary care settings ( MAIL, MoPH, MoT) M 2.3.4.5 Collate and analyses antibiotics residues surveillance data from food in to useful information (MoPH, MAIL,FAO,WHO) M 2.3.4.6 Collate and analyses antibiotics residues surveillance data from environment in to useful information (MoPH, NEPS, UNEP) M Key outputs National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 25 | P a g e  Standards for antibiotics residues, national framework and results of surveillance of antibiotics residues in food and linkages with AMR developed and published  Standards for antibiotics residues, national framework and results of surveillance of antibiotics residues in environment and linkages with AMR developed and published Strategic Priority 3 Reduce the incidence of infection through effective infection prevention and control Infection prevention and control (IPC) in healthcare Objective 3.1 Develop and establish a strategic national plan for IPC in health care Strategic interventions and activities 3.1 .1 Ensure development and implementation of infection prevention and control policies and strategies across all tiers of healthcare system 3.1.1.1 Define terms of reference and scope and establish National Coordinating Unite (NCU) for infection prevention and control (MoPH) S 3.1.1.2 Define core element of IPC, and establish standardized definitions for elements at different tiers of health care settings in public and private facilities (MoPH, WHO) S 3.1.1.3 Conduct IPC assessments and gap analyses at different levels and all categories of health care settings (MoPH) S-M 3.1.1.4 Streamline hand hygiene and sanitation as components of performance monitoring/performance payment within different schemes quality programs initiatives (MoPH) 3.1.1.5 Develop national IPC standards and targets in different tiers of health care settings, and a phased implementation plan based upon risk and need based matrix, patient and healthcare worker/ professionals/attendants/vendors and community safety, designing interventions, including reuse of single use devices (MoPH) S 3.1.1.6 Develop national IPC implementation plan (in a phased approach) based upon risk and need based matrix, patient and healthcare workers/ professionals/attendants/vendors and community safety with clearly defined interventions (MoPH) S 3.1.1.7 Establish a standardize surveillance program on healthcare associated infections (HCAIs) in a tiered network that utilizes uniform case definitions, methodologies, and reporting mechanisms (MoPH) S-M 3.1.1.8 Develop capacity – infrastructure and skilled human resources with adequate financial resources to implement the national IPC plan (MoPH) S-M-L National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 26 | P a g e 3.1.1.9 Develop monitoring and evaluating framework to assess the phased implementation of national IPC plan (MoPH) S-M 3.1.1.10 Incorporate IPC in curricula for education and training of professionals in human health (MoPH) S-M Key outputs  IPC national coordinating unit establish and it is scope defined  Core elements of IPC for different tiers of health care settings established  National IPC standards developed and targets defined  National IPC plan with M&E framework endorsed and implemented  National HAI surveillance establish in identified facilities Infection prevention in animal health Objective 3.2 Establish IPC program in veterinary settings and animal husbandry Strategic interventions and activities 3.2.1 Ensure development and implantation of infection prevention and control program in animal and food sector 3.2.1.1 Include biosafety, biosecurity, hygiene and infection prevention and control in curricula for education and training of animal health and food professionals and workers (MoPH, MAIL, MoT) M 3.2.1.2 Establish IPC coordinating unite within MoPH (at Center and state level), with designated staff and defined terms of reference (MoPH) S 3.2.1.3 Train staff in cities and villages level for biosafety, biosecurity principles and practices (MoPH) M-L 3.2.1.4 Increase awareness in community for good production practice (proper hygiene/sanitation/practice of IPC); demonstrate profitability in various production systems (MoPH) S-M-L 3.2.1.5 Develop, implement and monitor the national plan for IPC in animal and food sector (MAIL, MoPH, MoT) M Key outputs  IPC Program for animal and food sector implemented and monitored at national and sub national level National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 27 | P a g e Hygiene, sanitation and infection prevention in community Objective 3.3 Strengthen infection prevention outside healthcare setting to limit the development and spread of AMR Strategic intervention and activities 3.3.1 Promote personal hygiene through behavioral change activity 3.3.1.1 Assess knowledge and practice of personal hygiene in different social groups (MoPH, MoIC) S 3.3.1.2 Develop behavioral change communication and social mobilization campaigns to promote IPC (MoPH, MoIC, MoHE, MoE, WHO) 3.3.1.3 Implement sustained IPC campaigns that are socially and culturally acceptable in local context, in collaboration with academic organizations and communications experts ( MoPH, MoIC, WHO) M 3.3.1.4 Insure engagement of mass media and new IT tools (mobile technology etc.) (MoPH, UNICEF) S 3.3.1.5 Ensure appropriate immunization against VPDs (MoPH) M 3.3.1.6 Involve community leaders in media campaign, information, education, communication at villages level, schools, showcase, importance in the community (MoPH, MoIC, MoH, UNICEF, WHO) Key outputs  Behavior change communication and social mobilization campaign developed and implemented 3.3.2 Strengthen infection prevention and hand hygiene compliance, in different social groups 3.3.2.1 Assess knowledge, attitude & practice of IPC (with emphasis on hand hygiene) in different social groups in community (MoPH, WHO) S 3.3.2.2 Develop national hand hygiene campaign in alignment with Global Hand Hygiene Day (MoPH, MoE, UNICEF)M 3.3.2.3 Implement IPC campaign with collaboration of academic organizations (MoPH, UNICEF) S 3.3.2.4 Reinforce behavior change through IEC and social mobilization campaigns to promote personal hygiene including patient attendance (MoPH, MoIC, MoE, UNICEF) M-L 3.3.2.5 Educate and train children about importance of hand hygiene at school level (MoPH, MoE, UNICEF) S 3.3.2.6 Enhance awareness of IPC and hand hygiene amongst farmers and fishermen (MAIL, MoPH, FAO, OIE) Key outputs National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 28 | P a g e  Study on IPC practices, emphasis on hand hygiene  Hand hygiene campaign implemented Objective 3.4 Align healthcare support industry with infection prevention and control Strategic interventions and activities 3.4.1. Develop and strengthen alliance for IPC 3.4.1.1. Identify area of collaboration keeping healthcare need, patients and healthcare workers’ safety and long-term industry perspective in alignment (MoPH) S-M 3.4.1.2. Collaborate with other government bodies and ministries, regulatory and industry partners as needed (MoPH) S-M-L 3.4.1.3. Establish a board for IPC professionals in public and private healthcare institutions, to review devices and modalities in healthcare, to review infection prevention and control mechanisms and adequacy (MoPH) M-L Reduce environmental spread of AMR Objective 3.5 Reduce environmental contamination with resistance genes, resistance pathogens and antimicrobial residues Strategic interventions and activities 3.5.1 Develop strategic interventions to reduce impact of AMR on the environment 3.5.1.1 Develop policy of registrations of farms, factories, slaughter houses, wet markets, aquaculture units, food processing unites, feed manufacturers, health care facilities, veterinary care facilities (MAIL, MoPH) M-L 3.5.1.2 Based on environment risk assessment developed guidelines for locating farms, factories, slaughter houses, wet markets, processing unites, feed manufacturers, health care facilities, and veterinary care facilities; ensuring compliance by strengthening existing guidelines and enforcement strategies related to payments benefits etc. (MAIL, MoPH) M-L 3.5.1.3 Develop policy and implementation mechanisms on extended producers responsibility for expired/unused antibiotics (MoPH) M-L 3.5.1.4 Develop and implement a strategy and operational plan to reduce environmental impact on AMR (MoPH, NEPA) S-M-L Key output  National plan to reduce environmental impact of AMR developed and implemented National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 29 | P a g e Strategic priority 4 Optimize the use of antimicrobial agents in health, animals and food Regulated access to high-quality antimicrobials Objective 4.1 Ensure uninterrupted access to high-quality antimicrobial medicines Strategic interventions and activities 4.1.1 Strengthen national regulatory authority for improved quality, safety of antimicrobials 4.1.1.1 Review and strengthen national regulatory authority and regulation regarding use and access to antimicrobials, as per levels of health care (MoPH) S-M-L  Regulatory enforcement to prohibit sale of antimicrobials as OTC under Drugs & Cosmetics Act, and Rules; identify unlicensed pharmacies unqualified medical practitioners and prescribers; organize studies on antibiotic sales to understand incentives to sell or buy antibiotics; review categorization of high end antimicrobials as well as new antibiotics in schedule of regulations; create focal point for networking for information exchange among states, and establish an online forum on use and access as per level of healthcare; expedite regulatory processes to ensure uninterrupted supply quality assured antibiotics; regulate the availability of probiotics without resistance determinants 4.1.1.2 Strengthen and enforce regulations to minimize substandard, spurious, falsely labeledand falsified antimicrobials (MoPH) S-M-L 4.1.1.3 Establish a quality management system for supply chain management of antimicrobials (MoPH) S-M-L Key outputs  National regulatory authority strengthened and regulation implemented  Quality management system implemented for supply chain management of antimicrobials 4.1.2 Create/develop and enforce enabling regulatory framework and intersectoral coordination for regulation on use of antimicrobials in animals and food safety 4.1.2.1 Establish independent veterinary regulatory authority (MAIL, OIE, FAO) S-M 4.1.2.2 Restrict and phase-out non-therapeutic use of antimicrobial such as their use as growth promoters and disease prevention in animals (MAIL,) S-M-L National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 30 | P a g e 4.1.2.3 Foster development of antimicrobial policies and evidence based standard treatment guideline for food animals (MAIL, MoPH) S-M 4.1.2.4 Restrict and gradually eliminate the use of restricted antibiotics, which are critically important for humans in non-human sectors especially food producing animals (MAIL, VRA, NDRA) S-M 4.1.2.5 Restrict antibiotic in animal fee, feed premix; ensure registration and use of registered products only; regulate their importation, direct distribution; ensure appropriate labeling (MAIL, MoPH) 4.1.2.6 Ensure prescription sale of antibiotics and their use under supervision; regulate bulk selling, importation and labeling for species specific use (MAIL) S 4.1.2.7 Ensure labeling of food from animals produced with or without routine use of antibiotics (MAIL) S 4.1.2.8 Fast track implementation of the codex alimentarius and OIE guidelines on antimicrobial resistance (MAIL, OIE, FAO) Key output  Regulatory authority established for rational use of antibiotics in food and animal sector Surveillance of antimicrobial use Objective 4.2 Establish the national surveillance system for antimicrobial use Strategic interventions and activities 4.2 .1 Institutionalize national surveillance system for antimicrobial use(AMU) in humans, animals, agriculture & food sectors 4.2.1.1 Develop methodology to estimate national consumption of antibiotics through an expert consultation (MoPH, MAIL, WHO, 4.2.1.2 Use of AMC tool to measure consumption of antibiotics at health care facilities (MoPH, WHO) S-M-L 4.2.1.3 Ensure registration of and data collection from manufacturers, prescriber and bulk users (farmers and feed manufacturers) of antibiotics (MAIL, MoPH) S 4.2.1.4 Standardize tools to measure consumption of antibiotics in animal health facilities, food and agriculture (MAIL, MoPH, FAO) S-M 4.2.1.5 Organize training workshop to develop capacity to measure consumption and use of antibiotics (MoPH, MAIL, WHO, FAO) S M-L 4.2.1.6 Organize national consultation to strengthen AMU surveillance program in human, animal and food sectors (MoPH, MAIL) S-M-L National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 31 | P a g e 4.2.2 Establish a monitoring system to assess antimicrobial consumption in humans, animals & food sectors 4.2.2.1 Develop monitoring framework to estimate national consumption of antimicrobials through an experts consultation (MoPH, MAIL, WHO, FAO) M-L 4.2.3 Foster optimal use of antimicrobials 4.2.3.1 Ensure capacity development of institutions for antibiotics audits and feedback to ensure optimal use (MoPH, WHO) S-M-L 4.2.3.2 Regulate the establishment of comities to develop and update hospital formularies and STGs; provide training, CME, establish system for audits and review (MoPH, WHO) M-L 4.2.3.3 Implement system to ensure compliance with standard guidelines (STGs) (MoPH) M-L Key outputs  National surveillance for antimicrobials use, established in human, animal and food sectors  Feedback mechanism established for all stakeholders  Annual national AMU surveillance report published and disseminated Antimicrobial stewardship in human health Objective 4.3 Improve appropriate use of antimicrobials in healthcare Strategic interventions and activities 4.3.1 Establish antimicrobial stewardship programs in healthcare facilities 4.3.1.1 Harmonize and regularly update national antimicrobial use guideline; encourage development and use of similar guidelines at regional, and district level facilities (MoPH) S 4.3.1.2 Ratification dissemination of national guidelines from stakeholders (MoPH) S 4.3.1.3 Define terms of reference for multidisciplinary antimicrobial stewardship committees and teams at various levels of healthcare facilities, with M&E framework (MoPH) S  Experts consultation to develop the terms of reference for antimicrobial stewardship (AMS) committees/teams at various level of healthcare facilities 4.3.1.4 Develop resources for AMS programs and implement trainings in phased manner (MoPH) S National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 32 | P a g e  Identify a diverse pool of technical experts for collecting and collating evidence for national AMSP; and creating training packages and resources  Engage or identify center(s) with capability for providing e-training for self-learning and refresher training 4.3.1.5 Establish M&E framework for antimicrobial stewardship (MoPH) S  Expert consultation to develop M&E programs at different levels of healthcare facilities 4.3.1.6 Develop operational plan to implement facilities-based AMS programs at different levels of healthcare; identify and strengthen capacities of 6-8 institutions in different part of country with functional AMSP who are willing to be future nodal centers for regional trainings (MoPH) M 4.3.1.7 Implement the operational plan at selected tertiary care hospitals, district hospitals, sub district and primary healthcare facilities in phased manner (MoPH) M 4.3.1.8 Develop robust data management systems for AMS programs that also facilitate the generation of facility-level specific or regional antibiograms (MoPH) M 4.3.1.9 Streamline antibiotic in various central and state schemes by introducing quality indicators linked to performance monitoring/appraisal and innovative financial mechanisms (MoPH) M Key outputs  Antimicrobial stewardship programs implemented in selected health facilities in phased manner  Regular review of AMS programs done Objective 4.4 Improve appropriate use of antimicrobials in the community Strategic interventions and activities 4.4.1 Increase awareness of appropriate antimicrobial use among provider, dispenser and consumer populations 4.4.1.1 Develop awareness campaigns targeted at prescribers, providers and dispensers regarding existing rules/law and appropriate use of antimicrobials (MoPH, MAIL, UNICEF) S-M-L 4.4.1.2 Develop awareness campaigns targeted at consumers and community, including schools and colleges regarding patient risks of inappropriate antibiotics use (MoPH, MAIL, MoE, MoHE, UNICEF) S-M-L 4.4.2 Monitor antimicrobial use in community settings National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 33 | P a g e 4.4.2.1 Use AMC tool to measure antimicrobial use in community settings, including standalone clinics and pharmacies (MoPH) S-M-L 4.4.2.2 Initiate surveillance to measure antimicrobial use in selected community settings (MoPH) S-M-L Objective 4.5 Strengthen the legislation regarding various facets of antimicrobials Strategic interventions and activities 4.5.1 Strengthen legislation to regulate prescription and dispensing of antimicrobials 4.5.1.1 Organize a consultation with regulatory bodies to review current legislation on antimicrobial prescriptions and feasibility to strengthen existing legislation and to introduce new legislations (MoPH) S-M 4.5.1.2 Identify additional regulatory interventions or support needed to effectively implement schedule HI and X restrictions (MoPH) S-M-L Key output  Legislation and regulation strengthened and implemented to optimize use of antibiotics Objective 4.4 Improve knowledge and skills of prescribers, dispensers and medical trainees Strategic interventions and activities 4.6.1 Develop structured (and mandatory) training programs on optimal antimicrobial use 4.6.1.1 Collaborate with regulatory bodies to mandate periodic training to optimize antibiotic use through pre-service and in-service trainings (MoPH, MoHE) S M-L 4.6.1.2 Promote measures for overall health improvement and service delivery (MoPH) M  Detect and treat malnutrition at an early stage  Insure up-to-date vaccination  Prevent sexually transmitted diseases  Early diagnosis of malaria and viral infections to reduce antibiotic use 4.6.1.3 Develop strategies to improve efficacy and broaden coverage of existing vaccines and their usage, especially by at-risk populations e.g. Haemophilus influenza type b (Hib), influenza, pneumococcal and typhoid vaccines (MoPH) National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 34 | P a g e Key output  Collaborations forged for improving knowledge and skills relating to antimicrobial use Antimicrobial stewardship and policies in animal husbandry and food Objective 4.4 Improve and ensure appropriate use of antimicrobials in animals Strategic interventions and activities 4.7.1 Establish antimicrobial stewardship programs for rational use of antimicrobials in animal facilities, agriculture, and food processing units 4.7.1.1 Develop and implement operational plan for antimicrobial stewardship (AMS) in animal facilities, with a One Health Approach (MoPH, FAO,MAIL)  Support small and mid-size poultry, dairy and fish farmers to reduce use of antibiotics, avoid non-therapeutic use and move to safer alternatives; issues “ pond health cards” to promote the health of fish farms through a systematic farm-specific assessment and feedback mechanism; develop and implement biosecurity practices across food animal production sectors and support small-and-medium scale farmers Key output  Antimicrobial stewardship programs implemented in animal facilities 4.7.2 Establish and implement national policies on use of antimicrobial agents in animals and agriculture 4.7.2.1 Develop national plan on restricting (ban/phase off ) use of critically important antibiotics (MoPH, MAIL) S-M  Evidence-based policy guided by data generated from well implemented antimicrobial stewardship across various sectors 4.7.2.2 Implement and monitor national plan to restrict use of critically important antibiotics in animals/agriculture (MAIL, MoPH) M-L Key output  System established and implemented to restrict use of critically important antibiotics in animals and agriculture National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 35 | P a g e Strategic priority 5 Promote investment for AMR activities, research and innovation Financing for AMR Objective 5.1 Prepare the economic case for sustainable investments for AMR interventions Strategic interventions and activities 5.1.1 Strategies to secure sustainable funds for implementation of the NAP-AMR 5.1.1.1 Assess impact of AMR – morbidity, mortality and cost of AMR in Afghanistan (MoPH) S 5.1.1.2 Develop the operational plan (with cost) of the plan to implement NAP AMR (MoPH, MAIL) S 5.1.1.3 Estimate the investment gap for NAP-AMR, and develop resource mobilization plan for sustainable action against AMR (MoPH, MoF) S 5.1.1.4 Define center-state & other stakeholders’ roles in implementation & financing (MoPH) S 5.1.1.5 Develop a long term resource mobilization plan with clear roles of different stakeholders (All Ministries) S-M Key outputs  Impact of AMR and cost-benefit analysis documented  Resource mobilization plan endorsed and implemented Research and innovation Objective 5.2 Identify priorities for basic and operational research to optimize use of antimicrobials and improve infection prevention and control in human and animal health 5.2.1 Foster research and innovations to tackle AMR 5.2.1.1 Review need for new medicine, vaccines and diagnostics as well as other innovations (MoPH) 5.2.1.2 Define research priorities for AMR innovation (MoPH) S 5.2.1.3 Innovation and research interventions in respect of developing alternatives to antimicrobials and adjuvant remedies for infectious disease (MoPH) S-M-L 5.2.1.4 Develop and implement strategy/plan to promote/fast-track research for innovation to tackle AMR (MoPH) S-M-L National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 36 | P a g e Key outputs  National research priorities for AMR defined and published  National strategy/plan developed to foster research and innovation to tackle AMR  Development of new antibiotics, alternative tools and diagnostics supported 5.2.2 Prepare a national operational research agenda 5.2.2.1 Organize expert consultation to identify current gaps in knowledge and priorities topics for research (MoPH) S 5.2.2.2 Publish the national research agenda for AMR (MoPH, MAIL) S-M-L Key output  Annual publication of operational research agenda on AMR 5.2.3 Encourage research for evidence-informed policy-making 5.2.3.1 Coordinate basic research projects in human, animals, food and environment sectors (MoPH, MAIL, NEPA,WHO,FAO,OIE) S-M-L 5.2.3.2 Fund and pilot basic and operational projects in human, animals, food and environment (MoPH, MAIL, NEPA,WHO,FAO,OIE) S-M-L Key output  Evidence generated based on AMR research Strategic priority 6 Strengthen Afghanistan commitment and collaborations on AMR at international, national and sub-national levels International role Objective 6.1 Strengthen Afghanistan commitment on AMR through collaborations Strategic interventions and activities 6.2.1 Strengthen intersectoral coordination of AMR activities 6.2.1.1 Review Afghanistan existing collaboration on AMR and identify priority areas as well as coordination mechanisms (MoPH, WHO) S National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 37 | P a g e 6.2.1.2 Establish an annual forum on AMR for donors and partners to share information and facilitate coordinated mobilization of recourses prioritized AMR activities (MoPH, WHO) S-M-L 6.2.1.3 Collaborate with other countries to combat AMR (MoPH) S-M-L Key output  International collaboration strengthened and established National role Objective 6.3 Strengthen national collaborations to tackle AMR with disease control programs Strategic interventions and activities 6.3.1 Strengthen drug resistance containment activities & linkages 6.3.1.1 Strengthen HIV/STI resistance activities (MoPH) S-M-L 6.3.1.2 Strengthen MDR/XDR-TB activities (MoPH) S-M-L 6.3.1.3 Strengthen drug resistance activities for malaria (MoPH) S-M-L 6.3.1.4 Strengthen drug resistance activities in leprosy and NTDs (MoPH) S-M-L 6.3.1.5 Strengthen IDSP’s AMR activities (MoPH) S-M-L 6.3.1.6 Establish linkages to share best practice and information amongst vertical diseases programs and national AMR program (MoPH) S-M-L Key output  Integrated AMR containment in alignment with vertical disease programs Sub-national role Objective 6.4 Strengthen sub-national collaboration to tackle AMR Strategic interventions and activities 6.4.1 Establish AMR as a state-level priority 6.4.1.1 Convene state-level advocacy meetings to priority action against AMR with One Health approach (MoPH, WHO, FAO) S-M-L 6.4.2 Develop state action plan on containment of Antibiotic Resistance (SAP-CAR) aligned to NAP-AMR 6.4.2.1 Convene regional stakeholder workshop to develop SAP-CAR (MoPH, WHO, FAO) National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 38 | P a g e 6.4.2.2 Organize a stakeholder consultation on SAP-CAR in selected state (in first phase) S Key output  SAP-CAR developed – in 5 selected states in first phase – and subsequently in all states/UTs 3.5. monitoring and evaluation plan Monitoring and evaluation (M&E) is an integral part of the national plan on AMR to ensure objective review and monitoring of the implementation progress. The M&E framework shall be finalized based on the final national action plan, and shall be developed according to the draft outline below. Planning element (activity linked to the NAP-AMR) indicator Type and purpose Value (calculation) Frequency of data collection Data source Method baseline target Measure awareness and knowledge of AMR in different social and professional groups Level of awareness by target group Assessment, baseline survey, monitoring and evaluation of outcome Awareness scores stratified by target group (composite indicator) Baseline and periodic( based on schedule of awareness campaign) Baseline survey, post intervention survey reports Awareness survey; knowledge practice(KAP) studies Measured in baseline survey 50% increase over baseline score Awareness/behavior change communication campaign on AMR and AMU Number of IEC recourses developed Monitoring and evaluation of output IEC resources stratified by stakeholders Annually Baseline post campaign Awareness campaign report None Based on NAP Review and consolidate AMR in curricula for health professional Revise curricula available for target professional group M&E of input Yes/No No. of curricula No. of professional Group targeted Annually Key information at MoPH Key informant interview ………… Revised curricula with AMR Review and consolidate AMR in curricula for professional in animal health food industry and agriculture Revised curricula for target professional groups M&E of input Yes/No No. of curricula No. of professional Group targeted Annually Key information at MoPH, MAIL Key informant interview ………… Revised curricula with AMR National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 39 | P a g e Planning element (activity linked to the NAP AMR) indicator Type and purpose Value (calculation) Frequency of data collection Data source Method baseline target Write and approve term of reference for a national coordinating center for AMR surveillance National coordination center terms of reference approved M&E input Yes/No Annually Key information at MoPH AMR surveillance program implementation report No terms of reference for national coordinating center Define ToR for national coordinating center Write and approve terms of reference for national reference laboratories National reference lab term of reference written and approved M&E input Yes/No Annually Key information at MoPH AMR surveillance program implementation report No terms of reference for NRL Define terms of reference for NRL Write and approve term of reference for a national infection prevention coordination unit IPC unite terms of reference written and approved M&E input Yes/No Annually Key information at MoPH IPC program implementation report No quality management system Define terms of reference for IPC unit Establish a quality management system for the medicines supply chain QMS established and introduced M&E input Yes/No Annually Key information of department of Pharmaceutical Key information interview No terms of reference for antimicrobial stewardship committees Quality management system implemented Write generic terms of reference (ToR) for multidisciplinary antimicrobial stewardship committees and teams Antimicrobial stewardship committee ToR written and approved M&E input Yes/No Annually Key information at MoPH Key information interview No research agenda Define ToR for AMS committes Engage relevant experts to identify research topics on AMR Draft research agenda prepared M&E input Yes/No Annually Key information at MoPH Key information interview Define AMR research agenda National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 40 | P a g e References  WHO May 2014. Sixty-seventh World Health Assembly, WHA67.25; agenda item 16.5 24: Antimicrobial resistance. (http://apps.who.int/gb/ebwha/pdf files/WHA67 R25 en.pdf,acessed 14 February 2017)  WHO, 2015. Sixty-eight World Health Assembly, WHA68.7; agenda item 15.1 26: Global action plan on antimicrobial resistance (http://apps.who.int/medicinedocs/documents/s21889en/s21889en.pdf, accessed 14 February 2017)  WHO, 2015. Global Action Plan on Antimicrobial Resistance. (http:/www.who.int/antimicrobial-ressitance/publications/global-action-plan/en/, accessed 14 February 2014)  World Health Organization. United Nations high-level meeting on antimicrobial resistance. Antimicrobial Resistance. Geneva: World Health Organization; 2016. 3. (http://www.who.int/antimicrobial-resistance/events/UNGA-meeting-amr sep2016/en/, accessed 30 September 2016 National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 41 | P a g e Annex 1: Governance committees/groups for AMR Intersectoral Coordination Committee on AMR (ICC-AMR) The purpose of the intersectoral coordination committee on Antimicrobial Resistance is to oversee and coordinate policy decisions for activities related to antimicrobial resistance in all sectors in alignment with AMR-related public health goals. Terms of reference  Lead and facilitates the coordination of the national (along with sub-national and international response to the threat of AMR;  Ensure information sharing to reinforce AMR-related activities amongst all sectors;  Review and revise terms of reference of technical advisory group on AMR;  Ensure coordination of the health system and other sectors to achieve the AMR related public health goals;  Facilitate and synergies existing and new initiatives to achieve the goal of combating AMR in Afghanistan;  Facilitate collaboration with internal and external agencies and organizations for AMR-related activities;  Endorse national action plan on AMR, and ensure adequate logistic and resource mobilization to cover any funding gap; and  Oversee progress of NAP-AMR and ensure program planning and implementation. Constitution of ICC-AMR  Secretary (MoPH) Chair  Joint Secretary, (MAIL) Member  Secretary, Department Animal Husbandry, Dairying and fisheries Member  Secretary, Department of Health research Member  Secretary, Department of Biotechnology Member  Director General Curative Medicine Member  Joint Secretary, (NEPA) Member  Joint Secretary, Department of Pharmaceuticals Member   Joint Secretary, (Ministry of information and culture) Member  Joint Secretary, (Ministry of finance) Member  Joint Secretary, (MoHE) Member  Joint Secretary, (MoT) Member Frequency of meetings:  It is proposed that ICC-AMR shall meet at least once every quarter  The frequency of meetings shall be decided in the first meeting of ICC-AMR National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 42 | P a g e Technical Advisory Group on AMR (TAG-AMR) The purpose of Technical Advisory Group on Antimicrobial Resistance shall be to review the approach and initiatives for combating AMR in Afghanistan and make recommendations on technical issues. Term of reference:  Provide technical advice and reports to the Inter-Sectoral Coordination Committee on Antimicrobial Resistance (ICC-AMR);  Technical review and revise the draft NAP-AMR;  Provide technical oversight for initiatives to combat AMR in Afghanistan; and  Review and revise the terms of reference of the core working group on AMR. Constitution of TAG-AMR  General Director of Curative Medicine Joint chair  Secretary, Department of Health research Joint chair  Drug control Authority Member  Commissioner, Department of Animal Husbandry Member  Representative, food safety and standard Authority Member  Representative, NEPA Member  Representative, Department of Agriculture research Member  Representative, Ministry of Information and culture Member  Representative, Department of Biotechnology Member  Representative, Department of Pharmaceuticals Member  WHO representative to Afghanistan Member  WHO Focal point of AMR Member  Hospital’s Directors Member  Professionals of Different Specialty Member  Senior Microbiologist Member  Senior pharmacologist Member  Consultant, infectious disease Member Frequency of meetings:  TAG-AMR shall meet at least once every quarter. Core working group on AMR (CWG-AMR) The Core Working Group on Antimicrobial Resistance shall provide technical and operational inputs to the designated national coordinating center for AMR in Afghanistan to develop and implement the National Action Plan on Antimicrobial Resistance (NAP-AMR). Terms of reference  Identify and map stakeholder for AMR-related activities; National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 43 | P a g e  Lead the development of the national action plan on AMR in Afghanistan with active engagement of all key stakeholders;  Ensure regular data collection and information sharing through effective communication and coordination amongst all stakeholders;  Coordinate national activities for establishing/linking surveillance system for AMR and antimicrobial use;  Develop and disseminate national AMR reports annually; and  Facilitate and monitor/evaluate the overall implementation of NAP-AMR. Constitution of CWG-AMR  Director, National Center for Disease Control  Deputy Drug Controller  Microbiologist  Pharmacologist  Surgeon  Pediatrician  Department of animal husbandry  Environment experts  Food experts  Finance/budget experts  Communication experts  WHO experts Frequency of meetings:  The CWG-AMR shall meet at frequency intervals; it is proposed that it meet at least once every month during the initial phase. The technical advisory group and core working group are governance mechanisms specific to the human health sector. Similar groups may be needed in other sectors to coordinate their response in tackling AMR. National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 44 | P a g e Annex 2: Operational plan and budget (template) The operational plan and budget shall be developed after the strategic priorities are finalized, as per national financial rules and regulations, and shall be added based on finalized priorities/activities as per template below. Item Description date location Responsible entity Cost (USD) Source of funding indicator Strategic Priority 1: Improve awareness and understanding of AMR through effective communication education and training Activit y 1 AMR Awareness Sub activity 1.1.1 The suppliers and pharmaceutical importing companies should be given full awareness on AMR to import quality medicine Q1 2018 Kabul and 4 regions NMHRA 10,000 WHO Orientation sessions conducted in each region Sub activity 1.1.2 Orientation Seminars should be conducted for the religious leaders on the proper use of antibiotics and the hazardous of AMR Q2 2018 Kabul and 4 regions National AMR Committee and Regional AMR Committee 15000 WHO Orientation seminars conducted in each region Activi ty 2 Sub activity 1.2.1 Conducting a baseline study/KAP survey on AMR at national level at least in the 5 capital zones of the country Q3 2018 Kabul and 4 regions National AMR Core working group 50000 ??? Report of KAP survey Sub activity 1.2.2 Advocacy for the inclusion of AMR in the curriculum of schools and universities. Q1 2019 ….. National AMR Core Working group 15000 ….. Curriculum of the schools and universities with AMR Sub activity 1.2.3 Orientation seminars and IEC materials on AMR for the students in the universities and schools Q2 2019 National AMR Core Committee and AMR regional Committee 60,000 Number of orientation seminars for schools and universities Sub Activity 1.2.4 The Public and Animal health clinics/pharmacies should be instructed through the NRAs not to distribute antibiotics for animals without prescription of Doctor of Veterinary. Q1 2018 MAIL and Agriculture Directorate in the provinces 30000 Letter from NRAs Sub Activity 1.2.5 The veterinary doctors should give orientation to all the farm/livestock owners not to use milk of the relevant animals from Q4 2018 National AMR Committee and MAIL 10000 Leaflets National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 45 | P a g e 24 till 48 h after antibiotic use by animals. (Printing of leaflets) Establishment of AMR Committees at regional level. TOR to be developed by the National AMR Committee Q3 2018 National AMR Committee 10,000 Monthly reports of the AMR committees Strategic Priority 2: Lab Strengthening Item Description date location Responsibl e entity Cost (USD) Source of funding indicator Activity 2.1 Lab Capacity building Sub activity 2.1.1 Strategic plan development to strengthen microbiology laboratories for AMR surveillance in humans, animals, food and environment Q3 2018 Nation GlASS Sub Comittee 10000 Strategic plan Sub activity 2.1.2 Training workshops held for AST in medical and food labs and environment labs Q4 2018 ….. National GLASS Sub Committee 30000 Number of training workshop Sub Activity 2.2.1 Standards for antibiotics residues, national framework and results of surveillance of antibiotics residues in food and linkages with AMR developed and published Q1 2019 GLASS Committee 10,000 Standards available for anti ? biotics residue Sub Activity 2.2.2 National AMR reference labs designated Q3 2018 GLASS Committee 3000 Availability of design for Ref labs Sub Activity 2.2.3 Afghanistan enrolled in GLASS Q2 2018 GLASS Committee 0 Reporting to GLASS Sub Activity 2.2.4 Training workshops held for AST in medical and food labs and environment lab Q4 2018 National AMR Committee 20,000 Training Report Sub Activity 2.2.5 AMR surveillance database available in human, food and environment Annual report of national AMR surveillance with data from all sectors published Q2 2019 Surveillanc e departmen t 10,000 Availability of AMR database in human, food and environmental sectors Strategic Priority 3: Infection prevention and control (IPC) in healthcare Activity 3.1 National IPC Program National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 46 | P a g e Sub activity 3.1.1 Establishment of IPC national coordinating unit Q3 2018 National IPC Committee /IPC departmen t 3000 Availability of National IPC Coordination unit Sub activity 3.1.2 Development, Endorsement of and implementation National IPC plan with M&E framework Q4 2018 National IPC Committee /Dept 3000 Availability and implementation of National IPC framework Sub Activity 3.1.3 Establishment of National HAI surveillance in identified facilities Q4 2018 National IPC Committee /Dept 15000 Report of HAI Surveillance Sub Activity 3.1.4 Development of National IPC standards and targets defined Q1 2019 National IPC Committee /Dept 3000 Availability of national IPC standards Sub Activity 3.1.5 IPC Program for animal and food sector implemented and monitored at national and sub national level Q1 2019 National IPC Committee /Dept 20000 Availability of IPC national program in food and animal sector Sub Activity 3.1.6 Conducting Campaign for Behavior change communication and social mobilization Q2 2019 National AMR Committee Campaign reports Sub Activity 3.1.7 Study on IPC practices, emphasis on hand hygiene Q2 2019 National IPC Committee /Dept 20000 Sub Activity 3.1.8 Conducting Hand hygiene campaign Q2 2019 National IPC Committee /Dept 60,000 Activity 3.2 Impact of AMR Sub Activity 3.2.2 Develop strategic interventions to reduce impact of AMR on the environment in terms of policy of registrations of farms, factories, slaughter houses, wet markets, aquaculture units, food processing unites, feed manufacturers, health care facilities, veterinary care facilities Q3 2019 National AMR Committee 20000 Item Description date location Responsibl e entity Cost (USD) Source of funding indicator National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 47 | P a g e Sub Activity 3.2.2 Development of guidelines for locating farms, factories, slaughter houses, wet markets, processing unites, feed manufacturers, health care facilities, and veterinary care facilities, based on environment risk assessment and ensuring compliance by strengthening existing guidelines and enforcement strategies related to payments benefits etc. Q3 2019 GLASS Committee 10,000 Sub Activity 3.2.2 Develop policy and implementation mechanisms on extended producers’ responsibility for expired/unused antibiotics. Q4 2019 GLASS Committee 3000 Sub Activity 3.2.3 Develop and implement a strategy and operational plan to reduce environmental impact on AMR Q1 2019 Strategy and operational plan developed and implemente d 15000 Activity 4.1 Strengthening Regulatory bodies Sub Activity 4.1.1 National regulatory authority strengthened and regulation implemented to ban the use of Antibiotics on OTC in health and animal sector and ban malpractices and maluses of antimicrobials in both sector 2018 Revised Laws/Acts Sub Activity 4.1.2 Quality management system implemented for supply chain management of antimicrobials 2018 20,000 Availability of quality management system Sub Activity 4.1.3 Regulatory authority established for rational use of antibiotics in food and animal sector to enforce the rational use of antibiotics in food and animal sector and restrict and phase-out non-therapeutic use of antimicrobial such as their use as growth promoters and disease prevention in animals 2019 100,000 Availability of regulatory authority Sub Activity 4.1.4 Establish National surveillance for antimicrobials use, in human, animal and food sectors and publishing/disseminating annual AMR report 2019 20,000 Annual AMR surveillance report National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 48 | P a g e Sub Activiy 4.1.5 Develop operational plan to implement facilities-based AMS programs at different levels of healthcare; identify and strengthen capacities of 6-8 institutions in different part of country with functional AMSP who are willing to be future nodal centers for regional trainings (MoPH) M 2019-20 50,000 Plan available Sub Activity 4.1.6 Implement the operational plan at selected tertiary care hospitals, district hospitals, sub district and primary healthcare facilities in phased manner 2020 10,000 Implementation report Sub Activity 4.1.7 Establish and implement a system to restrict use of critically important antibiotics in animals and agriculture 2019 National AMR with Animal Health 5000 Item Description date location Responsibl e entity Cost (USD) Source of funding indicator Strategic Intervention 5: Financing AMR Activity 5.1 Studying the impact of the AMR Sub activity 5.1.1 5.1.1.1 Assess impact of AMR – morbidity, mortality and cost of AMR in Afghanistan (MoPH 2019 National AMR Comm 40,000 Study report Sub activity 5.1.2 Develop resource mobilization plan to finance the action plan 2018 National AMR Committee 5000 Resource mobilization plan Sub Activit y 5.1.3 Review need for new medicine, vaccines and diagnostics as well as other innovations, and define research priorities for AMR innovation 5.2.1.3 2019-20 National AMR Committee 0 Review report 5.1.4 Sub Activit y Innovation and research interventions in respect of developing alternatives to antimicrobials and adjuvant remedies for infectious disease 2020 National AMR Committee 30,000 Report of interventions 5.1.5 Sub Activity Evidence generated based on AMR basic research projects in human, animals, food and environment sectors research and interventions 2020 National AMR Committee 30,000 AMR research report Strategic Priority 6: Strengthen Afghanistan commitment and collaborations on AMR at international, national and sub-national levels National Action Plan on Antimicrobial Resistance/Afghanistan Timeline S: short term <1 year; M: medium term 1-3 years; L: long term>3 years 49 | P a g e Activity 6.1 AMR Collaboration Sub Activity 6.1.1 Review Afghanistan existing collaboration on AMR and identify priority areas as well as coordination mechanisms 2018-22 National AMR Committee 0 Sub Activity 6.1.2 Establish an annual forum on AMR for donors and partners to share information and facilitate coordinated mobilization of recourses prioritized AMR activities 2019 National AMR Committee 15000 Annual report Collaborate with other countries to combat AMR 2019-22 National AMR Committee 10,000 Coordination report Sub Activity 6.1.2 Convene state-level advocacy meetings to priority action against AMR with One Health approach and develop state action plan on containment of Antibiotic Resistance (SAP-CAR) aligned to NAP-AMR 2019 National AMR Committee 20,000 Meeting reports Sub Activity 6.1.3 Convene regional stakeholder workshop to develop SAP-CAR 2019 National AMR Committee 10,000 Report of workshop Sub Activit y 6.1.4 Integrated AMR containment in alignment with vertical disease programs to reduce MDR/TB……. 2019 National AMR Committee 15,000 plan