National Action Plan on Antimicrobial Resistance (2018-2022)

5.1 Governance In order to institutionalize the action on AMR, a focal Person was identified by the Ministry of Health and the Ministry of Agriculture and Forests. The Drug Technical Advisory Committee (DTAC) was identified as the National Steering Committee, as it has representation from all relevant agencies to advice the government on matters related to AMR. However, there is no national policy on AMR. Due to limited capacity and the complexity of AMR, the activities have not been carried out in a systematic manner. There is no lead/Focal agency/program at the MoH and MoAF, for systematic planning and budgeting for AMR activities. Multi-sectoral collaboration is weak and requires further harmonization. 6

5.2 Rational Use of Antimicrobials Under the initiatives of the Essential Drugs Program, antibiotic guidelines have been developed in 2007 and revised in 2012 but the guidelines have been adapted from the international guidelines and do not incorporate the antimicrobial resistance pattern in the country. In addition, compliance to these guidelines has been poor. The guideline needs to be reviewed and updated based on the antimicrobial resistance pattern and compliance to it should be promoted through institution of audit mechanism and regular awareness programs. There is no antibiotic guideline for animal health and needs to be developed. Although Standard Treatment Guideline is available, there are no clinical treatment pathways for infectious diseases both in human and animal health. Training workshops on rational use of drugs is carried out from time to time but lacks specific focus on antimicrobials. Routine prescription monitoring on antimicrobial use is done at the National Referral Hospital level but it is not systematic and monitoring is weak. There is inadequate interdisciplinary coordination and lack of clinical auditing in ensuring rational use of antimicrobials. There is a need to develop mechanisms to promote coordination within the disciplines.

5.3 Surveillance and monitoring of AMR and antimicrobials use Although routine isolation and antibiotic susceptibility testing should be carried out on all clinical samples, the facility is available only in the three referral Hospitals and Phuentsholing General Hospital for human health and National Center for Animal Health (NCAH) and Regional Livestock Development Center (RLDC) for animal health, respectively. There is limited number of skilled human resource and no systematic reporting in place for antimicrobial resistance. Although data is available, they are not analyzed and used for influencing prescribing behavior. There is no system for monitoring antimicrobial utilization and sharing of information among the relevant stakeholders. 7

5.4 Education and Awareness There is no structured educational curriculum on AMR for the health and livestock trainees and Information Education and Communication (IEC) materials on AMR has not been developed. The concepts and principles on rational use of antimicrobials need to be included in the University curricula. There should be mandatory core training on rational use of antimicrobials for all categories of health care providers. There should be a structured orientation program for the new recruits and expatriates in addition to regular CME for in-service professionals on antimicrobials. Despite having guidelines for treatment of various diseases, there is no practice of routine prescription audit of antimicrobials. This could be attributed to poor sensitization and adherence to existing policies and guidelines. General public must be sensitized on the rational use of antimicrobials.

5.5 Research There is no enabling environment for research on antimicrobial use. The support to carry out research is inadequate both in terms of financial and human resources. Planning is not evidence based and available evidences are not utilized for planning activities related to antimicrobials. As such, there is limited scope and incentive for research. Research should be encouraged and accorded priority. In order to address effective intervention at the local level, regular operational researches should be planned and carried out.

5.6 Collaboration The coordination among relevant agencies within the country, as well as with relevant international organizations is weak. Inadequate coordination amongst the programs and sectors has resulted in weak implementation of activities to combat AMR. 8 The coordination among the various technical committees and agencies needs to be strengthened.

5.7 Control and Regulation Although there is no specific mention on regulation of antimicrobials in the Medicines Act of the Kingdom of Bhutan, 2003, antibiotics are classified under prescription-only medicines in the regulations and thus their sale in the private pharmacies is regulated. However, there are no regulatory provisions on control of non-therapeutic use of antimicrobials use in animals and other agricultural practices. Therefore, there is a need to include such provisions under the medicines rules and regulations. 6. Objectives The objective of this document is to operationalize and facilitate the effective implementation of policies and plans to combat AMR effectively through multi-sectoral and multidisciplinary collaboration under One Health approach. Based on the above rationale, guiding principles and the situation analysis the action plan shall focus on achieving the following objectives. Objective 1: To establish a governance structure to spearhead the AMR activities. Objective 2: To promote rational use of antimicrobial agents at all levels of health care and veterinary settings Objective 3: To institute surveillance and monitoring system on AMR and antimicrobials use Objective 4: To create and promote awareness on AMR through educational and public campaigns Objective 5: To establish and promote a system of research on AMR Objective 6: To foster national and international collaboration Objective 7: To strengthen control and regulatory system 9 Objective 1: To establish a governance structure to spearhead the AMR activities The Drug Technical Advisory Committee (DTAC) shall function as the National Steering Committee and provide technical guidance on AMR. A Division/Program shall be designated as the focal agency within the MoH and MoAF to coordinate the activities. A focal person each for human and animal health shall be designated to provide technical assistance related to AMR program/division. The focal person of the MoH shall act as the national focal point for AMR. All AMR activities shall be included and budgeted in the annual work plan in line with the national action plan. Hospital-based antimicrobial stewardship program shall be instituted in all the national and regional Hospitals. Objective 2: To promote rational use of antimicrobial agents at all levels of healthcare and veterinary settings The national antibiotic guideline shall be reviewed and updated based on the antimicrobial resistance pattern in the country. Adherence to the guidelines shall be promoted through institution of audit mechanism, regular training and awareness programs. Rational use of antimicrobials shall be included in the training workshops related to rational use of drugs. The system of prescription monitoring on antimicrobial use shall be strengthened in all the major hospitals. Interdisciplinary coordination shall also be enhanced to promote rational use of antimicrobials. The rational use of antimicrobials shall be promoted at all levels of healthcare and veterinary settings. A robust antimicrobial stewardship program led by a dedicated team of appropriate professionals shall be established. Objective 3: To institute surveillance and monitoring system on AMR and antimicrobials use The resistance pattern of organisms to antimicrobials shall be monitored regularly and the report shall be shared with the prescribers regularly and presented to the National Medicines Committee meeting. The resistance pattern shall be considered in development of guidelines and procurement of antibiotics. The capacity of the laboratory surveillance on AMR shall be 10 strengthened up to the major district hospitals. Antimicrobials use shall be monitored and reported routinely. Objective 4: To create and promote awareness on AMR through educational and public campaigns Structured curriculum on AMR should be developed and introduced in the university curriculum. A robust training program for the training of in-service professionals shall be initiated. Regular awareness campaigns shall be carried out for general public through the use of different IEC materials and media. Objective 5: To establish and promote a system of research on AMR Adequate provisions in terms of fund and other resources shall be made to encourage research on AMR. Evidences produced from these researches shall be utilized for policy and planning interventions in future. Objective 6: To foster national and international collaboration National and international collaboration shall be promoted to harness the expertise and share knowledge, capacity building and use data productively. Membership to international organization on AMR shall be encouraged. Objective 7: To strengthen control and regulatory system The regulatory process of ensuring quality, safety and efficacy of antimicrobials in the country shall be implemented. Antimicrobial use in animal feeds and other non-therapeutic uses shall be restricted. 11 Performance Lead Implementing Strategies Activities Baseline Target Timeline Indicator Agency Partners Objective 1: To establish a governance structure to spearhead the activities of AMR

1.1.1.1 National MoH, MoAF, DRA,

1.1.1 Develop Action plan 0 1 Jun-17 DMS JDWNRH AMR National endorsed

1.1 The government Action Plan for 1.1.1.2 National MoH, MoAF, DRA, shall allocate adequate endorsement Action Plan printed 0 500 Jan-18 DMS JDWNRH resources for the and disseminated operationalization of 1.1.2 Sensitize National Action Plan. relevant 1.1.2.1 Percentage MoH, MoAF, DRA, stakeholders on of stakeholders 0 >90% Dec-18 JDWNRH the AMR National sensitized Action Plan

1.2.1.1 ToR

1.2 A

1.2.1 ToR for the endorsed and Division/Program shall Focal Agencies Executive order be designated as the developed and issued for the MoH, MoAF, DRA, focal agency within the NA NA Jul-18 DRA focal agency identified focal JDWNRH MoH and MoAF to identified within agency by Bhutan coordinate the MoH and MoAF Medicines Board activities. (BMB)

1.3.1 Institute 1.3.1.1 AMR National AMR Steering committee MoH, MoAF, DRA,

1.3 A Steering 0 1 Jul-18 DRA Steering identified and JDWNRH Committee shall be Committee endorsed by BMB instituted at the national level to advise the government on all 1.3.2 Develop 1.3.2.1 ToR for the ToR for the AMR Steering matters related to AMR. MoH, MoAF, DRA, National AMR committee 0 1 Jul-18 DRA JDWNRH Steering developed and Committee endorsed by BMB 12 Performance Lead Implementing Strategies Activities Baseline Target Timeline Indicator Agency Partners

1.3.3 Conduct Steering 1.3.3.1 No. of 2 times MoH, MoAF, DRA, 0 10 DMS Committee meetings carried out Annually JDWNRH meeting

1.4 There shall be a 1.4.1.1 Focal person

1.4.1 Designate a designated national designated and focal person for MoH, MoAF, DRA, focal person for human endorsed by the 0 2 Jul-18 DRA AMR in MoH and JDWNRH and animal health to National AMR MoAF provide technical steering committee assistance related to

1.4.2 Define the AMR. The focal person 1.4.2.1 ToR for roles and MoH, MoAF, DRA, of the human health focal person 0 1 Jul-18 DRA responsibilities of JDWNRH shall act as the National developed the focal persons Focal Point. 1.5.1.1

1.5.1 Constitute Antimicrobial antimicrobial 8 (5 in stewardship team stewardship team Animal /unit at the National MoH, MoAF, DRA, at the National and 0 Health, 3 in Aug-18 DMS/DoL and regional JDWNRH regional hospitals Human hospitals and and livestock Health)

1.5 Hospital based Livestock centers centers antimicrobial constituted stewardship programs 1.5.2 ToT for 1.5.2.1 ToT for 16(human shall be instituted Hospital based Stewardship team in MoH, MoAF, 0 and animal Sept- 18 DMS/DoL antimicrobial NRH and RRHs and JDWNRH health) stewardship livestock centers.

1.5.3 Develop 1.5.3.1 ToR/ ToR/ working working procedure MoH, MoAF, 0 1 Oct-18 DMS/DoL procedure for for Stewardship JDWNRH Stewardship team team developed 13 Performance Lead Implementing Strategies Activities Baseline Target Timeline Indicator Agency Partners 10 (1 from

1.5.3.2 Report on animal 2 reports MoH, MoAF, the stewardship 0 health and DMS/DoL Annually JDWNRH activities published 1 from human)

1.5.4.1 Biannual

1.5.4 Biannual meeting for hospital 2 meeting for antimicrobial 30 meeting/ hospital 0 DMS MoH, JDWNRH stewardship team meetings center/yea antimicrobial held. (only for r stewardship team human health)

1.5.5 Capacity

1.5.5.1 No. of health building for professionals trained Antimicrobial 0 7 Mar-18 DMS MoH, JDWNRH on TDM. (only for dosing human health) optimization 14 Performance Lead Strategies Activities Baseline Target Timeline Implementing Partners Indicator Agency Objective 2: To promote rational use of antimicrobial agents at all levels of healthcare and veterinary settings 2.1.1.1

2.1.1 Develop antibiotic and revise Jun-17 guideline antibiotic 1 2 (launch), 20 ( DoL MoAF, DRA developed and

2.1 Guidelines, guideline for rev) revised for protocols and clinical animal use animal use treatment pathways

2.1.2 Revise shall be developed 2.1.2.1 the antibiotic 2 for the management antibiotic 1 (2012) Every 2 years DMS MoH, DRA, JDWNRH guideline (2019,2021) of infectious diseases guideline based on the to promote rational revised antibiogram use of antimicrobials. generated 2.1.2.2 through Antibiotic 0 1 Jun-19 DMS MoH, DRA, JDWNRH laboratory guideline app surveillance developed

2.2.1 Pre- 1 each for service 2.2.1.1 No. of Human Health

2.2 Pre-service and MoH, MoAF, DRA, orientation on orientation 0 10 and 1 for DMS/DoL in-service JDWNRH AMR modules conducted Animal Health trainings/orientation and guidelines Annually programs on proper use of antimicrobial 2.2.2.1 AMR 2 (1 for use, resistance module Animal

2.2.2 In MoH, MoAF, DRA, prevention and developed for 0 Health and 1 Dec-18 DMS/DoL service JDWNRH containment In-service for Human training measures shall be orientation Health) workshop on organized regularly AMR modules 2.2.2.2 No. of for health Annually and guidelines training/ professionals 0 5 (Animal Health DoL MoAF workshop only) conducted 15 Performance Lead Strategies Activities Baseline Target Timeline Implementing Partners Indicator Agency

2.3.1 Develop Infection 2.3.1.1 No. of control Infection guidelines and guidelines and 0 1 Mar-19 DoL MoAF standard SoPs operating developed and procedures disseminated (SOPs)

2.3.2 Revise the Infection 2.3.2.1 2 (1 each for control Infection human guidelines and Control 0 health and Jan-20 DMS/DoL MoH, DRA, JDWNRH standard Guideline and animal operating SoPs revised health)

2.3 Infection control procedures and prevention (SOPs) practices shall be 2.3.3 strengthened Coordinate meeting between the 2.3.3.1 No. of Infection coordination 0 5 1 Annually DMS MoH, JDWNRH control and meeting AMS conducted committee (only for human health)

2.3.4 Capacity building in (5 from

2.3.4.1 No. of Infectious Human Health diseases 0 Health, 5 Dec-18 DMS/DoL MoH, MoAF,JDWNRH professionals management from animal trained for the AMS health) sites 16 Performance Lead Strategies Activities Baseline Target Timeline Implementing Partners Indicator Agency

2.3.5 Capacity

2.3.5.1 No. of building for Certified infection Infection 0 6 Feb-19 DMS MoH,JDWNRH control nurses Control (for human Nurses trained health only)

2.3.6 CME on infection 2.3.6.1 No. of control Health October 0 600 DMS MoH, JDWNRH practices (For Professionals 18,19,20,21,22 human health trained only) 17 Lead Implementing Strategies Activities Performance Indicator Baseline Target Timeline Agency Partners Objective 3: To institute surveillance and monitoring system of AMR 9 (4 in Human

3.1.1.1 Microbiology Health MoH, MoAF, 15 Jul-19 DMS/DoL testing facilities equipped and 5 in JDWNRH Animal

3.1.1 Establish Health) Microbiology 3.1.1.2 No. of Lab MoH, MoAF, testing facilities 15 28 Jul-19 DMS personnel trained JDWNRH at all major 3.1.1.3 Subscribed to MoH, MoAF, Hospitals/Labs NA 5 Annually DMS

3.1 Lab-based CLSI Standard JDWNRH AMR 20 (10 surveillance 3.1.1.4 Participated in centers each MoH, MoAF, shall be External quality 1 from human Annually DMS JDWNRH established assessment and animal health) 2 times (1 each for

3.1.2.1 No. of training MoH, MoAF, NA 10 animal and DMS/DoL

3.1.2 Lab based conducted JDWNRH human) Annually AMR 3.1.2.2 Lab testing MoH, MoAF, surveillance NA 15 Jan-18 DMS/DoL standardized JDWNRH training and networking Dec-18,19,20,21,

3.1.2.3 AMR reports MoH, MoAF, NA 75 22 (1 report/center DMS/DoL generated JDWNRH annually)

3.2 Lab-based

3.2.1.1 AMR residual Antimicrobial 0 1 Mar-18 BAFRA MoH, MoAF testing facilities equipped residual 3.2.1 surveillance Strengthen 3.2.1.2 No. of Lab 0 8 Apr-18 BAFRA MoH, MoAF shall be AMR residual personnel trained established in testing facilities 3.2.1.3 Sampling guideline food and food and testing SoPs 0 2 May-18 BAFRA MoH, MoAF products developed and sensitized 18 Lead Implementing Strategies Activities Performance Indicator Baseline Target Timeline Agency Partners

3.2.1.4 Subscribed to 1 subscriptions 0 5 BAFRA MoH, MoAF AOAC/IS annually 3.2.1.5Subscribe to External Quality 0 5 1 EQA annually BAFRA MoH, MoAF assessment (PT/ILC) and procure QC sample

3.2.1.6 Reports generated on level of antibiotic 0 5 1 annually BAFRA MoH, MoAF residue in food and food products 18 from

3.3.1.1 Health Human professionals trained on Health, 25 MoH, MoAF, 0 Sept- 18 DMS/DoL antimicrobial consumption from JDWNRH

3.3.1 Monitor methodology Animal antimicrobial health consumption 2 (1 each for

3.3.1.2 SoP for measuring human 3.3Antimicrobi MoH, MoAF, antimicrobial consumption 0 health and Oct-18 DMS/DoL al consumption JDWNRH developed animal surveillance health) shall be 3.3.2 Reporting established 3.3.2.1 Reports on of 1report/center MoH, MoAF, antimicrobial consumption 0 75 DMS/DoL Antimicrobial Annually JDWNRH generated consumption

3.3.3 Point 3.3.3.1 Health prevalence Professionals trained on 0 30 Jun -18 DMS MoH, JDWNRH survey of antimicrobial use survey antimicrobial 3.3.3.2 Reports generated use (only in from the PPS on 0 10 2 annually DMS MoH, JDWNRH Human Health) antimicrobial use 19 Lead Implementing Strategies Activities Performance Indicator Baseline Target Timeline Agency Partners

3.4.1 Training of health

3.4.1.1 Health Professional on

3.4 Health Care Professionals trained on 0 40 Jun-18 DMS MoH, JDWNRH HAI survey associated HAI survey (only in Human Infections Health) surveillance

3.4.2 Point shall be prevalence established 3.4.2.1 Reports generated survey of HAI 0 10 2 annually DMS MoH, JDWNRH from the PPS on HAI (only in Human Health) 20 Lead Implementing Strategies Activities Performance Indicator Baseline Target Timeline Agency Partners Objective 4: To create and promote awareness on AMR through educational and public campaigns

4.1 The health professionals shall be educated on AMR and rational 4.1.1 Develop a module 2 (1 for use of for AMR and HH MoH, MoAF,

4.1.1.1 Module developed antimicrobials incorporate in the 0 and 1 Jul-18 DMS/DoL DRA, JDWNRH, and incorporated through the existing curriculum of for KGUMSB incorporation in the the relevant institutions AH) curriculum of the relevant training institutes. 7 (2

4.2.1.1 TV program anime, MoH, MoAF, developed and 2 in 5 years DMS/DoL 4..2.1 Develop 5 talk DRA, JDWNRH aired TV/radio Program on shows) AMR and broadcast 4.2.1.2 Radio Program MoH, MoAF, developed and 0 5 in 5 years DMS/DoL DRA, JDWNRH aired

4.2 The public 4.2.2.1 Number of education and 4.2.2 Design, develop, posters, brochure/leaflet MoH, MoAF, awareness shall be brochure/leaflets on 4 20 in 5 years DMS/DoL designed, developed, DRA, JDWNRH promoted through AMR printed and distributed appropriate 4.2.3. Observe medium. 4.2.3.1 Awareness week MoH, MoAF, Antibiotic awareness NA 5 annually DMS/DoL observed DRA, JDWNRH week

4.2.4 Create awareness 4.2.4.1 No. of school among the School health coordinators 0 >90% annually DMS MoH, MoE Health Coordinators covered and Village health 4.2.4.2 No. of Village 0 >80% annually DMS MoH workers on AMR Health Workers covered 21 Performance Lead Implementing Strategies Activities Baseline Target Timeline Indicator Agency Partners Objective 5: To promote research on Antimicrobial Resistance

5.1.1 Publish National

5.1.1.1 National data on Antimicrobial MoH, MoAF, Data on AMR 0 5 1 annually DMS/DoL pattern and DRA, JDWNRH Published antimicrobial use

5.1.2.1 Human MoH, MoAF, Health related AMR 0 5 May-18 DMS DRA, JDWNRH Research Prioritized

5.1.2.2 Human Health related AMR Jul- MoH, MoAF,

5.1 Research on 5.1.2 Prioritize and 0 5 DMS Study Protocol 18,19,20,21 DRA, JDWNRH AMR shall be a conduct research in developed priority and Human health related to need-based AMR research shall be 5.1.2.3 Human promoted to Health related AMR Jul- MoH, MoAF, 0 5 DMS generate Study conducted and 19,20,21,22 DRA, JDWNRH evidence for published clinical practice, rational use and 5.1.3.1 Animal support policy May- MoH, MoAF, Health related AMR 0 4 DoL and planning. 18,19,20,21 DRA, JDWNRH Research Prioritized

5.1.3.2 Animal

5.1.3 Prioritize and Health related AMR Jul- MoH, MoAF, 4 DoL conduct research in Study Protocol 18,19,20,21 DRA, JDWNRH Animal health related developed to AMR

5.1.3.3 Animal Health related AMR Jul-19, 20, MoH, MoAF, 0 4 DoL Study conducted and 21, 22 DRA, JDWNRH published 22 Performance Lead Implementing Strategies Activities Baseline Target Timeline Indicator Agency Partners

5.1.4.1 Food related MoH, MoAF, AMR Research 0 3 Mar-18 BAFRA DRA, JDWNRH Prioritized

5.1.4 Prioritize and

5.1.4.2 Food related conduct collaborative Jun-18, 20, MoH, MoAF, AMR Study 0 3 BAFRA research in Human and 21 DRA, JDWNRH Protocol developed Food health related to

5.1.4.3 Food related AMR AMR Study Aug-19, 21, MoH, MoAF, 0 3 BAFRA conducted and 22 DRA, JDWNRH published

5.1.5.1 Collaborative MoH, MoAF, research on AMR 0 2 May-18,20 DMS/DoL DRA, JDWNRH Prioritized

5.1.5 Prioritize and

5.1.5.2 Collaborative conduct collaborative MoH, MoAF, AMR research 2 Jul-18,20 DMS/DoL research in Human and DRA, JDWNRH Protocol developed Animal health related

5.1.5.3 Collaborative to AMR research on AMR MoH, MoAF, 0 2 Apr-20,22 DMS/DoL conducted and DRA, JDWNRH published 23 Performance Baselin Lead Implementing Strategies Activities Target Timeline Indicator e Agency Partners Objective 6: To strengthen national and international collaboration

6.1.1 Conduct

6.1.1.1 No. of Collaboration meeting/ national seminars among the stakeholder MoH, MoAF, National Stakeholders 0 5 1 annually DMS meeting/seminar DRA, JDWNRH to review AMR / workshop activities and conducted challenges 6.1.2.1 Mechanism established on MoH, MoAF, sharing of NA NA Jan-18 DMS DRA, JDWNRH Expertise and

6.1 Institutional resources among networking and the Institutions collaboration for

6.1.2.2 No. of the exchange of 6.1.2 Institutional projects best practices in networking and undertaken in MoH, MoAF, combating AMR collaboration shall be 0 2 Jan-20 DMS collaboration DRA, JDWNRH and capacity established with with the building relevant agencies both institutions within and outside the

6.1.2.3 Research country for capacity outcome building and resource presented in the MoH, MoAF, sharing 0 10 2 annually DMS International DRA, JDWNRH conferences and seminars 6.1.2.4 Membership MoH, MoAF, acquired for the 0 2 Jan-18 DMS DRA, JDWNRH Global networks related to AMR 24 Performance Baselin Lead Implementing Strategies Activities Target Timeline Indicator e Agency Partners

6.1.3.1 No. of 5 (Lab, DRA, institutional MoH, MoAF, 0 BAFRA, DoL, Jan-19 DMS linkages DRA, JDWNRH AMS) established

6.1.3 Institutional 9 (2 MD Micro, 2 networking for MSc Micro, 1 technical support MSc Micro Vet,

6.1.3.2 No. of 2 Infectious MoH, MoAF, fellowship 0 Jan-19 DMS/DoL Disease DRA, JDWNRH related to AMR Pharmacist, 2 MSc. Food Micro)

6.1.4.1 No. Of

6.1.4 Subscribe to journals/ MoH, MoAF, AMR periodicals/ 0 20 4 annually DMS periodicals DRA, JDWNRH journals subscribed to. 25 Performance Implementing Strategies Activities Baseline Target Timeline Lead Agency Indicator Partners Objective 7: To strengthen control and regulatory system

7.1 There shall be regulatory provisions on 7.1.1 Incorporate manufacture, regulatory import, sale and provisions on 7.1.1.1 storage of antimicrobials in Regulations 0 1 Aug-18 DRA MoH/MoAF antimicrobials in human, animal and revised human, animal agricultural health and practice agricultural practices

7.2.1 Approve market authorization for

7.2.1.1 Market antimicrobials MoH/MoAF, authorization based on evidence NA 100% Annually DRA Manufacturers and issued and GMP of safety and supplies audit reports efficacy and GMP

7.2 The audit of the antimicrobials in manufacturers. the country shall be of proven quality, 20% of

7.2.2 Conduct QC 7.2.2.1 safety and efficacy available testing of Antimicrobials NA 100% DRA MoH/MoAF antibiotics antimicrobials tested (annually)

7.2.3 Monitoring of 7.2.3.1 No. of storage conditions Inspection 2 rounds 50% NA DRA MoH/MoAF in medical and conducted and in 5 years Annually veterinary stores. reports produced 26 Performance Implementing Strategies Activities Baseline Target Timeline Lead Agency Indicator Partners 7.3.1.1

7.3.1 Include Regulatory regulatory provisions for

7.3 The non- provision in the non-therapeutic NA 1 Aug-18 DRA MoAF ( DoL) therapeutic use of rules and use of antimicrobials in regulations antimicrobials in animal feed and place agricultural practice 7.3.2.1

7.3.2 Conduct including residues Monitoring and regular monitoring in food products testing of Jan- and testing of shall be restricted. antimicrobials in NA 100% 18,19,20,21,2 BAFRA MoAF antimicrobials in animal feed and 2 animal feed and food products food products conducted

7.4 The sale of 7.4.1.1 antimicrobials in Inspection

7.4.1 Strengthen private pharmacies report and routine inspection Jul- shall be allowed sensitization and increase NA 100% 18,19,20,21,2 DRA MoH/MoAF only under workshop for sensitization of the 2 prescriptions of private private pharmacies certified health pharmacies professionals. conducted

7.5.1.1 Protocol NA 1 Feb-19, 21 DMS DRA

7.5 There shall be revised

7.5.1 Review mechanisms for protocol for the use 7.5.1.2 control of higher generation Prescribers antimicrobials use NA >90% Apr-19 DMS antimicrobials sensitized on the in the public sector. protocol

7.6. Institute an 7.6.1 Conduct 7.6.1.1 No. of effective overall periodic monitoring monitoring MoH. MoAF, DRA, 0 1 Annually DMS M&E system of the (project status meetings JDWNRH AMR NAP check) meetings conducted 27 Performance Implementing Strategies Activities Baseline Target Timeline Lead Agency Indicator Partners components 7.6.2.1 Program Personnel 0 1 Feb-19 DMS MoH trained on M&E

7.6.2 Conduct end

7.6.2.2 No. of of plan period post evaluation with TA implementation from an evaluation (end of plan 2021 (project MoH. MoAF, DRA, expert and generate 0 1 DMS period) end period) JDWNRH an evaluation report evaluations conducted and report generated 28 7. References i. Department of Health (2000), UK Antimicrobial Resistance Strategy and Action Plan, United Kingdom. ii. Ministry of Agriculture (2001), Livestock Act of Bhutan, Thimphu, Royal Government of Bhutan. iii. Ministry of Agriculture & Forest (2013), Livestock Sector Development Policy of the Kingdom of Bhutan, Thimphu, Royal Government of Bhutan. iv. Ministry of Health (2003), Medicines Act of the Kingdom of Bhutan, Thimphu, Royal Government of Bhutan v. Ministry of Health (2007), National Drug Policy, Thimphu, Royal Government of Bhutan. vi. Ministry of Health (2011), National Health Policy, Thimphu, Royal Government of Bhutan. vii. World Health Organization (2010), Regional Strategy on Prevention and Containment of Antimicrobial Resistance, New Delhi; Regional Office for South-East Asia. viii. World Health Organization (2011), Establishment of National Laboratory-based Surveillance of Antimicrobial Resistance, New Delhi; Regional Office for South-East Asia. . 29