National Action Plan on Prevention and Containment of Antimicrobial Resistance in Liberia 2018 – 2022

4.8 Strengthen EPA to address AMR

4.9 Collaborate with WAHO and ECOWAS focal persons to combat counterfeit drugs 5. Develop the 5. Ensure 5.1 Establish a multisectoral research agenda on AMR 5.1 economic case for sustainable 5.2 Establish Public-Private Partnerships (PPP) for AMR R&D sustainable investment 5.3 Establish funding mechanism for AMR Research & Development investment that through research (R&D) takes account of and development the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions. 30 Operational Plan The NAP on AMR budget summary according to the five strategic objectives of the GAP is a total of US$29,527,564 for the 5 years (table 7). The operational plan with the specific activities to be implemented, timelines and budget lines can be found in tables 8 – 10. Table 7: NAP for AMR budget summary 2018 - 2022 No Strategic Objectives 2018 2019 2020 2021 2022 Total Improve awareness and $884,185 $ 908,797 $ 808,854 $823,550 $ 752,300 $4,177,686 understanding of AMR through 1. education and training Strengthen knowledge and $1,939,203 $ 1,385,795 $1,756,217 $1,284,125 $ 1,284,125 $ 7,649,464 evidence base through 2. surveillance Reduce the incidence of infection $3,042,265 $ 2,140,086 $1,909,048 $1,905,298 $ 1,905,298 $10,901,995 through effective sanitation, 3. hygiene and IPC measures Optimize the use of antimicrobial $1,994,268 $1,016,553 $1,485,224 $1,011,221 $ 694,254 $ 6,201,519 medicines in human and animal 4. health Ensure sustainable investment $205,700 $ 67,800 $187,800 $67,800 $ 67,800 $ 596,900 through research and 5. development # Total $8,065,621 $ 5,519,030 $ 6,147,142 $5,091,993 $ 4,703,777 $29,527,564 31 STRATEGIC OBJECTIVE 1: IMPROVE AWARENESS AND UNDERSTANDING OF AMR THROUGH EDUCATION AND TRAINING Table 8: Strategic objective 1 operational plan No Interventions Specific activities Time-frame Cost (USD)

1.1 Conduct AMR 1.1.1 Establish a national AMR Risk communication and education Within year 1 - integrated taskforce knowledge, 1.1.2 Organize a working committee to develop and update KAP survey Within year 1 & 4 3,000 attitude and questionnaire practice (KAP) 1.1.3 Recruit data collectors for KAP survey Within year 1 & 4 4,500 behavioral survey 1.1.4 Conduct one day orientation workshop for data collectors in Within year 1 & 4 1,500 to guide training Monrovia and education 1.1.5 Conduct one day pre-test KAP survey in Monrovia Within year 1 & 4 3,000

1.1.6 Roll out KAP survey in 4 regions in Liberia Within year 1 & 4 27,000

1.1.7 Hire a local consultant to analyze KAP pre-test survey data and roll Within year 1 & 4 18,000 out data

1.1.8 Print copies of validated KAP survey reports Within year 1 & 4 3,000

1.1.9 Disseminate copies of validated KAP survey reports to relevant Within year 1 & 4 - sectors and key stakeholders

1.1.10 Develop information, education and communication (IEC) materials Within year 2 & 5 on behaviour change communication (BCC) materials such as 56,554.00 billboards, posters, flyers, banners on optimal antimicrobial use and AMR, targeting diverse stakeholders in human, animal, plant and environmental health in simple English and vernaculars

1.1.11 Distribute IEC materials on BCC materials such as billboards, posters, - flyers, banners on optimal antimicrobial use and AMR, targeting 32 diverse stakeholders in human, animal, plant and environmental health in vernaculars

1.2 Develop and 1.2.1 Develop risk communication strategy for AMR informed by the Within year 2 75,500 disseminate a results of the KAP survey and behaviour of the general public, policy comprehensive makers, animal and health service providers, veterinarians and farmers communication 1.2.2 Print communication strategy on AMR for stakeholders Within year 1 - strategy for AMR

1.2.3 Disseminate communication strategy amongst stakeholders Within year 1 - for various

1.2.4 Produce materials and messages on AMR in various local languages for Within year 1 - stakeholders 15 community radio stations across the country

1.3 Conduct regular 1.3.1 Conduct one day stakeholders engagement meeting with county Within year 1 public awareness authorities, line ministries, civil societies organizations, religious campaigns and groups and partners on AMR at county level community 1.3.2 Conduct stakeholders engagement meeting with district authorities Within year 1 107,500.00 engagement (commissioners, educational officers, traditional Leaders, paramount meetings on AMR and clan chiefs, women and youth groups, religious leaders, CHVs Supervisors, Securities and partners on AMR (district level)

1.3.3 Orient gCHVs to conduct monthly community awareness at Within 5 years household level to promote sanitation, hand hygiene and IPC to 3,465,000.00 control AMR

1.3.4 Organize activities to raise awareness during World Antibiotic Within 5 years Awareness Week 21,500

1.3.5 Print and disseminate hand hygiene posters for use by patient and Within in year healthcare workers mainly in hospitals 45,000.00

1.3.6 Conduct regular mass media awareness on AMR 200,000

1.4 Enhance AMR 1.4.1 Conduct a workshop to update health education messages on AMR for Within 1 years 750 capacity in pre- school curriculums 33 service institutions 1.4.2 Conduct a workshop for regulatory bodies to amend their Acts to Within 1 years 76,494.00 (human, animal, include AMR and IPC environmental, 1.4.3 Organize meetings with professional boards to incorporate AMR into Within 5 years 7,000 food production their pre-service curriculum and food safety 1.4.4 Train professional educators at different levels on AMR issues Within 2 years 10,500 workforce)

1.4.5 Update CHAs training curriculum to include hand hygiene and AMR Within 2 years 3,000

1.4.6 Improve microbiology curriculum to include AMR detection Within 1 year - education and training in pre-service laboratory institutions

1.4.7 Reproduce food safety standards for AMR key stakeholders in the 15 Within 1 year 4,888 counties

1.4.8 Participate in the revision of nutrition policy for Liberia to include Within 1 year - AMR

1.4.9 Distribute food safety standards for AMR key stakeholders in the 15 Within 1 years - counties

1.5 Enhance AMR 1.5.1 Develop in-service AMR orientation package Within 2 years - capacity in-service 1.5.2 Print and disseminate in-service AMR orientation package to MOH, Within 2 years institutions MOA, and other sectors. 50,000.00 (human, animal, 1.5.3 Incorporate AMR into in-service training for midlevel health workers Within 2 years - environmental, food production 1.5.4 Adopt and adapt relevant food safety standards Within 1 years - and food safety 1.5.5 Print and distribute food safety standards for AMR key stakeholders workforce) in the 15 counties 34 STRATEGIC OBJECTIVE 2: STRENGTHEN KNOWLEDGE AND EVIDENCE BASE THROUGH AMR SURVEILLANCE Table 9: Strategic objective 2 operational plan No Interventions Specific activities Time-frame Cost (USD

2.1 Strengthen lab AMR 2.1.1 Training of lab staff at 8 sentinel sites (in human, animal and Within 5 years 117,010 capacity environment health)

2.1.2 Conduct facility-based mentorship for laboratory staff at sites Within 5 years 513,240

2.1.3 Procure essential equipment and supplies for antibiotic residual Within 5 years 882,209 testing for AMR surveillance

2.1.4 Strengthen laboratory capacity to conduct AMR HCA surveillance Within 5 years 42,785

2.1.5 Participate in GLASS, including capacity building of lab personnel Within 5 year for data management for sharing on various platforms (national, 456, 210 regional and global)

2.1.6 Develop a manual of SOPs for AMR surveillance in the context of Within 2 years 45,621 One Health

2.1.7 Established Quality Assurance System for AMR Within 2 years 42,785

2.1.8 Conduct in-county and external quality Assurance of reference lab Within 5 years 15,000

2.1.9 Train laboratory staff on QMS in the context of One Health Within 5 years 3,000

2.2 Establish a surveillance 2.2.1 Install Laboratory information management system (LMIS) Within 2 years 150,000 system for AMR in

2.2.2 Identify and establish sentinel sites for healthcare- associated Within 2 years human health infections (HAI) surveillance system including surgical site 23,776 infections (SSIs)

2.2.3 Establish surveillance for environmental pollution/hazard Within 1 years 1,804,758

2.2.4 Identify priority organisms, samples and testing panels Within 2 years - 35

2.2.5 Train clinicians, veterinarians and environmental technicians on Within 1 year 1,126,590 appropriate sample collection and submission

2.2.6 Document the AMR HCA profile to inform policy Within 5 years - development/review

2.2.7 Establish AMR active surveillance system Within 1 year 185,925

2.3 Establish a surveillance 2.3.1 Conduct a country situational analysis of drug use in animal health Within 1 years 600,000 system for (animal owners/traders) and make recommendations with respect AMR in animal health to establishing animal health surveillance system

2.3.2 Strengthen veterinarian lab capacity to confirm AMR in animal Within 5 years 902,379 health through procurement of reagents, laboratory consumables including Culture Media (antibiotic disk)

2.3.3 Conduct one day workshop of 75 participants, including Within 5 years environmental technicians to develop and validate AMR laboratory detection and reporting plan 38,247

2.3.4 Conduct 5-days sessions to train 261 health workers, livestock Within 5 years officers, environmental technicians and laboratory aides on AMR samples collection and Laboratory Technicians on the use of specialized diagnostics techniques and laboratory equipment

2.3.5 Collect and transport food samples to the laboratory for analysis Within 5 years 182,400 to monitor antibiotics residue in meat products at the slaughterhouses in country; meet inspectors at slaughterhouses on a monthly basis

2.3.6 Monitor antibiotic residues in animal feed, pesticide residue in Within 5 years - honey, in aquaculture and food products etc; Laboratory analysis on samples collected monthly 36

2.4 Establish an integrated 2.4.1 Establish an AMR central coordinating unit (NPHIL/MOH)- office Within year 1-5 AMR surveillance system operational cost 142,000

2.4.2 Develop an integrated AMR surveillance plan Within year 1 -

2.4.3 Print and distribute the AMR surveillance plan Within year 1 -

2.4.4 Establish a centralized data management system for regular Within year 1, 3 - sharing of AMR data between MOH, NPHIL, MOA, FDA and EPA &5 (local consultancy)

2.4.5 Train personnel on data management and reporting 225,318

2.4.6 Harmonize laboratory methodologies and data reporting for - characterization of AMR organisms with relevant drug combinations in hospitals

2.4.7 Harmonize surveillance for antimicrobial resistance with Within 5 years - antimicrobial utilization on farms

2.5 Establish an early 2.5.1 Adopt international standards for AMR early warning Within 3 years - warning system to 2.5.2 Train/sensitize lab techs, clinicians and vets on identification and Within 3 years 150,212 determine risk factors of evaluation of risk AMR 2.5.3 Compile and provide information on identified risks Within 5 years - 37 STRATEGIC OBJECTIVE 3: REDUCE THE INCIDENCE OF INFECTION THROUGH EFFECTIVE SANITATION, HYGIENE AND IPC MEASURES Table 10: Strategic objective 3 operational plan No Interventions Specific activities Timeline Cost (USD

3.1 Orient healthcare 3.1.1 Ensure AMR is embedded within the IPC TWG (based at QMU) Within 1 year - workers (HCWs) on the

3.1.2 Printing of National IPC guidelines Within 1 year - National IPC Guidelines

3.1.3 Conduct a four-day orientation workshop for facility and county Within 1 year Done! IPC focal persons (56) on National IPC Guidelines

3.1.4 Orientate all healthcare workers at each facility on the National Within 2 year 438,468 IPC guidelines

3.1.5 Monitor implementation of the National IPC guidelines at health Within 5 years 247,900 facilities

3.2 Strengthen community 3.2.1 CHAs organize community hygiene/sanitation awareness with key Within 5 years - level prevention stakeholders

3.2.2 Celebration of global handwashing day in schools by holding Within 5 years 225,000 special program

3.2.3 Commemorate global handwashing day using social media Within 5 years -

3.2.4 Meet with business/marketing associations to highlight Within 5 years - importance of handwashing and waste management in their respective settings

3.2.5 Undertake food inspection of foods and food products for public 382,470 consumption

3.2.6 Update/develop community waste management protocol to Within 2year - include AMR 38

3.2.7 Train waste technicians (solid and liquid waste) and Within 2 years 433,825 environmental engineers in community waste management protocol

3.2.8 Meet with superintendent, CHO, county livestock officers, and Within 2 years 5,895 development superintendent to advocate for building standardized community toilets and public waste bins to control organic and human waste

3.2.9 Develop Water Safety Plans (WSP) for 15 counties, including Within 5 years 300,000 printing, validation, orientation, dissemination and monitoring) of water safety plans

3.2.10 Print water safety plans for 15 counties Within 1 year -

3.2.11 Develop and validate community level water safety plans Within 5 years 15,000

3.2.12 Disseminate and monitor adherence to water safety plans, Within 5 year 37,752 including household level for 15 counties

3.2.13 Monitor adherence to WSPs in 15 counties Within 5 year 7,074

3.2.14 Provide support to LWSC and Public Works to increase access to Within 5 years - safe drinking

3.3 Strengthen IPC in health 3.3.1 Establish alcohol based hand rub (ABHR) production plants at Within 5 years 7,522,135 care facilities selected facilities

3.3.2 Advocate with key stakeholders for the establishment of plant for Within - the production of gaseous chlorine to enhance the treatment of drinking water

3.3.3 Print and disseminate hand hygiene posters at health facilities, Within 5 years schools and food centers 30,000

3.3.4 Commemorate global hand hygiene day using social media Within 1 year -

3.3.5 Perform Hand hygiene audits at hospitals (public and private) Within 5 years 235,950 39

3.3.6 Finalize and validate safe management of health care waste Within 1 year 30,000 guidelines

3.3.7 Print and distribute safe management of health care waste Within 1 year 50,000 guidelines

3.3.8 Orient HCWs on safe management of health care waste guidelines Within 1 year -

3.3.9 Ensure screening, isolation and referral pathway for epidemic Within 2 years - prone diseases are in place at health facilities

3.4 Strengthen animal health 3.4.1 Update/develop farm biosecurity guidelines for different Within 5 years 56,250 and agricultural practices categories of animal farms, slaughter (abattoirs) facilities, and agriculture facilities

3.4.2 Develop and validate safe waste management guidelines Within 1 year 56,250 (including sanitation and hygiene) for animal facilities and farms

3.4.3 Hold a one day validation workshop for safe waste management Within 1 year 3,000 guidelines for animal facilities and farms

3.4.4 Orientate facilities and farms workers in the waste management Within 5 years guidelines 375,530

3.4.5 Monitor the implementation of safe waste management Within 5 years 256,710 guidelines for animal facilities and farms

3.4.6 Printing and distribution of safe management guidelines for Within 5 years 10,000 animal facilities and farms

3.4.7 Adopt and implement standards published in OIE and Codex Within 2 years 7,500 Alimentarius code of practice to minimize AMR

3.4.8 Train famers in standard animal husbandry practices to reduce Within 5 years 150,212 need to use antimicrobial agents

3.4.9 Undertake regular checks on sanitation and hygiene on animal Within 5 years 7,074 facilities and farms 40

3.4.10 Undertake regular checks on animal feeds for contamination Within 5 years -

3.4.11 Develop/update standards for farm infrastructure that promotes Within 2 years 5,250 infection prevention in animal handling facilities and farms

3.4.12 Establish manure/animal waste processing plant for fertilizer Within 5 years - production

3.4.13 Develop guidelines for infection prevention materials for animal Within 2 years 12,000 facilities and farms

3.4.14 Develop recommendations for use of vaccines as a method of Within 5 years 750.00 preventing infections in animals and reducing antimicrobial use STRATEGIC OBJECTIVE 4. OPTIMIZE THE USE OF ANTIMICROBIAL MEDICINES IN HUMAN AND ANIMAL HEALTH Table 11: Strategic objective 4 operational plan No Interventions Specific activities Time-frame Cost (USD

4.1.1 Establish and develop TOR for Antimicrobial Medicines Taskforce Within 1 year -

4.1 Develop and enforce in the context of One Health legislation on 4.1.2 Conduct a 2- day workshop to develop a legislation on the use of Within 1 year 76,494 prescriptions for antimicrobial agents in human, animals, plants and the combating AMR environment

4.1.3 Validate a legislation on the use of antimicrobial agents in human, Within 1 year 2,150 animals, plants and the environment

4.1.4 Print and disseminate updated Public Health Law with AMR Within 1 year 15,000 components 41

4.2 Reflect AMR in key 4.2.1 Revise National Medicine Policy to include AMR Within 2 year - documents (National 4.2.2 Print and distribution of revised National Medicine Policy Within 2 years 20,000 Medicine Policy, Standard

4.2.3 Update the National Drug Formulary to include AMR Within 2 years - Treatment Guidelines,

4.2.4 Printing and distribution of revised National Drug Formulary Within 3 years 10,000 Essential Medicine List

4.2.5 Revise the Standard Treatment Guidelines to include AMR Within 3 years - 2016)

4.2.6 Printing and distribution of STG Within 2 years 70,000

4.2.7 Conduct TOT for professionals to promote responsible prescribing Within 2 years 229,482 practices, dispensing and administrative principles for antimicrobials

4.3 Establish AMR 4.3.1 Develop antimicrobial stewardship working manual and Within 2 year - stewardship program for procedures selected facilities 4.3.2 Print and distribute antimicrobial stewardship working manuals in Within 2 year 70,000 the context of One Health

4.3.3 Train HCWs on antimicrobial stewardship in the context of One Within 3 years 751,060 Health

4.3.4 Facilitate AMR stewardship programs in selected healthcare Within 3 years facilities 751,060.00

4.3.5 AMR TWG to review and provide feedback to facility AMR Within 3 years - stewardship programs

4.3.6 Scale up stewardship programs Within 5 years -

4.4 Establish an antimicrobial 4.4.1 Develop AMR prescription reporting system in the context of One Within 3 years - prescription monitoring Health (animal, human health) system 4.4.2 Validate prescription reporting form Within 2 years -

4.4.3 Printing reporting form Within 2 years -

4.4.4 Disseminate prescription reporting form Within 2 years - 42

4.4.5 Monitor and evaluate implementation of AMR prescription Within 2-5 117,900 reporting system (supportive supervision)

4.5 Establish a monitoring 4.5.1 Develop monitoring system for non-prescribed antimicrobials in Within 5 years 7,500 system for non-prescribed collaboration with line ministries and the security sector antimicrobials 4.5.2 Re-establish and reinforce the implementation of penalties for Within 5 years 235,800 illegal selling of antimicrobials

4.5.3 Reinforce the post marketing surveillance at the LMHRA Within 5 years 276,267

4.5.4 Collaborate with state security to reinforce the confiscation of Within 5 years 375,530 illegal sale of antimicrobials and expired medicines

4.5.5 Reinforce the border security for illegal sale and importation of AM Within 5 years 5,632,950 medicines

4.5.6 Collaborate with ECOWAS through WAHO to combat Within 5 years - counterfeiting drugs

4.5.7 Develop and print SOP for identification and monitoring of non- Within 3 years 10,000 prescribed antimicrobials

4.5.8 Disseminate SOP for identification and monitoring of non- Within 3 years - prescribed antimicrobials

4.6 Strengthen the LMHRA 4.6.1 Procure essential commodities for the LMHRA QC Lab in one health Within 5 years 1,443,806 drug quality control lab context.

4.6.2 Training and mentorship of LMHRA drug quality control lab Within 5 years 99,160 technicians

4.6.3 Training in physico-chemical drug quality control Within 5 years 99,160

4.6.4 Quality control training in microbiology of drugs Within 5 years 99,160

4.6.5 Training in quality control of medical devices Within 5 years 99,160

4.6.6 Training in quality control of cosmetics Within 5 years 99,160 43

4.7 Establish/strengthen 4.7.1 Revise and update Animal Health Law to include AMR and update Within 2 years 3,750 animal drug regulatory legislation for control and use of veterinary drugs (trade, use, body to address AMR importation, etc)

4.7.2 Identify and activate animal health regulatory body group Within 2 years -

4.7.3 Monitor implementation of Animal Health Laws which includes Within 5 years 185,925 AMR

4.8 Strengthen EPA to address 4.8.1 Monitor implementation of Environmental law which includes Within 5 years 185,925 AMR AMR

4.9 Collaborate with WAHO 4.9.1 Conduct periodic coordination meetings with WAHO on combating Within 5 years 117,010 and ECOWAS focal counterfeit drugs (including supportive supervision) persons to combat 4.9.2 Implement defined activities from coordination meetings held to Within 5 years - counterfeit drugs combat counterfeit drugs STRATEGIC OBJECTIVE 5: ENSURE SUSTAINABLE INVESTMENT THROUGH RESEARCH AND DEVELOPMENT Table 12: Strategic objective 5 operational plan No Interventions Specific activities Time-frame Cost (USD

5.1 Establish a multi-sectoral 5.1.1 Establish an AMR Investment, Research and Development (R&D) Within 1 year - research agenda Taskforce and develop TOR on AMR 5.1.2 Build human resource capacity in AMR R&D Within 1 year 25,000

5.1.3 Establish ethical and regulatory mechanisms for AMR R&D, in Within 1 year 45,000 collaboration with national ethical and regulatory bodies

5.1.4 Develop guidelines for invitro/invivo diagnostics Within 2 years 750

5.1.5 Develop policy and strategy (guidelines) for national AMR R&D Within 1 year 10,000 44

5.1.6 Promote LMHRA standards for all research products to include Within 5 years 25,000 therapeutics and vaccines

5.1.7 Hold one day workshop to validate policy and strategy for AMR Within 1 year 2,150 R&D

5.1.8 Print and disseminate policy and strategy for AMR R&D Within 1 year 5,000

5.1.9 Engagement meeting with relevant stakeholders to identify Within 5 years 25,000 current gaps in knowledge (i.e. research capacity gaps analysis) and potential research areas

5.1.10 Identify and train early career researchers on grant writing with Within 2 years 25,000 emphasis on AMR R&D

5.1.11 Establish a center of excellence for AMR research with focus on Within 2 years 25,000 one health

5.1.12 Conduct AMR-related research project (e.g. detecting pesticide Within 5 years 25,000 residues in honey) with One Health approach

5.1.13 Establish/support a platform for sharing AMR research findings Within 5 years 25,000 annually

5.2 Establish Public-Private 5.2.1 Conduct multi-sectoral coordination and AMR TWG consultative Within 5 years 23,000 Partnerships (PPP) for meetings and develop TOR AMR R&D 5.2.2 Conduct monthly AMR TWG to meetings to discuss key issues Within 5 years 23,000 including research

5.2.3 Hold joint annual AMR review meetings with PPP including private Within 5 years 23,000 sector and NGOs to orient them on AMR activities including research

5.2.4 Establish and promote regional and international collaboration Within 5 years 50,000 for AMR R&D 45

5.3 Establish funding 5.3.1 Advocate and lobby for funding from government and partners Within 1 year - mechanism for AMR R&D (including pharmaceutical companies) to support AMR-related research

5.3.2 Post calls for funding opportunities onto institutional websites Within 2 years - and mailing list of stakeholders

5.3.3 Identify and twin local laboratories with foreign laboratories to Within 5 years 240,000 support research in AMR, and research exchange programs to transfer skills and mentorship

5.3.4 Develop AMR related research proposals/grants using one Within 1 year - health approach Total $29,527,564 46 Risk Analysis Implementing such a comprehensive plan has its risks; it is important to be aware of these and to have mitigation strategies in place to address them. These are described in table 13. Table 13: NAP for AMR risk identifications and mitigations Strategic objectives Risk Identification Risk Mitigation

1.0 Improve awareness and ● High costs related to some media ● Adapt existing awareness materials e.g. WHO and OIE understanding of AMR campaigns. WAAW materials to the Liberia context with funding and through education and assistance from the development partners. training ● Unavailability of prime-time slots on ● Consolidate PR budgets of participating Ministries to secure television. prime-time slots. ● Lack of ownership and commitment by one ● Official inter-Ministerial launch of the NAP on AMR or more Ministries/stakeholder. ● Lack of ownership and commitment by ● Include AMR awareness activities in the Ministry’s Strategic stakeholders. Plans and Annual Performance Plans ● Refusal of professional councils to amend ● Identify influential professionals, academics and thought scopes of practice. leaders to serve as AMR champions and advocates. ● Resistance to curriculum review by training ● Lobby professional councils to make such content institutions and Universities. mandatory to scopes of practice. ● Curriculum review process is not ● Include such content in adhoc presentations by “AMR focal undertaken annually and is protracted. persons of different sectors”. ● Host AMR-related symposia and conferences. 47 ● Competing training priorities and budgets. ● Schedule training in tandem with the official launch of the NAP; include such training in training plans funded through the human resources budget. ● Possible lack of expertise in certain ● Adapt existing open source content to the Liberia context. components of Veterinary AMR. ● Develop partnerships with academic institutions and industry. ● Lack of time/interest and high workloads. ● Identify AMR champions and advocates to communicate the AMR message at facility level

2.0 Strengthen knowledge ● Inadequate human, infrastructural and ● Source investment from development partners such as the and evidence base operational resources within hospitals with Fleming Fund/USAID to set up infrastructure. through surveillance laboratories for sentinel sites ● Undertake domestic resource mobilization. ● Secure a dedicated budget vote for NAP implementation from MFDP. ● Inadequate technical capacity with the ● Develop technical capacity via training plans funded through requisite training to undertake laboratory the human resources budget. testing for AMR ● Competing priorities. ● Use existing GLASS/Fleming Fund/ EUCAST/CLSI guidelines to develop SOPs suited to the Liberia context ● Budget austerity measures preclude ● Leverage funds from existing budgets of relevant Ministries. dedicated budget vote. ● Undertake domestic resource mobilization. ● Secure funds from external development partners.

3.0 Reduce the incidence of ● Inadequate human, infrastructural and ● Include IPC implementation in the Ministry Strategic Plans infection through operational resources. and Annual Performance Plans. 48 effective sanitation, ● Inadequate technical capacity to implement ● Initiate Train-the-Trainer programs. hygiene and IPC IPC. ● Develop technical capacity training plans funded through measures the human resources budget. ● Leverage the Clinical Services vote to improve infrastructure and implement standard precautions ● Leverage the water and sanitation vote. ● Lack of knowledge and uptake by farmers ● Sensitize farmers on the animal welfare and economic and food producers. benefits of such practices. ● Lack of resources to implement such ● Institute a participatory approach to guideline development measures country-wide. and implementation. ● Include biosecurity in the MOAFS Strategic Plans and Annual Performance Plans. ● Enforce legislation/regulations related to control of animal diseases. ● Lack of national biosecurity ● Include biosecurity in the MOAFS Strategic Plans and Annual policy/guidelines for producers

4.0 Optimize the use of ● Competing priorities ● Adapt international good practice to the Botswana context. antimicrobial ● Develop technical capacity via training plans funded through medicines in human the human resources budget. and animal health ● Priority supply chain not approved. ● Include AMR commodities in cognate priority supply chains such as those for tuberculosis and HIV. ● Inadequate human and operational ● Develop technical capacity training plans funded through resources. the human resources budget. 49 ● Leverage existing infectious disease, medical microbiology, pharmacy & IPC human and operational resources to initiate ABS programs. ● Inadequate representative surveillance data ● Institute sentinel surveillance programs. ● Collate and analyze existing data from passive and research- based surveillance. ● Lack of coordination and communication. ● Formally launch guidelines in healthcare facilities. ● Unavailability of in-country experts and data ● Adapt international guidelines to the Liberia context. to develop and STG implement guidelines. ● Institute surveillance programs to ensure evidence-based STGs. ● Formally launch guidelines in the food production industry and amongst famers ● Refusal of farmers and food producers to ● Introduce a mandatory document quality management keep or share records of medicines system. utilization ● Protracted process for the introduction ● Enhance technical legal capacity review and amendment of regulations and ● Improve the inspectorate services policies on AMR ● Lack of an enforcement workforce. ● Weak inspectorate services. ● Inadequate technical capacity. ● Insufficient legal counsel. ● Lack of political will ● Liberia is signatory to the UN Political Declaration and WHA 68.7 on the GAP on AMR. ● Austerity measures preclude an additional ● Undertake domestic resource mobilization. budget vote. ● Source external funds from development partners. 50

5.0 Ensure sustainable ● Lack of engagement and commitment by ● Identify influential professionals and academics to advance investment through one or more Ministries/ stakeholders. this initiative. research and ● Absence of a collaboration culture. ● Initiate research-related Memoranda of Understanding development ● Lack of interest in postgraduate ● Credentialing with higher degrees should be linked to qualifications and research workplace rewards such as increased remuneration and promotion. 51 Resource Mapping and Mobilization To date, several key stakeholders are providing support to AMR-related activities in the country (table 14). Table 14: Partner mapping No Partners Areas of Key focus Status (e.g. interventions ongoing, (technical, financial) not status) 1. U.S. Pharmacopeial Technical Support for the Liberia Medicines Health Regulatory Authority Ongoing (thru Sept Convention (LMHRA). 2019) Technical assistance in assessment of quality assurance and quality control in Liberia; strategic planning; guidelines and SOP for regulation of pharmaceutical products in Liberia; training of quality control lab personnel. Promoting the Quality of Medicine (PQM) 2. G2G - Bilateral Technical, Financial Integrated Management of Childhood Illnesses (IMCI) and Ongoing (thru Program with MOH Integrated Community Case Management (ICCM); Sept. 2021) Infection Protection & Control (IPC); Expanded Package of Health Services (EPHS); 3. Maternal and Child Technical: IMCI, IPC Ongoing thru Sept Survival Project Restoration of 2019 (MCSP)/Johns Hopkins Health Services Program for (RHS) International IMCI Education in Expanding Malaria Ongoing thru Sept Services (EMS) 2019 52 Gynecology and Pre-service training of midwives and laboratory technicians Obstetrics (JHPIEGO) Human Resources for Health (HRH) Ongoing thru Sept 2018 4. USAID: FAO/ECTAD Technical Animal health surveillance, diagnostics, strategic planning, Ongoing curriculum development, capacity building/workforce development: MOA/CVL 5. USAID: Predict2 (Eco- Technical Bio-surveillance of wild viruses, some capacity building thru Ongoing Health Alliance) local NGO 6. USAID:P&R (DAI: Technical - One Health Closing Nov. 2018 Development facilitation; strategy Alternative development International 7. USAID: Infectious Technical Infectious diseases detection & surveillance, and related New - TBD Disease Detection & laboratory strengthening activities including: multisectoral Surveillance (IDDS) strategic planning and integration of public health and animal health laboratory and epidemiological information; capacity building of One Health laboratory workforce; zoonotic surveillance; Strengthen biosafety, improve quality assurance, sample and data collection and analysis to prevent AMR; support regional networking laboratory activities and training. 8. GIZ Technical - Establishment of AMR sentinel system in south east based on Ongoing facilitation; strategy regional reference lab at Harper (JJ Dossen). Antimicrobial stewardship projects at County Hospitals in south east (GK, ML, RG). Support to central level in policy development. 53 development, financial 9. USAID: Procurement Technical Supply Chain, strategic technical assistance; support to the Ongoing and Supply Central Medicine Store (CMS). Management (PSM)/Chemonics 10. USAID: Project Last Technical Supply Chain, strategic planning/organizational support to the Ongoing Mile (PLM) CMS 11. NPHIL: REDISSE, World Technical and Research (Detection of AMR in Diarrhoea) Ongoing Bank Financial 12 GOL/NPHIL Technical, strategy Research (Detection of AMR in Paediatric Diarrhoea) Ongoing development 13. WHO Technical and AMR, IPC/WASH, Epi-surveillance, Laboratories Ongoing Financial 14. CDC /ACCEL Technical and AMR, IPC/WASH – strengthening AMR detection capacity (e.g. Ongoing Financial culture and sensitivity testing) at Redemption and JFD. As noted from the above, there are limited resources which have as yet not been committed. Cognizance of this, the NAP on AMR is the responsibility of the government and will be funded through the following mechanisms which will be led by the AMR pillar to: ● Work in collaboration with the Ministry of Finance and Development Planning (MFDP) to ensure the provision of funding for the implementation of the NAP on AMR. ● Lobby for a dedicated budget for the implementation of the NAP on AMR. ● Leverage existing, cognate budgets within and across Ministries by consultation and collaboration, e.g. budgets allocated for vaccination, IPC, medicines procurement etc. ● Prioritize the NAP on AMR in line Ministries budgets annually. 54 ● Undertake domestic resource mobilization. For example, the County governments will provide budgets for the implementation of the NAP within their jurisdictions. ● Source external funds/grants/loans from development partners, including the UN agencies, EU, Fleming Fund, USAID, CDC, private pharmaceutical companies on the basis of a comprehensive business plan. 55 Monitoring and Evaluation Plan The goal of the AMR NAP M&E plan is to establish a system that is robust, comprehensive, fully integrated and well-coordinated to guide monitoring of the implementation of the AMR NAP and evaluate impact. The objective of the AMR NAP M&E plan is to provide a framework for tracking progress and demonstrating results of the AMR NAP over the short and medium term. The Monitoring and evaluation (M&E) plan includes the sub-activities, performance indicators, targets, baselines, data source, frequency of collection and responsible entity (table 15). Monitoring should take place bi-annually and be led by the AMR unit. Evaluation of the implementation of the NAP AMR should take place at half way through the timeframe (last quarter of 2020) and at the end of Year 5 (mid- 2022). Table 15: Monitoring and Evaluation plan Liberia AMR NAP: Monitoring & Evaluation Plan Sub-activity Performance Indicator Target Baseline Data collection Frequency of Responsible entity source data collection Objective 1: Improve awareness and understanding of AMR through education and training

1.1 Conduct and disseminate AMR integrated knowledge, attitude and practice (KAP) behavioural survey to guide training and education

1.1.1 Establish a risk Task force formed with 1 No AMR TWG Once AMR TWG and communication and list of members and TOR partners education taskforce

1.1.2 Organize a working Questionnaire for KAP 1 No AMR TWG Once AMR TWG and committee to develop KAP developed partners survey questionnaire 56

1.1.3 Recruit collectors for KAP List of data collectors 1 No AMR TWG Once AMR TWG and survey recruited partners

1.1.4 Conduct one day Training report with # of 1 No AMR TWG Once AMR TWG and orientation workshop for participants partners data collectors in Monrovia

1.1.5 Pre-test KAP survey tool in KAP pre-test report 1 No AMR TWG Once AMR TWG and Monrovia partners

1.1.6 Roll out KAP survey in 4 KAP survey roll out 4 No Rollout report Once AMR TWG and regions in Liberia report partners

1.1.7 Hire a local consultant to Local consultant hired 1 No AMR TWG Once AMR TWG and analyze KAP pre-test survey and analyzed KAP pre- partners data and roll out data test survey data

1.1.8 Print and disseminate # KAP survey reports 100 No Health Once Health Promotion copies of validated KAP printed and Promotion Unit (MoH), NPHIL and survey reports to relevant disseminated partners sectors and key stakeholders

1.1.9 Develop and distribute IEC # of billboards produced 15 in each No Health Once Health Promotion materials on BCC materials and distributed county (225) Promotion unit (MoH), NPHIL and such as billboards, posters, partners flyers, banners on optimal # of fliers produced and 3000 per No Health Annually antimicrobial use and AMR, distributed county Promotion unit targeting diverse # of posters produced 3000 per No Health Annually stakeholders in human, and distributed county Promotion unit animal, plant and environmental health. 57

1.2 Develop and disseminate a comprehensive communication strategy for AMR for various stakeholders

1.2.1 Develop a communication Communication strategy Validated No Health Once AMR TWG and strategy for AMR NAP communicati Promotion unit partners informed by the results of on strategy the KAP survey

1.2.2 Disseminate strategy # of stakeholders aware 100 No key stakeholders Once AMR TWG and among stakeholders of AMR communication interview partners strategy

1.2.3 Produce materials and # of AMR communication 15 No Health Once Health Promotion messages on AMR in messages available in promotion (MoH), NPHIL AMR various languages for 15 different dialects unit/radio TWG and partners community radio stations stations across the country # of AMR communication 2 No Health Annually messages available in promotion Simple English unit/radio stations

1.3 Conduct regular public awareness campaigns on AMR

1.3.1 Conduct stakeholders’ # engagement meeting 15 No Health Once AMR TWG and engagement meeting with reports with participants Promotion Unit partners county authorities, line listing ministries, civil societies organizations, religious groups and partners on AMR at county level 58

1.3.2 Conduct stakeholders # District engagement 91 No Health Once AMR TWG and engagement meeting with meeting reports Promotion Unit partners district authorities (commissioners, educational officers, traditional Leaders, paramount and clan chiefs, women and youth groups, religious leaders, CHVs Supervisors, Securities and partners on AMR at the district level)

1.3.3 Conduct monthly # CHA reports with AMR ? No CHA/CHSS Monthly Community Health awareness through the activities included (MoH) CHAs at household levels to promote hand hygiene and IPC to control AMR

1.3.4 Organize activities to raise # AMR awareness week 5 Yes Key informants Annually Health Promotion awareness during World observed with report Interview (KII) Unit (MoH), NPHIL Antibiotic Awareness Week AMR TWG and partners 59

1.4 Enhance AMR capacity in pre-service institutions (human, animal, environmental, food production and food safety workforce)

1.4.1 Conduct a workshop to # of updated school 100 Yes School Once Health Promotion update health education curricular with AMR curriculums Unit, NPHIL AMR messages on AMR for contents TWG and partners school curriculums

1.4.2 Conduct a workshop for Workshop report with # ? Yes Regulatory Once AMR TWG and regulatory bodies to amend of regulatory bodies bodies partners their Acts to include AMR amended acts to include institutions and IPC AMR

1.4.3 Organize meeting with # of updated 15 Yes Professional Once AMR TWG and professional boards to professional boards pre- boards partners incorporate AMR into their service curriculum with curriculums pre-service curriculum AMR issues

1.4.4 Train professional # health professional 50 Yes Universities, Once MOE/ Universities, educators at different levels teacher/educators/lectur health and vet MoH, MOA, NPHIL on AMR issues es trained on AMR professional and partners councils

1.4.5 Enhance pre-service Updated pre-service 1 Yes Pre-service Once MOE/ Universities, laboratory institutions laboratory curriculum to laboratory laboratory microbiology training to include AMR detection curriculum Boards/Nursing include AMR detection Boards, Pharmacy Board, LMRHA, LMDC and partners 60

1.5 Enhance AMR capacity in in-service institutions (human, animal, environmental, food production and food safety workforce)

1.5.1 Develop in-service AMR AMR orientation package 1 No WHO AMR Once MOE/ Universities, orientation package training package regulatory bodies and partners

1.5.2 Print and disseminate in- # AMR orientation 50 No MOH/MOA/othe Once The Health service AMR orientation package printed and r sectors Promotion Unit, package to MOH, MOA, disseminated NPHIL and partners other sectors

1.5.3 Incorporate AMR into in- Updated mid-level health 1 No Midlevel training Once MOE/ Universities, service training for midlevel worker training curriculum, regulatory bodies health workers curriculum and partners

1.5.4 Adopt and adapt relevant Updated standards 1 Yes Liberia CODEX Once AMR TWG and food safety standards committee partners standards

1.5.5 Print and distribute food # printed and 100 Yes Liberia CODEX Within 4 The Health safety standards for AMR disseminated food safety committee years Promotion Unit, key stakeholders in the 15 standards standards NPHIL and partners counties

1.5.6 Update CHAs training Updated CHA training 1 Yes CHA training Within 2 Community Health curriculum to include hand curriculum to include curriculum years Division and hygiene and AMR AMR issues partners

1.5.7 Participate in Liberia’s Updated nutrition policy 1 Yes Nutrition unit Once MoH and partners nutrition policy revision to to include AMR issues include AMR 61 Objective 2: Strengthen knowledge and evidence base through surveillance

2.1 Strengthen lab AMR capacity

2.1.1 Training of lab staff at 8 # lab staff trained 30 No NRL, LIBR, NSL, Biannually AMR TWG, and sentinel sites Vet. Lab partners

2.1.2 Conduct facility-based # sites mentored 30 No NRL, LIBR, NSL, Annually AMR TWG, and mentorship for laboratory Vet. Lab partners staff at sites

2.1.3 Procure essential List of equipment and ? no NRL, LIBR, NSL, Once NPHIL, MOA, MOH, equipment and supplies for supplies procured Vet. Lab Ministry of antibiotic residual testing Commerce and for AMR surveillance Industry (MOCI)

2.1.4 Train lab tech to conduct #/% of trained lab tech in 5 Yes Training Twice Universities, MoH, AMR HCA surveillance microbiology with credentials (e.g. MOA, NPHIL, EPA, emphasis in AMR certificate) AMR TWG, and partners

2.1.5 Develop a manual of SOPs Manual of procedures Published Yes NRL, LIBR, NSL, Once AMR TWG, partners for AMR surveillance (MOP) MOP Vet. Lab

2.1.6 Conduct in-county and # quality assurance Accredited Yes NRL, LIBR, NSL, Biannually National Lab. TGW external quality Assurance undertaken labs Vet. Lab for in county, and partners of reference lab annually for external 62

2.1.7 Training of Laboratory staff # staff trained in QMS Accredited Yes NRL, LIBR, NSL, Biannually National Lab. TGW on QMS labs Vet. Lab for in county, and partners annually for external

2.1.8 Install Laboratory LMIS installation LMIS Yes NRL, LIBR, NSL, Once National Lab. TGW information management installed Vet. Lab and partners system (LMIS)

2.1.9 Procure VITEK 2 List of VITEK 2 2 No NRL, LIBR, NSL, Once National Lab. TGW microbiological analyzer (30 equipment procured Vet. Lab and partners Clinical Parameters) for NRL

2.2 Establish a surveillance system on AMR in human health

2.2.1 Establish a national AMR AMR surveillance and 1 No AMR TWG Once AMR TWG and surveillance and laboratory laboratory taskforce partners taskforce formed with list of members and TOR

2.2.2 Identify and establish # of functional HCA 8 No Reports, site Annually AMR TWG and sentinel sites for sentinel sites visits partners healthcare- associated infections (HAI) surveillance system including surgical site infections (SSI)

2.2.3 Identify priority organisms, List of priority organisms, 1 No NRL & LIBR and Once Lab. TWG samples and testing panels samples and testing hospitals using Global Antimicrobial panels identified conducting antimicrobial 63 Resistance Surveillance susceptibility System (GLASS) approach testing (AST)

2.2.4 Train clinicians, Training report with # of ? No Training Once MOA, MOH, NPHIL veterinarians and clinicians, veterinarians certificate ARM TWG & environmental technicians and environmental partners on appropriate sample technicians trained collection, packaging and submission

2.2.5 Document the AMR HAI AMR HCA profile report 5 No AMR TWG Annually MOH, NPHIL ARM profile to inform policy TWG and partners development/review

2.2.6 Establish AMR active AMR active surveillance 1 No NRL and LIBR Once AMR TWG and surveillance system system established partners

2.3 Establish a surveillance system for AMR in animal health

2.3.1 Conduct a country situational Drug use in animal health 1 No Animal owners/ Once MOA, NPHIL, AMR analysis of drug use in animal CSA report traders TWG health (animal owners/traders) and make recommendations with respect to establishing animal health surveillance system

2.3.2 Strengthen veterinarian lab List of reagents and lab. ? ? NRL/LIBR Once MOA, AMR TWG capacity to confirm AMR in animal consumables, including and partners health through procurement of culture media procured reagents and laboratory 64 consumable, including: Culture Media (antibiotic disk)

2.3.3 Conduct one day workshop of Workshop report with # AMR lab No LIBR Once AMR TWG and 75 participants to develop and of participants detection partners validate AMR laboratory detection and and reporting plan reporting plan validated

2.3.4 Conduct 5-day sessions to # trained on sample 261 No Training once MOA, AMR TWG train 261 health workers, livestock collection, diagnostic certificates and partners officers, laboratory aides on AMR techniques, lab samples collection and Laboratory equipment Technicians on the use of specialized diagnostics techniques and laboratory equipment

2.3.5 Collect and transport food # food samples analyzed ? No NRL and LIBR, Monthly MOA, NSL samples to the laboratory for National analysis to monitor antibiotics Standard Lab residue in meat products at the (NSL) slaughter houses in country; meet inspectors at slaughterhouses on a monthly basis

2.3.6 Monitor antibiotic residues in # animal feed, pesticide ? No NSL, Agriculture Monthly MOA, AMR TWG animal feed, pesticide residue in samples analyzed Vet. Lab and partners honey, in aquaculture and food 65 products etc; Laboratory analysis on samples collected monthly

2.4 Establish an integrated AMR surveillance system

2.4.1 Establish an AMR central AMR unit established 1 No MOH/NPHIL Once AMR TWG and coordinating unit (NPHIL/MOH) partners

2.4.2 Develop an integrated AMR Approved Integrated 1 No AMR unit Once AMR TWG and surveillance plan AMR surveillance plan partners

2.4.3 Print and distribute the AMR # copies printed and 100 No AMR unit Once AMR TWG surveillance plan disseminated

2.4.4 Establish a centralized data Centralized AMR data 1 No NRL and LIBR, Once AMR TWG/NRL, management system for regular system established LIBR sharing of AMR data between MOH, NPHIL, MOA and EPA (local consultancy)

2.4.5 Train personnel on data # of personnel trained ? No NRL, LIBR Once AMR TWG/NRL, management and reporting LIBR

2.4.6 Harmonize laboratory # of laboratories with 11 6 NRL and LIBR, Once AMR TWG/NRL, methodologies and data reporting harmonized reporting Vet. Lab, NSL LIBR for characterization of AMR methodologies organisms with relevant drug combinations in hospitals

2.4.7 Harmonize surveillance for Harmonized surveillance ? NRL and LIBR, Once MOA, AMR TWG antimicrobial resistance with for AMR on farms Vet. Lab, NSL and partners antimicrobial utilization on farms 66

2.5 Establish an early warning system to determine risk factors and drivers of AMR and impact on public, animal health and the economy

2.5.1 Adopt international Copy of the standard Adopted No NRL, LIBR, NSL, Once National Lab. TWG standards for AMR early warning standards Vet. Lab and partners

2.5.2 Sensitize lab techs, clinicians # staff sensitized ? No NRL, LIBR, NSL, Once National Lab. TWG and vets on identification and Vet. Lab, EPA Lab and partners evaluation of risks

2.5.3 Compile and provide # risks identified Risks events No NRL, LIBR, NSL, Annually National Lab. TWG information on identified risks routinely identified Vet. Lab, EPA, and partners AST Lab. Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention control measures.

3.1 Orient healthcare workers (HCWs) on the National IPC Guidelines

3.1.1 Ensure AMR is embedded QMU activities report 52 No AMR TWG/ MoH Weekly IPC TWG, QMU and within the IPC TWG at QMU with AMR components QMU partners

3.1.2 Establish a AMR IPC and AMR IPC and IPC WASH 1 No AMR TWG Once AMR TWG WASH Taskforce TWG formed with list of members and TORs

3.1.3 Printing and distribution of # copies of national IPC 1000 No MoH QMU Once QMU (MoH) and National IPC guidelines guidelines printed and partners distributed

3.1.4 Conduct a 4 - day Training report with #/% 65 No MoH - QMU Once QMU (MoH) and orientation workshop for of facility and county IPC partners facility and county IPC focal focal persons oriented on the National IPC persons on National IPC guidelines Guidelines 67

3.1.5 Orientate all healthcare Training report /% facility 14,913 (SQS No MoH - QMU Once QMU (MoH) and workers at each facility on IPC focal persons raining report) partners the National IPC guidelines oriented on IPC guidelines

3.1.6 Monitor implementation of #/% facilities 800 Yes MoH - QMU Annually QMU (MoH) and the National IPC guidelines implemented National partners at health facilities IPC guidelines

3.1.7 Integrate IPC contents in # of revised curricula in Updated Yes Health training Once AMR TWG, curriculum for all health health training curriculum institutions Universities, MOH, training institutions institutions that reflect MOA, MOE, IPC partners

3.2 Strengthen community prevention

3.2 CHAs organize community #/% of CHAs reporting on ? Yes CHAs monthly Bi-annually Community Division handwashing awareness hand hygiene community report/MoH (MoH) and partners meeting with key stakeholders awareness activities

3.3 Celebrate global handwashing #/% of schools ? No School annually MOE, QMU/MoH day in schools by holding celebrating global reports/MoH, and partners special program handwashing day MoE

3.4 Commemorate global # radio/social media ? No Local radio, Annually QMU/MoH and handwashing day using radio social partners including social media media/MoH

3.5 Meet with business/marketing # of meetings held with List of No Meeting report, Once Community Division associations to highlight business/marketing participants MoH (MoH) and partners 68 importance of handwashing associations and number and waste management in of participants their respective settings

3.6 Undertake inspection of # of facilities with foods ? Yes Inspection Annually MOCI, NPHIL, MoH foods and food products for and food products reports, MOCI, and partners public consumption inspected NPHIL

3.7 Update/develop community Community waste Community Yes Community Once NPHIL, MoH, LWSC, waste management protocol management protocol waste waste EPA and partners to include AMR updated/developed management management protocol protocol, NPHIL updated

3.8 Train waste technicians (solid #/% of waste technicians ? Yes Training Once DEOH, MoH, LWSC and liquid waste) and and engineers trained certificates, and partners environmental engineers in NPHIL, MoH, community waste LWSC management protocol

3.9 Meet with superintendent, Meeting report 15 No Meeting report, Once NPHIL, MoH, MOA, CHO, county livestock officers, AMR TWG EPA, LWSC and and development partners superintendent to advocate to build standardized community toilets and public waste bins to control organic and human waste 69

3.10 Develop and validate Water # of WSP completed 15 No DEOH NPHIL Once NPHIL, LWSC and Safety Plans (municipal water partners system) for 15 counties

3.11 Print and disseminated WSP # of WSP printed and 50 No DEOH NPHIL Once NPHIL, LWSC and (municipals water system) for distributed partners 15 counties

3.12 Develop and validate Community WSP 1, 000 No DEOH NPHIL Once NPHIL, LWSC and community levels WSP developed and validated partners

3.13 Disseminate and monitor #/% of communities and 1, 000 No DEOH NPHIL Quarterly NPHIL, LWSC and adherence of communities to counties implementing partners WSPs WSPs

3.14 Provide support to LWSC and Reports 15 Yes DEOH NPHIL Annually NPHIL, LWSC and Public Works to increase partners access to safe drinking

3.15 Conduct periodic water safety # of houses 20? No DEOH NPHIL Monthly NPHIL, LWSC and monitoring at household level partners

3.3 Strengthen IPC in health care facilities

3.3.1 Establish alcohol based #/% facilities producing 5 No MoH Once QMU/MoH and hand rub (ABHR) ABHR partners production plants at selected facilities

3.3.2 Advocate to key # of plants gaseous 1 No MoH Annually QMU/MoH and stakeholders and donors to chlorine plant partners establish plant for producing gaseous chlorine 70 to enhance drinking water treatment

3.3.3 Print and disseminate hand # of posters printed and 1,500 No Health facilities Annually QMU/MoH and hygiene posters at health disseminated partners facilities

3.3.4 Print and disseminate hand # of posters printed and 1,500 No Health facilities Annually QMU/MoH and hygiene posters at health disseminated partners facilities, schools and food centers

3.3.5 Commemorate global hand # radio programs with 5 Yes Health Annually QMU and Health hygiene day using radio and hand hygiene talks promotion unit Promotion social media (May 5) Unit/MoH and partners

3.3.6 Perform Hand hygiene # of audits performed 840 Yes QMU Quarterly National QMU, audits at hospitals (public County Quality and private) Management, Team and partners

3.3.7 Finalize and validate safe Finalized guidelines Validated Yes DEOH Once NPHIL, LWSC and management of health care guidelines partners waste guidelines

3.3.8 Print and distribute safe # printed and distributed 1,000 No DEOH Once NPHIL, LWSC and management of health care guidelines partners waste guidelines

3.3.9 Orient Healthcare workers # HCWS oriented 800 No DEOH Once NPHIL, LWSC and on safe management of partners 71 health care waste guidelines

3.3.10 Ensure screening, isolation # facilities with screening, Yes MOH Annually MOH, NPHIL and referral pathway for isolation amenities epidemic prone diseases are in place at health facilities

3.4 Strengthen animal health and agricultural practices

3.4.1 Update/develop farm # biosecurity guidelines 0 No MOA Once NPHIL, MoH, MOA, biosecurity guidelines for developed EPA and partners different categories of animal farms, slaughter facilities, abattoirs and agriculture facilities

3.4.2 Develop and validate safe # of animal health safe 1 No MOA, NPHIL Once MOA, EPA , NPHIL, waste management management guidelines MoH, and partners guidelines (including developed, validation sanitation and hygiene) for report animal facilities and farms

3.4.3 Printing and distribution of # guidelines printed and 1,000 No MOA Once MOA, EPA , NPHIL, safe management distributed MoH, and partners guidelines for animal facilities and farms 72

3.4.4 Orientate facilities and Report with list of ? No MOA Once MOA, EPA , NPHIL, farms workers in waste participants MoH, and partners management guidelines

3.4.5 Monitor implementation of # of supervision ? No MOA Quarterly MOA, EPA , NPHIL, safe waste management conducted with report MoH, and partners guidelines for animal facilities and farms

3.4.6 Adopt/implement # Code of practice 1,000 ? MOA Annually MOA, EPA , NPHIL, standards published in OIE MoH, and partners and Codex Alimentarius code of practice to minimize AMR

3.4.7 Train farmers in standard # farmers trained ? MOA Once MOA and AMR animal husbandry practices TWG to reduce need to use antimicrobial agents

3.4.8 Undertake regular checks # facilities and farms ? MOA MOA and AMR TWG on sanitation and hygiene checked for proper on animal facilities and hygiene and sanitation farms

3.4.9 Undertake regular checks # feed samples checked MOA MOA and AMR TWG on animal feeds for contamination

3.4.10 Develop/update standards Guidelines 1 MOA Once MOA, AMR TWG for farm infrastructure that developed/updated and partners promotes infection 73 prevention in animal handling facilities and farms

3.4.11 Develop guidelines for Guidelines MOA MOA AMR TWG and infection prevention developed/updated partners materials for animal facilities and farms

3.4.12 Develop recommendations Vaccine AMR TWG, for use of vaccines as a recommendations MoH/EPI and method of preventing developed partners infections in animals and reducing antimicrobial use Objective 4: Optimize the use of antimicrobial agents medicines in human and animal health.

4.1 Develop and enforce legislation on prescriptions for combating AMR

4.1.1 Establish a AMR TWG formed with list of 1 No AMR TWG Once AMR TWG Antimicrobial Medicines members and TOR Taskforce in One Health context

4.1.2 Conduct a 2-day workshop Updated Public Health 1 Yes Law Library Once Pharmacy Board, to develop a legislation on Law with combating AMR TWG and the use of antimicrobial AMR section partners 74 agents in human, animals, plants and the environment

4.1.3 Validate a legislation on the Validated Public Health 1 Yes Law Library Once Pharmacy Board, use of antimicrobial agents Law with combating AMR TWG and in human, animals, plants AMR section partners and the environment

4.1.4 Print and disseminate #/% printed and 100 copies Yes key stakeholders Once Pharmacy Board updated Public Health (PH) disseminated PH Law to and implementers Law with AMR components key stakeholders and interview implementers

4.2 Reflect AMR in key documents (National Medicine Policy, Standard Treatment Guidelines, Essential Medicine List 2016)

4.2.1 Update National Medicine National Medicine Policy 1 Yes LMHRA Once Pharmacy Policy to include AMR updated Board/MoH, AMR TWG and partners

4.2.2 Print and distribution of # of copies printed and 2, 000 Yes LMHRA Once Pharmacy revised National Medicine distributed Board/MoH, AMR Policy TWG and partners

4.2.3 Update the National Drug National Drug Formulary 1 Yes LMHRA Once Pharmacy Formulary to include AMR updated Board/MoH, AMR TWG and partners

4.2.4 Printing and distribution of # of copies printed and 2,000 Yes LMHRA Once Pharmacy revised National Drug distributed Board/MoH, Formulary LMRHA, AMR TWG and partners 75

4.2.5 Update the Standard STG updated 1 Yes LMHRA Once Pharmacy Treatment Guidelines to Board/MoH, include AMR LMRHA, AMR TWG and partners

4.2.6 Printing and distribution of # of copies printed and 2,000 Yes LMHRA Once Pharmacy updated STG distributed Board/MoH, LMRHA, AMR TWG and partners

4.2.7 Conduct TOT for # of professionals trained 20 Yes MOH/LMRA Once Pharmacy professionals to promote Board/MoH, responsible prescribing LMRHA, AMR TWG practices, dispensing and and partners administrative principles for antimicrobials

4.3 Establish AMR stewardship program for facilities

4.3.1 Develop antimicrobial MOP developed 1 No MOH and Once Pharmacy stewardship working partners Board/MoH, manual and procedures in LMRHA, AMR TWG and partners the context of One Health

4.3.2 Print and distribute # of copies printed and 1,000 No AMR TWG Once Pharmacy antimicrobial stewardship distributed Board/MoH, working manual LMRHA, AMR TWG and partners

4.3.3 Train HCWs on # of HCWs trained 100 No MOH/AMR TWG Twice Pharmacy antimicrobial stewardship Board/MoH, 76 LMRHA, AMR TWG and partners

4.3.4 Establish AMR stewardship # of AMR stewardship 3 No Selected Once Pharmacy programs in selected programs facilities Board/MoH, facilities LMRHA, Universities, AMR TWG and partners

4.3.5 Review and provide # of feedback provided 3 No AMR TWG Quarterly Pharmacy feedback to facility AMR Board/MoH, stewardship programs LMRHA, AMR TWG and partners

4.3.6 Scale up stewardship # of AMR stewardship 15 Yes AMR TWG/ Annually Pharmacy programs programs facilities Board/MoH, LMRHA, AMR TWG and partners

4.4 Establish an antimicrobial prescription monitoring system

4.4.1 Develop AMR prescription AMR prescription 1 No MOH Once Pharmacy reporting system and reporting form and Board/MoH, mechanism for human mechanism developed LMRHA, AMR TWG health (One Health) context and partners

4.4.2 Validate prescription Prescription form 1 No LMHRA/MOH Once Pharmacy reporting form validated Board/MoH, LMRHA, AMR TWG and partners

4.4.3 Print and distribute # forms printed and 2,000 No LMHRA/MOH Annually Pharmacy reporting form distributed Board/MoH, 77 LMRHA, AMR TWG and partners

4.4.4 Monitor and evaluate # forms reviewed and ? No LMHRAMOH Bi-annually Pharmacy implementation of AMR feedback given to Board/MoH, prescription reporting prescriber LMRHA, AMR TWG system (supportive and partners supervision)

4.5 Establish a monitoring system for non-prescribed antimicrobials

4.5.1 Develop monitoring system Non-prescribed 1 No LMHRA, MoH, Pharmacy for non-prescribed antimicrobials MOA Board/MoH, antimicrobials in monitoring system LMRHA, AMR TWG collaboration with line established and regulatory ministries and the security authorities sector

4.5.2 Re-establish and reinforce Implemented penalties ? No LMHRA, MoH, Quarterly Pharmacy the implementation of for illegal selling of MOA Board/MoH, penalties for illegal selling antimicrobials LMRHA, AMR TWG of antimicrobials and regulatory authorities

4.5.3 Reinforce the post Post-marking ? No LMHRA, MoH, Quarterly Pharmacy marketing surveillance at surveillance conducted MOA Board/MoH, the LMHRA LMRHA, AMR TWG and regulatory authorities 78

4.5.4 Collaborate with state Confiscation of illegal ? No LMHRA, MoH, Monthly Pharmacy security to reinforce the sale of antimicrobials MOA, Justice Board/MoH, confiscation of illegal sale of and expired medicines Ministry LMRHA, AMR TWG antimicrobials and expired reinforced and regulatory medicines authorities and Justice Ministry

4.5.5 Reinforce the border Report of borders on 49 No Ministry of Pharmacy Board/ security for illegal sale and illegal sale and Justice (MoJ) MoH, LMRHA, AMR importation of importation of TWG and antimicrobial medicines antimicrobial medicines regulatory authorities and MoJ

4.5.7 Collaborate with ECOWAS Counterfeit drugs ? LMRHA, MoH Pharmacy through WAHO to combat identified Board/MoH, counterfeiting drugs LMRHA, AMR TWG and regulatory authorities MoJ

4.5.8 Develop and print SOP for Copies of SOP LMHRA, MoH Pharmacy identification and Board/MoH, monitoring of non- LMRHA, AMR TWG prescribed antimicrobials and regulatory authorities and MoJ

4.5.9 Disseminate SOP for Report LMHRA Once Pharmacy identification and Board/MoH, monitoring of non- LMRHA, AMR TWG prescribed antimicrobials and regulatory authorities 79

4.6 Strengthen the LMHRA drug quality control lab

4.6.1 Procure essential Commodities procured LMHRA Annually LMRHA, Pharmacy commodities for the LMHRA QC Board/MoH, AMR Lab TWG and regulatory authorities

4.6.2 Training and mentorship of # of lab technicians LMHRA, MoH, Annually LMRHA, Pharmacy LMHRA drug quality control trained MOA Board, MoH, AMR lab technicians TWG and regulatory bodies

4.6.3 Training in physico- Lab technicians/staff LMHRA, MoH, Annually LMRHA, Pharmacy chemical drug quality trained MOA Board, MoH, AMR control TWG and regulatory bodies

4.6.4 Quality control training in Lab technicians trained LMHRA, MoH, LMRHA, Pharmacy microbiology of drugs MOA Annually Board, MoH, AMR TWG and regulatory bodies

4.6.5 Training in quality control of Lab technicians trained LMHRA, MoH, Annually LMRHA, Pharmacy medical devices MOA Board, MoH, AMR TWG and regulatory bodies

4.6.6 Training in quality control of Lab technicians trained LMHRA, MoH, Annually LMRHA, Pharmacy cosmetics MOA Board, MoH, AMR 80 TWG and regulatory bodies

4.7 Establish/strengthen animal drug regulatory body to address AMR

4.9.1 Revise and update Animal Updated Animal law Yes LMHRA, MoH, Once LMRHA, Pharmacy Health Law to include AMR MOA Board, MoH, AMR and update legislation for TWG and regulatory control and use of bodies veterinary drugs (trade, use, importation, etc)

4.9.2 Identify and activate animal Animal health regulatory No LMHRA, MoH, Once LMRHA, Pharmacy health regulatory body body activated MOA Board, MoH, AMR group TWG and regulatory bodies

4.9.3 Monitor implementation of Report No LMHRA, MoH, Quarterly LMRHA, Pharmacy Animal Health Laws which MOA Board, MoH, AMR includes AMR TWG and regulatory bodies

4.10 Strengthen EPA to address AMR

4.10.1 Monitor implementation of Reports No LMHRA, MoH, Quarterly LMRHA, Pharmacy Environmental law which EPA Board, EPA, MoH, includes AMR AMR TWG and regulatory bodies 81

4.8 Collaborate with WAHO and ECOWAS focal persons to combat counterfeit drugs

4.9.1 Conduct periodic Meetings reports Quarterly MOH, NPHIL coordination meetings with WAHO and ECOWAS on combating counterfeit drugs (Supportive supervision)

4.9.2 Implement defined # of activities Quarterly activities from coordination implemented meetings held to combat counterfeit drugs Objective 5: Ensure Sustainable Investment Through Research and Development

5.1 Establish a multi-sectoral research agenda on AMR

5.1.1. Establish an AMR AMR R &D taskforce with 1 No AMR TWG 1 AMR TWG, OHTC Investment, R&D taskforce TOR developed and partners and develop TOR

5.1.2. Human resource capacity # of persons trained in ? No AMR TWG 1 AMR TWG, OHTC building in AMR R&D AMR-related research and partners from different sectors (human, animal, plant and environment)

5.1.3. Establish ethical and AMR research ethics 1 No AMR TWG 1 AMR TWG, OHTC regulatory mechanisms for developed and partners 82 AMR research and development

5.1.4. Develop policy and strategy Policy and strategy for 1 No AMR TWG, 1 AMR TWG, OHTC, for national AMR R&D, national AMR research LMHRA LMHRA and including invitro/invivo and development with partners diagnostics invitro/invivo diagnostics components

5.1.5. Engagement meetings with Report 1 No AMR TWG 1 AMR TWG, OHTC relevant stakeholders to and partners identify current gaps in knowledge and potential research areas

5.1.6. Promote LMHRA standards Report 60 No AMR TWG Monthly AMR TWG, OHTC for all research products to and partners include therapeutics and vaccines

5.1.3 Hold one day workshop to Workshop report 1 No AMR TWG 1 AMR TWG, OHTC validate policy and strategy and partners for AMR research

5.1.4 Print and disseminate ARM # of copies printed and 1000 No AMR TWG 1 AMR TWG, OHTC, research protocols distributed Research & Ethic Committees, and partners

5.1.5 Engagement meeting with Meeting minutes 1 No AMR TWG Twice AMR TWG, OHTC, relevant stakeholders to Research & Ethic identify current gaps in 83 knowledge (i.e. research Committees, and capacity gaps analysis) and partners potential research areas

5.1.6 Identify and train early # of trainees ? No AMR TWG Annually AMR TWG, OHTC, career researchers on grant Research & Ethic writing with emphasis on Committee, and AMR R&D partners

5.1.7 Establish a center of List of centers for 15 No AMR TWG Annually AMR TWG, OHTC excellence for AMR excellence in AMR and partners research with focus on one research health

5.1.8 Conduct AMR-related # of AMR/one health 375 No AMR TWG Annually AMR TWG, OHTC, research project (e.g. related concept research Research & Ethic detecting pesticide residues and articles published on Committee, and AMR in honey) with One Health partners approach

5.1.9 Establish a platform for # of platforms 5 No AMR TWG/OHTC Annually AMR TWG/OHTC sharing AMR research established/symposia and partners findings annually held

5.1.6 Identify PHD students to # of PhD candidates 5 No AMR TWG/OHTC Annually AMR TWG/OHTC undertake research (no cost and partners implication)

5.1.7 Purchase vehicle for the Vehicle purchased 1 No AMR TWG/OHTC Once AMR TWG/OHTC operationalization of AMR and partners activities in Liberia 84

5.1.8 Vehicle maintenance and Maintenance report 60 No AMR TWG/ Monthly Drivers and or lubricant for routine OHTC designee operation

5.2 Establish Public-Private Partnerships (PPP) for AMR R&D

5.2.1 Conduct multi-sectoral Consultative meetings Yes MR TWG/ OHTC Quarterly AMR TWG/ OHTC coordination and AMR TWG held with report and partners consultative meetings and develop TOR

5.2.2 Conduct monthly AMR TWG Meetings held with 60 No MR TWG/ OHTC Monthly AMR TWG/ OHTC to meetings to discuss key report and partners issues (including AMR research)

5.2.3 Hold joint annual AMR Meetings held with 5 No MR TWG/ OHTC Annually AMR TWG/ OHTC review meetings with PPP report and partners including private sector and NGOs to orient them on AMR activities including research

5.2.4 Establish and promote Regional and ? No MR TWG/ OHTC Annually AMR TWG/ OHTC regional and international international and partners collaboration for AMR R&D collaborations developed

5.2 Establish funding mechanism for AMR Research & Development (R&D)

5.3.1 Advocate and lobby for # proposals funded by 10 No AMR TWG/ Bi-annually AMR TWG/ OHTC funding from government amount (report) OHTC and partners 85 and partners (including pharmaceutical companies) to support AMR-related research

5.3.2 Post calls for funding # of research funding 10 No AMR TWG/ Bi-annually AMR TWG/ OHTC opportunities onto posted OHTC and partners institutional websites and mailing list of stakeholders

5.3.3 Develop AMR related # of AMR-related ? No AMR TWG/OHTC Bi-annually AMR TWG, OHTC research proposals/grants research proposals and partners using one health approach developed and grants applied for

5.3.4 Identify and twin local # of MOUs and twinning 15 No AMR TWG/ Annually AMR TWG/ OHTC laboratories with foreign partnerships OHTC and partners laboratories to support research in AMR, and research exchange programs to transfer skills and mentorship 86 References 1. Assessment of Governance and Corruption in the Pharmaceutical Sector; Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network, 2010; www.worldbank.org/publications. 2. CDC: ANTIBIOTIC RESISTANCE THREATS in the United States, 2013 3. A situation Analysis of the Liberian Pharmaceutical Sector and Access to Quality Assured Essential Medicines; Theophilus Ndorbor 4. FAO: Action Plan on Antimicrobial Resistance 2016-2020 Available at: www.fao.org/3/a-i5996e.pdf 5. http://www.garpkenya.org/2017/11/amr-national-action-plan-and-policy-launch- 2017/ 6. http://www.who.int/antimicrobial-resistance/national-action-plans/en/ 7. http://www.rrasia.oie.int/fileadmin/Regional_Representation/Programme/I_Welfar e/2016_VPFP_Tokyo_4th/2-01_Aidara-Kane_WHO_Global_AP_and_Followup.pdf, 8. http://www.afro.who.int/sites/default/files/201707/NATIONAL%20ACTION%20PLA N%20FNL%2010%20May%202017.pdf, Tanzania Nation Action Plan 9. OIE Standards, Guidelines and Resolution on antimicrobial resistance and the Prudent use of antimicrobial agents. Available at: http://www.oie.int/fileadmin/Home/eng/Media_Center/docs/pdf/PortailAMR/EN_ OIE-AMRstrategy.pdf 10. World Bank Group. Drug-resistant infections; A threat to our economic future (Sept 2016) 11. World Health Organization. Antimicrobial Resistance Global Report on Surveillance (2014) 12. World Health Organization. Global Action Plan on Antimicrobial Resistance, 2015. Available at: www.wpro.who.int/entity/drug_resistance/.../global_action_plan_eng.pdf 13. World Health Organization. Global Antimicrobial Resistance Surveillance System (2015) 14. World Health Organization. Global Tuberculosis Report 2017. Available at: http://www.who.int/tb/publications/global_report/en/ 15. World Health Organization. The evolving threat of antimicrobial resistance. Options for action. 2012 16. World Health Organization. WHO Regulatory Systems Strengthening, National Regulatory Authority Assessment Report; Liberia; September 2015 17. WHO. General Programme Work (GPW 13, 2018-2023) 18. Essential Package of Health Services. Ministry of Health and Social Welfare, Monrovia, Liberia (2011) 87

Annex 1: NAP on AMR Technical Working Group and Contributors Name Position and Organization Rev. Tijli Tarty Tyee, Sr. Chief Pharmacist, Ministry of Health, Republic of Liberia (Member OHTC & Chairperson, AMR TWG) Sonpon Sieh One Health Coordinator, NPHIL Thomas K. Nagbe Director, Infectious Disease & Epidemiology, NPHIL (Member OHTC) John Korfeh Thomas Chemist, Liberia Water & Sewer Corporation (Member AMR TWG) John Dogba Public Health Diagnostic Laboratory, NPHIL (Member OHTC & AMR TWG) Henry Kohar Laboratory Focal Person, NPHIL (Member OHTC AMR TWG) April Baller Epidemic Preparedness and Response Officer, WHO (Member OHTC and AMR TWG Secretariat) Moses B. Bolongei National IPC Officer, WHO (Member AMR TWG) Monica Dea GHSA Advisor, USAID/Liberia Charles W. Oliver Infectious Disease Team Lead, USAID/Liberia Ben Woods Senior AMR and TB Technical Advisor, USAID/Global Health Bureau Jessica Kayamori FAO Arthur Brown MHS/ Mother Patter College of Health Sciences Joseph Jimmy MOH Garmie Voupawoe CVL - MOA Jasper Mason Mother Patter College of Health Sciences Sister Barbara Mother Patter College of Health Sciences David Sumo Director, Liberia Health Products and Regulatory Authority Anthony Twywan Infection Prevention and Control Consultant, WHO Dr Julia T. Garbo National AIDs Control Program (NACP) Victoria Katawera Laboratory Technical Officer, WHO (Member OHTC) 88 Gertrude Mulbah Laboratory Technical Assistant (Member AMR TWG) Blessing G. Opoola Laboratory Technical Assistant (Member AMR TWG) Benjamin Vonhm NPHIL Fahn Taweh NPHIL Etag Belayneh MOA Watta Anthony MOA Gulu Gwrso CDC Joseph Gichuru ACCEL James D.K. Goteh Director, Pharmacovigilance, LMRHA Pricilla Dilah NPHIL 89