National Multisectoral Plan on antimicrobial resistance 2019-2023

Foreword The development of the National Action Plan on Antimicrobial Resistance is a milestone achievement being just the third such plan completed in the Pacific Region. The global threat of antimicrobial resistance, especially during this time of accelerating climate change, is important for our community here in the Marshall Islands where resistance to antimicrobials has been experienced albeit infrequently. Although we do not yet have high rates of resistance, the ever increasing rates of NCDs in our community have created seriously compromised immune systems in our people. Because of this situation we need to be proactive and vigilant towards increasing awareness of antimicrobial resistance amongst our people and our communities. The challenge in preventing the increased threat that we face in the Marshall Islands needs full commitment from professionals across all sectors where antimicrobials are used. The objectives of this AMR plan to raise public awareness and the activities identified require a well-coordinated and carefully conceived approach for its successful implementation. The antimicrobial resistance monitoring and surveillance is a necessary and critical component of this plan and will need cooperation between all of our relevant sectors and partners in order for us to consider and act on the results in a timely manner. I believe that the more we raise awareness with regard to the threat of antimicrobial resistance the better we will be able to effectively protect our citizens in the future. Jack~ Secretary of Health· and Human Services for the Republic of the Marshall Islands Page 2 of21 Acknowledgement First and foremost the contributions from the representatives of the Ministries of Health & Human Services, the Public School System, the Ministry of Natural Resources & Commerce, the Ministry of Finance, Banking & Postal Services, the College of the Marshall Islands, all the nongovernmental organizations and those representatives of the private sector are hereby gratefully acknowledged. We would also like to thank and acknowledge office of the WHO at the Director of Pacific Technical Support in Suva and Country Liaison Office in FSM for their tremendous support of this effort. Lastly, we would I ike to thank all those people who he/ ped organize the meetings and he/ ped create the earlier drafts of this document. Page 3 of21 Table of Contents ACRONYMS ............................................................................................................................................... . 1. INTRODUCTION ................................................................................................................................... . 2. SlJMMARY OF COUNTRY SITUATION ANALYSIS ....................................................................... . 3. GOVERNANCE OF ANTIMICROBIAL RESISTANCE .................................................................. . 4. ACTION PLAN ON ANTIMICROBIAL RESISTANCE ............................ .. ....... ................... ............ . GOAL ............... ...... ................ ............................................. ............................ .................... ............ .. . .. ......... . STRATEGIC OBJECTIVES .................... .............................. ...................... . ... . ......... ..... .... ......... ................ . 5. ANTIMICROBIAL RESISTANCE OPERATIONAL PLAN ............................................................ . OBJECTIVE 1: ESTABLISH AND ENSURE GOVERNANCE, SUST AJNABLE INVESTMENT AND ACTIONS TO COMBAT ANTIMICROBIAL RESISTANCE ... ................ . .............. ... .................. . .... ... .......... ......................... . OBJECTIVE 2: IMPROVING AWARENESS AND UNDERSTANDING OF ANTIMICROBIAL RESISTANCE ACROSS ALL INSTITUTIONS AND SECTORS .... .. .............. ... .......................................... ............................. ....... . OBJECTIVE 3: STRENGTHEN SURVEILLANCE, DIAGNOSTIC CAPACITY AND RESEARCH ON ANTIMICROBIAL RESISTANCE ..................... .... ............ .. ................ ... ................. .... ............. ......... ................... . OBJECTIVE 4: REDUCING INCIDENCE OF ANTIMICROBIAL RESISTANCE THROUGH EFFECTIVE INFECTION PREVENTION AND CONTROL MEASURES, FOOD SAFETY AND HYGIENE .... ................................... . OBJECTIVE 5: OPTIMIZE THE USE OF ANTIMICROBIAL MEDICINES IN HUMAN AND ANIMAL HEALTH ...... ...................... .... .. ........... .. ... . .. ............. .. . .. .. ............... .. .... . ... . ... .... ............................................ . .. . Page 4 of21 Acronyms AMR AST CMI CSA EQA IEC IPC MORO MIEPA MICNGOS MOEST MOFBPS MOHHS MNRC M&E MRD PPE PTC QMS RMI TOR TWG WASH WHO Antimicrobial Resistance Antibiotic susceptibility testing College of the Marshall Islands Country situational analysis External quality assessment Information, Education, and Communication Infection prevention and control Multidrug-resistant organism Marshall Islands Environmental Protection Agency Marshall Islands Council of Non-governmental organizations Ministry of Education, Sports & Training Ministry of Finance, Banking & Postal Services Ministry of Health & Human Services Ministry of Natural Resources & Commerce Monitoring and evaluation Ministry of Resource & Development Personal protective equipment Pharmacy & Therapeutic Committee Quality management system Republic of Marshall Islands Terms of Reference Technical Working Group Water, Sanitation and Hygiene World Health Organization Page 5 of21 1.0 Introduction In 2014, the World Health Organisation (WHO) declared antimicrobial resistance as a global health threat that requires urgent collaborative action. High rates of resistance to hospital and community-acquired infections have been reported globally, with some of the highest rates reported in the Western Pacific Region. The Ministry of Health & Human Services of the Republic of Marshall Islands has identified antimicrobial resistance as one of the priority agenda items following commitments made at the world WHO Regional Committee for the Western Pacific in 2014 and subsequent re-commitment at the World Health Assembly in 2015 and United Nations General Assembly in 2016. The National Action Plan on Antimicrobial Resistance is supported by the priority actions listed in the Action Agenda for Antimicrobial Resistance in the Western Pacific Region 1, which was endorsed by the 65th session of the Regional Committee for the Western Pacific Region in 2014. In addition, on May 2015 the Global Action Plan on Antimicrobial Resistance2 was also endorsed at the 68th session of the World Health Assembly, where all Member States committed to developing national plans on antimicrobial resistance within the two years following endorsement. This plan was developed based on the country context and two rounds of multi stakeholder consultation meetings. It focuses on 4 main principles of the global action plan; 1) whole-of-society engagement, 2) prevention first, 3) access to effective treatment, ancl 4) sustainability. 1 WHO (2015), Action agenda for antimicrobial resistance in the Western Pacific Region, Available at: https://iris.wpro.who.int/handle/10665.1/10898 2 WHO (2015), Global Action Plan on Antimicrobial Resistance, Available at: https ://www. who. int/ antim icrobial-resista nce/globa I-actio n-pla n/ en/ Page 6 of21 2.0 Summarv of brief Situational Analysis on Antimicrobial Resistance in RMI The Republic of Marshall Islands (RMI) is comprised of 29 atolls and five major islands with an estimated population of 54,200 in 2013. The Marshall Islands have two hospitals (one in Majuro and one in Ebeye) and 56 health-care centres in the outer atolls and islands. Both of the main hospitals provide primary, secondary and limited tertiary care.3 Diabetes and cancers are the leading causes of death in RMI with high mortality and morbidity for both noncommunicable and communicable diseases. TB is also a leading cause of death and the RMI has reported cases of multidrug resistant TB. The Ministry of Health & Human Services responses to these disease burdens and health emergencies remains a challenge, hence calling for multi-sectoral approach. In addition to these problems, there have been laboratory reports released by the national hospitals on multidrug-resistance organisms (MDROs).4 In the RMI, it is known that antimicrobials are used in both human and animal health. However, the quantity of antimicrobials consumed by each department and the impact of AMR in RMI has not been fully established. The country self-assessment completed in 2017 and 2019 revealed the followings: t. Governance and coordination of AMR in RMI • There are no formal multi-sectoral governance or coordination mechanisms on AMR in the country with no AMR plans under development that also link to other disease programs such as HIV, tuberculosis, malaria or neglected tropical diseases. • Only human health is actively involved in developing and implementing the AMR National Action Plan with little engagement from other sectors. • The Food safety and WASH programs need to be strengthened. • The RMI h~s laws or regulations on the prescription and sale of antimicrobials for human use but not on animal use, which needs to be updated according to the current context and regulatory environment. 11. Awareness and Understanding of AMR 111. • Some activities are in place in parts of the country to raise awareness about risks of AMR and actions that can be taken to address it with the active involvement of MOH. • Trainings are not available for human health workers and other key stakeholders e.g. farmers and farm workers, extension workers, food and feed processors and retailers, environmental specialists, related to AMR. Surveillance and Laboratory Capacity 3 WHO (2017), Pacific Island Countries and Area - WHO Cooperation Strategy 2018-2022 4 Ibid Page 7 of21 • The national monitoring system does not exist for consumption and rational use of antimicrobials in human health, animals and pesticide use in plant production • There is a lack of resources and capacity to establish and support national surveillance systems for AMR in human, animal and other sectors • AMR data is collated locally for common bacteria, but the data collection does not use a standardized approach and lacks national coordination and/or quality management, with information not shared widely to assist in decision making. • Laboratory standard protocols need to be developed and reviewed periodically using the global standards. • Laboratory support for animal health and food is not available in country. 1v. Infection Prevention and Control (IPC) • A national IPC programme is in place but national IPC policy needs to be updated and strengthened. Only the national hospitals are implementing the IPC policy, however gaps still exist that require close monitoring and ongoing auditing. • The IPC and laboratory needs to improve on data sharing and needs to collaborate on the surveillance of MDRO's. v. Optimize the use of antimicrobial medicines • An antimicrobial guideline is in place and has been implemented in the national hospitals, however prescriber's practices and adherence need to be monitored and audited periodically. There is no Clinical Pharmacist in the RMI. • Regulation needs to be updated to ensure the quality, safety and efficacy of antimicrobial products and their distribution, sale or use in both human and animal health. This country's self-assessment confirms the priority areas that need to be strengthened and improved to minimize the impact of AMR in RMI. These baseline findings will inform the development of National Multi sectoral Plan on AMR in the Republic of Marshall Island. Page 8 of21 3.0 Governance of Antimic.-obial Resistance in RMI 1. Cabinet - high level political commitment and endorse AMR plan. 11. National Disaster Committee (Chief Secretary's Office) - to provide briefing to Cabinet and update on progress of AMR National Action Plan (NAP) implementation in RMI with further recommendations for Cabinet consideration and endorsement. 111. Secretary of Health & Human Services - is the Chair of the AMR committee and shall provide reports/feedback/submissions to the National Disaster Committee. 1v. RMI AMR Committee (newly formed) - directs and guides RMI response (planning) to AMR related activities and coordinates external assistance and funding to support the implementation of AMR activities in RMI. ' Page 9 of21 Proposed AMR Governance Structure Cabinet I ' \ I National Health Security Task Force- Chief Secretary Office RMI AMR Committee - Chair Secretary of Health Secretariat- IPC/MOH Page 10 of21 RMI National AMR Committee (newly formed) Suggested Members: ► Chairman/Secretary: Ministry of Health & Human Services ► Vice Chairman: Secretary of Natural Resources & Commerce ► Public School System (Education) ► College of the Marshall Islands ► Ministry of Finance, Banking & Postal Services/Customs ► Private Sector Doctor ► MICNGOs (observers) ► TB Staff Doctor ► 177 Health Plan Doctor Term of Reference: • Purpose: To implement the AMR action plan in RMI • Meet on quarterly basis (and other times on an ad hoc basis) • Report to the Minister of Health & Human Services in the RMI • Supported by the RMI AMR technical working group • Mobilize resources and prioritize allocation of funds • Monitoring and evaluation of outcomes • Review and update the National Action Plan and Operational Plan every 2 years Page 11 of21 4.0 Goal To reduce the negative impact of antimicrobial resistance on health systems in the Republic of Marshall Islands 4.1 Strategic Objectives 1. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance • Establish AMR governance structure for finalizing and implementing the National Action Plan • Ensure political commitment on the implementation of the National Action Plan • Enforcement of appropriate legislations in all sectors • Ensure sustainable investment in combating AMR 2. Improving awareness and understanding of antimicrobial resistance across all institutions and sectors • Promote information sharing on the situation of AMR and use of antimicrobials across institutions and sectors • Raise awareness on AMR to health-care workers and veterinarians 3. Strengthen surveillance, diagnostic capacity and research on antimicrobial resistance • Develop a national AMR surveillance system with a reference laboratory • Strengthen food safety capacity to combat AMR • Strengthen research and information sharing on AMR 4. Reducing incidence of antimicrobial resistance through effective infection prevention and control measures, food safety and hygiene • Establish a national infection prevention and control program • Strengthen the Water, Sanitation and Hygiene (WASH) program to promote safe water and hygiene practices • Promote good infection control and biosecurity practices in animal husbandry • Strengthen Good Hygienic Practices (GHP) and Hazard Analysis and Critical Control Point (HACCP) in food handling and processing • Strengthen vaccination program in human and animal sectors Page 12 of 21 5. Optimize the use of antimicrobial medicines in human and animal health • Strengthen regulations to promote the responsible use of antimicrobials • Strengthen national guidelines and programs to control the use of antimicrobials • Strengthen procurement and the supply of antimicrobials Page 13 of21 5.0 RMI National AMR Operational plan (Years: 2019-2023) 1.1 Establish AMR governance structure for fmalizing and implementing the national action 1.1.1 Formalize the establishment of a National and State AMR committee Establish the AMR committee in RMI Identify reporting structure and communication channel for the AMR committee in RMI Develop a clear terms of reference for the AMR committee 1.1.2 Develop a National Action and Operational Plan for AMR -- Develop the draft national action and operational plan for RMI Establish technical working group (TWG) to assist in implementing the AMR ,Ian Mar202Q Mar2020 Mar2020 Mar2020 Mar2020 1.1.3 Develop a budeet for implementation of the action plan and identify fundin2 sources Consultation with key stakeholders for costing the AMR activities outlined in the I Jun 2020 AMRolan Formal submission of costed plan to the cabinet for endorsement I Jul 2020 Conduct consultation meeting with key partners for the identification of funding I Jul 2020 sources 1.1.4 Re2ular monitorine and evaluation of the implementation of the national action plan Hold a quarterly meeting to discuss implementation of the national action plan I Quarterly Annual meeting for M&E of AMR action plan implementation and making amendments to the plan Conduct costing impact assessment on AMR Yearly Dec 2023 MOH MOH I MOH I MOH I MOH National AMR committee National AMR committee National AMR committee National AMR committee National AMR committee National AMR committee AMR committee formalized and endorsed by cabinet AMR committee structure established I ToR develo2ed I National operational plan I endorsed b~ cabinet TWG established Costing completed Costed plan endorsed by cabinet Funding sources identified Meeting minutes disseminated Annual review conducted Assessment completed and report submitted Page 14 of21 SUB-ACTIVITY TIMELINE 1.2 Ensure political commitment on the implementation of the national action plan 1.2.1 Establish a hie:h level commitment between national and state level Develop a AMR memorandum of understanding between key sectors Mar2020 1.3.1 Strene;then lee:islation of AMR in both human and animal sector Review/amend existing legislation(s) and ensure it incorporate- clauses related to I Ongoing AMR in both human and animal health Develop new legislation on AMR , where applicable I Ongoing 1.4 Ensure sustainable investment in combatin2 AMR 1.4.1 Create an enabline: environment for access to effective antimicrobials (e.e;. infrastructure, roads, su Strengthen policy and legislation to support the availability and accessibility of I Ongoing antimicrobials to both human and animal health IMPLEMENTER National AMR committee MOH MRD National AMR committee MOH MRD chainl National AMR committee Dedicated budget for AMR I Ongoing I National AMR committee 1.4.2 Invest in appropriate human resources and infrastructure to ensure sustainable implementation of the national action plan Ensure one dedicated staff for AMR secretariat and identify AMR champions in I June 2020 I National AMR committee each sector Assess all facilities to ensure its adequate to prevent, control and respond to I Dec 2020 National AMR committee AMR Develop human resource and training plan for staff to sustain the implementation I Dec 2020 National AMR committee of AMR plan on the situation of AMR and use of antimicrobials across institutions and sectors 2.1.1 Develop awareness raisine: materials and conduct awareness activities Strengthen the development of IEC materials on AMR for the general public and I Ongoing 1olicy makers Conduct regular AMR advocacy and awareness using all means of I Quarterly communication/ mass media National AMR committee All key stakeholders National AMR committee All key stakeholders INDICATOR MoU signed by different sectors Legislation revised and endorsed New legislation passed and endorsed Policy and legislation updated Submission passed by cabinet AMR secretariat and champions identified and endorsed 100% of facilities assessed Human resource and training IEC materials printed 4 awareness raising communication conducted annually Page 15 of 21 SUB-ACTIVITY Hold annual awareness campaign to celebrate World Antibiotic Awareness Week Conduct regular awareness raising for farmers, importers, exporters, food processors, and animal production officers TIMELINE Annually 6 monthly Engage & train community leaders, NGO's, civil societies, churches, sports I Annually g£oups to raise awllreness on AMR (ex Youth to Youth Convention) 2.1.2 Promote effective sanitation and hand hveiene in the commuoi Participate in the world hand hygiene ~y I Annually Update promotional materials to raise awareness of hand hygiene and effective I On-going sanitation in the community 2.1.3 Develop an educational programme for schools ! all levels) on AMR and rational use with ke: Revise the education curriculum to capture AMR, basic sanitation and hand I Dec 2020 hygiene awareness raising in all schools 2.2 Raise awareness on AMR to health-care workers and veterinarians IMPLEMENTER National AMR committee All key stakeholders National AMR committee All key stakeholders National AMR committee All key stakeholders National AMR committee National AMR committee :es al AMR committee OE 2.2.1 Include AMR as core component of professional education1. training for health-care ,rofessionals and veterinarians Include AMR as core component of professional education in health, agricultural I On-going and fisheries sector Enrolling health-care workers and veterinarians/livestock officers on any AMR online course offered on POLHN or from other institutions Conduct AMR perception survey of health-care workers and veterinarians/livestock officers 3.1.1 Strenethen laboratory staff caoacitv for trainine: on microbiol Strengthen capacity oflaboratory staff in microbiology testing and analysis of antibiogram Continuous participation in external quality assessment on AMR On-going Dec 2020 timicrobial susc Dec 2019 On-going National AMR committee MOH MRD National AMR committee MOH MRD National AMR committee MOH MRD National AMR committee MOH National AMR committee MOH INDICATOR Awareness week campaigns conducted annually 2 awareness raising communication conducted annuall 2 training session conducted Hand hygiene day celebrated IEC materials printed and disseminated Curriculum revised and integrated AMR included in the course modules for health and agriculture Participants completed online course and receive certificates Perception survey completed and report submitted All laboratory staff trained National laboratory fully enrolled on EQA Page 16 of21 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR 3.1.2 Strengthen laboratory capacity and infrastructure for AMR surveillance Identification of a reference laboratory for AMR in human and animal health for Dec 2020 National AMR committee National reference laboratory further genotyping MOH identified Review regularly standard operating procedures for antibiotic susceptibility Annually National AMR committee SOP's updated and endorsed testing and quality management system in all laboratories MOH Implement QMS and EQA programmes in all laboratories that conduct antibiotic On-going National AMR committee EQA & QMS conducted susceptibility testing MOH annually Enrol national laboratory for accreditation Dec 2023 National AMR committee Identified laboratory MOH accredited Develop database for AMR reporting and analysis Dec 2020 National AMR committee AMR Database developed MOH Establish and improve the electronic laboratory information system for AMR Dec 2021 National AMR committee Electronic system fully reporting and surveillance in all laboratories MOH operational in all laboratories Ensure consistent availability oflaboratory consumables and reagents On-going National AMR committee l 00% availability of supplies MOH 3.2 Stremrthen food safety capacity to combat AMR 3.2.l Promote random and regular testing on meat and other food product for AMR pathogens and antibiotic residues Undertake random sample collection and testing for AMR pathogens and Ongoing National AMR committee 2 samples randomly selected antibiotic residues in food and meat MRD and tested per year 3.3 Strengthen research and information sharing on AMR 3.3.1 Promote collaborative research projects on AMR in human and animal health and the environment Include AMR sessions in an annual gatherings or meetings or conference Ongoing National AMR committee AMR part of annual conference agenda/session Conduct antimicrobial consumption survey Dec 2021 National AMR committee AMC survey completed and report submitted Build relationship with other research institutions and collaborating centre for On-going National AMR committee MoU in place AMR 3.3.2 Conduct bacteria susceptibilitv survey/proftle Develop a detail antibiogram for RMI Jun 2020 National AMR committee Antibiogram data for all MOH states available Page 17 of21 SUB-ACTIVITY 3.3.3 Ensure sbarin2 of AMR surveillance and use data Regular sharing of AMR surveillance and antimicrobial consumption to key stakeholders, including re g ional and international Strengthen mechanism for reporting AMR in RMI Establish/stren g then a national infection control committee Develop and review the national infection prevention and control policy Print and disseminate the national infection prevention and control policy to key stakeholders Conduct training on infection prevention and control policy and guidelines targeting patients. health care workers and health administrators 4.1.2 Disposal of expired dru2s and non-rel?:istered drui?s and medical waste Assess medical waste disposal system including disposal of antimicrobials in RMI Develop guidelines on disposal ofunused antibiotics (including veterinary medicines) Assess and strengthen incineration of medical waste in national hospitals 4.2 Implement the Water 1. Sanitation and Hveiene 4.2.1 Develop the WASH pro2ram in communities and schools Conduct consultation to communities and school on WASH program in RMI Develop a WASH program and guidelines for communities and schools in RMI TIMELINE On-going Ongoing Mar2020 Mar 2020 Mar2020 Annually Dec 2020 Dec 2020 Dec 2020 Jun 2020 Jun 2020 IMPLEMENTER National AMR committee MOH National AMR committee MOH National AMR committee National Infection Prevention and Control Committee I National Infection Prevention and Control Committee National Infection Prevention and Control Committee INDICATOR AMR data available for sharin: AMR standard template and mechanism in place IC committees established National IC policy endorsed I 00 copies printed for distribution 2 trainings per year I National Infection Prevention I Assessment report submitted and Control Committee MOH I National Infection Prevention I Guidelines endorsed and Control Committee MOH I National Infection Prevention I Hospital incinerator fully and Control Committee functioning MOH National AMR committee MOH MOE MRD National AMR committee MOH WASH program endorsed by communities and schools WASH program and idelines endorsed Page 18 of21 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR MOE MRD Implement WASH program in communities and schools Aug2020 National AMR committee WASH program MOH implemented MOE MRD Conduct awareness training on WASH program in communitie.s and schools Ongoing National AMR committee 2 trainings per year MOH MOE MRD 4.3 Promote good infection control and biosecurity practices in animal husbandry 4.3.1 Strengthen infection prevention and control in animal husbandrv Develop infection prevention and control policy specific for animal farms and Dec 2020 National AMR committee IPC policy endorsed clinics MRD Conduct training on infection prevention and control policy to farmers and Ongoing National AMR committee 2 trainings per year veterinarians MRD Print and distribute infection prevention and control policy to all key Dec2020 National AMR committee 100 copies printed for stakeholders MRD distribution Promote use of personal protective equipment (PPE) in hospitals & animal health Ongoing National AMR committee 100% availability of PPE MOH supplies MRD 4.4 Implement Good Hv2ienic Practices (GHP) and Hazard Analvsis and Critical Control Point <HACCP) in food handling and processing 4.4.1 Establish GHP and HACCP pro2ram Conduct consultation to communities on GHP and HACCP program Ongoing National AMR committee 1 consultation meeting MOH conducted MRD Develop a GHP and HACCP program and guidelines for RMI Ongoing National AMR committee GHP & HACCP program and MOH guidelines endorsed MRD Implement GHP and HACCP program Ongoing National AMR committee GHP & HACCP program MOH implemented MRD Page 19 of21 SUB-ACTIVITY TIMELINE Conduct awareness training on GHP and HACCP program in communities Ongoing 4.5 Strenl?then vaccination pro1rram in human and animal sectors 4.5.1 Implement vaccination pro2ram in both human and animal sectors Continue conducting awareness on vaccination program Ongoing 5.1.1 Enforce the use of prescription on antimicrobials in the human and animal sector Develop/Review existing medicine legislation to cover the prescribing and use of I Dec 2020 antimicrobials in both human and animal health Conduct awareness on medicine legislation to veterinarians, medical doctors and I Dec 2020 other key health workers in RMI Print and disseminate the updated medicine legislation to key stakeholders Dec 2020 Conduct inspection on pharmacy, medical clinic and animal clinic on the counter I Annually sales of antimicrobials 5.2 Establish and develop national 2uidelines and pro2rams to control the use of antimicrobials 5.2.1 Develop and finalized antibiotic 2uidelines based on countrv antibio2ram for human and animal use Review a national antibiotic guidelines for human use I Ongoing - every 2 years Develop a national antibiotic guideline for animal use I Dec 2020 Develop and updating of essential medicine list for both human and animal use I Ongoing - every 2 years using AWaRe classification Conduct training on antibiotic guideline and rational prescribing to veterinarians, I Annually medical doctors and other key health workers in all states 5.2.2 Support the role of Medicines Therapeutic Committee in hospital Review the ToR of MTC to ensure that it cover AMR I Jun 2020 IMPLEMENTER National AMR committee MOH MRD National AMR committee MOH National AMR committee MOH National AMR committee MOH National AMR committee MOH National AMR committee MOH National AMR committee MOH National AMR committee MRD National AMR committee MOH MRD National AMR committee MOH MRD National AMR committee MOH INDICATOR 2 trainings per year 2 awareness per year Legislation updated and endorsed Awareness conducted Legislation printed and distributed Inspection conducted and report submitted Guidelines published Guidelines published EML updated & published l training per year T oR updated and endorsed Page 20 of21 SUB-ACTIVITY TIMELINE IMPLEMENTER INDICATOR Conduct training workshops for MTCs members on their role on AMR Aug2020 National AMR committee 1 training completed ... MOH Develop the national medicine policy to ensure the rational use of medicines Dec 2020 National AMR committee Medicine policy endorsed including antimicrobials MOH 5.2.3 Strem~then border control for detection of imported antimicrobials Ensure that medicine legislation will cover the declaration of all antimicrobials Dec 2020 National AMR committee Boarder control legislation that enters the country including the ban on the use of antibiotics on animal feed MOH updated and endorsed as growth oromoters Customs 5.2.4 Stren!!then Antimicrobial Stewardship Pro!!ram & Pharmacovigilance Develop and implement basic antimicrobial stewardship (AMS) program in Dec 2020 National AMR committee AMS program developed and hosoital MOH implemented Develop the system on pharmacovigilance of antimicrobials including other Dec 2021 National AMR committee Database and guideline on essential medicines MOH pharmacovigilance system developed 5.3 Stren2then procurement and supply of antimicrobials 5.3.1 Strenothen oreoualification of antimicrobials to ensure quality assured antimicrobials Develop process of market authorization (MA) and registration including Dec 2021 National AMR committee Prequalification policy and prequalification of antimicrobials MOH guideline updated and endorsed Conduct training on product assessment and physical verifications to pharmacy Dec 2021 National AMR committee 2 trainings conducted insoectors, customs, para-vet in RMI MOH Build relationship with other stringent regulatory authority and using any sub Ongoing National AMR committee MoU in place regional platform to access information on quality of antimicrobials MOH 5.3.2 Ensure the availabilitv and accessibility of quality antimicrobials Conduct in depth assessment of the medicine supply system in RMI Jun 2020 National AMR committee Assessment report completed MOH Develop a procurement and supply strategies of antimicrobials in RMI Jun 2020 National AMR committee Procurement plan developed MOH Review the procurement and donation policies of medicines Jun 2020 National AMR committee Procurement and donation MOH policies updated and endorsed Page 21 of21