Multi-sectoral National Action Plan on Antimicrobial Resistance Mongolia, 2022-2025

1. Approve the “Multi-sectoral national action plan on antimicrobial resistance for 2022-2025.

2. Assign the Medicine and Medical Devices Regulatory Agency (D. Narantuya) and General Authority for Veterinary Medicine Services (D.Batchuluun) to ensure implementation of the national action plan and establish multi-sectoral national committee to monitor, discuss implementation results every half year and inform to Government ministries.

3. Assign the State Secretary of Ministry of Health (Ts. Erdembileg) and State Secretary of Ministry of Food, Agriculture and Light Industry (T. Jambaltseren) to monitor implementation of the multi-sectorial national action on AMR.

4. Assign all directors, heads of the health and food, agriculture and light industry organizations to estimate and plan annual budget for implementation of the national plan at organization’s level. MINISTER OF HEALTH MINISTER OF FOOD, AGRICULTURE, LIGHT INDUSTRY S. ENKHBOLD MENDSAIKHAN.Z 2 Contents Abbreviations ............................................................................................................ 4 Background………………………………………………………………………………… 7 Rationale to develop the strategy ................................................................................ 7 Prevalence of antibiotic consumption in Mongolia ....................................................... 9 Prevalence of AMR in Mongolia ................................................................................ 90 Purpose of the strategy ......................................Errore. Il segnalibro non è definito. Strategic objectives ................................................................................................... 10 Expected outcomes ................................................................................................. 111 Budget required for the implementation of the NAP: results of the cost and budget estimation exercise.................................................................................................. 122 Monitoring and evaluation ....................................................................................... 133 References .............................................................................................................. 144 Planned activities of the multi-sectoral national action plan on AMR (2022-2025) ….16 3 Abbreviations AMR Antimicrobial Resistance ATC Anatomic Therapeutic Class AWaRE Access, Watch and Reserve COVID-19 Corona Virus Disease of 2019 DDD Daily Defined Dose DID Daily Defined Dose per 1000 Inhabitants FAO Food and Agriculture Organization GAP Global Action Plan GASI Government Agency for Specialized Inspection GAVS General Authority for Veterinary Services GDHI General Department for Health Insurance GLASS Global Antimicrobial Resistance and Antibiotic Use IVM Institute for Veterinary Medicine MMRA Medicines and Medical Devices Regulatory Agency MNUMS Mongolian National University of Medical Sciences MULS Mongolian University of Life Sciences MoFALI Ministry of Food, Agriculture and Light Industry MoES Ministry of Education and Science MoET Ministry of Environment and Tourism MoF Ministry of Finance MoH Ministry of Health NAP Multi-sectoral national action plan on AMR NCCD National Center for Communicable Diseases NCHD National Center for Health Development NCPH National Center for Public Health NCZD National Center for Zoonotic Diseases NGO Non-government organization SRLFM State Reference Laboratory for Food and Medicine OIE World Organization for Animal Health OTC Over -The- Counter PPI Plant Protection Institute SCVL State Central Veterinary Laboratory SDG Sustainable Development Goals SLVMTC State Laboratory for Veterinary Medicine Testing and Certification UN United Nations WAAW World Antibiotic Awareness Week WHO World Health Organization 4 Background Antimicrobial resistance (AMR) is a major problem that affects our ability to treat infections in all countries and all people. Resistant organisms can easily spread through human and animal migration, food or water, and resistant genes can be transferred from one species to another, without any consideration about one’s wealth or status or any geographical or ecological restrictions. Therefore, countries should coordinate and control AMR across all stakeholders, including governments, international organizations, private entities, investors and individuals. Internationally, substantial guidance and tools for containing and combating AMR are available. In 2015, the Global Action Plan on Antimicrobial Resistance (GAP) was endorsed by the Member States of the World Health Organization (WHO), Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE) in

2015.(1) The GAP included 5 strategic objectives offering a framework for national action plans to combat and contain AMR in the subsequent period of 10 –years.(1) The GAP was then reaffirmed as a blueprint for tackling AMR during the 71st session of the UN General Assembly, where 193 Heads of State adopted resolution A/RES/71/3, which included a high-level political declaration committing countries to support and implement the GAP at national, regional and global levels. Following the GAP, AMR was encompassed within the Sustainable Development Goals (SDGs) as Framework for Action in 2016.(2) The WHO performed a global surveillance of AMR, identifying key challenges in Member States. The identified challenges include a lack of comprehensive strategy to combat AMR in countries, unjustified use of antibiotics, lack of national and regional control mechanism to detect and control AMR, as well as insufficient actions to undertake when AMR is detected.(3) As of today, more than 80% of the antibiotics in the veterinary sector is used for non-medical purpose; instead it is used as breed-mix for animal growth purposes, which in turn increases the risk of food-borne antibiotic resistance in humans. The FAO reports on antibiotics used in the veterinary sector also indicate that the use of antibiotics will increase by almost 40% to 105.6 tonnes by 2030, when compared to 2010.(4) Inappropriate use of antimicrobials may lead to development of antimicrobial resistance. Consequences of AMR include negative outcomes on individual, organizational as well as economic level. Negative outcomes on the individual level may include prolonged treatment effects, development of adverse events and potentially increased mortality. For health organizations, the prevalence of AMR may lead to difficulties to provide treatment for infectious diseases, limited to no choice of treatment alternatives, increased treatment cost. Therefore patients, health care professionals and the countries should work together and responsively to assure the quality and responsible use of antimicrobials at all times. 5 On the other hand, no new antimicrobials were developed in the pipeline for the last 30 years. This means that the choice of available treatment is very limited with increased antimicrobial resistance to current medicines. Non-communicable diseases, including cancer, diabetes, injuries were the main cause for mortality in 2018, whereas the multi-drug resistance or super-bacteria will most likely take this place, the estimates show that up to one million residents will likely to die due to the development of super-bugs.(5) Globally, AMR infections are estimated to cause 700,000 deaths each year. If no action is taken, this figure is predicted to rise to 10 million, alongside a cumulative cost of $100 trillion, by 2050.(6) AMR also threatens many of the SDGs.(6) The World Bank estimates that 28 million people will be forced into extreme poverty additionally in less than 30 years unless AMR is contained.(7) The WHO Assembly on AMR also emphasized the collaborative approach to be undertaken in the midst of the fight against AMR and endorsing a concerted “One Health” approach — which linked various sectors and actors in defence of human, animal and environmental health. They also agreed to mobilize adequate, predictable and sustained resources to implement those programmes and pledged to raise awareness of the phenomenon around the world.(8, 9) The WHO/FAO/OIE tripartite survey of stakeholders involved in the assessment of the NAP indicated that the developing and implementation strategies should be focused on One-health approach and include all stakeholders in the human, animal as well as food sectors. (8, 9) (10) 6 Rationale to develop the strategy The GAP sets out five strategic objectives: (1) to improve awareness and understanding of antimicrobial resistance; (2) to strengthen knowledge through surveillance and research; (3) to reduce the incidence of infection; (4) to optimize the use of antimicrobial agents; and (5) to ensure sustainable investment in countering antimicrobial resistance. These objectives can be attained through the implementation of clearly identified actions by Member States, therefore, it is expected that countries will develop their own national action plans on antimicrobial resistance in line with the global plan. Programs to improve appropriate use of antimicrobials have been implemented in Mongolia since 2013. The Animal Health Law which was adopted by the Parliament in 2017has played an important step towards compliance with international standards and a precondition for increased exports of livestock products. Also, it served as one of the major rudiments towards developing the 1st multi-sectoral national action plan to combat the AMR in Mongolia (12) which was approved jointly by the Health Minister and Minister for Food and Light Industry reinforced in 2017. (13) Mongolian 1st National Action Plan (2017-2020): Re-Cap The 1st Mongolian national action plan to combat AMR (2017-2020) was developed and approved the Government in 2017. The goal of the National Action Plan was to promote rational use of antibiotics and prevention from the emergence and spread of AMR, improve surveillance of AMR and diagnostics, treatment of antimicrobial infections and enhance quality of hospital care. It consisted of six components. ➢ Establish a governance mechanism and ensure multisectoral role to combat antimicrobial resistance, sustainable investment and functioning ➢ Strengthen surveillance and diagnostic capacity for AMR and research ➢ Reduce spread of infections through better infection prevention and control ➢ Ensure quality and safety of antimicrobial medicines ➢ Optimize use of antimicrobials in the human and animal sectors ➢ Raise awareness and understanding of AMR and rational use of the general public, herdsmen and health professionals. The implementation of the 1st multi-sectoral national action plan was assessed in a recent review.(14) The 1st NAP included a total of 69 activities within the six components. Of those activities, almost 60% were successfully implemented (n= 40, 7 58%), one-third were assessed as half-completed (20, 29%), and 9 activities were not achieved (13%). Overall, the implementation status of the NAP was 87%. A number of challenges caused a delay in the implementation the strategy, more specifically activities specified in the veterinary sector were not executed, mostly due to the ongoing COVID- 19 restrictions.(14) The challenges and causes of delayed implementation have been briefly described in this rapid review and reflected to continue their implementation in the next multi-sectoral national action plan on AMR. Prevalence of antibiotic consumption in Mongolia Published studies regarding the antibiotic consumption include the WHO supported surveillance study on antibiotic consumption. The study employed import and manufactured data to provide estimates with WHO standardized methodology. The Daily Defined Dose per 1000 inhabitants (DID) indicated it was the highest in 2015 among the Western Pacific Countries (15, 16), although a later repeat study in 2019 indicated a decrease by 21.3% (DID=37) (15). A 5-year hospital level data on used antibiotics were reported in 2020.(17) The DDD/100 beds was 199-420, much higher than those findings reported from similar settings in other countries. Overall, the consumption of antibiotics is still excessive(18), urging the Government to undertake substantial actions. As of November 2021, there were 4243 medicines registered, of which 11% (n=471) were antibiotics. Most of registered antibiotics were imported (n=440), and approximately 7% were locally manufactured.(19) Analysis of reimbursed medicines from the Health Insurance General Agency indicated the most dispensed medicines belonged to amoxicillin (38.8%). The dispensed cohort involved patients aged 0 to 19 years (20). Although amoxicillin was the most prevalent dispensed medicine, the recent data shows that the proportion of macrolides, fluroquinolones and carbapenems increased, potentially due to global pandemic situation.(20) These are antibiotic classes belong to the ‘Watch’ group that have higher resistance potential and should be prioritized as key targets of stewardship programs and monitoring.(21) In 2021, a national-wide study was executed by the Medicines and Medical Devices Regulatory Authority of Mongolia.(22) The study assessed the knowledge, attitude and practice towards antimicrobial resistance and appropriate use of antimicrobial medicines in the community and health professionals. The study reported that the community members have inconsistent source of information regarding the appropriate use of medicines, depending on their residency. Moreover, the doctors indicated the long waiting time for sensitivity analysis as one of the major challenges when prescribing antibiotics. Among the respondents, only one- third had sufficient knowledge, one in five respondents had appropriate attitude towards antimicrobials and AMR(22). 8 Prevalence of AMR in Mongolia Data regarding antimicrobial resistance are insufficient in Mongolia. Previous reports from two tertiary hospitals in Mongolia demonstrated that only one in five infections, microbiological diagnostics (19%) were done, with antibiotics were given without sensitivity testing in 92% of cases.(23) Increasing rates of MRSA confirmed cases were reported from Mongolian hospitals. Data from 4 major hospitals of Ulaanbaatar showed 3% MRSA in 207 Staphylococcus aureus strains investigated.(24) A 2013 study reported that among 251 Staphylococcus aureus isolates, methicillin resistance was confirmed in 8.8% of isolates (22/251)(25) A 2021 study investigated the rate of gram-negative multi-drug resistant organism in admitted and hospitalized patients in Mongolia. Of 158 eligible patients, baseline colonization rate was found in almost 30% (n=46). After hospitalization, this rate increased up to 70(p<0.01). Enterobacterales were found to be the predominant colonizer and was highly resistant to 3rd generation cephalosporin, particularly cefotaxime.(26) Increased use of cefotaxime was found in two hospitals of Mongolia(11.1–13.1 DDD/100 bed days and 4.2–15.7 DDD/ 100 bed days).(17) This reiterates the high risk of hospital-acquired infection being posed to inpatients and the need for strengthening the infection control in the hospitals.(26) In farm animals, particularly chicken, resistant bacteria to Campylobacter species were detected in Ulaanbaatar area. The study reported that all isolates were resistant to tetracycline, and 3 Campylobacter coli isolates were resistant to erythromycin.(27) Considering high antibiotic use, documentation of prevalent AMR in both human and animal isolates, it is important to control and monitor the consumption of antimicrobials and AMR in Mongolia. In particular, evidence-based data regarding the AMR need to be generated at the national level. Moreover, the data must be analysed and distributed to relevant authorities to inform the practice, as well as the policymakers. Existing efforts and future actions must are directed to strengthen surveillance system for resistant pathogens, prevent the spread of infection and share and exchange findings with international organizations and other countries. Amongst others, the key activities to prioritize are stop the over-the-counter (OTC) availability of antimicrobials from community pharmacies, strengthening control of reimbursed antimicrobials via electronic prescription and dispensing system (triage linkage between the prescriber, dispenser, health insurance claims, and the patient), intensified actions towards improving the knowledge and attitude on AMR among public, especially among herders and those residing in remote areas. 9 Purpose of the strategy The Multi-sectoral national action plan on antimicrobial resistance aims to prevent and tackle antimicrobial resistance through improving surveillance in human and animal health sectors, controlling the consumption, strengthening infection prevention control, and increasing knowledge and attitude of public, human and animal health professionals to optimize use of antimicrobials. Strategic objectives

1. Strengthen the governance mechanism to prevent from AMR, establish a multi- sectoral coordination committee which will develop and monitor annual action plan and its implementation.

2. Improve the detection and surveillance of antimicrobial resistance, strengthen capacity to collate, analyze and inform data on antimicrobial resistance at national level.

3. Strengthen responsible use of antimicrobials by controlling antimicrobial consumption, reducing irrational use of antimicrobials, and implementing effective stewardship programs.

4. Improve infection prevention and control, undertake preventive measures from environmental contamination, stop the spread of infection.

5. Raise awareness of antimicrobials among community, professionals, incorporate the training modules in high school curricula, improve knowledge and practice to prevent and reduce antimicrobial resistance. 10 Expected outcomes Strategic Current baseline Expected outcomes objectve Governance No fully functioning Established multi-sectoral committee, committee organized committee meeting at least twice a year Surveillance, No baseline study Generated, analyzed national data linked prevention with GLASS. Consumption of DID 37 according to DID decreased by 10% (DID 27) antimicrobials imported and manufactured data, started estimation using Completed estimation using health health insurance data insurance data based on the WHO ATC/DDD methodology with report by AWARE classification. No baseline data Available baseline data in veterinary sector available in the veterinary sector Infection No baseline data Information available on hospital-acquired prevention control infection and surveillance Information, Advocacy and trainings At least 5 main activities organized every education, for WAAW year for the celebration of WAAW advocacy AMR integrated into the postgraduate training Integrated AMR modules to secondary and curriculum high school curricula, and in agriculture sector’s training programs. 11 Budget required for the implementation of the NAP: results of the cost and budget estimation exercise The required budget to implement detailed activities was estimated using the WHO- NAP- budgeting tool. The estimates include inflation rates for the year 2023, 2024 and 2025, respectively(28). At the time of writing the report, 3000.2 MNT was equal to 1 USD. The local UN tariffs applicable for individual organizations and activities were used to calculate the estimates, unless otherwise specified. The required 4-year budget for the implementation of the NAP was estimated to be 13,914,468,019.12 MNT. Most (70%) of the budget will be spent for the activities classified in the ‘infection prevention control’ strategic area for both human and veterinary sectors. Activities planned under this strategic objective included procurement of equipment and tools required for sanitation and disinfection, as well as consumables, infrastructure repairs, maintenance required for infection control and monitoring. Activities relating to governance and coordination require more than 12% of the planned budget in 2022, whereas the estimated budget decreases by one-third in the following years of the NAP implementation. Approximately 15% of the planned budget is directed to implement activities in the area of strengthening surveillance, generating evidence-based knowledge. Surveillance/Evidence/Knowledge 13,5 15,7 16,7 14,0 Prevention of Infection 70,9 72,2 73,3 77,2 Optimized Use 0,2 0,2 0,2 0,2 Governance/Coordination 12,2 4,7 3,5 4,0 Awareness/Education/Training 3,2 7,1 6,4 4,7 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % of annual cost 2022 % of annual cost 2023 % of annual cost 2024 % of annual cost 2025 Figure 1 Proportion of allocated budget by strategic objective, by year A small proportion of the funding is indicated as available or partially funded (0.65%, 90,179,787.46 MNT), mostly through the government and international donor organizations. 12 Table 1 Required budget overview and availability by strategic objective and year (in million tugriks) Strategic Awareness/ Governance/ Optimized IPC Surveillance/ objectives Education/ Coordination Use Evidence/ Training Knowledge Funding Yes No Yes No No No Yes No availability Required budget 0 92.74 12.5 338.24 6.38 2040.68 5.5 382.77 in 2022 Required budget 1.34 233.33 14.37 142.64 6.2 2390.16 9.65 511.34 in 2023 Required budget 1.42 231.45 14.63 112.06 5.88 2679.8 10.21 602.26 in 2024 Required budget 0 189.57 15.69 147.5 6.3 3139.76 4.87 565.25 in 2025 Monitoring and evaluation The interim and final monitoring and evaluations will be performed jointly by the Ministry of health, ministry of food, agriculture and light industry involving relevant agencies and stakeholders. 13 References

1. World Health Organization. Global action plan on antimicrobial resistance. 2015.

2. Assembly UG. Political declaration of the high-level meeting of the general assembly on antimicrobial resistance. New York, NY: United Nations. 2016.

3. World Health Organization. Global surveillance of antibacterial resistance in humans: second WHO technical consultation. World Health Organization; 2014.

4. Food and Agriculture Organization. The FAO Action Plan on Antimicrobial Resistance 2021–2025. FAO Rome, Italty; 2021.

5. Murray CJ, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022.

6. O’Neill J. Antimicrobial resistance: tackling a crisis for the health and wealth of nations. The review on antimicrobial resistance. Review on Antimicrobial Resistance, London, United Kingdom. London, United Kingdom, https://amr-review. org/sites/default/files/AMR …; 2014.

7. World Bank. Drug-resistant infections: a threat to our economic future: World Bank; 2017.

8. World Health Organization. Antimicrobial resistance: a manual for developing national action plans. 2016.

9. World Health Organization. Country progress in the implementation of the Global Action Plan on Antimicrobial Resistance: WHO, FAO and OIE global tripartite database. 2018.

10. World Health Organization. Strategic framework for collaboration on antimicrobial resistance: together for One health: Food & Agriculture Org.; 2022.

11. Монгол улс. Антибиотикийн зохистой хэрэглээг төлөвшүүлэх, эмэнд нянгийн тэсвэржилт үүсэхээс сэргийлэх стратеги /2013-2017/. 2013.

12. Монгол улс. Мал, амьтны эрүүл мэндийн тухай. 2018.

13. Монгол улс. Нянгийн тэсвэржилтээс сэргийлэх үйл ажиллагааны салбар дундын төлөвлөгөө /2017-2020/. 2017.

14. Ministry of Health. Rapid assessment of the implementation of National Action Plan to Combat Antimicrobial Resistance in Mongolia /2017-2020/. 2022.

15. Монгол улс, Эрүүл мэндийн яам. Антибиотик эмийн тандалт судалгаа 2019.

16. Dorj G, Dembereldorj B, Choijoo A, Enkhee E, Sanjjav T, Blix HS. National surveillance of antibiotic consumption in Mongolia. International Journal of Infectious Diseases. 2020;101:96.

17. Dorj G, Salvesen Blix H, Sunderland B, Gankhulug B, Tegshee O, Purevkhuu M, et al. Antibiotic utilization trends in two state hospitals of Mongolia from 2013 to 2017. BioMed Research International. 2019;2019.

18. World Health Organization. Antimicrobial consumption in the WHO Western Pacific Region: early implementation of the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS). 2021.

19. Монгол улс, Эм эмнэлгийн хэрэгслэлийн зохицуулалт хяналтын газар. Монгол улсын эм зүйн салбарын үзүүлэлт. 2021.

20. Монгол улс, Эрүүл мэндийн даатгалын сан. Эрүүл мэндийн даатгалын сангаас хөнгөлттэй үнээр олгогдох эм. 2020.

21. World Health Organization. 2021 AWaRe classification. 2021.

22. Монгол улс, Эм эмнэлгийн хэрэгслэлийн зохицуулалт хяналтын газар. Иргэдийн эмийн зохистой хэрэглээний талаарх мэдлэг, чадвар, хандлагын судалгаа. 2021.

23. Ider B-E, Clements A, Adams J, Whitby M, Muugolog T. Prevalence of hospital-acquired infections and antibiotic use in two tertiary Mongolian hospitals. Journal of Hospital Infection. 2010;75(3):214-9.

24. Orth D, Grif K, Erdenechimeg L, Battogtokh C, Hosbayar T, Strommenger B, et al. Characterization of methicillin-resistant Staphylococcus aureus from Ulaanbaatar, Mongolia. European Journal of Clinical Microbiology and Infectious Diseases. 2006;25(2):104-7.

25. Nair R, Hanson BM, Kondratowicz K, Dorjpurev A, Davaadash B, Enkhtuya B, et al. Antimicrobial resistance and molecular epidemiology of Staphylococcus aureus from Ulaanbaatar, Mongolia. PeerJ. 2013;1:e176. 14

26. Baljin B, Gurjav U, Tulgaa K, Baldan G, Gunchin B, Sandag T, et al. High Acquisition Rate of Gram-Negative Multi-Drug Resistant Organism Colonization During Hospitalization: A Perspective from a High Endemic Setting. Infection and Drug Resistance. 2021;14:3919.

27. Byambajav Z, Bulgan E, Hirai Y, Nakayama M, Tanaka M, Nitta Y, et al. Research Note: Antimicrobial resistance of Campylobacter species isolated from chickens near Ulaanbaatar city, Mongolia. Poultry Science. 2021;100(3):100916.

28. World Bank. Inflation, consumer prices (annual %). 2022. 15 Planned activities of the multi-sectoral national action plan on AMR (2022-2025) Year No Collaborating Implementing Activity Indicator Outcome organizations 2022 2023 2024 2025 agency Strategic objective 1: Strengthen the governance mechanism to prevent from AMR, establish a multi-sectoral coordination committee which will develop and monitor annual action plan and its implementation 1.1 Establish a multi-sectoral The decision of the Biannual meetings shall be MoH, MoFALI, coordination committee to meeting held at 7 least times, MMRA, GAVS WHO, FAO, MoE, ensure implementation, and + + + + actions discussed. MoET, Codex- monitoring of the NAP national committee 1.2 Present and discuss results of The number of Results on AMR and MMRA, GAVS Human drug activities against AMR, use resolutions antimicrobial use will be council, Veterinary and consumption of achieved in presented at least 4 times drug council antimicrobial drugs in in + + + + meetings. human and agriculture sector, provide recommendations and make decisions 1.3 Include budget required to The required Required budget to All MoH, MoFALI implement AMR activities in budget included in implement the activities will implementing organizations annual financial + + + + the financial plan. be included in the annual organizations plan budget of the organizations 1.4 Conduct external evaluation Number of external Mid and final evaluations Multi-sectoral MoH, MoFALI, on NAP implementation evaluations will be completed, committee MMRA, GAVS, - + - + recommendations and WHO, UN, FAO conclusions will be made. 1.5 Organise national conferences Number of National conferences will be Multi-sectoral MoH, MoFALI, on prevention and control of organized attended by at least 250 committee MMRA, GAVS, AMR - + + + conferences, and participants WHO, UN, FAO, seminars /OIE/ 16 1.6 Include AMR related indicators Indicators included Guidelines on antimicrobials MOH, NCHD, Health in the accreditation and in the assessment will be developed, GAVS, organizations, performance evaluation - + + + laboratories will be linked to MoFALI MASM indicators in human and the WHONET. veterinary organizations 1.7 Join international networks, Number of At least 5 times to attend MoH, MoFALI, WHO, movements combatting AMR conferences and international conferences MMRA, GAVS, UN, FAO, OIE to learn and exchange meetings attended on AMR. NCCD information + + + + 1.8 Translate codex standard on 2 codex guidelines, 1 MoFALI, UN, MASM, GAVS food –borne AMR, discuss it at regulation of practice will be FAO MASM, technical committee - + - + translated and approved. and public to get approval 1.9 Revise and update regulation Number of Health Minister’s Order will MMRA Health for Drug Therapeutic approved be approved. organizations Committee in relation to AMR + + - - regulations 1.10 Conduct an assessment on Report of the Recommendations based Multi-sectoral MoH, MoFALI, AMR legal framework in the assessment and on the assessment will be committee GAVS, MoET, agriculture sector - + - recommendation provided. GASI, International organizations Strategic objective 2: Improve the detection and surveillance of antimicrobial resistance, strengthen capacity to collate, analyze and inform data on AMR at national level 2.1 Develop and revise regulations Number of 2 NCCD, GAVS MoH, MoFALI, with focus on detection, approved MMRA, surveillance of AMR and - + + - regulations International identify roles and functions of organizations authorities and organizations, information and reporting 2.2 Conduct lab based Number of studies Recommendationand NCCD, GAVS MNUMS, IVM, surveillance study on AMR in conclusion based on study Human and human and veterinary sectors + + + + results will be reported. veterinary health departments in aimag and city, International organizations 17 2.3 Develop and revise guidelines, Number of newly Guidelines, SOPs will be NCCD, GAVS MNUMS, IVM, SOPs in conducting and implemented approved SCVL, SLVMTC analysing sensitivity tests to - + - - analysis methods detect AMR 2.4 Investigate the possibility to Report of the study, Recommendations on MoH, NCHD, link hospital e-system /HIS, recommendation linking the programs to hospitals LIS/ with WHONET and + + - - WHONET will be provided exchange information 2.5 Conduct a situational analysis + - - - Report of the Assessment on capacity to GAVS, SCVL, MoFALI, UN, FAO on capacity of AMR assessment detect AMR and conduct IVM, SLVMTC, surveillance in food and surveillance will be SRLFM, agriculture laboratories using completed NCCD UN, FAO proposed methods ‘ATLASS’ 2.6 Conduct trainings for human Number of Laboratory staff will be MoH MMRA, NCCD, and veterinary laboratories on trainings, report of trained NCZD, IVM, NCPH, linkage and data exchange - + + - the consultant human and with global surveillance veterinary systems (GLASS, WHONET), laboratories invite international consultants 2.7 Build national capacity to - + + + Number of At least once per year NCCD, GAVS MoH, MoFALI, collect, collate, analyse and professionals trainings will be organized MMRA report AMR data involved in the and knowledge of the training professionals will be improved 2.8 Expand linkage of national Number of health Central hospital, specialized NCCD Aimag and district laboratory system with organizations centres, aimag and district hospitals, WHO WHONET, by enabling aimag, + + + + linked to the hospitals will be linked to district laboratories in a system WHONET. stepwise manner 2.9 Develop report on resistance Nature and At least 6 reports will be NCCD Health and inform to health care prevalence of distributed to health organizations organizations twice a year + + + + resistant microbes organizations 2.10 Undertake external quality Number of External evaluation will be NCCD, MoH, MoFALI, evaluation for microbiology externally completed NCZD, GAVS WHO, OIE laboratories in human and + + + + evaluated veterinary sectors laboratories 18 2.11 Strengthen capacity of the Number of trained At least 50% of laboratory GAVS MoH, MoFALI, laboratory staff in quality staff staff will be trained and their Codex- national assurance, management and - + + - skills improved. committee standard methods to detect AMR and conduct sensitivity analysis 2.12 Conduct surveillance studies Number of Report of surveillance, MoFALI PPI, GASI to detect resistance rates of surveillance tests recommendations common pathogens causing + - + - distributed to relevant disease in plants authorities Strategic objective 3: Strengthen responsible use of antimicrobials by controlling antimicrobial consumption, reducing irrational use of antimicrobials, and implementing effective stewardship programs 3.1 Estimate consumption of Number and Reports will be distributed GAVS MoH, MoFALI antimicrobials used in classification of to national and international veterinary by OIE method and + + + + antimicrobials used organizations develop reports in the veterinary sector 3.2 Estimate consumption of Results on Consumption of MMRA MoH, WHO, antimicrobials used in the imported and antimicrobials will be research human sector annually, + + + + locally produced estimated at the national organisations distribute the results to health antimicrobials level, compared with the care organizations and Region stakeholders, partners 3.3 Conduct surveillance studies Surveillance Conclusion and NCCD MMRA, Health on healthcare-associated reports recommendations based on organizations resistant bacteria in hospitals - + + + study results will be distributed to relevant authorities 3.4 Develop and get approval on Regulation -1, List Regulation and list of drugs GAVS Veterinary drug list of prescription medicines of drugs-1 will approved, shared with council and regulation on prescription + - - - public community in the veterinary sector 3.5 Develop a mapping tool for Mapping, database Annual data on GAVS SLVMTC, GASI, vetenary medicines on antimicrobials and turnover Veterinary drug dispensing, use, disposal, - + + + will be produced. wholesalers, monitoring and information Veterinary and set-up database pharmacy 19 3.6 Conduct assessment on use of Number of Recommendations and MMRA Health antibiograms in hospitals to assessed conclusions based on organizations prescribe and select antibiotics + - + - organizations assessment will be in patient treatment distributed to relevant authorities. 3.7 Require GMP for all local Number of local Local manufacturers MMRA Drug antimicrobial manufacturing, producers certified producing antimicrobials will manufacturers, support to conduct continuous - + + + with GMP be certified with GMP. NGOs, associations trainings 3.8 Include a requirement for Indication of the Order will be approve MMRA Drug wholesalers bioequivalence test on multi- regulation/ clause sourced generic antimicrobials + + + + order to be registered in the country 3.9 Conduct surveillance studies Number of Conclusion and MMRA Health on hospital-level consumption surveillance studies recommendations based on organizations of antimicrobial drugs - + + + study results will be developed and distributed to relevant authorities 3.10 Implement antimicrobial Number of health Central hospital and MMRA Central hospitals, stewardship programs in organizations specialized centers will specialized health organizations, invite + + + + implement the AMS. hospitals international consultant to conduct the trainings and share expertise 3.11 Take multi-sectoral joint + + + + Number of controls All community pharmacies MMRA, GAVS, GASI measures to stop OTC and inspections о will sell antibiotics only per Drug availability of antimicrobials in prescription. association community pharmacies 3.12 Conduct surveillance of + + + + Surveillance report Conclusion and GAVS Research antimicrobial residues in meat recommendations based on organizations, and milk study results will be laboratories in developed and distributed aimag and city, to relevant authorities SCVL Strategic objective 4: Optimize infection prevention and control, undertake preventive measures from environmental contamination, stop the spread of infection 4.1 Organize capacity building Number of trained Trainings will be organized MoH, NCCD Universities, trainings on AMR and IPC for health care staff and knowledge and MNUMS health care workers + + + + expertise of doctors will be improved 20 4.2 Organise capacity building + + + + Number of trained MMRA, GAVS, MoH, MNUMS, trainings on AMR and IPC for inspectors GASI, GDHI MoFALI, medicine and medical care International inspectors organizations 4.3. Develop a guideline on the Number of Manual will be developed MoFALI MoH appropriate use of international and distributed to veterinary antimicrobials based on + + - - resources organizations international standards and guidelines /One health/ 4.4 Develop training and Number of Information materials will be MoH, NCCD International awareness raising materials developed distributed to health organizations on IPC for health care workers + + - - materials organizations 4.5 Organize evaluation and + + + + Number of Recommendations based MoH, NCCD Aimag, city health supportive supervisions on organizations on assessment results will departments AMR and IPC in health care enrolled in be distributed to relevant organizations assessment and authorities monitoring 4.6 Increase supply of sanitation Number of devices Sanitation and disinfection Health - and hygiene equipment and used sanitation and of soft goods will be organizations devices for soft goods in + + + + disinfection improved hospitals 4.7 Increase stock on linen and Stock of patient Patients will be provided Health - other goods for hospitalized gowns, bed, soft required sheets, gowns organizations patients + + + + goods from internal stock 4.8 Conduct surveillance study on - + - + Surveillance report Recommendations based NCCD MNUMS, health hospital -acquired infections on assessment results will departments and pathogens be distributed to relevant authorities Strategic objective 5: Raise awareness of antimicrobials among community, professionals, incorporate the training modules in high school curricula, improve knowledge and practice to prevent and reduce antimicrobial resistance 5.1 Conduct a KAP survey on Number of planned Planned activities will be MMRA, GAVS MoH, MoFALI, rational use of antimicrobials activities implemented . MoE, NCPH, and AMR among public + + + + research 21 annually to develop and organizations, implement awareness raising Public relations and advocacy plan organizations 5.2 Disseminate information thru + + + + Number of results Community members MMRA, GAVS MoH, MoFALI, media regarding AMR in knowledge will be improved NGOs human health and agriculture sectors according to the developed plan 5.3 Develop public communication - + - - Communication Communication strategy will International MoH, MoFALI strategy on AMR and use of strategy document be distributed to relevant organizations, antimicrobials will be developed authorities. GAVS, MMRA and approved 5.4 Organise World Antimicrobial Number of Activities and trainings will MMRA, GAVS MoH, MoFALI Awareness Week every year activities, trainings be completed in accordance + + + + with the working plan 5.5 Organise AMR campaigns Program will Activities and trainings will MMRA, GAVS, International during other world health days include topics on be completed in accordance NCPH organizations with emphasis of relevant + + + + AMR with the working plan issues 5.6 Organise one-month campaign Number of health Plans and agenda will be MMRA Health at hospitals on rational use of organisations developed and distributed organizations antimicrobials every year + + + + implementing the to health organizations. campaign 5.7 Capacity building on - + + - Number of Knowledge of healthcare MMRA, GAVS GDHI, Higher estimation of AMR economic healthcare staff staff will be improved, education burden enabling them to estimate providers, selected the economic burden hospitals caused by AMR 5.8 Conduct assessment on KAP - + + - Number of Recommendations based MMRA, GAVS Health on AMR among health and assessments on assessment results will organizations veterinary sector workers be distributed to relevant authorities 5.9 Develop training program for + + - - Number of Trainings will be conducted MoFALI, Education providers herders and agriculture organized trainings in accordance to the GAVS, MULS workers on good practices working plan related to appropriate use of antimicrobials to improve their knowledge and practice 22 5.10 Include modules on AMR and Number of Module will be integrated in MULS, MoES GAVS, Higher rationale use of antimicrobials veterinary doctors the training program, education in postgraduate training - + + - receiving the credit knowledge of veterinarians providers, NGOs programs for veterinary hours will be improved professionals 5.11 Include AMR surveillance, - + + - Number of credit Module will be integrated in NCCD MMRA laboratory detection methods hours included in the training program, in the laboratory programme of the program knowledge of students will the field epidemiology training be improved curriculum 5.12 Organise trainings with credit Number of family Knowledge of family group MMRA, NCPH, Higher hours on rational use, group practitioners practitioners will be NCHD, AFGP education providers prescription policy and + + + + receiving credit improved consequences of AMR for hours PHC (soum and family health) practitioners 5.13 Develop a proposal to include Number of activities Recommendations will be MMRA, GAVS MoES rational use of antimicrobials, to be included in developed and submitted to AMR consequences in the - + + - the program the MoES secondary school health programme and discuss 5.14 Organize national and Number of trainings Trainings will be conducted GAVS Education providers subnational trainings on AMR in accordance to the and rational use of - + + + working plan antimicrobials with credits 23