National Action Plan on Antimicrobial Resistance (2024-2028)

2.1 AMR in humans and animals 3

2.2 Awareness and understanding of AMR 5

2.3 Surveillance of AMR 6

2.4 Infection prevention and control 7

2.5 Optimum use of antimicrobials 8

2.6 Investment, research, and innovation 9 3. Country Response 11

3.1 Developing the National Action Plan on AMR 11

3.2 Governance Mechanism 11 4. National Action Plan on Antimicrobial Resistance 15

4.1 Vision 15

4.2 Goal 15

4.3 Mission 15

4.4 Objectives 15

4.5 Strategic priorities 15 5. Interventions, Activities, and Key Outputs 17

5.1 Strategic Priority 1 17

5.2 Strategic Priority 2 22

5.3 Strategic Priority 3 30

5.4 Strategic Priority 4 38

5.5 Strategic Priority 5 49 6. Cost Estimate and Management of Financial Resources 52 7. Provisions Related to Monitoring and Evaluation 53 8. Provisions Related to Reporting 53 9. Risks 54 10. Modification in Annex 54 11. Powers to explain 55 12. Provisions of Automatic Void 55 13. Annexes 56 Annex 1: Terms of Reference of The Steering Committee 56 Annex 2: Terms of Reference of Technical Working Committee 56 Annex 3: Monitoring and Evaluation Framework 57 List of 2. Abbreviations Situation Analysis and Acronyms ADICD Animal Disease Investigation and Control Division AH/s Animal Hospital/s AHRC Animal Health Research Center AITC Agriculture Information and Training Center AMC Antimicrobial Consumption AMS Antimicrobial Stewardship AMU Antimicrobial Use AMR Antimicrobial Resistance AMSP Antimicrobial Stewardship Programme APUA Alliance for the Prudent Use of Antibiotics AST Antimicrobial Susceptibility Testing AWaRe Access, Watch, Reserve Class of Antimicrobials CDC Curriculum Development Center CFPCC Central Fisheries Promotion and Conservation Center CRVH Central Referral Veterinary Hospital CSD Curative Service Division CTEVT Council for Technical Education and Vocational Training CVL Central Veterinary Laboratory DAH Directorate of Animal Health DDA Department of Drug Administration DFTQC Department of Food Technology and Quality Control DoAA Department of Ayurveda and Alternative Medicine DoC Department of Custom DoE Department of Education DoEnv Department of Environment DoHS Department of Health Services DoI Department of Industry DLS Department of Livestock Services DTC Drug and Therapeutic Committee EDCD Epidemiology and Disease Control Division I EDP External Development Partners EML Essential Medicine List EQAS External Quality Assurance System ESBL Extended-Spectrum Beta-Lactamase FAO Food and Agriculture Organization FGD Focus Group Discussion FSMS Food Safety Management System FWD Family Welfare Division GAP Global Action Plan GARP Global Antibiotic Resistance Partnership GHP Good Husbandry Practice GLASS Global Antimicrobial Resistance Surveillance System GMP Good Management Practice GVP Good Veterinary Practice HCAI/s Healthcare-Associated Infections HEPA High-Efficiency Particulate Air HIV Human Immunodeficiency Virus IACG Interagency Coordination Group IEC Information Education and Communication IEE Initial Environment Examination I/NGOs International Non-Governmental Organisations IoM Institute of Medicine IPC Infection Prevention and Control MDR Multidrug Resistant MoALD Ministry of Agriculture and Livestock Development MoCIT Ministry of Communication and Information Technology MoEST Ministry of Education, Science and Technology MoF Ministry of Finance MoFAGA Ministry of Federal Affairs and General Administration MoFE Ministry of Forest and Environment II MoHP Ministry of Health and Population MoSD Ministry of Social Development MRLs Maximum Residual Limits MS Medical Superintendent MSS Minimum Service Standard M&E Monitoring and Evaluation NAFLQML National Animal Feed and Livestock Quality Management Laboratory NAP National Action Plan NARTC National Ayurvedic Research and Training Center NCASC National Centre for AIDS And STD Control NCC National Coordinating Center NGO/s Non-Government Organisation/s NHEICC National Health Education Information and Communication Center NHRC National Health Research Council NHPC Nepal Health Professional Council NHTC National Health Training Center NLRMPO Nepal Livestock Resource Management and Promotion Office NPC National Planning Commission NPhC Nepal Pharmacy Council NPHL National Public Health Laboratory NRA National Regulatory Authority NSSD Nursing and Social Security Division NTC National Tuberculosis Control Center NTWC National Technical Working Committee NVC Nepal Veterinary Council NVPL National Vaccine Production Laboratory OIE World Organization for Animal Health OPMCM Office of the Prime Minister and Council of Minister III QSRD Quality Standards and Regulation Division SOP Standard Operating Procedure STG Standard Treatment Guideline STI Sexually Transmitted Infection STP Standard Treatment Protocol TWC Technical Working Committee UNEP United Nations Environment Programme VPDs Vaccine-Preventable Disease/s VSDRL Veterinary Standards and Drug Regulatory Laboratory WHO World Health Organization IV Executive 2. SituationSummary Analysis Antimicrobial resistance (AMR) is one of the major public health issues globally. World Health Organization has listed it as one of the top ten global public health threats facing humanity. Addressing this issue promptly is crucial to preserving the achievements made in the health and medicine sector thus far. Antimicrobial resistance is attributed to approximately 1.3 million deaths worldwide annually, with a projected global economic loss of 1 to 3 trillion US Dollars by 2030. It is estimated that by 2030, AMR could force up to 28 million people into extreme poverty. In May 2015, the 68th World Health Assembly endorsed the Global Action Plan (GAP) on Antimicrobial Resistance (GAP-AMR) to tackle AMR and urged the member states to develop their own National Action Plan on AMR in alignment with GAP-AMR by May 2017. Nepal also expressed its commitment to develop a National Action Plan to combat AMR at the United Nations General Assembly on 21 September 2016. Various policy documents, including the National Health Policy, 2076 (2019), the Fifteenth Five-Year Plan, and the National Animal Health Policy, 2078, issued by the Government of Nepal have prioritized AMR as an important public health issue and have highlighted the need to address without delay. To contain AMR, this multisectoral NAP has been developed in coordination and collaboration with the relevant sectors and stakeholders. The five strategic priorities identified for the NAP-AMR are as follows: 1. Improve awareness and understanding of AMR through effective communication, education, and training, 2. Strengthen the knowledge and evidence related to AMR through surveillance and research, 3. Reduce the incidence of infection through effective infection prevention and control, V 4. Optimize the use of antimicrobial agents in the human, animal, and food sectors, 5. Ensure sustainable resources for the containment of AMR along with promoting investment in research and innovation. Each strategic priority has its own set of objectives, and various strategic interventions under these objectives and various activities based on such strategic interventions have been proposed. Within each strategic priority and focus area, strategic interventions including the key activities and key outputs for those interventions have been provided along with timelines for completion - short (within 1 year), medium (between 1 and 3 years), and long-term (between 3 and 5 years). Various committees have been proposed for the implementation of this action plan. Provisions have been made for coordination and collaboration with all three tiers of government. It is expected that resources will be managed with the support of all three tiers of government, development partners and nongovernmental organizations. The NAP-AMR also includes the monitoring and evaluation (M&E) plan to assess the quality of the activities being implemented and track the progress. The primary objective of the NAP-AMR is to ensure the rational use of antimicrobials and contain AMR. This plan is expected to improve awareness and understanding regarding AMR in Nepal, reduce inappropriate antimicrobial consumption and optimize antimicrobial use. It is expected that the NAP-AMR will improve IPC in Nepal and eventually contribute substantially to AMR containment in the country. The development of a comprehensive and integrated approach at the national, provincial, and local levels has been ensured to address AMR. At the same time, all sectors of “One Health” and stakeholders including all professional organizations, academia, civil societies, media, and consumer groups will be engaged in the successful implementation of this National Action Plan. This NAP is expected to bring greater coordination and cooperation among “One Health” stakeholders to contain AMR, which will aid in the management of patients, reduce morbidity and mortality, and achieve SDGs and Universal Health Coverage. VI 1. Background Antimicrobial resistance has emerged as a major public health issue worldwide. With the emergence of resistance in bacteria, fungi, parasites, and viruses that cause human illnesses, medical treatment of infections faces a heightened challenge. Antimicrobial resistance is attributed to approximately 1.3 million deaths worldwide annually, with a global economic loss of 1 to 3 trillion US Dollars by 2030, according to a World Bank projection. It is estimated that by 2030, AMR could force up to 28 million people into extreme poverty. In addition, in low-income countries, the cost of medical treatment resulting from AMR is projected to increase by 25 percent, which, in turn, jeopardizes the achievements of the SDGs 2030. Recognizing the threat early on, health ministers from the South-East Asia Region, including Nepal, signed the Jaipur Declaration on Antimicrobial Resistance in 2011 (WHO SEARO, 2011). In May 2015, the 68th World Health Assembly endorsed the Global Action Plan (GAP) on Antimicrobial Resistance (GAP-AMR) based on a “One Health” approach to tackle AMR. The GAP emphasizes the importance of multi-sectoral involvement in addressing the problem of AMR. In 2016, the global commitment to combat AMR was further strengthened by the high-level meeting on AMR at the United Nations General Assembly, in which global leaders reiterated their commitment to act on AMR through a political declaration that was adopted as a UN General Assembly resolution (UN, 2016). At the global level, the United Nations Secretary-General has established the Interagency Coordination Group (IACG) to improve coordination among international organizations and to ensure effective global action against this threat to health security. The IACG is co- chaired by the UN Deputy Secretary-General and the Director-General of WHO and includes high-level representatives of relevant UN agencies, other international organizations, and individual experts across different sectors. National Action Plan on Antimicrobial Resistance 1 In Nepal, the Public Health Service Act, 2075 (2018) prohibits the sale or distribution of antibiotics without a medical prescription and requires maintaining quality standards of consumables, including food and meat. The National Health Policy, 2076 (2019) highlights the need to develop a national action plan to reduce AMR and effectively regulate and control the misuse of antibiotics. It is notable that the Nepal Health Sector Strategy 2015–2020 also identifies AMR as a public health challenge and implementation of One Health approach to address AMR. Likewise, this National Action Plan builds on the “One Health Strategy, 2076” (2019) endorsed by the Council of Ministers. The National Action Plan on Antimicrobial Resistance with the following strategic priorities has been developed to address the AMR problems nationally: 1. Improve awareness and understanding of AMR through effective communication, education, and training, 2. Strengthen the knowledge and evidence related to AMR through surveillance and research, 3. Reduce the incidence of infection through effective infection prevention and control, 4. Optimize the use of antimicrobial agents in the human, animal, and food sectors, 5. Ensure sustainable resources for the containment of AMR along with promoting investment in research and innovation. 2 National Action Plan on Antimicrobial Resistance 2. Situation Analysis

2.1 AMR in humans and animals Nepal has a high prevalence of infectious and communicable diseases that contribute to higher morbidity and mortality. Nepal is one of the 30 countries with a high prevalence of AMR in the world. According to the report on Nepal Burden of Disease, 2019, the most common infectious diseases include respiratory infections, tuberculosis, and typhoid infections, among others. Increasing antimicrobial resistance makes the treatment of infections more challenging. In Nepal, the livestock sector alone contributes to around 13% of the national gross domestic product and over a quarter (27%) of the agricultural gross domestic product. With increasing demand for livestock products, livestock farming is growing at an annual rate of around 1.23%. Factors such as the use of antibiotics as growth promoters in animals and agriculture, poor husbandry practices, lack of awareness of good management practices (GMP), and irrational use of antibiotics have contributed to AMR development in the livestock sector.

2.1.1 Human health sector Many studies on antibiotic prescribing patterns in Nepal have shown that most patients were unnecessarily prescribed more than one antibiotic concurrently without bacterial confirmation or susceptibility testing. Antimicrobials are commonly prescribed for conditions that do not require antibiotics, such as colds, coughs, and diarrhoea. Moreover, self-medication is common in Nepal, and most people do not comply with the physician-directed duration of treatment. In addition, pharmaceutical companies with vested interests offer incentives to physicians to prescribe “their” brand of drugs. According to a study, it has been found that 74.1% of hospitals in Nepal do not have wastewater treatment facilities. Another study showed that due to inadequate infection prevention and control practices, and monitoring of healthcare quality National Action Plan on Antimicrobial Resistance 3 standards, healthcare-associated infections with highly resistant bacterial pathogens are rapidly increasing in hospitals. Studies have shown a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in tertiary care hospitals in Kathmandu valley. Penicillin-resistant Neisseria gonorrhoea infection is also on the rise in hospitals, and systematic surveillance of AMR is needed to detect the emergence of resistant strains and guide effective treatment. Recently, it has been found that most antibiotics are becoming less effective due to the development of resistance by bacteria. Amoxicillin, ciprofloxacin, and norfloxacin, which are used for Escherichia coli infections, are effective only in <40% of cases, and even worse, are effective in <20% of pneumonia cases caused by Klebsiella spp, studies indicate.

2.1.2 Animal health sector Veterinary medicines and feed supplements worth tens of millions of rupees are sold in Nepal every year. According to a study, almost 13% of the total veterinary expenditure was under the category of “antibiotics”. Likewise, another study shows the growing trends in antibiotic sales. Veterinary drugs are dispensed through para vets or retail outlets that have suboptimal storage facilities and personnel with limited veterinary training. Studies in Nepal have found that retailers and distributors do not have adequate knowledge of the effective dosage and possible side effects of veterinary drugs. Tetracycline, enrofloxacin, neomycin-doxycycline, levofloxacin, colistin, and tylosin are the most commonly consumed antibiotics in Nepal, with ampicillin, amoxicillin, ceftriaxone, and gentamicin being the most inappropriately prescribed ones. Farmers use antibiotics in feed to compensate for poor farm sanitation and hygiene to get more returns. Owing to the ignorance regarding drug withdrawal periods and the negative impact on animal and human health, as well as long-term use, animal products arriving on the market could contain antimicrobial residues above the permitted level, which promotes the development of AMR. Safe and judicious use of antibiotics is still not practiced in dairy farms, and the risk to public health due to residues in milk is high. Studies have shown pork meat to be highly contaminated with antibiotic-resistant Campylobacter spp.; the high prevalence of AMR patterns in 4 National Action Plan on Antimicrobial Resistance avian pathogenic E. coli strains isolated from broiler chickens has also been revealed. These findings suggest the need for effective surveillance, monitoring mechanisms and interventions for controlling the misuse of antibiotics. Studies have also found inadequate regulations and guidelines for the use of veterinary drugs and limited AMR surveillance in the veterinary field. The Antibiotic Sensitivity Test reports from the Central Veterinary Laboratory (CVL) have demonstrated increasing resistance to a wide range of antibiotics. In a large annual sampling from different locations and various animals/products (poultry, buffalo meat, dairy farms products, and milk samples) (n = >1,000), isolates including E. coli, S. aureus, Streptococcus spp., Micrococcus, and Pasteurella were found to be highly resistant to enrofloxacin, amoxicillin, and colistin sulphate and less sensitive to tetracycline, gentamicin, and levofloxacin. Farmers commonly use antibiotics for farm animals without consulting veterinarians. Additionally, over-prescription, under-prescription, empirical antibiotic therapy, and irrational prescription of broad-spectrum antibiotics (intended for rapid cure) by veterinarians have all contributed to antibiotic resistance. Veterinary health workers and paravets who prescribe medicines, including antibiotics, need to be provided with an orientation on AMR. This is a broad overview of the AMR situation in Nepal. The following sections provide information regarding the AMR situation according to the strategic priorities of the action plan.

2.2 Awareness and understanding of AMR The first strategic objective of the NAP-AMR is to address AMR by improving the awareness and understanding of AMR through effective communication, education, and training. All stakeholders, including the general population, need to be sensitized on the “One Health” approach to address AMR. This includes understanding and awareness regarding AMR, antibiotics, and their optimal use. The “One Health” approach for AMR containment targets the following sectors - human health, animal health (including agriculture/plant health, food, and feed), and the environment. Incorporation of AMR and related topics in all relevant professional courses is also National Action Plan on Antimicrobial Resistance 5 included as a strategic intervention. This comprehensive approach simultaneously targets the general population of farmers, policymakers, and professionals in all relevant sectors. These professionals include those who are currently in service or private practice, along with those who will be starting their respective careers after the completion of their studies. There is ample evidence that several factors play a role in the over-prescription or inappropriate use of antibiotics in the community. These include patient-related issues, interests of pharmaceutical companies, financial incentives for prescribers or drug sellers (pharmacists), lack of knowledge and understanding among all stakeholders, peer pressure, poor healthcare systems, and gaps in regulations. A few studies conducted in Nepal have clearly shown that knowledge and awareness about common health problems, medicines, and antibiotics can be increased through interventions among schoolteachers, school children, and drug retailers. A dedicated and systematic approach is needed to collect baseline data and information to guide targeted evidence-based interventions.

2.3 Surveillance of AMR Surveillance is one of the primary measures to contain AMR. There are several reports and research studies on AMR patterns in Nepal, but these are limited to tertiary care hospitals and laboratories. As a result, they may not adequately reflect the overall antimicrobial susceptibility trends across the country. Laboratory surveillance for AMR in Nepal started as early as 1999 with a limited number of participating laboratories and few organisms. Since 2004, the NPHL has been conducting this program at the national level and has been designated as the National Coordinating Center (NCC) for AMR surveillance. The ten different organisms monitored by the national AMR surveillance program included Vibrio cholerae, Shigella spp., Streptococcus pneumoniae, Haemophilus influenzae, N. gonorrhoeae, Salmonella typhi, and paratyphi, then in 2009, extended-spectrum beta-lactamase (ESBL)-producing E. coli was also included. In 2013, MRSA was added, and in 2016, multidrug-resistant (MDR) Klebsiella spp. and MDR Acinetobacter were added as well. Currently, 26 sites (hospitals/laboratories) are included in AMR surveillance for 10 priority organisms, and the results are reported to the Global Antimicrobial 6 National Action Plan on Antimicrobial Resistance Resistance Surveillance System (GLASS). However, expansion of lab sites, upgrading of laboratory infrastructure, and training of human resources will be required to tackle AMR. In the veterinary sector, seven laboratories, including CVL, five provincial veterinary laboratories distributed across the country and the National Avian Disease Investigation Laboratory in Chitwan participate in AMR surveillance of four priority bacteria – E. coli, Salmonella, Enterococci and Campylobacter. There is a need to strengthen the reporting mechanism in the surveillance of AMR in the veterinary sector. Studies have suggested that common bacteria isolated from animals in Nepal, such as E. coli, Bacillus, Campylobacter, Salmonella, Pseudomonas, Staphylococci, and Streptococci, have developed resistance against commonly used antimicrobials such as gentamicin, amoxicillin, enrofloxacin, ceftriaxone and even colistin. It is imperative to strengthen laboratories and scale up AMR surveillance and expand its scope to include samples from a wider spectrum of sources – including animal, environmental, and food samples – to align with the principles of a “One Health” surveillance system. Further, it is important to link the data and information on surveillance of antibiotic use and consumption with lab-based AMR surveillance for developing effective strategies to tackle the problem, especially at the institutional level.

2.4 Infection prevention and control The infection prevention and control (IPC) program is a key intervention for containing AMR. Functional IPC programs reduce the rates of healthcare-associated infections and volume of antimicrobial consumption (AMC) and are vital in preventing AMR. Although infection prevention and control in healthcare settings is included as one of the components in the Minimum Service Standards (MSS) for hospitals, not all hospitals have functional IPC programs. Only a few hospitals have developed their own IPC policy and have formed IPC committees. Although infection prevention and control applies primarily to healthcare facilities, it also involves infection prevention at the population level. Therefore, a multisectoral coordination is necessary. National Action Plan on Antimicrobial Resistance 7 Nepal has a good immunization coverage of >80%. At present, 10 vaccines against 13 types of antigens are being provided free of charge through the National Immunization Program in Nepal. Vaccines help reduce the incidence of infections, and, consequently, reduce the need to use antimicrobials. Similarly, IPC programs are needed at all animal health facilities. In animals, vaccines against bacterial infections such as hemorrhagic septicemia, black quarter and anthrax in cattle and buffalo, and cholera and mycoplasma-mediated disease in fowls have decreased the incidence of infections, thereby reducing antibiotic use. This NAP contributes to carrying out these programs effectively and responsibly through infection prevention systems with biosafety and biosecurity in the laboratories and through compliance with the IPC guidelines in the healthcare facilities.

2.5 Optimum use of antimicrobials One of the main drivers of AMR is the inappropriate use of antibiotics. Overuse of antibiotics, their intake without medical prescription, ignorance of full course, doses, self-medication practices, untimely use, and misuse make the microorganisms resistant to antibiotics. Therefore, the optimal use of antibiotics in the human, animal, livestock, food, and feed sectors, and proper disposal of antimicrobials from manufacturing units, healthcare facilities, farms, and residential areas are important. Unless all stakeholders are aware of the need to optimize the use of antibiotics and understand the “One Health” nature of AMR and the extent of resistance, behaviour changes to ensure the appropriate use of antimicrobials will remain challenging. Regular and effective surveillance of the antimicrobial consumption (AMC) pattern contributes to ensuring the optimal use of antibiotics. Despite antibiotics being prescription drugs in Nepal as per the Drug Act 2035 (1978), they are freely available over the counter for human or animal use. Although standard treatment guidelines (STGs) were endorsed by the MoHP in 2014, they are not being used widely, as shown by various studies. However, the revised version of the STGs was approved in 2023. 8 National Action Plan on Antimicrobial Resistance In Nepal, the drug regulatory authority responsible for licensing as well as monitoring the quality of antibiotics is the Department of Drug Administration (DDA). The DDA also regularly audits samples (medicines) from the market (retail pharmacies) for substandard quality or counterfeits. However, there is no active surveillance on antibiotic consumption or their appropriate prescription. The Veterinary Standards and Drug Regulatory Laboratory (VSDRL) under the Department of Livestock Services (DLS) regulates veterinary drug use and veterinary vaccines imported into the country. It also serves as an OIE focal laboratory for reporting the antimicrobials used in animals. Recently, the DLS banned the use of antibiotics for growth promotion in pre-mix feeds, but a monitoring system to check and enforce the ban is not that effective. Currently, there are 55 domestic pharmaceutical companies producing antibiotics in Nepal. Among these, eight companies also manufacture drugs, including antibiotics, for the animal sector. However, only 28 companies are certified as Good Manufacturing Practices (GMP) compliant, and among them, only one company produces drugs for animals. The 50th meeting of the Drug Advisory committee has recommended an immediate ban on the import of colistin for use in animal feed to the DDA. The surveillance of antibiotic residues in food products such as meat, milk, and fish, is the responsibility of the Department of Food Technology and Quality Control (DFTQC), which conducts residue testing for selected chemicals including antibiotic residues. DFTQC has a structure set up with a testing facility for antibiotic residue in its National Food and Feed Reference Laboratory (NFFRL). The National Food Safety Policy- 2076 (2019) has been approved by the Government of Nepal, which focuses on developing standards (Maximum Residue Level) for drug residues in animal-origin foods.

2.6 Investment, research, and innovation Globally, new antibiotics are being developed continually, but they are thought to be insufficient to mitigate the growing antimicrobial resistance. Therefore, conserving the effectiveness of available antimicrobials is the need of the hour. There is a need to conduct further studies and research to devise strategies to protect the newer antimicrobials from resistance and use them judiciously. National Action Plan on Antimicrobial Resistance 9 Operational research on antibiotic resistance, the use and consumption of antibiotics, awareness and understanding of AMR and antibiotics, infection prevention and control, behavioural changes in antibiotic consumption, and antimicrobial stewardship (AMS) is required. It is necessary to conduct studies to understand the behaviour, incentive, and capacity of all the stakeholders and to develop and implement innovative strategies. Considering the rich cultural heritage and ancient knowledge of herbal medicines, in vitro and in vivo studies are necessary for developing alternatives to antimicrobials for humans, animals as well as agriculture. Multi-stakeholder engagement in studies, research, and innovation, aligned with the ‘One Health’ approach, and the direct involvement of all three tiers of government, according to their authorities and responsibilities under federalism, as well as development partners including the WHO, can be seen as further opportunities to contain AMR. 10 National Action Plan on Antimicrobial Resistance 3. Country Response

3.1 Developing the National Action Plan on AMR This NAP has been developed with high-level political commitment with multi- stakeholder engagement and in line with the “One Health” strategy to combat antimicrobial resistance (AMR). The National Health Policy, 2076 (2019) has prioritized the containment of AMR as a major health agenda. The National Steering Committee - AMR, and the National Technical Working Committee (NTWC) – AMR haven been formed to respond to the issue of AMR institutionally. Similarly, various thematic committees have also been provisioned for the implementation of the activities within the strategic interventions. During the development of the NAP-AMR, each sector conducted sectoral meetings with representation from all relevant stakeholders for the containment of AMR on each strategic objective and drafted sector-wise interventions, and activities, with a timeline and key outputs. The sectoral drafts were compiled, and the compiled draft was discussed within the NTWC-AMR. The inputs and recommendations received from the discussion were incorporated into the draft which was then submitted to the Steering Committee-AMR for approval. The suggestions and inputs from the Steering Committee were also incorporated into the draft before sharing it with the Ministry of Finance and the National Planning Commission for their input and suggestions. The final draft that incorporated their feedback was then submitted to the cabinet for endorsement.

3.2 Governance Mechanism The mechanisms listed below are in place with the representation of relevant stakeholders for the implementation, feedback, monitoring, and evaluation of this action plan. These mechanisms will carry out the effective implementation of the NAP-AMR, provide insights for the formulation of policy and plan formulation, and aid in resolving implementation challenges. The human resources required for National Action Plan on Antimicrobial Resistance 11 providing technical support to the following Committees will be managed by the relevant ministries themselves or with the support of partner agencies working in the field of AMR.

3.2.1 National Steering Committee (NSC) - AMR There will be a National Steering Committee – AMR chaired by the Secretary of the Ministry of Health and Population, with its secretariat based at the Quality Standards and Regulation Division (QSRD), Ministry of Health and Population. The composition of the committee is listed below: Secretary, Ministry of Health and Population Chair Additional Health Secretary, Quality Standards and Member Regulation Division Joint Secretary, Ministry of Finance Member Joint Secretary, Ministry of Home Affairs Member Joint Secretary, Ministry of Education, Science, and Technology Member Joint Secretary, Ministry of Communication and Information Member Technology Joint Secretary, Animal Health Division, Ministry of Agriculture Member and Livestock Development Joint Secretary, Environment and Biodiversity Division, Ministry Member of Forest and Environment Chief Specialist, Policy, Planning and Monitoring Division, Member Ministry of Health and Population Joint Secretary, National Planning Commission Member Director General, Department of Ayurveda, and Alternative Medicine Member Director General, Department of Drug Administration Member Director General, Department of Agriculture Member Director General, Department of Food Technology and Quality Control Member Director General, Department of Livestock Services Member Director General, Department of Environment Member Director General, Department of Health Services Member Member Secretary, National Health Research Council Member Division Chief, Quality Standards and Regulation Division, Member Secretary Ministry of Health and Population 12 National Action Plan on Antimicrobial Resistance The terms of reference of the steering committee are provided in Annex 1. The steering committee will meet at least once a year. The procedures of the meeting will be determined by the committee itself. There will be a Provincial Steering Committee - AMR chaired by the Secretary of the provincial ministry overseeing health, also consisting of representatives from all “One Health” sectors. The constitution and terms of reference of this committee will be as prescribed by the provincial government. Additionally, in case of a requirement to form the committees relating thereto at the local level, the provincial steering committee will facilitate the formation of such committees at the local levels.

3.2.2 National Technical Working Committee (NTWC) - AMR There will be a National technical working committee (NTWC)-AMR chaired by the chief of the Quality Standards and Regulation Division of the Ministry of Health and Population, with its secretariat at the same division. The composition of the NTWC-AMR will be as follows: Division Chief, Quality Standard and Regulation Division, MoHP Chair Director, Curative Service Division (CSD), DoHS Member Director, National Public Health Laboratory (NPHL) Member Director, Epidemiology and Disease Control Division (EDCD), DoHS Member Chief, Animal Disease Investigation and Control Division (ADICD) Member Chief, Central Veterinary Laboratory (CVL), DLS Member Chief, Veterinary Standards and Drug Regulatory Laboratory Member Section Chief, Curative Service, Education and Research Section, Member PPMD, MoHP Drug Administrator, Department of Drug Administration (DDA) Member Senior Food Research Officer, Department of Food Technology Member and Quality Control (DFTQC) Senior Divisional Chemist, Department of Environment (DoEnv) Member Director, Animal Health Research Division, NHRC Member Chief, Plant Quarantine and Pesticide Management Center Member Senior Veterinary Officer, Animal Health Division, MoALD Member National Action Plan on Antimicrobial Resistance 13 Senior Veterinary Officer, One Health Section, DLS Member Under Secretary, Ministry of Education, Science and Technology Member Under Secretary, National Planning Commission Member Two clinical pharmacologists of which at least one is female Member working in academia nominated by MoHP World Health Organization Member Drug Administrator, Quality Standard and Regulation Division Member Secretary Terms of reference for the technical working committed are provided in Annex 2. The technical working committee will meet at least once every three months. The procedures for the meeting of the committee will be determined by itself in coordination with the National Steering Committee.

3.2.3 Thematic committees For effective implementation of the activities proposed under the strategic priorities of the National Action Plan on Antimicrobial Resistance, thematic committees will be formed with representation of “One Health” stakeholders. The formation and terms of reference of the thematic committee will be approved by the Steering Committee upon recommendation of the Technical Committee on AMR. The thematic committee will facilitate the implementation of the activities included in the NAP by incorporating them into their annual programs in coordination with the Technical Working Committee. The thematic committee will meet at least once every three months. The procedures for the meeting of the thematic committees will be determined by the National Technical Working Committee (NTWC) in coordination with the Steering Committee. 14 National Action Plan on Antimicrobial Resistance 4. National Action Plan on Antimicrobial Resistance Nepal’s NAP on AMR (2024-2028) focuses mainly on AMR control, prevention, and management. This action plan has been formulated in alignment with the GAP on AMR adopted by the 68th World Health Assembly.

4.1 Vision AMR free Nepal.

4.2 Goal To reduce the mortality, morbidity, and economic impact of AMR through coordination and collaboration amongst all relevant stakeholders and strengthening of the mechanisms established to address AMR in Nepal.

4.3 Mission To promote the health status of people through optimal use of antibiotics.

4.4 Objectives To reduce the burden of AMR by implementing the National Action Plan on Antimicrobial Resistance through multisectoral coordination and collaborations for the containment of AMR.

4.5 Strategic priorities The NAP-AMR outlines the following strategic priorities to be implemented in collaboration with all the “One Health” sectors over five years to tackle the public health challenge of AMR in Nepal. National Action Plan on Antimicrobial Resistance 15 1. Improve awareness and understanding of AMR through effective communication, education, and training. (a) Information, Education, and Communication (b) Education and training. 2. Strengthen the knowledge and evidence related to AMR through surveillance and research. (a) Surveillance of AMR: human, animal, and environment sectors (b) Capacity and quality enhancement of laboratories 3. Reduce the incidence of infection through effective infection prevention and control. (a) Human health: Healthcare, infection prevention and control (b) Animal health: Animal healthcare, infection prevention and control (c) Community and community: Sanitation and infection prevention 4. Optimize the use of antimicrobial agents in human, animal, agriculture sector and food. (a) Surveillance and regulations for the rational use and consumption of antibiotics (b) Rational prescription for and use of antibiotics by health practitioners: Human, animal, and food sectors (c) Optimal use and regulation of antibiotics 5. Ensure sustainable resources for the containment of AMR along with promoting investment in research and innovation (a) Financing (b) Research (c) National and international collaboration 16 National Action Plan on Antimicrobial Resistance 5. Interventions, Activities, and Key Outputs The interventions, activities, and key outputs under the specific objectives of key focus areas of the strategic priorities are elaborated in the following section. Each activity has a timeline, which is classified as short-term (S) with an expected achievement in 1 year; medium-term (M), with an expected horizon of 1–3 years; and long-term (L), with a 3–5-year timeline.

5.1 Strategic Priority 1: Improve awareness and understanding of Antimicrobial Resistance (AMR) through effective communication, education, and training. Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies 5.1.1 5.1.1.1 Assess awareness, (a) Update the existing Short-term MoFE, Other “One Baseline data and Communication & IEC understanding, and available studies regarding (1 year) NHRC, Health” identification of gaps in (Objective: Increase knowledge of AMR and awareness, understanding, DLS, agencies awareness, understanding, awareness and antimicrobial use (AMU) and knowledge of AMR DFTQC and knowledge of AMR and understanding of AMR and among key stakeholders of and appropriate use of antibiotic use prepared use of antibiotics through one health including the antibiotics across “One effective information and general population Health” sectors. communication) National Action Plan on Antimicrobial Resistance 17 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (b) Conduct a nationwide Short- and MoHP, Other "One baseline survey Medium- MoFE, Health" on awareness and term MoALD agencies understanding of AMR and (1-3 years) knowledge about the use of antibiotics across “One Health” sectors

5.1.1.2 Document the (a) Map and identify the Short-term NHEICC, Other “One Database of existing IEC existing communication and expertise of different (1 year) MoFE, Health” material available with all resource materials on AMR stakeholders, individuals, AITC agencies the agencies related to and organizations including the One-health approach supporting agencies to prepared document and develop communication resources (b) Prepare a database of IEC Short-term MoFE, Other "One materials by scientifically (1 year) AITC, Health" assessing the existing IEC NHEICC agencies materials on AMR awareness and their use ensuring that all the stakeholders of "One Health" are represented.

5.1.1.3 Develop evi- (a) Identify the gap Short- and MoALD, Other “One Evidence-based IEC dence-based IEC materials between the existing level Medium- MoFE, Health” materials and resources on on containment of AMR and the required level of term (1-3 DFTQC, agencies AMR and appropriate use and appropriate use of knowledge on AMR and years) NHEICC of antibiotics developed antibiotics targeting the conduct workshops to Implementation plan stakeholders of the “One develop evidence-based for programs on raising Health” system and their Information, Educatiotn, awareness about the implementation strategy and Communication (IEC) containment of AMR materials and a sustained prepared communication program 18 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (b) Develop targeted Medium NHEICC, Other "One programs for stakeholders and Long- MoALD, Health" based on ICE materials and term (3-5 MoFE, agencies communication programs years) DFTQC on AMR to raise awareness about AMR containment and the appropriate use of antimicrobials.

5.1.1.4 Utilize the developed (a) Conduct sustainable and Medium MoALD, Other "One Comprehensive and IEC materials and conduct effective awareness programs and Long- MoFE, Health" sustained communication communication programs to on AMR to raise awareness term (3-5 DFTQC, agencies program for AMR promote AMR awareness among years) NHEICC containment implemented academia, for each sector professional associations, councils, civil society World AMR Awareness organizations, municipal bod- Week celebrated every year ies, media, and the general public. (b) Celebrate the World Medium- MoHP, Other "One AMR Awareness Week in and Long- MoFE, Health" coordination with various term (3-5 MoALD agencies stakeholders years)

5.1.2 Education and 5.1.2.1 Strengthen the (a) Review and revise Short- and MoHP, Related Professional curricula Training (Objective: knowledge and capacity of the relevant curriculums Medium- MoFE, Councils of revised Improve knowledge and professionals of all sectors to include AMR and term (1-3 MoALD the Ministries capacity development regarding AMR and related related topics as the core years) and other Training module (pre- of key professionals and topics through education component of professional "One Health" service and in-service) related stakeholders on AMR and training education with credit hours agencies content revised, topics on and its containment through according to academic level AMR and its containment education and training) National Action Plan on Antimicrobial Resistance 19 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (b) Review the curriculum Short- and MoHP, Related The training module for (syllabus) for registration Medium- MoFE, Councils of licensing of professionals and licensing exams of term (1-3 MoALD the Ministries revised with AMR and its all relevant professional years) and other related topic councils to include topics "One Health" such as AMR and its agencies containment, appropriate use of antibiotics, disposal of antibiotics, biosafety and biosecurity and revise them in a timely manner. (c) Revise the training Short- and MoHP, Related module on AMR and its Medium- MoFE, Councils of containment for pre-service term (1-3 MoALD the Ministries and in-service training. years) and other "One Health" agencies d) Develop a module on Short- and MoHP, Related AMR and incorporate it in Medium- MoFE, Councils of the Continuing Professional term (1-3 MoALD the Ministries Development (CPD) years) and other program across “One Health” "One Health" sectors agencies

5.1.2.2 Introduce the (a) Develop and incorporate Medium- MoHP, Other "One AMR and its related topics concept of AMR, its a module on AMR, its and Long- MoFE, Health" included in the middle and containment, appropriate containment, appropriate term (3-5 MoALD agencies high school curriculum use of antibiotics, sanitation use of antibiotics, sanitation years) and hand hygiene, and and hand hygiene, and related topics as part of related topics as part of the secondary and higher middle and high school secondary curriculum curriculum 20 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.1.2.3 Strengthen the (a) Conduct training needs Short-term MoHP, Other "One Training resources knowledge, skills, and analysis across all the sectors (1 year) MoFE, Health" developed for key capacity of key stakeholders for AMR containment MoALD agencies stakeholders of the “One including policymakers for Health” sector behavioural change. (b) Develop training Short- and MoHP, Other "One resources including a Medium- MoFE, Health" agen- distance education course term (1-3 MoALD cies on the use of antibiotics years) and AMR for capacity development among professionals. (c) Implement training all Short- and MoHP, Other "One key stakeholders as per the Medium- MoFE, Health" National Action Plan on AMR term (1-3 MoALD agencies years)

5.1.2.4 (a) Establish a strategy for Short-, NTWC MoHP, MoFE, Mechanisms developed Improve interdepartmental interdepartmental commu- Medium- MoALD for inter-departmental and multisectoral (“One nication and coordination and Long- and intersectoral Health”) coordination to for AMR containment and term (1-5 communication and contain AMR data sharing years) coordination. (b) Strengthen AMR multi- Short-, NTWC MoHP, MoFE, sectoral coordination and Medium- MoALD AMR risk-sharing among and Long- “One Health” stakeholders term (1-5 years) National Action Plan on Antimicrobial Resistance 21

5.2 Strategic Priority 2: Strengthen the knowledge and evidence related to AMR through surveillance and research Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.2.1 Surveillance of AMR 5.2.1.1 Strengthen the (a) Strengthen the Short-term NTWC MoHP, MoFE, AMR surveillance (Objective: Strengthen existing AMR surveillance National AMR surveillance (1 year) MoALD mechanism for "One national surveillance system structures and establish coordination committee Health" sectors established and coordination structure an AMR surveillance having representation from for AMR surveillance in governance framework in each sector for integrated National Reference humans, animals, food & coordination with the “One AMR surveillance in a “One Laboratory for AMR feed, and environment) Health” stakeholders Health” approach with the surveillance designated mandate to coordinate and strengthened nationwide surveillance of AMR (b) Revise and approve Short-term NTWC MoHP, MoFE, terms of reference for a (1 year) MoALD National Coordinating Centre (NCC) to implement AMR surveillance in "One Health" sectors (c) Designate and strength- Short-term MoHP, NTWC en a National Reference Lab- (1 year) MoFE, oratory with the mandate to MoALD coordinate surveillance of AMR in “One Health” sectors 22 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.2.1.2 Establish National (a) Develop a National Short- and MoHP, Other "One National AMR surveillance Antimicrobial Resistance guideline for AMR Medium- MoFE, Health" agen- standards established in (AMR) surveillance standards surveillance with standards term (1-3 MoALD cies “One Health” sectors in “One Health” sectors for AMR surveillance sites years) including active and passive Consolidated annual surveillance and diagnostic report of National AMR stewardship in "One Health" surveillance with data from sectors all the sectors published and disseminated (b) Develop standardized Short- and MoHP, Other "One protocol and Standard Medium- MoFE, Health" agen- operating procedure (SOPs), term (1-3 MoALD cies methodologies for sample years) testing and Antimicrobial Susceptibility Testing (AST) in all sectors (c) Organize Annual Short-term MoHP, Other "One consultation to strengthen (1 year) MoFE, Health" agen- AMR surveillance program MoALD cies in “One Health” sectors and publish sectoral AMR surveillance report d) Organize a national Short-, MoHP, Other "One annual consultation and Medium- MoFE, Health" agen- dissemination workshop and Long- MoALD cies to strengthen the AMR term (1-5 surveillance program and years) dissemination of integrated AMR surveillance reports of “One Health” sectors National Action Plan on Antimicrobial Resistance 23 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.2.1.3 Standardize data (a) Standardize AMR Short- and MoHP, Other "One AMR surveillance database analysis and information surveillance data Medium- MoFE, Health" agen- available across “One management for AMR management across sectors term (1-3 MoALD cies Health” sectors surveillance by developing surveillance years) standards for data collection, AMR surveillance report reporting, collation & published and utilized analysis for an update of standard treatment protocol (b) Implement mechanisms Short- and MoHP, Other "One to collate and analyze AMR Medium- MoFE, Health" agen- Annual AMR surveillance surveillance data into useful term (1-3 MoALD cies reports shared at the global information and make an years) level (GLASS) online database available to all stakeholders and policymakers for updating the Standard Treatment Protocol (STP) and other evidence- based decision-making (c) Conduct capacity-build- Short-, MoHP, Other "One ing training for participat- Medium- MoFE, Health" ing laboratories including and Long- MoALD agencies private sectors for data term (1-5 reporting, collation, and years) analysis (d) Ensure sharing of nation- Short-, MoHP, Other "One al AMR surveillance data at Medium- MoFE, Health" agen- the global level (GLASS) and Long- MoALD cies term (1-5 years) 24 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.2.1.4 Establish a (a) Review and strengthen Short- and MoFE, MoHP, DLS, National standards and surveillance system for the organizational structure Medium- MoALD DFTQC surveillance systems antimicrobial residues and of the animal, food, and term (1-3 for antibiotic residue contaminants in the animal, environment laboratory years) established food, agriculture, feed, and to incorporate appropri- environment sectors ate human resources for surveillance of antimicrobial residues and contaminants in “One Health” sectors (b) Develop a national framework for surveillance and regulation of antibiotic residues i. Food from an animal Short- and VSDRL Other "One product such as meat, milk, Medi- Health" agen- egg, and fish um-term cies (1-3 years) ii. Processed food and feed Short- and DFTQC, Other "One Medium- DLS Health" term (1-3 agencies years) (c) Develop a national Short- and DoEnv Other "One framework for surveillance Medium- Health" of antibiotic residues in term (1-3 agencies the environment including years) effluents from farms, and factories (pharmaceutical industry, food, animal feed, meat, dairy, and fish processing industries) National Action Plan on Antimicrobial Resistance 25 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (d) Develop the standards for determining the Maximum Residual Limit (MRL) of antimicrobials i. Food from an animal Short- and VSDRL Other "One product such as meat, milka Medium- Health" term (1-3 agencies years) ii. Processed food, feed, milk, Short- and DFTQC Other "One and milk products Medium- Health" term (1-3 agencies years) (e) Develop standards Short- and DoEnv, Other "One for antibiotic residues Medium- MoFE Health" in industrial effluents, term (1-3 agencies emissions, and waste from years) farms, human health care, and veterinary care settings (f ) Collate and analyze antibiotic residue surveillance data into useful information and publish the report annually i. Food from the animal Short- and VSDRL, Other "One Medium- CVL Health" term (1-3 agencies years) 26 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies ii. Processed food and feed Short- and DFTQC Other "One Medium- Health" term (1-3 agencies years) iii. Environment Short- and DoEnv Other "One Medium- Health" term (1-3 agencies years)

5.2.2 Laboratory capacity 5.2.2.1 Strengthen capacity (a) Define and develop A strategic plan (Objective: Strengthen for laboratory-based Standard Operating for strengthening microbiology laboratory surveillance of antimicrobial Procedures (SOPs) for microbiology laboratories capacity for AMR resistance in “One Health” microbiology laboratories in “One Health” sectors surveillance in “One Health” sectors. for Antimicrobial Sensitivity for AMR Surveillance sectors) Testing (AST)and standards developed and for quality assurance in “One implemented Health” sectors i. Human Health Short- and NPHL Other "One Medium- Health" term (1-3 agencies years) ii. Animal health Short- and CVL Other "One Medium- Health" agen- term (1-3 cies years) iii. Food and feed Short- and DFTQC, Other "One Medium- DLS Health" agen- term (1-3 cies years) National Action Plan on Antimicrobial Resistance 27 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies iv. Environment Short- and DoEnv Other "One Medium- Health" term (1-3 agencies years) (b) Assess and strengthen Short-term MoHP, Other "One the current laboratory (1 year) MoFE, Health" capacity for AMR MoALD agencies surveillance based on the standards developed for microbiology laboratories in "One Health" sectors (c) Develop a national Short- and NPHL, Other "One strategy based on the Medium- CVL, Health" agen- laboratory assessment to term (1-3 DFTQC, cies strengthen microbiology years) DLS, laboratory capacity in all MoFE sectors (d) Develop a plan for Medium- NPHL, Other "One external quality assurance and Long- CVL, Health" (EQAS) of all laboratories term (3-5 DFTQC agencies for AMR surveillance for all years) laboratories across "One Health" sectors 28 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.2.2.2 Strengthen and (a) Establish a National Medium- NPHL Other "One National Coordinating enhance the capacity of Coordinating Center and Long- Health" agen- Center (NCC) designated, the designated National (NCC) and strengthen its term (3-5 cies and its capacity Coordinating Center (NCC) capacity for molecular years) strengthened for molecular for Antimicrobial Resistance level identification, level identification and Surveillance across “One confirmation, and detailed detailed characterization of Health” sectors characterization of target the target pathogen pathogens for AMR surveillance and external quality scheme and increase capacity of established National Biorepository in humans, animal, food & feed sector, and environment to address AMR (b) Conduct joint training Short-, NPHL Other "One workshops for bacterial Medium-, Health" agen- identification, antimicrobial and Long- cies susceptibility testing (AST), term (1-5 and data harmonization years) including all sectors National Action Plan on Antimicrobial Resistance 29

5.3 Strategic Priority 3: Reduce the incidence of infection through effective infection prevention and control (IPC) Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.3.1 Infection Prevention 5.3.1.1 Ensure the (a) Designate and bring into Short-term MoHP Other "One National focal Unit for IPC and Control (IPC) in implementation of infection operation a National focal (1 year) Health" designated, and its terms healthcare prevention and control unit to oversee infection agencies of reference and scope (Objective: Develop and guidelines in all healthcare prevention and control with defined implement infection facilities defined terms of reference prevention and control plans and scope National IPC Guidelines and strategies in healthcare for all levels of healthcare (b) Develop national IPC Short-term CSD Other "One settings facilities developed and guidelines and establish IPC (1 year) Health" agen- disseminated standards for different levels cies of healthcare facilities National IPC (c) Establish and strengthen Short-term CSD Other "One implementation plan with IPC committees in health (1 year) Health" M&E framework endorsed care facilities and ensure agencies and implemented coordination with the Antimicrobial Stewardship National HCAI surveillance Committee system established and (d) Incorporate IPC as quality Short-, MoHP Other "One implemented in identified indicators (QI) in existing Medium-, Health" agen- facilities healthcare facility guidelines and Long- cies and standards term (1-5 Infrastructure for Infection years) Prevention and Control (IPC) upgraded in hospitals 30 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (e) Conduct an IPC Short-, CSD Other "One implementation assessment Medium-, Health" and develop an IPC and Long- agencies implementation framework term (1-5 targeting all levels of years) healthcare facilities with a monitoring and evaluation framework (f ) Develop and implement Short-, NPHL Other "One standardized surveillance Medium-, Health" programs on healthcare- and Long- agencies associated infections (HCAIs) term (1-5 in hospitals with reporting years) mechanisms (g) Develop skilled human Medium-, MoHP Other "One resources for Infection and Long- Health" Prevention and Control term (3-5 agencies (IPC) for all kinds and levels years) of hospitals in a phased manner (h) Develop Infection Medium-, MoHP Other "One Prevention Infrastructure and Long- Health" agen- for environmental control in term (3-5 cies operation theatre (OT) and years) intensive critical care units (ICU) of hospitals (i) Ensure appropriate Short-, MoHP Other "One immunization of the health Medium-, Health" care workers against and Long- agencies Vaccine-Preventable term (1-5 Diseases (VPDs) years) National Action Plan on Antimicrobial Resistance 31 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.3.2 Infection Prevention 5.3.2.1 Establish a (a) Designate a National Short-, DLS, Other "One National focal unit for and Control (IPC) in Animal mechanism to ensure focal unit to oversee Medium-, DFTQC, Health" IPC in the animal sector Health the development and infection prevention and and Long- MoHP agencies designated (Objective: Develop and implementation of infection control with defined terms term (1-5 implement infection prevention and control of reference and scope to years) Standards, protocols, prevention and control (biosafety and biosecurity) oversee infection prevention and guidelines for IPC plans and interventions measures in all animal health and control in livestock, in animal and food in veterinary settings, and and livestock production fisheries, and the food sector sectors established and animal husbandry and food settings including fisheries implemented (b) Develop policies, Medium-, DLS, Other "One sector) as well as the food and feed guidelines, and standard and Long- DFTQC, Health" sector IPC program for the protocols, Standard term (3-5 MoHP agencies animal and food sector Operating Procedures (SOP) years) implemented and on infection prevention monitored and control (biosafety and biosecurity) in animal health, livestock and fisheries, animal husbandry, and food & feed sector (c) Train veterinary and Medium-, DLS, Other "One food safety professionals of and Long- DFTQC, Health" all levels on biosafety and term (3-5 MoHP agencies biosecurity principles and years) practices (d) Include biosafety, Medium-, AITC, Other "One biosecurity, hygiene & and Long- NVC Health" sanitation, and infection term (3-5 agencies prevention and control years) in pre-service, in-service education, and training curricula of professionals working in animal health and the food and feed sector 32 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (e) Promote vaccination Short-, DLS Other "One of food-producing and Medium-, Health" companion animals against and Long- agencies diseases of public health term (1-5 importance to prevent years) infection and apply biosecurity and biosafety measures in outbreak response (f ) Develop and disseminate Short- and DLS Other "One guidelines on Good Medium- Health" Husbandry Practice term (1-3 agencies (GHP), Good Veterinary years) Practice (GVP), and Good Aquaculture Practice to improve IPC in animal health settings (g) Implement and promote Short- and MoALD, Other "One Good Husbandry Practice Medium- DFTQC Health" (GHP), Good Veterinary term (1-3 agencies Practice (GVP), Good years) Management Practice (GMP), FSMS (Food Safety Management System), Good Aquaculture Practice, Good Agriculture Practice in all settings of animals & food and feed production (h) Develop, implement, and Short- and DLS, Other "One monitor the national plan for Medium- DFTQC Health" IPC in the animal and food term (1-3 agencies sector years) National Action Plan on Antimicrobial Resistance 33 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.3.3 Infection prevention 5.3.3.1 Promote personal (a) Develop behavioral Short- and NHEICC, Other "One Behavioural change in the community through hygiene, health diet and change communication Medium- AITC Health" communication and healthy diet, lifestyle, and lifestyle through behavioral and social mobilization term (1-3 agencies social mobilization sanitation change communication campaigns to promote IPC years) campaigns developed and (Objective: Strengthen activities in the community implemented infection prevention and (b) Implement IPC Short-, NHEICC, Other "One control in the community to campaigns in the school and Medium-, AITC Health" limit the development and community and different and Long- agencies spread of AMR) vulnerable groups in term (1-5 collaboration with academic years) institutions, community- based organizations, mother’s groups, farmers groups, and related stakeholders (c) Conduct comprehensive Short-, FWD Other "One public awareness program Medium-, Health" on Vaccine-Preventable and Long- agencies Diseases (VPDs) in the term (1-5 community years) (d) Expand the "My health, Short-, DoAA Other "One My Responsibility" program Medium-, Health" to all levels and Long- agencies term (1-5 years) 34 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.3.3.2 Strengthen (a) Celebrate the Global Short-, NHEICC Other "One Hygiene practices followed adherence to hygiene Handwashing Day Medium-, Health" for IPC control in the practices to prevent and Long- agencies community infection in the community term (1-5 years) Curriculum module developed to educate (b) Develop a module to Medium-, NSSD Other "One and train the children on educate and train children and Long- Health" personal hygiene about the importance of term (3-5 agencies personal hygiene at the years) school level through a school health program (c) Enhance awareness of Short- and AITC Other "One IPC and sanitation amongst Medium- Health" farmers, food and animal term (1-3 agencies handlers and traders years)

5.3.4 Reduce the 5.3.4.1 Develop strategies to (a) Develop, Medium-, MoHP, Other "One Legislation, strategy, and environmental spread of reduce the impact of AMR revise & strengthen envi- and Long- MoALD, Health" plans required to reduce AMR on the environment ronmental standards and term (3-5 MoFE agencies the environmental impact (Objective: Reduce guidelines years) of AMR developed and environmental related to implemented contamination with registration (licensing) of antimicrobial residues and farms, pharmaceutical fac- resistant pathogens) tories, slaughterhouses, wet markets, aquaculture units, food and feed processing units, healthcare facilities, and veterinary care facilities National Action Plan on Antimicrobial Resistance 35 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (b) Develop, revise, and Medium-, MoFE Other "One implement necessary guide- and Long- Health" lines based on the Initial term (3-5 agencies Environment Examination years) (IEE) and Environment Im- pact Assessment (EIA) and implement (c) Establish the required Medium-, DDA Other "One mechanism as well as review and Long- Health" and revise the existing acts term (3-5 agencies and policies to implement years) mechanisms for the disposal of expired or unused antibiotics. (d) Develop and implement a strategic plan to reduce the impact of AMR on the environment. i. Develop necessary Short-, MoFE Other “One legislation for environmental Medium-, Health” risk assessment to reduce and Long- agencies the environmental spread term (1-5 of AMR; develop tools years) for environmental risk assessment, develop SOPs; and conduct awareness program ii. Define standards and Short- and monitor antibiotic residues Medium- and bacterial load in term (1-3 effluents years) 36 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies iii. Disinfect the treatment Short- and plants to reduce bacterial Medium- load and prevent the spread term (1-3 of AMR years) iv. Prepare and implement Short- and the sector-specific manuals Medium- and guidelines to improve term (1-3 the environmental years) management of AMR National Action Plan on Antimicrobial Resistance 37

5.4 Strategic Priority 4: Optimize the use of antimicrobial agents in human, animal, and food sectors Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.4.1 Regulation of access 5.4.1.1 Strengthen National (a) Review and reform the Short- and DDA Other "One The structures of the to quality antimicrobials Regulatory Authority (NRA) organizational structure Medium- Health" National Regulatory (Objective: Ensure access to capacity to improve access of the National Regulatory term (1-3 agencies Authority and the sectoral antimicrobial medicines with to quality-assured, safe, and Authority (NRA) and years) authorities strengthened appropriate regulations on efficacious antimicrobial other sectoral regulatory their use. medicines authorities as required Uninterrupted availability for the containment and of quality-assured, safe, prevention of AMR and efficacious antibiotics ensured (b) Revise the National Short-term DDA Other "One Essential Medicine List (1 year) Health" Guideline on safe (NEML) based on the Access, agencies disposal of expired and Watch, and Reserve (AWaRe) antimicrobials developed category of antibiotics and implemented by the World Health Organization (c) Develop a guideline Short- and DDA Other "One on safe disposal of Medium- Health" antimicrobials and enforce it. term (1-3 agencies years) (d) Identify unlicensed Short-, DDA Other "One pharmacies and vendors Medium-, Health" and enforce regulations and Long- agencies to prohibit the unethical term (1-5 practice and sale of years) antimicrobial as Over-the- Counter (OTC) medicines in human and animal health 38 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (e) Conduct regular post- Short-, DDA Other "One marketing surveillance Medium-, Health" (PMS) and quality testing and Long- agencies of antimicrobials used term (1-5 for human and animal years) health and publish a report annually (f ) Develop and enforce Short-, DDA Other "One guidelines on the sale of Medium-, Health" Reserve category antimicro- and Long- agencies bial medicines listed in the term (1-5 National Essential years) Medicine List (NEML) through hospital pharmacies on the recommendation of a doctor. g) Implement the pharmaco- Short-, DDA Other "One vigilance program in Medium-, Health" healthcare facilities and Long- agencies and ensure effective term (1-5 management of the use of years) antimicrobial medicines. (h) Develop a guideline on Short- and DDA Other "One forecasting, quantification, Medium- Health" storage, and distribution term (1-3 agencies of essential antimicrobial years) medicines for uninterrupted supply National Action Plan on Antimicrobial Resistance 39 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (i) Periodically test the herbal Medium- DDA Other "One products claiming to have and Long- Health" anti-infective properties term (3-5 agencies for the presence of any years) antibiotic substance

5.4.1.2 Develop appropriate (a) Establish a Veterinary Short- and MoHP, Other "One Animal health sector legal and institutional Regulatory Division within Medium- MoALD Health" representation structure and promote the Department of Drug term (1-3 agencies strengthened in the intersectoral coordination Administration with years) National Regulatory for regulations on the use human resources from Authority for regulatory of antimicrobial agents in the veterinary sector for enforcement of antibiotic livestock and fisheries enforcement of regulation use in animal health on the use of antimicrobials in the animal (livestock and Enforcement of regulations fisheries) sector on the use of antibiotics in feed and feed premix (b) Ban the use of Short- and MoALD Other "One Standard treatment antimicrobials as growth Medium- Health" guidelines developed for promoters in animal feed term (1-3 agencies the use of antimicrobials years) in the animal health sector and implemented (c) Develop a National Short- and MoALD Other "One Essential Medicine List Medium- Health" (NEML) for the animal term (1-3 agencies health sector and standard years) treatment guidelines for the treatment of animals (livestock and fisheries) 40 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (d) Ensure regulation of Short-, DLS, Other "One quality, storage, labeling, Medium-, DFTQC Health" use etc. of domestically and Long- agencies produced and imported term (1-5 feed and feed premix. years) (e) Develop and implement Short- and MoALD Other "One the required regulations Medium- Health" to regulate antibiotic term (1-3 agencies use in freshwater, inland years) fisheries, aquaculture, and beekeeping (f ) Review and revise Medium- MoALD Other "One regulations of withdrawal and Long- Health" period for food products term (3-5 agencies produced from animals, that years) have used antibiotics, and reared for the production of milk, eggs, and meat (g) Develop and revise Short-, DLS, Other "One national standards, Medium-, DFTQC Health" guidelines, and procedures and Long- agencies in alignment with the Codex term (1-5 Alimentarius Commission years) and WOAH guidelines on antimicrobial resistance National Action Plan on Antimicrobial Resistance 41 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.4.2 Surveillance of 5.4.2.1 Develop a national (a) Form a committee under Short-term DDA Other "One National surveillance antimicrobial use and antimicrobial use (AMU) the leadership of national (1 year) Health" system for antimicrobial consumption and consumption (AMC) drug regulatory body for agencies consumption and use (Objective: Establish the estimation system in human Antimicrobial Consumption established and operational national surveillance system and animal health (AMC) surveillance under the Capacity of designated for antimicrobial use and “One Health” approach. focal persons and consumption) institutions enhanced for the surveillance of antimicrobial consumption (AMC) and antimicrobial use (AMU) AMR, AMU, and AMC surveillance reports published and (b) Establish an effective Short-term DDA Other "One disseminated annually data management system (1 year) Health" as per the “One Health” through the collection agencies approach and analysis of the data to measure the manufacturing, import, and consumption of antimicrobials in the human and animal health sector (c) Conduct joint as well as Short- and DDA, Other "One sectoral training programs Medium- DLS Health" agen- for focal persons and term (1-3 cies related organizations that years) are designated to monitor antimicrobial consumption in the human and animal health sector 42 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (d) Monitor the use of Short-, MoHP Other "One antibiotics and designate a Medium-, Health" focal unit for Antimicrobial and Long- agencies Use (AMU) surveillance term (1-5 studies for hospitals years) (e) Develop antimicrobial Short-, MoHP Other "One use (AMU) surveillance tool Medium-, Health" to measure antimicrobial use and Long- agencies in health facilities term (1-5 years) (f ) Make provisions for Short-, MoHP Other "One national-level training Medium-, Health" programs to strengthen the and Long- agencies capacity to implement AMU term (1-5 surveillance programs in years) hospitals (g) Organize annual reviews Medium- MoHP, Other "One to maintain coordination and Long- MoALD, Health" and cooperation amongst term (3-5 MoFE agencies the "One Health" sectors in years) AMR

5.4.2.2 Promote optimum (a) Conduct the audits of Short- and CSD Other "One Capacity of staff to perform use of antimicrobials in antibiotics use in health Medium- Health" antibiotic audits enhanced human health care facilities and carry term (1-3 agencies out capacity development years) Provision of hospital programs to ensure the pharmacy with a functional optimum use of antibiotics Drug and Therapeutic Committee in every hospital National Action Plan on Antimicrobial Resistance 43 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (b) Establish a pharmacy in Short- and CSD Other "One every hospital and ensure Medium- Health" provision for a Drug and term (1-3 agencies Therapeutic Committee to years) regulate the pharmacy's operation

5.4.3 Antimicrobial 5.4.3.1 Establish an (a) Collate and analyze Short-term EDCD Other "One Standard Treatment stewardship in human antimicrobial stewardship incidence data on prevalent (1 year) Health" Guidelines developed, health program (AMSP) in human and emerging infectious agencies disseminated, and regularly (Objective: Improve healthcare facilities diseases in Nepal updated appropriate use of antimicrobial medicines in The Antimicrobial human healthcare) Stewardship Program (AMSP) developed and (b) Develop, implement, Short- and CSD Other "One implemented in selected and regularly update Medium- Health" healthcare facilities national Standard Treatment term (1-3 agencies Guidelines (STG) based years) on infectious disease prevalence and AMR surveillance data (c) Adapt the WHO Antimi- Medium- CSD Other "One crobial Stewardship toolkit term (3 Health" agen- as per Nepal's context years) cies (d) Develop a training Medium- CSD Other "One manual and conduct and Long- Health" training of trainers on term (3-5 agencies antimicrobial Stewardship years) to operationalize AMSP in all health facilities 44 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (e) Implement the Medium- CSD Other "One Antimicrobial Stewardship and Long- Health" (AMS) program at all levels term (3-5 agencies of healthcare facilities in a years) phase-wise manner starting from tertiary care hospitals and academia. Form and mobilize the Antimicrobial Stewardship Committee in healthcare facilities for this purpose.

5.4.4 Antimicrobial 5.4.4.1 Improve the (a) Collate and analyse Short term DLS Other "One Antimicrobial stewardship stewardship in animal appropriate use of incidence data on infectious (1 year) Health" implemented for health antimicrobials in animal diseases of common agencies the rational use of (Objective: Improve health occurrence in the animal antimicrobials in the appropriate use of animal sector (livestock and (b) Develop, implement, Short term DLS Other "One antimicrobial medicines in fisheries) and regularly update (1 year) Health" animal healthcare) National Standard Treatment agencies Existing legislation Guidelines (STG) based revised to prohibit the on infectious disease use of reserved-category prevalence and AMR antibiotics (which are surveillance data important for human health) h in the animal sector National Action Plan on Antimicrobial Resistance 45 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (c) Establish an Antimicrobial Medium- DLS Other "One Stewardship Program and Long- Health" (AMSP) for rational use of term (3-5 agencies antimicrobials in animals years) including animal husbandry and aquaculture to prevent non-therapeutic use of antibiotics (d) Revise the existing Short, MoALD, Other "One legislation to prevent the Medium DDA Health" use of reserve-category and Long- agencies antibiotics, which are term (1-5 critically important for years) human health, in the animal sector.

5.4.5 Rational use 5.4.5.1 Increase awareness (a) Conduct awareness Short, DDA, Other "One Dispensers and farmers of antimicrobials in among dispensers and campaigns and orientation Medium DLS Health" informed on the rational community settings farmers on the appropriate programs regarding and Long- agencies use of antibiotics (Objective: Improve use of microbial existing rules, laws and term (1-3 appropriate use of regulations, and rational use years) antimicrobials in the of antimicrobials targeted community) at registered dispensers and farmers

5.4.5.2 Monitor antimicrobial (a) Employ Antimicrobial Medium- DDA Other "One Surveillance on antibiotic use in community settings use (AMU) surveillance tools and Long- Health" agen- use in community settings from community pharmacies to measure antimicrobial term (3-5 cies carried out and an increase for both humans and use in community settings years) in the rational use of animals including standalone clinics antibiotics and community pharmacies 46 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.4.6 Regulation 5.4.6.1 Amend legislation (a) Organize consultations Short-term MoHP Other "One Legislation amended to of the prescription to regulate dispensing, with national regulatory (1 year) Health" regulate the dispensing and dispensing of prescription, and residual bodies and stakeholders agencies of antimicrobials on antimicrobials limits of antimicrobials in to review and make timely prescription (Objective: Amend the “One Health” sectors amendments to the current existing legislation legislation to discourage Reserve category regarding various facets of over-the-counter (OTC) sale antibiotics dispensed antimicrobial use) of antimicrobials through hospital pharmacies only (b) Organize consultations Short-term MoALD Other "One with National Regulatory (1 year) Health" Antibiotic residue limits bodies and other sectors agencies in animal products, food for the development of products, feed, and legislation for the regulation environment-regulated of antibiotic residue limits in animal products, food Enforcement of regulation products, feed, and the on the prescription of environment antibiotics by registered (c) Review legislation to Short-term DDA Other "One medical practitioners only implement regulatory (1 year) Health" in the human and animal intervention for categorizing agencies health sector antibiotics as Reserve antibiotics for use in special cases and ensuring they are only used upon prescription (d) Record and audit Short-term DDA Other "One the prescriptions of (1 year) Health" antimicrobial medicines to agencies discourage their sale and dispensing without medical prescriptions. National Action Plan on Antimicrobial Resistance 47 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (e) Carry out legal Short, MoHP, Other "One consultation for legislation Medium MoALD Health" on the prescription of and Long- agencies antibiotics by veterinarians term (1-5 registered in Nepal years) Veterinary Council (NVC) 48 National Action Plan on Antimicrobial Resistance

5.5 Strategic Priority 5: Ensure sustainable resources for the containment of AMR with promoting investment in research and innovation Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.5.1 Financing for AMR 5.5.1.1 Prepare a plan to (a) Conduct expert Short- and MoHP Other "One Impact, cost, and benefit of (Objective: Ensure secure sustainable funds consultation and develop Medium- Health" AMR activities assessed sustainable investments to with the participation of all monitoring tools for term (1-3 agencies address AMR) “One Health” sectors for the assessing the impact of AMR years) Sectoral cost-sharing implementation of NAP-AMR ensured in “One Health” (b) Assess the impact of AMR Short- and MoHP, Other "One sectors – morbidity, mortality, and Medium- MoALD Health" treatment cost due to AMR term (1-3 agencies in the country years) (c) Develop an operational Short-term MoHP, Other "One plan (with budget and (1 year) MoALD, Health" costing) to implement NAP- MoFE agencies AMR (d) Develop a resource Short- and MoHP, Other "One mobilization plan for the Medium- MoALD, Health" implementation of the term (1-3 MoFE agencies National Action Plan on AMR years)

5.5.2 Research for 5.5.2.1 Carry out operational (a) Organize expert Medium- NHRC, Other "One AMR-related topics containment of AMR research to improve consultation to identify term (3 NARC Health" researched based on the (Objective: Promote research infection prevention and priority topics for promoting years) agencies priority to combat AMR) control in human and animal operational research for health tackling AMR Scientific research conducted on alternative medicine National Action Plan on Antimicrobial Resistance 49 Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies (b) Conduct operational Short- and NHRC, Other “One research on topics such as Medium- NARC Health” infection prevention control term (1-3 agencies in healthcare facilities, years) rational use of antibiotics, the practice of biosecurity principles on the farm and behavioral change studies (c) Promote scientific Medium- DoAA Other "One research to develop an and Long- Health" alternative to antimicrobials term (3-5 agencies and adjuvant remedies for years) the prevention and control of infectious disease

5.5.3 International 5.5.3.1 Strengthen (a) Identify the potential Short- and MoHP, Other “One International collaboration Collaboration international collaboration development partners for Long-term MoALD, Health” strengthened for the (Objective: Promote with donors and partners for the implementation of the (1-5 years) MoFE agencies implementation of NAP- international collaboration NAP-AMR implementation NAP-AMR AMR and coordination for the implementation of NAP- (b) Establish an annual Short- and MoHP, Other “One AMR) forum on AMR with donors Long-term MoALD, Health” and partners to share (1-5 years) MoFE agencies information and facilitate coordinated mobilization of resources for prioritized AMR activities (c) Collaborate with thematic Medium- MoHP, Other “One and sectoral international term (3 MoALD, Health” organizations to combat years) MoFE agencies AMR 50 National Action Plan on Antimicrobial Resistance Strategic Lead Partner Agen- Focus Area Activities Timeline Key outputs Intervention Agency cies

5.5.4 National 5.5.4.1 Strengthen drug (a) Establish functional Short-, EDCD, Other “One Every stakeholder is Collaboration resistance containment linkages among national Medium-, NTC, Health” aware of the NAP-AMR (Objective: Strengthen activities and establish programs such as human and Long- NCASC, agencies activities conducted across national collaborations with linkages among disease disease and animal disease term (1-5 DLS “One Health” sectors and disease control programs to control programs with the control programs, and years) collaboration strengthened tackle AMR) national AMR program vaccination programs to for functional linkage, share best practices to feedback, cost-sharing, combat AMR and development of new programs

5.5.5 Provincial and local 5.5.5.1 Facilitate (a) Organize activities to Short- and MoHP, Other “One Increased awareness at the level collaboration prioritization of AMR create awareness and Medium- MoALD Health” provincial and local level (Objective: Strengthen sub- containment activities at the sensitization on AMR burden term (1-3 agencies about AMR national collaborations to provincial and local level for and its containment at the years) tackle AMR tackling AMR province and local level Provincial and local action under the “One Health” plans on AMR aligned with approach NAP-AMR developed in all the provinces and local (b) Collaborate and Short- and MoHP, Other “One level coordinate with the Medium- MoALD Health” provincial and local level term (1-3 agencies governments to develop years) provincial and local action plans on AMR aligning with NAP-AMR National Action Plan on Antimicrobial Resistance 51 6. Cost Estimate and Management of Financial Resources The Ministry of Health and Population, with the support from WHO, has prepared a cost estimate for this Action Plan. The total cost estimate for the implementation of this Action Plan is estimated to be NRs. 4,586 million. The total cost estimate is then disaggregated into five fiscal years. The cost allocation, therefore, is as follows: NRs. 1,132 million for the first year, NRs. 1,118 million for the second year, NRs. 1,085 mil- lion for the third year, NRs. 599 million for the fourth year, and NRs. 650 million for the fifth year. Out of the total cost estimate for five years, around two-thirds (61 percent) of the cost will be spent at the federal level, 12 percent will be spent at the provincial level, and 27 percent will be spent at the local level. Of the total cost estimated for implementation of this Action Plan, based on the strategic priority sectors, the first strategic priority will have 15 percent, the second strategic priority will have 28 per- cent, the third strategic priority will have 41 percent, the fourth strategic priority will have 12 percent, and the fifth strategic priority will have 4 percent of the cost. Similarly, to implement activities for the four sectors spelled out in this Action plan (human health, animal health, food, and environment), it is estimated that NRs. 2,065 million will be spent on the human health sector, NRs. 1,996 million will be spent on animal health, NRs. 416 million will be spent on the food sector and NRs. 109 mil- lion will be spent on the environment sector. For the implementation of the Action Plan, the Government of Nepal, provincial governments, and local governments will manage the resources. Similarly, financial support will also be sought from the de- velopment partners and the non-government organizations for the implementation of this Action Plan. For the implementation of the activities outlined in the Action Plan, the concerned ministries/ sectors and their tier of the government will manage the required budget in their annual plans for the implementation of activities falling under their sector. 52 National Action Plan on Antimicrobial Resistance 7. Provisions Related to Monitoring and Evaluation The National Steering Committee will be responsible for monitoring and evaluation of the implementation of the Action Plan lie with. The monitoring and evaluation of the Action Plan will be a continuous process throughout the implementation period. The National Steering Committee may carry out monitoring and evaluation activities through the National Technical Working Committee. Similarly, with regard to the provincial and local level, the concerned province and local level may form a monitoring and evaluation committee as required to regularly monitor the implementation. The monitoring and evaluation may also be carried out through an electronic system as required. The review report related to monitoring and evaluation from all sectors of “One Health” and the federal, provincial, and local levels will be submitted to the National Steering Committee through the National Technical Working Committee. The monitoring and evaluation report will be submitted in the approved prescribed format. The format related to monitoring and evaluation has been provided in Annex 3. 8. Provisions Related to Reporting All sectors of “One Health” and the committees at all levels will submit progress reports annually to the National Steering Committee. The format for the report to be submitted from the local, provincial, and sectoral committees will be approved by the National Steering Committee. The report according to this approved format will be submitted by the local level to the province, the province and the sectoral committee to the National Technical Working Committee. The National Technical Working Committee will submit the compiled report received from all levels to the National Steering Committee. National Action Plan on Antimicrobial Resistance 53 9. Risks There is a risk of facing difficulty in regard to the implementation of the strategies identified by this action plan if the financial resources cannot be managed adequately and infrastructure development, improvement in organizational structure, and management of human resources cannot be carried out in a timely manner. Also, the implementation may be at risk if there is a lack of effective coordination and collaboration. The risk associated with the financial resources will be primarily managed by the Government of Nepal, the federal, provincial, and local governments through the allocation of budget in their respective annual programs for the implementation of the activities listed in this Action Plan. Similarly, the provision put forth by the Action Plan for financial support from the development partners and non-government organizations will also further support in mitigating the risk posed by the financial resource limitations. The risk will be mitigated through the implementation of this Action Plan through the coordination and collaboration among all stakeholders and sectors and the development of infrastructure and improvement in organizational structures in a timely manner. 10. Modification in Annex The Ministry of Health and Population will modify the annexures mentioned in this action plan, if required, upon the recommendation from the National Steering Committee. 54 National Action Plan on Antimicrobial Resistance 11. Powers to explain The National Steering Committee will resolve any predicament if such a predicament arises during the implementation of this Action plan by making the required decisions. 12. Void Provision If anything contained in this action plan contradicts any provision thereby included in the prevailing laws of Nepal, such provision will be void to the extent of its contradiction. National Action Plan on Antimicrobial Resistance 55 Annexes

Annex 1: Terms of Reference of The National Steering Committee In addition to those contained elsewhere in this Action Plan, the National Steering Committee will have the following terms of reference: • To provide leadership for the coordination and collaboration with all levels of the government and national and international stakeholders for the prevention of anti-microbial resistance. • To facilitate the implementation of the action plan and make required efforts for the financial management. • To make required arrangements for the coordination and collaboration with all sectors of “One Health” to achieve public health goals related to anti-microbial resistance. • To guide and support the National Technical Working Committee.

Annex 2: Terms of Reference of Technical Working Committee In addition to those contained elsewhere in this Action Plan, the Technical Working Committee will have the following terms of reference: • To provide the leadership for the implementation of the National Action Plan for Anti-Microbial Resistance with the active participation of all major stakeholders. • To coordinate with the National Steering Committee in the implementation of the action plan and submit recommendations, if required, in relation to policy provisions during implementation. • To identify and engage the stakeholders for AMR-related activities. • To communicate and coordinate among the sectoral committees on AMR effectively. • To coordinate for the strengthening of surveillance systems related to anti- microbial resistance, use of anti-microbial drugs, and hospital-bound infections. 56 National Action Plan on Antimicrobial Resistance • To carry out monitoring and evaluation in relation to the overall implementation of the action plan and submit the progress report to the National Steering Committee.

Annex 3: Monitoring and Evaluation Framework Strategic Priority Activity Output Outcome Long-term Impact Strategic Priority 1: Organize awareness programs Number of awareness Awareness related to Quality health services Improve awareness among all related stakeholders of programs related to anti- anti-microbial resistance will have been ensured and understanding of “One Health” sectors and the public. microbial resistance. increased among the target through the rational use of AMR through effective group. antimicrobials. communication, education, Develop information, education, and Number of AMR-related IEC and training. communication materials related to materials developed anti-microbial resistance and rational use of microbials. Strategic Priority 2: Conduct surveillance of anti- No. of anti-microbial Annual report on anti- Strengthen the knowledge microbial resistance. resistance surveillance sites. microbial resistance and evidence related to AMR surveillance. through surveillance and Develop an integrated database on Integrated anti-microbial research anti-microbial resistance. resistance database Strengthening and developed. expansion of surveillance The morbidity and mortality system. related to anti-microbial resistance will have reduced. Use of data in planning and decision-making process. Strategic Priority 3: Reduce Develop and institutionalize No. of health facilities with Reduction in the rate of the incidence of infection mechanisms for the prevention and institutional mechanisms infection. through effective infection control of incidences of infection. for infection prevention and Sustainable investment in prevention and control. control Capacity building in the sector of anti-microbial Conduct training on infection infection prevention and resistance will have ensured prevention No. of human resources control. through strengthened trained in infection coordination and prevention and control collaboration among the sectors of “One Health”. National Action Plan on Antimicrobial Resistance 57 Strategic Priority Activity Output Outcome Long-term Impact Strategic Priority 4: Optimize Review and make timely revisions No. of revised legal and The revised policy the use of antimicrobial in the existing legal and policy policy documents documents will have been agents in the human, animal, documents related to anti-microbial effectively implemented. and food sectors resistance. Mechanism for prescription and distribution of reserve Optimal use of antibiotics Make special provisions for the use antibiotics for use in humans according to their of Reserve Category antibiotics and veterinary developed/ classification. formed Strategic Priority 5: Ensure Ensure and mobilize resources for Budget appropriation from The activities outlined in the sustainable resources for the the AMR activities from “One Health” the concerned ministry for Action Plan will have been containment of AMR with sectors. AMR activities through the implemented after their promoting investment in inclusion of the activities inclusion in the ministerial research and innovation Identify and conduct AMR-related in the annual plan and annual plan and programs. research and innovation activities programs. from all sectors of “One Health”. AMR research will have been The investment made from conducted in a sectoral or the concerned sector in integrated manner and such AMR-related research. research will have been institutionalized. 58 National Action Plan on Antimicrobial Resistance TECHNICAL SUPPORT BY: National Action Plan on Antimicrobial Resistance 59