Implementation Plan: National Antimicrobial Resistance Containment Strategic Plan (2018-2022)

2.1. Strategic Objective 1: Improve awareness and understanding of AMR through effective communication, education, and training............................................................................................... 11

2.2. Strategic objective 2: Strengthen the knowledge and evidence base for AMR containment through surveillance and research ......................................................................................................... 14

2.3. Strategic Objective 3: Reduce the incidence of infection across human, environment, and animal communities and health care through individual and environmental sanitation, hygiene, and infection prevention measures............................................................................................................... 17

2.4. Strategic objective 4: Optimize the use of antimicrobial medicines in human and animal health through AMR stewardship .......................................................................................................... 20

2.5. Strategic objective 5: Enhance leadership, governance, coordination, and investment in containing AMR ...................................................................................................................................... 21 3. MONITORING AND EVALUATION FRAMEWORK ........................................................................... 25 Page | 2 ACKNOWLEDGEMENTS The GOE would like to thank the UK Department of Health and Social Care for the support to strengthen the AMR surveillance under its Fleming Fund Grants Programme. Special thanks go to the Fleming Fund Country Grant for supporting the development of this implementation plan through Mott MacDonald and ICAP at Columbia University. Additional support was provided by the World Health Organization. (Z =j1rz,-1� Dr. Roland Xolani Diamini Dr. Vusi Magagula Mr. Trevor Shongwe Director, Veterinary & Director, Health Services Director, Water Affairs Livestock Services Ministry of Agriculture Ministry of Health Ministry of Natural Resource & Energy Page I 4 CONTRIBUTORS The development of the implementation plan for the AMR strategy has been made possible by contributions from the following people: Ms Fortunate Bhembe AMRCC Coordination, Deputy Director Pharmaceutical Services, MOH Dr Zizwe Cindzi AMRCC Chairperson, Regional Veterinary Officer, MOA Mr Nhlanhla Nhlabatsi AMRCC Member, Epidemiology Unit, MOH Ms Sindisiwe Dlamini AMRCC Member, Chief Laboratory Technologist, MOH Ms Thuli Magagula AMRCC Member, Assistant Director Pharmaceutical Services, MOH Mr Sipho Shongwe AMRCC Member, Environmental Unit, MOH Mr Thabang Masangane AMRCC Member, Quality Management Focal Person, MOH Mr Sihle Gama AMRCC Member, Pharmacist, MOH Ms Sifundo Zwane AMRCC Member, Regional Pharmacist, MOH Mr Jabulani Njabulo AMRCC Member, MOA Mkhonta Mr Cyril Sabelo Dlamini AMRCC Member, MOA Mr Walter Sukati AMRCC Member, Department of Water Affairs, MONRE Ms Khanyisile Mabuza FAO Dr Khosi Mthethwa WHO Ms Lindiwe Skonela Epidemiologist, MOH Ms Andiswa Dlamini Laboratory Technologist, MOH Ms Gugu Tsabedze Laboratory Manager, Mbabane Government Hospital, MOH Dr Ronald Xolani Dlamini Director, Department of Veterinary & Livestock Service, MOA Dr Nhlanhla Shongwe Deputy Director, Division of Veterinary Services, MOA Dr Sihle Mdluli Veterinary Epidemiologist, MOA Dr Patrick Dlamini Senior Veterinary Officer, MOA Dr Ruben Sahabo Country Director, ICAP Dr Tesfay Abreha Technical Director, ICAP Dr Harrison Kamiru M&E Director, ICAP Ms Cebisile Ngcamphalala Associate Director, Health Systems Strengthening, ICAP Ms Sehlephi Kuhlase Associate Director, ICAP Mr Knowledge Denhere Microbiologist, ICAP Dr Nondumiso BQ Ncube Senior Pharmacy Advisor, ICAP Page | 5 LIST OF ABBREVIATIONS AH Animal Health AMC Antimicrobial Consumption AMR Antimicrobial Resistance AMRCC Antimicrobial Resistance Containment Committee AMS Antimicrobial Stewardship AMU Antimicrobial Use ASLM African Society for Laboratory Medicine BCC Behavior Change Communication CANGO Coordinating Assembly of Non-Governmental Organizations CDC Centers for Disease Control and Prevention DVS Division of Veterinary Services EEA Eswatini Environmental Authority FAO Food and Agriculture Organization FESBC Federation of Swazi Business Community GOE Government of Eswatini GLASS Global Antimicrobial Resistance Surveillance System HH Human Health HIV Human Immunodeficiency Virus ICAP ICAP at Columbia University IDSR Integrated Disease Surveillance and Response IEC Information Education Communication IPC Infection Prevention Control IPCC International Plant Protection Convention M&EP Monitoring and Evaluation Plan MICT Ministry of Information Communication and Technology MOA Ministry of Agriculture MOH Ministry of Health MONRE Ministry of Natural Resources and Energy MOU Memorandum of Understanding MPED Ministry of Planning and Development MTD Ministry of Tinkhundla & Development NAP National Antimicrobial Resistance Containment Strategic Plan OHC One Health Committee OI Opportunistic Infection OIE World Organization for Animal Health PTC Pharmaceutics and Therapeutics Committee REPS Royal Eswatini Police Service SDG Sustainable Development Goals SRA Eswatini Revenue Authority SWASA Eswatini standards authority TB Tuberculosis Page | 6 THO Traditional Healers Organization TOR Terms of Reference TWG Technical Working Group UNEP United Nations Environmental Program UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children's Fund WHA World Health Assembly WHO World Health Organization Page | 7 EXECUTIVE SUMMARY Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi, and parasites change over time and no longer respond to antimicrobial medicines; making infections harder to treat, and increasing the risk of disease spread, severe illness, and death. Due to the increased global concern on AMR, the World Health Assembly (WHA) called upon member states to develop national action plans (NAPs) to contain AMR. A holistic and multisectoral (One Health) approach is needed to contain the increasing threat of AMR because antimicrobials used to treat various infectious diseases in animals may be the same or be like those used in humans. Resistant bacteria arising either in humans, animals or the environment may spread from one to the other, and from one country to another. To curb and contain AMR, the Government of Eswatini appointed an AMR Containment Committee (AMRCC) with members from the Ministry of Health (MOH), Ministry of Agriculture (MOA), Ministry of Natural Resources and Energy (MONRE), FAO and WHO country office representatives in 2016. The AMRCC then developed a National AMR containment strategic plan 2018-2022 as a foundation for activities to curb and contain AMR. This document, the implementation plan of the national AMR containment strategic plan 2018- 2022, outlines the plan to implement the strategic objectives, activities, and monitoring and evaluating progress of activities. This implementation plan is to be executed for the period of October 2020 to September 2025 and takes into consideration the following: • Translating the strategic objectives to activities and actions. • Aligning the implementation plan with existing policies, regulations, and guidelines, and identifying opportunities for improvement. • Facilitating national coordination of the implementation of AMR surveillance strategies in the different sectors. • Monitoring the implementation plan outputs and collating experiences for future adjustments. The implementation plan will be operationalized by the technical departments in the respective Ministries with support of implementing partners on key areas, and support from other AMR stakeholders locally and internationally. Under this implementation plan, five strategic objectives will be implemented: Strategic Objective-1: Improve awareness and understanding of AMR through effective communication, education, and training: The awareness of stakeholders on AMR including healthcare professionals, the public, various institutions, schools, and the community will be raised through different communication means, education, community mobilization and health Page | 8 promotion in respective ministries to ensure that up-to-date information on global and country AMR status is disseminated nationwide. Strategic Objective-2 Strengthen the knowledge and evidence base for AMR containment through surveillance and research: A functional surveillance system particularly in the human and animal health sectors will be established to monitor and inform policy decision making on slowing the spread of AMR. Accurate and timely data on patterns of antimicrobial use and resistance will be generated to guide local treatment protocols. Antimicrobial use (AMU), antimicrobial consumption (AMC) and AMR data will be used to guide on areas of research that need to be strengthened to promote appropriate use of antimicrobial agents. The AMR data will also be used to inform and improve programming in the country and reporting to the global antimicrobial resistance surveillance system (GLASS). Strategic Objective-3: Reduce the incidence of infection across human, environment, and animal communities and healthcare through individual and environmental sanitation, hygiene, and infection prevention measures: Infection prevention and control (IPC) practices will be re-enforced to improve personal and environmental hygiene coupled with the IPC measures in both human and animal health sectors to stop the chain of infection, reducing the spread of infections in humans and animals, in food establishments, and in the community. Strategic Objective-4: Optimize the use of antimicrobial medicines in human and animal health through AMR stewardship: Activities will be implemented that promote the optimal use of antimicrobial medicines in both human and animal health sectors through an improved regulatory framework for antimicrobials, availability and use of guidelines, improved prescribing practices by clinicians and veterinary practitioners, and sound use of antimicrobials by consumers and farmers. Strategic Objective-5: Enhance leadership, governance, coordination, and investment in containing AMR: The AMRCC will be strengthened to high level government coordination across the multi-sector ministries including health, agriculture, and Ministry of Natural resources and Energy. The coordination, monitoring and evaluation of the implementation plan will be conducted by the AMRCC according to their defined terms of reference, supported by a One Health Committee (OHC). The AMRCC will spearhead a close collaboration with the country representatives of WHO and FAO, and regional organizations such as OIE, African Union, Africa CDC, SADC and ASLM. Page | 9 1. INTRODUCTION Antimicrobial resistance (AMR) is the ability of pathogenic microbes to develop resistance to the effects of antimicrobial medication. Antimicrobial resistance develops over time, but is accelerated by inappropriate use of antimicrobial medicine, lack of access to health services, and through antimicrobial residues in soil, crops, and water. Antimicrobial resistant microbes are found in people, animals, food, and the environment (in water, soil, and air). They can spread between people and animals, including from food of animal origin, and from person to person. Poor infection control, inadequate sanitary conditions and inappropriate food-handling encourage the spread of antimicrobial resistance. New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases such as pneumonia, tuberculosis, blood poisoning, gonorrhea, and foodborne diseases with antimicrobial agents. Antimicrobial resistance has been recognized as a threat to the gains made in health and development and to the attainment of sustainable development goals (SDG) in health security, poverty, economic growth, and food security. For example, emerging resistance to HIV, TB and malaria is an obstacle to the achievement of SDG target 3.31. At the same time, actions required to achieve SDGs may also have deleterious effects on AMR e.g., the estimated 70% increase in the use of antimicrobials required to double food/animal production between 2010 and 2030 to achieve food security (SDG 2)1. Globally, there is an urgent need to change the antimicrobial prescription and use practices. In recognition of this need, the World Health Assembly adopted the Global Action Plan on Antimicrobial Resistance in May 2015 and called upon member states to develop national action plans (NAPs) to contain AMR. Accordingly, the Government of Eswatini appointed the AMR Containment Committee (AMRCC) with members from the Ministry of Health (MOH), Ministry of Agriculture (MOA), Ministry of Natural Resources and Energy (MONRE) in 2016. This committee developed the National AMR Containment Strategic Plan 2018-2022 using a One Health approach. The implementation plan of the delineates the plan to implement, monitor and evaluate the National AMR Containment Strategic Plan 2018-2022. 1 https://www.oie.int/amr2018/wp-content/uploads/2018/11/2-Sally-Davies-OIE-the-UN-IACG-on-AMR.pdf Page | 10 2. THE IMPLEMENTATION PLAN Based on the National AMR Containment Strategic Plan 2018-2022, the Government will implement strategic objectives for the period of October 2020 to September 2025. This is the implementation plan after the development of the strategic plan, and it will take the following considerations into account: • Translate the strategic objectives to activities and actions. • Align the implementation plan with existing policies, regulations, and guidelines, and identify opportunities for improvement. • Align the implementation plan with funding support including the Fleming Fund support where relevant. • Improve the national coordination of the implementation of AMR surveillance strategies in the different sectors. • Monitor the implementation plan outputs and collate experiences for future adjustments. The implementation plan will be operationalized by technical departments in the respective Ministries with support of implementing partners and other AMR stakeholders on key areas as detailed below. The coordination, monitoring and evaluation of the implementation plan will be conducted by the AMRCC according to their defined terms of reference.

2.1. Strategic Objective 1: Improve awareness and understanding of AMR through effective communication, education, and training The focus of this strategic objective is to raise the awareness of the community on AMR through different means at different levels of the society. The relevant experts and officers in charge of communication, community mobilization and health promotion in respective ministries must be up to date with the current global and country AMR status, and equipped with the required knowledge and resources to raise awareness on issues pertaining to AMR in the country. They will be expected to work closely with health workers, animal & plant health workers, and environmental experts at all levels under one health approach to contribute to increasing literacy on AMR in the Kingdom of Eswatini. This will be achieved through information, education, and communication (IEC) products developed and disseminated to cross-sectoral audiences including schools, the public and AMR stakeholders in various institutions. Detailed activities that will be undertaken to improve awareness and understanding of AMR are outlined in Table 1. Page | 11 Table 1. Improve awareness and understanding of AMR through effective communication, education, and training. Responsible Priority output Activity Lead Supporting ICAP, WHO, OIE, Training: Provide training to health workers, AMRCC, MOH, FAO animal and plant health practitioners, MOA, MONRE Parliament, environmentalists, private sector, NGOs, CANGO, FESBC, Judiciary Commission Stakeholder Awareness: conduct awareness ICAP, on current global and country AMR status AMRCC, MOH, WHO, activities with Media Houses, MOA, MONRE OIE, Parliamentarians, Judiciary, Community FAO leaders World Antimicrobials Awareness Week ICAP, (WAAW): Organize and conduct WAAW in WHO, Eswatini that convenes scientists, human and AMRCC, MOH, OIE, animal health professionals, government, MOA, MONRE FAO, national and international AMR stakeholders, Rotary Club and the public. Training on management of antimicrobial agents: Facilitate the raising of awareness Raise awareness ICAP, about sound management of antimicrobial AMRCC, MOH, on AMR to WHO, medicines at all levels, and across sectors and MOA, MONRE promote OIE, behavioral government departments (regulators, FAO change wholesalers, suppliers) Public awareness: ICAP, WHO, • Conduct public awareness OIE, FAO, campaigns on proper use of Rotary Club antimicrobials in humans, animals, Mobile service AMRCC, MOH, and the environment, and on providers, MOA, MONRE infection, prevention, and control. Municipalities, Ministry of Tinkhundla & Development (MTD) • Conduct national review workshops ICAP, WHO, on strategies of AMR control, OIE, FAO, strategies on awareness creation – Rotary Club impact of awareness campaigns or Mobile service AMRCC, MOH, feedback on these - and reviewing & providers, MOA, MONRE redesigning IEC materials. Municipalities, Ministry of Tinkhundla & Development (MTD) Page | 12 Responsible Priority output Activity Lead Supporting Producing Information, Education and Communication / Social and Behavior Change Communication (IEC/SBCC) materials: Develop & distribute IEC and SBCC material on proper usage of antimicrobial agents by humans and in animals and disseminate information on appropriate use of antimicrobials to stakeholders and the community, as necessary. Information will include the following ICAP, messages: WHO, i. Promote rational/appropriate use of OIE, antimicrobials. FAO, ii. Educate/train public on good AMRCC, MOH, UNESCO, practices that will reduce infection, MOA, MONRE UNICEF, CANGO and on use of antimicrobials for Traditional Healers growth promotion and clinical Organization treatment purposes. (THO) iii. Provide regular, up-to-date, and unbiased medicine information to veterinary & human health providers, animal owners, and communities. iv. Facilitate the raising of awareness about sound management of antimicrobial agents at all levels across sectors and government departments. Awareness creation in schools: • Advocate for sensitization of all school going individuals on IPC and AMR by re-enforcing hand washing ICAP, and sanitation in schools and AMRCC, MOE, WHO, creating awareness through the Tertiary institutions, OIE, following events: MOH, MOA, FAO, i. World hand washing day MONRE UNESCO, (October 15th) UNICEF ii. Distribution of job aids on hand washing techniques iii. World Toilet Day (19th November) ICAP, WHO, • Develop & distribute IEC/BCC MOE, MOH, MOA, OIE, FAO, materials for AMR to schools. MONRE UNESCO, UNICEF Develop or Develop training material: Review and AMRCC, Tertiary ICAP, WHO, strengthen update training materials for AMR curricula in institutions, OIE, FAO, Page | 13 Responsible Priority output Activity Lead Supporting antimicrobial the context of One Health approach for pre- MOH, MOA, UNESCO, training service and in-service trainings. MONRE UNICEF, MOE curricula for training human Advocate for incorporation of AMR AMRCC, MOH, ICAP, WHO, health, containment program in pre- and in-service MOA, MONRE, OIE, FAO, veterinary, and training curriculum for all professionals Tertiary institution UNESCO, environmental involved in AMR containment. UNICEF, UNFPA professionals Advocate for inclusion of AMR containment ICAP, AMRCC, MOH, training in continuous professional WHO, OIE, FAO MOA, MONRE development programs in the three (3) sectors. Annual seminar: Regularly update AMRCC, MOH, ICAP, professionals on new global developments to MOA, MONRE WHO, OIE, FAO mitigating AMR.

2.2. Strategic objective 2: Strengthen the knowledge and evidence base for AMR containment through surveillance and research The key strategy to slowing down or preventing the emergence of AMR is to have a functional surveillance system particularly in the human and animal health sectors. A functional surveillance system will enable the Government of Eswatini to generate accurate and timely data on patterns of antimicrobial resistance, detect new and emerging resistance at an early stage and guide local treatment protocols. It will also enable utilization of AMR data to inform and improve programming and reporting to the global antimicrobial resistance surveillance system (GLASS). Developing a surveillance system will involve a comprehensive cross-sectoral situational analysis/needs assessment to identify current gaps and opportunities in policy guidelines and in existing information system infrastructure for surveillance. It will also involve a review of the current national health research agenda to include AMR. Activities that are planned under this strategic objective are detailed in Table 2. Table 2: Strengthen the knowledge and evidence base for AMR containment through surveillance and research. Responsible Priority output Activity Lead Supporting Research & surveillance needs assessment: ICAP, WHO, Conduct situational analyses/needs assessment AMRCC, MOH, OIE, of 3 sectors involved in AMR surveillance to MOA, MONRE, FAO identify current gaps in policy, guidelines, and National Health Identify current tools for Research and Surveillance in all Research gaps in AMR sectors. Coordination Unit surveillance and research KAP status survey: Conduct a knowledge, AMRCC, MOH, ICAP, WHO, attitude, and practice (KAP) survey among MOA, MONRE OIE, animal, environment, and human health FAO, UNEP stakeholders; regulatory and enforcement Page | 14 Responsible Priority output Activity Lead Supporting bodies; and the public on antimicrobial use and AMR. Conduct regular knowledge assessment on AMRCC, MOH, WHO, OIE, medicines use and adherence in line with MOA, MONRE FAO, UNEP Standard Treatment Guidelines/Essential Medicines List (STG/EML) as per specified conditions. Setting up AMR research agenda: Conduct AMRCC, MOH, ICAP, WHO, AMR-related operational research to identify MOA, MONRE, OIE, FAO and address gaps in the existing national research agenda. Develop an AMR surveillance and research AMRCC, MOH, ICAP, WHO, plan: MOA, MONRE OIE, FAO Develop plans to monitor AMU, AMC, and AMR in all sectors. Establishment of partnership: Identify AMRCC, Ministry of ICAP, WHO, potential collaboration with higher institutions Education (MOE), OIE, FAO, in promoting and conducting AMR research and Tertiary institutions, UNESCO, surveillance. MOH, MOA, MONRE UNICEF Strengthen the National Research Council to AMRCC, MOH, ICAP, WHO, coordinate the research agenda among all MOA, MONRE OIE, FAO sectors. Promote dissemination of research findings at AMRCC, MOH, ICAP, WHO, National and International forums. MOA, MONRE OIE, FAO Identification of sentinel sites: Identify AMRCC, MOH, ICAP, WHO, sentinel sites for implementation of AMR MOA, MONRE OIE, FAO surveillance in all sectors. Renovations: Conduct renovation works of AMRCC, MOH, ICAP, WHO, laboratories to establish capacity for AMR MOA, MONRE OIE, FAO testing. AMRCC, MOH, ICAP, WHO, Equipment/supplies: Equip laboratories with Build capacity in MOA, MONRE OIE, FAO necessary laboratory testing analyzers and AMR surveillance necessary reagents and consumables. for human and Training: Train laboratory personnel in animal AMRCC, MOH, ICAP, WHO, animal health, health (AH) and human health (HH) sectors on MOA, MONRE OIE, FAO environment, and advanced microbiology techniques. agriculture sectors Data management system: AMRCC, MOH, ICAP, WHO, • Build the capacity of the epidemiology MOA, MONRE, OIE, FAO units to collect, analyze and utilize MICT, AMR data to improve programming MPED e.g., renovate, establish, and equip AMR data centers in all sectors. • Conduct quarterly data review meetings. Page | 15 Responsible Priority output Activity Lead Supporting Expansion of sentinel sites: Develop roadmaps AMRCC, MOH, ICAP, WHO, for the expansion of AMR testing into more MOA, MONRE OIE, FAO public health laboratories in all sectors. AMR surveillance in food and drinking water: AMRCC, MOA, ICAP, WHO, Strengthen the identification of resistant MONRE OIE, FAO pathogens and antimicrobial residue monitoring/ testing in food of plant and animal origin and drinking water. AMR surveillance in food animals: Support AMRCC, MOA ICAP, WHO, Veterinary services to build capacity for AMR OIE, FAO surveillance using surveillance in live poultry and poultry meat as an example. Training: Train laboratory staff and sample AMRCC, MOA, MOH ICAP, WHO, handlers on collection, handling, packaging, OIE, FAO and shipping of samples. Residue monitoring: Establish and strengthen AMRCC, MOA, ICAP, WHO, residue monitoring/testing in food of plant and MOH, MONRE OIE, FAO animal origin, and environmental residue monitoring/testing for pharmaceutical manufacturers. Develop structured surveillance systems: AMRCC, MOH, ICAP, WHO, MOA, MONRE OIE, FAO • Develop a defined set of surveillance data elements for the 3 sectors involved in AMR containment e.g., epidemic prone conditions, priority pathogens, vaccine preventable diseases, opportunistic infections (OIs) for HIV/TB. • Examine livestock production systems AMRCC, MOA ICAP, to assess sources likely to contribute OIE, FAO most to potential risk to animal & Establish a human health (prioritization of value comprehensive chains for surveillance) AMR surveillance • Develop a structured surveillance AMRCC, MOH, ICAP, WHO, system system in AMR to enable reporting to MOA, MONRE OIE, FAO national, regional, and international entities e.g., GLASS, OIE, International Plant Protection Convention (IPPC), etc. • Establish a national interoperable AMR AMRCC, MOH, ICAP, WHO, surveillance system in the context of MOA, MONRE OIE, FAO One Health approach with reports combining the 3 sectors involved in AMR. • Implement an AMR surveillance AMRCC, MOH, ICAP, WHO, system through a phased-in process MOA, MONRE OIE, FAO according to the capacities built at all Page | 16 Responsible Priority output Activity Lead Supporting levels (global, national, regional, community) of human, animal, and environmental sectors. • Establish an electronic surveillance AMRCC, MOH, ICAP, WHO, system in the context of IDSR through MOA, MONRE OIE, FAO partnership with public, private, and other related agencies for electronic reporting on AMR. AMU and AMC surveillance: AMRCC, MOH, ICAP, WHO, MOA, MONRE OIE, FAO • Conduct assessments of the current AMU and AMC surveillance systems in all 3 sectors. • Develop AMU/AMC surveillance AMRCC, MOH, ICAP, WHO, protocols/strategies in all sectors. MOA, MONRE OIE,FAO AMRCC, MOH, ICAP, WHO, • Support the collection and analyses of MOA, MONRE OIE, FAO AMU and AMC data from surveillance sites of the 3 sectors as part of strengthening AMR surveillance. AMU, AMC, and AMR reporting: AMRCC, MOH, ICAP, WHO, MOA, MONRE OIE, FAO • Support the dissemination of AMU and AMC surveillance reports to local stakeholders and policy makers, as well as regional and international entities.

2.3. Strategic Objective 3: Reduce the incidence of infection across human, environment, and animal communities and health care through individual and environmental sanitation, hygiene, and infection prevention measures Good infection prevention control (IPC) practices are essential elements in a strategy to contain AMR. The Eswatini AMR strategic action to improve personal and environmental hygiene coupled with IPC measures in both human and animal health sectors will stop the chain of infection and reduce the spread of infections in humans and animals, in food establishments, and in the community. This reduction in infection will in turn decrease the need for antimicrobials and emergence of AMR. Activities that will be undertaken under this strategic objective to enhance IPC, personal, and environmental hygiene are detailed in Table 3. Page | 17 Table 3: Reduce the incidence of infection across human, environment, and animal communities and health care through individual and environmental sanitation, hygiene, and infection prevention measures. Responsible Priority output Activity Lead Supporting Strengthening Implementing IPC AMRCC, MOH, ICAP, WHO, OIE, FAO • Conduct gap assessment in IPC policies MOA & guidelines in the 3 sectors • Develop/Review and update IPC AMRCC, MOH, ICAP, WHO, OIE, FAO policies/guidelines. MOA • Develop/review/update immunization AMRCC, MOH, ICAP, WHO, OIE, FAO policies and guidelines and disseminate MOA them to all healthcare facilities to improve immunization uptake and coverage. • Identification and training of regional AMRCC, MOH, ICAP, WHO, OIE, FAO focal people (Trainer of Trainers) to MOA lead IPC services. • Provide training to service point staff AMRCC, MOH, ICAP, WHO, OIE, FAO (including RHMTs & Extension officers) MOA Strengthen IPC and the community to implement IPC at veterinary policies and guidelines. and human • Strengthen vaccine programs in the AH AMRCC, MOA ICAP, WHO, OIE, health service sector. FAO, Communities, points farm enterprises • Develop an IPC electronic app. AMRCC, MOH, ICAP, WHO, OIE, FAO MOA • Print & Disseminate IPC AMRCC, MOH, ICAP, WHO, OIE, FAO policies/guidelines for animal and MOA human health at service points. • Facilitate installation of hand-washing AMRCC, MOH, ICAP, WHO, OIE, FAO facilities at all service points with safe MOA running water or sanitizers. • Procure and provide materials and AMRCC, MOH, ICAP, WHO, OIE, FAO resources for IPC at all animal and MOA human service points. AMRCC, MOH, ICAP, WHO, OIE, FAO • Implement IPC policies and guidelines. MOA • Monitor implementation of IPC AMRCC, MOH, ICAP, WHO, OIE, FAO guidelines. MOA Policies, regulation & guidelines: AMRCC, MOH, ICAP, WHO, OIE, FAO • Develop/review/update food hygiene MOA Strengthen IPC and safety in food policies/guidelines/standards for food establishments establishments (slaughter sites, food and production/processing sites, communities distributers, restaurants, grocery stores, food vendors). Page | 18 Responsible Priority output Activity Lead Supporting • Inspect food AMRCC, MOA, ICAP, WHO, OIE, FAO establishments/environment and MOH, MONRE slaughter sites to ensure good operational practices and food hygiene. Information dissemination: Print and AMRCC, MOA, ICAP, WHO, OIE, FAO disseminate food hygiene and safety MOH policies/guidelines/standards/procedures for food establishments including developing an electronic app. Training: Provide training to food AMRCC, MOA, ICAP, WHO, OIE, FAO establishment staff to implement food hygiene MONRE policies and guidelines. Awareness: AMRCC, MOH, ICAP, WHO, OIE, FAO • Provide information, education, and MOA, MONRE communication (IEC) materials for proper hand washing at all food service points and key public areas. • Provide IEC materials for proper food AMRCC, MOH, ICAP, WHO, OIE, FAO storage/ environment handling for the MOA, MONRE public at food selling sites. Waste management policy: AMRCC, MOH, ICAP, WHO, OIE, FAO • Finalize the health care waste policy MOA, MONRE, and regulation. EEA AMRCC, MOH, ICAP, WHO, OIE, FAO • Print and disseminate health care AMRCC, MOA waste policies and regulations. MONRE, EEA AMRCC, MOH, ICAP, WHO, OIE, FAO • Quarterly training on health care waste MONRE, MOA, policies and regulations. EEA • Implement and monitor compliance to AMRCC, MOH, ICAP, WHO, OIE, FAO health care waste policies and MOA, MONRE, regulations. EEA • Educate and promote the construction AMRCC, MOH, ICAP, WHO, OIE, FAO of ventilated pit latrines. MONRE, EEA • Train households on waste AMRCC, MOH, ICAP, WHO, OIE, FAO management and disposal practices. MOA, MONRE • Quarterly meetings to enforce the AMRCC, ICAP, WHO, OIE, FAO Environmental Act of 2000. MONRE, EEA • Sensitize designers, development and AMRCC, ICAP, WHO, OIE, FAO implementing partners of water and MONRE, MOH, wastewater treatment facilities on EEA AMR. • Educate, promote, and improve AMRCC, MOA, ICAP, WHO, OIE, FAO practices on the protection of water MONRE, EEA, sources from contamination (Ministry Ministry of of Housing, Communities). Housing & Development Page | 19

2.4. Strategic objective 4: Optimize the use of antimicrobial medicines in human and animal health through AMR stewardship Use of antimicrobials, even when rational and prudent, can precipitate emergence of resistance2. Over-prescription, easy access to over-the-counter medicines, and lack of a regulatory framework on rational use of antimicrobials all contribute towards the emergence of AMR. Strategies that will be used to address optimal use of antimicrobial medicines in Eswatini will target and improve the antimicrobials regulatory framework, availability and use of treatment guidelines, improved prescribing practices by clinicians and veterinary practitioners, and appropriate use of antimicrobials by consumers and farmers. Detailed activities that will be undertaken to actualize these strategies are outlined in Table 4. Table 4: Optimize the use of antimicrobial drugs in humans and animals’ health through AMR stewardship. Responsible Priority output Activity Lead Supporting Develop guidelines on prudent use of AMRCC, MOA ICAP, WHO, OIE, antimicrobial agents in AH sector: FAO • Develop guidelines for good agriculture practices for plant protection. • Audit adherence to guidelines Use of treatment guidelines: AMRCC, MOH ICAP, WHO, OIE, Enforce • Provide support in the FAO interventions development of adult and pediatric aimed at treatment guidelines for infectious improving the diseases based on AMR patterns. use of • Provide training to clinicians in AMRCC, MOH ICAP, WHO, OIE, antimicrobials hospitals and health centers, and FAO nurses in primary care units on up- to-date infectious diseases treatment guidelines. • Monitor the utilization of AMRCC, MOH ICAP, WHO, OIE, bacteriological testing services to FAO inform rational use of antimicrobials. • Activate hospital/health facility AMRCC, MOH ICAP, WHO, OIE, Promote rational FAO PTCs and strengthen their capacity prescribing and to improve the use of good dispensing antimicrobials and other medicines. practices of • Develop National terms of AMRCC, MOH ICAP, WHO, OIE, antimicrobials in reference for AMS committees. FAO humans and animals • Establish AMS Committees and AMRCC, MOH ICAP, WHO, OIE, ensure they have facility TORs FAO 2 https://www.flemingfund.org/wp-content/uploads/bfcda6342f6f0e7ae1337e08b3273a94.pdf Page | 20 Responsible Priority output Activity Lead Supporting (adapted from the national TORs) in health facilities. • Train healthcare workers, AMRCC, MOMA, ICAP, WHO, OIE, veterinary and plant health MOH FAO practitioners on AMC/AMU/AMR principles. • Train animal health workers on AMRCC, MOA ICAP, WHO, OIE, rational use of antimicrobials. FAO • Supportive supervision and audits AMRCC, MOH ICAP, WHO, OIE, of antimicrobials prescribing with FAO onsite feedback to HH sites. • Supportive supervision and audits AMRCC, MOA ICAP, WHO, OIE, of antimicrobials prescribing FAO conducted in AH with feedback to animal and plant health workers. • Collect, analyze, and report AMR AMRCC, MOH ICAP, WHO, OIE, Data on a quarterly basis on all HH FAO sentinel sites. • Train all hospitals and health AMRCC, MOH ICAP, WHO, OIE, centers on AMC/AMU/AMR FAO Support activities. evidence-based • Collect, analyze, and report AMR AMRCC, MOA ICAP, WHO, OIE, selection of data quarterly at the laboratory FAO antimicrobials level in the AH sector. for the essential • Collate annual evidence to guide AMRCC, MOA, MOH ICAP, WHO, OIE, medicines list use of antimicrobials in managing FAO (EML) to infectious diseases in HH and AH. conserve their • Selection of antimicrobials based AMRCC, MOH, MOA ICAP, WHO, OIE, effectiveness on the bacterial susceptibility FAO and longevity profiles in both AH and HH sites. • Profiling of antimicrobial resistance AMRCC, MOH, MOA ICAP, WHO, OIE, patterns in AH and HH. FAO • Provide support in the revision AMRCC, MOH ICAP, WHO, OIE, (add/remove antimicrobials) of FAO STGs/ EML in HH.

2.5. Strategic objective 5: Enhance leadership, governance, coordination, and investment in containing AMR Following the World Health Assembly (WHA) in May 2015 and its call for action, the Government took the first key step by establishing an AMRCC in 2016 with a mandate to coordinate the multi- sectoral implementation of the national action plan to tackle AMR. To be able to perform these duties, the AMRCC will be strengthened to exercise its role and responsibilities according to defined terms of reference and to effect government coordination across the health, agriculture, and environmental sectors. A strengthened AMRCC will also monitor implementation of the National AMR Containment Strategic Plan, work closely with donor and implementing partners Page | 21 to raise awareness, and mobilize resources to accelerate implementation of the strategic plan. A close collaboration with the tripartite representatives (WHO, OIE, FAO) is instrumental to maximize technical support and gauging efforts to international standards in addition to the collaborations with regional organizations such as the African Union (AU), Africa CDC, Southern African Development Community (SADC) and African Society for Laboratory Medicine (ASLM). A One Health Committee (OHC) which will be the highest reporting structure for governance and coordination and leadership of all “One Health” public health related matters of the multi- sector ministries will be established to promote the one health approach to tackle AMR. Membership of the OHC will be as follows: • Director of Health Services, MOH • Director of Veterinary and Livestock Services, MOA • Director of Agriculture/Chief Research Officer, MOA • Director of Water Affairs, MONRE • Director of Eswatini Tourism & Environmental Authority • Subject Matter Chairpersons (to serve as Committee Secretariat) o AMRCC Chairperson/ Co-Chairperson o IHR Focal Person o Rabies Coordination o Communication Focal Persons o Any other organized specific group • CANGO • Country Representatives from WHO, FAO, and United Nations Environmental Program (UNEP). Detailed activities that will be undertaken to enhance governance, coordination and investment are outlined in Table 5. Table 5: Enhance leadership, governance, coordination, and investment in containing AMR Priority output Responsible Activity Lead Supporting Strengthening of the AMRCC functions: AMRCC, MOH, MOA, ICAP, WHO, OIE, • Training on one health Ministry of FAO Strengthen • Revising TOR as needed Commerce, Ministry capacity of the of Finance, CANGO One Health Advocate/ ensure AMR agenda is included OHC, AMRCC ICAP, WHO, OIE, Committee (OHC) in national sector specific strategic plans. FAO to provide co- Ensure that AMR activities are prioritized OHC, AMRCC ICAP, WHO, FAO, ordination in sector specific budget allocation. OIE oversight and Support the commissioning of the AMR OHC, MOH, MOA, ICAP, WHO, OIE, leadership for strategic plan. MONRE, AMRCC FAO AMR containment Facilitate semi-annual OHC meetings. OHC, AMRCC, MOH, ICAP, WHO, OIE, MOA, MONRE FAO Page | 22 Priority output Responsible Activity Lead Supporting Facilitate the development/review of OHC, AMRCC, MOH, ICAP, WHO, OIE, National level Antimicrobial stewardship MOA, MONRE FAO committee TOR. Support the Medicine Regulatory OHC, AMRCC ICAP, WHO, OIE, Authority to review the status of FAO implementation of the Medicines and Related Substances Act 9 of 2016. Promote evidence-based policy OHC, AMRCC, MOH, ICAP, WHO, OIE, development/review and decision making MOA, MONRE FAO through AMR data dissemination, use, as well as increasing literacy on AMR issues. Facilitate the establishments of AMR TWG OHC, AMRCC, MOH, ICAP, WHO, OIE, involving all stakeholders including private MOA, MONRE FAO firms and developmental partners. Facilitate quarterly AMR and AMU/C data AMRCC ICAP, WHO, OIE, sharing, reviews by the TWG and reporting FAO to the AMRCC. Organize validation and dissemination AMRCC ICAP, WHO, OIE, meeting on AMR implementation plan FAO with stakeholders. Support key ministries to organize semi- ICAP, WHO, OIE, Strengthen annual AMR data review meetings to FAO national sensitize stakeholders, providers, policy AMRCC partnership, makers on emerging AMR/AMU/AMC coordination, and issues and formulate recommendations to collaboration at address these issues. all levels Organize quarterly AMRCC meetings to AMRCC ICAP, WHO, OIE, review progress of the implementation FAO plan. Organize round-table forums with OHC, AMRCC ICAP, WHO, OIE, stakeholders to discuss AMR resource FAO mobilization and co-ordination mechanisms. Organize quarterly co-ordination meetings AMRCC, MOH, MOA, ICAP, WHO, OIE, with the Tripartite representatives in MONRE FAO country (WHO, OIE, FAO) to discuss progress, challenges, and gaps in technical support of the AMR strategy Strengthen implementation. regional and Strengthen collaboration with regional AMRCC, OHC ICAP, WHO, OIE, international AMR organizations such as Africa CDC and FAO partnerships and ASLM to build capacity for AMR collaboration surveillance in Eswatini through regular meetings. Collaborate with neighboring and AMRCC, OHC ICAP, WHO, OIE, regional/international partners on AMR FAO containment, research in medicines, diagnostic tools, vaccines, and Page | 23 Priority output Responsible Activity Lead Supporting interventions through exchange update meetings. Establish a one health triad electronic OHC, AMRCC, MOH, ICAP, WHO, OIE, system for adequate regulation and MOA FAO monitoring of medicines importation and distribution. Strengthen cross Ensure import regulation documents for AMRCC, MOA, MOH ICAP, WHO, OIE, border animal and human health sectors are FAO collaboration for available and used at customs offices and importing and borders. exporting plant, Training & Awareness: AMRCC, MOA, ICAP, WHO, OIE, animal and • Provide trainings to Veterinary MONRE FAO human medicines staff working at ports of entry. • Create awareness to customs office staff on the key components of the regulations for human health and agricultural imports. Work closely with customs services to AMRCC, MOH, MOA, ICAP, WHO, OIE, establish systems for tracking of imported MONRE FAO medicines, plants, and animals at ports of entry. Review and Conduct mid and end-term review of AMR AMRCC, OHC ICAP, WHO, OIE, update current strategic plan implementation. FAO National AMR Develop the next 5-year AMR strategic AMRCC, OHC ICAP, WHO, OIE, containment plan (2023 - 2027). FAO strategy Develop a concept note for improving One OHC, AMRCC ICAP, WHO, OIE, Health governance and co-ordination. FAO Strengthen in- country One Advocate for consolidation and OHC, AMRCC, IHR ICAP, WHO, OIE, Health co- strengthening of governance and co- focal point FAO ordination mechanism ordination of all public health issues in the one health context. Page | 24 3. MONITORING AND EVALUATION FRAMEWORK The monitoring and evaluation plan (M&EP) is an important accompaniment to the national AMR containment implementation plan. The key component of the M&EP is the performance framework (Table 6) detailing performance measures (indicators), targets, responsible persons, and timeline for each activity. Implementation of the annual operational plans will detail other components including a logic model, data collection and reporting tools, data sources and data management processes, and reporting frequency. Regular evaluation will also be undertaken at planned intervals to assess whether planned outcomes were achieved. Table 6: Performance Framework for Implementation of the National Antimicrobial Resistance Containment Strategic Plan 2020 – 2025. Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 SO1 Improve awareness and understanding of AMR through effective communication, education, and training Training: Provide training to health Number of health ICAP, workers, animal and plant health workers, private WHO, practitioners, environmentalists, private sector, Veterinary OIE, AMRCC, sector, NGOs practitioners, FAO 1000 MOH, Media Houses, Parliament, X X X X X MOA, Parliamentarians, CANGO, MONRE Judiciary, FESBC, Community Judiciary Raise leaders trained. Commission awareness Number of on AMR to Stakeholder Awareness: conduct 1.1 stakeholders AMRCC, ICAP, promote awareness on current global and country sensitized on MOH, WHO, behavioral AMR status activities with Media Houses, 1000 X X X X X current Global MOA, OIE, change Parliamentarians, Judiciary, Community and Country AMR MONRE FAO leaders status World Antimicrobial Awareness Week Number of ICAP, AMRCC, (WAAW): Organize and conduct WAAW in WAAW events WHO, MOH, Eswatini that convenes scientists, human organized OIE, 5 MOA, X X X X X and animal health professionals, FAO, MONRE government, national and international Rotary Club AMR stakeholders. Page | 25 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 Training on management of antimicrobial AMRCC, agents: Facilitate the raising of awareness ICAP, WHO, Number of MOH, about sound management of antimicrobial OIE, awareness events 300 MOA, X X X X X medicines at all levels, and across sectors FAO organized MONRE and government departments (regulators, wholesalers, suppliers) Public awareness: ICAP, WHO, • Conduct public awareness OIE, FAO, campaigns on proper use of Rotary Club antimicrobials in humans, animals, AMRCC, Mobile and the environment, and on Number of MOH, service infection, prevention, and control. campaigns 15 MOA, providers, X X X X X conducted MONRE Municipalitie s, Ministry of Tinkhundla & Development (MTD) • Conduct national review workshops on strategies of AMR control, strategies of awareness Number of AMRCC, ICAP, WHO, creation – impact of awareness national review MOH, OIE, campaigns or feedback on these - 5 X X X X X workshops MOA, FAO and reviewing & redesigning IEC organized MONRE materials. Producing IEC/SBCC materials: Develop & ICAP, distribute IEC and SBCC material on proper WHO, AMRCC, usage of antimicrobial agents by humans Number of times OIE, MOH, and in animals and disseminate information IEC materials 5 FAO, X X X X X MOA, on appropriate use of antimicrobials to developed UNESCO, MONRE, stakeholders and the community, as UNICEF, necessary. CANGO Page | 26 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 Information will include the following Traditional messages: Healers i. Promote rational/appropriate use Organization of antimicrobials. (THO) ii. Educate/train public on good practices that will reduce infection, and on use of antimicrobials for growth promotion and clinical treatment purposes. iii. Provide regular, up-to-date, and unbiased medicine information to veterinary & human health providers, animal owners, and communities. iv. Facilitate the raising of awareness about sound management of antimicrobial agents at all levels across sectors and government departments. Awareness creation in schools: • Advocate for sensitization of all i. Number of school going individuals on IPC and WHW events 5 AMRCC, AMR by re-enforcing hand washing organized MOE, and sanitation in schools and ii. Number of job Tertiary ICAP, WHO, creating awareness through the aids institutions OIE, FAO, following events: disseminated , X X X X X UNESCO, i. World hand washing (WHW) iii. Number of 5 MOH, UNICEF day (October 15th) WTD events MOA, ii. Distribution of job aids on supported. MONRE hand washing techniques 5 iii. World Toilet Day (WTD) Page | 27 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 • Develop & distribute IEC/BCC Number of AMRCC, materials for AMR to schools. schools MOE, ICAP, WHO, supported with MOH, 953 OIE, FAO, IEC/BCC MOA, X X X X X UNESCO, materials MONRE UNICEF Develop training material: Review and Number of AMRCC, update the training materials for AMR training packages MOE, ICAP, curricula in the context of One Health developed Tertiary 2 per WHO, approach for pre-service and in-service institution, sector OIE, trainings. MOH, X X X X X FAO, MOA, UNESCO, MONRE Develop or UNICEF strengthen antimicrobi Advocate for incorporation of AMR Number of AMR AMRCC, al training containment program in pre- and in-service containment MOH, curricula for ICAP, WHO, training curriculum for all professionals programs MOA, training OIE, FAO, involved in AMR containment. developed, MONRE, human 1 UNESCO, X X

1.2 Tertiary health, UNICEF, institutions veterinary, UNFPA and environmen Number of AMRCC, tal Advocate for inclusion of AMR containment professionals MOH, ICAP, professional training in continuous professional trained 500 MOA, WHO, OIE, X X X s development programs in the three (3) MONRE FAO sectors. Annual seminar: Regularly update Number of AMRCC, ICAP, professionals on new global developments refresher MOH, 500 WHO, OIE, to mitigating AMR. trainings MOA, X X FAO conducted MONRE Page | 28 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 SO2 Strengthen the knowledge and evidence base for AMR containment through surveillance and research Research & surveillance needs Number of needs AMRCC, assessment: Conduct situational assessment MOH, analyses/needs assessment of 3 sectors reports MOA, involved in AMR surveillance to identify disseminated ICAP, MONRE, current gaps in policy, guidelines, and tools 3 (1 per WHO, National X X X for Research and Surveillance in all sectors. sector) OIE, Health FAO, UNEP Research Coordinati on Unit KAP status survey: Conduct a knowledge, KAP report WHO, AMRCC, attitude, and practice survey among animal, OIE, 1 MOH, environment, and human health; regulatory FAO, X X MOA, and enforcement bodies; and the public on UNEP MONRE Identify antimicrobial use and AMR current Conduct regular knowledge assessment on Number of AMRCC, gaps in WHO, medicines use and adherence in line with Assessments MOH,

2.1 AMR OIE, Standard Treatment Guidelines/ Essential Conducted 1 MOA, X X X X X surveillance FAO, Medicines List (STG/EML) as per specified MONRE and UNEP conditions research Setting up AMR research agenda: Conduct Number of 1 report AMRCC, AMR-related operational research per operational per MOH, ICAP, WHO, sector to identify and address gaps in the research reports sector, 1 MOA, OIE, existing national research agenda. identifying gaps combine X X MONRE FAO in AMR research d report from sectors Develop an AMR surveillance and research Number of AMU, 1 plan plan: AMC, AMR plans per AMRCC, Develop plans to monitor AMU, AMC, and developed sector, 1 MOH, ICAP, WHO, AMR in all sectors. combine X X MOA, OIE, FAO d plan MONRE from all sectors Page | 29 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 Establishment of partnership: Identify Number of AMRCC, ICAP, potential collaboration with higher meetings MOE, WHO, institutions in promoting and conducting conducted with Tertiary OIE, AMR research and surveillance. higher 5 institution, X X X X X FAO, institutions on MOH, UNESCO, AMR MOA, UNICEF MONRE Strengthen the National Research Council Number of to coordinate the research agenda among capacitation AMRCC, all sectors. workshops 10 (2 per MOH, ICAP, WHO, X X X X X conducted with year) MOA, OIE, FAO the National MONRE Research Council Promote dissemination of research findings Number of 8 (2 per at National and International forums. dissemination year: 1 AMRCC, workshops National, MOH, ICAP, WHO, X X X X attended/conduct 1 MOA, OIE, FAO ed Internati MONRE onal) Identification of sentinel sites: Identify Number of AMRCC, ICAP, 8 (4 HH, sentinel sites for implementation of AMR sentinel sites MOH, WHO, 2 AH, 2 Build surveillance in 3 sectors. identified in 3 MOA, OIE, X X X Environ capacity in sectors MONRE, FAO ment) AMR surveillance Renovations: Conduct renovation works of Number of AMRCC, 8 (4 HH, ICAP, for human laboratories to establish capacity for AMR laboratories MOH, 2 AH,2 WHO, 2.2 and animal testing. renovated MOA, X X X Environ OIE, health, MONRE, ment) FAO environmen t, and Equipment/supplies: Equip laboratories Number of AMRCC, ICAP, 8 (4 HH, agriculture with necessary laboratory testing analyzers laboratories that MOH, WHO, 2 AH,2 sectors and necessary reagents and consumables. receive lab MOA, OIE, X X X X X Environ equipment and MONRE, FAO ment) supplies Page | 30 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 Training: Train laboratory personnel in AH Number of AH AMRCC, ICAP, and HH sectors on advanced microbiology and HH personnel MOH, WHO, techniques. trained TBC MOA, X X X X X OIE, MONRE FAO, Data management system: Number of 4 Data • Build the capacity of the strengthened AMRCC, centers epidemiology units to collect, sectoral data MOH, ICAP, (1 central analyze and utilize AMR data to centers MOA, WHO, and 3 improve programming e.g., MONRE, OIE, X X X X X sectoral) renovate, establish, and equip AMR MICT, FAO 20 data centers in all sectors. MPED meetings • Conduct quarterly data review meetings Expansion of sentinel sites: Develop Number of public 11 AMRCC, ICAP, roadmaps for the expansion of AMR testing health (9 HH, 1 MOH, WHO, into more public health laboratories in all laboratories AH, 1 X X X X X MOA, OIE, sectors. conducting AMR environm MONRE FAO testing ent) AMR surveillance in food and drinking Number of 6 water: Strengthen the identification of different food (poultry, resistant pathogens and antimicrobial types undergoing pork, AMRCC, ICAP, WHO, residue monitoring/ testing in food of plant residue testing beef, MOA, OIE, FAO X X X X X and animal origin and drinking water. dairy, MONRE water, vegetabl es) AMR surveillance in food animals: Support Number of Veterinary services to build capacity for protocols ICAP, WHO, AMR surveillance using surveillance in live developed for AMRCC, 2 OIE, FAO X X poultry and poultry meat as an example. surveillance in MOA poultry Page | 31 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 Percentage of AMRCC, ICAP, WHO, Training: Train laboratory staff and sample staff trained on MOA, 100% OIE, FAO X X X X X handlers on collection, handling, packaging, sample collection MOH and shipping of samples. Residue monitoring: Establish and Number of AMRCC, strengthen residue monitoring/testing in testing sites MOA, ICAP, WHO, food of plant and animal origin, and established 2 X X X MOH, OIE, FAO environmental residue monitoring/testing MONRE for pharmaceutical manufacturers. Develop structured surveillance systems: Number of • Develop defined set of surveillance surveillance 1 central AMRCC, ICAP, data elements for 3 sectors frameworks framewo MOH, WHO, involved in AMR containment e.g., developed and rk with 3 MOA, OIE, X X X epidemic prone conditions, priority disseminated sector MONRE FAO pathogens, vaccine preventable represen disease, opportunistic infections tation (OIs) for HIV/TB. • Develop a structured surveillance Number AMRCC, system in AMR to enable reporting surveillance ICAP, MOH, Establish a to national, regional, and information 1 WHO, MOA, X X comprehens international entities e.g., GLASS, systems OIE, MONRE 2.3 ive AMR OIE, International Plant Protection developed. FAO surveillance Convention (IPCC), etc. system • Establish a national interoperable Number of AMRCC, ICAP, AMR surveillance system in the reports 20 MOH, WHO, context of One Health approach disseminated (4 per MOA, OIE, X X X X X with reports combining 3 sectors year) MONRE FAO involved in AMR. • Implement an AMR surveillance Number of levels AMRCC, ICAP, system through a phased-in reporting on AMR 20 MOH, WHO, process according to the capacities (4 per MOA, OIE, X X X X X built at all levels (global, national, year) MONRE FAO regional, community) of human, animal, and environmental sectors Page | 32 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 • Establish an electronic surveillance A surveillance AMRCC, ICAP, system in the context of IDSR system MOH, WHO, through partnership with public, established 1 MOA, OIE, X X X private, and other related agencies MONRE FAO for electronic reporting on AMR. AMU and AMC Surveillance: Surveillance AMRCC, ICAP, WHO, • Conduct assessments of the report compiled 3 (1 per MOH, OIE, X current AMU and AMC surveillance sector) MOA, FAO systems in all 3 sectors MONRE Surveillance AMRCC, ICAP, WHO, • Develop AMU/AMC surveillance protocols for 3 (1 per MOH, OIE, X X protocols/strategies in all 3 sectors. AMU/AMC sector) MOA, FAO developed MONRE • Support the collection and analyses AMU/AMC data AMRCC, ICAP, of AMU and AMC data from collected on 20 MOH, WHO, surveillance sites of the 3 sectors as quarterly basis (4 per MOA, X X X X X OIE, part of strengthening AMR year) MONRE FAO surveillance AMU, AMC, and AMR Reporting: Number of AMRCC, 20 ICAP, Support the dissemination of AMU and reports MOH, (quarterl WHO, AMC surveillance reports to local disseminated MOA, X X X X X y per OIE, stakeholders and policy makers, as well as stakeholders and MONRE year) FAO regional and international entities. policy Makers. Reduce the incidence of infection across human, environment, and animal communities and health care through individual and S03 environmental sanitation, hygiene, and infection prevention measures 3 reports Strengthen Strengthening Implementing IPC (1 per AMRCC, Report on gaps IPC at • Conduct gap assessment on IPC sector) MOH, ICAP, WHO, identified in each X X veterinary policies & guidelines in the 3 and 1 MOA, OIE, FAO sector 3.1. and human sectors combine MONRE health d report service Number of IPC 6 (1 per • Develop/Review and update IPC AMRCC, ICAP, WHO, points policies/guideline sector X X policies/guidelines MOH, OIE, FAO s and Page | 33 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 developed/review twice MOA, ed during MONRE the period) Number of • Develop/review/update Immunization immunization policies and policies & AMRCC, guidelines and disseminate them to 325 ICAP, WHO, guidelines MOH, X X X X X all healthcare facilities to improve (MOH) OIE, FAO developed/review MOA immunization uptake and ed/updated and coverage. disseminated Number focal AMRCC, • Identification and training of people identified MOH, ICAP, WHO, regional focal people (Trainer of 20 X X and trained on MOA, OIE, FAO Trainers) to lead IPC services. IPC MONRE • Provide training to service point Percentage of staff (including RHMTs & Extension service point staff AMRCC, ICAP, WHO, officers) and the community to trained on IPC 100% MOH, X X X X X OIE, FAO implement IPC policies and policies and MOA guidelines. guidelines • Strengthen vaccine programs in AH Vaccine ICAP, WHO, the AH sector. programs OIE, FAO, AMRCC, strengthened Communities X X X X X MOA , farm enterprises AMRCC, IPC electronic app 2 (MOA, ICAP, WHO, • Develop an IPC electronic app. MOH, developed MOH) OIE, FAO MOA IPC • Print & Disseminate IPC (325 AMRCC, policies/guideline ICAP, WHO, policies/guidelines for animal and MOH, MOH, X X X X s for AH and HH OIE, FAO human health at service points. 10MOA) MOA at service points Page | 34 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 • Facilitate installation of hand- % of service AMRCC, washing facilities at all service ICAP, WHO, points with hand- 100% MOH, X X X X X points with safe running water or OIE, FAO washing facilities MOA sanitizers. % of AH & HH • Procure and provide materials and service points AMRCC, ICAP, WHO, resources for IPC at all animal and with IPC 100% MOH, X X X X X OIE, FAO human service points. materials & MOA resources IPC policies and AMRCC, • Implement IPC policies and ICAP, WHO, guidelines 2 MOH, X X X X X guidelines. OIE, FAO implemented MOA % of personnel AMRCC, • Monitor implementation of IPC utilizing IPC ICAP, WHO, 100% MOH, X X X guidelines. guidelines at OIE, FAO MOA service points Policies, regulation, and guidelines: Food hygiene & • Develop/review/update food safety hygiene and safety policies/guideline AMRCC, policies/guidelines/standards for s/standards ICAP, WHO, 2 MOH, X X X X X food establishments (slaughter developed/review OIE, FAO MOA sites, food production/processing ed/updated Strengthen sites, distributers, restaurants, IPC in food grocery stores, food vendors). establishme • Inspect food Number of 3.2. nts and establishments/environment and inspection visits AMRCC, 10 (2 per ICAP, WHO, communitie slaughter sites to ensure good conducted MOH, X X X X X year) OIE, FAO s operational practices and food MOA hygiene. Information dissemination: Print and % of food disseminate food hygiene and safety hygiene & safety AMRCC, ICAP, WHO, policies/guidelines/standards/procedures for policies/guideline 100% MOA, X X X X OIE, FAO food establishments including developing s/standards/proce MOH an electronic application. dures printed & Page | 35 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 disseminated for food establishments Training: % food • Provide training to food establishments AMRCC, ICAP, WHO, establishment staff to implement staff trained on 100% MOA, X X X X X OIE, FAO food hygiene policies and implementation MONRE guidelines. of food hygiene % of food service Awareness: points and key AMRCC, • Provide information, education, public areas with MOH, ICAP, WHO, and communication (IEC) materials 100% X X X X X IEC materials for MOA, OIE, FAO for proper hand washing at all food proper hand MONRE service points and key public areas. washing % of food selling • Provide IEC materials for proper sites with IEC AMRCC, food storage/ environment materials for MOH, ICAP, WHO, 100% X X X X X handling for the public at food proper food MOA, OIE, FAO selling sites. storage/environm MONRE ent handling Waste management policy: Finalized health AMRCC, • Finalize the health care waste care waste policy MOH, policy and regulation. and regulation MOA, MONRE, ICAP, WHO, 2 Eswatini X X X OIE, FAO Environme ntal Authority (EEA) Number of health AMRCC, • Print and disseminate health care care waste 325 MOH ICAP, WHO, MOH, X X X waste policies and regulations. policies and 10 MOA OIE, FAO MOA, EEA regulations Page | 36 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 printed and disseminated. Number of AMRCC, trainings on • Quarterly training on health care MOH, ICAP, WHO, health care waste 80 X X X waste policies and regulations. MONRE, OIE, FAO policies and MOA, EEA regulations Number of Awareness on waste management, sensitized health compliance facilities and • Quarterly sensitization of health health service AMRCC, facilities, veterinary clinics, and points on proper MOH, ICAP, WHO, 80 X X X X X other health service points on disposal of MONRE, OIE, FAO proper disposal of expired or expired or MOA, EEA obsolete antimicrobials to reduce obsolete AMR. antimicrobials to reduce AMR • Annual sensitization and enforcement for manufacturing % of AMRCC, industries on adherence to effluent manufacturing MOH, ICAP, WHO, 100% X X X X X disposal and waste management industries MONRE, OIE, FAO guidelines for the environment to sensitized MOA, EEA safeguard against AMR. • Implement and monitor number of health AMRCC, compliance to health care waste care waste MOH, ICAP, WHO, policies and regulations. policies and 3 MOA, X X X X X OIE, FAO regulations MONRE, implemented EEA AMRCC, % of facilities MOA, complying to the ICAP, WHO, 100% MOH, X X X waste policies OIE, FAO MONRE, and regulations EEA Page | 37 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 % of eligible households AMRCC, • Educate and promote the trained on MOH, ICAP, WHO, construction of ventilated pit 100% X X X X X construction of MONRE, OIE, FAO latrines. ventilated pit EEA latrines AMRCC, MOH, MOA, % of households • Train households on waste MONRE, trained on waste ICAP, WHO, management and disposal 100% Ministry of X X X X X management and OIE, FAO practices. Housing & disposal practices Urban Developme nt • Quarterly meetings to enforce the Number of AMRCC, Environmental Act of 2000. engagement MONRE, sessions with the MOH, EEA, EEA Ministry of ICAP, WHO, 20 X X X X X management Housing & OIE, FAO Urban Developme nt • Sensitize designers, development Number of and implementing partners of sensitization water and wastewater treatment sessions held with facilities on AMR designers, AMRCC, development & ICAP, WHO, 20 MONRE, X X X X X implementing OIE, FAO MOH, EEA partners of water and wastewater treatment facilities on AMR. Page | 38 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 AMRCC, % of communities MOA, trained on the MONRE, • Educate, promote, and improve protection of EEA, ICAP, WHO, practices on the protection of 100% X X X X X water sources Ministry of OIE, FAO water sources from contamination. from Housing & contamination Developme nt SO4 Optimize the use of antimicrobial drugs in humans and animals’ health through AMR stewardship Develop guidelines on prudent use of Number of antimicrobial agents in AH sector: guidelines for • Develop guidelines for good good agriculture AMRCC, ICAP, WHO, 1 X X X X X agriculture practices for plant practices for plant MOA OIE, FAO protection. protection • Audit adherence to guidelines developed Use of treatment Guidelines: Number of adult • Provide support in the and pediatric development of adult and pediatric treatment Enforce AMRCC, ICAP, WHO, treatment guidelines for infectious guidelines for 325 X X X intervention MOH OIE, FAO diseases based on AMR patterns. infectious s aimed at diseases 4.1. improving developed the use of antimicrobi • Provide training to clinicians in Number of hospitals and health centers, and Clinicians trained als nurses in primary care units on up- on infectious AMRCC, ICAP, WHO, 4000 X X X X to-date infectious diseases diseases MOH OIE, FAO treatment guidelines. treatment guidelines • Monitor the utilization of % of eligible bacteriological testing services to prescriptions AMRCC, ICAP, WHO, inform rational use of antibiotics. informed by 100% X X X X X MOH OIE, FAO Culture and antimicrobial Page | 39 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 sensitivity testing (AST) • Activate hospital/health facility PTCs and strengthen their capacity % of proposed AMRCC, ICAP, WHO, to improve the use of PTC activities 100% X X X X X MOH OIE, FAO antimicrobials and other completed medicines. • Develop National terms of AMS TORs AMRCC, ICAP, WHO, 1 X reference for AMS committees. developed MOH OIE, FAO • Establish AMS Committees and ensure they have facility TORs AMS committees AMRCC, ICAP, WHO, 14 X X Promote (adapted from the national TORs) established MOH OIE, FAO rational in health facilities. prescribing Number of HCWs, and good veterinary and • Train healthcare workers (HCWs), dispensing plant health AMRCC, 4.2. veterinary and plant health ICAP, WHO, practices of practitioners 5500 MOH, X X X X X practitioners on AMC/AMU/AMR OIE, FAO antimicrobi trained on MOA principles. als in AMC/AMU/AMR humans and principles animals Train animal and plant health workers on Percentage of rational use of antimicrobials. Veterinary animal health workers AMRCC, ICAP, WHO, 100% X X X X X trained on MOA OIE, FAO rational use of antimicrobials Supportive supervision and audits of Number of Antibiotics prescribing audits with onsite supportive AMRCC, ICAP, WHO, feedback to HH sites. supervisions, 56 X X X X X MOH OIE, FAO prescription audits, and Page | 40 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 feedback meetings conducted Supportive supervision and audits of Number of Antibiotics prescribing conducted in AH supportive with onsite feedback to animal and plant supervisions, health workers prescription 8 (1 per AMRCC, ICAP, WHO, X X audits, and quarter) MOA OIE, FAO feedback meetings conducted Collect, analyze, and report AMR data on a Number of AMR quarterly basis on all HH sentinel sites. Quarterly reports AMRCC, ICAP, WHO, 20 X X X X X from HH shared MOH OIE, FAO with AMRCC Train all hospitals and health centers on Number of Support AMC/AMU/AMR activities. facilities trained evidence- AMRCC, ICAP, WHO, on 8 X X X X based MOH OIE, FAO AMC/AMU/AMR selection of activities antimicrobi Collect, analyze, and report AMR data Number of AMR als for the quarterly at the laboratory level in the AH Quarterly reports AMRCC, ICAP, WHO, essential 20 X X X X X 4.3. sector. from AH shared MOA OIE, FAO medicines with AMRCC list (EML) to Collate annual evidence to guide use of Number of desk AMRCC, conserve ICAP, WHO, antibiotics in managing infectious diseases review reports of 5 MOA, X X X X X their OIE, FAO in HH and AH. AMR evidence MOH effectivenes s and Selection of antibiotics based on the % of eligible ICAP, WHO, longevity bacterial susceptibility profiles in both AH samples with AST 100% AMRCC, OIE, FAO and HH sites. results in AH MOH, % of eligible MOA ICAP, WHO, 100% X X X X X prescriptions in OIE, FAO Page | 41 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 HH accompanied by AST results Profiling of antimicrobial resistance patterns % of resistant AMRCC, ICAP, WHO, in AH and HH. antibiotics <10% MOH, X X X X X OIE, FAO identified MOA STGs/EML Provide support in the revision (add/remove AMRCC, ICAP, WHO, revised on a 2- 2 X X X X antibiotics) of STGs/ EML in HH MOH OIE, FAO year basis SO5 Enhance leadership, governance, coordination, and investment in containing AMR Strengthening of the AMRCC functions: Number of ICAP, WHO, • Training on one health trainings and 4 AMRCC, X OIE, FAO • Revising TORs as needed revised TORs Advocate/ ensure AMR agenda is included in All sectors with OHC, ICAP, WHO, national sector specific strategic plans AMR 3 X Strengthen AMRCC OIE, FAO plan/component capacity the Ensure that AMR activities are prioritized in Key ministry One Health OHC, ICAP, WHO, sector specific budget allocation budgets with 3 X X X X X Committee AMRCC FAO, OIE AMR component (OHC) to provide co- Support the commissioning of the AMR AMR strategic OHC, 5.1. ordination strategic plan plan launched AMRCC, ICAP, WHO, oversight and disseminated 1 MOH, X OIE, FAO and MOA, leadership MONRE for AMR Facilitate semi-annual OHC meetings Number of OHC OHC, containmen meetings AMRCC, ICAP, WHO, t 10 MOH, X X X X X OIE, FAO MOA, MONRE Facilitate the development/review of Approved TORs OHC, ICAP, WHO, National level Antimicrobial stewardship in place 1 AMRCC, X OIE, FAO committee TOR MOH, Page | 42 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 MOA, MONRE Support the Medicine Regulatory Authority Number of review to review the status of implementation of meetings OHC, ICAP, WHO, 5 X X X X the Medicines and related substances act AMRCC OIE, FAO X 9of2016 Promote evidence-based policy Number of review OHC, development/review and decision making meetings AMRCC, ICAP, WHO, through AMR data dissemination, use, as conducted 5 MOH, X X X X X OIE, FAO well as increasing literacy on AMR issues. MOA, MONRE Facilitate the establishments of AMR TWG established AMR OHC, involving all stakeholders including private TWG AMRCC, ICAP, WHO, firms and developmental partners. 1 MOH, X X OIE, FAO MOA, MONRE Facilitate quarterly AMR and AMU/C data Number of review ICAP, WHO, sharing, reviews by the TWG and reporting meetings 20 AMRCC X X X X X OIE, FAO to the AMRCC. conducted Organize validation and dissemination Number of meeting on AMR implementation plan with dissemination ICAP, WHO, Strengthen 3 AMRCC X stakeholders. meetings OIE, FAO national partnership, Support key ministries to organize semi- Number of AMR coordinatio annual AMR data review meetings to data review 5.2. n, and sensitize stakeholders, providers, policy meetings ICAP, WHO, collaboratio 10 X X X X X makers on emerging AMR/AMU/AMC issues AMRCC OIE, FAO n at all and formulate recommendations to address levels these issues. Organize quarterly AMRCC meetings to Number of review ICAP, WHO, review progress of the implementation plan. meetings 20 AMRCC X X X X X OIE, FAO Page | 43 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 Organize round-table forums with Number of stakeholders to discuss AMR resource meetings OHC, ICAP, WHO, 2 X X X X X mobilization and co-ordination AMRCC OIE, FAO mechanisms. Organize quarterly co-ordination meetings Number of with the Tripartite representatives in meetings country (WHO, OIE, FAO) to discuss ICAP, WHO, 20 AMRCC X X X X X progress, challenges, and gaps in technical OIE, FAO support of the AMR strategy Strengthen implementation. regional Strengthen collaboration with regional Number of and organizations such as Africa CDC and ASLM meetings AMRCC, ICAP, WHO, 10 X X X X X internation to build capacity for AMR surveillance in OHC OIE, FAO 5.3. al AMR Eswatini through regular meetings partnership Collaborate with neighboring and Number of s and regional/international partners on AMR meetings AMRCC, ICAP, WHO, collaboratio containment, research in medicines, 5 X X X X X OHC OIE, FAO n diagnostic tools, vaccines, and interventions through exchange update meetings. Establish a one health triad electronic Electronic system system for adequate regulation and in place MOH, ICAP, WHO, 1 X X monitoring of medicines importation and MOA OIE, FAO distribution. Strengthen Ensure import regulation documents for Import regulation AMRCC, cross border animal and human health sectors are document in ICAP, WHO, 2 MOA, X X collaboratio available and used at customs offices and place OIE, FAO MOH n for borders. importing Training and awareness: Number of 5.4. and • Provide trainings to veterinary staff customs officials AMRCC, exporting working at ports of entry. trained ICAP, WHO, 100 MOA, X X X X plant, • Create awareness to customs staff OIE, FAO X animal, and MONRE on the regulations for human health and agricultural imports. Page | 44 Responsible Timeline Activity Performance Objective Key activities Target Lead Supporting Y Y Y Y Y No measure 1 2 3 4 5 human Work closely with customs services to Systems AMRCC, medicines establish systems for tracking of imported established MOH, ICAP, WHO, medicines, plants, and animals at ports of 1 X X X MOA, OIE, FAO entry. MONRE Conduct mid and end-term review of AMR End term review AMRCC, ICAP, WHO, 2 X X strategic plan implementation. conducted OHC OIE, FAO Develop the next 5-year AMR strategic plan Follow on AMRCC, ICAP, WHO, (2023-2027). strategic plan in 1 X OHC OIE, FAO place Develop a concept note for improving One One Health Strengthen OHC, ICAP, WHO, Health governance and co-ordination. Concept note in 1 X X in-country AMRCC OIE, FAO place One Health

5.6. Advocate for consolidation and Number of OHC, co- strengthening of governance and co- advocacy AMRCC, ICAP, WHO, ordination 5 X X X X X mechanism ordination of all public health issues in the meetings IHR focal OIE, FAO one health context conducted point Page | 45