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1、Sustaining Action Against Antimicrobial Resistance i Sustaining Action Against Antimicrobial Resistance A CASE SERIES OF COUNTRY EXPERIENCESPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedSustaining Action Against Antimicrobial Resistan
2、ce A CASE SERIES OF COUNTRY EXPERIENCESCopyright 2022 by International Bank for Reconstruction and Development/The World Bank and World Health Organization1818 H Street NW,Washington,DC 20433 Telephone:202-473-1000;Internet:www.worldbank.org Some rights reserved.This work is available under the Crea
3、tive Commons Attribution-3.0 IGO license(CC BY 3.0 IGO)https:/creativecommons.org/licenses/by/3.0/igo/.Suggested citation.Sustaining Action Against Antimicrobial Resistance:A Case Series of Country Experiences.Washington,DC:World Bank and the World Health Organization;2022.License:CC BY 3.0 IGO.The
4、findings,interpretations,and conclusions expressed in this work do not necessarily reflect the views of The World Bank,its Board of Executive Directors,or the governments they represent,or those of WHO.The World Bank and WHO do not guarantee the accuracy,completeness,or currency of the data included
5、 in this work and does not assume responsibility for any errors,omissions,or discrepancies in the information,or liability with respect to the use of or failure to use the information,methods,processes,or conclusions set forth.The boundaries,colors,denominations,and other information shown on any ma
6、p in this work do not imply any judgment on the part of The World Bank and/or WHO concerning the legal status of any territory or the endorsement or acceptance of such boundaries.Terminology used to refer to countries,territories and areas as well as representation of countries,territories and areas
7、,including delimitation of frontiers or boundaries,in this publication follows the institutional style and practice of the World Bank as lead publishing organization,and may be at variance with those used by the WHO.Sustaining Action Against Antimicrobial Resistance 3 TABLE OF CONTENTSTABLE OF CONTE
8、NTSAcknowledgements 4Acronyms 5Executive Summary 6Introduction 12WHO Costing and Budgeting Tool for National Action Plans on Antimicrobial Resistance 15Sierra Leone:Prioritizing for Impact 16Country Context 16Using the WHO AMR Costing and Budgeting Tool 16Accelerating Country Action on Antimicrobial
9、 Resistance 19Burkina Faso:Sustaining Political Commitment 20Country Context 20Key Successes 20Future Opportunities 22Jordan:Data for Action 24Country Context 24Key Successes 24Future Opportunities 26Malawi:Effective Governance for Action 28Country Context 28Key Successes 29Future Opportunities 31Co
10、nclusion 32More Information and Additional Resources 33References 354 Sustaining Action Against Antimicrobial Resistance ACKNOWLEDGEMENTSThis report was a collaboration between the World Health Organization(WHO)and the World Bank.The WHO team was led by Anand Balachandran,Unit Head of AMR National A
11、ction Plans and Monitoring.The World Bank team was led by Naomi Rupasinghe and Tonny Muthee,Health Specialists in the Health Nutrition and Population Global Practice,and Sarah Bolongaita(Consultant,World Bank)was the Lead Author.Zlatina Dobreva(Technical Officer,WHO),Breeda Hickey(Technical Officer,
12、WHO),Sarah Paulin-Deschenaux(Technical Officer,WHO),Nienke Bruinsma(Technical Officer,WHO),and Alessandro Patriarchi(Consultant,WHO)contributed to the development and review of the content.The team is grateful for the support and guidance provided by Feng Zhao(Practice Manager,Global Engagement,Heal
13、th,Nutrition and Population Global Practice),and Juan Pablo Uribe(Global Director,Health,Nutrition and Population Global Practice).The following colleagues also provided guidance and inputs:Akiko Kitamura,Chiho Suzuki,Collins Zamawe,Ernest Massiah,Franck Cesar Jean Berthe,Gaston Sorgho,Hugh Riddell,
14、Kofi Amponsah,Magnus Lindelow,Moussa Dieng,Rekha Menon,Sherin Varkey,Takahiro Hasumi,Aissatou Chipkaou and Marize de Fatima Santos(from the World Bank)and Ponnu Padiyara(from WHO).This case series was also supported by the collaboration and inputs of Erta Kalanxhi and Jessica Craig from the One Heal
15、th Trust,and the following country team members:Sierra Leone:Anna Maruta(WHO,Sierra Leone)and Dr Joseph Sam Kanu(Deputy Manager,National Disease Surveillance Programme,Ministry of Health and Sanitation)Burkina Faso:Ruth Sawadogo(Market Surveillance and Quality Control of Health Products,Burkina Faso
16、),Flicit Nana(Quality Care and Patient Safety,Burkina Faso),Zackaria Gansan(Burkinabe Observatory for Quality and Safety of Care,Burkina Faso),Rasmata Oudraogo(AMR Committee,Burkina Faso)Jordan:Lora Alsawalha(WHO,Jordan),Bassim Zayed(WHO,Jordan),Hayaa Banat(Senior Pharmacovigilance Specialist,Jordan
17、 Food&Drug Administration),Ala Ben Tareif(Head of IPC department,Ministry of Health and national AMR focal point),Abeer Mowaswis(Head of Health Awareness department),Zina Halsa(Director,Pharmacy and Clinical Pharmacy Directorate,Ministry of Health),Rola Ghanem(GLASS focal point and head of microbiol
18、ogy at Central Public Health Laboratories,Ministry of Health).Malawi:Watipaso Kasambra(AMRNCC Coordinator,Ministry of Health and Population,Laboratory Services,Malawi),Paul Kawale(African Institute for Development Policy,Malawi),Owen Musopole(Ministry of Health and Population,Malawi),Charles Mwansam
19、bo(Ministry of Health and Population,Malawi),Kenneth Nyoni(Ministry of Health and Population,Malawi),and Ellen Nzima(Ministry of Health and Population,Malawi)Funding for these case studies was provided to WHO by the Government of the Kingdom of Saudi Arabia,the Government of the United Kingdom of Gr
20、eat Britain,and Northern Ireland(UK Aid/Fleming Fund),the Government of the Republic of Korea(Korea International Cooperation Agency KOICA)and to the World Bank by the Government of Denmark.Sustaining Action Against Antimicrobial Resistance 5 TABLE OF CONTENTSACRONYMSAFIDEPAfrican Institute for Deve
21、lopment PolicyAMCAntimicrobial consumptionAMRAntimicrobial resistanceAMUAntimicrobial useAWaReAccess,watch,reserve(classification of antibiotics)CDCCenters for Disease ControlCOVID-19Coronavirus Disease 2019DRUMDrivers of Resistance in Uganda and MalawiFAOFood and Agricultural OrganizationGLASSGloba
22、l Antimicrobial Resistance and Use Surveillance SystemIDAInternational Development AssociationIPCInfection prevention and controlJARSSJordan National Antimicrobial Resistance Surveillance SystemJFDAJordan Food and Drug AdministrationKOICAKorea International Cooperation AgencyNAPNational Action PlanN
23、CCNational Coordinating CommitteeREDISSERegional Disease Surveillance Systems EnhancementTrACSSTripartite Antimicrobial Resistance Country Self-Assessment SurveyUKUnited KingdomUNEPUnited Nations Environment ProgrammeUSDUnited States dollarWAAWWorld Antimicrobial Awareness WeekWASHWater,sanitation,a
24、nd hygieneWHOWorld Health OrganizationWOAHWorld Organisation for Animal HealthEXECUTIVE SUMMARYNasanje,Malawi.Credit:Jenny Matthews/Alamy Stock Photo6 Sustaining Action Against Antimicrobial Resistance 7 Executive SummaryAntimicrobial medications,including antibiotics,have saved millions of lives wo
25、rldwide since the early 1900s when the first modern antimicrobials were discovered.Since then,antimicro-bials have become more central in medicine,underpinning our ability to not only respond to infec-tious disease but also to conduct a host of medical procedures,including life-enhancing surgeries,c
26、ancer chemotherapy,and organ transplantation.Alarmingly,however,many antimicrobials have lost their effectiveness due to antimicrobial resistance(AMR).AMR refers to the ability of microbes bacteria,viruses,fungi,and parasites to evolve in ways that protect them from the medications intended to elimi
27、nate them.While AMR is a naturally occurring evolutionary process,human-led behaviors have rapidly increased its emergence and spread.The main drivers of AMR include:(1)the misuse and overuse of antimicrobials;(2)lack of access to clean water and adequate sanitation for people and animals;(3)poor in
28、fection prevention and control measures in healthcare facilities and farms;(4)limited access to quality,affordable medicines,vaccines,and diagnostics;and(5)lack of awareness and knowledge about AMR.The impact has been drastic:infections are harder to treat,and the risk of severe illness and death is
29、 rising.In 2019,4.95 million deaths were associated with AMR,with the highest burden in western Sub-Saharan Africa at an estimated 27.3 deaths per 100,000.1In recognition of the threat posed by AMR,countries around the world endorsed the World Health Organizations(WHO)Global Action Plan on AMR and c
30、ommitted to developing and implementing their own national action plans(NAPs)on AMR.2 While countries are at various stages of progress,very few have fully implemented all the activities outlined in their NAPs.Only 32 out of 163 countries reporting to the Tripartite3 AMR Country Self-Assessment Surv
31、ey(TrACSS)in 2021 have NAPs on AMR that are currently being implemented and actively monitored,and only six are low-and lower-middle-income countries.4 This is partly due to the complex nature of AMR,which calls for a multisectoral approach that engages stakeholders in human,animal,and plant health;
32、food and feed production;and the environmentthe One Health approach.Financial chal-lenges also pose a significant barrier to sustainable implementation of NAP activities.Facing many competing priorities,countries,particularly those in low-and middle-income settings,must make smart tradeoffs in favor
33、 of the most cost-effective and impactful AMR actions.The WHO and the World Bank recognize the need to better support countries as they strive to address the growing threat of AMR.The two organizations are united as technical and opera-tional partners,ready to draw upon their comparative advantages
34、to collectively provide countries with comprehensive support.The WHO provides technical support to countries as they develop and implement their NAPs on AMR,a process which contains six major steps:(1)strengthening governance,(2)prioritizing activities,(3)costing the operational plan,(4)mobilizing r
35、esources,1 Christopher JL Murray et al.,“Global Burden of Bacterial Antimicrobial Resistance in 2019:A Systematic Analysis,”The Lancet 0,no.0(January 19,2022),https:/doi.org/10.1016/S0140-6736(21)02724-0.2 World Health Organization,Global Action Plan on Antimicrobial Resistance(Geneva,Switzerland:Wo
36、rld Health Organization,2015),https:/apps.who.int/iris/handle/10665/193736.3 The Tripartite refers to the Food and Agricultural Organization(FAO),the World Organisation for Animal Health(WOAH),and the World Health Organization(WHO).In March 2022,the United Nations Environment Programme(UNEP)formally
37、 joined the partnership hereafter called the“Quadripartite.”4 Food and Agricultural Organization,World Organization for Animal Health,and World Health Organiza-tion,“Global Database for the Tripartite Antimicrobial Resistance(AMR)Country Self-Assessment Survey(TrACSS)Website,”2021,http:/amrcountrypr
38、ogress.org/.8 Sustaining Action Against Antimicrobial Resistance Executive Summary(5)implementing prioritized activities,and(6)monitoring and evaluating progress(Figure 1).The newest addition to the WHOs catalogue of support tools,which includes templates,checklists,resource packs,handbooks,webinars
39、,and e-learning modules,is the WHO Costing and Budgeting Tool for NAPs on AMR.The tool aims to assist countries to cost prioritized AMR activities from their NAPs and mobilize resources.It utilizes a modular approach that allows various government ministries to independently cost the components of t
40、he NAP that are relevant to their respective sector.The tool then consolidates all the modules to provide a fully costed NAP on AMR.If funding gaps exist,the World Bank stands ready to support through established financing mechanisms,including investment project financing,development policy financin
41、g,and program-for-results.The following case series showcase recent country experiences while developing and imple-menting their NAPs for AMR.The first case study focuses on Sierra Leone,where the WHO pilot tested the prototype WHO Costing and Budgeting Tool for NAPs on AMR.Sierra Leone gained valua
42、ble insights on prioritization,and the lessons learned from this pilot test,along with additional pilots in Jamaica,Paraguay,and Somalia,were instrumental for WHO in finalizing the Costing and Budgeting Tool,which was officially launched in October 2021.The three other case studies focus on countrie
43、s in which the WHO has a history of strong country engagement on AMR:Burkina Faso,Jordan,and Malawi.These case studies highlight key actions,drawn from the countries NAPs on AMR,which have led to meaningful improvements in national capacity to prevent,detect,and respond to AMR.They also outline crit
44、ical next steps on the path forward to sustained implemen-tation of their NAPs on AMR.Malawi has strengthened governance-the first step in effective NAP implementation(see Figure 1).To strengthen governance,the WHO recommends that countries establish an overarch-ing multisectoral coordination mechan
45、ism for AMR,as well as supportive technical working groups if needed.Malawi has chosen to address AMR through a One Health approach and has smartly defined specific roles for relevant government ministries,implementation partners,and civil soci-ety organizations.These stakeholders are provided with
46、overarching governance and coordination through the National Coordinating Committee(NCC),comprised of members from various sec-tors and backgrounds.Malawis strong governance for AMR has enabled success in raising public awareness,ensuring safer prescribing practices,and strengthening infection preve
47、ntion and con-trol(IPC)measures in health facilities.Similarly,Burkina Faso has benefited from a One Health governance structure,established in January 2019 by inter-ministerial decree.The countrys AMR Committee sits within a broader National Coordinating Platform on One Health,and has successfully
48、enacted several key actions against AMR,including strengthening surveillance,ensuring safer antimicrobial prescribing prac-tices,and improving water and sanitation.The 2019 inter-ministerial decree was essential for these successes.It defined the countrys governance structure for AMR action and incl
49、uded details on the composition and activities of the AMR Committee by outlining five subcommittees,one for each key objective of the countrys NAP.While Burkina Fasos NAP was never formally approved by the national government,the country has shown that an organized and dedicated governance structure
50、 can support meaningful AMR action,even while NAPs are in the process of development or approval.Sustaining Action Against Antimicrobial Resistance 9 Executive SummaryFigure 1 Six steps for sustainable implementation of national action plans(NAPs)on antimicrobial resistance(AMR).1.Strengthen governa
51、nce Establish a functional multisectoral coordinating mechanism and technical working groups with clear terms of reference,budget and an accountability framework.2.Prioritize activities Initiate a consultative process to prioritize activities based on an assessment of the current situation,resources
52、 available,and the impact and feasibility of activities.3.Cost the operational plan Develop,cost and budget an operational plan that includes prioritized activities,who is to do what,when and where,and integrates existing funding sources.4.Mobilize resources Map existing and potential funders,advoca
53、te to fill the funding gap and where possible leverage domestic financing through other national plans and budgets.5.Implement prioritized activitiesWork with internal and external stakeholders to sustainably implement the prioritized activities.FOR SUSTAINABLE IMPLEMENTATION OF NATIONAL ACTION PLAN
54、S ON ANTIMICROBIAL RESISTANCESTEPS123456Periodically monitor and evaluate progress in implementing the plan or activities,communicatingprogress and lessons learned.6.Monitor and evaluateSource:WHO Implementation Handbook for National Action Plans on Antimicrobial Resistance:Guidance for the human he
55、alth sector.Available from:https:/apps.who.int/iris/handle/10665/352204.10 Sustaining Action Against Antimicrobial Resistance Executive SummarySierra Leone served as a pilot testing country for the WHO Costing and Budgeting Tool for NAPs on AMR,and cleverly utilized the opportunity to develop a two-
56、year operational plan for implementing its NAP.With the support of WHO,multisectoral costing coordinators in Sierra Leone embarked on the second step of NAP implementation:prioritizing activities(see Figure 1).In general,the process of prioritization is consultative and based on situational and need
57、s assess-ments,resource availability,and the feasibility and anticipated impact of activities.In Sierra Leone,coordinators took a pragmatic approach,focusing on prioritizing AMR activities with the largest expected impact and which would be least challenging to implement.Building upon this prioritiz
58、ed list,the costing coordinators developed an operational plan that situated their prioritized activities within the strategic objectives of the NAP,as well as a defined timeframetwo-years,in this case.Sierra Leone then estimated the cost of its operational plan using the WHO Costing and Budgeting T
59、ool,which is step three of NAP implementation(see Figure 1).Now with a fully costed operational plan,the country is well positioned to mobilize resources(step four of NAP implementation)for sustainable implementation of its prioritized AMR activities.Jordan,through its 2018-2022 NAP,has prioritized
60、surveillance for AMR and antimicrobial consumption(AMC).Surveillance is a cornerstone for assessing the spread and drivers of AMR and for monitoring the impact of policies,regulations,and interventions.In Jordan,the establish-ment of AMR and AMC surveillance systems(aligned with step five of NAP imp
61、lementation:imple-ment prioritized activities)have helped the country to identify targeted actions for antimicrobial stewardship interventions,including guidance and regulations aimed at ensuring safer prescribing practices among healthcare workers.Surveillance is also a key tool for step six of NAP
62、 implemen-tation:monitoring and evaluation(see Figure 1).Monitoring and evaluation is necessary to track whether responsible stakeholders are appropriately implementing actions under their authority and to assess whether those actions are having the intended effect.All countries showcased have made
63、good progress in developing and implementing some aspects of their NAPs;however,insufficient and inconsistent financing has posed a major bar-rier for sustainable and full implementation of their NAPs.The WHO Costing and Budgeting Tool for NAPs on AMR is an excellent resource for catalyzing collabor
64、ation,prioritizing AMR activities,and developing operational plans.It also helps to prepare countries for engaging in step four of NAP implementation:resource mobilization(see Figure 1).Given that AMR cannot be positioned as a siloed program,governments should seek to leverage resources across minis
65、terial programs and strategic plans.However,even after pooling resources across ministries,many countries will find that budget gaps still remain.In this case,the World Bank stands ready to support through invest-ment project financing,results-based loans,or development policy loans,which can be tar
66、geted toward AMR-specific or AMR-sensitive5 objectives.In addition to its financing capacity,the World 5 AMR-specific interventions have the reduction of AMR emergence and spread as their primary purpose.AMR-sensitive interventions,on the other hand,have other primary purposes(such as infection prev
67、ention in health care,greater access to water and sanitation in the community,or improved animal husbandry prac-tices)but contribute indirectly to addressing the emergence and spread of AMR.AMR-sensitive interventions can be designed and delivered in ways that maximize their impact on AMR(and improv
68、e their cost-effective-ness).Sustaining Action Against Antimicrobial Resistance 11 Executive SummaryBank has experience operating in every major area6 of development.The institution is therefore particularly well positioned to support governments as they seek to convene public and private stakeholde
69、rs across sectors in a coordinated fight against AMR.This case series is intended for policymakers in low-and middle-income countries who are interested in advancing their countries capacity to fight AMR.Using recent country experi-ences,this case series aims to showcase some relatively easy entry p
70、oints for AMR action and to highlight how the WHO and the World Bank can provide support to countries as they strive to develop and implement their NAPs for AMR.6 The World Bank has 18 global practices,including several with particular relevance for AMR:agriculture;en-vironment&natural resources;hea
71、lth,nutrition&population;human development;social sustainability and inclusion;and water.12 Sustaining Action Against Antimicrobial Resistance ACKNOWLEDGEMENTSINTRODUCTION12 Credit:WHO Jordan Country OfficeSustaining Action Against Antimicrobial Resistance 13 IntroductionAntimicrobial resistance(AMR
72、)occurs when microbes bacteria,viruses,fungi,and parasites evolve in ways that reduce medicines ability to fight them.AMR has made many infections,particularly bacterial infections,increasingly difficult or even impossible to treat.7 Without effective medicines,the number of people with severe micro
73、bial infections will increase,as will the number of people who die from these infections.In 2019,4.95 million deaths were associated with AMR,with the highest AMR-attributable death rates occurring in western sub-Saharan Africa.8 While AMR is a natural evolutionary process that occurs over time,many
74、 human-led behaviors have increased its occurrence.The main drivers of AMR include:(1)the misuse and overuse of antimicrobials;(2)lack of access to clean water and adequate sanitation for people and animals;(3)poor infection preven-tion and control measures in healthcare facilities and farms;(4)limi
75、ted access to quality,affordable medicines,vaccines,and diagnostics;and(5)lack of awareness and knowledge about AMR.9 AMR is a complex problem that requires a multisectoral approach.The One Health approach brings together multiple sectors and stakeholders engaged in human,animal,and plant health;foo
76、d and feed production;and the environment to work together in the design and implementation of programs,policies,legislation,and research to attain better public health outcomes.During the 2015 World Health Assembly,countries around the world endorsed the Global Action Plan on AMR and committed to d
77、eveloping and implementing their own national action plans(NAPs)on AMR.10Countries are at various stages of developing and implementing their NAPs on AMR.Eighty-six percent(140 of 163 countries)responding to the Tripartite11 AMR Country Self-Assessment Survey(TrACSS)have developed their own NAPs.How
78、ever,only 50 percent(82)of countries have func-tional AMR coordination committees(or multisectoral working groups)for delivering their plans,and even fewer(20%;32 countries)are implementing and actively monitoring their plans.12A key barrier to implementation is costing;policymakers must first know
79、how much their pol-icies will cost before they can be financed and put into action.To support countries in costing their NAPs,the World Health Organization(WHO)developed the WHO Costing and Budgeting Tool for NAPs on AMR.(https:/www.who.int/teams/surveillance-prevention-control-AMR/who-amr-costing-a
80、nd-budgeting-tool).The tool utilizes a modular approach that allows various ministries to independently cost the components of the national action plan that are relevant to their respec-tive sectors.Afterwards,the tool then consolidates all the modules to provide a fully costed NAP on AMR.The first
81、case study in this series highlights the lessons learned by Sierra Leone(and the WHO)as they pilot tested the Costing and Budgeting Tool.7 World Health Organization,Global Action Plan on Antimicrobial Resistance;Murray et al.,“Global Burden of Bacterial Antimicrobial Resistance in 2019.”8 Murray et
82、al.,“Global Burden of Bacterial Antimicrobial Resistance in 2019.”9 World Health Organization,“Antimicrobial Resistance,”World Health Organization website,November 17,2021,https:/www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance.10 World Health Organization,Global Action Plan on Anti
83、microbial Resistance.11 The Tripartite refers to the Food and Agricultural Organization(FAO),the World Organisation for Animal Health(WOAH),and the World Health Organization(WHO).In March 2022,the United Nations Environment Programme(UNEP)formally joined the partnership hereafter called the“Quadripa
84、rtite.”12 Food and Agricultural Organization,World Organization for Animal Health,and World Health Organiza-tion,“Global Database for the Tripartite Antimicrobial Resistance(AMR)Country Self-Assessment Survey(TrACSS)Website.”Introduction14 Sustaining Action Against Antimicrobial Resistance Additiona
85、lly,for countries to progress from planning to acting,AMR coordination committees must have a clearly defined role and the remit to develop and implement an operational plan.Operational plans should embed NAP activities into the national development agenda,sectoral strategies,and budgets,and should
86、coordinate an aligned approach to delivering NAP activities across sectors and stakeholders.Creating and empowering AMR coordination committees and comprehensively implementing and monitoring the prioritized activities outlined in their NAPs operational plan takes time;but there are several relative
87、ly easy entry points for AMR action that countries can utilize to accelerate their fight against AMR.The remaining case studies in this series showcase successful actions against AMR that three countries Burkina Faso,Jordan,and Malawi have taken along their journey to fully operationalizing and impl
88、ementing their NAPs on AMR.Sustaining Action Against Antimicrobial Resistance 15 WHO COSTING AND BUDGETING TOOL FOR NATIONAL ACTION PLANS ON ANTIMICROBIAL RESISTANCE16 Sustaining Action Against Antimicrobial Resistance Country ContextRecognizing the grave threat AMR poses to humans,animals,and the e
89、nvironment,the Government of Sierra Leone established a multisectoral coordination group in 2017,with offi-cials from the Ministry of Health and Sanitation;the Ministry of Agriculture,Forestry,and Food Security;and the Environmental Protection Agency.The coordination group was tasked with integratin
90、g the countrys various AMR initiatives into a single,concerted effort for fighting AMR.They developed the National Strategic Action Plan for Combating AMR(20182022),Sierra Leones first national policy that specifically focuses on AMR.13 While Sierra Leones NAP was well-designed,the government strugg
91、led to implement the plan.There was limited knowledge on how much the plans activities would cost and uncertainty surrounding which activities to prioritize given limited resources.Using the WHO AMR Costing and Budgeting ToolIn December 2020,Sierra Leone became the first country to begin pilot testi
92、ng the WHO Costing and Budgeting Tool for NAPs on AMR(“WHO Tool”).Following the initial meeting of Sierra Leones AMR multisectoral coordination group,12 costing coordinators were nominated from the two ministries and the Environment Protection Agency.The coordinators were tasked with produc-ing a fu
93、lly costed two-year operational plan for the NAP.The costing coordinators were initially trained on the WHO Tool during a three-day workshop in January 2021.They met again the following month,along with staff from the WHO Sierra Leone country office,to determine which AMR activities would be include
94、d in the operational plan.The coordinators prioritized activities according to their expected impact.Activities with larger expected impact and those considered more feasible less challenging to implement were given higher priority.Building upon this prioritized list,the costing coordinators then us
95、ed the WHO Tool to estimate the cost of their operational plan.13 Government of Sierra Leone,“National Strategic Plan for Combating Antimicrobial Resistance 2018-2022,”June 10,2018,https:/www.who.int/publications/m/item/sierra-leone-national-strategic-plan-for-combat-ing-antimicrobial-resistance.“Th
96、e costing exercise provided an opportunity for multisectoral stakeholders to have a more granular insight into the NAP leading to prioritization of activities guided by likely impact of the intervention and feasibility in a resource limited setting.”Gerald Shambira,Consultant,WHO Sierra Leone Countr
97、y OfficeSierra Leone:Prioritizing for ImpactSustaining Action Against Antimicrobial Resistance 17 WHO Costing and Budgeting Tool for National Action Plans on Antimicrobial Resistance Results and Lessons LearnedUsing the WHO Costing and Budgeting Tool for NAPs on AMR,the Government of Sierra Leone es
98、timated the cost of its two-year operational plan for prioritized activities to be approxi-mately USD 2.15 million,a large but feasible amount.Knowing the level of financing required not only helps with prioritization,but also serves as the first step for identifying funding sources.The Internationa
99、l Development Association(IDA)at the World Bank is one such source;the IDA provides investment project financing,results-based loans,and development policy loans to help countries address AMR through both AMR-sensitive such as strengthening health,water,or agricultural systems and AMR-specific initi
100、atives.For example,the World Bank is currently supporting Ethiopia in increasing access to safe water supply and sanitation services through the One WASH Consolidated Water Supply,Sanitation,and Hygiene Account Project.14 The ongo-ing project,which aims to improve access to water,sanitation,and hygi
101、ene(WASH)facilities in schools and health centers,is intended to complement interventions to improve health impacts,decrease school dropout rates,and reduce the contamination of water bodies.The investments made through this project will also have meaningful,positive impacts on AMR,given that lack o
102、f access to clean water and adequate sanitation is a key driver of AMR emergence and spread.By costing their NAPs,countries are better positioned to incorporate priority AMR activities into broader AMR-sensitive projects,like One WASH,or propose financing for key AMR-specific activities in World Ban
103、k projects.Sierra Leones National Strategic Action Plan for Combating AMR was developed using a One Health approach;therefore,the countrys decision to engage all relevant ministries in its AMR prioritization and costing activities was key to its success.The country created a multi-sectoral coordinat
104、ion group,with officials from three ministries,15 to develop and cost a two-year operational plan for AMR.The involvement of several ministries encouraged wider buy-in from stakeholders in the health,agriculture,and environment sectors.Furthermore,expertise on AMR and how to use the WHO Tool,acquire
105、d through a dedicated training workshop,is now shared across the government;multiple ministries have officials with knowledge and experience that will be beneficial in future AMR costing and budgeting exercises.Now that Sierra Leones two-year operational plan has been costed,the country is well posi
106、-tioned to mobilize resources and begin implementing its priority AMR activities.The mul-tisectoral coordination group is currently seeking endorsement from the government on the operational plan.In the meantime,the plan is being used to identify funders,such as the World Bank,and to engage with imp
107、lementing partners,like the WHO,who can support Sierra Leone in its fight against AMR.Sierra Leone could build on the momentum created during costing their national action plan by further strengthening multisectoral collaboration and coordination.In line with its costed operational plan,the focus co
108、uld be on improving awareness and understanding 14 World Bank,“Development Projects:One WASHConsolidated Water Supply,Sanitation,and Hygiene Ac-count Project(One WASHCWA)-P167794,”Text/HTML,World Bank,accessed June 3,2022,https:/proj-ects.worldbank.org/en/projects-operations/project-detail/P167794.1
109、5 Ministry of Health and Sanitation,the Ministry of Agriculture and Forestry,and the Ministry of Environment through the Environment Protection Agency.18 Sustaining Action Against Antimicrobial Resistance Sierra Leone:Prioritizing for Impactof AMR through effective communication,education,and traini
110、ng as well as strengthening the evidence and knowledge base for AMR through designing and implementing an AMR surveillance and antimicrobial consumption system.Such data could further support the implementation of the NAP on AMR.“We found the tool very easy to use.The costing exercise provided us an
111、 opportunity to develop a two-year costed national action plan that highlights key priority activities with high impact.The exercise also assisted with AMR resource allocation and will be used to mobilize additional funding for AMR activities.”Dr.Joseph Sam Kanu,Deputy Manager,National Disease Surve
112、illance Program,Ministry of Health and Sanitation and AMR Focal PointACCELERATING COUNTRY ACTION ON ANTIMICROBIAL RESISTANCESustaining Action Against Antimicrobial Resistance 19 20 Sustaining Action Against Antimicrobial Resistance Country ContextBurkina Fasos National Strategic Plan to Combat Antim
113、icrobial Resistance 20172020 was developed by the Ministry of Health in collaboration with the Ministry of Animal Resources and Fisheries,the Ministry of Agriculture and Water Facilities,and the Ministry of Environment,Green Economy,and Climate Change.The National Strategic Plan outlines five key ob
114、jectives:(1)strengthening AMR and antimicrobial use surveillance and research;(2)reducing the incidence of infectious disease through infection prevention and control measures;(3)improving antimicrobial use in the human,animal,and agricultural health sectors;(4)strengthening the regulatory envi-ronm
115、ent;and(5)improving awareness and understanding of AMR through communication,edu-cation,and training.The development of Burkina Fasos first National Strategic Plan represents an important first step in the countrys fight against AMR.But the plan was never formally approved by the national government
116、,which slowed its impact.Even though progress on the National Strategic Plan stalled,an inter-ministerial decree issued in January 2019 established a One Health Technical Steering Committee,organized to oversee seven thematic One Health Committees,one of which is the AMR Committee.This governance st
117、ructure is part of a larger National Coordinating Platform on One Health that was established by a presidential decree.Members of the AMR Committee had been working together on AMR objec-tives well before the decree integrated their efforts within a One Health Framework,which eased the committees de
118、velopment and allowed it to quickly become functional.The AMR Committee has since established a reporting mechanism between itself and the One Health Technical Steering Committee and meets regularly to oversee and coordinate the implementation of the National Strategic Plan across and within the sec
119、tors.Key SuccessesBurkina Fasos AMR Committee has been successfully implementing several key actions against AMR:strengthening AMR surveillance;ensuring safer antimicrobial prescribing prac-tices;and improving water,sanitation,and hygiene in hospitals.The 2019 inter-ministerial degree was essential
120、for these successes,as it defined the countrys governance structure for AMR action and included details on the composition and activities of the AMR Committee by outlining five subcommittees respectively responsible for laboratory surveillance;antimicrobial consump-tion,quality,and rational use;regu
121、lation;communication and awareness among the public;and infection prevention and control.The decree also specified 88 representatives.Burkina Faso:Sustaining Political CommitmentSustaining Action Against Antimicrobial Resistance 21 Accelerating Country Action on Antimicrobial ResistanceStrengthened
122、AMR surveillanceSurveillance is an essential tool to inform policies and infection prevention and control responses;it is the cornerstone for assessing the spread of AMR and monitoring the impact of local,national,and global strategies.Burkina Faso has established an AMR surveillance system consisti
123、ng of 15 designated laboratories for the detection of AMR pathogens using international standard operating procedures.16 The surveillance system is overseen by the Ministry of Healths Laboratories Directorate,although historically these laboratories have not had sufficient resources such as reagents
124、 and culture media to enable them to adequately test for AMR.Following the development of the countrys Strategic Action Plan,the Ministry of Health developed a national guide for laboratory surveillance of AMR,containing a list of antibiotics with high resistance risk for monitoring.In 2019,Burkina
125、Faso established the laboratory at the University Hospital Souro Sanou in Bobo Dioulasso as the national reference laboratory for the detection of AMR pathogens.Safer prescribing practices for healthcare workersAntibiotic overuse hastens the emergence of AMR.Health systems must ensure access to good
126、-quality antimicrobials when needed,but this must be balanced with robust systems to prevent inappropriate use and overprescribing.Provisions on the rational use17 of antimicrobials were integrated into Burkina Fasos National Strategic Plan,and guidelines to enable appropriate use of antimicrobials
127、have been implemented in most health facilities nationwide.In August 2020,the country developed a guide for appropriate antibiotic prescribing to support healthcare workers to adopt rational antibiotic use practices,and the national list of essential medicines integrated the WHOs AWaRe(Access,Watch,
128、and Reserve)classifications.Monitoring and surveillance results are used to inform action and to update treatment guidelines and the national essential medicines list.Improved water,sanitation,and hygieneInadequate water,sanitation,and hygiene(WASH)contributes to the spread of infectious disease and
129、 antibiotic use.The Burkina Faso Observatory for Quality and Safety of Care was launched after a United States CDC call for AMR initiatives in 2019.18 The Observatory aims to monitor and improve the WASH conditions of healthcare facilities across the country.As a result of Burkina Fasos commitment t
130、o improving WASH,91 percent of the countrys hospitals have basic water service,and 100 percent have hand hygiene stations at the point of care.Figure 2 presents the different health indicators that Burkina Faso is tracking under its National Strategic Plan to Combat Antimicrobial Resistance.16 Flemi
131、ng Fund,“Terms of Reference for Request for Proposals:First Fleming Fund Country Grant to Burkina Faso,”2019,https:/www.flemingfund.org/wp-content/uploads/925c5ee3257fe051847dc1ee37e67128.pdf.17 Rational use of medicines means that patients receive medications that are appropriate to their clinical
132、needs,in doses that meet their own individual requirements,for an adequate period of time,and at the low-est cost to them and their community.18 Centers for Disease Control and Prevention,“The Antimicrobial Resistance(AMR)Challenge Website,”Centers for Disease Control and Prevention,February 26,2021
133、.https:/www.cdc.gov/drugresistance/intl-activities/amr-challenge.html.22 Sustaining Action Against Antimicrobial Resistance(A)No capacity(D)Demonstrated capacity(E)Sustained capacity(C)Developed capacity(B)Limited capacityBurkina Faso:Sustaining Political CommitmentFuture OpportunitiesThe Government
134、 of Burkina Faso recognizes the threat of AMR and has smartly utilized sev-eral key entry points for action against AMR.These AMR actions,and the 2019 inter-ministerial decree that enabled their success,indicate Burkina Fasos growing political commitment to AMR.While Burkina Fasos National Strategic
135、 Plan to Combat Antimicrobial Resistance 20172020 was never endorsed,the government has built upon elements of the plan to develop a new Strategic Plan for 20222024.An important next step for the country is to endorse the countrys new NAP and develop a legal,governing framework for its implementatio
136、n.Additionally,the government must allocate sufficient financial resources for the imple-mentation of priority AMR activities in its NAP.For many low-and middle-income countries,domestic financing may not be sufficient for comprehensive,nationwide implementation of AMR activities.There are many pote
137、ntial funding sources for supporting NAP implementation.The International Development Association(IDA)at the World Bank,for example,provides investment Figure 2 TrACCS human health indicators for Burkina Faso,20202021Source:Global Database for the Tripartite Antimicrobial Resistance(AMR)Country Self
138、-assessment Survey(TrACSS)Raising awareness and understanding of AMR risks and responseTraining and professional education on AMR in the human health sectorAwareness and EducationAdoption of“AWaRe”classification of antibiotics in the National Essential Medicines ListOptimizing AMU in human healthOpt
139、inizing AMUNational monitoring system for consuption and rational use of antimicrobials in human healthNational surveillance system for AMR in humansSurveillanceIPC in human health careIPCMulti-sector and One Health collaboration/coordinationIPCSustaining Action Against Antimicrobial Resistance 23 A
140、ccelerating Country Action on Antimicrobial Resistanceproject financing,results-based loans,and development policy loans to help countries address AMR through both AMR-sensitive initiatives such as strengthening health,water,or agricultural systems,and AMR-specific ones.The World Bank is currently s
141、upporting Burkina Faso in improv-ing access to water supply and sanitation services in rural areas of the country,particularly in the southwest region where access is particularly limited.19 As of February 2021,the Burkina Faso Water Supply and Sanitation Program has helped the Government to provide
142、 more than 60,000 people with access to improved sanitation services,which will,in turn,have meaningful,positive impact on AMR.The World Bank is also supporting the region through the Regional Disease Surveillance Systems Enhancement(REDISSE)Project,which aims to support West African countries in es
143、tab-lishing an active and functional One Health Platform,enhancing surveillance and information sys-tems,and strengthening laboratory capacity.20Tackling AMR requires sustained and coordinated action at scale across a range of institutions and sectors,including human and animal health,food productio
144、n,environment,water and san-itation,education,and trade.Many different stakeholders,with different ways of working,need to be brought together to coordinate and scale up their efforts in a way that maximizes their impact on AMR.Clear commitment from the national government,as signaled through an end
145、orsed NAP,is an important first step to be followed by the establishment of a functioning AMR coordination committee with a mandate to deliver on NAP activities.To accelerate the evidence-based imple-mentation of the NAP on AMR,not only in the human health but also in other sectors,Burkina Faso coul
146、d strengthen multisectoral collaboration and coordination.Building further on its success in improving prescribing practices,the AWaRe classification of antibiotics could be incorporated into treatment guidelines and antimicrobial stewardship strategies to improve antimicrobial use.In addition,the c
147、ountry could focus on expanding the implementation of the IPC program at the national and health facility levels,in line with the second strategic objective of its NAP on AMR.19 World Bank,“Development Projects:Burkina Faso Water Supply and Sanitation Program-P164345,”Text/HTML,World Bank,accessed J
148、une 3,2022,https:/projects.worldbank.org/en/projects-operations/proj-ect-detail/P164345.20 World Bank,“Development Projects:Regional Disease Surveillance Systems Enhancement(REDISSE)-P154807,”Text/HTML,World Bank,accessed June 3,2022,https:/projects.worldbank.org/en/projects-oper-ations/project-deta
149、il/P154807.24 Sustaining Action Against Antimicrobial Resistance Country ContextIn 2017,a national multisectoral AMR committee was formed and tasked with developing Jordans first NAP on AMR and to subsequently coordinate and monitor its implementation.Members of the committee comprised representativ
150、es from several sectors and organizations:the Ministry of Health,the Ministry of Agriculture,the Jordan Food and Drug Administration(JFDA),the Procurement and Supply Directorate,public health professionals,pharmacy associations,aca-demics,and representatives from medical,veterinary,pharmaceutical.Th
151、e resulting NAP,Jordans National Action Plan for Combating Antimicrobial Resistance(20182022),is now being imple-mented and monitored.It has five strategic objectives:(1)improving awareness and understanding of AMR through effective communication,education,and training;(2)strengthening knowledge and
152、 evidence through surveillance;(3)reducing the incidence of infection through effective IPC;(4)optimizing the use of antimicrobial agents in health,animals,and food;and(5)promoting invest-ment for AMR activities,research,and innovation.The AMR committee also developed an opera-tional plan with an al
153、located budget for each strategic objective of the NAP.Key SuccessesUnder the leadership of the multisectoral AMR committee in charge of NAP implementation,Jordan has been successful at implementing several key actions against AMR.These include strengthening AMR surveillance,strengthening antimicrob
154、ial consumption(AMC)surveillance,ensuring safer antimicrobial prescribing practices,and increasing public awareness of AMR.Strengthened AMR surveillance Surveillance is an essential tool to inform policies and IPC responses;it is the cornerstone for assessing the spread of AMR and monitoring the imp
155、act of local,national,and global strat-egies.Since 2018,WHO has worked with the Ministry of Health of Jordan to establish a com-prehensive and representative national AMR surveillance system and to build the surveillance capacities of national stakeholders.In July 2019,the Minister of Health officia
156、lly endorsed the“Jordan National Antimicrobial Resistance Surveillance System(JARSS),”which generates qual-ity data based on internationally standardized laboratory methods and interpretation metrics for antimicrobial sensitivity testing.A national coordinating committee oversees the functioning of
157、the surveillance system,and a national reference laboratory provides support,training,and exter-nal quality assessment.Data on antimicrobial susceptibility testing are also collected.Currently,JARSS includes 23 sentinel sites(57 percent of tertiary healthcare facilities in Jordan)in the human health
158、 sector,and data have been reported annually to the WHO Global Antimicrobial Resistance and Use Surveillance System(GLASS)since 2018.In November 2020,Jordan published their first national AMR surveillance report during World Antimicrobial Awareness Week(WAAW).Jordan:Data for ActionSustaining Action
159、Against Antimicrobial Resistance 25 Strengthened AMC surveillance Data on AMC provide an important basis for understanding the patterns and amount of anti-microbial consumption and use,which can inform policies,regulations,and interventions to optimize their use and minimize the AMR risk.Since 2017,
160、the JFDA has been responsible for collecting data on imported and locally manufactured antimicrobials and has set up a national sur-veillance system for monitoring AMC.In addition to its successful implementation at the national level,the department of Pharmacy and Clinical Pharmacy at the Ministry
161、of Health established AMC surveillance in eight hospitals.In 2019,approximately 59 percent of the antibiotics con-sumed nationally were from the WHOs AWaRe classification Access21 group,in accordance with the WHOs target of Access group antibiotics comprising at least 60 percent of total antibiotic
162、consumption.Antibiotics from the Watch group represented roughly 41 percent total consumption,and Reserve group antibiotics comprised less than 0.05 percent.However,AMC data from 2020 has shown the unfortunate impact of the COVID-19 pandemic on national consumption patterns.22 The proportion of anti
163、biotics consumed in the Access group fell to 49 percent and the proportion in the Watch group increased to 51 percent.23 Safer prescribing practices for healthcare workers Antibiotic overuse hastens the emergence of AMR.Health systems must therefore ensure access to good-quality antimicrobials when
164、needed,but this must be balanced with robust systems to prevent inappropriate use and overprescribing.Based on the data generated through the AMR and AMC surveillance systems,Jordan was the first low-or middle-income country in the WHOs Eastern Mediterranean region to develop a national antimicrobia
165、l stewardship policy and national clinical guidelines for priority infections.The AMR and AMC data also inform target-ing of antimicrobial stewardship interventions at national and health facility levels.The JFDA has incorporated the WHO AWaRe classification of antibiotics in local treatment guideli
166、nes and has reclassified antibiotics in the Reserve group to“hospital use only,”so that they are not accessible from community pharmacies.Additionally,to help prevent over-the-counter dispensing,a new law in Jordan prohibits pharmacists from prescribing antibiotics to patients.Jordan was also among
167、the first countries in the region to develop a national IPC program,with national guidelines which were updated in 2017.21 As defined by the WHOs AWaRe classifications,antibiotics in the Access group are effective against wide range of common pathogens and have lower resistance potential.Antibiotics
168、 in the Watch group have higher resistance potential and should be used sparingly and with caution;antibiotics in the Reserve group are con-sidered“last resort”options and should be reserved for treating infections due to multi-drug-resistant organ-isms.22 Sayer Al-Azzam et al.,“An Assessment of the
169、 Impact of Coronavirus Disease(COVID-19)Pandemic on National Antimicrobial Consumption in Jordan,”Antibiotics 10,no.6(June 9,2021):690,https:/doi.org/10.3390/antibiotics10060690.23 World Health Organization,“Antimicrobial Consumption-Data for Action,”https:/www.who.int/news-room/events/detail/2022/0
170、2/07/default-calendar/webinar-antimicrobial-consumption-data-for-action.Accelerating Country Action on Antimicrobial Resistance26 Sustaining Action Against Antimicrobial Resistance Jordan:Data for ActionGreater public awareness of AMRTo address some of the knowledge gaps and behaviors that drive unn
171、ecessary antibiotic use,Jordan implemented two important initiatives.The first initiative,the Tailoring Antimicrobial Resistance Program(TAP),aimed to reduce patient demand for antibiotics as treatment for mild upper respiratory tract infections,which are often viral and therefore not affected by an
172、tibiotic treatments.24 The initiative was successfully implemented in six primary healthcare centers.The second initiative,launched in November 2018,aimed at increasing AMR awareness among med-icine,pharmacy,and veterinary undergraduate students from three universities.Students were mobilized to use
173、 their smart phones to make informational videos on behaviors linked to AMR.Over 100 students participated in a two-day training,which was followed by a competition for the best video.Approximately 30 video clips,shared widely on social media,were awarded a prize for their clever presentation of hyg
174、ienic behaviors and appropriate antibiotic use.Future OpportunitiesJordan has made great progress in recognizing and responding to the threat of AMR,in sur-veillance for example,but there remains a need to review the NAP and expand implementation to other areas.The strategic objectives outlined in t
175、he current Jordan NAP(20182022)are well-aligned with the Global Action Plan on AMR.Jordans capacity to implement is well demonstrated by its development of robust surveillance systems for AMR and AMC.The surveillance systems have helped the country identify targeted actions for antimicrobial steward
176、ship interventions.However,Jordan should consider reviewing,updating,and prioritizing NAP activities and their time frame.Additionally,few domestic resources have been mobilized to support the implementation of the NAP.Furthermore,the use of AMR and AMC surveillance data is mostly limited to the hum
177、an health sector,and decision-makers in other sectors should also consider generating and using data in planning their activities to address AMR for a truly comprehensive One Health approach.Key areas for improvement in Jordan include:(1)strengthening multisectoral and One Health collaboration and c
178、oordination,(2)expanding training and professional education on AMR,(3)improving IPC measures,and(4)increasing public awareness of AMR.An important first step in strengthening multisectoral and One Health collaboration and coordination at the national level is to promptly resume meetings of the AMR
179、committee,which were deferred due to COVID-19,and to link Jordans NAP with existing action plans in other sectors.To expand training and professional education on AMR,Jordan could consider focusing efforts on physicians.A recent study found that one-third of physicians reported no knowledge of any i
180、nitiatives on antibiotic awareness and resistance and nearly 90 percent were unaware or unsure of the existence of a NAP on AMR.25 Additionally,IPC compliance and effectiveness could be regularly assessed in health facilities,and Jordan could s also strive to improve hygienic and IPC practices in an
181、imal husbandry and in food 24 Nasser M.Kaplan et al.,“Implementation of the WHO Approved Tailoring Antimicrobial Resistance Programs(TAP)Reduces Patients Request for Antibiotics,”Antibiotics 9,no.8(August 12,2020):507,https:/doi.org/10.3390/antibiotics9080507.25 Reema A.Karasneh et al.,“Exploring In
182、formation Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan,”Antibiotics 10,no.8(August 11,2021):963,https:/doi.org/10.3390/antibiot-ics10080963.Sustaining Action Against Antimicrobial Resistance 27 processing.In line with the first strategic objective of its
183、NAP on AMR,Jordan could further improve its efforts to promote awareness and understanding of AMR by regularly implementing targeted,nationwide,government-supported activities to change the behavior of key stakeholders policy makers,healthcare professionals and the public with regular monitoring of
184、their impact.Insufficient and inconsistent financing is a threat to the sustainable implementation of AMR actions in Jordan.For many low-and middle-income countries,domestic financing may not be sufficient for comprehensive,nationwide implementation of AMR activities.There are many poten-tial fundin
185、g sources for supporting NAP implementation.The World Bank provides investment proj-ect financing,results-based loans,and development policy loans to help countries address AMR through both AMR-sensitive initiatives such as strengthening health,water,or agricultural sys-tems and AMR-specific ones.Fo
186、r example,in Serbia the World Bank supported the government in reducing antibiotic consumption,decreasing the systematic use of antibiotics from a defined daily dose per thousand inhabitants from 36.5 to 30.0 from 2015 to 2016,respectively.At the time,compared with other European countries,Serbias c
187、onsumption rate was high,but through sus-tained efforts,it became significant lower by 2018.Serbia achieved this improvement through the Second Serbia Health Project.26 The countrys Ministry of Health launched a concerted campaign and established an expert working group for the rational use of antib
188、iotics.It developed a national program for the control of bacterial resistance and implemented public campaigns for the rational use of antibiotics.The Ministry also established partnerships with over 20 institutions and orga-nizations to improve awareness,education,and improved regulation and overs
189、ight of antibiotics.26 World Bank,“Development Projects:Second Serbia Health Project-P129539,”Text/HTML,World Bank,ac-cessed June 3,2022,https:/projects.worldbank.org/en/projects-operations/project-detail/P129539.Accelerating Country Action on Antimicrobial Resistance28 Sustaining Action Against Ant
190、imicrobial Resistance Country ContextIn the Republic of Malawi,analysis of available AMR data suggests that resistance of common pathogens to various antimicrobials has increased since the early 2000s.27 The government has recognized this threat,and has mobilized resources for its mitigation.Malawi
191、identified AMR as a critical area for intervention in its Health Sector Strategic Plan-II,published in 2017,and further developed a NAP on AMR,the Antimicrobial Resistance Strategy 20172022,which outlines health policy and implementation objectives and yearly operational plans and budget-ary require
192、ments.28 Furthermore,the NAP incorporates a One Health approach for addressing AMR and defines specific roles for relevant government ministries,implementation partners,and civil society organizations.Malawis AMR strategy is well aligned with the Global Action Plan on AMR and is based on a comprehen
193、sive situational analysis conducted as part of the Antibiotic Stewardship and Conservancy in Africa project funded by the Norwegian Agency for Development Cooperation(Norad).29 Malawi has functioning governance and coordination mechanisms for AMR with a multisec-toral National Coordinating Committee
194、(NCC),technical working groups,and a core group of interdisciplinary stakeholders that oversee and coordinate national and subnational AMR strategy.Malawis AMR strategy,outlined in its NAP,has five core objectives:(1)improve aware-ness and understanding of AMR through effective communication,educati
195、on,and training;(2)improve knowledge and evidence of AMR through research and surveillance;(3)reduce incidence of infection through effective sanitation,hygiene,and prevention measures;(4)ensure sustainable investment through research and development;and(5)optimize the use of antimicrobial medicines
196、 in the agriculture,human,and animal health sectors.A five-year operational plan describes annual output targets including the number and type of activity such as workshops,meetings,training,and deliverables for each core objective.Notably,the NAP also includes detailed annual cost esti-mates for ea
197、ch objective as well as sources of funding,risks,and assumptions.27 The Center for Disease Dynamics,Economics&Policy,“ResistanceMap:Malawi,”2022,https:/resistance-map.cddep.org/.28 Government of the Republic of Malawi,“Antimicrobial Resistance Strategy 2017-2022,”2017,https:/www.who.int/publications
198、/m/item/malawi-antimicrobial-resistance-strategy-2017-2022;Government of the Republic of Malawi,“Health Sector Strategic Plan II(2017-2022),”2017,https:/extranet.who.int/countryplan-ningcycles/sites/default/files/planning_cycle_repository/malawi/health_sector_strategic_plan_ii_030417_smt_dps.pdf.29
199、Government of the Republic of Malawi,“Antimicrobial Resistance Strategy 2017-2022.”Malawi:Effective Governance for ActionSustaining Action Against Antimicrobial Resistance 29 Key SuccessesMalawis NCC has been successfully implementing several key actions against AMR:increasing public awareness of AM
200、R;ensuring safer antimicrobial prescribing practices;and strengthen-ing infection prevention and control(IPC)measures.Greater public awareness of AMRIncreased public awareness of AMR helps to encourage best practices among the general public,healthcare workers,farmers,animal health professionals,and
201、 policy makers to avoid the continued emergence and spread of drug-resistant infections.The Government of Malawi has set a national target to increase awareness and understanding of AMR among the public and professional stakeholders in the human health,animal health,and agricultural sectors from zer
202、o percent in 2016 to 90 percent by 2022.In 2019,the regional nonprofit research policy institute,the African Institute for Development Policy(AFIDEP),in collaboration with the Malawi Ministry of Health,organized“the big walk”in Lilongwe to promote knowledge among the public on the pru-dent use of an
203、tibiotics.Since then,the Drivers of Resistance in Uganda and Malawi(DRUM)consor-tium has designed and distributed several AMR informational materials during World Antimicrobial Awareness Week.This event emphasized the role of the media in promoting AMR awareness and behavior change regarding prudent
204、 antimicrobial use.Members of the press actively participated in the discussion on debunking myths and misconceptions regarding AMR.Engagements around AMR through this event shed light on the challenge of communicating scientific knowledge to the public due to the lack of a vernacular term for“antib
205、iotic”in Chichewa,a language spoken by 70 percent of the population.Safer prescribing practices for healthcare workers Antibiotic overuse hastens the emergence of AMR.Health systems must ensure access to good-quality antimicrobials when needed,but this must be balanced with robust systems to prevent
206、 inappropriate use and overprescribing.Malawis NAP on AMR aims to reduce inappropri-ate antimicrobial use by 100 percent across the agriculture,human,and animal health sectors by 2022,and the government also aims to ensure uninterrupted access to high-quality antimicrobials by strengthening relevant
207、 regulations and legislation.The NCC is tasked with ensuring appropriate antimicrobial use and implementing evidence based antimicrobial stewardship policies,programs,and interventions.Queen Elizabeth Central Hospital,a 1,300-bed hospital in Blantyre that provides free inpatient care,introduced an a
208、ntimicrobial stewardship program between 2016 and 2018.A prescribing application for smartphones,meant to help healthcare workers appropriately prescribe antibiotics,resulted in a more optimal use of antimicrobials,and highlighted the feasibility of anti-microbial stewardship programs in resource-li
209、mited settings.Malawi updated its standard treat-ment guidelines in 2015 to include antimicrobial treatment recommendations for specific bacterial infections and other medical conditions,and the Ministry of Health is currently revising its national essential medicines list to include the World Healt
210、h Organizations(WHO)AWaRE classifications and explicit references to AMR.Accelerating Country Action on Antimicrobial Resistance30 Sustaining Action Against Antimicrobial Resistance Malawi:Effective Governance for ActionStrengthened infection prevention and control measures and immunizationIPC measu
211、res,including vaccination,hand hygiene,and maintenance of clean,hygienic medi-cal facilities,equipment,and practices can help to limit the spread of infectious diseases and reduce antimicrobial consumption.In Malawi,a strong vaccination program,which includes all WHO-recommended vaccines and boasts
212、coverage rates between 60 and 90 percent,provides a backbone of support for the countrys IPC efforts in the health sector.National IPC guidelines and capacity-building activities have been implemented across the health system,and there is a clear model for improving IPC measures at all healthcare le
213、vels.IPC monitoring and capacity-building activities cascade from the Ministry of Health to district-level hospitals which,in turn,are respon-sible for ensuring and sustaining these capacities at lower-tier health facilities and in the commu-nity.During the COVID-19 pandemic,Malawi prioritized IPC a
214、nd water,sanitation,and hygiene(WASH)efforts in its national pandemic response.A score card was developed to guide quick,one-hour assessments of IPC and WASH and helped the country to document whether facilities had adequate personal protective equipment,standard operations procedures in place,and s
215、ufficient educational materials to guide best IPC practices.Figure 3 below presents how Malawi is tracking key health indicators and actions being taken to achieve them.(D)No capacity(D)Demonstrated capacity(E)Sustained capacity(C)Developed capacity(B)Limited capacityFigure 3 TrACCS human health ind
216、icators for Malawi,2020-2021Source:Global Database for the Tripartite Antimicrobial Resistance(AMR)Country Self-assessment Survey(TrACSS)Raising awareness and understanding of AMR risks and responseTraining and professional education on AMR in the human health sectorAwareness and EducationAdoption o
217、f“AWaRe”classification of antibiotics in the National Essential Medicines ListOptimizing AMU in human healthOptinizing AMUNational monitoring system for consuption and rational use of antimicrobials in human healthNational surveillance system for AMR in humansSurveillanceIPC in human health careIPCM
218、ulti-sector and One Health collaboration/coordinationIPCSustaining Action Against Antimicrobial Resistance 31 Future OpportunitiesMalawi has made great strides in recognizing and responding to the threat of AMR.The coun-trys NAP is well aligned with the Global Action Plan on AMR and provides a stron
219、g foundation for multisectoral action through its One Health perspective.An important enabler of success has been Malawis commitment to comprehensive planning.The countrys NAP outlines clear roles and responsibilities for all relevant stakeholders and describes clear objectives,budgetary requirement
220、s,and monitoring and evaluation frameworks for implementation.To keep momentum on improving awareness and understanding of AMR and in line with the first strategic objective of Malawis NAP,initiatives on improving public awareness could be expanded.At the same time,incorporating AMR and AMS core com
221、petencies into pre-and in-service training could enhance the knowledge and understanding of AMR among healthcare professionals.Leveraging the experience and lessons learned through the established national AMR surveillance system,Malawi could further build its evidence base by the implementing a nat
222、ional antimicrobial consumption surveillance system.Malawi has made great progress in implementing aspects of its NAP;however,lack of con-sistent and sufficient financial and human resources for AMR activities has been a major barrier for sustainable implementation.For many low-and middle-income cou
223、ntries,domestic financing may not be sufficient for comprehensive,nationwide implementation of AMR activities.There are many potential funding sources for supporting NAP implementation.The International Development Association(IDA)at the World Bank,for example,provides investment project financ-ing,
224、results-based loans,and development policy loans to help countries address AMR through both AMR-sensitive initiatives such as strengthening health,water,or agricultural systems and AMR-specific programs.For example,from 2015-2021,the World Bank supported countries in West Africa in measuring the pre
225、valence of animal diseases with high AMR risk and vaccinating animals against those diseases.3030 World Bank,“Development Projects:Regional Sahel Pastoralism Support Project-P147674,”Text/HTML,World Bank,accessed February 15,2022,https:/projects.worldbank.org/en/projects-operations/project-de-tail/P
226、147674.Accelerating Country Action on Antimicrobial Resistance32 Sustaining Action Against Antimicrobial Resistance The countries in this case series showcase meaningful actions that can be taken to address AMR regardless of a countrys technical capacity or its stage of NAP implementation.Sierra Leo
227、ne,a country at an early implementation stage,smartly utilized the WHOs Costing and Budgeting Tool to move towards more effective implementation of its NAP by prioritizing key activ-ities and costing a two-year operational plan.In Jordan,where the countrys NAP has been actively implemented since 201
228、9,the Government focused on strengthening AMR and AMC surveillance to enhance monitoring and evaluation capacities and inform strategic policymaking for the future.Burkina Fasos organized and dedicated governance structure for AMR succeeded in improving water,sanitation,and hygiene and making prescr
229、ibing practices for healthcare workers safer,even though formal approval for the countrys NAP stalled.No matter the starting point,there are always a host of impactful actions that countries can take to mitigate the threat of AMR.While easy entry points for AMR action tend to be single-sector interv
230、entions(e.g.,strength-ening IPC in healthcare settings),AMR is a complex problem that requires both sector-specific actions and multisectoral,One Health approaches.Countries can build the foundation for a multi-sectoral approach through their AMR governance structure,for which the WHO recommends a d
231、ed-icated overarching multisectoral coordination mechanism,with supporting technical working groups as needed.Malawis AMR governance structure is an excellent example.The countrys National Coordinating Committee,comprised of members from various sectors and backgrounds,defines the roles for governme
232、nt ministries,implementation partners,and civil society organizations and coor-dinates their AMR actions.Burkina Faso similarly benefits from a One Health governance structure.The countrys AMR Committee,which sits within a broader National Coordinating Platform on One Health,has created five subcomm
233、ittees,one for each key objective of the countrys NAP.The WHO and the World Bank recognize the need to better support countries at all stages of NAP implementation as they strive to address the growing threat of AMR.The two organizations are united as technical and operational partners,ready to draw
234、 upon their comparative advantages to collectively provide countries with the support they need,spanning the spectrum from implement-ing easy entry point interventions to operationalizing a comprehensive multisectoral One Health approach.The WHO stands ready to provide guidance and technical assista
235、nce.The Costing and Budgeting Tool for NAPs on AMR(showcased by the Sierra Leone case study)is just one of WHOs many support tools;other resources include global norms and standards,targeted technical assis-tance,templates,checklists,resource packs,handbooks,webinars,and e-learning modules(see the M
236、ore Information&Additional Resources section for links to some of these tools).And,if funding gaps exist,the World Bank stands ready to provide financing through established mechanisms,including investment project financing,development policy financing,and program-for-results.In addition to its fina
237、ncing capacity,the World Bank has experience operating in every major area31 of development,making it particularly well suited to support countries as they seek to convene public and private stakeholders across sectors in a coordinated fight against AMR.31 The World Bank has 18 global practices,incl
238、uding several with particular relevance for AMR:agriculture;en-vironment&natural resources;health,nutrition&population;human development;social sustainability and inclusion;and water.CONCLUSIONSustaining Action Against Antimicrobial Resistance 33 TABLE OF CONTENTSTechnical GuidanceAntibiotic prescri
239、bing and resistance:Views from low-and middle-income prescribing and dis-pensing professionals Document.Antimicrobial resistance fact sheet Website.Antimicrobial stewardship programmes in health-care facilities in low-and middle-income countries:a WHO practical toolkit Document.GLASS guidance for na
240、tional reference laboratories Document.Global antimicrobial resistance and use surveillance system(GLASS)report:2021 Document.Global Database for the Tripartite Antimicrobial Resistance(AMR)Country Self-assessment Survey(TrACSS)Website.Minimum requirements for infection prevention and control progra
241、mmes Document.National antimicrobial resistance surveillance systems and participation in the Global Antimicrobial Resistance Surveillance System(GLASS):a guide to planning,implementation,and monitoring and evaluation Document.Supporting countries with national action plan implementation Website.Tec
242、hnical brief on water,sanitation,hygiene and wastewater management to prevent infec-tions and reduce the spread of antimicrobial resistance Document.The TAP toolbox:exercises,tools and templates to support your tailoring antimicrobial resis-tance programmes plan Document.The TAP quick guide:a practi
243、cal handbook for implementing tailoring antimicrobial resistance programmes Document.WHO access,watch,reserve(AWaRe)classification of antibiotics for evaluation and monitoring of use,2021 Document.WHO AMR Costing and Budgeting Tool Website.WHO costing and budgeting tool for national action plans on
244、antimicrobial resistance:user guide Document.WHO implementation handbook for national action plans on antimicrobial resistance:guidance for the human health sector Document.MORE INFORMATION AND ADDITIONAL RESOURCESMore Information and Additional Resources34 Sustaining Action Against Antimicrobial Re
245、sistance WHO policy guidance on integrated antimicrobial stewardship activities Document.World Antimicrobial Awareness Week Website.Policy GuidanceBurkina Faso national action plan on antimicrobial resistance:review of progress in the human health sector Document.Burkina Faso:National multisectoral
246、strategic plan to combat antimicrobial resistance Document,French.Global action plan on antimicrobial resistance Document.Malawi:Antimicrobial resistance strategy 2017-2022 Document.National action plan for combating antimicrobial resistance in the Hashemite Kingdom of Jordan Document.Sierra Leone N
247、ational Strategic Plan for Combating Antimicrobial Resistance 2018-2022 Document.Financing GuidanceAfrica CDC Regional Investment Financing Project Website.Burkina Faso Water Supply and Sanitation Program Website.One WASH-Consolidated Water Supply,Sanitation,and Hygiene Account Project Website.Regio
248、nal Disease Surveillance Systems Enhancement(REDISSE)Website.Regional Sahel Pastoralism Support Project Website.Second Serbia Health Project Website.World Bank financing Website.Sustaining Action Against Antimicrobial Resistance 35 TABLE OF CONTENTSAl-Azzam,Sayer,Nizar Mahmoud Mhaidat,Hayaa A.Banat,
249、Mohammad Alfaour et al.2021.“An Assessment of the Impact of Coronavirus Disease(COVID-19)Pandemic on National Antimicrobial Consumption in Jordan.”Antibiotics 10(6):690.https:/doi.org/10.3390/antibi-otics10060690.Centers for Disease Control and Prevention.2021.“The Antimicrobial Resistance(AMR)Chall
250、enge Website.”Centers for Disease Control and Prevention(February 26,2021).https:/www.cdc.gov/drugresistance/intl-activities/amr-challenge.html.Fleming Fund.2019.“Terms of Reference for Request for Proposals:First Fleming Fund Country Grant to Burkina Faso.”https:/www.flemingfund.org/wp-content/uplo
251、ads/925c5ee3257fe051847d-c1ee37e67128.pdf.Food and Agricultural Organization,World Organization for Animal Health,and World Health Organization.2021.“Global Database for the Tripartite Antimicrobial Resistance(AMR)Country Self-Assessment Survey(TrACSS)Website.”http:/amrcountryprogress.org/.Governmen
252、t of Sierra Leone.2018.“National Strategic Plan for Combating Antimicrobial Resistance 2018-2022.”https:/www.who.int/publications/m/item/sierra-leone-nation-al-strategic-plan-for-combating-antimicrobial-resistance.Government of the Republic of Malawi.2017.“Antimicrobial Resistance Strategy 2017-2022
253、.”https:/www.who.int/publications/m/item/malawi-antimicrobial-resistance-strategy-2017-2022.Government of the Republic of Malawi.2017.“Health Sector Strategic Plan II(2017-2022).”https:/extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/malawi/health_sector_strategi
254、c_plan_ii_030417_smt_dps.pdf.Kaplan,Nasser M.,Yousef S.Khader,Mahmoud A.Alfaqih,Rami Saadeh,and Lora Al Sawalha.“Implementation of the WHO Approved Tailoring Antimicrobial Resistance Programs(TAP)Reduces Patients Request for Antibiotics.”Antibiotics 9,no.8(August 12,2020):507.https:/doi.org/10.3390/
255、antibiotics9080507.Karasneh,Reema A.,Sayer I.Al-Azzam,Mera A.Ababneh,Iman A.Basheti et al.2021.“Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan.”Antibiotics 10,no.8(August 11,):963.https:/doi.org/10.3390/antibiotics10080963.Murray,Chris
256、topher J.L.,Kevin Shunji Ikuta,Fablina Sharara,Lucien Swetschinski et al.2022.“Global Burden of Bacterial Antimicrobial Resistance in 2019:A Systematic Analysis.”The Lancet 0,no.0(January 19,2022).https:/doi.org/10.1016/S0140-6736(21)02724-0.REFERENCESReferences36 Sustaining Action Against Antimicro
257、bial Resistance The Center for Disease Dynamics,Economics&Policy.2022.“ResistanceMap:Malawi,”2022.https:/resistancemap.cddep.org/.World Bank.“Development Projects:Africa CDC Regional Investment Financing Project-P167916.”Text/HTML.World Bank.Accessed February 15,2022.https:/projects.worldbank.org/en
258、/proj-ects-operations/project-detail/P167916._.“Development Projects:Burkina Faso Water Supply and Sanitation Program-P164345.”Text/HTML.World Bank.Accessed June 3,2022.https:/projects.worldbank.org/en/proj-ects-operations/project-detail/P164345._.“Development Projects:One WASHConsolidated Water Sup
259、ply,Sanitation,and Hygiene Account Project(One WASHCWA)-P167794.”Text/HTML.World Bank.Accessed June 3,2022.https:/projects.worldbank.org/en/projects-operations/project-detail/P167794._.“Development Projects:Regional Disease Surveillance Systems Enhancement(REDISSE)-P154807.”Text/HTML.World Bank.Acce
260、ssed June 3,2022.https:/projects.worldbank.org/en/projects-operations/project-detail/P154807._.“Development Projects:Regional Sahel Pastoralism Support Project-P147674.”Text/HTML.World Bank.Accessed February 15,2022.https:/projects.worldbank.org/en/projects-opera-tions/project-detail/P147674._.“Deve
261、lopment Projects:Second Serbia Health Project-P129539.”Text/HTML.World Bank.Accessed June 3,2022.https:/projects.worldbank.org/en/projects-operations/project-detail/P129539.World Health Organization.2015.Global Action Plan on Antimicrobial Resistance.Geneva,Switzerland:World Health Organization.http
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