Situational analysis of
antimicrobial resistance
in the South-East Asia Region, 2018
Report 2018
An update on two years of implementation
of national action plans
Situational analysis of
antimicrobial resistance
in the South-East Asia Region, 2018
Report 2018
An update on two years of implementation
of national action plans
Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018 ISBN: 978-92-9022-702-1
© World Health Organization 2019
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CONTENTS
Acknowledgements vi
List of acronyms vii
Foreword ix
Executive summary xi
Background 1
Recent relevant initiatives and developments in the Region 2
Intercountry meetings to review situation of
NAP implementation in the Region 6
Results of situational analysis of NAP implementation 10
General trends in NAP implementation 10 Trends specific to focus areas 14Conclusions 28
Way forward and recommendations 31
Key recommendations to address main challenges of
AMR containment in the Region 31 Way forward for WHO and its regional Triparte partners 34
Country profiles 36
Bangladesh 36 Bhutan 43 DPRK 49 India 55 Indonesia 62 Maldives 70 Myanmar 77 Nepal 83
Sri Lanka 90
Thailand 98 Timor-Leste 105
Annex 1: List of focus areas and indicators assessed 115 Annex 2: Situation analysis Tool 2018
(WHO Regional Office for South-East Asia Region) 117
Annex 3: List of participants 124
Acknowledgements
The South East Asia Regional Office of WHO (WHO-SEARO) wish to express their appreciation to all those whose considerable work in preparing for, and facilitating, the meeting, and reviewing this report efforts made this publication possible. This was a significant demonstration of the value of the Tripartite plus UNEP in working together to understand the complexity of antimicrobial resistance and its management and the inputs from the partners below is gratefully acknowledged.
FAO HQ
- Henk Jan Ormel, Senior Veterinary Policy Advisor FAO Regional Office for Asia and the Pacific
- Katinka de Balogh, Senior Animal Health and Production Officer - Mary Joy Gordoncillo, AMR Regional Surveillance Coordinator OIE
- Pennapa Matayompong, Programme Coordinator, Sub-regional Representation for South East Asia
- Pasang Tshering, Consultant, Regional Representation for Asia and the Pacific UNEP Asia
- Kakuko Nagatani-Yoshida, Regional Coordinator for Chemicals, Waste and Air Quality
- Masato Motoki, Environment and Health Officer - Montira Pongsiri, Senior Research Associate WHO HQ
- Elizabeth Tayler, Technical Officer, AMR Secretariat - Pravarsha Prakash, Technical Officer, AMR Secretariat
The technical advice of Visanu Thamlikitkul, Director of WHO Collaborating Centre for AMR Prevention and Containment at the Faculty of Medicine Siriraj Hospital, Mahidol University and Viroj Tangcharoensathien, Senior advisor to the International Health Policy Programme (IHPP), Ministry of Public Health in Thailand is gratefully acknowledged.
The meeting would not have been possible without the financial support of the United States Agency for International Development, USAID (Grant US -2016 1054 – Amendment 28 - One health surveillance of AMR in Asia) and the Government of Canada (Grant arrangement between Canada DFATD and WHO – D004200 – Combating Antimicrobial Resistance) and we are grateful for this but also the on-going technical advice from Dan Schar, Senior Regional Emerging Infectious Diseases Advisor, USAID and Sudarat Damrongwatanapokin Regional Animal Health Advisor, USAID.
List of acronyms
AAW Antibiotic Awareness Week AMR antimicrobial resistance AMS AMR stewardship
AMSP AMR stewardship programme AMU antimicrobial use
API active pharmaceutical ingredient AR antibiotic residues
CDSCO Central Drugs Standard Control Organization DRA drug regulatory authority
EPI expanded programme on immunization EQAS external quality assurance system ESBL extended-spectrum beta lactamases EWS early warning system
FAO Food and Agriculture Organization GAP global action plan
GAP-AMR global action plan on antimicrobial resistance GDP good distribution practices
GLASS Global Antimicrobial Resistance Surveillance System GMP good manufacturing practices
GPP good pharmacy practices HAI health-care-associated infection HiB haemeophilus influenza B HIV human immunodeficiency virus
IEC information, education and communication IPC infection prevention and control
JANIS Japanese Nosocomial Infection Surveillance System LMIC lower-middle income country
MoH Ministry of Health
M&E monitoring and evaluation MoU memorandum of understanding
NADFC National Agency of Drug and Food Control NAP national action plan
NAP-AMR national action plan on antimicrobial resistance NRA national regulatory authority
NGO nongovernmental organization OTC over-the-counter
OIE World Organisation for Animal Health – Office International des Epizooties
PCV pneumococcal conjugate vaccine R&D research and development SEA South-East Asia
SEARN South-East Asia Regional Network SDG sustainable development goal SOP standard operating procedures ToR terms of reference
UHC universal health coverage
UNEP United Nations Environment Programme
USAID United States Agency for International Development WASH water, sanitation and hygiene
WHA World Health Assembly WHO World Health Organization
Antimicrobial resistance (AMR) has been on the rise globally. One of the biggest concerns in modern medical science relates to resistant bacteria, due to which even common respiratory infections, skin sores and diarrhoea can become untreatable and place millions at risk. Experts warn that if steps are not taken by 2050, one in six deaths might be attributable to drug-resistant strains of tuberculosis, malaria, human immunodeficiency virus (HIV) and certain bacterial infections. If the current situation continues unchecked, AMR could result in a decline of 1.1–3.8% in the annual global gross domestic product (GDP), and could have a major impact on global poverty.
At the United Nations General Assembly in New York in September 2016, global leaders committed themselves to fighting AMR. Despite the fact that they had come together, challenges persisted as national health priorities were influenced by different country contexts. Since 2010, WHO has taken steps to further the work on AMR in the Region. A global Tripartite partnership for One Health was signed with the Food and Agriculture Organization (FAO) and World Organisation for Animal Health (OIE) to provide a strategic vision and see to sharing of responsibilities to address health risks at the human–
animal–environment interface. This was reinforced with the signing of an Memorandum of Understanding (MoU) in 2018, with details on combatting health risks at the health-care-associated infection (HAI) interface in the context of the One Health approach, and including AMR.
In the last two years, the work initiated in 2010 has gained momentum with high-level advocacy meetings setting the stage for stakeholder engagement, donor support and technical activities for AMR containment. A situation analysis tool developed in 2016 provided technical guidance for assessing the functionality of the measures and capacity to contain AMR in the Region.
This was followed up in 2018 with two intercountry meetings in Bangkok, where Tripartite members and Member States reviewed implementation and assessed the progress made in the two years since the last situation analysis in 2016. This report provides a synthesis of the discussions and an update on the status of the national action plans (NAP) in Member States.
More recently, the Interagency Coordination Group (IACG) on AMR, co-chaired by the UN Deputy Secretary General and the WHO Director General, recommended building a partnership that goes beyond the
Foreword
Tripartite.i The renewed prioritization of this issue, along with binding commitments at the national, regional and global levels, will see stronger leadership and political buy-in, placing greater accountability for progress on AMR with individual countries. While we commend the IACG initiative for a global governance structure, we believe that global governance will need a relay at the regional level, identifying clear actions and translating global recommendations into implementation. We hope we can sustain funding to the interventions above, with the support of valued partners such as the United States Agency for International Development (USAID) and UK’s Fleming fund to fight AMR and save millions of lives.
Poonam Khetraphal Singh Regional Director WHO South-East Asia Region
i http://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_Future_global_governance_for_
AMR_120718.pdf
Executive summary
Ever since antibiotics were developed in the 1940s, scientists have warned that their improper use will lead to bacterial resistance. On the basis of the data presented in WHO’s Global Health Estimates, by the year 2050, about one in six deaths could be due to drug-resistant strains of tuberculosis, malaria, HIV and bacterial infections.
WHO’s efforts to work with Member States to develop their national action plan on antimicrobial resistance (NAP- AMR)
Since 2010, WHO has worked with FAO and OIE in a global Tripartite partnership for One Health to provide a strategic vision and ensure sharing of responsibilities to address health risks at the human–animal–
environment interface. The Tripartite coordinated the development of a common multipronged regional action plan in support of countries, highlighting priority issues of governance and multisectoral coordination, capacity-building, gaps in knowledge and strengthening of systems. The announcement of the global action plan against antimicrobial resistance (GAP-AMR) in 2015 was followed by advocacy initiatives at the global and regional levels by WHO and the Tripartite, calling for the development of comprehensive NAPs-AMR that were aligned to strategic objectives and implemented using the One Health approach. It also provided
technical support for developing and monitoring the progress of Member States with respect to their NAPs- AMR.
Situational analysis of 2016 As a first step in implementing the AMR prevention and containment efforts in the Region, a situational analysis was initiated by the
Regional Office in 2016. The findings culminated in a roadmap providing clear guidance on initiatives that Member States need to put in place to achieve sustainable AMR containment.
By mid-2017, all 11 Members States had prepared NAPs and initiated programmes. These varied according to each country’s context and
national health priorities. While the higher-income countries focused on emerging infectious disease outbreaks and AMR, the lower- income countries viewed AMR as an abstract concept, looking instead to strengthen local health systems to address endemic and
‘neglected’ diseases. Not having accurate national estimates on the AMR burden limited many countries, particularly those in the low- and middle-income category (LMIC), in the matter of making a case for substantial investment in containing AMR.
Bangkok meetings and situational analysis of 2018
In 2018, two back-to-back follow-up meetings were held in Bangkok to assess progress and identify gaps and challenges in NAP implementation in the Region and suggest actionable recommendations. The meetings brought together country-led intersectoral teams, comprising representatives from the national drug regulatory authority (DRA), national referral laboratory, AMR stewardship programme (AMSP) and national officers in charge of the human and animal health sectors and environment sectors from the Member States, in addition to technical experts from FAO,
Situational analysis tool of 2018
1. The advanced tool used for the situational analysis and monitoring of AMR was the same as that used by the Regional Office in 2016.
2. The tool was used to conduct system-wide analysis of AMR prevention and containment programmes, focusing on seven areas from the 2016 tool (NAP aligned with the GAP- AMR governance; awareness-raising; national AMR surveillance system; rational use of antimicrobials and surveillance of use/sales; infection prevention and control (IPC) and AMR stewardship; research and innovation; and One Health engagement. Further, it added the eighth focus area of overarching coordination mechanisms for One Health engagement.
3. It assessed progress on 30 indicators as a proxy for strategic interventions/programmes across eight focus areas and introduced 10 additional indicators.
4. Phase 3 or initial implementation was used as a cut-off for assessing progress. This is because this is one of the most challenging phases for programmes, especially in the context of developing countries, since it signifies an important shift from planning and identification of resources (Phases 1 and 2) to the initiation of implementation with political commitment and support (Phase 3 and above).
OIE, United Nations Environment Programme (UNEP) and WHO collaborating centres from the Region.
The situational analysis and review of implementation was carried out using the participatory methodology of guided discussion and conducted jointly by national stakeholders and WHO in collaboration with FAO, OIE and UNEP representatives. The national stakeholders assessed themselves with supporting evidence and justification on each of the indicators under individual focus areas, documenting strengths, challenges and implementation gaps.
Assessing the progress of a country
The 2018 tool assessed the progress of NAP-AMR implementation based on 30 indicators as a proxy for strategic interventions/programmes across eight focus areas. These included 20 initial indicators (from the 2016 situational analysis tool) and 10 newly introduced indicators.
For the purpose of analysis, Phase 3 or initial implementation was used as the cut-off for assessing the progress as it is an important milestone that signifies an important shift from planning and identification of resources (Phases 1 and 2) to initiation of implementation with political commitment and support (Phase 3 and above).
Country progress was defined by the proportion of indicators that reached Phase 3 and above and was calculated for each country (followed by the calculation of median progress, i.e. median of country progress) in 2016 and 2018. The progress against individual indicators was assessed as the number of countries that achieved implementation of the level of Phase 3 and above by 2018.
Results of the situational analysis, 2018
The situational analysis of 2018 revealed significant progress in the implementation of NAPs across different focus areas and their indicators in the Member States in the preceding two years.
Based on the original 20 indicators, median country progress was significantly higher at 55% in 2018 (i.e. 50% of the countries had at
least 55% of the 20 initial indicators that reached Phase 3 and above);
progress against the same indicators in 2016 was 25%. On the basis of all 30 indicators (including the 10 new indicators introduced in the situational analysis tool of 2018), the median country progress in 2018 was 40%.
In terms of how the indicators improved in countries, 17 out of the 20 indicators assessed in 2016 showed progress in 2018. The maximum progress was made in sanitation and hygiene programmes in community settings (10 countries in 2018), raising of awareness among the general public (nine countries in 2018), education and training (nine countries in 2018), NAP-AMR and governance structure (eight countries), regulations
dealing with antimicrobials and active pharmaceutical ingredients or APIs (eight countries in 2018), strengthening of the national laboratory network, surveillance of antimicrobial use and sales among humans, and regulation of over- the-counter (OTC) sales (seven countries for each indicator in 2018).
Implementation remained the same in “IPC in health-care settings”, whereas there was a decline in the number of countries in the case of
“national AMR containment policy”
and “AMSP in health-care settings”, mainly due to recalibration of earlier assessments. None of the countries was able to demonstrate initial implementation of early warning systems in the two years.
As for the indicators newly assessed in 2018, none of the countries had implemented national policy/
regulatory frameworks for the controlled release of antibiotic residues (AR) in the environment.
Similarly, none had a platform for sharing AMR data across sectors or awareness and education programmes for the environment sector.
All Member States achieved >Phase 4 or full operations in at least one indicator in 2018. Thailand emerged as a leader, with 14 indicators in Phase 4 and above. It was followed by Sri Lanka (9), Bangladesh (7) and Indonesia (6). The Democratic People’s Republic of Korea (DPRK) (1) and Timor-Leste (2) had the least number of indicators in full operation.
Some continuing challenges The overall findings showed the animal health sector has made less progress across different focus areas and indicators. Limited systemic capacity of the animal health sector and lack of resources can explain some of the gaps in progress. This could impact One Health engagement and effective multisectoral collaboration. The environment sector, in particular, is less integrated across all focus areas and indicators, and this probably reflects a lack of clarity in the collaborative frameworks that necessitate their involvement.
In a majority of the countries, implementation of AMR surveillance in the human health sector has not been initiated so far. It is lagging more in the animal and environment sectors. Similarly, AMR/
antimicrobial use (AMU) surveillance, IPC in health-care facilities, HAI surveillance and AMSP in most countries in the Region have failed to reach initial implementation in the last two years. None of the countries
started initial implementation of early warning systems during this period.
An in-depth analysis revealed a lack of policies, standards and guidelines which, in turn, lead to an inability to highlight the relevance of these activities in the resource-constrained Region.
A key challenge faced by countries relates to having in place effective operational plans and regulatory frameworks that could be suitably adapted to AMR containment efforts.
Most countries in the Region are yet to put together a strategic research agenda that is relevant to current policies and programmes, and address implementation challenges facing AMR containment efforts.
Recommendations and next steps Strengthening governance and multisectoral collaboration is a priority, as is expanding awareness on AMR (emphasized as a continuous effort targeting different sectors and population groups as well as through academic curricula and training for students and working professionals).
To initiatite and improve standardized and robust AMR/AMU surveillance across sectors, it was agreed that WHO and its Global Antimicrobial Resistance Surveillance System (GLASS), and the Tripartite partners must extend support as a matter of priority, providing technical support and guidelines.
A key recommendation that resonated with all Member States was to standardize and implement IPC and antimicrobial stewardship programmes nationwide by involving hospital personnel, NGOs and key influencers in the community. To avoid the irrational use and resale of
antimicrobials, it was also agreed by all Member States that regulations to monitor pharmacies and online outlets would be necessary. Further, checking the import of medical products for public and animal health sectors by promoting regulatory cooperation in South East Asia Regional Network (SEARN) that is more acceptable and innovative would strengthen AMR containment.
These efforts would then drive the One Health agenda.
It was agreed that the regional tripartite partners and UNEP will continue to support the implementation of NAPs-AMR in Member States by providing evidence-based technical guidance customized for each country. Going forward, the momentum thus achieved will be sustained through stronger multisectoral collaboration, including the creation of platforms that can enable joint planning, exchange of surveillance information and sharing of resources.
Background
Antimicrobial resistance is a global public health concern that has significant health and financial consequences. The prevalence of AMR been rising steadily and in many parts of the developing world, the levels of increase are considered
“dangerously high”. The developing countries are more vulnerable than others due to their large population, coupled with a lack of financial, technical and human resources to deal with the high burden of infectious diseases.
10 million deaths may be
attributed to AMR by 2050 at the global level and nine million in developing countries, with 4.7 million in Asia, 4.2 million in Africa and 392,000 in Latin America.1
The 11 Member States of the Region are Bangladesh, Bhutan, DPRK, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. They are lower-middle income countries (LMICs), which are home to 1.9 billion people.
Although the Region has made steady social and economic progress, a large proportion of the population continues to live in poverty.
Inadequate housing and sanitation accelerate person-to-person, and environmental, spread of resistant pathogens and genes.
Antibiotics are widely used in the Region for therapeutic and non- therapeutic reasons in human beings, animals, aquaculture and agriculture, including for the promotion of growth. This inevitably leads to the presence of antibiotic residues in the environment, paving the way for bacteria to develop resistance through selective pressures. Qualitative risk analysis suggests that this Region is probably at the highest risk globally for the emergence and spread of AMR.2 According utmost priority to the issues related to AMR, the Region has developed comprehensive
policies and adopted several Regional Committee resolutions on the
prevention and containment of AMR.
These include:
i. A series of high-level advocacy meetings held to help set the stage for the engagement of stakeholders, support from donors and technical activities for AMR containment.
ii. A situational analysis tool prepared in 2016 to provide technical guidance for assessing functionality and capacity in terms of governance, policy and
1 Review of antimicrobial resistance. Tackling drug-resistant infections globally: final report and recommendations.
Chaired by Jim O Neil. May 2016 [http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf]
2 One Health approach to tackle antimicrobial resistance in South-East Asia. Poonam Khetrapal Singh, regional director BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3625 (Published 05 September 2017) Cite this as: BMJ 2017;358:
j3625
systems available to contain AMR (used in 10 of 11 Member States).
iii. The situational analysis was used to create a regional roadmap to help guide the Member States in developing their national AMR prevention and containment programmes.
iv. A workshop was held in 2016, for all Member States, to review the progress of planning and implementation status with respect to NAP-AMR. This was combined with in-country review visits. The Regional Office developed a roadmap to assist Member States to develop their national AMR prevention and containment programmes and to implement NAP. The roadmap proposed five phases of development based on activities implemented as part of the NAP (Fig 1).
v. Collaboration was initiated with FAO and OIE as a follow- up to the 2016 meeting and the development of NAP-AMR to hold intercountry meetings to:
– review the implementation of NAP-AMR;
– identify challenges to the containment of AMR;
– assess the usefulness of the situational analysis tool in supporting NAP
implementation; and – explore the flexibility of the
tool to expand and include agriculture, aquaculture and environmental sectors in alignment with the One Health approach.
Recent relevant initiatives and developments in the Region
After the announcement of the GAP-AMR, SEA Region has taken serious note of its high vulnerability.
Responding to the situation, it has translated the GAP-AMR into a public health priority and backed it with strong advocacy and policy initiatives. These developments have highlighted the political commitment of the regional leadership in this area. There have been important events and initiatives since the last situational analysis, as shown in Box 1. A multipronged strategic approach has been adopted, and there has been a wide range of policy proclamations, advocacy meetings and statements. Multisectoral coordination mechanisms have been put in place, efforts have been made to raise awareness efforts, and technical support has been provided to countries for generating policy- relevant evidence and monitoring of AMR containment efforts.
Fig. 1. Roadmap for action on AMR in WHO SEA Region, 2016
BOX 1. Special initiatives and developments in SEA Region in 2017–18
Policy statements
i. “Adopting an integrated approach to make progress towards universal health coverage (UHC) and ensuring access to effective treatment of infectious diseases while reducing risk of AMR”: Outcome of a high-level meeting on “UHC as a tool to combat infectious diseases” held on 30–31 May 2018 in Tokyo, Japan.
ii. “Improving prevention, diagnosis and clinical management of sepsis and promoting AMR containment initiatives”: adopting the 70th WHA resolution in May, 2017.
Technical support for policy relevant evidence
i. Participation in Global antimicrobial surveillance system (GLASS): Encouraging Member States to participate in GLASS; nine out of 11 countries enrolled in GLASS and started to prepare for submission of surveillance data.
ii. Scientific and literary work to support AMR containment: In 2017, a publication titled “Situation Analysis on AMR in SEAR” was released during the 70th Regional Committee meeting at Maldives, serving as baseline data for national AMR control programmes to measure progress. Other developments included:
- DPRK followed Maldives’ example and undertook a situation analysis.
- Regional AMR risk assessment was conducted and the result was published in the British Medical Journal in 2017, presenting initiatives from India, Indonesia and Thailand.
- Priority intervention areas were identified, and pilots initiated within the framework of the NAPs on the basis of baseline risk assessment. The findings from these pilots will form the basis of national level programms to strengthen AMR surveillance and control.
iii. WHO-led key projects undertaken proposed and approved:
- An extended-spectrum beta-lactamases (ESBL) pilot project was initiated in Indonesia in 2017 as part of the regional integrated surveillance project. India and Nepal agreed to start the project by 2018-19
- An environmental surveillance and study on the role and impact of AMR on the environment was commissioned, on the basis of a recent WHO study: “Snapshot survey of AMR in East Kolkata Wetlands, India”.
- Studies were conducted on a six-year retrospective analysis of antimicrobial consumption data in several Member States to determine the extent and pattern of use of antibiotics.
iv. Adopting a regional approach: The approach was adopted through a SEARN platform that could help control and regulate the quality of antibiotics sold in the Region in human and animal sectors.
v. Integrated surveillance: Proposing an integrated surveillance to be strengthened combining surveillance in humans with animals and in the environment.
vi. Technical guidance: Extending technical guidance to build lab-supported human AMR surveillance in Member States.
Multisectoral coordination mechanisms
Developing NAP-AMR in all Member States: Available in WHO library at http://www.searo.who.int/entity/
antimicrobial_resistance/national-action-plans/en/.
Strengthening coordination mechanisms: Multiple sectors were drawn in to promote intersectoral
coordination at the national level and to coordinate bi-regional (SEA and Western Pacific) activities related to AMR containment in collaboration with the Regional Tripartite members (FAO & OIE).
Constituting an AMR coordination group: In 2017, coordination mechanisms were established between departments in the Regional Office, led by the Senior Advisor to the Regional Director with a view to enabling comprehensive planning and engagement across sectors for AMR containment and utilizing the available resources and expertise in the Region optimally.
Advocacy and awareness initiatives
i. Participating actively in a regional workshop on AMR in SEA, in Penang, Malaysia, on 26-28 March 2018: It provided a platform to share lessons and experiences on how Asian countries have responded to the AMR crisis and how these can lead to evidence-based decisions and initiatives to tackle the issue.
ii. Holding World Antibiotic Awareness Week: Since 2015, celebrations are held every November to improve awareness and understand AMR through effective communication, education and training.
Key message in 2017: Seek advice from qualified health-care professional before taking antibiotics.
Key message in 2018: Think twice. Seek advice. Misuse of antibiotics puts us all at risk.
Monitoring AMR containment efforts
i. Completing AMR self-assessment process: All countries in the Region participated in a global self- assessment process and the data was updated by June 2017.
The WHO Regional Office for South- East Asia is committed to supporting periodic situational analysis activities across the Region. It also provides technical support that may be needed in the areas of surveillance, laboratory capacity, human
resources, impact assessment and research to combat AMR in close coordination with Tripartite experts.
In the light of this commitment, two back-to-back intercountry meetings were organized from 23–27 July 2018 in Bangkok, Thailand. These were held jointly with the Tripartite partners (FAO and OIE) and UNEP to review the implementation of NAPs by the Member States. The meetings sought to build momentum towards the containment of AMR and a subsequent reversal of trends.
General objective
• Monitor progress and address gaps in the implementation of -NAPs-AMR in the Region Specific objectives
• To review progress on the implementation of NAPs-AMR;
• To review progress in the development of national
programmes for the containment of AMR;
• To share good practices and lessons learnt;
• To identify gaps, barriers and challenges in the implementation of AMR-NAPs and possible solutions and enablers; and
• To make recommendations for effective implementation, considering the progress made, and suggest additions to update NAPs.
Methodology for situation analysis of NAP implementation
The situation analysis, 2018 and review of implementation was carried out using the participatory methodology of Guided Discussion.
Briefly, Guided Discussion is a
“transformative” approach to public health research. As a participatory
Intercountry meetings that had good representation used the Guided Discussion approach to undertake an exhaustive review that was inclusive and participatory. It built on the 2016 situational analysis to bring in a fresh perspective with more nuances and insights, enabling Member States to identify areas for strengthening cross-sectoral collaboration at the national level for AMR containment.
Intercountry meetings to
review situation of NAP
implementation in the
Region
approach, it ensures the involvement of all relevant stakeholders, both marginal and dominant groups, and enables them to voice their opinions.
Participation is empowering, i.e.
it leads to a participant-initiated action agenda and empowerment to participate in policy change.
Guided Discussion is particularly useful after the participants have gained knowledge and experience on the topic of interest. In a Guided Discussion, the facilitator stimulates thought and “draws out” information with the help of questions that have a specific purpose and clear meaning.
The ideas, facts and agreements that emerge as a result of the discussion are recorded.
The implementation review in the intercountry meetings was conducted jointly by the national stakeholders and WHO (the Regional Office and country offices), in collaboration with FAO, OIE and UNEP representatives.
The latter facilitated the exchange with national stakeholders who assessed themselves with supporting evidence and justification on a set of indicators and focus areas (Annex 1). This was done using a list of core questions from the Situational
analysis tool (Annex 2) that was an advanced version of the 2016 tool.' Once a consensus was reached between the national stakeholders and facilitators on the level of progress made in implementing NAPs during 2017–2018, the phase of implementation for that indicator was ascertained and recorded. This was followed by the documentation of the strengths, challenges and implementation gaps.
Fig. 2. Review methodology adopted for conducting NAP implementation
The use of the Guided Discussion approach at the intercountry meetings ensured that the review was more inclusive and participatory than the assessment methodology of 2016. The
situational analysis in the latter was carried out during in-country visits by officials and consultants from the Regional Office, as well as experts and external consultants, through dialogue with national stakeholders. The involvement of experts from FAO, OIE and UNEP brought in a fresh perspective that widened the horizons beyond the Ministry of Health (MoH), enabling countries to identify areas for strengthening cross-sectoral collaboration at the national level for AMR containment.
Mul stakeholder review
• Performed jointly by naonal stakeholders and WHO
• Naonal
stakeholders assess themselves with supporng evidence and jusficaon
Guided discussion
• Elicits exchange between facilitators and stakeholders through use of core quesons
• Consensus achieved on grading of phase of implementaon
Themac analysis
• Ascertains the phase of implementaon by focus area
• Idenfies and summarizes strengths, challenges and implementaon gaps
Tool used for situational analysis and monitoring of AMR
The situation analysis tool of 2018 was an improvement over the one used in 2016. As in the case of the 2016 assessment, the tool was used to conduct a system-wide analysis of programmes for the prevention and containment of AMR.
Focus areas: The 2018 situational analysis tool focused on eight areas.
Seven were included from the 2016 tool: (1) NAP being in line with GAP-AMR governance; (2) raising of awareness; (3) national AMR surveillance system; (4) rational use of antimicrobials and surveillance of use/sales (community-based);
(5) infection, prevention control and AMR stewardship; (6) research and innovation; and (7) One
Health engagement. An additional area, ‘Overarching coordination mechanisms for One health
engagement’, was introduced in the 2018 tool.
Indicators: The 2018 tool assessed the progress against 30 indicators as a proxy for strategic interventions/
programmes across eight focus areas. These included 20 old indicators and 10 new introduced indicators. The new indicators were:
one indicator under focus area 5 on
“Infection prevention and control”;
three indicators under focus area 7 on “One Health engagement”; and six indicators under the newly introduced focus areas 8 on “Overarching
coordination mechanism”. A list of the 20 old and 10 newly introduced indicators is given in Annex 1.
Assessment of progress: For the purpose of this report, Phase 3 or initial implementation was used as the minimum threshold for assessing progress. Phase 3 is one of the most challenging phases for programmes, especially in the context of developing countries. It is an important
milestone as it signifies a shift from the planning and identification of resources to the initiation of implementation.
Only 20 indicators (from the situational analysis tool, 2016) were considered while calculating the proportion for measuring the progress of a country in 2016 and its median progress between 2016 and 2018. DPRK was excluded from this calculation as the country was not a part of the situational analysis in 2016. To assess the status of country progress in 2018, the proportion of indicators that reached Phase 3 and above was calculated for all 30 indicators.
The progress of individual indicators was assessed as the number of countries that achieved an
implementation level of Phase 3 and above in 2018. For indicators that were assessed in 2016 (baseline), the number of countries that were able to achieve an implementation level of Phase 3 and above in 2018 were compared to the baseline.
Country progress was defined as the proportion of indicators that reached Phase 3 or above and was calculated for each country (followed by calculation of median progress, i.e. median of country progress in the years 2016 and 2018).
Participant profile: Country-led intersectoral teams comprised representatives, one each from the national drug regulatory authority, national referral laboratory and AMSP, and national officers in- charge of human health, animal health and environmental sectors, from all Member States of the Region.
The technical experts included those from FAO (Headquarters and Regional Office for Asia and Pacific), OIE and global and regional offices of UNEP, two WHO collaborating centres from the Region and all three levels of WHO that facilitated and coordinated the sessions. Partners such as the United States Agency for International Development (USAID), Mott MacDonald for UK Fleming Fund, Canada’s International
Development Research Centre (IDRC) Asia Regional Office (New Delhi, India), and International Health Policy Programme of the Thai Ministry of Public Health actively participated.
Limitations of the methodology Two significant limitations were noted in the methodology that was adopted.
i. The analysis was primarily based on group discussions between national programme managers with facilitators providing an overview for each indicator.
The approach and tool provided an opportunity to the national stakeholders to present perceived challenges and needs and for them to discuss the justification with external partners, such as FAO, OIE and WHO, to seek feasible and consensual recommendations.
ii. Incremental phase-based evaluation helped national programme managers to gain an understanding of progress from one phase to the next phase. The review was primarily based on the understanding and interpretation of the national stakeholders. Though the group involved in analysing the situation was quite broad, it did not include all stakeholders, like civil society, NGOs, education sector experts and likewise, who would have had a bearing on the overall assessment.
To replace performance assessment based on the review of select participants by an assessment based on the effectiveness of interventions, WHO is currently developing performance indicators to measure the impact of AMR containment activities to support the monitoring of NAP implementation.
The 2018 situational analysis revealed significant progress in the implementation of NAPs by Member States in the preceding two years across the seven focus areas. Since face-to-face Guided Discussions ensured greater in-depth understanding of the situational analysis tool as well as assessment of the status of implementation among the national stakeholders there was consensus on revising downward progress against some of the indicators. The following sections describe the progress made.
General trends in NAP implementation
There were a few significant trends in the implementation of NAPs, both with respect to overall progress in countries and to progress in focus areas and specific indicators which help draw lessons from the process.
Overall progress in countries In 2016, Bhutan, Indonesia and India reported the highest proportion of indicators reaching Phase 3 or above (country progress of 45%). Timor- Leste had no indicator in Phase 3 and above (0% country progress);
the median of country progress was at 25%. In contrast, when the same indicators were assessed in 2018, the evidence of progress was more substantial, with median country progress at 55%, ranging from
country progress at 95% in Thailand to 15% in Timor-Leste). Overall, 9 out of 10 countries made progress in the proportion of indicators in Phase 3 between and 2016 and 2018 (Fig. 3).
On the basis of the 30 indicators (including the 10 additional indicators), the median country progress in 2018 was at 40%
(maximum country progress at 83.3%
in Thailand and minimum 16.7% in Nepal and Timor-Leste), compared to 25% (Fig. 4)
Progress of focus areas and indicators
Seventeen out of the 20 indicators assessed in 2016 showed progress in 2018 (Table-1). The maximum progress in terms of the number of countries in implementation Phase 3 and above was made in sanitation and hygiene programmes in
community settings and establishing a functional National Regulatory Authority or Drug Regulatory Authority (10 countries in 2018), awareness among the general public (nine countries in 2018), education and training (nine countries in 2018), NAP-AMR and governance structure (eight countries), regulations of finished products and APIs (eight countries in 2018), national laboratory network strengthening, surveillance of use and sale in humans, regulation of OTC sales (seven countries in each indicator in 2018). The number
Results of situational analysis of NAP
implementation
Fig. 3. Progress of NAP-AMR implementation, 2016–18
Fig. 4. Progress of NAP-AMR implementation by country, 2016–18
20 45
0
45 45
10 15
25 25
30
0 25 60
50
0 60
65
40 35
20 80
95
15 56.7 55
40.0 30.0
46.7 43.3
30.0 30.0
16.7 63.3
83.3
16.7 40.0
0 10 20 30 40 50 60 70 80 90 100
Bangladesh Bhutan DPRK* India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand TLS Median
progress
)%( evoba dna 3 esahp ni srotacidni fo noitroporP
2016* 2018* 2018**
Progress of NAP AMR implementaon, by country, SEAR (2016-18)
016
*Progress assessed for 20 indicators based on Situaon Analysis tool 2016; Situaon Analysis was not conducted in DPRK in 2 and so progress not compared in 2018
** Progress assessed for 30 indicators (10 newly introduced indicators) based on Situaon Analysis tool 2016
Progress of NAP AMR implementaon in SEAR (2016 18)
2016* 2018* 2018**
*Progress assessed for 20 indicators based on Situaon Analysis tool 2016; Situaon Analysis was not conducted in DPRK in 2016 and so progress not compared in 2018
** Progress assessed for 30 indicators (10 newly introduced indicators) based on Situaon Analysis tool 2016
Table 1. Phases of indicators in eight focus areas for all Member States of the Region during the situational analysis review of AMR in 2018 S. No.Focus area and subindicatorsBangladeshBhutanDPR KoreaIndiaIndonesiaMaldivesMyanmarNepalSri Lanka ThailandTimor-Leste 2018201620182016201820162018201620182016201820162018201620182016201820162018201620182016 1National AMR plan and governance 1.1NAP in line with GAP-AMR32333NA3223423222435322 2Raising awareness 2.1Campaigns to raise public awareness43433NA2243323222424242 2.2Education and training strategies for professionals31322NA3233313212315331 3National AMR surveillance system 3.1National human AMR surveillance32222NA3222222243435321 3.2National laboratory network strengthening32331NA4211214233525411 3.3Early warning systems11121NA221NA111112112111 4Rational use of antimicrobials and surveillance of use/sale (community-based) 4.1 A national AMR containment policy for control of human use of antimicrobials;AMR stewardship
2 1 2 2 2 NA2 32 4 2 21 1 12 2 23 2 21 4.2
National regulatory authorities or drug regulatory authorities
43453NA4454433343423221 4.3
Surveillance of antimicrobial use and sales in humans
32213NA3333322213314221 4.4
Regulation of finished antibiotic products and active pharmaceutical ingredients (APIs)
43443NA445NA422222324212 4.5
Regulation of OTC sale and inappropriate sale of antibiotics and APIs by pharmacies 43551 NA444NA422223424221 5Infection prevention and control and AMR stewardship programme 5.1
AMR stewardship programme in health-care settings
22222NA1333112212214311 5.2IPC programme in health-care setting 22233NA3333222311433211 5.3National HAI and related AMR surveillance22243NA3322123111424211 5.4Sanitation and hygiene41555 NA344NA422342444332 5.5Vaccination4 NA1NA1NA3NA2NA1NA4NA2NA3NA3NA4NA 6Research and innovation 6.1
R&D and innovation on AMR prevention and containment and research funding
22221NA2222213211214111
S. No.Focus area and subindicatorsBangladeshBhutanDPR KoreaIndiaIndonesiaMaldivesMyanmarNepalSri Lanka ThailandTimor-Leste 2018201620182016201820162018201620182016201820162018201620182016201820162018201620182016 7One Health engagement 7.1 A national AMR containment policy and regulatory framework for control and registration of use in animal sector
42321 NA2232121112433211 7.2
National surveillance of AMR ,and use and sale of antimicrobials at national level in the veterinary sector
AMU-2 AMR-2
2
AMU-2 AMR-2
1
AMU-1 AMR-1
NAAMU-1 AMR-2 1
AMU-3 AMR-3
2AMU-1 AMR-1 3AMU-1 AMR-11 AMU-1 AMR-2 2AMU-2 AMR-3 1
AMU-3 AMR-3
2 AMU-1 AMR-11 7.3
Biosecurity (infection prevention and control) in the animal sector
32223 NA3243 111221325211 7.4
AMR awareness generation and education in the animal sector
22321NA1231111111314211 7.5
A national AMR containment policy and regulatory framework to control release of AR and AMR into the environment and management there in
1NA1NA1 NA1NA1 NA1NA1 NA1 NA2 NA2 NA1 NA 7.6
National surveillance of AR and AMR in waste water from manufacture and human/animal/fish use and disposal in institutions and the home
3NA1NA1 NA1+NA1 NA1 NA1 NA1 NA1NA1+ NA1 NA 7.7
Raising awareness on AMR and education in the environmental sector 1NA1NA1NA1NA1NA2 NA1 NA1NA1NA2 NA1 NA 8Overarching coordination mechanisms for One Health engagement 8.1
Overarching AMR coordination mechanisms between all relevant sectors
4NA3 NA2NA2NA1NA2NA2 NA2NA2 NA4NA1 NA 8.2
Inclusion and engagement of all relevant sectors in the NAP-AMR
2 NA2 NA1NA3 NA2 NA2 NA 2NA2 NA2 NA5 NA 3 NA 8.3
A platform and/or mechanism for sharing of AMU monitoring data from all relevant sectors
4 NA2 NA1NA1 NA1 NA1 NA1 NA1NA3NA3 NA1 NA 8.4
A platform and/or mechanism for sharing of AMR surveillance data from al relevant sectors
2 NA1NA1NA2NA2 NA1 NA2NA2 NA2NA2 NA1NA 8.5
AAW is nationally coordinated and celebrated, with involvement of and contribution from all relevant sectors
4 NA3 NA1NA1 NA1NA3NA5 NA3 NA2NA5 NA3NA 8.6
A mechanism for co-sharing of resources for AMR initiatives in the country
1 NA1 NA1NA1NA1NA2NA1 NA1NA3 NA 3 NA1 NA
NA: Not assessed 1+ - Discussion in Phase 2 allocation inconclusive
Table 1 contd.
of countries achieving a level of implementation of Phase 3 and above remained the same in the indicator on “IPC in health-care settings”, whereas in the case of “national AMR containment policy” and “AMSP in health-care settings”, there was a decline in the number of countries, mainly due to recalibration of earlier assessment. None of the countries was able to demonstrate initial implementation of early warning systems in the two years.
Ten additional indicators were introduced in the situational analysis tool of 2018. Seven countries were in Phase 3 and above with regard to the implementation of the “nationally coordinated AAW” and six countries in “vaccination”. In three countries each, “overarching coordination mechanism”, “inclusion and
engagement of relevant sectors” and
“platform for sharing AMU data” were at Phase 3 and above in 2018. None of the countries had implemented a national policy/regulatory framework for the controlled release of AR and AMR in the environment. Nor had any of the countries established a platform for the sharing of AMR data across sectors or initiated awareness and education programmes for the environment sector.
All Member States were able to achieve > Phase 4 or full operations with regard to at least one indicator in 2018. Thailand was the leader, with 14 indicators in Phase 4 and above, followed by Sri Lanka (10), Bangladesh (7) and Indonesia (6);
DPRK (1) and Timor-Leste (2) had the least number of indicators in full operation.
Trends specific to focus areas
Focus area 1: NAP in line with the GAP-AMR (Fig. 5)
Indicator 1.1: NAP in line with the GAP-AMR/level of governance Five Member States (45%), namely, Bangladesh, Bhutan, DPRK, India, and Myanmar have developed their NAP in line with the GAP-AMR, including operational strategies with defined activities and budgetary provisions (Phase 3).However, though India has a NAP, the federal nature of the country requires the drawing up of state action plans. These are still being developed for the priority states to initiate decentralized implementation, Kerala being one of the first to develop an action plan.
Fig. 5. Focus area 1: NAP in line with GAP-AMR
4
8
0 1 2 3 4 5 6 7 8 9
2016 2018
No of countries (> phase 3)
In Indonesia, the AMR working group has been established and its NAP is under development (Phase 2).1 In Nepal, the NAP has been prepared in line with the GAP-
1 On the basis of its discussion with the facilitators, the national team from Indonesia proposed a phased revision from Phase 3 in 2016 to Phase 2 in 2018 for this indicator.
