Landscape Analysis of Tools to Address Antimicrobial Resistance - MAY 2021

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Landscape Analysis of Tools to Address Antimicrobial Resistance - MAY 2021
Landscape Analysis of Tools to Address Antimicrobial Resistance   1

Landscape Analysis of Tools to
Address Antimicrobial Resistance
MAY 2021
Landscape Analysis of Tools to Address Antimicrobial Resistance - MAY 2021
Appendixes                                                                                  2

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Landscape Analysis of Tools to Address Antimicrobial Resistance - MAY 2021
Landscape Analysis
of Tools to Address
Antimicrobial Resistance

MAY 2021
Table of Contents











World Bank Group                                                                          6


This report was written by a World Bank team led by Angela Mazimba (Research
Analyst), with contributions from Naomi Rupasinghe (Health Specialist) and Ana
Cristina Canales Gomez (Food and Agriculture Specialist), under the guidance of Feng
Zhao (Practice Manager for Global Engagement within Health, Nutrition and Population)
and Muhammad Pate (Global Director, Health, Nutrition and Population).

The team is grateful for the peer review guidance provided by Claire Chase
(Senior Water Economist), Franck Berthe (Senior Livestock Specialist), Stephen Dorey
(Senior Health Specialist), Fatima Barry (Health Specialist), and Sambe Duale (Senior
Public Health Specialist), as well as the support of Sanne Helt (Advisor), Anne Himmel-
farb (Editor), Gabriel Francis (Program Assistant) and Marize de Fatima Santos
(Program Assistant).

The team is also grateful for the guidance and advice of Anand Balachandran, Unit
Head, National Action Plans and Monitoring and Evaluation Unit, AMR Division, World
Health Organization; Arshnee Moodley, Team Leader, International Livestock Research
Institute, AMR Hub, CGIAR; Breeda Hickey, Technical Officer, National Action Plans and
Monitoring and Evaluation Unit, AMR Division, World Health Organization; Clara L. Davis,
Science and Technology Advisor, USAID; Constanza Vergara, Veterinarian and Agricul-
tural Economist, Chilean Ministry of Agriculture; Elizabeth Tayler, Team Leader, National
Action Plans and Monitoring and Evaluation Unit, AMR Division, World Health Organiza-
tion; Javiera Cornejo Kelly, Assistant Professor, Faculty of Animal and Veterinary Scienc-
es, University of Chile; Jing Xu, Animal Production and Health Division, Animal Health
Service, Food and Agriculture Organization; Jorge Pinto Ferreira, Deputy Head, AMR
and Veterinary Products Department, World Organisation for Animal Health; Nobuko
Ichikawa, Principal Environmental Economist/Environmental Advisor, European Bank for
Reconstruction and Development; Olga B. Jonas, Research Associate, Department of
Health Policy and Management, Harvard University T. H. Chan School of Public Health;
Renzo Guinto, Associate Professor of Global Public Health, St. Luke’s Medical Center Col-
lege of Medicine; Sarah Paulin, Technical Officer, National Action Plans and Monitoring
and Evaluation Unit, AMR Division, World Health Organization.

The report was funded by the Danish Ministry of Foreign Affairs as part of the World
Bank’s program on Antimicrobial Resistance (AMR).
Landscape Analysis of Tools to Address Antimicrobial Resistance                   7


 AMR                   antimicrobial resistance

 ASEAN                 Association of Southeast Asian Nations

 CDC                   US Centers for Disease Control and Prevention

 FAO                   Food and Agriculture Organization of the United Nations

 GAP-AMR               Global Action Plan on Antimicrobial Resistance

 GARP                  Global Antibiotic Resistance Partnership

 GDP                   gross domestic product

 GLASS                 Global Antimicrobial Resistance Surveillance System

 IPC                   infection prevention and control

 IHR                   International Health Regulations

 JPIAMR                Joint Programming Initiative on Antimicrobial Resistance

 LIC                   low-income country

 LMICs                 low- and middle-income countries

 MDR                   multi-drug resistance

 NGO                   nongovernmental organization

 OECD                  Organisation for Economic Co-operation and Development

 OIE                   World Organisation for Animal Health

 PVS                   Performance of Veterinary Services

 SDG                   Sustainable Development Goal

 SORT IT               Structured Operational Research and Training IniTiative

 STAR-IDAZ             Strategic Alliance for Research on Infectious
                       Diseases of Animals and Zoonoses

 TB                    tuberculosis

 WASH                  water, sanitation, and hygiene

 WHO                   World Health Organization

 XDR                   extensive drug resistance
World Bank Group   8
Landscape Analysis of Tools to Address Antimicrobial Resistance                                     9

Executive Summary

This report describes the current land-                   The scoping review identified 90 tools
scape of tools supporting the develop-                    aimed at supporting a range of entities
ment and implementation of policies and                   in establishing policies and implement-
interventions to address antimicrobial                    ing interventions to address AMR. These
resistance (AMR). A landscape analysis                    tools are targeted at national govern-
was undertaken to provide World Bank                      ments (ministries of health, agriculture,
staff, teams, and clients with a repository               environment), national centers for disease
of tools that can be used to address AMR.                 control, medical professionals, veterinar-
The analysis defined tools as frameworks,                 ians, laboratory technicians, pharmacists,
guidelines, documents, and strategy                       the private sector, producers and traders
development guides with the primary pur-                  in agriculture, nongovernmental organiza-
pose of supporting development and im-                    tions, and the country offices of organiza-
plementation of policies and interventions                tions such as the World Health Organiza-
to address AMR. A secondary purpose of                    tion (WHO) and the Food and Agriculture
the report was to identify gaps in the ex-                Organization (FAO) of the United Nations.
isting landscape of tools and recommend
areas for consideration by policy makers,                 Tools on implementation and surveil-
donors, and implementers.                                 lance predominate, but they are spar-
                                                          ingly contextualized. Of 90 tools identi-
A two-stage scoping review of existing                    fied, 47 focused on implementation, but
tools was performed, drawing on the                       they were rarely focused specifically on
Global Action Plan on AMR as a refer-                     low-income regions. Though tools were
ence for global guidance on AMR pre-                      developed to be adaptable, only six were
vention and control (WHO 2015a). In the                   developed for low-income countries,
first stage, landmark reports on AMR were                 among them the WHO AMR Stewardship
reviewed to develop the approach to de-                   Programmes in Healthcare Facilities in
fining and identifying relevant tools, and                Low- and Middle-Income Countries Toolkit
to help define six programming domains                    (WHO 2019c); the Fleming Fund’s AMR
for addressing AMR. These domains were                    Surveillance in Low- and Middle-Income
(i) awareness raising, (ii) antimicrobial                 Settings: A Roadmap for Participation in
stewardship, (iii) surveillance, (iv) infec-              the Global Antimicrobial Surveillance Sys-
tion prevention and control in human and                  tem (GLASS) tool (Fleming Fund 2016);
animal health, (v) the reduction of patho-                and the Structured Operational Research
gen spread in the environment, and (vi)                   and Training IniTiative on AMR, coor-
development of a national research agen-                  dinated by the Special Programme for
da. In the second stage, a targeted search                Research and Training in Tropical Diseases
of gray and peer-reviewed literature and                  (TDR) (UNICEF et al. 2019). Given that
related websites was performed to iden-                   low- and middle-income countries (LMICs)
tify tools containing intervention options                face disproportionate human, animal, and
for AMR action. Consultations were also                   economic impacts from AMR (World Bank
conducted with experts across the One                     2017), this finding points to a significant
Health spectrum1, to seek guidance, vali-                 gap and suggests that more can be done
date findings, and source further tools.                  to provide tools to support actors in

1 The One Health approach is explained in the last section of chapter 1.
World Bank Group                                                                        10

LMICs, where implementation of                More tools are needed to support costing
activities to address AMR is likely           AMR interventions, and on leveraging
more complex and challenging than             public and private finance to address
in higher-income countries.                   AMR. Of 90 tools reviewed, 3 were iden-
                                              tified as potential costing mechanisms
Stand-alone tools to reduce pathogen          for AMR activities. One tool, the RAND
spread, specifically related to environ-      Corporation (2014) methodology for
mental surveillance and management,           estimating the economic costs of AMR, is
are also limited. Of the 90 tools identi-     focused on measuring the cost of AMR at
fied, 13 provided some coverage of the        the global level. For the national level, the
mechanisms required for reducing or lim-      PVS Gap Analysis tool (OIE 2020) pro-
iting the spread of pathogens in the envi-    vides a costing methodology for national
ronment. Of these, four tools that address    veterinary services. The WHO is also in
domestic and agricultural solid waste         the process of developing a modular tool
and wastewater management specifical-         that will support countries with costing,
ly acknowledge the threat of pathogen         budgeting, and prioritizing activities con-
dissemination into the natural environ-       tained within their AMR National Action
ment. Tools such as the “Technical Brief      Plans (NAPs) (WHO 2021). The tool will
on Water, Sanitation, Hygiene (WASH)          facilitate budgeting gaps analyses and
and Wastewater Management to Prevent          allow countries to advocate for additional
Infections and Reduce the Spread of           funding for prioritized AMR activities.
Antimicrobial Resistance (AMR)” (WHO,         Given the economic limitations that coun-
FAO, and OIE 2020b) address WASH and          tries in lower-income regions face, there
wastewater management to limit dispersal      is room to leverage national costing and
via fecal sludge and liquid waste, silent     economic burden studies for more
transmission of resistant microorgan-         effective AMR programming.
isms, and release of other pollutants and
antimicrobial compounds. The Review on        There is a need for more tools on inter-
Antimicrobial Resistance (2015) paper and     ventions that are focused at the commu-
the United Nations Environment Pro-           nity or individual level. Only one tool, the
gramme’s Frontiers report (UNEP 2017)         WHO (2018c) Competency Framework for
provide an overview of the pathways of        Health Workers’ Education and Training
environmental transmission from water         on Antimicrobial Resistance, focused on
and food systems. It is important to note     awareness raising interventions at the
that this focus on the spread of patho-       individual level. A second tool, “Antibiotic
gens into the environment entailed im-        Prescribing and Resistance” (WHO and
portant search limitations. While not the     Antimicrobial Resistance Centre at the
focus of this review, a broader framework     London School of Hygiene and Tropical
for the nexus between AMR, environ-           Medicine 2017), highlights the perspec-
ment, and related issues such as climate      tives of prescribers and health profes-
change and zoonoses could be outlined         sionals in low-income settings. Recently
and would result in a broader array of        articulated community engagement
more indirect tools. For example, certain     frameworks for AMR research and action
tools in the environmental sector are         (Mitchell et al. 2019) may form a founda-
designed specifically to address climate      tion for the development of further tools
change, but there is a high potential that    in this area. However, the lack of tools to
these tools could also lead to benefits for   support implementing agencies in engag-
AMR risk reduction. Making these linkages     ing with individuals and communities may
clearer and more visible will require more    be a knowledge and practice gap that is
targeted investments to produce clearer       of interest to donors and policy makers.
guidance and to reinforce knowledge and
other resources in the sector.
Landscape Analysis of Tools to Address Antimicrobial Resistance   11
World Bank Group                                                                                    12

Chapter 1:

Background: Why does                                      Antimicrobials used to treat infectious dis-
antimicrobial resistance matter?                          eases in animals are also used in humans,
                                                          and resistant microorganisms arising in
Antimicrobial resistance (AMR)—the                        humans, animals, or the environment may
resistance of microbes to antimicro-                      spread across any of those boundaries
bials—continues to pose a significant                     (FAO, OIE, and WHO 2017).
threat to global health security (World
Bank 2019). AMR occurs when microbes                      Failure to make progress on controlling
(bacteria, fungi, viruses, and parasites)                 AMR is a significant development chal-
mutate in response to their exposure to                   lenge because of AMR’s disproportion-
antimicrobials. This natural development                  ate impact on low- and middle-income
means that drugs that were previously                     countries (LMICs), and specifically its
effective in treating diseases become                     negative impact on poverty reduction,
ineffective, making infections lethal or                  food security, health and well-being, and
persistent. Pathogens may be resistant to                 inequality reduction. AMR is estimated
several antimicrobials: multi-drug resis-                 to cause 700,000 deaths annually, and
tance (MDR) describes resistance to two                   deaths attributed to AMR are predicted
or more antimicrobial agents in three or                  to rise to 10 million annually by 2050
more antimicrobial classes; extensive drug                (Review on Antimicrobial Resistance
resistance (XDR) describes resistance to                  2016). The rise of drug-resistant tubercu-
at least one agent in all but one or two                  losis (TB) highlights the potential impact
antimicrobial categories; and pan-drug re-                of AMR for LMICs. The cost of treating
sistance describes resistance to all agents               MDR-TB or XDR-TB can be significantly
in all antimicrobial categories. Microbes                 more expensive than drug-sensitive TB.
developing resistance to multiple drugs                   For example, in 2011 only 2 percent of
are sometimes referred to as “superbugs.”                 South Africa’s TB cases were drug resis-
An infection caused by a superbug is                      tant. However, those cases consumed 32
harder to treat because fewer effective                   percent of South Africa’s national budget
drugs are available. In some extreme cas-                 for TB treatment.3
es, treatment may not even exist. Given
                                                          In 2016, the World Bank analyzed the
the range of everyday medical interven-
                                                          global economic impact of AMR and
tions that are enabled by effective antimi-
                                                          found that by 2050 AMR could negative-
crobials, the potential impact of losing the
                                                          ly affect the global economy by as much
ability to use antimicrobials constitutes a
                                                          as 3.8 percent of annual gross domes-
“slow-moving tsunami” (WHO 2016a).
                                                          tic product (GDP). Two scenarios were
Successive international declarations                     considered. In a high-impact scenario, the
have acknowledged the global threat of                    world would lose 3.8 percent of annual
AMR (UN General Assembly 2016). While                     GDP. Mild impacts would likely reduce
the devastating potential for the health                  GDP by 1.1 percent (World Bank 2017).
sector has been widely documented,                        These effects stand to be profound in
stakeholders have also recognized that                    two ways. First, they would be felt on an
the causes of resistance go well beyond                   ongoing basis. Second, they would have
the health sector, making it critical to                  a disproportionate impact on low-income
draw on a One Health approach2.                           countries (LICs), which would experience

2 The One Health approach is explained in the last section of this chapter.
3 T
   B Alliance, “Drug Resistance: A Response to Antimicrobial Resistance Includes Tackling TB,”
Landscape Analysis of Tools to Address Antimicrobial Resistance                                   13

larger drops in economic growth than                   inhibit progress toward the SDGs (Figure
wealthy countries, in turn increasing glob-            1), while a focus on the SDGs is also a way
al poverty and economic inequality. AMR                to contribute to containing AMR. For ex-
thus has a two-way relationship with the               ample, improved water management and
Sustainable Development Goals (SDGs):                  sanitation will help limit infectious disease
the emergence and spread of AMR will                   risks.


Source: World Bank 2019.

Purpose and structure

The purpose of this landscape analysis is              require collaboration across sectors, as
to provide World Bank teams and clients                well as adaptive solutions that incentivize
with a repository of tools that can be                 patients, farmers, medical professionals,
used to address AMR through the devel-                 companies, and industries to use antimi-
opment and implementation of policies                  crobials differently (World Bank 2019).
and interventions. A secondary purpose
is to identify gaps and areas for further              Within this wider context, this landscape
consideration and support by policy mak-               analysis is intended to highlight the
ers, donors, and implementers.                         development of a range of tools and ap-
                                                       proaches that support programming and
Since the Global Action Plan on AMR                    policy implementation to contain AMR
(WHO 2015a) and the UN General As-                     at the global and national levels. While
sembly’s (2016) Political Declaration on               gaps and blind spots remain, global- and
Antimicrobial Resistance were issued,                  national-level policy makers, ministries,
meetings and reports have documented                   and implementing institutions have a
the importance of AMR as a global threat.              substantial foundation on which to draw.
These developments reflect a growing                   While the focus of this report remains
understanding of AMR as a technical issue,             technical, it is intended as a step toward
and a recognition of the threat posed by               the uptake of adaptive approaches. For
AMR to global health security and socio-               example, while efforts to contextualize
economic well-being. Nevertheless, action              tools remain important, this landscape
to address AMR has been slower to mate-                analysis demonstrates that a range of ma-
rialize, in part because effective action can          terials is available to support actors across
World Bank Group                                                                      14

the One Health spectrum in addressing          importance of a cross-sectoral approach
AMR, prioritizing investments, and imple-      to global health security. It showcases
menting NAPs.                                  how environmental changes, along with
                                               ecological and human dynamics, can am-
The report is organized as follows. The        plify pressures at the interfaces between
remainder of this chapter discusses how        humans, animals, and the ecosystems they
the analysis draws on a One Health ap-         share. A growing number of drivers have
proach. Chapter 2 explains the methodol-       increased the risk of infectious disease
ogy used to define, search for, and select     emergence and spread. AMR is one of
the tools, and lists key domains for action    these drivers. Addressing the emergence
on AMR. Chapter 3 presents the findings        and spread of resistance requires a sys-
from the review. Chapter 4 offers some         tems approach that includes the human,
conclusions concerning gaps and oppor-         animal, and environmental dimensions.
tunities. Appendix A provides a list of the    AMR has widely been acknowledged as
tools identified in the analysis, along with   a “quintessential” One Health issue (Rob-
short descriptions and links. Appendix B       inson et al. 2016). The analysis sought
offers further details on the methodology.     to reflect the multidisciplinary and mul-
                                               tisectoral approach associated with One
Drawing on a                                   Health by going beyond the confines
One Health approach                            of health and public health systems to
                                               consider tools and approaches being
The World Bank (2018) Operational              used in agriculture, water, and environ-
Framework for Strengthening Human,             mental programming.
Animal, and Environmental Public Health
Systems at their Interface highlights the

“According to the World Bank (2018, 3), a One Health approach is:
  a collaborative approach for strengthening systems to prevent,
   prepare, detect, respond to, and recover from primarily infectious
   diseases and related issues such as antimicrobial resistance that
   threatens human health, animal health, and environmental health
   collectively, using tools such as surveillance and reporting with an
   endpoint of improving global health security and achieving gains
   in development.”
Landscape Analysis of Tools to Address Antimicrobial Resistance   15
World Bank Group                                                                                                16

Chapter 2:
A two-stage scoping review was con-                        range of tools was identified; these are
ducted to examine the landscape of                         documented in Table 1. The six domains
tools on AMR. Building on the steps by                     identified are (i) awareness raising; (ii)
the global community to strengthen the                     antimicrobial stewardship; (iii) surveil-
response to AMR after 2015, the first                      lance, monitoring and research for nation-
stage included a review of the landmark                    al surveillance systems with a One Health
or seminal reports that are considered to                  approach; (iv) infection prevention and
have guided global AMR action over the                     control in human and animal health; (v)
last five years.4 These reports, listed in                 reduction of the spread of pathogens into
Box 1, were selected based on their role                   the environment; and (vi) the operational
in establishing a platform for action at                   research agenda. Box 2 provides the
the global level. From this initial review,                definition of tools used for the purpose
a series of recurrent priority actions or                  of this review.
domains through which to organize the


  •    HO (World Health Organization).
      W                                                    •    IE (World Organisation for Animal
      2015. “Global Action Plan                                Health). 2016. “The OIE Strategy on
      on Antimicrobial Resistance.”                            Antimicrobial Resistance and the
                                                               Prudent Use of Antimicrobials.”
  •   “ Review on Antimicrobial Resis-
       tance.” 2016. Tackling Drug-Resistant               •    ECD (Organisation for Economic
       Infections Globally: Final Report and                   Co-operation and Development).
       Recommendations. Review on Anti-                        2018. “Stemming the Superbug
       microbial Resistance chaired by                         Tide: Just a Few Dollars More.”
       Jim O’Neill.
                                                           •   IACG (Interagency Coordination
  •    AO (Food and Agriculture
      F                                                        Group). 2019. “No Time to Wait:
      Organization of the United Nations).                     Securing the Future from
      2016. “The FAO Action Plan on Anti-                      Drug-Resistant Infections.”
      microbial Resistance 2016–2020.”

4 S
   eminal or landmark reports are sources that “initially presented an idea of great importance or influence
  within a particular discipline” and are frequently cited in other sources. Northcentral University Library,
  “Research Process: Finding Seminal Works,”
Landscape Analysis of Tools to Address Antimicrobial Resistance                                       17


  Domain                        Definition for the purpose of this report

  Awareness raising             Improve awareness, understanding, and knowledge of AMR
                                through communication, education, and training at local, national,
                                and regional levels

  Antimicrobial                 Promote the optimal use of antimicrobial agents through
  stewardship                   appropriate prescribing in diverse health care settings, especially
                                in primary care

  Surveillance, monitor-        Under a One Health approach, strengthen knowledge and
  ing and research for          evidence through AMR and associated public health surveillance,
  national surveillance         monitoring, and research for national systems
  systems with a One
  Health approach

  Infection prevention          Reduce infections (including hospital- and community-acquired
  and control in human          infections) in humans and animals
  and animal health

  Reduction of the              Monitor and regulate environmentally related activities or
  spread of pathogens           products that result in the spread of AMR pathogens
  into the environment

  Operational research          Strengthen and sustain operational research capacity for evi-
  agenda                        dence-based decision-making to improve program performance

Source: World Bank.
World Bank Group                                                                                    18


     For the purpose of this report, tools are defined as frameworks, guidelines,
     documents, and implementation strategies and similar mechanisms that aim to
     support government in developing policies and implementing programs that
     address AMR.

     This approach is not intended to be exhaustive. Evaluating the effectiveness
     of a given treatment, approach, or tool is not within scope of this report. Thus
     the analysis does not seek to comparatively or qualitatively assess the 90 tools
     identified. There are also many valuable tools that are outside the scope of this
     report, such as those that focus on diagnostics within health care settings or on
     specific treatments, therapies, or vaccines.

The second stage of the search targeted                  Supplementary searches were conduct-
peer-reviewed and gray literature as well                ed on websites of relevant stakeholders
as websites of international organiza-                   and organizations. These included the
tions, nongovernmental organizations                     CGIAR, the Fleming Fund, the Food and
(NGOs), government bodies, think tanks,                  Agriculture Organization of the United
and research institutions focused on                     Nations (FAO), the International Federa-
AMR (Figure 2). The review of published                  tion of Pharmaceutical Manufacturers and
and gray literature sought to identify                   Associations (IFPMA), the Organisation
tools that target antimicrobial resistance               for Economic Co-operation and Develop-
affecting human health, animal health                    ment (OECD), ReAct, the United Nations
(terrestrial and aquatic), and the environ-              Children’s Fund (UNICEF), the US Centers
ment. In combination with search terms                   for Disease Control and Prevention (CDC),
related to antimicrobial resistance over                 the Wellcome Trust, World Health Orga-
the One Health spectrum, search terms                    nization (WHO), and the World Organisa-
were developed along the six domains for                 tion for Animal Health (OIE).
AMR programing (table 1). Three inter-
national databases—PubMed, Cochrane                      Studies were selected based on the
Library, and the FAO database AGRIS—                     abstracts and titles identified via elec-
were searched using the search terms as                  tronic searches and were independently
detailed in (appendix 3, table C.3). These               screened based on the specified inclu-
databases were selected to be compre-                    sion criteria. The search of published
hensive and to cover a broad range of dis-               literature yielded 122 potentially relevant
ciplines reflected in the six domains. The               citations after title and abstract screening.
search terms for international publications              After data characterization, 17 relevant
were applied to title, abstract, keyword,                publications (containing 22 tools—8 listed
and full text. The search of gray literature             and 14 contextual) remained and were
was conducted using Google’s search en-                  included in the review. Between Sep-
gine. The strategy also incorporated back-               tember and November 2020, the search
ward and forward reference searching to                  targeting gray literature was conducted;
identify important sources, contextualize                this produced 226 potentially relevant
sources within current developments in                   publications and resulted in the addition
the AMR landscape, and identify addition-                of another 82 tools. In total, 90 tools were
al publications of relevance.5                           included in the analysis. The process from

5 For more information on the method used, see Tricco et al. (2015, 224).
Landscape Analysis of Tools to Address Antimicrobial Resistance                                                       19

identification to final inclusion of tools is                     tional agencies, academic institutions, and
represented in Figure 2.                                          NGOs involved in AMR. The purpose of
                                                                  these consultations was to seek guidance
This search was supplemented by 12                                on the methodological approach and the
consultations with experts across the                             appropriateness of the list of tools iden-
One Health spectrum. Consultations were                           tified and to address potential gaps and
conducted with purposively selected                               omissions. Appendix B lists experts who
experts from the Tripartite organizations                         were consulted.
(WHO, FAO, and OIE), relevant interna-


                  42 tools identified      12 tools identified       99 tools identified       3 tools identified

                  by searching             by searching              through expert            by searching
                  internet                 websites of               consultations             Tripartite (WHO,
                  (via Google)             international             (including                FAO, and OIE)
                                           organizations,            WHO AMR                   expert meetings
                  26 tools identified      NGOs, government          resource pack)            and other AMR
                  by searching             bodies, think tanks,                                symposiums
                  PubMed, Cochrane         and research
                  library, and FAO’s       institutions focused
                  AGRIS                    on AMR

                                                        182 tools identified
                                                    through primary searches

                                                                                             21 duplicate tools

                                                     17 tools screened using
                                                       titles and abstracts

                     12 tools identified                                                       49 publications
                       via citations in                                                    removed for not fitting
                      primary articles                                                       the inclusion criteria

                                                      110 tools assessed for
                                                     eligibility using full text

                                                                                           22 tools removed
                                                                                           due to exclusion
                                                                                           - Older guidelines

                                                                                             or policies
                                                       90 tools included in
                                                     this landscape analysis               - Other tool types
                                                                                             dated before 2015
                                                                                           - Focused only on
                                                                                             pipeline research

Source: World Bank.
World Bank Group                                                                           20

Guided by the AACODS (authority, ac-            control or mitigation strategies for antimi-
curacy, coverage, objectivity, date,            crobial resistance in human health, animal
significance) approach (Tyndall 2010),          health (terrestrial and aquatic), and the
inclusion and exclusion criteria were           environment. Publications that includ-
developed for the review of frameworks,         ed tools on specific population groups,
guidelines, documents, and implemen-            clinical research, point of care diagnostics,
tation strategies (Box 3). Retrieved            treatments, therapies, or vaccines were
documents were excluded if they were            excluded from the review, as were studies
published prior to 2015 and did not relate      that could not be electronically retrieved.
to AMR or to AMR program implemen-              Dissertations, theses, letters to the editor,
tation, interventions, or policies. The         opinion pieces, feature articles, and arti-
search was restricted to peer-reviewed          cles intended as marketing or advertising
and gray literature in English because          material were also excluded.
of limited resources for translation. The
search sought to identify tools that target


   Inclusion                                     Exclusion

   •   Incorporate international and            •    ocus on or assess quality of AMR
        national guidance on AMR action              program implementation

   •    ssess documents associated with
       A                                         •    ocus on specific point of care
       policy frameworks, monitoring and             diagnostics, treatments, therapies,
       surveillance frameworks, and NAPs             or vaccines

   •    ssess program implementation
       or interventions and policies on
       AMR action

Source: World Bank.

Two spreadsheets were developed to              mendations, implementation strategy,
confirm relevance and to extract data           regional action plan, national action plan,
from published and gray literature. Data        regional surveillance program, national
extraction was based on the following: (i)      surveillance program, and research pro-
characteristics of publications—i.e. author,    gram. This selection was derived induc-
year of publication, title, and related orga-   tively from the range of tools selected.
nization; (ii) potential tools categorized by   The primary audience was also noted
intervention area (drawing on the six pre-      and included governments, international
viously described domains) and intended         organizations, NGOs, scientific bodies,
audience; and (iii) publication source.         research bodies, health professionals, vet-
                                                erinarians, human health facilities, surveil-
After inclusion, documents underwent            lance personnel, and farmers, traders, and
more detailed review and were cate-             producers. Further details on the catego-
gorized by intervention area, tool type,        rization are provided in tables B.1 and B.2
and intended audience. The intervention         in appendix B.
areas drew on the six domains previously
described. The tool types included the
following: AMR policy, guidelines/recom-
Landscape Analysis of Tools to Address Antimicrobial Resistance                              21

The review has important limitations.                  To provide a manageable scope of in-
First, it does not seek to be exhaustive but           quiry, this review focused primarily on
rather provides a repository of major tools            AMR-specific interventions. AMR can be
and works that can support a diverse                   seen through two types of interventions:
range of readers in understanding the                  AMR-specific and AMR-sensitive solutions
landscape of existing materials. Second,               (Wellcome Trust 2020a). AMR-specific
it does not seek to assess the quality of              approaches and solutions have the pri-
included publications. In line with a scop-            mary goal of mitigating the development
ing review, this analysis seeks to identify            or transmission of resistant pathogens.
and map existing tools for antimicrobial               AMR-sensitive solutions leverage other
resistance programming across the One                  agendas for the benefit of addressing
Health spectrum.                                       AMR, including the broader global health
                                                       agenda related to (for example) improved
                                                       hygiene and sanitation.
World Bank Group   22
Landscape Analysis of Tools to Address Antimicrobial Resistance                                  23

Chapter 3:
Findings and Analysis
The scoping review identified 90 tools                 The chapter also provides findings on the
that seek to support a range of inter-                 tools, across six domains. Table 3 lists the
ventions and are relevant in a range of                90 tools organized by domain. In the dis-
contexts. This chapter discusses the char-             cussion of findings, each domain contains
acteristics of the tools reviewed, including           a brief definition and examples of tools
the types of tools, their target audience,             through which various interventions and
and their purpose. Table 2 provides a list             policies for AMR action are presented.
of the tools by type and audience.



                 RESEARCH PROGRAM







                           AMR POLICY

                                          0           10          20      30         40        50

Source: World Bank.

Tool type

The 90 tools identified in the review                  of tools focused on implementation strat-
were classified into nine categories.                  egy (47), the provision of guidelines (26),
Fourteen tools highlighted efforts to de-              policy (4), and support to national (28)
velop and coordinate operational research              and regional surveillance mechanisms (13).
programs for AMR, with only five tools                 To highlight the low- to middle-income
(three specifically) outlining mechanisms              focus of this analysis, two NAPs in mid-
for costing AMR interventions or evaluat-              dle-income countries (Ghana and South
ing their cost-effectiveness. The majority             Africa) and two NAPs in low-income
World Bank Group                                                                                           24

countries (Uganda and Malawi) were                      Over half of the tools in the review (52)
reviewed.6 These countries were identified              were focused at the national level and
through initial research and internal World             developed for adaptation by national
Bank consultations as potential case                    governments (ministries of health, agricul-
studies for AMR preparedness 7 relative to              ture, environment). Over half (48) outlined
other LMICs.                                            intervention options for national health fa-
                                                        cilities, national veterinary services, medical
The Association of Southeast Asian Na-                  doctors, and pharmacists. Thirty-one tools
tions Regional Strategy (ASEAN 2016)                    were developed for national centers for
and the Africa Centers for Disease Con-                 disease control and other national scientific
trol’s Antimicrobial Resistance Surveil-                bodies, and 20 tools outlined the roles and
lance Networks (African Union and Africa                appropriate actions of stakeholders such as
CDC 2018) were categorized as regional                  pharmaceutical companies and producers
action plans.                                           and traders in agriculture.


Most tools were developed to target more
than one audience, including stakeholders
within the public sector, academia, scien-
tific bodies, and the private sector.







                                  0          10         20        30          40          50         60

Source: World Bank.

6 See Government of Ghana (2017); Government of South Africa (2018); Government of Uganda (n.d.). Outline
  of Malawi’s National AMR Strategy accessed at:
7 WHO, FAO, and OIE, Country Progress in the Implementation of the Global Action Plan on Antimicrobial
  Resistance: WHO, FAO and OIE Global Tripartite Database,
Landscape Analysis of Tools to Address Antimicrobial Resistance                                                                                                                                                                                                                                                                                                                                         25


  TOOL                                 Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                     Health professionals, veterinarians,
                                                                                                                                                                                                                                                                            International organizations, NGOs

                                                                                                                                                                                                                                                                                                                Scientific bodies, research bodies

                                                                                                                                                                                                                                                                                                                                                     human health facilities, surveil-
                                                                                                                                                    Regional surveillance program

                                                                                                                                                                                    National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                            Farmers, traders, producers,
                                                                            Implementation strategy

                                                                                                                                                                                                                                        Economic mechanisms
                                                                                                      Regional action plan

                                                                                                                             National action plan

                                                                                                                                                                                                                    Research programs

                                                                                                                                                                                                                                                                                                                                                     lance personnel

                                                                                                                                                                                                                                                                                                                                                                                            private sector
                                  AMP Policy

 Global Action Plan

 Strategy on AMR and the
 Prudent Use of Antimicrobials

 FAO Action Plan on
 Antimicrobial Resistance

 FAO Assessment Tool for
 Laboratories and Surveillance
 Systems (FAO–ATLASS)

 Progressive Management Path-
 way for AMR (FAO-PMP AMR)

 FAO Surveillance
 Evaluation Tool (SET)

 FAO Laboratory
 Mapping Tool (LMT)

 WHO AMR Stewardship
 Programmes in Healthcare
 Facilities and LMICs Toolkit

 Global Antimicrobial
 Resistance Surveillance
 System (GLASS)

 AWaRe tool

 AMR Framework for Action
 Supported by the IACG

 WHO Situation Analysis

 Antimicrobial Resistance:
 A Manual for Developing
 National Action Plans

 Country Progress on the
 Implementation of the Global
 Action Plan on Antimicrobial
 Resistance: WHO, FAO and
 OIE Global Tripartite Database
World Bank Group                                                                                                                                                                                                                                                                                                                                                                                      26

  TOOL                                Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                    Health professionals, veterinarians,
                                                                                                                                                                                                                                                                           International organizations, NGOs

                                                                                                                                                                                                                                                                                                               Scientific bodies, research bodies

                                                                                                                                                                                                                                                                                                                                                    human health facilities, surveil-
                                                                                                                                                   Regional surveillance program

                                                                                                                                                                                   National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                           Farmers, traders, producers,
                                                                           Implementation strategy

                                                                                                                                                                                                                                       Economic mechanisms
                                                                                                     Regional action plan

                                                                                                                            National action plan

                                                                                                                                                                                                                   Research programs

                                                                                                                                                                                                                                                                                                                                                    lance personnel

                                                                                                                                                                                                                                                                                                                                                                                           private sector
                                 AMP Policy

WHO Competency Framework
for Health Workers’ Education
and Training on Antimicrobial

Strategic Research Agenda:
Joint Programming Initiative
on Antimicrobial Resistance

Technical Brief on Water, San-
itation, Hygiene (WASH) and
Wastewater Management to
Prevent Infections and Reduce
the Spread of Antimicrobial
Resistance (AMR)

Guidelines on Core Compo-
nents of Infection Prevention
and Control Programmes at
the National and Acute Health
Care Facility Level

FAO Resource Package on
Good Hygiene Practices

FAO Good Practices for Biose-
curity in the Pig Sector

Antimicrobials in Agricul-
ture and the Environment:
Reducing Unnecessary Use and

Monitoring and Evaluation
of the Global Action Plan on
Antimicrobial Resistance:
Framework and Recommended

Tripartite AMR Country
Self-Assessment Survey



WHO Benchmarks for IHR
Landscape Analysis of Tools to Address Antimicrobial Resistance                                                                                                                                                                                                                                                                                                                                          27

  TOOL                                  Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                      Health professionals, veterinarians,
                                                                                                                                                                                                                                                                             International organizations, NGOs

                                                                                                                                                                                                                                                                                                                 Scientific bodies, research bodies

                                                                                                                                                                                                                                                                                                                                                      human health facilities, surveil-
                                                                                                                                                     Regional surveillance program

                                                                                                                                                                                     National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                             Farmers, traders, producers,
                                                                             Implementation strategy

                                                                                                                                                                                                                                         Economic mechanisms
                                                                                                       Regional action plan

                                                                                                                              National action plan

                                                                                                                                                                                                                     Research programs

                                                                                                                                                                                                                                                                                                                                                      lance personnel

                                                                                                                                                                                                                                                                                                                                                                                             private sector
                                   AMP Policy

 Methodology to Analyze
 AMR-Relevant Legislation in the
 Food and Agriculture Sector

 Global Analysis and Assess-
 ment of Sanitation and
 Drinking-Water (GLAAS)

 AMR Benchmark

 WHO/UNICEF Joint Monitoring
 Programme for Water Supply,
 Sanitation and Hygiene

 WHO Hand Hygiene Self-As-
 sessment Framework,
 and the WHO Infection
 Prevention and Control
 Assessment Framework

 OIE PVS Pathway

 PVS Gap Analysis Tool

 STAR-IDAZ International
 Research Consortium

 WHO Model List of Essential
 Medicines: 20th list

 ReAct Online Toolbox for
 National Action Plans

 Declaration by the Pharmaceu-
 tical, Biotechnology and Diag-
 nostics Industries on Combat-
 ing Antimicrobial Resistance

 Tackling Antimicrobial
 Resistance: Ensuring
 Sustainable R&D

 World Antibiotic Awareness
 Week 2018: Monitoring
 & Evaluation Report

 Guidelines for the Prevention
 and Control of Carbapen-
 em-Resistant Enterobacteria-
 ceae, Acinetobacter baumannii
 and Pseudomonas aeruginosa
 in Health Care Facilities
World Bank Group                                                                                                                                                                                                                                                                                                                                                                                          28

  TOOL                                   Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                       Health professionals, veterinarians,
                                                                                                                                                                                                                                                                              International organizations, NGOs

                                                                                                                                                                                                                                                                                                                  Scientific bodies, research bodies

                                                                                                                                                                                                                                                                                                                                                       human health facilities, surveil-
                                                                                                                                                      Regional surveillance program

                                                                                                                                                                                      National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                              Farmers, traders, producers,
                                                                              Implementation strategy

                                                                                                                                                                                                                                          Economic mechanisms
                                                                                                        Regional action plan

                                                                                                                               National action plan

                                                                                                                                                                                                                      Research programs

                                                                                                                                                                                                                                                                                                                                                       lance personnel

                                                                                                                                                                                                                                                                                                                                                                                              private sector
                                    AMP Policy

Global Framework for
Development & Stewardship
to Combat Antimicrobial
Resistance: Draft Roadmap

WASH in Health Care Facilities:
Practical Steps to Achieve Uni-
versal Access to Quality Care

WASH in Health Care Facilities:
Global Baseline Report 2019

Progress on Drinking Water,
Sanitation and Hygiene: 2017
Update and SDG Baselines

Ghana National Action Plan

South African Antimicrobial
Resistance Strategy Frame-
work: A One Health Approach

Global Priority List of Antibiot-
ic-Resistant Bacteria to Guide
Research, Discovery, and De-
velopment of New Antibiotics

Diagnostic Stewardship:
A Guide to Implementation
in Antimicrobial Resistance
Surveillance Sites

Africa CDC Antimicrobial
Resistance Surveillance
Network (AMRSNET)

ASEAN Regional Strategy
on AMR Communication
and Advocacy

Estimating the Economic Costs
of Antimicrobial Resistance:
Model and Results
Landscape Analysis of Tools to Address Antimicrobial Resistance                                                                                                                                                                                                                                                                                                                                          29

  TOOL                                   Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                       Health professionals, veterinarians,
                                                                                                                                                                                                                                                                              International organizations, NGOs

                                                                                                                                                                                                                                                                                                                  Scientific bodies, research bodies

                                                                                                                                                                                                                                                                                                                                                       human health facilities, surveil-
                                                                                                                                                      Regional surveillance program

                                                                                                                                                                                      National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                              Farmers, traders, producers,
                                                                              Implementation strategy

                                                                                                                                                                                                                                          Economic mechanisms
                                                                                                        Regional action plan

                                                                                                                               National action plan

                                                                                                                                                                                                                      Research programs

                                                                                                                                                                                                                                                                                                                                                       lance personnel

                                                                                                                                                                                                                                                                                                                                                                                              private sector
                                    AMP Policy

 Antibacterial Agents in Clinical
 Development: An Analysis of
 the Antibacterial Clinical De-
 velopment Pipeline, Including

 Resistance Map

 Health Workers’ Education
 and Training on Antimicrobial
 Resistance: Curricula Guide

 The Structured Operational Re-
 search and Training IniTiative
 on AMR, coordinated by the
 Special Programme for Re-
 search and Training in Tropical
 Diseases (TDR)

 Integrated Surveillance of
 Antimicrobial Resistance

 The 4th Annual OIE Report on
 Antimicrobial Agents Intended
 for Use in Animals

 Tackling Antimicrobial Resis-
 tance Together (Working Pa-
 per 5.0): Enhancing the Focus
 on Gender and Equity

 Summary Report of the FAO/
 WHO Expert Meeting on
 Foodborne Antimicrobial Re-
 sistance: Role of Environment,
 Crops and Biocides

 The Environment as a Driver
 of Antibiotic Resistance

 Frontiers 2017: Emerging Is-
 sues of Environmental Concern

 Preventing the Next Pandemic:
 Zoonotic Diseases and How
 to Break the Chain of

 Reframing Resistance
World Bank Group                                                                                                                                                                                                                                                                                                                                                                                      30

  TOOL                                Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                    Health professionals, veterinarians,
                                                                                                                                                                                                                                                                           International organizations, NGOs

                                                                                                                                                                                                                                                                                                               Scientific bodies, research bodies

                                                                                                                                                                                                                                                                                                                                                    human health facilities, surveil-
                                                                                                                                                   Regional surveillance program

                                                                                                                                                                                   National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                           Farmers, traders, producers,
                                                                           Implementation strategy

                                                                                                                                                                                                                                       Economic mechanisms
                                                                                                     Regional action plan

                                                                                                                            National action plan

                                                                                                                                                                                                                   Research programs

                                                                                                                                                                                                                                                                                                                                                    lance personnel

                                                                                                                                                                                                                                                                                                                                                                                           private sector
                                 AMP Policy

Gulf–Middle East–North Africa
Antimicrobial Stewardship

Tackling Antimicrobial Re-
sistance Together (Working
Paper 1.0): Multisectoral

An Analysis of the Animal/
Human Interface with a Focus
on Low- and Middle-Income

The AWaRe Campaign: “Adopt
AWaRe. Handle Antibiotics
with Care”

Antibiotic Prescribing and Re-
sistance: Views from Low- and
Middle-Income Prescribing
and Dispensing Professionals

Uganda Antimicrobial Resis-
tance National Action Plan

Malawi National AMR
Strategy (2017–2022)

The Joint External
Evaluation Tool

The Global Research on
AntiMicrobial Resistance
Project (GRAM)

International Instruments on
the Use of Antimicrobials
across Human, Animal and
Plant Sectors

US CDC Laboratory Assess-
ment of AMR Testing Capacity

Guidelines for the Develop-
ment of National Action Plan
for Health Security
Landscape Analysis of Tools to Address Antimicrobial Resistance                                                                                                                                                                                                                                                                                                                                             31

  TOOL                                  Tool Type                                                                                                                                                                                                                    Audience

                                                                                                                                                                                                                                                                                                                                                      human health facilities, surveillance
                                                                                                                                                                                                                                                                                                                                                      Health professionals, veterinarians,
                                                                                                                                                                                                                                                                             International organizations, NGOs

                                                                                                                                                                                                                                                                                                                 Scientific bodies, research bodies
                                                                                                                                                     Regional surveillance program

                                                                                                                                                                                     National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                              Farmers, traders, producers,
                                                                             Implementation strategy

                                                                                                                                                                                                                                         Economic mechanisms
                                                                                                       Regional action plan

                                                                                                                              National action plan

                                                                                                                                                                                                                     Research programs

                                                                                                                                                                                                                                                                                                                                                                                              private sector
                                   AMP Policy

 Industry Alliance against
 AMR Progress Report

 Industry Roadmap for
 Progress on Combatting
 Antimicrobial Resistance

 Time Is Running Out
 Technical Note

 OIE Data Collection Template

 Core Elements of Human Anti-
 biotic Stewardship Programs in
 Resource-Limited Settings

 ACORN (Clinically-Oriented
 Antimicrobial Resistance Sur-
 veillance Network)

 AMR Surveillance in Low- and
 Middle-Income Settings: A
 Roadmap for Participation in
 the Global Antimicrobial Sur-
 veillance System (GLASS)

 Critically Important Antimicro-
 bials for Human Medicine:
 5th Revision

 WHO Guide for the Stepwise
 Laboratory Improvement Pro-
 cess Towards Accreditation
 in the African Region

 WHO Global Guidelines on
 the Prevention of Surgical
 Site Infection

 Infection Control in Healthcare
 Personnel: Infrastructure and
 Routine Practices for Occupa-
 tional Infection Prevention and
 Control Services
World Bank Group                                                                                                                                                                                                                                                                                                                                                                                            32

     TOOL                                Tool Type                                                                                                                                                                                                                     Audience

                                                                                                                                                                                                                                                                                                                                                        human health facilities, surveillance
                                                                                                                                                                                                                                                                                                                                                        Health professionals, veterinarians,
                                                                                                                                                                                                                                                                               International organizations, NGOs

                                                                                                                                                                                                                                                                                                                   Scientific bodies, research bodies
                                                                                                                                                       Regional surveillance program

                                                                                                                                                                                       National surveillance program

                                                                                                                                                                                                                                                                                                                                                                                                Farmers, traders, producers,
                                                                              Implementation strategy

                                                                                                                                                                                                                                           Economic mechanisms
                                                                                                        Regional action plan

                                                                                                                               National action plan

                                                                                                                                                                                                                       Research programs

                                                                                                                                                                                                                                                                                                                                                                                                private sector
                                    AMP Policy

 WHO Guidelines on Use
 of Medically Important
 Antimicrobials in
 Food-Producing Animals

 Draft WHO Costing and
 Budgeting Tool for National
 Action Plans on
 Antimicrobial Resistance

 Draft WHO Implementation
 Handbook for National
 Action Plans on
 Antimicrobial Resistance

 Draft FAO Situation Analysis
 of AMR Risks in the Food and
 Agriculture Sectors

  Totals (90 tools in total)           5          26                           47                             2                      7                      13                           28                              15                      5               52                14                                   31                                             48                              20

Discussion of the findings
across domains

As indicated in chapter 2, six domains for                                                                                                            Three domains were well covered by the
actions and interventions were identi-                                                                                                                tools identified in the review. These were
fied for this review based on a review                                                                                                                surveillance interventions (46 out of the
of seminal reports: (i) awareness raising;                                                                                                            90 tools), infection prevention and control
(ii) antimicrobial stewardship; (iii) sur-                                                                                                            (34 out of 90), and stewardship policies
veillance; (iv) infection prevention and                                                                                                              and intervention options (34 out of 90).
control in human and animal health; (v)                                                                                                               In contrast, only 13 tools considered the
the reduction of pathogen spread in the                                                                                                               spread of pathogens in the environment
environment; and (vi) development of a                                                                                                                in detail, with 5 tools providing detailed
national research agenda. These domains                                                                                                               attention and 8 looking at broader issues
cut across human, animal, and environ-                                                                                                                related to this area.
mental health and key sectors (health,
agriculture, and water, sanitation, and                                                                                                               Domain 1: Awareness raising
hygiene) and are part of a multisectoral
                                                                                                                                                      Of the tools reviewed, 30 focused on
One Health approach.
                                                                                                                                                      increasing awareness and understanding
                                                                                                                                                      of AMR and highlighted the importance

8 The tools are listed in order of review.
Landscape Analysis of Tools to Address Antimicrobial Resistance                                33

of improved understanding of the behav-                for action on AMR (Box 4). Other tools
ioral drivers among consumers, health                  address improved evidence on the be-
professionals, veterinarians, farmers,                 havioral drivers for antimicrobial use and
animal owners, and the general public.                 resistance in human and animal health,
At the global level, the Global Action Plan            encouraging the development of re-
on Antimicrobial Resistance, or GAP-AMR                sources for the promotion of appropriate
(WHO 2015a) encourages the identifica-                 antibiotic prescribing in primary health
tion and prioritization of existing initia-            care and animal health settings. One such
tives to improve understanding about                   tool that is in development, an “antibiotic
AMR and appropriate antimicrobial use in               footprint” for countries and individuals
settings across the One Health spectrum.               (Limmathurotsakul et al. (2019), has been
The investigation and promotion of new                 proposed as a global tool to communicate
initiatives to introduce AMR information               the scale of antibiotic use across human,
and key messages to new audiences was                  animal, and environmental health. The
also apparent. For example, the Refram-                tool would attribute antibiotic use across
ing Resistance toolkit (Wellcome Trust                 these sectors to specific activities, with
2019) was developed by the Wellcome                    the wider aim of contributing to global
Trust to tailor strategies for impact com-             target setting for reductions in antibiotic
munication on AMR that would enable                    use. A useful companion tool is ReAct’s
more effective communication for public                (2016) AMR Stakeholder Mapping exer-
AMR awareness. Through its Responsive                  cise conducted in 2016, which provides
Dialogue Toolkit, the Wellcome Trust has               an overview of key actors across areas of
also developed participatory approaches                intervention and related sectors for AMR.
to communication and program design
World Bank Group                                                                         34


    To support engagement and activism on AMR, the Wellcome Trust developed
    a guide and toolkit for using the Responsive Dialogue framework, an approach
    that seeks to involve communities in the design, implementation, and enforce-
    ment of solutions and policies to address antimicrobial resistance. The approach
    is designed to enable policy makers, practitioners, the public, and other AMR
    stakeholders to co-create solutions that inform AMR policies. It centers on
    five principles:

    Inclusivity: RDs [Responsive Dialogues] provide inclusive and open spaces
    where people can freely and comfortably express their views. They are designed
    to include vulnerable, marginalized, less vocal people and to understand a wide
    range of views, beliefs and knowledge systems.

    Accessibility: RDs are informative with a range of people and experts providing
    evidence in accessible, balanced and unbiased ways.

    Community-based: RDs work with community groups, networks and local citi-
    zens, involving people from all walks of life.

    Respectful: RDs move beyond simply gathering views to building dialogue and
    reflection to genuinely co-design responses, considering people’s views, practic-
    es and experiences

    Responsive: RD processes are designed to be transparent and accountable,
    providing clear and open communication about the RDs to the public and com-
    mitment to act on recommendation arising from the dialogues (Wellcome Trust

    The toolkit has been piloted in two countries (Thailand and Malawi), where initial
    research and application focused on the connection between AMR and women’s
    groups. The dialogues generated ideas on increased communication surround-
    ing daily hygiene through food preparation, washing, and integration of hygiene
    facilities in schools.

Source: World Bank 2020b.
Landscape Analysis of Tools to Address Antimicrobial Resistance                                      35

Tools within this domain also provide                   gaps in the national- or context-specific
guidance on how to maximize the effi-                   tools that are needed to ensure updated
cacy of antimicrobials. For the human                   curriculum outcomes and competencies
health sector, frameworks like the WHO’s                for AMR-related training, especially for
AWaRe tool aim to improve knowledge                     low-income settings.
on the judicious use of antibiotics among
human and animal health professionals.9                 Domain 2: Antimicrobial stewardship
The AWaRe tool classifies antibiotics
                                                        AMR stewardship tools aim to promote
into three groups—access, watch, and
                                                        mechanisms to measure appropriate
reserve—specifying categorizations to
                                                        antibiotic use, in part by ensuring that
account for quality, shortages, access, and
                                                        prescribing and dispensing practices are
appropriate use. The FAO Action Plan on
                                                        aligned with national prescribing guide-
Antimicrobial Resistance (FAO 2016) and
                                                        lines for antibiotic use in human and an-
the Strategy on AMR and the Prudent
                                                        imal health. In this review, 34 tools show
Use of Antimicrobials (OIE 2016) set out
                                                        the importance of antimicrobial steward-
strategies for amplifying knowledge and
                                                        ship—the reduction of unnecessary or
awareness of AMR in the animal and plant
                                                        inappropriate use of microbials, predom-
health sectors. Through annual World An-
                                                        inantly in clinical settings—for addressing
tibiotic Awareness Weeks and subsequent
                                                        AMR. While antimicrobial stewardship is a
accompanying monitoring and evaluation
                                                        standard practice in some clinical settings,
reports,10 the OIE has sought to translate
                                                        the tools demonstrate that more needs
technical and biological concepts for
                                                        to be done to integrate stewardship in
applicability to a wide range of stake-
                                                        other settings, such as interventions
holders in the agriculture, livestock, and
                                                        designed to improve adherence to pre-
fisheries sectors.
                                                        scribing guidelines.
Tools in the human and animal health
                                                        A series of international standards, set
sectors also set out guidance on educa-
                                                        out in WHO and FAO documentation,
tion for health professionals. The WHO
                                                        also provide important reference points
Competency Framework for Health Work-
                                                        for stewardship programming. In the
ers’ Education and Training on Antimi-
                                                        report “International Instruments on the
crobial Resistance (WHO 2018c), which is
                                                        Use of Antimicrobials across the Human,
supplemented by the WHO Health Work-
                                                        Animal and Plant Sectors” (WHO, FAO,
ers’ Education and Training on Antimicro-
                                                        and OIE 2020a), the Tripartite organiza-
bial Resistance: Curricula Guide (WHO
                                                        tions provide an overview of international
2019b), provides guidelines for health
                                                        instruments to assist national govern-
professionals to better understand and
                                                        ments in adapting and adopting relevant
increase their awareness of antimicrobial
                                                        international standards with implications
resistance. Tools such as the report “Anti-
                                                        for antimicrobial use. The most recent
biotic Prescribing and Resistance: Views
                                                        version of the WHO Model List of Essen-
from Low- and Middle-Income Prescribing
                                                        tial Medicines (WHO 2019d) is a reference
and Dispensing Professionals” (WHO and
                                                        point for categorizing antibiotics and
Antimicrobial Resistance Centre at the
                                                        organizing stewardship recommendations
London School of Hygiene and Tropical
                                                        (namely identification, testing, and imple-
Medicine 2017) highlight the perspectives
                                                        mentation of stewardship interventions in
of prescribers and health professionals in
                                                        general practice). The WHO list of Criti-
low-income settings, providing a founda-
                                                        cally Important Antimicrobials for Human
tion for the development of context-spe-
                                                        Medicine (WHO 2019a) can be utilized to
cific tools. Even so, this review noted
                                                        formulate risk management strategies for

9 World Health Organization, “Adopt AWaRe: Handle Antibiotics with Care,”
10 See for example WHO (2018d).
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