Landscape Analysis of Tools to Address Antimicrobial Resistance - MAY 2021
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Landscape Analysis of Tools to Address Antimicrobial Resistance 1 Landscape Analysis of Tools to Address Antimicrobial Resistance MAY 2021
Appendixes 2 © 2021 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages dissemi- nation of its knowledge, therefore, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org.
Landscape Analysis of Tools to Address Antimicrobial Resistance MAY 2021
Table of Contents ACKNOWLEDGMENTS 6 ABBREVIATIONS 7 EXECUTIVE SUMMARY 9 CHAPTER 1: INTRODUCTION 12 CHAPTER 2: METHODOLOGY 16 CHAPTER 3: FINDINGS AND ANALYSIS 23 CHAPTER 4: CONCLUSIONS 51 REFERENCES 55 APPENDIX A: SUMMARY OF TOOLS 61 APPENDIX B: FURTHER DETAILS ON METHODOLOGY 78 APPENDIX C: EXPERT CONSULTATIONS 84
World Bank Group 6 Acknowledgements 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
Abbreviations
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 resistanceWorld 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:
Introduction
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,”
https://www.tballiance.org/why-new-tb-drugs/antimicrobial-resistance.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.
FIGURE 1: THE TWO-WAY RELATIONSHIP BETWEEN THE SDGS AND AMR
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 acrossWorld 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:
Methodology
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
BOX 1: LANDMARK REPORTS USED TO INFORM DATA COLLECTION
AND ORGANIZATION
• HO (World Health Organization).
W • IE (World Organisation for Animal
O
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
O
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,” https://ncu.libguides.com/researchprocess/seminalworks.Landscape Analysis of Tools to Address Antimicrobial Resistance 17
TABLE 1: SIX DOMAINS TO GUIDE DATA COLLECTION AND ANALYSIS
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
BOX 2: DEFINING TOOLS
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-
FIGURE 2: SEARCH STRATEGY AND PROCESS
42 tools identified 12 tools identified 99 tools identified 3 tools identified
IDENTIFICATION
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
SCREENING
182 tools identified
through primary searches
21 duplicate tools
removed
17 tools screened using
titles and abstracts
ELIGIBILITY
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
criteria:
- Older guidelines
INCLUSION
or policies
90 tools included in
this landscape analysis - Other tool types
dated before 2015
- Focused only on
pre-clinical
antibacterial
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
BOX 3: INCLUSION AND EXCLUSION CRITERIA
Inclusion Exclusion
• Incorporate international and • ocus on or assess quality of AMR
F
national guidance on AMR action program implementation
• ssess documents associated with
A • ocus on specific point of care
F
policy frameworks, monitoring and diagnostics, treatments, therapies,
surveillance frameworks, and NAPs or vaccines
• ssess program implementation
A
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.
FIGURE 3: TOOL TYPE
ECONOMIC MECHANISMS
RESEARCH PROGRAM
NATIONAL SURVEILLANCE PROGRAM
REGIONAL SURVEILLANCE PROGRAM
NATIONAL ACTION PLAN
REGIONAL ACTION PLAN
IMPLEMENTATION STRATEGY
GUIDELINES/ RECOMMENDATIONS
AMR POLICY
0 10 20 30 40 50
NUMBER
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-incomeWorld 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.
Audience
Most tools were developed to target more
than one audience, including stakeholders
within the public sector, academia, scien-
tific bodies, and the private sector.
FIGURE 4: AUDIENCE
GOVERNMENTS
INTERNAL
ORGANIZATIONS, NGOs
SCIENTIFIC BODIES,
RESEARCH BODIES
HEALTH PROFESSIONALS,
VETRINARIANS, HUMAN
HEALTH FACILITIES,
SURVEILLANCE PERSONNEL
FARMERS, TRADERS,
PRODUCERS,
PRIVATE SECTOR
0 10 20 30 40 50 60
NUMBER
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: https://cdn.southampton.ac.uk/assets/imported/transforms/
content-block/UsefulDownloads_Download/C6C715AED6784622962EB30060C6B30C/A%20Munthali%20
-%20Malawi%20AMR%20Strategy.pdf
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, https://www.who.int/antimicrobial-resistance/
global-action-plan/database/en/.Landscape Analysis of Tools to Address Antimicrobial Resistance 25
TABLE 2: SUMMARY OF 90 TOOLS: TOOL TYPE AND AUDIENCE
TOOL Tool Type Audience
Health professionals, veterinarians,
International organizations, NGOs
Scientific bodies, research bodies
human health facilities, surveil-
Regional surveillance program
National surveillance program
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
lance personnel
private sector
Governments
AMP Policy
Global Action Plan
on AMR (GAP-AMR)
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 DatabaseWorld 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
lance personnel
private sector
Governments
AMP Policy
WHO Competency Framework
for Health Workers’ Education
and Training on Antimicrobial
Resistance
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
Waste
Monitoring and Evaluation
of the Global Action Plan on
Antimicrobial Resistance:
Framework and Recommended
Indicators
Tripartite AMR Country
Self-Assessment Survey
(TrACSS)
FAOSTAT
FAOLEX
WHO Benchmarks for IHR
CapacityLandscape 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
lance personnel
private sector
Governments
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 FacilitiesWorld 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
lance personnel
private sector
Governments
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 ResultsLandscape 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
lance personnel
private sector
Governments
AMP Policy
Antibacterial Agents in Clinical
Development: An Analysis of
the Antibacterial Clinical De-
velopment Pipeline, Including
Tuberculosis
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
Transmission
Reframing ResistanceWorld 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
lance personnel
private sector
Governments
AMP Policy
Gulf–Middle East–North Africa
Antimicrobial Stewardship
Network
Tackling Antimicrobial Re-
sistance Together (Working
Paper 1.0): Multisectoral
Coordination
An Analysis of the Animal/
Human Interface with a Focus
on Low- and Middle-Income
Countries
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
(2018–2023)
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
(LAARC)
Guidelines for the Develop-
ment of National Action Plan
for Health SecurityLandscape 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
private sector
Governments
AMP Policy
personnel
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 ServicesWorld 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
Guidelines/recommendations
Farmers, traders, producers,
Implementation strategy
Economic mechanisms
Regional action plan
National action plan
Research programs
private sector
Governments
AMP Policy
personnel
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
8
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
BOX 4: BUILDING AWARENESS AND ENGAGEMENT: THE WELLCOME TRUST’S
RESPONSIVE DIALOGUE TOOLKIT
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
2020b).
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,” https://adoptaware.org/.
10 See for example WHO (2018d).You can also read
