ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN - 2017-2021 Strategic Framework, Operational Plan, and Monitoring and Evaluation ...

 
ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN - 2017-2021 Strategic Framework, Operational Plan, and Monitoring and Evaluation ...
ZIMBABWE
ONE HEALTH ANTIMICROBIAL RESISTANCE
NATIONAL ACTION PLAN
2017-2021

Strategic Framework, Operational Plan, and Monitoring
and Evaluation Plan

September, 2017
ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN - 2017-2021 Strategic Framework, Operational Plan, and Monitoring and Evaluation ...
CONTENTS

ABBREVIATIONS AND ACRONYMS ..................................................................................... ii
FOREWORD ..........................................................................................................................iv
ACKNOWLEDGEMENTS ........................................................................................................ v
1.0 BACKGROUND AND SITUATION ON AMR .................................................................... 1
2.0 EXECUTIVE SUMMARY .................................................................................................. 4
3.0 GOVERNANCE ............................................................................................................... 6
     3.1 Governance structure ................................................................................................ 6
     3.2 Leadership ............................................................................................................... 6
          3.2.1 Roles of the appointed positions ........................................................................
                                                                                                                        7
     3.3 Guiding principles	����������������������������������������������������������������������������������������������������� 9
4.0 STRATEGIC FRAMEWORK ............................................................................................ 10
     4.1 STRATEGIC PLAN AND STRATEGIC OBJECTIVES FOR AMR IN ZIMBABWE ........... 11
          4.1.1 Strategic objective 1 – Education, training and awareness: To raise awareness
          and educate the population, professionals and policy makers on AMR.......................
          11
          4.1.2 Strategic objective 2 – Surveillance: Improve detection and understanding of the
          AMR and antimicrobial use patterns and trends through surveillance........................ 11
          4.1.3 Strategic objective 3 – Infection prevention & control, good animal husbandry
          and biosecurity: Reduce the need for antimicrobials by improving IPC, animal health
          and management practices including biosecurity, WASH and immunisation............... 13
          4.1.4 Strategic Objective 4 – Rational use of antimicrobials: Improve controlled access
          and optimise the use of antimicrobials in humans and animals..................................14
          4.1.5 Strategic objective 5 – Sustainable Investment into AMR interventions and re-
          search into new antimicrobials and alternatives to antimicrobials................................ 15
5.0 OPERATIONAL PLANS...................................................................................................16
    5.1 Strategic objective 1 – Education, training and awareness..........................................16
    5.2 Strategic objective 2 – Surveillance.......................................................................... 23
    5.3 Strategic objective 3 – Infection prevention and control and biosecurity...................... 29
    5.4 Strategic Objective 4 – Rational use of antimicrobials................................................ 34
    5.5 Strategic objective 5 – Investment into research and development.............................39
6.0 MONITORING AND EVALUATION................................................................................. 42
    6.1 Approach and components of M&E........................................................................... 42
ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN - 2017-2021 Strategic Framework, Operational Plan, and Monitoring and Evaluation ...
ABBREVIATIONS AND ACRONYMS

AMR          Antimicrobial resistance            ICAZ       Infection Control Association of
                                                            Zimbabwe
AMU          Antimicrobial use
                                                 IDSR       Integrated Disease Surveillance
CDC          Centers for Disease Control and                and Response
             Prevention                          IPC        Infection Prevention and Control
CDDEP        Center for Disease Dynamics,
                                                 IEC        Information, Education and
             Economics & Policy
                                                            Communication
CEO          Chief Executive Officer
                                                 LMAC       Livestock & Meat Advisory
CIA          Critically Important                           Council
             Antimicrobials                      MAMID      Ministry of Agriculture,
CPD          Continuous Professional                        Mechanization and Irrigation
             Development                                    Development

CSO          Civil Society                       MCAZ       Medicine Control Authority
                                                            Zimbabwe
CVL          Central Veterinary Laboratory       MDRO       Multi-drug resistant organism

DDD          Defined Daily Doses                 MEWC       Ministry of Environment, Water
                                                            and Climate
DLS          Directorate Laboratory Services
                                                 MLCSCZ     Medical Laboratory and Clinical
DLVS         Department of Livestock and                    Scientists Council Zimbabwe
             Veterinary Services                 MoHCC      Ministry of Health and Child
                                                            Care
DPS          Department of Pharmacy
             Services                            MoE        Ministry of Education
DR&SS        Department of Research and          MoF        Ministry of Finance
             Specialist Services
DVS          Division of Veterinary Services     MoS&T      Ministry of Science &
                                                            Technology
EMA          Environmental Management            NAP        National Action Plan
             Agency
EML          Essential Medicines List            NBA        National Biotechnology Authority

FAO          Food Agricultural Organisation of   NGO        Non-governmental organisation
             the United Nations
                                                 NHIS       National Health Information
GAL          Government Analyst Laboratory                  System
GARP         Global Antibiotic Resistance        NIPCC      National Infection and
             Partnership                                    Prevention Control Committee
HAI          Health-care associated              NMRL       Naitonal Microbiology Reference
             infections                                     Laboratory
HCW          Health-care workers                 NMTPAC     National Medicine &
                                                            Therapeutics Policy Advisory
HMTC         Hospital medicines therapeutic                 Committee
             committees

THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021               v
OIE         World Organization for Animal
             Health
 PATAM       Health-care workers

 RCZ         Hospital medicines therapeutic
             committees
 ReAct       Infection Control Association of
             Zimbabwe
 STG         Standard Treatment Guideline

 STI         Sexually Transmitted Infections

 TMPC        Traditional Medical Practitioners
             Council
 TMD         Traditional Medicines
             Department
 TWG         Technical Working Group

 UZ          University of Zimbabwe

 VHW         Village Health Workers

 VMDG        Veterinary Medicines General
             Dealers
 WASH        Water Sanitation and Hygiene

 WHO         World Health Organization

 ZACH        Zimbabwe Association of
             Church-related Hospitals
 ZiMA        Zimbabwe Medical Association

 ZIMCHE      Zimbabwe Council for Higher
             Education
 ZIMRA       Zimbabwe Revenue Authority

 ZINATHA     Zimbabwe National Traditional
             Healers Association
 ZINQAP      Zimbabwe National Quality
             Assurance Programme
 ZINWA       Zimbabwe National Water
             AUthority
 ZRP         Zimbabwe Republic Police

 ZVA         Zimbabwe Veterinary Association

THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021   vi
Foreward
Antimicrobial resistance (AMR) has become an increasingly serious threat to national and global public
health that requires prioritised action across all government sectors and society. Antimicrobials have
been hailed as one of the most important discoveries in medical history as they have successfully
treated many diseases in both animals and humans promoting the health and well-being of individu-
als. AMR is threatening the effective prevention and treatment of an ever increasing range of infec-
tions caused by bacteria, viruses, parasites and fungi and impacting on the health and productivity of
livestock. It is important that we preserve the current antimicrobials that are available as it takes an
average of 12 years for new antimicrobials to be available for use.

Following the adoption of the Global Action Plan (GAP) on Antimicrobial Resistance by the 68th World
Health Assembly in May 2015, Zimbabwe immediately put in place a framework towards developing
the AMR National Action Plan by starting with a situational analysis to help understand the situation
around AMR and any efforts to contain it that were in place. The Global Action Plan urges Member
States “to have in place, national action plans on antimicrobial resistance and with standards and
guidelines established by relevant intergovernmental bodies.”

Findings of the AMR situation analysis that was carried out showed that AMR will grow in Zimbabwe
if it is not tackled in a holistic manner. This national action plan is in line with the Global Action Plan
and outlines the following 5 strategic objectives:-

•   To improve awareness and understanding of AMR through effective communication, education and
    training;

•   To strengthen the knowledge and evidence base through surveillance and research;

•   To reduce the incidence of infection through effective sanitation, hygiene and infection prevention
    measures;

•   To optimize the use of antimicrobial medicines in human and animal health;

•   To develop the economic case for sustainable investment that takes into account the needs of all
    countries and to increase investment in new medicines, diagnostic tools, vaccines and other inter-
    ventions.

Therefore, the three governmental departments and other relevant stakeholders whose responsibili-
ties intersect on human, animal and environmental health outcomes, and therefore are responsible
for implementing the ‘One Health’ approach in Zimbabwe, have committed themselves to investing
resources in designing sound strategies and interventions to preserve the effectiveness of our antimi-
crobial agents, in order to ensure sustainable dependence on them and to slow down the emergence
and spread of AMR in Zimbabwe. This National Action Plan on AMR will be implemented by all sectors
in coordinated manner to significantly slow down the development of antimicrobial resistance.

Dr. Pagwesese David Parirenyatwa           Dr. Joseph Made                  Ms. Oppah Muchinguri-Kashiri
        Minister of Health               Minister of Agriculture              Minister of Environment
         and Child Care                Mechanization and Irrigation              Water and Climate
                                             Development

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Acknowledgements
The Ministry of Health and Child Care, the Ministry of Agriculture Mechanisation and Irrigation De-
velopment and the Ministry of Environment, Water and Climate would like to thank the World Health
Organization (WHO), Food and Agriculture Organization (FAO) of the United Nations for the financial
and technical support during the development of this document. Special thanks also go to the Global
Antibiotic Resistance Partnership (GARP), under the Centers for Disease Dynamics, Economics &
Policy (CDDEP) and Action on Antibiotics Resistance (ReAct) for their support and guidance of both
the Situation Analysis and the National Action Plan (NAP).

The three ministries are grateful for the commitment and involvement of the Zimbabwe Antimicrobial
Resistance Core Group and the 5 technical working groups who have been working tirelessly in the
production of these documents usinga ‘One Health’ approach.

Special thanks also go to the core national action plan writing team who were:-

    Sekesai Mtapuri-Zinyowera, Ministry of Health & Child Care
    Tapiwanashe Kujinga, Pan-African Treatment Access Movement
    Portia Manangazira, Ministry of Health and Child Care
    Unesu Ushewokunze-Obatolu, Ministry of Agriculture, Mechanisation and Irrigation Development
    Ropafadzai Hove, Ministry of Health and Child Care
    Pamela Woods, University of Zimbabwe, Department of Animal Science
    Newman Madzikwa, Ministry of Health and Child Care
    Valerie Robertson, University of Zimbabwe, Department of Medical Microbiology
    Jairus Machakwa, Division of Veterinary Services
    Zivanai Makoni, Medicines Control Authority of Zimbabwe
    Stanley Midzi, World Health Organisation
    Lawrence Dinginya, Division of Veterinary Services
    Marcelyn Magwenzi, University of Zimbabwe, Department of Medical Microbiology
    Kudzaishe Vhoko, Division of Veterinary Services
    Tsitsi Monera-Penduka, University of Zimbabwe, School of Pharmacy
    Samuel Swiswa, Division of Veterinary Services
    Wilfred Motsi, Ministry of Water, Environment and Climate
    Jose Alves Phiri, Ministry of Health & Child Care
    Jonathan Mufandaedza, National Biotechnology Authority of Zimbabwe
    Elizabeth Gonese, Centers for Disease Control and Prevention
    Francisca Mutapi, University of Edinburgh, Institute for Infection and Immunology Research
    Takafira Mduluza, University of Zimbabwe, Biochemistry Department

THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021                  viii
1. BACKGROUND AND SITUATION ON AMR

The Government of Zimbabwe through the antimi-            diarrheal diseases. One major driver of resistance is
crobial resistance (AMR) core group conducted an          increased antimicrobial consumption in both humans
analysis of the AMR situation in Zimbabwe in the          and animals. However the data on antimicrobial use
human, animal and environmental sectors follow-           and patterns of AMR in humans and animals in Zim-
ing the ‘One Health’ approach advocated by World          babwe are limited.
Health Organization (WHO), World Organisation
for Animal Health (OIE), and Food and Agriculture            Although the country’s vaccination coverage rate for
Organization of the United Nations (FAO). This in-        children under 1 year is at 89%, more can be done
terest is borne out of the fact that AMR is a cross       to prevent infections, including improving general
cutting problem affecting human, animal and the           hygiene and sanitation and implementing infection
environment that calls for coordinated action across      prevention and control (IPC) measures in all health
these sectors. It develops from changes at genetic        institutions. A significant dent has been made in the
levels through mutations or as acquired traits in the     occurrence of rotavirus diarrhoea through vaccina-
microorganism. As a naturally occurring phenom-           tion; however the persistent challenges of poor water,
enon, AMR is accelerated by selection pressure in         sanitation and hygiene practices have kept diarrhoea
the environment of the microorganism. Because             cases related to typhoid and other bacteria causes as
microorganisms are present in the natural environ-        common occurrences. Whilst oral rehydration with
ment, when AMR develops, it can also escalate and         Zinc, is the standard treatment of choice for diarrhoea,
spread in the environment with implications on the        antibiotics are often used and resistance is spreading.
well-being of all forms of life. Events precipitating
                                                             In Zimbabwe there is lack of meaningful surveil-
AMR in microorganisms can therefore have impli-
                                                          lance data to help understand resistance patterns,
cations on pathogenicity and therefore plant, ani-
                                                          prevalent organisms and guide policy development,
mal and human health. This puts pressure on the
                                                          due to constraints in the laboratory testing systems.
ability of human and animal health systems as well
                                                          Only 25 percent of the human public health labora-
as agricultural production, particularly as the pace
                                                          tories have the necessary staffing, equipment and
of discovery and innovation of more effective anti-
                                                          reagents to perform culture and susceptibility testing
microbials has significantly slowed down over the
                                                          on human samples, which limits the diagnostic ca-
last three decades.
                                                          pabilities of health care professionals treating patients
   Zimbabwe has faced serious economic challenges         and the availability of antimicrobial resistance data to
over the years, which have affected all aspects of        guide clinical practice and policymaking.
life, not least of which is the health sector’s ability
                                                            Zimbabwe has an essential medicines list (EML)
to provide health care, and which has resulted in a
                                                          that was last updated in 2015, but access to antimi-
shortage of health-care workers and stock outs of
                                                          crobials is still limited in many areas, and should be
medicines. The agriculture sector is one of the most
                                                          expanded alongside efforts to improve supply chains
important pillars of the Zimbabwean economy, with
                                                          and storage. The primary reason for lack of access
the majority of the population dependent directly or
                                                          to medicines is lack of finances at the national level
indirectly on agriculture.
                                                          and fragmented funding from donors. Widespread
  Zimbabwe faces significant and growing resistance       unregulated availability of antimicrobials over-the-
in common infections such as TB, malaria, HIV, re-        counter (OTC) for use in humans and animals has
spiratory infections, sexually transmitted infections     been reported despite regulations that prohibit sale
(STIs), urinary tract infections (UTIs), meningitis and   without a valid prescription and the possibility that

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a pharmacist may lose their license or be fined for      cern about dangers of residues of veterinary medical
contravening these laws. More needs to be done           agents in food for consumers. For a wide variety of
to improve incentives for appropriate antibiotic use,    infections especially those caused by viruses, and
create disincentives for the overuse of antibiotics      some bacteria, effective vaccines are available for
and illegal access to antimicrobials of poor quality     prevention. Some vaccination programs are offered
through sound legislation and policy.                    as a public good depending on their importance to
                                                         production system economies and to public health.
  The use of antimicrobials in crop production is        For others, the adoption of good animal husbandry
less well acknowledged although there is potential       and hygienic practices may go a long way in reduc-
in the food horticulture industry.                       ing infection pressure. While these alternatives to
                                                         antimicrobial use (AMU) are being promoted, some
   Infectious diseases caused by microbiological
                                                         important diseases such as vector-borne rickettsial
agents including bacteria, fungi, protozoa and vi-
                                                         (Erlichia of ruminants and dogs) and protozoan (Ba-
ruses in animals inflict significantly important eco-
                                                         besiases, Trypanosomiasis, Theileria spp) diseases
nomic and public health impact in animal produc-
                                                         could benefit from development of effective, user-
tion systems. The use of antimicrobial agents is
                                                         friendly vaccines. Vector-borne diseases therefore
therefore an important aspect of animal healthcare.
                                                         still rely on chemical vector control with its environ-
However, because of the constant infection chal-
                                                         mental implications or the frequent use of antibiot-
lenge to animals in the environment, overdepen-
                                                         ics for some of them. The range of options in the
dence and abuse of antimicrobials have contribut-
                                                         prevention of microbial infections can therefore still
ed to the development of AMR, which results from
                                                         be explored through research.
selection pressure at genetic level. This tendency is
being exacerbated by the need for repetitive treat-         Animal disease surveillance is one of the im-
ment such as occurs in milk producing animals            portant tools for intelligence gathering to facilitate
and mass treatments as called for in managing            early detection of higher impact endemic and
small stock and aquatic animal infections. In other      trans-boundary animal and zoonotic diseases and
instances, the prophylactic and metaphylactic use        pests. General and disease specific surveillance is
of antimicrobial medicines, in order to achieve sus-     also a useful tool in the generation of evidence for
tainably high productivity levels, are to blame for      sanitary safety assurance of traded animal-source
the rising occurrence of AMR, which risks affecting      products. Disease specific surveillance programs
the availability of some key antibiotics essential for   exist for brucellosis in dairy cattle, salmonellosis in
use in treatment of human disease.                       breeder poultry flocks and slaughtered cattle and
                                                         pigs aimed at infection reduction. Surveillance data
  The regulatory oversight on the use of veterinary
                                                         could be of additional use in the determination of
medicines suffers from the weak distribution of
                                                         emerging risks due to AMU and resistance. This re-
veterinary services particularly in the numbers and
                                                         quires laboratory testing capacity and capability for
distribution of veterinarians and veterinary parapro-
                                                         the determination of resistance as well as monitor-
fessionals. This defeats the intention of the medi-
                                                         ing for residues in animal tissues.
cines control legislation whose aim is to promote
the rational and safe use of medicines. A large             Present veterinary laboratory testing capacity is lim-
range of prescription medicines can therefore be         ited by personnel skills and equipment. Culture and
accessed and used by lay personnel and animal            sensitivity tests for AMR and a limited range of residue
keepers without the necessary controls to ensure         testing can be done, especially in support of animal-
judicious and prudent use.                               source food exports but no monitoring is carried out
                                                         for the local market on a ‘client pays’ basis. There are
  Greater reliance on preventive veterinary medicine
                                                         currently limited capacities to support a comprehen-
has however been gaining popularity due to the con-
                                                         sive residue monitoring programme in animal slaugh-

THE ZIMBABWE ONE HEALTH ANTIMICROBIAL RESISTANCE NATIONAL ACTION PLAN, 2017-2021                               10
ter establishments, and to monitor or regulate residue     more research to be done including surveillance. In
levels in abattoir waste and their disposal pathways.      order to prevent resistance, cultural methods are em-
The confirmatory tests for AMR still take long and         ployed to control diseases such as crop rotation, use
could benefit from the development and adaptation of       of clean seed and use of resistant varieties.
more rapid detection methods to facilitate rapid and
                                                              Environmental monitoring and surveillance for
precise decisions on the choice of medicines remov-
                                                           AMR needs to be mainstreamed within a general na-
ing the element of “trial and error”.
                                                           tional strategy to scale down the rate of emergence
   Widespread unregulated availability of over the         of AMR. To do this, a clear understanding is required
counter medicines and informal cross-border impor-         of drivers in each sub-sector in relation to safeguards
tation of antimicrobials for use in humans and animals     on the lists of essential veterinary and medical anti-
has been reported despite legislation prohibiting sale     microbials, especially those intended for specific use
without prescription. Policy, legislation and implemen-    in human disease.
tation gaps have allowed the routine inclusion of an-
                                                              Access to good water and sanitation facilities
tibiotics in feeds, while weak veterinary capacity has
                                                           is lowest in rural areas, where two thirds of the
been blamed for the wide access to antimicrobials by
                                                           population resides including a few residential
animal keepers, without the necessary checks. En-
                                                           areas in the urban areas. Added to this, hospitals,
forcement of existing legal provisions and incentives
                                                           clinics and manufacturing industries have poor
for appropriate antibiotic use, with disincentives for
                                                           liquid and solid waste disposal methods and the
the overuse of antibiotics and illegal access to antimi-
                                                           capacity to regulate the disposal and treatment of
crobials are required.
                                                           clinical waste is limited. As a result, antimicrobials
  Chemicals are used in the crop sector as fungicides      and antimicrobial residues are likely entering the
or for their bacteriostatic effects. There is need for     environment, including drinking water and soil.

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2.0 EXECUTIVE SUMMARY

The AMR situation analysis that was carried out by the          The NAP will also prioritise the building of labora-
multi-sectorial Zimbabwe AMR Core Group indicated            tory diagnostic capacity, as this forms the basis for
that the problem of AMR, caused by a combination             treatment decisions for human and animal health-
of factors, can be addressed through a roadmap to-           care professionals and supports informed decisions
wards slowing down the pace of AMR development               about AMU. Laboratory capacity is also needed to
and enhancing sustainable reliance on AMU in public          conduct AMR surveillance, which will be incorpo-
health promotion. The following 5 strategic objectives       rated into the existing integrated disease surveil-
were identified in Zimbabwe, which align with the            lance and response (IDSR) system for humans and
WHO Global Action Plan objectives, in order to ensure        notifiable disease surveillance system for animals.
preservation of the available antimicrobials so that in-     A combined surveillance reporting system will be
fectious diseases are treatable:                             created to ensure the One Health approach to un-
                                                             derstanding the magnitude, patterns and dynamics
   • Raise awareness and educate the population,             of AMR. A monitoring system for AMU will be estab-
     professionals and policy makers on AMR.                 lished in the public and private sectors to measure
                                                             and monitor the usage of antimicrobials in humans,
   • Improve understanding of the AMR burden
                                                             animals and crop production, its disposal into the
     and antimicrobial use patterns through sur-
                                                             environmental, and determine the impact of AMR
     veillance.
                                                             interventions on reducing use.
   • Reduce the need for antimicrobials by improv-
                                                                In order to minimize the development of AMR,
     ing infection prevention and control, improved
                                                             renewed attention will be brought to current infec-
     farm practices and biosecurity, water sanita-
                                                             tion prevention and control practices to reduce the
     tion and hygiene, and immunisation.
                                                             spread and transmission of multi-drug resistant or-
   • Improve controlled access and optimise the              ganisms (MDROs). Surveillance of hospital-acquired
     use of antimicrobials in humans and animals             infections (HAIs) will support these efforts. Biosecu-
                                                             rity measures, and better hygiene and health man-
   • Sustainable investment into AMR and re-                 agement practices for animals will be promoted and
     search into alternatives to antimicrobials.             strengthened through improved policies, guidelines
                                                             and practices, training and capacitation of regulatory
   This National Action Plan (NAP) will help to plan the
                                                             bodies to improve enforcement and testing mecha-
development and implementation of a comprehen-
                                                             nisms. The relevant authorities will focus on appro-
sive national communication and awareness plan to
                                                             priate environmental controls, the provision of water,
educate the public, professionals and policy makers on
                                                             sanitation and hygiene (WASH) facilities in commu-
ways to prevent infections, treat infections appropriately
                                                             nities, health and veterinary facilities, and promotion
and conserve antimicrobials. It will strengthen the edu-
                                                             of improved hygiene behaviours.
cation curriculum in all educational sectors from pri-
mary to tertiary education, improving the knowledge of         Stewardship programs will need to be incorpo-
school children and educating human, animal and en-          rated into the hospital medicines therapeutic com-
vironmental health care professionals, both as students      mittees (HMTCs) to ensure prudent and appropri-
and postgraduates, to be aware of the threat of AMR          ate use of antimicrobials. Measures will need to be
and ways to minimize its development and spread in           implemented to ensure consistent and sustained
humans, animals and the environment.                         access to quality medicines by strengthening pro-

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curement systems, supply chains and storage fa-          updated EML that reflects the current diseases and
cilities for antimicrobials and ensuring sustained       pathogens in humans to improve treatment.
funding for the antimicrobials on the Essential Med-
icines List (EML). Control of quality veterinary medi-      Both short-term and long-term research needs
cines will need to be increased and simultaneously       to be carried out to understand the links, drivers
strengthened without limiting access to animal keep-     and dynamics of AMR development and spread be-
ers through enhanced involvement of veterinarians        tween the human, animal, and environmental inter-
in the provision of guidance on antimicrobial use        faces and to create innovative diagnostic tools, new
in the field as well as scope of practice for veteri-    vaccines, and alternative therapies such as probi-
nary paraprofessionals under veterinary oversight.       otics and traditional remedies. Funding for these
Public access to antimicrobials at the point of the      types of research activities will be provided by the
pharmacy and veterinary medicine general dealers         Government with the support and collaboration of
(VMGDs) is to be controlled through improvements         development partners and the private sector.
to regulatory processes. This will ensure prudent
                                                           Implementation of this plan requires sustained
use without undermining access to quality antimi-
                                                         commitment into years to come and a monitoring
crobials and care.
                                                         and evaluation plan will be needed to evaluate its
  At the same time, the rational use of antimicro-       impact. The plan will be achieved through the “One
bials in health facilities will be improved through      Health” approach which embraces an integrated,
functional hospital medicines therapeutic commit-        unified effort across sectors, addressing the cross
tees, standard treatment guidelines (STG’s) and an       cutting nature of AMR.

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3.0 GOVERNANCE

3.1 Governance Structure
The AMR governance structure was formed and en-            The governance structure was formed after a
dorsed in August 2016 by the Secretary for Health        consultative process that involved relevant stake-
and Child Care to allow for coordination, manage-        holders from the relevant ministries, civil society
ment and monitoring of AMR activities in the coun-       (CSOs), academia and non-governmental orga-
try (See Figure 1 below). The AMR focal point is the     nizations (NGOs). Technical working groups that
AMR Coordinator who will work under the Depart-          are aligned to the strategic objectives of the Global
ment of Epidemiology and Disease Control (EDC),          Action Plan were formed at a multi-sectoral ‘One
the Directorate Laboratory Services (DLS) in the         Health’ stakeholder’s forum that was held in June
Ministry of Health and Child Care (MoHCC) and the        2016 (See Figure 1 below).
Division of Livestock and Veterinary Services (DLVS).

                                                  Fig 1: Governance structure of the Zimbabwe AMR activities

3.2 Leadership
The Secretary for Health in the MoHCC is the office      Irrigation Development and the Ministry of Environ-
that is responsible for leading national AMR activi-     ment, Climate & Water. The focal point, the Zimba-
ties. The Core Group shall also report to the Perma-     bwe AMR Core Group and the Advisory Committee
nent Secretaries through the advisory committees         were all appointed by the Secretary for Health for a
in the Ministry of Agriculture, Mechanisation and        period of 5 years.

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3.2.1 Roles of the appointed positions                      •   The national delegation to the World Organ-
                                                                isation of Animal Health (OIE)
AMR Focal Point
                                                            •   University of Zimbabwe
The functions of the National AMR focal point include:
                                                            •   Biomedical Research and Training Institute
   i. Building sustained partnerships and working
      nationally and internationally on containment         •   Civil society
      of AMR;
                                                            •   National Biotechnology Authority of Zimba-
   ii. Leading and coordinating activities of the               bwe
       AMR National Action Plan;
                                                            •   Ministry of Finance and Economic Develop-
   iii. Facilitating and overseeing implementation of           ment
       activities through the AMR Core Group;
                                                         The roles and responsibilities of the AMR Core
   iv. Ensuring regular data collection and informa-     Group include:
      tion sharing by instituting effective communi-
      cation and coordination mechanisms among             i. Mobilising resources for the national response
      all stakeholders, the members of the Core               against AMR. Creating correct and relevant
      Group and their constituencies, sectors and             messaging on AMR in order to guide education
      disciplines and;                                        and awareness programmes on AMR to ensure
                                                              that the public and all other relevant stakehold-
   v. Coordinating national activities as per the Na-         ers are sensitised on AMR issues.
      tional Action Plan for the AMR program.
                                                           ii. Facilitating the establishment of surveillance
The Zimbabwe AMR Core Group                                   systems to monitor AMR.

The Zimbabwe AMR Core Group is a multi-sectoral            iii. Disseminating active and passive surveil-
group comprising of 18 members, an appointed                   lance data on antimicrobial use (AMU) and in-
Chairperson, Deputy, Coordinator, Secretariat and              tegrated laboratory surveillance data to policy
Committee Members. Members of the Core Group                   makers and other relevant partners.
are from the following organizations:
                                                           iv. Enabling research activities on relevant AMR
   •     Ministry of Health & Child Care                      issues.

   •     Ministry of Agriculture, Mechanisation and        v. Encouraging rational use of medicines through
        Irrigation Development                                the establishment of antimicrobial steward-
                                                              ship programs.
   •    Ministry of Environment, Climate & Water
                                                           vi. Supporting the implementation of infection pre-
   •    Department of     Livestock and Veterinary
                                                              vention and control (IPC) and biosecurity mea-
        Services
                                                              sures to reduce and control the spread of AMR.
   •    Medicines Control Authority of Zimbabwe
                                                           vii. Monitoring implementation of AMR-related
   •    Food & Agricultural Organization of the               activities by other organisations, institutions
        United Nations (FAO)                                  and stakeholders.

   •    World Health Organization (WHO)                    viii. The AMR Core Group will be accountable for
                                                              the process of implementation of this NAP.

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The Zimbabwe AMR Advisory Committee                          vi. Identifying any gaps in the evidence base,
                                                                such as those requiring further research or
There is a multisectoral 12-member Advisory Com-                surveillance.
mittee made up of policy makers within the three
core ministries, consultants from the University of       Five technical working groups (TWG) that are
Zimbabwe, FAO, WHO, CDC and interested private            aligned with the strategic objectives of the Global
practitioners from both human and animal health.          Action Plan were formed in June 2016, as follows:
This committee has strategic governing responsi-
                                                             • Education and Awareness
bilities that include the following:
                                                             • Surveillance and Research
   i. Providing practical advice and guidance to
      the process of carrying out an AMR situational         • Infection Prevention & Control and Biosecurity
      analysis and the national action plan.
                                                             • Antimicrobial Use
   ii. Providing advice and guidance in the imple-
      mentation, monitoring and evaluation of the            • Research and Development
      AMR NAP.
                                                          The chairperson of each TWG is a member of the
   iii. Contributing to improved capacity, includ-        Zimbabwe AMR core group. The roles and respon-
       ing research advice, practical and scientific      sibilities of TWGs include the following:
       advice to the Core Group and government on
                                                             • Building sustained partnerships and work in
       strategies to:
                                                               their sector on containment of AMR;
        - minimize the incidence of healthcare as-
                                                             • Identifying other relevant stakeholders;
        sociated infections (HAIs)
                                                             • Facilitating and overseeing implementation,
        - monitor AMR and reduce its develop-
                                                               including monitoring and evaluation (M&E) of
        ment and spread
                                                               the NAP through the TWG;
        - maintain the effectiveness of antimicro-
                                                             • Ensuring regular data submission and informa-
        bial use (AMU) and optimize antimicrobial
                                                               tion sharing to the Core Group by instituting
        prescribing in the treatment and preven-
                                                               effective communication systems, frameworks
        tion of microbial infections
                                                               and coordination among all members of the
        - take into account the relevant work of               TWG.
        other expert groups, in the human and vet-
        erinary fields when making its recommen-
        dations
                                                          3.3 Guiding Principles
   iv.     Assisting the Zimbabwe National AMR
      Core group on its scientific priorities and work,   The guiding principles that the Zimbabwe NAP will fol-
      including horizon-scanning and long-range           low are in line with those articulated in the 68th WHA:
      planning as well as dealing with immediate
                                                          (i) Whole-of-society engagement including a One
      risks and opportunities.
                                                          Health Approach
   v. Reviewing and evaluate the effectiveness of
                                                          A knowledge, attitudes and practices survey of the
      the on-going work of the AMR core group.
                                                          general public and animal and human health pro-

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fessionals and a point-prevalence survey carried          microbials prescribed by qualified professionals
out in 18 hospitals showed widespread irrational          and used appropriately by individuals will ensure
antimicrobial use and varied knowledge of AMR.            quality health care provision at low cost.
The whole of society should therefore be engaged
in curbing AMR in the country as each individual          (iv) Sustainability
has a role to play, hence education and awareness
                                                          Implementation of this NAP will require to be
of AMR will be intensified.
                                                          integrated into the work programs of all relevant
(ii) Prevention first                                     ministries to ensure activities will be carried out.
                                                          Therefore, political commitment and international
Water, sanitation and hygiene (WASH), improved            collaboration and support are needed to promote
practices in individuals, among medical and veteri-       the technical and financial investment necessary
nary professionals, organisations and at the farm lev-    for effective running of the NAP interventions.
els are low cost interventions areas with immediate       Government institutions and other relevant sec-
impact to prevent the spread of infections. These are     tors will need to commence utilising the available
basic first steps that can be undertaken, followed by     resources and build on this to ensure sustainabil-
infection prevention control in hospitals, better bios-   ity.
ecurity and good farm practices and routine vaccina-
tion of humans and animals.                               (v) Incremental targets for implementation

(iii) Access                                              This NAP has a phased approach that can be
                                                          achieved in a stepwise manner, considering
Access to information on AMR is key to empower-           short-term priority areas in the five strategic ob-
ing individuals and the nation as a whole. Access         jectives in order to meet both local needs and
to diagnostic services and access to quality anti-        global priorities.

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4.0 STRATEGIC FRAMEWORK
The Zimbabwe NAP is built on a foundation of re-                 to optimise responsible use in animals and
search and development and the necessary politi-                 humans
cal commitment and investment to ensure the sus-
                                                               • Investment in research and development which
tainability of the AMR program.
                                                                 seeks innovative ideas of alternatives to antimi-
The four key pillars of the strategy are:                        crobials or quicker diagnostic techniques.

   • Surveillance of AMR and AMU patterns in ani-             Finally, the implementation of the Zimbabwe NAP
     mals, humans and crops.                                depicts a strong inter-sectoral coordinating mecha-
                                                            nism as its foundation and has its roof which is
   • Prevention, which will reduce the need for antimi-     overarching and cross-cutting indicating the need
     crobials through effective IPC, farm biosecurity and   to raise awareness and educate the public, profes-
     good farm practices, WASH and immunisation             sionals and policy makers on AMR and responsible
   • Rational antimicrobial use, which seeks to im-         antimicrobial use. The Coordinating mechanism will
     prove controlled access to antimicrobials and          ensure that all these strategies are implemented.

          Fig 2: Strategic objectives

4.1 Strategic Plan and Strategic Objectives
for AMR in Zimbabwe
4.1.1 Strategic Objective 1 – Education, training           key AMR messages reach and resonates with all
and awareness: To raise awareness and educate               sectors and corners of the country. In coming up
the population, professionals and policy makers             with the training and awareness program for AMR
on AMR                                                      both the formal and informal systems of informa-
                                                            tion dissemination will be utilized. The formal ap-
Developing and implementing a home-grown train-             proach will encompass all the national educational
ing and awareness program is key to ensuring that           and training programs, which are well structured in

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terms of content and the way they are delivered,        mation will be of common importance to human,
which are aimed at developing specific competen-        animal and ecosystem health. This multi-sectoral
cies or skills relevant to AMR. Informal approaches     initiative encompasses laboratories from the Min-
will also be used to relay key messages in simple       istry of Health and Child Care (MoHCC), Ministry
language that is understandable to all individuals      of Agriculture, Mechanisation and Irrigation De-
regardless of social, economic or educational sta-      velopment (MAMID), the Ministry of Environment,
tus. Zimbabwe is well advanced in terms of having       Water and Climate (MEWC), National Biotechnol-
access to modern forms of communication such as         ogy Authority, City Health laboratories and private
print, broadcast, audio and electronic communica-       laboratories. AMU information is also lacking and
tion media. However, individuals in different parts     this new surveillance will include processes for col-
of the country do not all have equal access to these    lecting antimicrobial use data.
communication channels. This disparity in access
will be considered when developing the AMR train-       Specific objectives for surveillance are to:
ing and awareness strategy and plan.
                                                           1. Strengthen diagnostic laboratory capacity to
Specific objectives for education and awareness are:          improve healthcare professionals’ ability to
                                                              make informed AMU decisions.
   1. To improve awareness and understanding of
      AMR for the public, professionals and policy         2. Integrate the surveillance for humans, ani-
      makers.                                                 mals and the environment into a ‘One Health’
                                                              integrated surveillance system.
   2. To strengthen the knowledge of human, ani-
      mal and environment health professionals             3. Establish an AMU monitoring system for anti-
      through improved curricula.                             microbials for human and animal use.

   3. To educate farmers and animal keepers on AMR         4. Analyze and report surveillance data to sup-
      to support good antimicrobial use practices.            port clinical and policy decision making in rel-
                                                              evant sectors.
   4. To strengthen the knowledge of school chil-
      dren on AMR at primary, secondary and ter-           5. Strengthen capacities for generating and ana-
      tiary level education.                                  lysing AMR/AMU data to inform policy develop-
                                                              ment, better targeting of interventions and man-
The activities to achieve these strategic objectives          agement decisions and to monitor progress.
are described in more detail in the operational plan
in section 3.                                           The activities to achieve these strategic objectives
                                                        are described in more detail in the operational plan
                                                        in section 3.

4.1.2 Strategic Objective 2 – Surveillance:
Improve detection and understanding of the
AMR and antimicrobial use patterns and trends           4.1.3 Strategic Objective 3 – Infection
through surveillance                                    prevention & control, good animal husbandry
Surveillance is important to detect the magnitude of    and biosecurity: Reduce the need for
AMR, and help to monitor trends in space and time.      antimicrobials by improving IPC, animal
Sound survey designs backed by laboratory testing       health and management practices including
are important tools in detecting AMR. Embracing         biosecurity, WASH and immunisation
the ‘One Health’ approach will help to gain efficien-   Existing biosecurity measures, good farm manage-
cies by reducing duplicative functions on the work      ment practices and national IPC programs need to be
of a similar nature for the same end. AMR infor-        strengthened. Biosecurity is defined by OIE as “The

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implementation of practices that create barriers in or-        4. Strengthen and expand vaccination programs
der to reduce the risk of the introduction and spread of          in animals and humans to improve prevention
disease agents”. The three principles of biosecurity are          and control of disease, and reduce AMU
segregation, cleaning, and disinfection; where segre-          5. Reduce the transmission of infectious dis-
gation is the creation and maintenance of barriers that           eases in communities, health-care centers,
limit the potential opportunities for infected animals            veterinary and plant facilities through effective
and contaminated materials to enter an uninfected                 water, sanitation and hygiene practices, and
site. Improvement in animal health management prac-               provision of appropriate facilities.
tices includes farm facilities and movement controls,
documentation of treatment provided to animals, the         The activities to achieve these strategic objectives
provision of appropriate care to sick animals and the       are described in more detail in the operational plan
prevention of illegal cross border movements.               in section 3.

   The purpose of IPC in health care as defined by
WHO, is “to prevent the occurrence of health-care           4.1.4 Strategic Objective 4 – Rational use of an-
associated infections (HAIs) in patients, health-care       timicrobials: Improve controlled access and op-
workers (HCWs), visitors and other persons associated       timise the use of antimicrobials in humans and
with health-care facilities”(WHO 2009). Core compo-         animals
nents of an IPC program include IPC management
structures and human resources such as training, pro-       The availability of antimicrobials according to the
gram staffing and occupation health support and IPC         National Standard Treatment Guidelines (STGs) and
guidelines that describe IPC activities such as hand        Essential Medicines List, which are based upon the
hygiene, standard and transmission based precau-            current pathogen resistance patterns, is critical to
tions, waste and linen management, environmental            patient outcomes. Robust regulatory and medicine
cleaning, disinfection processes and surveillance ac-       management systems, including procurement, dis-
tivities. Infections can also be prevented by effective     tribution and dispensing systems, are needed to
vaccination programs and by improving water, sanita-        support access to safe, effective and affordable anti-
tion and hygiene practices, and availability and acces-     microbials and remove incentives for illegal dispens-
sibility at community level.                                ing and poor quality medicine sales.

   Specific objectives for Infection, prevention and con-      Access and availability of certain key antimicro-
trol, good animal husbandry and biosecurity are:            bials to animal keepers should be maintained and
                                                            expanded and the necessary control mechanisms
   1. Strengthen the existing biosecurity measures on       implemented to prevent irresponsible use. An impor-
      hatcheries, farms, aquaculture establishments,        tant element will be on-going education and aware-
      slaughter houses, and food processing estab-          ness of key individuals involved in the distribution
      lishments etc., for pathogen risk reduction           and administration of antimicrobials in animals. In
   2. Improve movement controls of animals and              addition, a sound regulatory environment that con-
      animal products, and border control mecha-            trols and enforces the responsible use of antimicro-
      nisms to reduce trans-boundary animal dis-            bials in humans, animals and the environment is es-
      ease occurrence transmission                          sential to the effective control of AMR.

   3. Track and reduce the burden of health-care as-        Specific objectives for rational use of antimicrobials are:
      sociated infections (HAIs) through improving IPC
      practices in all health care facilities in Zimbabwe      1. Improving access to quality assured antimi-
                                                                  crobials to animal keepers by increasing ac-

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cess points for the sale and provision of anti-       which are termed as short to medium-term plans to be
     microbials.                                           implemented in the face of the current problem.

   2. Strengthening control of antimicrobials and             The long-term strategies need stronger collaboration
      their use in animal health by farmers and para       from local, regional and international research institu-
      veterinarians without limiting access.               tions as they require vast amounts of resources and time.
   3. Implementing sustainable supervision, audit
                                                           Short to medium term (1-5 years) investment and
      and feedback mechanisms in health facilities
                                                           research needs
      by having functional medicines therapeutic
      committees in health institutions to ensure          Local collaboration linking human-animal-environment
      appropriate antimicrobial use by prescribers.        research activities is required in the following areas:
                                                              • Support research on the model of transmis-
   4. Ensuring that Standard Treatment Guide-
                                                                sion between organisms and the transmis-
      lines (STG’s) and the Essential Medicines List
                                                                sion of resistant bacteria among different
      (EML) reflect the current resistance patterns
                                                                reservoirs (human-animal-environment).
      and pathogens in humans and animals.

   5. Ensuring adequate supplies of quality assured           • Conduct research to understand the capacity
      essential antimicrobials at various levels of hu-         building needs such as human & financial
      man and animal health delivery systems.                   resources.

   6. Controlling public access to prescription            Long term investment and research needs
      only antimicrobials at the point of the phar-           • Innovative diagnostic tools especially AMR
      macy and veterinary medicine general dealers              rapid diagnostic tools (RDT’s)
      (VMGDs).
                                                              • User-friendly and affordable vaccines and
   7. Strengthening regulations to ensure appropri-             new vaccines
      ate use of antimicrobials in animals.
                                                              • New medicines, i.e. antibiotics
   8. Promoting stewardship and pharmacovigi-
      lance in the use of antimicrobials.                     • Alternative therapies (complementary medi-
                                                                cines, probiotics, etc.)
   The activities to achieve these strategic objec-
     tives are described in more detail in the opera-      Specific objectives for Investment, Research &
     tional plan in section 3.                             development are:
                                                              1. To ensure sustainable investment in counter-
                                                                 ing AMR through implementing the NAP.
4.1.5 Strategic Objective 5 – Sustainable
Investment into AMR interventions and                         2. Develop innovate modern diagnostics, vac-
research into new antimicrobials and                             cine and alternative therapy to AM.
alternatives to antimicrobials
                                                           The interventions to achieve these strategic objec-
There is a need to develop the economic case for sus-      tives are provided in the tables below and described
tainable investment that takes into account the need for   in more detail in the operational plan in section 3.
increased investment in new diagnostic tools, vaccines,
medicines and other interventions. The proposed ac-
tivities are divided into short-term (1-2years), medium-
term (2-5 years) and long-term (>5 years) research
strategies. This plan outlines the immediate actions,

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5.0 OPERATIONAL PLANS

Below are the detailed operational activities, time frames and indicators for monitoring the achievement of the
strategic objectives described above in the strategic plan. Time frames for completion of these activities have been
divided into short term (within the next 2 years), medium term (within the next 5 years) and long term (greater
than 5 years).

5.1 Strategic objective 1 – Education, training and awareness
The four key pillars of the strategy are:

    • Surveillance of AMR and AMU patterns in animals, humans and crops.

    • Prevention, which will reduce the need for antimicrobials through effective IPC, farm biosecurity and good
      farm practices, WASH and immunisation

    • Rational antimicrobial use, which seeks to improve controlled access to antimicrobials and to optimise
      responsible use in animals and humans

    • Investment in research and development which seeks innovative ideas of alternatives to antimicrobials or
      quicker diagnostic techniques.

Finally, the implementation of the Zimbabwe NAP depicts a strong inter-sectoral coordinating mechanism as
its foundation and has its roof which is overarching and cross-cutting indicating the need to raise awareness
and educate the public, professionals and policy makers on AMR and responsible antimicrobial use. The
Coordinating mechanism will ensure that all these strategies are implemented.

STRATEGIC OBJECTIVE: To improve awareness and understanding of AMR for the public, professionals and policy
makers
Intervention             Activities                                                             Responsibility    Timeframe
1.1 Develop a            1.1.1 Review existing communication and awareness strategies.          TWG               1st year
comprehensive national   1.1.2 Carry out an assessment on existing KAP (knowledge               representatives
communication and        attitudes and practices) with animal keepers, farmers and veterinary
awareness plan           extension workers in rural communities, key-informant interviews.
                         1.1.3 Utilise results from the existing KAP and additional KAP
                         including the national AMR situational analysis to inform on gaps
                         and areas of strengthening.
                         1.1.4 Draft a national communication and awareness plan to cover
                         topics including: AMR, AMU, IPC, biosecurity and animal health
                         management, food security and safety, WASH and hand washing,
                         stewardship, prescribing and treatment guidelines/practices,
                         enforcement, waste disposal, surveillance, residues, and testing
                         methods for humans and animals using various channels.
                         1.1.5 Pilot draft national communication and awareness plan in
                         small cohorts.
                         1.1.6 Adjust national communication and awareness plan based on
                         the results of pilot study.
                         1.1.7 Validation meeting to adopt final national communication
                         and awareness plan.

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1.2. Roll-out of            1.2.1 Host a stakeholder sensitisation meeting on the approved          Fluoroquinolone 1st – 2nd
the national AMR            plan (i.e. ministries of health, agriculture, environment, education,   AMR core group, year
communication and           drug authority, media, enforcement, farmer organizations,               MoHCC, TWG’s
awareness plan              professional associations, clinicians, nurses, pharmacists), hospital
                            CEOs/associations, university heads, FAO WHO, OIE, NGOs, faith
                            based organizations, provincial reps).
                            1.2.2 Review existing and produce Information, Education and
                            Communication (IEC) materials.
                            1.2.3 Training of trainers (in-service training).
                            1.2.4 Cascading of training to frontline cadres (nurses and
                            extension staff - veterinary).
                            1.2.5 Disseminating AMR information as identified in the
                            communications plan (will include stewardship, IPC, good practices,
                            animal health management, biosecurity, food safety etc) (channels
                            include online, newspaper, radio, television, fliers, road shows,
                            etc.) (target audiences i.e public, students, health professionals,
                            regulators).
                            1.2.6 Engage Civil Society Organisations (CSOs) and development
                            partners to mainstream AMR into programmes.
                            1.2.7 Use of champions in influencing AMR activities and attitudes
                            in all relevant sectors (see champion creation below).
                            1.2.8 Organise activities for World Antimicrobial Resistance
                            Awareness Week.
                            1.2.9 Presentations on AMR during other commemorative days e.g,
                            world TB day, hand hygiene day, World Veterinary Day, etc.

1.3. Identify and           1.3.1 Establish criteria to select AMR champions and specify role of    AMR core group;   2nd year
capacitate opinion          the champions.                                                          TWGs
leaders to champion
                            1.3.2 Identification of AMR champions/opinion leaders.
the AMR agenda in all
sectors.                    1.3.3 Capacitation of AMR champions and consensus building.

1.4. Advocate on IPC        1.4.1 Hold field days to promote good hygiene practices and             MoHCC             Ongoing
in human health,            sanitary measures.
and good animal
                            1.4.2 Hold meetings at the community level e.g. women’s groups,
health management
                            church organisations, farmer groups.
and biosecurity at
community level.            1.4.3 Train Village Health workers in IPC and AMR; and train para
                            veterinary auxiliaries in biosecurity and AMR.

1.5. Promote                1.5.1 Run education and awareness campaigns.                            MoHCC and         Ongoing
behavioural change                                                                                  relevant
                            1.5.2 Commemorate hand hygiene days.
and practices that instil                                                                           authorities
good hygiene in the         1.5.3 Mobilise resources for WASH facilities and activities.
community through
access to effective
water, sanitation and
hygiene facilities.

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STRATEGIC OBJECTIVE: To strengthen the knowledge of human, animal, environment health professionals and feed
manufacturers through improved curricula and educate farmers on AMR to support good prescribing practices
Intervention                Activities                                                             Responsibility    Timeframe
1.6 Strengthen curricula    1.6.1 Engage stakeholders and advocate for curricula review and        TWG/Core group    1st – 2nd
for human health            update.                                                                supporting        year
professionals (including                                                                           review panels,
                            1.6.2 Review and update tertiary educational curricula on AMR,
doctors, nurses,                                                                                   curricula
                            AMU, IPC, biosecurity, biosafety, WASH, stewardship, prescribing
pharmacists, laboratory                                                                            committees
                            and treatment guidelines, enforcement, surveillance, and lab
scientists, health                                                                                 at universities   1st – 2nd
                            testing for humans and animals.
promotion students,                                                                                and training      year
public health students).    1.6.3 Review and update educational curricula at professional in-      institutions in
                            service training levels for human health to strengthen AMR, AMU,       collaboration
                            IPC, biosecurity, biosafety, WASH, stewardship, prescribing and        with MoHCC
                            treatment guidelines, enforcement, surveillance, and lab testing for
                            humans and animals.
                                                                                                   MoHCC, NBA,
                            1.6.4 Develop training modules in IPC requirements to reduce
                                                                                                   HPA and its
                            transmission of MDRO to be used for training of health workers at
                                                                                                   Councils, Min
                            pre- service and in-service level.
                                                                                                   of Higher
                            1.6.5 Enforce continuous professional development (CPD) on AMR,        and Tertiary
                            AMU, IPC, biosecurity, biosafety, WASH, stewardship, prescribing       Education,
                            and treatment guidelines, enforcement, surveillance, and lab           Vocational
                            testing for humans and animals                                         Traning Schools
                            1.6.6 Formalize and strengthen mentoring and supervisory
                            program for junior doctors in the public sector
                            1.6.7 Formalize and strengthen mentoring and supervisory
                            program for junior pharmacists in the public sector
                            1.6.8 Formalise a training programme for all nurses at primary
                            health-care (PHC) on selection of antimicrobials for use at the
                            facilities
                            1.6.9 Strengthen mentoring and supervisory program for
                            prescribing nurses in the public sector

1.7. Strengthen curricula   1.7.1     Review and update tertiary educational curricula           TWG/Core group
for animal health           AMR, AMU, IPC, good animal health management practices               supporting
professionals.              and biosecurity, WASH, stewardship, prescribing and treatment        review panels,
                            guidelines, enforcement, surveillance and lab testing for humans     curricula        1st – 2nd
                            and animals                                                          committees       year
                                                                                                 at training
                            1.7.2      Review and update educational curricula at professional
                                                                                                 institutions in
                            in-service training levels for animal health to strengthen AMR, AMU,
                                                                                                 collaboration
                            IPC, good animal health management practices, biosecurity, WASH,
                                                                                                 with MoHCC and
                            stewardship, prescribing and treatment guidelines, enforcement,
                                                                                                 MoA, MoHTE
                            surveillance and lab testing for animals                                              Ongoing
                                                                                                 and Vocational
                            1.7.3      Formalize and strengthen mentoring program for junior     Training Schools
                            veterinarians in the public sector
                            1.7.4     Design and integrate AMU and AMR into continuous
                                                                                                   DVS
                            professional development of veterinarians
                            1.7.5     Enforce continuous professional development (CPD)
                            on AMR, AMU, IPC, good animal health management practices,
                            biosecurity, WASH, stewardship, prescribing and treatment
                            guidelines, enforcement, surveillance, and lab testing for animals
                                                                                                   DVS

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