Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023

Fourth p rogress analysis of im p lem entation of antim icrobial resistance action p lans in the W H O South-East A sia Region 2023 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 This fourth progress analysis offers a comprehensive assessment of the implementation status of national action plans on antimicrobial resistance (NAP-AMR) in the WHO South-East Asia Region spanning the period from 2017 to 2022. The analysis encompasses eight crucial focus areas, each evaluated through existing WHO regional indicators designed to monitor AMR progress. Notably, 50% of the 62 indicators have been successfully implemented by Member States of the Region, signifying a positive trend over 2017–2022. However, challenges persist in several key areas. The analysis highlights disparities in the degree of awareness about AMR in countries. It highlights significant activities in aquatic animal health and food safety but only ad hoc training in the human health sector. National AMR surveillance systems are not yet fully integrated or operational in every Member State, posing challenges to informed decision-making. Regulatory frameworks for antimicrobial use and sale vary between countries, and some crucial sectors such as plant production lack monitoring systems. The implementation of infection prevention and control measures and antimicrobial stewardship in health-care settings remains uneven. Progress in research and innovation is distributed among multiple organizations, while several countries lack legislation on AMR in the environmental sector. Finally, while there is notable progress in coordination mechanisms for ‘One Health’ engagement, there are still gaps, particularly in plant health and food production sectors. To address these issues, the report recommends assistance to strengthen NAP-AMR implementation, multisectoral collaboration, data-driven decision-making, innovative research and robust monitoring at both national and subnational levels. 9 789290 210870 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 ISBN: 978-92-9021-087-0 © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Printed in India Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 iii Contents List of tables ...................................................................................................................................v List of figures .................................................................................................................................vi Acknowledgements .......................................................................................................................ix Abbreviations and acronyms ...........................................................................................................x Foreword ..................................................................................................................................... xiii Executive summary ...................................................................................................................... xiv 1. Introduction ......................................................................................................................... 1 The antimicrobial resistance problem in the global and regional context ............................................. 1 The pathways to the Global Action Plan for combating antimicrobial resistance ................................. 2 Tracking Antimicrobial Resistance Country Self-Assessment Survey (TrACSS) ...................................... 3 Aim of the progress analysis ............................................................................................................... 3 2. Methods of the progress analysis ......................................................................................... 4 Survey methodology ........................................................................................................................... 5 Analyses approach .............................................................................................................................. 5 3. Progress of the implementation of the national action plans for antimicrobial resistance .... 12 Overall implementation progress in the SE Asia Region ..................................................................... 14 Focus area 1: National AMR Plan and governance ............................................................................ 15 Focus area 2: Raising awareness ....................................................................................................... 19 Focus area 3: National AMR surveillance systems .............................................................................. 28 Focus area 4: Legislation and community-based surveillance of use/sale of antimicrobial .................. 37 Focus area 5: Infection prevention and control, and antimicrobial stewardship ................................. 42 Focus area 6: Research and innovation ............................................................................................. 46 Focus area 7: Legislation and surveillance for AMR in the environment............................................. 47 Focus area 8: Overarching coordination mechanisms for One Health engagement ........................... 49 4. Programmatic issues and priority actions ............................................................................ 56 Focus area 1: National AMR Plan and governance ............................................................................ 56 Focus area 2: Raising awareness ....................................................................................................... 56 Focus area 3: National AMR surveillance system ............................................................................... 57 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023iv Focus area 4: Rational use of antimicrobials and surveillance of use/sale (community-based) ............ 57 Focus area 5: Infection prevention and control, and antimicrobial stewardship ................................. 58 Focus area 6: Research and innovation ............................................................................................. 58 Focus area 7: Legislation and surveillance for AMR in the environment ........................................... 59 Focus area 8: Overarching coordination mechanisms for One Health engagement ........................... 59 5. Related documents ............................................................................................................. 61 Annexes 1. Focus area and indicators of TrACSS 2016–2022 presented in the fourth progress analysis ............................................................................................ 65 2. Country profiles .................................................................................................................. 70 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 v List of tables Table A List of NAP-AMR in 11 countries of the Region ....................................................12 Table 1.1 Development of the National Action Plan on AMR (indicator 2.3, TRACSS 2022) ..............................................................................16 Table 2.1 Raising awareness and understanding of AMR risks and response (indicator 2.9, TrACSS 2022)* .............................................................................20 Table 2.2 Training and professional education related to AMR in the human health sector (indicator 3.1, TrACSS 2022)* ............................................23 Table 2.3 Training and professional education related to AMR in the veterinary sector (indicator 4.1, TrACSS 2022)* .............................................................................24 Table 2.4 Training and professional education focused on AMR, provided to farming (indicator 5.1, TrACSS 2022)* .............................................................................26 Table 2.5 Progress on strengthening veterinary services (indicator 4.3, TrACSS 2022)* ......27 Table 3.1 National surveillance system for antimicrobial resistance in live terrestrial animals (Indicator 4.7, TrACSS 2022)...................................................31 Table 3.2 National surveillance system for antimicrobial resistance in live aquatic animals (indicator 4.8, TrACSS 2022) ...............................................................................32 Table 3.3 National surveillance system for antimicrobial resistance in food (terrestrial and aquatic animal and plant origin) (indicator 5.3, TrACSS 2022) .....33 Table 3.4 National surveillance system for antimicrobial resistance in humans (indicator 3.3., TrACSS 2022) ..............................................................................34 Table 4.1 National monitoring system for consumption and rational use of antimicrobials in human health (indicator 3.2, TrACSS 2022) ..............................38 Table 5.1 Infection prevention and control in human health care (indicator 3.5, TrACSS 2022) ...............................................................................42 Table 5.2 Good management and hygiene practices to reduce the development and transmission of AMR in food processing (indicator 5.5, TrACSS 2022) ................44 Table 6.1 Examples of publications on AMR research in SE Asia Region countries during the rounds of 2021–2022 ........................................................................46 Table 8.1 Information on the use of data from TrACSS at the country level (indicator 2.4a-b, TrACSS 2022) ..........................................................................53 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023vi List of figures Fig. A A series of activities was conducted to develop the fourth progress analysis of NAP-AMR implementation in the SE Asia Region ...............................................4 Fig. B The median value of countries, level C or above implementation percentage; the number of indicators analysed varies between rounds (16, 34, 24, and 28 for the 2017, 2019, 2021, and 2022 rounds respectively). .............................14 Fig. C Proportion of indicators with implementation level C or above in each country from 2016 to 2022. Note: the number of indicators analysed varies between rounds (16, 34, 24, and 28 for the rounds of 2017, 2019, 2021, and 2022 respectively). Please refer to the definition of implementation level C in the Methods section. ............................................................................15 Fig. 1.1 Number of countries that developed NAPs on AMR, with level C and above (indicator 2.3, TrACSS 2022) ...............................................................................15 Fig. 1.2 Number of countries with NAP-AMR linked to any other existing action plans, strategies or targets (indicator 2.6, TrACSS 2022) ..............................................17 Fig. 1.3 Linkage between NAP-AMR and existing action plans, strategies, and targets (indicator 2.6, TrACSS 2022) ...............................................................................18 Fig. 1.4 The number of countries perceiving the impact of the COVID-19 pandemic on NAP-AMR implementation (indicator 2.7, TrACSS 2022) ......................................19 Fig. 2.1 Number of countries that have been conducting campaigns related to raising awareness and understanding of AMR risks and responses in relevant fields; comparisons between the years of 2019 and 2022 (indicator 2.9, TrACSS 2022) ...............................................................................21 Fig. 2.2 Number of countries in the SE Asia Region with progress on training and professional education, level C or above for human health (indicator 3.1, TrACSS 2022), animal health (indicator 4.1, TrACSS 2022), food and environment (indicator 5.1, TrACSS 2022) between 2017 and 2022 ....23 Fig. 2.3 Number of countries with progress on strengthening veterinary services, level C or above (indicator 4.3, TrACSS 2022) .....................................................27 Fig. 3.1 Number of countries with progression level C or above in usage of resistance surveillance data for decision-making (indicator 2.12, TrACSS 2022) and implementation of integrated surveillance system (indicator 2.13, TrACSS 2022) in 2022 ................................................................28 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 vii Fig. 3.2 Number of countries with capacity to perform AST for critically important bacteria and bacteria type assessed (TrACSS indicator 3.4.2, TrACSS 2022) ........29 Fig. 3.3 Number of SE Asia Region countries that reached level C and above in the national surveillance system for antimicrobial resistance in humans, using relevant antimicrobial consumption/use data to inform operational decision-making and amend policies for human health; comparison between 2017 and 2022 (indicator 3.3, TrACSS 2022) .......................................34 Fig. 3.4 Number of countries with effective integration (indicator 5.4a, TrACSS 2022), standardization and harmonization of procedure (indicator 5.4b, TrACSS 2022), relevance of diagnostic technique (indicator 5.4c, TrACSS 2022), and network data management (indicator 5.4d) at laboratories for AMR surveillance with progress level C or above between 2019 and 2022 .............................................35 Fig. 4.1 Number of SE Asia Region countries, with implementation level C and above, in national monitoring systems for consumption and rational use of antimicrobials in human health (indicator 3.2, TrACSS 2022). .............................37 Fig. 4.2 Number of SE Asia Region countries with implementation level C and above in optimizing antimicrobial use in human health (indicator 3.6, TrACSS 2022) ....39 Fig. 4.3 Number of SE Asia Region countries with implementation level C or above in “AWaRe” classification of antibiotics* in the National Essential Medicines List; comparison from 2020–2022 (indicator 3.7, TrACSS 2022) .................................40 Fig. 4.4 Number of SE Asia Region countries that have regulations on prescription and sale of antimicrobials for human use (indicator 2.8.1, TrACSS 2022), prescription and sale of antimicrobials for animal use (indicator 2.8.2, TrACSS 2022), use of antibiotics for growth promotion in terrestrial animals in the absence of risk analysis (indicator 2.8.5, TrACSS 2022), use of applicable pesticides with antimicrobial effects, such as bactericides and fungicides, used in plant production (indicator 2.8.6, TrACSS 2022) between 2019 and 2022 .....................................................................................41 Fig. 5.1 Number of SE Asia Region countries with implementation level C and above in infection prevention and control in human health care; comparison from 2017–2022 (indicator 3.5, TrACSS 2022) ...................................................43 Fig. 5.2 Number of SE Asia Region countries with implementation level C or above in good management and hygiene practices to reduce the development and transmission of AMR in food processing; comparison in 2019, 2021, and 2022 (indicator 5.5, TrACSS 2022) ...............................................................44 Fig. 5.3 Number of SE Asia Region countries with implementation level C or above in biosecurity and good animal husbandry practices to reduce the use of antimicrobials and minimize the development and transmission of AMR in terrestrial and aquatic animal production (indicators 4.9 and 4.10, TrACSS 2022) ...............................................................45 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023viii Fig. 7.1 Number of SE Asia Region countries that have legislation and/or regulations to prevent contamination of the environment with antimicrobials – antimicrobial compounds and their metabolites discharged to the environment (indicator 6.2, TrACSS 2022) ..............................48 Fig. 7.2 Number of SE Asia Region countries that have legislation and/or regulations to prevent contamination of the environment with antimicrobials – antimicrobial compounds and their metabolites discharged to the environment, new indicator in 2022 (indicator 6.2, TrACSS 2022) ...............................................................................48 Fig. 8.1 Number of SE Asia Region countries with implementation level C and above (2017–2022) in multisectoral and One Health collaboration/coordination (indicator 2.1, TrACSS 2022) ...............................................................................49 Fig. 8.2 Number of SE Asia Region countries with programmes for monitoring and evaluation of national AMR action plans (indicator 2.3b–g, TrACSS 2022) .........50 Fig. 8.3 Number of SE Asia Region countries that are actively involved in developing and implementing the AMR National Action Plan ................................................51 Fig. 8.4a Number of SE Asia Region countries deploying consumption/use data to inform operational decision-making and amend policies in relevant fields; comparisons in 2022 (indicator 2.11, TrACSS 2022) ............................................54 Fig. 8.4b Number of SE Asia Region countries utilizing consumption/use data to inform operational decision-making and amend policies in relevant fields; comparisons between 2020 and 2022 ................................................................55 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 ix Acknowledgements The WHO Regional Office for South-East Asia extends its sincere gratitude and appreciation to colleagues in the countries of the Region – Bangladesh, Bhutan, Democratic People’s Republic of Korea (DPR Korea), India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste – encompassing various fields, such as human health, animal health, plant health, agriculture and the environment, for their unwavering commitment to addressing antimicrobial resistance (AMR) through the implementation of national action plans (NAPs). We would also like to thank the AMR focal points at the WHO country offices in the Region who, in collaboration and coordination with colleagues from the country offices of the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (WOAH), and the United Nations Environment Programme (UNEP), provided ministries with continuous support to address the multifaceted challenges posed by AMR, including monitoring the progress of the implementation of NAPs through the Tracking AMR Country Self-Assessment Survey (TrACSS). We would also like to acknowledge the exceptional efforts made by our colleagues from relevant units at the WHO Regional Office as well as at WHO headquarters for their comprehensive reviews of and valuable feedback for this fourth progress analysis. Together, we can continue to safeguard the efficacy of antimicrobials and preserve their potential for saving the lives of future generations. This document was edited and designed by the Reports and Documentation Unit in the Regional Office. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023x Abbreviations and acronyms AMR antimicrobial resistance AMS antimicrobial stewardship API active pharmaceutical ingredients ARGs antimicrobial resistance genes AST antimicrobial susceptibility testing CPD continuing professional development EQA external quality assurance ESBL extended-spectrum β-lactamase FAO Food and Agriculture Organization of the United Nations FSS food safety strategy and policies GAP-AMR Global Action Plan on Antimicrobial Resistance GMP good manufacturing practices GHP good hygiene practices HS health security IPC infection prevention and control M&E monitoring and evaluation MRL maximum residue limit NAP national action plan(s) NAP-AMR National Action Plan for Antimicrobial Resistance NTD neglected tropical diseases OHS One Health strategy PVS performance of veterinary services SDGs Sustainable Development Goals STIs sexually transmitted infections TB tuberculosis TrACSS Tracking Antimicrobial Resistance Country Self-Assessment Survey Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 xi UNEP United Nations Environment Programme UNSCDF United Nations Sustainable Cooperation Development Framework WASH water, sanitation and hygiene WHO World Health Organization WOAH World Organisation for Animal Health WHO-SEARO WHO Regional Office for South-East Asia Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023xii Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 xiii Foreword Antimicrobial resistance (AMR) is a global health threat with devastating consequences for the efficacy of essential medicines and the ability to treat infectious diseases. Globally, AMR is directly responsible for approximately 1.27 million deaths per year, of which 389 000 are reported from the South Asia. Unless urgent action is taken, 10 million deaths are projected to occur every year globally, with a cumulative loss of US$ 100 trillion to the global economy by 2050. The WHO South-East Asia Region is particularly vulnerable to AMR due to high population density, limited access to health-care services, and the misuse and overuse of antimicrobials. However, since 2014 preventing and combating AMR has been a Flagship Priority Programme of the Region, with strong progress to show. Since 2018 all Member States have been implementing national action plans to address AMR, and each Member State has established a multisectoral working group or coordination committee on AMR. Most Member States continue to implement national monitoring systems for resistance pathogens and antimicrobial consumption, and all Member States are enrolled in the Global Antimicrobial Resistance Surveillance System (GLASS) for AMR. The South-East Asia Region is also the only WHO Region in which all countries carry out annual self-assessment surveys. I am pleased to present this Fourth Progress Analysis of implementation of national action plans (NAPs) for AMR that will take stock of and monitor progress, and also identify and address ongoing gaps. The Progress Analysis provides a comprehensive assessment of the growing threat posed by AMR in the Region and aims to support country progress by determining top priorities for follow-up action. The Progress Analysis shows that, overall, Member States have implemented 50% of the 62 indicators, and that there has been an increase in the number of countries where the national action plan for AMR is linked to at least one other national action plan, strategy or target. Though the Progress Analysis shows remarkable advancements, it also highlights several key areas for improvement, including the need to develop and operationalize the guidelines, standards and regulations contained in NAPs; increase multisectoral participation in implementing NAPs; enhance the use of AMR and AMC surveillance data for enhanced decision-making; strengthen research and innovation; and accelerate NAP implementation and monitoring at the subnational level. I urge all stakeholders to appropriately leverage this report, building on the Region’s tremendous momentum in tackling this global health threat. And I also express my utmost gratitude to contributing partners, including the Food and Agriculture Organization of the United Nations, the United Nations Environment Programme, and the World Organisation for Animal Health. Together, let us ensure our most precious drugs remain fit for purpose forever more. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023xiv Executive summary This in-depth fourth progress analysis provides the status of the NAP-AMR implementation in the WHO South-East Asia Region, covering the period 2017 to 2022. It is compared with the earlier status, using data from the Tracking Antimicrobial Resistance Country Self-Assessment Survey (TrACSS) and additional relevant information. The analysis is presented on the basis of eight focus areas and existing indicators of the WHO-SEARO tool for monitoring AMR, including (i) National AMR Plan and governance; (ii) raising awareness; (iii) national AMR surveillance system; (iv) rational use of antimicrobials and surveillance of use/sale (community-based); (v) infection prevention and control (IPC), and antimicrobial stewardship (AMS); (vi) research and innovation; (vii) legislation and surveillance for AMR in the environment; and (viii) overarching coordination mechanisms for One Health engagement. Overall, 50% of the 62 indicators have been implemented by SE Asia Region Member States. During 2017–2021, an increasing trend has been noted, particularly in eight SE Asia Region Member States. The overall status of the NAP-AMR implementation per focus area is as follows: (i) National AMR Plan and governance: Significant progress with regard to the number of countries that developed or updated NAP-AMR has been shown. There are, however, issues concerning the quality of NAP development and operationalization. There is progress on the number of countries reporting linkage of NAP-AMR with at least one other national action plan/strategy/target. However, there is lack of data on specific diseases/ health initiative targets that are linked with the NAP-AMR. Countries have reported that the COVID-19 pandemic has negatively impacted the governance, administrative, and operational processes of NAP-AMR in most countries. (ii) Raising awareness: Significant activities to raise awareness have been reported from the fields of aquatic animal health and food safety. However, AMR training in the human health sector is still being conducted on an ad hoc basis in most of the SE Asia Region countries. The relevant training in the animal health sector is still limited to educational institutions. Implementation of training and education programmes on environment, food production, food safety, and veterinary services is lagging behind in other sectors. (iii) National AMR surveillance system: Not all countries of the Region have resistance surveillance data that are used to inform decision-making and not all have established or started implementing integrated surveillance system for antimicrobial resistance. There is a general issue with integrating most of the laboratories into the national AMR surveillance system. The issue of reporting on laboratory integration and capacities is also apparent in countries, such as Maldives and Timor-Leste. (iv) Regulation and community-based surveillance of rational use/sale of antimicrobials: There is variation between countries that are reporting having legislation on prescription and sale of antimicrobials and those with the ability to monitor prescription/sale, especially in the sector of plant production. A significant number of countries do not report relevant indicators, which may result in misleading information, if not interpreted carefully. National AMR containment policies and regulatory frameworks for control and Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 xv registration of use of animals with regard to aquatic animals are still lagging behind those pertaining to terrestrial animals. The involvement of plant health, food production, food safety, and environment needs to be increased to inform operational decision-making and amend policies. There is lack of national legislation and a national monitoring system for antimicrobial pesticides in plant production. (v) Infection prevention and control (IPC), and antimicrobial stewardship (AMS): Although most of the countries have national IPC programmes, their implementation in health-care settings is still uneven, with only selected health-care settings implementing the IPC programmes. Lack of progress on the implementation for IPC in human health care was also reported. The implementation of good food production and hygiene practices to reduce the development and transmission of AMR in food processing and animal husbandry leaves a lot to be desired. (vi) Research and innovation: AMR-related research and innovation may have been carried out, but they are dispersed across several organizations. (vii) Legislation and surveillance for AMR in the environment: More than half of the countries of the Region did not have available data, related to the national assessment of risk in 17 sectors, relevant to human, animal, and plant health. Several countries have still not established any legislation for contamination. Passive surveillance of antimicrobial- related residues in water remains limited; it is needed. (viii) Overarching coordination mechanisms for One Health engagement: There is progress in the countries on reported coordination mechanisms for One Health engagement. Limited progress is reported by the Member States insofar as One Health engagement in plant health and food production is concerned. Monitoring of antimicrobial consumption/use data in plant health and environment has also not made notable progress. The programmatic issues mentioned above should be addressed by (i) providing assistance to the countries for strengthening NAP-AMR implementation through development and further operationalization of guidelines, standards, and regulations; (ii) encouraging and facilitating multisectoral involvement in the implementation of NAP-AMR by establishing and operating forums relevant to AMR containment at national and subnational levels; (iii) ensuring use of AMR and AMC surveillance data for decision-making; (iv) strengthening research and innovation in AMR fields; and (v) continuing the monitoring of NAP-AMR implementation at the country level and encouraging the country to implement NAP-AMR monitoring at the subnational level.

Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 1 1 Introduction The antimicrobial resistance problem in the global and regional context Antimicrobial resistance (AMR) has been highlighted as a major issue for human health. A comprehensive modelling study in 2019 estimated that the bacterial AMR problem was associated with 4.95 (95% CI 3.62–6.57) million deaths. About two out of three deaths due to bacterial infections are associated with AMR (8.88 million deaths from bacterial infections and 4.95 million deaths associated with resistance). AMR problems were cropping up in all regions, including South-East Asia. In 2019, sepsis was either the immediate cause of death or a contributing factor in 1.13 million deaths in the Region. Notably 68% of this sepsis was caused by bacterial infection. Mortality, caused by bacteria with antimicrobial resistance, was estimated to be between 96 981 and 369 343.1 The most prominent types of bacterial resistance, recorded in this Region, include fluoroquinolone-resistant Escherichia coli, third-generation cephalosporin-resistant Escherichia coli, and Klebsiella pneumonia. In South-East Asia, East Asia and Oceania Regions, 47.2 per 100 000 deaths, associated with resistance, and 11.7 per 100 000 deaths, attributable to resistance, are recorded.2 The COVID-19 pandemic can potentially change the AMR landscape. The problem occurs due to changes in antimicrobial use, related to COVID-19 treatment, infection control, and implementation and health systems context.1 The overload due to COVID-19 morbidity at health-care facilities can increase the risk of health care-associated infections and transmission of resistant microbial agents. During the early pandemic period, there was misinformation about the use of antimicrobials for COVID-19 patients, with an unclear basis of recommendation for the use of antimicrobials. It was estimated that up to 60% of COVID-19 patients were prescribed antimicrobial drugs. However, the COVID-19 pandemic can also be an opportunity to ensure better AMR control practice and policy due to the change in infection control behaviour and implementation of mass vaccination to control infectious diseases.3 1 Antimicrobial resistance (AMR) | Institute for Health Metrics and Evaluation (healthdata.org) 2 Knight GM, Glover RE, McQuaid CF, Olaru ID, Gallandat K, Leclerc QJ, Fuller NM, Willcocks SJ, Hasan R, van Kleef E, Chandler CI. Antimicrobial resistance and COVID-19: Intersections and implications. Elife. 2021 Feb 16;10: e64139. doi: 10.7554/eLife.64139. 3 Choudhury S, Medina-Lara A, Smith R. Antimicrobial resistance and the COVID-19 pandemic. Bull World Health Organ. 2022 May 1;100(5):295-295A. doi: 10.2471/BLT.21.287752. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20232 Nevertheless, coherent actions to control AMR are essential and need to be implemented at global, regional, and national levels. Efforts are being made to ensure political will for addressing AMR problems. The G20 High-Level Meeting in 2022 highlighted the AMR issues in Call to Action to G20 Leaders, Health and Finance Ministers; it discussed the collaborative actions needed to address AMR, including surveillance system strengthening and reaffirmed commitment to implementing the AMR National Action Plan. The G20 meeting also addressed the essential collaboration between the United Nations Secretary-General and other agencies for advancing antimicrobial stewardship through the One Health approach. The pathways to the Global Action Plan for combating antimicrobial resistance Actions to address AMR were first stated during the World Health Assembly (WHA51.17) in 1998. The message was reinforced in 2005 as a global public health movement. The commitment was enshrined in the World Health Assembly resolutions WHA58.27, WHA67.25, WHA68.7, WHA71.3, WHA72.5 and UNGA resolution 71/3. Based on the document, an initiative to address the AMR issue in the South-East Asia Region was flagged in 2010 with the launch of the Regional Strategy on Prevention and Containment of Antimicrobial Resistance 2010–2015.4 During 2010–2014, the milestones highlighting the action for combatting AMR included the Jaipur Declaration on AMR by 11 SE Asia Region health ministers and the Flagship Priority Programme. On 26 May 2015, the Sixty- eighth World Health Assembly launched the Global Action Plan to combat AMR (GAP-AMR),5 the chief objective of which is to ensure treatment and prevention of infectious diseases with quality-assured, safe, and effective medicines. The objectives of the GAP-AMR are to: € improve awareness and understanding of antimicrobial resistance through effective communication, education, and training; € strengthen the knowledge and evidence base through surveillance and research; € reduce the incidence of infection through effective sanitation, hygiene, and infection prevention measures; € optimize the use of antimicrobial medicines in human and animal health; and € develop the economic case for sustainable investment that takes into account the needs of all countries and increase investment in new medicines, diagnostic tools, vaccines, and other interventions. In 2016, the GAP-AMR was converted into a National Action Plan (NAP) in many countries, including in the South-East Asia Region. In the same year, all countries made efforts to mobilize resources for implementing the NAP.6 In the SE Asia Region, the commitment of countries to developing 4 World Health Organization. Regional Office for South-East Asia. (2010). Regional strategy on prevention and containment of antimicrobial resistance 2010–2015. 5 https://www.google.com/url?q=https://cdn.who.int/media/docs/default-source/antimicrobial-resistance/amr-spc- sel-glass/a68-r7-en.pdf?sfvrsn%3Dfa7f3dde_2&sa=D&source=docs&ust=1674095183262169&usg=AOvVaw3gY- boipzzfrkH0paYmirl. 6 World Health Organization. Regional Office for South-East Asia. (2019). Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018: An update on two years implementation of national action plans. World Health Organization. Regional Office for South-East Asia. https://apps.who.int/iris/handle/10665/327117. Licence: CC BY- NC-SA 3.0 IGO. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 3 NAPs had been emphasized during the Sixty-eighth Session of the WHO Regional Committee for South- East Asia, held in Dili in 2015, followed by the Sixty-ninth Session of the WHO Regional Committee for South-East Asia, held in Sri Lanka in 2016. All recent NAPs are available in the WHO repository.7 Tracking Antimicrobial Resistance Country Self-Assessment Survey (TrACSS) To monitor the implementation of GAP at the country level, in 2017, Tripartite institutions, consisting of WHO, FAO, WOAH, and UNEP, co-developed a framework and recommended indicators for the monitoring and evaluation (M&E) of GAP. The M&E framework included several indicators from TrACSS, which is a mechanism to monitor and evaluate the implementation of GAP at the country level. There are focus areas of monitoring with indicators for each area of TrACSS (Annex 1). Till 2022, there have been six rounds of TrACSS.8 During these TrACSS rounds, there have been some changes related to focus areas and indicators. The details of indicators per focus area are presented in Annex 1. In the fourth progress analysis, the results of the sixth round of TrACSS are included. Aim of the progress analysis The sixth round of TrACSS in 2022 has been agreed upon as the first global-level instrument for monitoring the implementation of GAP-AMR; it has been approved by relevant multisectoral parties. The instrument covers comprehensive indicators, with some additions to the indicators from the previous rounds of TrACSS. Overall, the fourth progress analysis describes in detail the status of the implementation of NAPs in the Region till 2022. Using the findings from TrACSS and other relevant sources, programmatic issues and priority actions are synthesized. This document can be used for intersectoral discussions in the SE Asia Region for better AMR policies and programmes. 7 https://www.who.int/teams/surveillance-prevention-control-AMR/national-action-plan-monitoring-evaluation/library-of- national-action-plans. 8 See: http://www.who.int/antimicrobial-resistance/global-action-plan/database/en/. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20234 2 Methods of the progress analysis The fourth progress analysis of NAP-AMR implementation in the Region was developed through mechanisms, as presented in Fig. A. The analysis was developed through these mechanisms: (1) a briefing meeting of the core WHO-SEARO team with the consultant; (2) concept note development by the consultant with feedback from the WHO-SEARO core team; (3) document review; (4) step-wise consultation meetings; and (5) finalization and plan for dissemination. Fig. A. A series of activities was conducted to develop the fourth progress analysis of NAP-AMR implementation in the SE Asia Region Core team Concept note Document/scoping review Consultation meeting – Chapter 1&2 Data analysis Consultation meeting – Chapter 3 Completing all parts of document Consultation meeting Dissemination The objectives of the fourth progress analysis are as follows: (1) Identify programmatic issues at the country level in NAP implementation and how those affect the health-related Sustainable Development Goals (SDGs) including the AMR-related indicators. (2) Identify priority actions or practical interventions for implementation in the light of the progress made for human health and from a One Health perspective. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 5 (3) Describe the progress on the implementation of NAPs regarding AMR in figures and graphs that transform data into actionable insights and information. (4) Support advocacy related to and dissemination of TrACSS. (5) Assess the opportunities to inform decision-makers about the potentially successful practical interventions for addressing AMR. Survey methodology This report focuses on analysing TrACSS data in the South-East Asian Region for 2021/2022 while also providing insights into the progress of TrACSS from 2017 to 2022. All WHO Member States in the Region participated in the four rounds of surveys that have been conducted with 100% response rate. TrACSS assesses national capacity and progress on a five-point scale (A to E), with levels A–B representing limited capacity and levels C–E representing nationwide implementation for most indicators. Countries should be aiming to reach level C–E on all indicators. Therefore, we used level C as a milestone for progress monitoring, following suggestions from the TrACSS country report (see 2022 TrACSS countries report). The response rates for each survey question varied as some countries were able to provide data from more sectors, compared with others; “no response” was treated as its own category throughout the analysis. The TrACSS instrument was composed of 10 questions, which aimed to evaluate the progress, related to GAP-AMR objectives. These involve: 1) improving awareness and understanding of antimicrobial resistance through effective communication, education, and training; 2) strengthening the knowledge and evidence base through surveillance and research; 3) reducing the incidence of infection through effective sanitation, hygiene, and infection prevention measures; and 4) optimizing the use of antimicrobial medicines in human and animal health. The TrACSS questionnaire was completed through self-assessment at the country level. The questionnaire was sent to country offices and AMR focal points at the Ministry of Health for each country by the WHO Regional Offices. One official response was submitted by each country through a unique link to avoid multiple responses from individual countries and was validated by all sectors involved. Therefore, the responses can summarize the national progress on AMR within each country. The TrACSS survey database is available at https://www.who.int/activities/monitoring-progress-antimicrobial-resistance. Analyses approach The analyses were conducted by mapping indicators, based on focus areas. There are eight focus areas: € Focus area 1: National AMR Plan and governance; € Focus area 2: Raising awareness; € Focus area 3: National AMR surveillance systems; € Focus area 4: Rational use of antimicrobials and surveillance of use/sale (community-based); € Focus area 5: Infection prevention and control, and antimicrobial stewardship; € Focus area 6: Research and innovation; Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20236 € Focus area 7: One Health engagement; and € Focus area 8: Overarching coordination mechanisms for One Health engagement. For each indicator, descriptive analyses of implementation were conducted in 2022. For each item, the progress was generally categorized into five levels: levels A, B, C, D, and E. For analyses of proportion, we further categorized the progress of each country into two groups: those achieving level C and above, and those below level C. For several indicators, level C is considered one of the most important milestones to initiate implementation at the national level. Each level is further described in each indicator listed. For this fourth progress analysis, there are 62 indicators, with 28 indicators having five different levels of implementation (levels A through E) and 34 indicators representing yes/ no questions. For focus area 6, involving research and innovation, we conducted literature search in PubMed for published studies from all Member States in the Region from 2021 to 2022. We used the combination of the keywords, “antimicrobial” and each country name, and its synonym, such as antibacterial, antibiotic, antifungal, antiviral, etc. for a formative search in the PubMed database. In the fourth progress analysis, we also track the progress of implementation right from the first TrACSS. In 2015–2016, through 2017–2018, one instrument was used: WHO-SEARO tool. However, in the fourth progress analysis, we include only the TrACSS indicators in analysing the progress for the countries of the Region and for each Member country. We also provided information on the individual country’s progress for selected indicators. There were 12 indicators that we included for country progress, representing all eight focus areas. The 12 indicators were chosen on the basis of the representativeness of the focus areas as well as the limited progress that had been made in the TrACSS rounds (Annex 2). Attached below is the complete list of questions included in each focus area. Focus area Level of implementation Focus area 1: NAP alignment with GAP-AMR Country progress with the development of a NAP-AMR C – National AMR action plan approved by the government and is being implemented Country updating the expired national AMR action plan Yes/No Country planning on AMR integrated with other existing action plans or strategies, related to the One Health strategy or the One Health mechanism, WASH, National Health Sector Plan, National Action Plan on Health Security, climate change and environmental planning, national development plans, national food safety strategy, others Yes/No Effect of the COVID-19 pandemic and the national response in the country to the NAP-AMR development and implementation process Yes/No Focus area 2: Awareness raising Raising awareness and understanding of AMR risks and response (human health, animal health, plant health, food production, food safety, environment) C – Limited or small-scale, some antimicrobial resistance awareness campaign activities at the local and/or subnational level about risks of antimicrobial resistance and actions to address it, targeting some but not all relevant stakeholders, based on stakeholder analysis Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 7 Focus area Level of implementation Training and professional education regarding AMR in the human health sector C – AMR is covered in 1) some pre-service training and in 2) some in-service training or other continuing professional development (CPD) for human health workers Training and professional education regarding AMR in the veterinary sector C – AMR and prudent use of antimicrobial agents are covered in the core curricula for graduating veterinarians and for veterinary paraprofessionals in some educational institutions Training and professional education regarding AMR in the aquatic animal health sector C – AMR and prudent use of antimicrobial agents are covered in the core curricula for graduating aquatic animal health professionals in some educational institutions Training and professional education regarding AMR in the farming/agriculture sector C – Tailored ad hoc AMR training courses are available for all or the majority of key stakeholders Progress with strengthening veterinary services C – Implementation of plan to strengthen capacity gaps in veterinary services underway Progress with strengthening the aquatic animal health sector C – Implementation of plan to strengthen capacity gaps in aquatic animal health services underway Focus area 3: National AMR surveillance systems Countries using relevant antimicrobial consumption/use data to inform operational decision-making and amend policies Yes/No Countries using relevant antimicrobial resistance surveillance data to inform operational decision-making and amend policies Yes/No Countries that established or started the implementation of an integrated surveillance system for antimicrobial resistance Yes/No National surveillance system for AMR in humans C – AMR data are collated nationally for common bacterial infections in hospitalized and community patients, but national coordination and standardization are lacking Capacity to perform antimicrobial susceptibility testing (AST) for critically important bacteria C – No, the country does not have a reference laboratory/laboratories performing susceptibility testing for any of the bacteria Capacity to perform AST for critically important fungi C – Yes for both Candida and Aspergillus Continuity of services for clinical bacteriology laboratories C – No, each bacteriology laboratory manages stockout without compulsory reporting Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20238 Focus area Level of implementation Standardized AST guidelines C – Only the National Bacteriology Reference Laboratory (NBRL) uses standardized AST guidelines External quality-assured bacteriology laboratory services C – EQA is compulsory and/or implemented only at the National Bacteriology Reference Laboratory Countries that have developed a national list of essential in- vitro diagnostics that includes all essential AMR diagnostics C – The country has NOT developed the national list of essential in-vitro diagnostics yet Countries that submitted antimicrobial use (AMU) data to the WOAH database on antimicrobial agents intended for use in animals Yes/No WOAH reporting options for the antimicrobial use database C – WOAH reporting option 2, on a regular basis, data is collected and reported to the OIE on the overall amount sold for use/used in animals by antimicrobial class, with the possibility to separate by type of use and animal group National surveillance system for antimicrobial resistance (AMR) in live terrestrial animals C – Some AMR data is collected at local levels, but a nationally standardized approach is not used. National coordination and/or quality management is lacking National surveillance system for antimicrobial resistance (AMR) in live aquatic animals C – Some AMR data is collected at local levels, but a nationally standardized approach is not used. National coordination and/or quality management is lacking National surveillance system for antimicrobial resistance (AMR) in food (terrestrial and aquatic animal, and plant origin) C – Some AMR data is collected – but a standardized approach is not used. National coordination and/or quality management is lacking Effective integration of laboratories in AMR surveillance C – Some laboratories performing AST are integrated in the national AMR surveillance system Level of the standardization and harmonization of procedures among laboratories in the AMR surveillance system C – Between 30% and 79% of laboratories follow the same AST guidelines Relevance of diagnostic techniques used by laboratories included in the AMR surveillance system C – Major modifications in the AST, bacterial isolation and identification protocols used are required to improve their adaptation to national AMR surveillance objectives Technical level of data management of the laboratory network in the AMR surveillance system C – Most laboratories of the network use computers to manage part of their data, but important improvements in the system are required Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 9 Focus area Level of implementation Focus area 4: Rational use of antimicrobials and surveillance of use/sale (community-based) National monitoring system for consumption and rational use of antimicrobial in human health C – Total sales of antimicrobials are monitored at the national level and/or some monitoring of antibiotic use at the subnational level National monitoring systems for antimicrobial intended used in animals (sales/use) C – Yes, aquatic animals only National monitoring systems for pesticide use in plant production, including antimicrobial pesticides, such as bactericides and fungicides C – National plan or system in place to collect data and report on the amount of pesticides sold/used nationally, including antimicrobial pesticides, such as bactericides and fungicides Country has laws and regulations on prescription and sale of antimicrobial use Yes/No Optimizing antimicrobial use in human health C – National guidelines for appropriate use of antimicrobials are available and antimicrobial stewardship programmes are being implemented at some health-care facilities. Adoption of access-watch-reserve (AwaRe) classification of antibiotics in the National Essential Medicines List C – Country has adopted the AWaRe classification of antibiotics in its National Essential Medicines List Optimizing antimicrobial use in terrestrial animal health C – National legislation covers all aspects of national manufacture, import, marketing authorization, control of safety, quality and efficacy, and distribution of antimicrobial products Optimizing antimicrobial use in aquatic animal health C – National legislation covers all aspects of national manufacture, import, marketing authorization, control of safety, quality and efficacy, and distribution of antimicrobial products Optimizing antimicrobial pesticide, such as bactericides and fungicides use in plant production C – National legislation covers all aspects of national manufacture, import, marketing authorization, control of safety, quality and efficacy, and distribution of pesticides, including antimicrobial pesticides, such as bactericides and fungicides Focus area 5: Infection prevention and control, and antimicrobial stewardship Infection prevention and control (IPC) in human health care C – A national IPC programme and an operational plan are available and national guidelines for health care IPC are available and disseminated. Selected health facilities are implementing the guidelines, with monitoring and feedback in place. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202310 Focus area Level of implementation Biosecurity and good animal husbandry practices to reduce the use of antimicrobials and minimize development and transmission of AMR in terrestrial animal production C – National plan agreed to ensure good animal husbandry and biosecurity practices in line with international standards (e.g. OIE Terrestrial Codes, Codex Alimentarius). Nationally agreed guidance for good practices developed, adapted for implementation at local farm and food production levels Biosecurity and good animal husbandry practices to reduce the use of antimicrobials and minimize development and transmission of AMR in aquatic animal production C – National plan agreed to ensure good animal husbandry and biosecurity practices in line with international standards (e.g. OIE Aquatic Code, Codex Alimentarius). Nationally agreed guidance for good practices developed, adapted for implementation at local farm and food production levels Good management and hygiene practices to reduce the development and transmission of AMR in food processing C – National plan agreed to ensure good manufacturing practices (GMP) and good hygiene practices (GHP) in line with international standards (e.g. Codex Alimentarius). Nationally agreed guidance for good practices developed, adapted for implementation, according to local food processing approaches Focus area 6: Research and innovation Publication of AMR-NAP Focus area 7: Legislation and surveillance for AMR in the environment A national assessment of risks for residues of antimicrobial compounds and antimicrobial-resistant pathogens in the environment Yes/No Country has legislation and/or regulations to prevent contamination of the environment with antimicrobials – antimicrobial compounds and their metabolites discharged to the environment Yes/No A system for regular monitoring (passive surveillance) of antimicrobial compounds and their metabolites (or residues) and resistant bacteria or antimicrobial resistance genes (ARGs) in water quality Yes/No Focus area 8: Overarching coordination mechanisms for One Health engagement Multisector and One Health collaboration/coordination C – Formalized multisectoral coordination mechanism with technical working groups, established multisectoral working group(s) is (are) functional, with clear terms of reference, regular meetings, and funding for working group(s) with activities and reporting/accountability arrangements defined Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 11 Focus area Level of implementation A monitoring and evaluation plan for the national AMR action strategies Yes/No Sectors are actively involved in developing and implementing the AMR National Action Plan Yes/No Information on the use of data from TrACSS at the country level Yes/No The country using relevant antimicrobial consumption/use data to inform operational decision-making and amend policies Yes/No Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202312 3 Progress of the implementation of the national action plans for antimicrobial resistance This chapter provides a description of the progress of the NAP implementation at regional and SE Asia Region country levels during 2016–2022. The progress is also presented for each focus area and indicators. A focus area represents a compilation of indicators, belonging to the same theme. It consists of eight areas: (i) National AMR Plan and governance; (ii) raising awareness; (iii) national AMR surveillance system; (iv) rational use of antimicrobials and surveillance of use/sale (community- based); (v) infection prevention and control (IPC), and antimicrobial stewardship; (vi) research and innovation; (vii) legislation and surveillance for AMR in the environment; and (viii) overarching coordination mechanisms for One Health engagement. The existing NAP-AMR in the SE Asia Region countries are presented in Table A. Table A. List of NAP-AMR in 11 countries of the Region Country Existing NAP-AMR Link to the document Bangladesh Bangladesh: Antimicrobial Resistance Containment in Bangladesh 2017–2022 Download Bhutan Bhutan: National Action Plan on Antimicrobial Resistance 2018–2022 Download DPR Korea DPR Korea: National Strategic Plan on Antimicrobial Resistance 2018–2020 Download Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 13 Country Existing NAP-AMR Link to the document India India: National Action Plan on Antimicrobial Resistance (NAP-AMR) 2017–2021 Download Indonesia Indonesia: National Action Plan on Antimicrobial Resistance Indonesia 2017–2019 Indonesia: Second National Action Plan on Antimicrobial Resistance Indonesia 2020–2024 Download Download Maldives Maldives: National Action Plan for Containment of Antimicrobial Resistance 2017–2022 Download Myanmar Myanmar: National Action Plan for Containment of Antimicrobial Resistance 2017–2022 Download Nepal Nepal: National Antimicrobial Resistance Containment Action Plan 2016 Download Sri Lanka Sri Lanka: National Strategic Plan for Combatting Antimicrobial Resistance in Sri Lanka 2017–2022 Download Thailand Thailand: National Strategic Plan on Antimicrobial Resistance 2017–2021 Download Timor-Leste The Democratic Republic of Timor-Leste: National Action Plan on Antimicrobial Resistance 2017– 2020 Download Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202314 The progress analysis will be presented in three domains: (1) overall implementation progress in the SE Asia Region; (2) implementation status per specific focus and indicator, and (3) individual country profiles. Overall implementation progress in the SE Asia Region Fig. B. The median value of countries, level C or above implementation percentage; the number of indicators analysed varies between rounds (16, 34, 24, and 28 for the 2017, 2019, 2021, and 2022 rounds respectively). 25.00% 29.41% 58.33% 50.00% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2017 2019 2021 2022 Pe rc en ta ge Rounds In 2022, 50% of the 28 indicators have been implemented by the SE Asia Region Member States, with Thailand having the highest percentage and Maldives the lowest. It is worth noting that the number of indicators varies for each round; hence, a comparison should only be made with the percentages. Throughout the rounds, from 2017 to 2021, there is a general increasing trend, with a slight dip in 2022 (Fig. B). This trend was apparent in eight (73%) Member States, with India showing a clear stagnation while countries, such as Maldives and Timor-Leste, fluctuated between rounds. There was a noticeable decline in the final two rounds, experienced by Myanmar (13%) and Sri Lanka (18%) (Fig. C). Level C indicates one of the important milestones to initiate implementation at the national level. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 15 Fig. C. Proportion of indicators with implementation level C or above in each country from 2016 to 2022. Note: the number of indicators analysed varies between rounds (16, 34, 24, and 28 for the rounds of 2017, 2019, 2021, and 2022 respectively). Please refer to the definition of implementation level C in the Methods section. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ba ng la de sh Bh ut an D PR K In di a In do ne si a M al di ve s M ya nm ar N ep al Sr i L an ka Th ai la nd Ti m or -L es te Pe rc en ta ge Country Round 2017 Round 2019 Round 2021 Round 2022 Focus area 1: National AMR Plan and governance Development of a national action plan on AMR (NAP-AMR) Fig. 1.1. Number of countries that developed NAPs on AMR, with level C and above (indicator 2.3, TrACSS 2022) 91% 100% 100% 91% 100% 91% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2017 2018 2019 2020 2021 2022 N um be r of c ou nt rie s Rounds In 2022, all countries were reported to have developed national action plans on AMR (Fig. 1.1). In the same year, eight countries declined, but it was due to a slight change in the A–E level classification, which moved up one level in 2022. Levels A and B in 2017–2021 were merged into level A in 2022, whereas Level D in 2021 was broken down into two group levels (level C and level D) in the same Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202316 year. Approval from the government is included in level C and an operational plan and monitoring arrangements are included in level D. Countries that seemed as though they were regressing by one level from TrACSS 2017–2021 to TrACSS 2022 (Table 1.1) actually remain on the same level. Therefore, there was no actual decline in progress for most countries. Only Indonesia reported regression in terms of funding. Two (18%) countries (Bangladesh and Thailand) reported that the National AMR Action Plan, with funding sources identified, is being implemented and has the relevant sectors involved, with a defined monitoring and evaluation process in place (Table 1.1.). Table 1.1. Development of the National Action Plan on AMR (indicator 2.3, TRACSS 2022) Countries 2017 2018 2019 2020 2021 2022 Bangladesh C C C D E E Bhutan C D D D D C DPR Korea A C C B D D India C D D D D C Indonesia C D D E E D Maldives C D D D D C Myanmar C D D D D C Nepal C C C C C B Sri Lanka C D D D D C Thailand C E E E E E Timor-Leste C C C E D C *Definition of scales, based on TrACSS 2021, 2022, is as follows: A No National AMR Action Plan A No National AMR Action Plan or plan under development B National AMR Action Plan under development B National AMR Action Plan developed C National AMR Action Plan developed C National AMR Action Plan approved by the government and is being implemented D National AMR Action Plan approved by the government that reflects Global Action Plan objectives, with an operational plan and monitoring arrangements D National AMR Action Plan has costed and budgeted an operational plan and has a monitoring mechanism in place E National AMR Action Plan has funding sources identified, is being implemented, and has relevant sectors involved, with a defined monitoring and evaluation process in place E Financial provision for the National AMR Action Plan implementation is included in the national plans and budgets Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 17 Revision and development of NAP-AMR There were seven additional questions to assess the information related to the development of NAP-AMR (indicator 2.3 a–g). One of them is indicator 2.3a, which showed that in 2022, four (36%) countries (Bhutan, Indonesia, Nepal, and Sri Lanka) reported no revision of the National AMR Action Plan or development of a new one, if the duration of the National AMR Plan was about to expire (indicator 2.3a). National Action Plan on AMR linked to any other existing action plan, strategy or target Fig. 1.2. Number of countries with NAP-AMR linked to any other existing action plans, strategies or targets (indicator 2.6, TrACSS 2022) 36% 55% 91% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2018 2021 2022 N um be r of c ou nt rie s Rounds In 2022, 10 countries reported linkages of the NAP-AMR to existing action plans, strategies or targets. There was progress, wherein six countries reported linkages in 2021, compared with four in 2018. Three countries (Bangladesh, DPR Korea, and Myanmar) consistently linked their NAP-AMR throughout the three rounds while other countries (with the exclusion of Thailand) managed to do so in 2022 (Fig. 1.2). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202318 Linkage of NAP-AMR with existing action plans, strategies, and targets Fig. 1.3. Linkage between NAP-AMR and existing action plans, strategies, and targets (indicator 2.6, TrACSS 2022). OHS: One Health strategy, TB: Tuberculosis, NTD: Neglected tropical diseases, STI: Sexually transmitted diseases, WASH: Water, sanitation, and hygiene, HS: Health security, UNSCDF: United Nations Sustainable Development Cooperation Framework, FSS: Food safety strategy and policies; #: Information from TrACSS 2020–2021; ^: Information from TrACSS 2021–2022 73% 27% 45% 9% 36% 27% 45% 18% 45% 27% 18% 45% 36% OHS^ HIV# TB# NTD# Mal# STI# WASH^Immunization^ HS^ Environment^ UNSCD-F^ FSS^ Agriculture^ Linkage to other existing action plans, strategies and targets All Member States had linked their NAPs-AMR with at least one other existing action plan, strategy, and target, most commonly with the One Health strategy (connected to eight NAPs-AMR). Among the Member States, Myanmar had the most reported linkages between NAP-AMR and other strategies. On the other hand, Maldives reported only a single linkage with the One Health strategy. There was also the problem of unavailable data in seven Member States (Bhutan, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste). Neglected tropical diseases had the maximum “missing data” (Fig. 1.3). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 19 The NAP-AMR development and implementation process affected by the COVID-19 pandemic Fig. 1.4. The number of countries perceiving the impact of the COVID-19 pandemic on NAP-AMR implementation (indicator 2.7, TrACSS 2022) *The positive impact is elaborated on below. 55% 100% 91% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Positive Impact* Negative Governance and administrative Impact Negative Operational  Impact N um be r of c ou nt rie s Indicators All Member States (100%) reported negative impact on governance and administration of NAPs- AMR due to the COVID-19 pandemic; 10 countries (91%) reported negative operational impact on NAP-AMR development and implementation while only India experienced no negative impact on its administrative process (Fig. 1.4). However, COVID-19 positively impacted many sectors, resulting in, say, better public understanding of bacterial versus viral infections and how they should be treated, and increased awareness about AMR and misuse of antimicrobials. It is evident that the COVID-19 pandemic and the national response affected NAP-AMR development and implementation. The figure above reveals NAP-AMR development and implementation were positively impacted by COVID-19 in six (54%) Member States (Bangladesh, DPR Korea, India, Indonesia, Myanmar, and Thailand). Focus area 2: Raising awareness All countries, except for Sri Lanka, had at least some awareness activities at the local and/or subnational level by 2022. In general, there was an increasing trend of countries raising awareness and ensuring better understanding of AMR risks and response, with a slight decline in implementation status in Myanmar and Sri Lanka during the 2022 round. Of all Member States, only Thailand and Timor-Leste had routine, targeted, nationwide, government-supported campaigns across sectors with regular monitoring. Sri Lanka was the only country to have regressed in this category, having only some activities to raise awareness by 2022 (Table 2.1). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202320 Table 2.1. Raising awareness and understanding of AMR risks and response (indicator 2.9, TrACSS 2022)* Country 2017 2018 2019 2020 2021 2022 Bangladesh B C C C C C Bhutan B C C C C C DPR Korea B C C C C D India C C C C C C Indonesia D D D D D D Maldives B D D D C C Myanmar A C D D D C Nepal B C C C C C Sri Lanka B D E C C B Thailand B E D E E E Timor-Leste D D D D D E *There are some variations in the definition of scales on this indicator from TrACSS 2020–2021, compared with previous surveys. The definition of indicator from TrACSS 2022 is as follows: A No significant awareness-raising activities regarding relevant aspects of risks of antimicrobial resistance B Some activities to raise awareness about risks of antimicrobial resistance and actions that address it C Some awareness activities at local and/or subnational level about risks of antimicrobial resistance and actions to address it, targeting some but not all relevant stakeholders, based on stakeholder analysis D Nationwide, government-supported antimicrobial resistance awareness-raising campaign, targeting all or the majority of priority stakeholder groups, utilizing targeted messaging accordingly within sectors E Routine, targeted, nationwide, government-supported campaign implemented to raise awareness of priority stakeholders across sectors, with regular monitoring Several sectors were included in the AMR awareness campaign. Human health, terrestrial animal health, and food safety were the sectors with the highest number of campaign activities while plant health and food production were the sectors with the least number of campaigns. In 2022, a new sector was included in the AMR awareness campaign related to aquatic animal health (Fig. 2.1.). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 21 Fig. 2.1. Number of countries that have been conducting campaigns related to raising awareness and understanding of AMR risks and responses in relevant fields; comparisons between the years of 2019 and 2022 (indicator 2.9, TrACSS 2022) 86% 64% 41% 32% 41%64% 45% 27% human health animal health aquatic animal health plant health food production food safety enviroment youth education Series1 100% 100% 0% 45% 55% 64% 64% 100% 100% 0% 45% 64% 91% 73% 100% 100% 0% 55% 64% 100% 64% 100% 100% 73% 64% 64% 100% 82% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 human health animal health aquatic animal health* plant health food production food safety enviroment N um be r of c ou nt rie s Indicator Round 2019 Round 2020 Round 2021 Round 2022 This sector is a main focus of campaign Although there are more campaigns in the human health sector than any other, the focus of these campaigns have evolved through time to include other key issues such as animal health and food safety, in addition to only human health. This is demonstrated by the reduced focus on human health since the campaigns in 2019 that covered 91% of the countries in the region (all of SE Asia Region with the exception of Nepal), and would only cover 73% of them in 2022. (Fig. 2.1). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202322 In the field of terrestrial animal health, there was a decrease in the number of countries that made this sector the focus of the campaign. In 2019–2020, three countries that made this sector the focus area included Bangladesh, Sri Lanka, and Myanmar. However, in 2022, Bangladesh, Indonesia, and Thailand made this sector the focus of the campaign. Regarding aquatic animal health, only Thailand has made this sector the campaign’s focus while countries that have not included this sector as part of the campaign include Bhutan, Maldives, and Timor-Leste (Fig. 2.1). Plant health and food production are the sectors with the least number of campaigns among several other sectors. In 2020–2021, plant health was the main focus of campaigns in Timor-Leste, but by 2022, no country had plant health as the main focus of AMR campaigns. A few activities related to the plant health campaign in 2022 were reported by some countries, except Bangladesh, Bhutan, DPR Korea, and Timor-Leste (Fig. 2.1). Regarding the food production sector, there was also a change in the countries which included this sector as the focus of their campaign. In 2020–2021, this sector was the focus of the Timor-Leste campaign; however, in 2022, the countries that included this sector as the focus of their campaigns were DPR Korea and Thailand. In 2022, Bangladesh, Bhutan, India and Timor-Leste did not included this sector in their campaigns (Fig. 2.1). Food safety is more or less a significant campaign focus area for SE Asia Region countries. From 2019 to 2022, there had been an increase in the number of countries campaigning in this sector. By 2022, all SE Asia Region countries had campaigns revolving around food safety. Countries that have made this sector the focus of campaigns include DPR Korea, Thailand and Timor-Leste (Fig. 2.1). The campaign to increase AMR awareness in the environmental sector also showed progress from 2019 to 2022; there was a decline in 2021 though. From 2020 to 2022, this sector was the focus of the campaign conducted by Timor-Leste. In 2022, this campaign had been carried out by most SE Asia Region countries, except Bhutan and Maldives (Fig. 2.1). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 23 Training and education for professionals in the human health sector Fig. 2.2. Number of countries in the SE Asia Region with progress on training and professional education, level C or above for human health (indicator 3.1, TrACSS 2022), animal health (indicator 4.1, TrACSS 2022), food and environment (indicator 5.1, TrACSS 2022) between 2017 and 2022 45% 0% 0% 55% 36% 0% 55% 55% 18% 73% 64% 9% 82% 82% 27% 91% 73% 18% 0 1 2 3 4 5 6 7 8 9 10 Human health Animal health Farming, food production, food safety and environmental sector 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N um be r of c ou nt rie s Indicators 2017 2018 2019 2020 2021 2022 During the 2022 round, human health was the most prominent sector in terms of training and education with regard to AMR for professionals, with the other two sectors showed a decrease in the number of countries, compared with the previous round. There is an increase in the number of countries that reached the implementation level C and above, from five (45%) countries in 2016 to 10 (91%) in 2022 (Fig. 2.2). Table 2.2. Training and professional education related to AMR in the human health sector (indicator 3.1, TrACSS 2022)* Country 2017 2018 2019 2020 2021 2022 Bangladesh B B C C C C Bhutan B A B B B C DPR Korea D B B B C C India C C C C C C Indonesia C B B C C C Maldives A C C C B B Myanmar B C C C C C Nepal B C C C C C Sri Lanka C C C C C C Thailand D D N/A C C C Timor-Leste A A B A C D Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202324 *There are changes in the scale definition across the rounds of TrACSS. The definition in the latest TrACSS is as follows: A No training for human health workers in AMR B Ad hoc AMR training courses on some human health-related disciplines C AMR is covered in 1) some pre-service training and in 2) some in-service training or other continuing professional development (CPD) for human health workers D AMR is covered in pre-service training for all relevant cadres. In-service training or other CPD, covering AMR, is available for all types of human health workers nationwide. E AMR is systematically and formally incorporated in pre-service training curricula for all relevant human health cadres. In-service training or other CPD in AMR is taken up by relevant groups for human health nationwide, in public and private sectors. These countries covered AMR in some pre-training and in-service training programmes or in other continuing professional development programmes. Ten countries included AMR-related capacity- building in at least some pre-service and in-service training as well as in continuing professional development programmes. During the final two years, the level of implementation stagnated in all Member States with the exception of Bhutan and Timor-Leste. Maldives only had AMR training courses in some human health-related disciplines (Table 2.2). Training and education in the animal sector Table 2.3. Training and professional education related to AMR in the veterinary sector (indicator 4.1, TrACSS 2022)* Country 2017 2018 2019 2020 2021 2022 Bangladesh B B B C C B Bhutan A A C C C C DPR Korea B B B B C D India B D D C D C Indonesia B B B B C E Maldives A A A B B B Myanmar A B C C C C Nepal B C C C C C Sri Lanka N/A E D D C C Thailand B D D D D E Timor-Leste A A B A B A Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 25 *There are changes in scale definition across the TrACSS rounds. The definition in the latest TrACSS is as follows: A No training of veterinary-related professionals (veterinarians and veterinary paraprofessionals), related to AMR B Training courses available for veterinary-related professionals C AMR and prudent use of antimicrobial agents are covered in the core curricula for graduating veterinarians and for veterinary paraprofessionals at some educational institutions. D Continuing professional training in antimicrobial resistance and antimicrobial use is available nationwide for veterinary-related professionals. E AMR is systematically and formally incorporated in the curricula for graduating veterinarians and veterinary paraprofessionals, and continuing professional training is a formal requirement. There is a general increasing trend, with its peak seen in 2021, involving nine (82%) Member States, covering AMR and prudent use of antimicrobial agents in their curricula; the number decreased to eight (73%) in 2022 (Fig. 2.2). Bangladesh and Maldives were yet to reach this stage, having courses available only for this issue; no courses were available in Timor-Leste (Table 2.3). Training and professional education focused on AMR in the aquatic animal health sector This information is taken from indicator 4.2. TrACSS 2022. Training in AMR in aquatic animal health has not been implemented in six (55%) Member States. Two countries (Bangladesh and Nepal) provide an ad hoc AMR training course, available for aquatic animal health professionals. In India and Thailand, AMR education is embedded in the core curricula of graduating aquatic animal health professionals at some educational institutions. Indonesia has incorporated AMR education as a formal system in education and continuing professional training. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202326 Training and education in the farming, food production, food safety, and environmental sectors Table 2.4. Training and professional education focused on AMR, provided to farming (indicator 5.1, TrACSS 2022)* Country 2018 2019 2020 2021 2022 Bangladesh B N/A B B B Bhutan A A A A B DPR Korea B B B C C India A B A B B Indonesia A B B B B Maldives B A B A B Myanmar B B B C B Nepal A C B B B Sri Lanka B B B B A Thailand B C C C C Timor-Leste A A A A A *The information on this indicator is not available from TrACSS 2016–2017. There are changes in scale definition across the rounds of TrACSS. The definition in the latest TrACSS follows: A No training provision on AMR for key stakeholders, e.g. agricultural extension workers, farmers, food safety officers, food and feed processors and retailers, environmental specialists B Tailored ad hoc AMR training courses available for at least two groups of key stakeholders C Tailored ad hoc AMR training courses available for all or the majority of key stakeholders D Tailored AMR training courses routinely available nationwide for all key stakeholders and completion of training a formal requirement for at least two groups of key stakeholders E Tailored AMR training courses routinely available nationwide and completion of training a formal requirement for all key stakeholders The number of Member States that provided tailored, ad hoc AMR training courses, available for all or the majority of key stakeholders during 2018–2022, fluctuated between zero and four (36%). It is also apparent that some Member States either stagnated or struggled to maintain their progress. This may indicate issues surrounding funding or prioritization of training courses (Table 2.4). Only DPR Korea and Thailand (18% of SE Asia Region countries) reported that tailored, ad hoc AMR training courses were available for all or the majority of key stakeholders. Comparing this indicator across TrACSS 2018–2022 reveals limited progress. Thailand has been implementing the tailored, ad hoc AMR training course for the majority of the key stakeholders since 2019. Meanwhile, DPR Korea has provided the tailored, ad hoc AMR training since 2021. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 27 Strengthening veterinary services Fig. 2.3. Number of countries with progress on strengthening veterinary services, level C or above (indicator 4.3, TrACSS 2022) 36% 36% 55% 64% 64% 64% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2017 2018 2019 2020 2021 2022 N um be r of c ou nt rie s Round There has been a slight increase in this indicator from 2017, but it has been stagnant over the past three years. In 2022, only seven (64%) Member States had implemented a plan to address strengthen the capacity gaps in their veterinary services (Fig. 2.3). Timor-Leste seems to have faced difficulties in maintaining progress, with the latter regressing to having no systematic approach at the national level (Table 2.5). Table 2.5. Progress on strengthening veterinary services (indicator 4.3, TrACSS 2022)* Country 2017 2018 2019 2020 2021 2022 Bangladesh B C C C C C Bhutan B B B C C C DPR Korea N/A C C C C C India C B B B B B Indonesia C B C C C C Maldives A A A B B B Myanmar D D D D D D Nepal B B B B B B Sri Lanka N/A B C C B C Thailand C D D D D D Timor-Leste B B B B C A Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202328 *There are changes in scale definition across the TrACSS rounds. The definition in the latest TrACSS is as follows: A No systematic approach at the national level to strengthening veterinary services B Veterinary services were assessed and plans developed to improve capacity, through structured approaches, such as OIE Performance of Veterinary Services (PVS) Evaluation and PVS Gap Analysis missions. C Implementation of plan to address strengthen capacity gaps in veterinary services underway D Monitoring of veterinary services performance carried out regularly, e.g. through PVS Evaluation Follow-Up missions E Documented evidence of strong capacity in compliance with OIE standards on the quality of veterinary services Strengthening aquatic animal health services 2022 was the only year to have the indicator 4.4. recorded, hence, the absence of any comparison. Seven (64%) Member States have implemented capacity strengthening, with Bangladesh, Myanmar, and Thailand also conducting monitoring initiatives. The remaining four countries (Bhutan, DPR Korea, Nepal, Timor-Leste) are yet to have any specific activities for this purpose. Focus area 3: National AMR surveillance systems Countries using relevant antimicrobial resistance surveillance data to inform operational decision-making and amend policies, and implementing an integrated surveillance system for antimicrobial resistance Fig. 3.1. Number of countries with progression level C or above in usage of resistance surveillance data for decision-making (indicator 2.12, TrACSS 2022) and implementation of integrated surveillance system (indicator 2.13, TrACSS 2022) in 2022 55% 55% 18% 0% 18% 27% 27% 73% 64% 27% 0% 18% 27% 9% 0 1 2 3 4 5 6 7 8 9 10 11 Human Health Terrestrial Animal Health Aquatic Animal health Plant Health Food Production Food Safety Environment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N um be r of c ou nt rie s Indicators Implementation of an Integrated Surveillance System Resistance surveillance data used to inform decision making Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 29 Eight (73%) Member States reported using resistance surveillance data to inform decision- making and amend policies; six (55%) implemented integrated surveillance systems for antimicrobial resistance. Overall, human health (together with terrestrial animal health, for the implementation of an integrated surveillance system) was the sector with more advanced implementation in both sub-indicators, with eight (73%) and six (54%) Member States respectively. Three (27%) countries (Maldives, Myanmar and Sri Lanka) were unable to provide resistance surveillance data that is used to inform decision-making, while five (45%) countries (Bangladesh, Maldives, Myanmar, Nepal and Sri Lanka), have not started the implementation of an integrated surveillance system. Plant health data lags behind the most because no country is currently reporting it (Fig. 3.1). Capacity to perform antimicrobial susceptibility testing (AST) for critically important bacteria Fig. 3.2. Number of countries with capacity to perform AST for critically important bacteria and bacteria type assessed (TrACSS indicator 3.4.2, TrACSS 2022) 18% 27% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Have reference lab for all 11 bacteria Have reference lab for some bacteria N um be r o f c ou nt rie s Indicators 18% 27% 36% 36% 36% 45% 45% 45% 45% 45% 45% 0% 20% 40% 60% 80% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Campylobacter spp. Haemophilus influenzae Acinetobacter baumannii Enterococcus faecium Streptococcus pneumoniae Pseudomonas aeruginosa Enterobacteriaceae E.coli, Klebsiella, Proteus Staphylococcus aureus Salmonellae Neisseria gonorrhoeae Shigella spp. Number of countries with referance lab for Almost half (five countries; 45%) of the Member States reported having one or more reference laboratories performing susceptibility testing for some of the listed bacteria in 2022. Only two (Timor- Leste and Bhutan) of the five countries reported having laboratory testing for all the 11 bacteria listed. Three other countries (DPR Korea, Indonesia, and Maldives) reported having laboratory testing only for some of the bacteria listed. Campylobacter spp. is reported to be the bacteria least capable of being tested, with only two countries being able to test it. Meanwhile, six Member States (Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand) did not provide data for this indicator (Fig. 3.2). Capacity to perform AST for critically important fungi Eight (73%) Member States had the capacity to perform AST for critically important fungi. Five countries (DPR Korea, India, Nepal, Sri Lanka, and Thailand) were able to perform AST for both Candida and Aspergillus; three (Bhutan, Maldives, and Myanmar) countries were capable of performing AST only for Candida while three other countries (Bangladesh, Indonesia, and Timor-Leste) did not have the capacity to do so. Continuity of services for clinical bacteriology laboratories Six (55%) Member States (Bhutan, DPR Korea, Indonesia, Sri Lanka, Thailand, and Timor-Leste) had stockouts, reported at some level in 2022. Indonesia and Thailand reported stockouts at the local Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202330 level. Bhutan, DPR Korea, Sri Lanka, and Timor-Leste reported stockouts at the national level. Four countries (India, Maldives, Myanmar, and Nepal) reported that each bacteriology laboratory managed stockouts without compulsory reporting. Bangladesh was unable to provide data on this indicator (TrACSS 3.4.4, 2022). Standardized AST guidelines All Member States reported having at least the National Reference Bacteriology/AST Laboratory or some clinical bacteriology laboratories, using the standardized AST guidelines, in 2022. Almost all (10/11) Member States, except Timor-Leste, have at least some clinical bacteriology laboratories, adhering to the standardized AST guidelines. This indicator was recorded in TrACSS 2022 with the code 3.4.5. External quality-assured bacteriology laboratory services All Member States reportedly made EQA compulsory in the National Bacteriology Reference Laboratory (NBRL). Moreover, three countries (27%), namely Bhutan, DPR Korea, and Thailand, have EQAs implemented for all the laboratories nationwide. This indicator was recorded in TrACSS 2022 with the code 3.4.7. Countries that have developed national lists of essential in vitro diagnostics that include all essential AMR diagnostics Six (55%) Member States, namely Bhutan, DPR Korea, India, Indonesia, Thailand, and Timor-Leste, developed their national lists of essential in vitro diagnostics in the 2022 round. Five of them (except Maldives) included all essential AMR diagnostics. Four countries (Bangladesh, Myanmar, Nepal, and Sri Lanka) have not yet developed such a list while Maldives has failed to report on this indicator (TrACSS 3.4.8, 2022). Countries that submitted antimicrobial use (AMU) data to the OIE (WOAH) database on antimicrobial agents intended for use in animals Eight (73%) Member States had submitted AMU data to the OIE database on antimicrobial agents intended for use in animals in the 2022 round. Two countries (DPR Korea and Timor-Leste) failed to submit data and Bangladesh did not report on this indicator (TrACSS 4.5b, 2022). OIE reporting options for the antimicrobial use database This particular indicator was only recorded in the 2022 round, with eight (73%) countries having OIE reporting options for antimicrobial use databases. Five countries (Bhutan, Maldives, Myanmar, Sri Lanka, and Thailand) used OIE reporting option 1 – on a regular basis, data is collected and reported to the OIE on the overall amount sold for use/used in animals by antimicrobial class, with the possibility of separating by type of use. Indonesia and Nepal used OIE reporting option 3 – data collected and reported, with the possibility of separating by type of use, animal group, and route of administration. India reported using only baseline information on a regular basis and reported it to the OIE. Meanwhile, three countries (Bangladesh, DPR Korea, and Timor-Leste) did not report on this indicator (TrACSS indicator 4.6, 2022). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 31 National surveillance system for antimicrobial resistance in live terrestrial animals Table 3.1. National surveillance system for antimicrobial resistance in live terrestrial animals (Indicator 4.7, TrACSS 2022) Country Surveillance level Available surveillance systems Bangladesh D Zoonotic pathogenic bacteria, commensal isolates, specific resistance phenotypes Bhutan D All DPR Korea B N/A India D Terrestrial animal isolates, zoonotic pathogenic bacteria, commensal isolates Indonesia D Commensal isolates Maldives C N/A Myanmar D Specific resistance phenotypes Nepal D Specific resistance phenotypes Sri Lanka C N/A Thailand E All Timor-Leste D Terrestrial animal isolates A There are no local or national strategies/plans for generating AMR surveillance data from animals for an AMR surveillance system. B National plan for AMR surveillance in place but laboratory and epidemiology capacities for generating, analysing, and reporting data are lacking. C Some AMR data are collected at local levels but a nationally standardized approach is not used; national coordination and/or quality management lacking. D Priority pathogenic/commensal bacterial species have been identified for surveillance; data systematically collected and reported on levels of resistance in at least one of those bacterial species, involving a laboratory that follows quality management processes, e.g. proficiency testing. E National system of AMR surveillance established for priority animal pathogens, zoonotic, and commensal bacterial isolates, which follows quality assurance processes in line with intergovernmental standards; laboratories that report for AMR surveillance follow quality assurance processes Ten (91%) Member States, except DPR Korea, had at least some AMR data collected at local levels in 2022. However, only Thailand reported having established systems that follow quality assurance processes, in line with intergovernmental standards. Among the Member States, DPR Korea lacks laboratory capacity for generating, analysing, and reporting data (Table 3.1.). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202332 National surveillance system for antimicrobial resistance in aquatic animals Table 3.2. National surveillance system for antimicrobial resistance in live aquatic animals (indicator 4.8, TrACSS 2022) Country Surveillance level Available surveillance system/s Bangladesh A N/A Bhutan A N/A DPR Korea A N/A India D No Indonesia D All* Maldives A N/A Myanmar B N/A Nepal A N/A Sri Lanka B N/A Thailand D All* Timor-Leste A N/A *Include aquatic animal isolates, linked to animal diseases, zoonotic pathogenic bacteria, and commensal isolates A No local or national strategies/plans for generating AMR surveillance data from aquatic animals for an AMR surveillance system B National plan for AMR surveillance in place, but laboratory and epidemiology capacities for generating, analysing, and reporting data lacking C Some AMR data collected at local levels, but a nationally standardized approach not used; national coordination and/or quality management lacking D Priority pathogenic/commensal bacterial species have been identified for surveillance; data systematically collected and reported on levels of resistance in at least one of those bacterial species, involving a laboratory that follows quality management processes, e.g. proficiency testing. E National system of AMR surveillance established for priority animal pathogens, zoonotic, and commensal bacterial isolates, which follows quality assurance processes in line with intergovernmental standards; laboratories that report for AMR surveillance follow quality assurance processes Three (27%) countries had at least some AMR data collected at local levels in 2022. Two of the countries (Indonesia and Thailand) have all data on three subindicators. Two countries (Myanmar and Nepal) lacked laboratory and epidemiology capacities while six countries (Bangladesh, Bhutan, DPR Korea, Maldives, Nepal, and Timor-Leste) did not have any strategy/plan regarding this issue (Table 3.2.). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 33 National surveillance system for antimicrobial resistance in food (terrestrial and aquatic animal and plant origin) Table 3.3. National surveillance system for antimicrobial resistance in food (terrestrial and aquatic animal and plant origin) (indicator 5.3, TrACSS 2022) Country Surveillance level Available surveillance system/s Bangladesh C N/A Bhutan D Terrestrial animal origin DPR Korea C N/A India D Terrestrial and aquatic animal origin Indonesia D Terrestrial animal origin Maldives A N/A Myanmar C N/A Nepal C N/A Sri Lanka A N/A Thailand D Terrestrial and aquatic animal origin Timor-Leste A N/A A No national plan for an AMR surveillance system B National plan for AMR surveillance in place, but capacity (including laboratory and reporting) lacking C Some AMR data are collected, but a standardized approach is not used; national coordination and/or quality management lacking. D Priority foodborne pathogenic/indicator bacterial species have been identified for surveillance; data systematically collected and reported on levels of resistance in at least one of those bacterial species, involving a laboratory that follows quality management processes, e.g. proficiency testing. E National system of AMR surveillance established for priority foodborne pathogens and/or relevant indicator bacteria, which follows quality assurance processes, in line with intergovernmental standards This indicator was only recorded in the 2022 round, with eight (73%) Member States having collected at least some AMR data. Four countries (Bhutan, India, Indonesia, and Thailand) have priority foodborne pathogenic/indicator bacterial species identified for surveillance. Three countries (DPR Korea, Myanmar, and Nepal) have collected some AMR data. Three countries (Maldives, Sri Lanka and Timor-Leste) did not have national plans for AMR surveillance in food (terrestrial and aquatic animal, and plant origin) (Table 3.3.). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202334 National surveillance system for antimicrobial resistance in humans Fig. 3.3. Number of SE Asia Region countries that reached level C and above in the national surveillance system for antimicrobial resistance in humans, using relevant antimicrobial consumption/use data to inform operational decision-making and amend policies for human health; comparison between 2017 and 2022 (indicator 3.3, TrACSS 2022) 73% 64% 82% 91% 91% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2018 2019 2020 2021 2022 N um be r of c ou nt rie s Round This indicator was documented over five years, from 2018 to 2022. By 2022, 10 (91%) Member States have collected data nationally on common bacterial infections in hospitalized patients and the community. Maldives is the only country to have data collected locally (Table 3.4). This indicator remains one of the most successful for all countries in terms of indicator scoring (Fig. 3.3). Table 3.4. National surveillance system for antimicrobial resistance in humans (indicator 3.3., TrACSS 2022) Countries 2018 2019 2020 2021 2022 Bangladesh C D D D D Bhutan C B C C D DPR Korea B B B C D India D D D D D Indonesia B B D D D Maldives C C C B B Myanmar C D C D D Nepal C D D D D Sri Lanka D D D D D Thailand C D D D D Timor-Leste A B B D E Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 35 *Definition of scales, based on TrACSS 2021–2022, is as follows: A No capacity for generating data (antibiotic susceptibility testing and accompanying clinical and epidemiological data) and reporting on antibiotic resistance B AMR data is collated locally for common bacterial infections in hospitalized and community patients, but data collection may not use a standardized approach and lacks national coordination and/or quality management. C AMR data are collated nationally for common bacterial infections in hospitalized and community patients, but national coordination and standardization are lacking. D There is a standardized national AMR surveillance system, collecting data on common bacterial infections in hospitalized and community patients, with an established network of surveillance sites, designated national reference laboratory for AMR, and a national coordinating centre, producing reports on AMR. E The national AMR surveillance system links AMR surveillance with antimicrobial consumption and/ or use of data for human health. By 2022, all Member States were already beyond the implementation level C, except for Maldives, which only had local data collection. There were eight (73%) Member States with progression (especially Timor-Leste) and two countries (India and Sri Lanka) with stagnation. Only Maldives displayed regression in this particular indicator; this warrants further investigation to determine possible programmatic issues in implementing a surveillance system for AMR in humans. Much can be learned from Timor-Leste, which moved up from A to E in five years. Lessons can also be drawn from countries, such as India and Sri Lanka, which consistently maintained a functioning national AMR surveillance system, covering antibiotics at hospitals and outpatient clinics, with external quality assurance (EQA) and a national coordinating centre producing reports on resistance levels over the five years of documentation (Table 3.4). Fig. 3.4. Number of countries with effective integration (indicator 5.4a, TrACSS 2022), standardization and harmonization of procedure (indicator 5.4b, TrACSS 2022), relevance of diagnostic technique (indicator 5.4c, TrACSS 2022), and network data management (indicator 5.4d) at laboratories for AMR surveillance with progress level C or above between 2019 and 2022 64% 27% 45% 36% 55% 36% 45% 36% 64% 45% 73% 55% 64% 45% 64% 64% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Effective integration Standardization and harmonization of procedures Relevance of diagnostic techniques Data management of network N um be r of c ou nt rie s Indicators 2019 2020 2021 2022 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202336 Effective integration of laboratories in AMR surveillance By 2022, seven (64%) Member States had some laboratories, performing antimicrobial susceptibility testing, that were integrated in the national AMR surveillance system. Two countries (DPR Korea and Thailand) showed progress and eight countries were stagnant (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, and Timor-Leste. Furthermore, Sri Lanka showed regression. Attention should be paid particularly to Maldives and Timor-Leste, which continued to have no information available on this indicator, to identify possible programmatic issues regarding this indicator. Possible programmatic issues may also be identified in the stagnation of Bangladesh, Bhutan, Indonesia, India, and Nepal, which were unable to totally integrate all the laboratories in the national AMR surveillance system. This indicator was recorded throughout the four TrACSS series (2019, 2020, 2021, 2022), representing the non-significant progress of only 55%–64% of SE Asia Region countries on the implementation of level C or above (indicator 5.4a, TrACSS 2022) (Fig. 3.4). Level of the standardization and harmonization of procedures among laboratories in the AMR surveillance system This information was taken from indicator 5.4.b TrACSS 2022. By 2022, five (45%) Member States – Bhutan, DPR Korea, Indonesia, Nepal, and Thailand – had at least 30% of their laboratories following the same AST guidelines. Much can be learnt from Thailand’s report, which showed that 100% of its laboratories used the same AST guidelines. Maldives and Timor-Leste did not provide information on this indicator. Bangladesh and India are on implementation level B. The proportion of SE Asia Region countries with implementation level C and above in standardization and harmonization of procedures among laboratories, from 2018 to 2021, was only 27–45% (Fig. 3.4). Relevance of diagnostic techniques used by laboratories included in the AMR surveillance system There was a general increasing trend in terms of the number of SE Asia Region countries with implementation level C or above with regard to relevance of diagnostic techniques, used by laboratories included in the AMR surveillance system, ranging from 45% to 73%, in 2021. Unfortunately, by 2022, the proportion decreased to seven countries (64%) – Bangladesh, Bhutan, DPR Korea, India, Indonesia, Nepal, and Thailand (Fig. 3.4). In Myanmar and Sri Lanka, major modifications in AST, bacterial isolation, and identification protocols used are required to improve their adaptation to the national AMR surveillance objectives. Maldives and Timor-Leste did not provide information on this indicator (indicator 5.4c., TrACSS 2022). Technical level of data management of the laboratory network in the AMR surveillance system There was a general increasing trend in terms of the number of SE Asia Region countries with level C or above with regard to the relevance of the technical level of data management of the laboratory network in the AMR surveillance system (see indicator 5.4d, TrACSS 2022).9 Just by 2022, it had doubled to seven (64%). Bangladesh and Thailand were the countries with the most advanced AMR data management systems, compared with other SE Asia Region countries, with only some minor 9 This indicator was recorded over four years, from 2019 to 2022, with the response from India (2019–2020) missing. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 37 improvements required at some laboratories of the network to improve the computerized management of AMR laboratory data. Five countries (Bhutan, DPR Korea, Indonesia, Nepal, and Sri Lanka) required system improvement in managing the AST data while they apply computerized data management to the laboratory network. Meanwhile, India and Myanmar were still at level B with AST data handled manually. Maldives and Timor-Leste did not provide information on this indicator. The progress of implementation in the technical level of data management of the laboratory network in the AMR surveillance system was rather slow. In 2018, four (36%) countries were on implementation level C (Fig. 3.4). Focus area 4: Legislation and community-based surveillance of use/sale of antimicrobial National monitoring system for consumption and rational use of antimicrobial in human health Fig. 4.1. Number of SE Asia Region countries, with implementation level C and above, in national monitoring systems for consumption and rational use of antimicrobials in human health (indicator 3.2, TrACSS 2022). 18% 9% 36% 36% 45% 55% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2017 2018 2019 2020 2021 2022 N um be r of c ou nt rie s Round Six (54%) Member States had the total sales of antimicrobials monitored at the national level and/or some monitoring of antibiotic use at the subnational level was conducted in 2022 (Fig. 4.1). Several countries showed significant progress over six years of recording (2017–2022), especially DPR Korea and Thailand, which had regular data collection and reporting at the national level by the 2022 round. However, several countries, such as Maldives, Myanmar, and Sri Lanka, had no national plan or system for monitoring use of antimicrobials by the 2022 round, despite improvements made in the previous years (Table 4.1). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202338 Table 4.1. National monitoring system for consumption and rational use of antimicrobials in human health (indicator 3.2, TrACSS 2022) Countries 2017 2018 2019 2020 2021 2022 Bangladesh A B B B B D Bhutan C B C C C C DPR Korea B A B B C E India C A B D B B Indonesia A B B B D D Maldives B D D B A A Myanmar A A A D A A Nepal A A A A B B Sri Lanka B B B A C A Thailand B B C B B E Timor-Leste B B C E E C *Definition of scales, based on TrACSS 2022, is as follows: A No national plan or system for monitoring use of antimicrobials B System designed for surveillance of antimicrobial use, which includes monitoring national-level sales or consumption of antibiotics and rational use of antibiotics in health services C Total sales of antimicrobials are monitored at the national level and/or some monitoring of antibiotic use was carried out at the subnational level. D Prescribing practices and antibiotic use are monitored in a national sample of health-care settings. E On a regular basis (every year/two years), data is collected and reported on: a) antimicrobial sales or consumption at the national level for human use; b) antibiotic prescribing and appropriate use, in a representative sample of health facilities, public and private. National monitoring systems for antimicrobials intended to be used in animals (sales/use) The indicator of national monitoring systems for intended use of antimicrobials in animals (sales/use) (indicator 4.5.a TrACSS 2022) was only recorded in the 2022 round. There were eight (73%) Member States (Bhutan, DPR Korea, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) with national plans or systems in place for monitoring sales/use of antimicrobials in animals. Four countries (36%) – Bhutan, Indonesia, Myanmar, and Thailand – reported having national monitoring for both terrestrial and aquatic animals while four countries (DPR Korea, Nepal, Sri Lanka, and Timor-Leste) reported their involvement in terrestrial animals only. This report shows that monitoring for aquatic animals was still lagging behind that for terrestrial animals. The remaining three countries (Bangladesh, India, and Maldives) were yet to implement this indicator. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 39 National monitoring system for antimicrobial-pesticide use in plant production, including bactericides and fungicides It is apparent that six (54%) Member States (Bangladesh, Bhutan, Indonesia, Myanmar, Thailand, and Timor-Leste) did not have national plans or systems for this indicator by the 2022 round. This may indicate a lack of prioritization in the national monitoring of antimicrobial use in plant production among several Member States; further investigation is needed to detect other possible barriers to the implementation of this indicator. In general, there was little to no progress, made by SE Asia Region Member States; it peaked with only two countries in 2019 and 2022. It is to be noted that the definition of scales for the 2022 round is different from that of the previous years; hence, a comparison should be carefully made by considering the different definitions. There were two countries (DPR Korea and India) that had national plans or systems in place to collect data and report on the amount of pesticides sold/used nationally, including antimicrobial pesticides, such as bactericides and fungicides. Optimizing antimicrobial use in human health Fig. 4.2. Number of SE Asia Region countries with implementation level C and above in optimizing antimicrobial use in human health (indicator 3.6, TrACSS 2022) 36% 36% 73% 64% 82% 82% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2017 2018 2019 2020 2021 2022 N um be r of c ou nt rie s Round In 2022, there were nine (82%) Member States (Bangladesh, Bhutan, DPR Korea, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) that had national guidelines for appropriate use of antimicrobials and antimicrobial stewardship programmes were being implemented at some health-care facilities. There was a general increasing trend over the six years of recording, peaking at nine (82%) Member States, despite a temporary halt in progress in the 2020 round. Six (54%) countries (Bangladesh, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste) showed significant progress during the six years. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202340 Adoption of “AWaRe” classification of antibiotics* in the National Essential Medicines List Fig. 4.3. Number of SE Asia Region countries with implementation level C or above in “AWaRe” classification of antibiotics* in the National Essential Medicines List; comparison from 2020–2022 (indicator 3.7, TrACSS 2022) 18% 55% 55% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 1 2 3 N um be r of c ou nt rie s Round There was a general increasing trend over the three years of recording, peaking at six (54%) Member States (Bhutan, Indonesia, Maldives, Nepal, Timor-Leste, and Thailand) that adopted the “AWaRe” classification of antibiotics in the National Essential Medicines List during 2021–2022. In 2022, DPR Korea and Sri Lanka regressed to not adopting “AWaRe” classification (Fig. 4.3). Optimizing antimicrobial use in animal health This indicator was only recorded in TrACSS 2022 (indicators 4.11 and 4.12). It is apparent that antimicrobial use was more optimized in terrestrial animal health than in aquatic animal health, with five (45%) Member States having national legislation that covered all aspects of national manufacture, import, marketing authorization, control of safety, quality and efficacy, and distribution of antimicrobial products respectively. Indonesia is the only country to have enhancement processes and control in place to ensure compliance with legislation in the sector of terrestrial animal health. Thailand has equal emphasis on terrestrial and aquatic animal health. On the other hand, Timor-Leste and Maldives are two countries with no national policies with regard to both terrestrial and aquatic animal health. Optimizing use of antimicrobial pesticides, such as bactericides and fungicides, in plant production Only two countries (DPR Korea and India) reported activities related to optimization of antimicrobial pesticide use in plant production in 2022 (TraCSS indicator 5.6.). There was a slight increase in the three years of recording, from one country in 2020 to two (18%) Member States in 2022, with national legislation that covers all aspects of national manufacture, import, marketing authorization, control of safety, quality, and efficacy, and distribution of pesticides, including antimicrobial pesticides, such as bactericides and fungicides, in plant production. There was an apparent stagnancy in almost all countries, except in DPR Korea; regression was detected in Indonesia. Timor-Leste was the only country to not have any national policy on this indicator. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 41 Country that has laws and regulations on prescription and sale of antimicrobials for human, animal, and plant use Fig. 4.4. Number of SE Asia Region countries that have regulations on prescription and sale of antimicrobials for human use (indicator 2.8.1, TrACSS 2022), prescription and sale of antimicrobials for animal use (indicator 2.8.2, TrACSS 2022), use of antibiotics for growth promotion in terrestrial animals in the absence of risk analysis (indicator 2.8.5, TrACSS 2022), use of applicable pesticides with antimicrobial effects, such as bactericides and fungicides, used in plant production (indicator 2.8.6, TrACSS 2022) between 2019 and 2022 100% 45% 64% 0% 100% 64% 64% 55% 100% 82% 73% 82% 100% 82% 73% 91% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Prescription and sale of antimicrobials/ for human use Prescription and sale of antimicrobials for animal use Antibiotics for growth promotion in the absence of risk analysis Marketing of pesticides in plant production N um be r of c ou nt rie s Indicatros 2019 2020 2021 2022 All countries of the Region had regulations focused on prescription and sale of antimicrobials for human use. In the animal sector, there was an increasing trend during the four rounds of TrACSS, peaking with nine (82%) Member States (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand) having laws and regulations on prescription and sale of antimicrobials for animal use. Five (45%) countries (Bangladesh, Bhutan, Indonesia, Sri Lanka, and Thailand) had maintained this over four years and four countries (DPR Korea, India, Myanmar, and Nepal) had managed to lay down laws and regulations within that round. However, countries, such as Maldives and Timor-Leste, were yet to lay down laws and regulations regarding this issue. Seven Member States (Bangladesh, DPR Korea, India, Indonesia, Nepal, Sri Lanka, and Thailand) had laws or regulations on prescription and sale of antimicrobials for aquatic animals. However, countries, such as Bhutan, Maldives, Myanmar, and Timor-Leste, were yet to promulgate laws and regulations on this indicator. This was only recorded in the 2022 round, hence, the absence of any comparison. Nine (64%) Member States (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand) had laws or regulations on prescription and sale of medicated feed. Six (54%) countries (Bangladesh, DPR Korea, India, Indonesia, Nepal, and Sri Lanka) had laws and regulations for both terrestrial and aquatic animals. However, countries, such as Maldives and Timor-Leste, were yet to lay down laws and regulations on this indicator. This was only recorded in the 2022 round, hence, the absence of any comparison. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202342 There was a slight increase during the four years of recording, peaking at eight (73%) Member States (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Myanmar, Sri Lanka, and Thailand) that had laws and regulations that prohibited the use of antibiotics for growth promotion in the absence of risk analysis. Five countries (Bangladesh, Bhutan, Indonesia, Myanmar, and Thailand) had maintained this during the four years. Three countries (DPR Korea, India, and Sri Lanka) had managed to have laws and regulations within that round. However, countries, such as Maldives, Nepal, and Timor-Leste, were yet to promulgate laws and regulations on this indicator. There was an increasing trend during the three years of TrACSS (2019–2022). Ten (91%) Member States (Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand) had legislation on marketing of pesticides, including antimicrobial pesticides, such as bactericides and fungicides, used in plant production, in 2022. Six (54%) countries (Bangladesh, Bhutan, Indonesia, Myanmar, Sri Lanka, and Thailand) had maintained this during the three years. Four countries (DPR Korea, India, Maldives, and Nepal) had managed to have legislation implemented within that period. Timor-Leste was the only country to not have any legislation on this indicator. Focus area 5: Infection prevention and control, and antimicrobial stewardship Infection prevention and control (IPC) in human health care Table 5.1. Infection prevention and control in human health care (indicator 3.5, TrACSS 2022) Countries 2017 2018 2019 2020 2021 2022 Bangladesh B B A B C C Bhutan C B B B B B DPR Korea A D C C C C India C C B B B C Indonesia D C C C C C Maldives B B B B A A Myanmar C C C C C C Nepal C A A A B B Sri Lanka C B C N/A D D Thailand C D B C D D Timor-Leste B C B B D B Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 43 *Definition of scales, based on TrACSS 2022, is as follows: A No national IPC programme or operational plan is available. B A national IPC programme or operational plan is available. National IPC and water, sanitation and hygiene (WASH), and environmental health standards exist but are not fully implemented. C A national IPC programme and operational plan are available and national guidelines for health care IPC are available and disseminated. Selected health facilities are implementing the guidelines, with monitoring and feedback in place. D National IPC programme is available, according to the WHO IPC core components guideline13, and IPC plans and guidelines are implemented nationwide. All health-care facilities have a functional built environment (including water and sanitation), and necessary materials and equipment to perform IPC, per national standards. E IPC programmes are in place and functioning at national and health facility levels, according to the WHO IPC core components guidelines. Compliance and effectiveness are regularly evaluated and published. Plans and guidance are updated in response to monitoring. Fig. 5.1. Number of SE Asia Region countries with implementation level C and above in infection prevention and control in human health care; comparison from 2017–2022 (indicator 3.5, TrACSS 2022) 64% 55% 36% 36% 64% 64% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2017 2018 2019 2020 2021 2022 N um be r of c ou nt rie s Round Four (36%) Member States (Bangladesh, DPR Korea, Sri Lanka, and Thailand) showed progress within that round, although many more countries showed inconsistencies and regressions (Table 5.1). Maldives had no national IPC programme or operational plan available, based on TrACSS 2022, after previously having had programmes and plans available. There was a fluctuating pattern over the six years of recording, eventually returning to seven (63%) Member States (Bangladesh, DPR Korea, India, Indonesia, Myanmar, Sri Lanka, and Thailand), where national IPC programmes and operational plans were available, and national guidelines for health care IPC were available and disseminated (Fig. 5.1). Selected health facilities implemented the guidelines, with monitoring and feedback in place in the 2022 round, as in the 2017 round. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202344 Good management and hygiene practices to reduce the development and transmission of AMR in food processing Fig. 5.2. Number of SE Asia Region countries with implementation level C or above in good management and hygiene practices to reduce the development and transmission of AMR in food processing; comparison in 2019, 2021, and 2022 (indicator 5.5, TrACSS 2022) 27% 36% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 2020 2021 2022 Nu m be r o f c ou nt rie s Round There was an increasing number of countries with good management and hygiene practices to reduce the development and transmission of AMR in food processing. Fig. 5.2. reveals trends from three (27%) countries, peaking at five (45%) Member States with national plans agreed upon to ensure good animal husbandry and biosecurity practices, in line with international standards, and a nationally agreed upon guidance for good practices, developed and adapted for implementation at local farm and food production levels, in the 2022 round. Table 5.2. Good management and hygiene practices to reduce the development and transmission of AMR in food processing (indicator 5.5, TrACSS 2022) Countries 2019 2021 2022 Bangladesh N/A A B Bhutan C B C DPR Korea B C C India B B B Indonesia D D D Maldives B B A Myanmar B D C Nepal B B B Sri Lanka B B B Thailand D D D Timor-Leste A B A Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 45 *Definition of scales, based on TrACSS 2022, is as follows: A No systematic efforts to improve good animal husbandry and biosecurity practices B Some activities in place to develop and promote good animal husbandry and biosecurity practices C National plan agreed upon to ensure good animal husbandry and biosecurity practices, in line with international standards (e.g. OIE Terrestrial Codes, Codex Alimentarius); nationally agreed upon guidance for good practices developed, adapted for implementation at local farm and food production levels D Nationwide implementation of plan to ensure good animal husbandry and biosecurity practices, and national guidance published and disseminated E Implementation of the nationwide plan monitored periodically There is a possible issue with regard to formulating a national plan, as evidenced by several countries’ stagnation at implementation level B (Table 5.2.). Maldives and Timor-Leste are yet to make any systematic effort to improve good animal husbandry and biosecurity practices. Biosecurity (IPC) in the animal sector Fig. 5.3. Number of SE Asia Region countries with implementation level C or above in biosecurity and good animal husbandry practices to reduce the use of antimicrobials and minimize the development and transmission of AMR in terrestrial and aquatic animal production (indicators 4.9 and 4.10, TrACSS 2022) 27% 18% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Terrestrial Animal Production Aquatic Animal Production N um be r of c ou nt rie s Indicator This indicator was only available in the 2022 round. Only Thailand had nationwide implementation of a plan to ensure good animal husbandry practices for both terrestrial and aquatic animals. Indonesia reported a nationwide implementation plan for terrestrial animals while Sri Lanka reported a nationwide implementation plan for aquatic animals. Bangladesh has a national plan agreement to ensure good animal husbandry and biosecurity practices, in line with the international standards for terrestrial animals. Timor-Leste is yet to make any systematic effort to improve good animal husbandry and biosecurity practices (Fig. 5.3). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202346 Focus area 6: Research and innovation R&D and innovation on AMR prevention and containment, and research funding Research on AMR has been conducted and published in peer-reviewed journals in most (10/11) of the SE Asia Region countries, as presented in Table 6.1. Table 6.1. Examples of publications on AMR research in SE Asia Region countries during the rounds of 2021–2022 Countries AMR research Funding Authors Bangladesh Yes National ministry, US CDC, UKRI GCRF One Health Poultry Hub, UK grant, institutional support Chapot et al., 2021 Mandal et al., 2022 Bhutan Yes No funding Wangmo et al., 2021 DPR of Korea No – – India Yes Institutional support* Balachandra et al., 2021 Nag et al., 2022 Indonesia Yes DFAT Setiawan et al., 2022 Wulandari et al., 2021 Ferdiana et al., 2021 Maldives Yes Institutional support* Maharath and Ahmed, 2021 Myanmar Yes NIH NLBHI, Bill and Melinda Gates Foundation, JSPS. Seifert et al., 2021 San et al., 2022 Nepal Yes NIH UK, partners, institutional support* Acharya et al., 2021 Liu et al., 2022 Sri Lanka Yes JSPS, UKRI, institutional support* Guruge et al., 2021 Gunasekara et al., 2022 Thailand Yes Wellcome Trust No funding Poomchaichote et al., 2021 Chotiprasitsakul, Bruminhent, and Watcharananan, 2022 Timor Leste Yes Fleming Fund, ACIAR Ting et al., 2022 *Institutional support indicates funding from a university or other educational institutions, usually affiliated with contributing authors. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 47 Research on AMR has been published in 10 (90%) Member States, from 2021 to 2022; these are indexed in PubMed. We used the combination of the keywords, “antimicrobial” and each country name, and its synonym (such as antibacterial, antibiotic, antifungal, antiviral, etc.), for a formative search in the database. No published studies from DPR Korea were found in the PubMed database. The funding for the researches on AMR was mainly obtained from other developed countries or research-focused institutions and organizations. Focus area 7: Legislation and surveillance for AMR in the environment A national assessment of the risks from residues of antimicrobial compounds and antimicrobial-resistant pathogens in the environment In 2022, there was only one (9%) Member Country (DPR of Korea) that was reported to have conducted a national risk assessment for residues of antimicrobial compounds and antimicrobial- resistant pathogens in the environment. DPR Korea reported that six out of 17 sub-indicators had not been implemented. Some of the indicators that were not implemented included intensive terrestrial production and intensive aquatic production, disposal of food, plant or animal products, contaminated with antimicrobial residues over the maximum residue limit (MRL), and liquid and solid waste from intensive aquatic animal production, prior to use in agriculture. Meanwhile, in 2021, four (36%) Member States (DPR Korea, India, Indonesia, and Myanmar) reported conducting a national risk assessment for AMR in the environment. However, these countries fully conducted only three types of risk assessments. Firstly, human sewage (including lack of basic toilets and management of wastewater and sludge, collected in sewer networks and onsite facilities, such as septic tanks) had been fully implemented in India. It had also been partially implemented by DPR Korea and Indonesia. Secondly, there were wastewater discharges from manufacturing sites for antimicrobial agents [either as active pharmaceutical ingredients (APIs) or finished products), conducted by India and Myanmar, and disposal of unused medicines and antimicrobial agents, carried out by Myanmar. Most of the other sub-indicators were still partially conducted or are yet to be implemented. The sub-indicator that the national assessment of risks for residues of antimicrobial compounds and antimicrobial-resistant pathogens in the environment performed the least well was run off waste from slaughterhouses (abattoirs) (indicator 6.1, TrACSS 2022). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202348 Legislation and/or regulations to prevent contamination of the environment with antimicrobials – antimicrobial compounds and their metabolites discharged to the environment Fig. 7.1. Number of SE Asia Region countries that have legislation and/or regulations to prevent contamination of the environment with antimicrobials – antimicrobial compounds and their metabolites discharged to the environment (indicator 6.2, TrACSS 2022) 27% 36% 45% 55% 55% 55% 64% 64% 45% 36% 36% 45% 45% 36% 55% 45% 0% 20% 40% 60% 80% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Disposal of food, plant or animal products contaminated with antimicrobial residues Liquid and solid waste from intensive terrestrial animal production prior to use in agriculture Wastewater discharges from manufacturing sites for antimicrobial agents Wastewater discharges from health facilities Discharges from intensive terrestrial animal production Runoff and solid waste from slaughterhouses Human sewage treatment quality Disposal of medicines, antimicrobial agents for human use Number of countries In di ca to r 2021 partial 2021 2022 Fig. 7.2. Number of SE Asia Region countries that have legislation and/or regulations to prevent contamination of the environment with antimicrobials – antimicrobial compounds and their metabolites discharged to the environment, new indicator in 2022 (indicator 6.2, TrACSS 2022) 0 1 2 3 4 5 6 7 8 9 10 11 Liquid and solid waste from intensive aquatic animal production prior to use in agriculture Human solid waste that may be used for agricultural purposes Storm runoff, wastewater treatment plant overflow or failure (in case of severe weather and flooding events Discharges from intensive aquatic animal production Overspray, drift, and leaching following pesticide applications Dust, drift, and leaching following fertilizer applications Disposal of medicines, antimicrobial agents for animal use Transnational and intercontinental transport and movement of food, goods, live animals and people Management of solid clinical waste Number of countries In di ca to r 2022 Legislation and/or regulations for contamination are presented in Figs. 7.1 and 7.2. The first figure shows a comparison of sub-indicators that have been introduced since 2021. Fig. 7.2 shows nine new sub-indicators in 2022. Three of the new sub-indicators were successfully carried out by only two countries (Maldives and Sri Lanka) in the field of storm runoff, wastewater treatment plant overflow or failure, liquid and solid waste from intensive aquatic animal production prior to use in agriculture as well as human solid waste that may be used for agricultural purposes (DPR Korea and Sri Lanka). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 49 In 2022, it was found that the countries reported an increase in almost all sub-indicators that remained the same as those in 2021, except in disposal of food, plant or animal products, contaminated with antimicrobial residues. Only India, Indonesia, and Thailand reported to have implemented this sub-indicator in 2022, whereas in 2021, five countries (Bangladesh, DPR Korea, Indonesia, Myanmar, and Thailand) reported implementing this sub-indicator (Fig. 7.1). In 2022, Sri Lanka was able to promulgate legislation and/or regulations for contamination while four countries (Bhutan, Nepal, Sri Lanka, and Timor-Leste) still reported lack of legislation for contamination. A system for regular monitoring (passive surveillance) of antimicrobial compounds and their metabolites (or residues), and resistant bacteria or antimicrobial resistance genes (ARGs) in water quality Only three (27%) countries (DPR Korea, Indonesia, and Maldives) reported having in place systems for regular monitoring of antimicrobial compounds and their metabolites, and resistant bacteria or antimicrobial resistance genes (ARGs) in water. DPR Korea and Indonesia reported having monitoring systems for wastewater, including drinking water and recreational waters. On the other hand, the monitoring system in Maldives is only used for drinking water (indicator 6.3, TrACSS 2022). Focus area 8: Overarching coordination mechanisms for One Health engagement Multisectoral and One Health collaboration/coordination Fig. 8.1. Number of SE Asia Region countries with implementation level C and above (2017–2022) in multisectoral and One Health collaboration/coordination (indicator 2.1, TrACSS 2022) 27% 36% 55% 73% 82% 82% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 N um be r of c ou nt rie s Round In 2022, nine out of 11 (81%) Member States reported implementation of level C or above for multisectoral and One Health collaboration. Three countries (Bhutan, India, and Nepal) reported formalized multisectoral coordination mechanisms (level C) while four countries (Bangladesh, DPR Korea, Indonesia, and Myanmar) reported level D implementation, which represents working jointly on issues, including agreement on common objectives. Only two countries (Thailand and Timor-Leste) reported level E implementation, deploying integrated approaches to executing the National AMR Action Plan, with relevant data and lessons learnt from all sectors used to adapt implementation of the action plan. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202350 Monitoring and evaluation plan for the national AMR action strategies Fig. 8.2. Number of SE Asia Region countries with programmes for monitoring and evaluation of national AMR action plans (indicator 2.3b–g, TrACSS 2022) 45% 27% 45% 36% 45% 55% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Data analysed and used by the AMR multisector coordination mechanism for decision making (2.3g) Relevant data disaggregated by sex, geographic location, income, etc (2.3f) Have adequate technical capacity, resources and established systems for collecting data (2.3e) Indicators collected regularly across all relevant sectors (2.3d) Country have focal point or specific working group (2.3c) Country have a monitoring and evaluation plan for the national AMR action plan (2.3b) Number of countries In di ca to r In 2022, additional questions for monitoring and evaluating NAP-AMR (2.3b) for One Health were added to TrACSS. Six countries (Bangladesh, DPR Korea, India, Indonesia, Thailand, and Timor-Leste) reported to have conducted monitoring and evaluation for NAP-AMR. For these six countries, follow- up questions were further explored with five sub-indicators (indicators 2.3c–2.3f). Only DPR Korea and Timor-Leste had said “yes” to all associated sub-indicators (Fig. 8.2). Bangladesh reported that it was yet to implement any sub-indicator. Meanwhile, all countries of the Region (except Bangladesh) with monitoring and evaluation plans had successfully implemented three other sub-indicators: working group for monitoring and evaluation (2.3c); sufficient technical capacity, resources, and established methods to collect data (2.3e); and the data analysed and used by the AMR multisectoral coordination mechanism for decision-making across all relevant sectors and to advocate for policy changes and allocation of adequate resources (2.3g). Two countries (India and Bangladesh) reported having no regular data collection across all sectors (2.3d). Only three countries (DPR Korea, India, and Timor-Leste) reported having relevant data disaggregated by several sociodemographic factors (sex, geographical location, income, etc.). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 51 Sectors actively involved in developing and implementing the AMR National Action Plan Fig. 8.3. Number of SE Asia Region countries that are actively involved in developing and implementing the AMR National Action Plan (*for animal health indicator, prior to 2022, the indicator measured both terrestrial and aquatic health while in 2022, the indicators were separated into two different indicators, namely terrestrial and aquatic; #new indicator in 2022) 100% 100% 55% 45% 100% 91% 73% Human Health Animal Health (terrestrial and aquatic) Plant Health Food ProductionFood Safety Environment Aquatic animal heath 2022 100% 91% 0% 100% 100% 0% 100% 100% 0% 100% 100% 0% 100% 100% 73% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Human Health Animal Health* Aquatic animal heath N um be r of c ou nt rie s Indicatros 2018 2019 2020 2021 2022 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202352 36% 36% 45% 36% 55% 36% 55% 36% 73% 45% 82% 45% 82% 36% 82% 55% 91% 55% 100% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Environment Plant Health Food Safety Food Production N um be r of c ou nt re is Indicators 2018 2019 2020 2021 2022 All countries implemented the NAP-AMR for human health, animal health, and food safety in 2022. Prior to 2022, the terrestrial and aquatic animal health indicators were combined into one indicator (animal health) while in 2022, the indicators were separated. Eight out of 11 Member States reported implementing the National Action Plan for AMR for aquatic animal health; these include Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. A steady increase in the number of SE Asia Region countries implementing the NAP-AMR in environment and food safety was reported. However, less progress was reported by the Member States on plant health and food production. In 2022, only six countries (India, Maldives Myanmar, Sri Lanka, Thailand, and Timor-Leste) reported participating in the NAP-AMR for plant health while five countries (DPR Korea, Indonesia, Myanmar, Thailand, and Timor-Leste) reported participating in the NAP-AMR for food production (indicator 2.2, TrACSS 2022). In 2022, 10 (91%) Member States engaged in at least three relevant sectors in One Health, namely human, terrestrial animal, and environmental health. Bhutan reported including humans and terrestrial animals without environmental health. Three countries (Myanmar, Thailand, and Timor-Leste) engaged additional stakeholders: human health, terrestrial animal health, aquatic animal health, plant health, food production, food safety, and environmental health. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 53 Information on the use of data from TrACSS at the country level Table 8.1. Information on the use of data from TrACSS at the country level (indicator 2.4a-b, TrACSS 2022) Countries Does the multisectoral coordination mechanism meet to discuss the response to the TrACSS questionnaire before submission? Does the multisectoral coordination mechanism review current and previous year data from TrACSS as a way to monitor the progress of AMR National Action Plan implementation? Bangladesh Yes Yes Bhutan Yes Yes DPR Korea Yes Yes India Yes Yes Indonesia Yes Yes Maldives Yes No Myanmar Yes Yes Nepal Yes Yes Sri Lanka Yes Yes Thailand Yes Yes Timor-Leste Yes Yes All countries responded positively to questions about multisectoral coordination meetings to discuss response to TrACSS questionnaire before submission (indicator 2.4 a). Ten Member States (except Maldives) stated that the multisectoral coordination mechanism reviewed current and previous-year data from TrACSS (indicator 2.4b) to monitor the progress of NAP-AMR implementation (Table 8.1). Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202354 The number of countries utilizing relevant antimicrobial consumption/use data to inform operational decision-making and amend policies Fig. 8.4a. Number of SE Asia Region countries deploying consumption/use data to inform operational decision-making and amend policies in relevant fields; comparisons in 2022 (indicator 2.11, TrACSS 2022) 64% 45% 36%9% 18% 27% 9% Human Health Terrestial Animal Health* Aquatic Animal Heath* Plant HealthFood Production Food Safety Environment 2022 In 2022, seven (64%) Member States (Bangladesh, Bhutan, DPR Korea, Indonesia, Nepal, Thailand, and Timor-Leste) reported that they deployed antimicrobial use or consumption data to inform operational decision-making and amend policies in relevant fields. For these seven countries, follow-up questions were further explored with seven sectors, namely human health, terrestrial animal health, aquatic animal health, plant health, food safety, food production, and environment. All seven countries stated “yes” for human health and terrestrial animal health sectors (Fig. 8.4a). Only Thailand stated “yes” for all relevant sectors. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 55 Fig. 8.4b. Number of SE Asia Region countries utilizing consumption/use data to inform operational decision-making and amend policies in relevant fields; comparisons between 2020 and 2022 (*in 2020–2021, terrestrial and aquatic animal were combined; #new indicator in 2022) (indicator 2.11, TrACSS 2022) 36% 27% 0% 9% 18% 9% 9% 64% 45% 0% 9% 27% 27% 9% 64% 64% 36% 9% 18% 27% 9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0 1 2 3 4 5 6 7 8 9 10 11 Human Health Terrestrial Animal Health* Aquatic Animal Health# Plant Health Food Production Food Safety Environment N um be r of c ou nt rie s Indicator 2020 2021 2022 In 2022, the TrACSS indicator further classified “animal health” into “terrestrial” and “aquatic”. Bangladesh, DPR Korea, Indonesia, and Thailand reported that the terrestrial animal sector performed better than the aquatic animal sector. Over three years, two sectors (plant health and environment) remained stagnant, with only one country (Thailand) reporting implementation in these areas. In 2022, Thailand and DPR Korea were the only two countries that reported utilizing relevant antimicrobial consumption/use data to inform operational decision-making and amend policies in food production. In 2021, Myanmar also reported implementation in this area (Fig. 8.4b). There was an increasing trend in the food safety sector over the three years of recording. (Fig. 8.4b). Three (27%) countries (DPR Korea, Thailand, and Timor-Leste) resorted to relevant antimicrobial consumption/use data to inform operational decision-making and amend policies in the food safety sector. The indicator, corresponding to the environment, shows stagnation from 2020 to 2022, with only one (9%) country (Thailand) utilizing relevant antimicrobial consumption/use data to inform operational decision-making and amend policies for the environment. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202356 4 Programmatic issues and priority actions Focus area 1: National AMR Plan and governance A significant progress on the number of countries that developed or updated NAP-AMR has been shown in this analysis. However, there is a challenge with regard to the quality of NAP-AMR. Charani et al.10 found an issue with the degree of maturity of the development of NAP and its operationalization. While there has been notable advancement in the number of nations that have reported the integration of national action plans on antimicrobial resistance (NAP-AMR) with other action plans, strategies or targets, there is currently a lack of available data regarding the specific diseases or health initiative targets that are related with AMR. The COVID-19 pandemic has had an adverse effect on the governance and administrative as well as operational processes of the national action plans on antimicrobial resistance in many countries. Priority actions € Costing details of NAP-AMR should be developed for further advocacy regarding funding for AMR control. € Information related to the linkage of NAP-AMR with other action plans/strategies/targets should be updated. € Discussions with all countries of the Region on specific actions to mitigate the negative impact of COVID-19 pandemic on NAP-AMR implementation is recommended. Focus area 2: Raising awareness Efforts on raising awareness about human health are maintained; significant progress on raising awareness has been shown in the fields of aquatic animal health and food safety. AMR training in the human health sector is still conducted at an ad hoc level in most countries of the Region. Relevant training in the animal health sector is still limited to educational institutions. Implementation rates of training and education programmes on the environment, food production, food safety, and veterinary services is lagging behind that in other sectors. 10 Charani E, Mendelson M, Pallett SJC, Ahmad R, Mpundu M, Mbamalu O, Bonaconsa C, Nampoothiri V, Singh S, Peiffer-Smadja N, Anton-Vazquez V, Moore LSP, Schouten J, Kostyanev T, Vlahović-Palćevski V, Kofteridis D, Corrêa JS, Holmes AH. An analysis of existing national action plans for antimicrobial resistance – gaps and opportunities in strategies optimizing antibiotic use in human populations. Lancet Glob Health. 2023 Feb 2: S2214-109X(23)00019-0. doi: 10.1016/S2214-109X (23)00019-0. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 57 Priority actions € Implementation of AMR training in the human health sector should be scaled up. € Relevant AMR training in the animal health sector should be expanded as continuing professional education in most countries of the Region. € There should be more efforts and investment in AMR training and education in the sectors of environment, food production, food safety, and veterinary services. Focus area 3: National AMR surveillance system Not all Member States have resistance surveillance data, used to inform decision-making, and not all have established or started implementing an integrated surveillance system for antimicrobial resistance. Across the sectors of AMR surveillance systems, human health- and terrestrial animal health-related surveillance systems have shown progress, compared with other sectors (aquatic animal health, food production, food safety, and environment). In addition, less than one third of the Member States have reference laboratories for AST for some or all 11 bacteria. A few countries lack the capacity to perform AST for fungi. Problems regarding stockouts of reagents for clinical bacteriology laboratories are still reported by the countries of the Region. Similarly, the National List of Essential In Vitro Diagnostics, which includes essential AMR diagnostics, is available only in six countries. There is progress on the implementation of national surveillance systems for AMR in terrestrial animals; however, this is not the case for aquatic animals. Integration of laboratories for AMR surveillance and the level of standardization and harmonization of procedures among laboratories experienced many challenges. Priority actions € Provide assistance to SE Asia Region countries to establish the integrated AMR surveillance systems, particularly in the sectors of aquatic animal health, food production, food safety, and environment. € Support forums to discuss the AMR surveillance data for informed decision-making at the SE Asia Region or country level. € Countries are encouraged to improve the capacity of reference laboratories for AST and ensure supplies to enable essential AMR diagnostics. € Provide technical assistance for integrating laboratories in the AMR surveillance, and standardize and harmonize procedures among laboratories. Focus area 4: Rational use of antimicrobials and surveillance of use/ sale (community-based) There is a discrepancy between countries that reported having legislation on prescription and sale of antimicrobials and those with the ability to monitor prescription/sale. A significant number of countries do not report relevant indicators, which may lead to misleading information, if not interpreted carefully. “Aquatic animals” are still lagging behind “terrestrial animals” with regard to Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202358 national AMR containment policy and regulatory framework for control and registration of use in animals. The involvement of plant health, food production, food safety, and environment needs to be increased to inform operational decision-making and amend policies. National legislation and a national monitoring system for antimicrobial pesticides in plant production are lacking. Priority actions € Developing and implementing national guidelines for antimicrobial use and stewardship as well as adopting “AWaRE” classification of antimicrobials for the National Essential Medicines List are necessary steps towards ensuring optimal use and access of antimicrobials. € The ability to monitor antimicrobial sale/use and utilize this data to enforce legislation on antimicrobial sale/use will be a key intervention for antimicrobial stewardship. These systems are also essential for guiding antimicrobial stewardship in all relevant sectors. € Develop national AMR containment policy and regulatory framework for aquatic animals. € Involve relevant antimicrobial consumption/use data in plant health, food production, food safety, and environment to inform operational decision-making and policy changes. € Strengthen the regulatory authority for national manufacture, import, marketing authorization, control of safety, quality and efficacy, and distribution of pesticides. € Develop guidelines, undertake training, implement and monitor antimicrobial stewardship (AMS) in health-care settings. Focus area 5: Infection prevention and control, and antimicrobial stewardship Most countries have national infection prevention and control (IPC) programmes. Nevertheless, implementation of IPC in health-care settings was selected. Lack of progress on the implementation of level C or above for IPC in human health care was also reported. Implementation of good management and hygiene practices to reduce development and transmission of AMR in food processing and animal husbandry was also lacking. Priority actions € An IPC programme that is implemented nationwide is necessary to strengthen the country’s capacity for preventing infections. € Improved water, sanitation, and hygiene (WASH) at health-care facilities and in the community, and strengthened routine immunization efforts are also integral to addressing AMR. € A nationwide plan to improve hygiene practices and reduce the development of AMR beyond human health care is needed, particularly in food processing and animal husbandry. Focus area 6: Research and innovation AMR-related research and innovation may have been carried out by academic and research institutes, but they are dispersed across several organizations and not systematically coordinated or recorded Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 59 at the national level. Research may have been conducted, but it did not have the NAP-AMR as its main focus. During the COVID-19 pandemic, there has been a surge in the use of antibiotics despite it being a viral infection; observation on this issue is already available but not visible yet. There is a need to develop interventions, based on the research findings. Priority actions € Establish a national AMR research consortium to fortify collaborations with academic and research institutions, civic society, and other stakeholders to mobilize resources and create evidence-based policy. € Promote research and innovation for data creation to support the successful application of NAP-AMR. € Publish the observation concerning antibiotic use during the COVID-19 pandemic and develop new interventions. Focus area 7: Legislation and surveillance for AMR in the environment More than half of the countries of the Region did not have available data, related to national assessment risk, in 17 sectors, relevant to human, animal, and plant health. A significant decline was also observed in the year 2022 in which only DPR Korea reported this indicator. Progress has been reported in sectors of regulation and/or legislation to prevent contamination. However, one particular sector – disposal of food, plant or animal products contaminated with antimicrobial residues over the maximum residue limit – showed regression. Several countries have not yet laid down any legislation for contamination. Passive surveillance of antimicrobial-related residues in water is still limited and needed. Priority actions € Assessing pollution impact, for example, through risk assessments, to prevent selection and further spread of resistance in the environment can help inform legislation and policy. € Improve water quality, which may further include surveillance systems that carefully monitor antimicrobial residues. € Meet current requirements for manufacturers, hospitals, and other relevant institutions with regard to disposal of antimicrobials in the environment; publicize, enforce, and discipline those who violate the regulations. € Work with academic institutions to conduct studies on quantifying antimicrobial residue in the environment. Focus area 8: Overarching coordination mechanisms for One Health engagement Following an increase in the multisectoral and One Health collaboration/coordination in 2017–2021, there had been a slight decline in 2022, with nine of the 11 countries having reached at least level C. Regarding sectors actively involved in developing and implementing the NAP-AMR, less progress in plant health and food production has been reported by the Member States. Regarding relevant antimicrobial consumption/use data use, the indicator in plant health and environment shows Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202360 stagnation from 2020 to 2022, with only one (9%) Member country (Thailand) utilizing relevant antimicrobial consumption/use data to inform operational decision-making and amend policies. Priority actions € A formalized multisectoral coordination mechanism with dedicated leadership, clear terms of reference, technical working groups, and adequate funding will create a solid foundation for NAP-AMR implementation and advocacy in the country. € Improve the current system of coordination across all sectors concerned, including increased engagement and participation of the environment, food safety, educational, aquaculture, and human and animal health sectors. € Build coordinated methods for antimicrobial surveillance, develop a platform for routine data exchange and monitoring, with stakeholders across all sectors, to ensure that policy decisions are supported by facts. € Maintain and improve coordination and collaboration across sectors outside of the World Antibiotic Awareness Week (WAAW) by keeping track of and evaluating development in many fields. € Assess the effect of awareness and education on the target population, particularly on the expected behaviour and usage of antimicrobial in relation to the prevention and control of AMR. € Map out the resources that are available across all sectors and coordinate their use for pertinent tasks in various sectors. € Build leadership capacity to ensure effective functioning of AMR multisectoral coordination structures. These structures are accountable for NAP-AMR prioritization, implementation, and monitoring through periodic review of data, including from TrACSS. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 61 5 Related documents TrACSS data: https://amrcountryprogress.org/download/Tripartite%20AMR%20Country%20Self- assessment%20Survey%20%E2%80%93%20TrACSS%20(1.1)%202016-2017%20(English).pdf. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202362 Annexes Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20232 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 3 A n n ex 1 Fo cu s ar ea a n d in d ic at o rs o f Tr A C SS 2 01 6– 20 22 p re se n te d in t h e fo u rt h p ro g re ss a n al ys is Fo cu s ar ea a n d in d ic at o rs In d ic at o r co d e o f ea ch T rA C SS r o u n d 20 17 20 18 20 19 20 20 20 21 20 22 Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p ro gr es s w ith d ev el op m en t of N A P- A M R 5. 1 5. 1 5. 1 5. 1 5. 1 2. 3 C ou nt ry u pd at in g th e ex pi re d N at io na l A M R A ct io n Pl an – – – – – 2. 3a C ou nt ry p la nn in g on A M R in te gr at ed w ith o th er e xi st in g ac tio n pl an s or s tr at eg ie s re la te d to O ne H ea lth S tr at eg y or O ne H ea lth m ec ha ni sm , W A SH , N at io na l H ea lth S ec to r Pl an , N at io na l A ct io n Pl an o n he al th s ec ur ity , c lim at e ch an ge a nd e nv iro nm en ta l p la nn in g, na tio na l d ev el op m en t pl an s, n at io na l f oo d sa fe ty s tr at eg y, o th er s – – – – – 2. 6 Ef fe ct o f th e C O V ID -1 9 pa nd em ic a nd t he n at io na l r es po ns e in t he co un tr y to N A P- A M R de ve lo pm en t an d im pl em en ta tio n pr oc es s – – – – 5. 2. 1 2. 7. Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (h um an h ea lth , a ni m al h ea lth , p la nt h ea lth , f oo d pr od uc tio n, f oo d sa fe ty , e nv iro nm en t) 6. 1 6. 2 6. 1 6. 2 6. 1 6. 1. 1 6. 1 6. 1. 1 6. 1 6. 1. 1 2. 9 2. 9. 1 Tr ai ni ng a nd p ro fe ss io na l e du ca tio n on A M R in t he h um an h ea lth se ct or 6. 3 6. 3 6. 2 6. 2 6. 2 3. 1 Tr ai ni ng a nd p ro fe ss io na l e du ca tio n on A M R in t he v et er in ar y se ct or 6. 4 6. 4 6. 3 6. 3 6. 3 4. 1 Tr ai ni ng a nd p ro fe ss io na l e du ca tio n on A M R in t he a qu at ic a ni m al he al th s ec to r – – – – – 4. 2 Tr ai ni ng a nd p ro fe ss io na l e du ca tio n on A M R in t he f ar m in g/ ag ric ul tu re s ec to r – 6. 5. 6. 4 6. 4 6. 4 5. 1. 5. 1. 1. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20234 Fo cu s ar ea a n d in d ic at o rs In d ic at o r co d e o f ea ch T rA C SS r o u n d 20 17 20 18 20 19 20 20 20 21 20 22 Pr og re ss o n st re ng th en in g ve te rin ar y se rv ic es 6. 5 6. 6 6. 5 6. 5 6. 5 4. 3 Pr og re ss o n st re ng th en in g th e aq ua tic a ni m al h ea lth s ec to r – – – – – 4. 4 Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m s C ou nt rie s ut ili zi ng r el ev an t an tim ic ro bi al c on su m pt io n/ us e da ta t o in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s – – – – – 2. 11 C ou nt rie s us in g re le va nt a nt im ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s – – – – – 2. 12 C ou nt rie s th at e st ab lis he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce s ys te m f or a nt im ic ro bi al r es is ta nc e – – – – – 2. 13 N at io na l s ur ve ill an ce s ys te m f or A M R in h um an s 7. 4 7. 4 7. 4 7. 4 7. 4 3. 3 C ap ac ity t o pe rf or m A ST f or c rit ic al ly im po rt an t ba ct er ia – – – – – 3. 4. 2 C ap ac ity t o pe rf or m A ST f or c rit ic al ly im po rt an t fu ng i – – – – – 3. 4. 3 C on tin ui ty o f se rv ic es f or c lin ic al b ac te rio lo gy la bo ra to rie s – – – – – 3. 4. 5 St an da rd iz ed A ST g ui de lin es – – – – – 3. 4. 6 Ex te rn al q ua lit y- as su re d ba ct er io lo gy la bo ra to ry s er vi ce s – – – – – 3. 4. 7 C ou nt rie s th at h av e de ve lo pe d a N at io na l L is t of E ss en tia l I n V itr o D ia gn os tic s th at in cl ud es a ll es se nt ia l A M R di ag no st ic s – – – – – 3. 4. 8 C ou nt rie s th at s ub m itt ed A M U d at a to t he O IE d at ab as e on an tim ic ro bi al a ge nt s in te nd ed f or u se in a ni m al s – – – – – 4. 5b O IE r ep or tin g op tio ns f or t he a nt im ic ro bi al u se d at ab as e – – – – – 4. 6 N at io na l s ur ve ill an ce s ys te m f or a nt im ic ro bi al r es is ta nc e in li ve te rr es tr ia l a ni m al s – – – – – 4. 7 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 5 Fo cu s ar ea a n d in d ic at o rs In d ic at o r co d e o f ea ch T rA C SS r o u n d 20 17 20 18 20 19 20 20 20 21 20 22 N at io na l s ur ve ill an ce s ys te m f or a nt im ic ro bi al r es is ta nc e in li ve aq ua tic a ni m al s – – – – – 4. 8 N at io na l s ur ve ill an ce s ys te m f or a nt im ic ro bi al r es is ta nc e in f oo d (t er re st ria l a nd a qu at ic a ni m al , a nd p la nt o rig in ) – – – – – 5. 3 Ef fe ct iv e in te gr at io n of la bo ra to rie s in t he A M R su rv ei lla nc e – – 7. 7a 7. 7a 7. 7a 5. 4a Le ve l o f th e st an da rd iz at io n an d ha rm on iz at io n of p ro ce du re s am on g la bo ra to rie s in t he A M R su rv ei lla nc e sy st em – – 7. 7b 7. 7b 7. 7b 5. 4b Re le va nc e of d ia gn os tic t ec hn iq ue s us ed b y la bo ra to rie s in cl ud ed in th e A M R su rv ei lla nc e sy st em – – 7. 7c 7. 7c 7. 7c 5. 4c Te ch ni ca l l ev el o f da ta m an ag em en t of t he la bo ra to ry n et w or k in t he A M R su rv ei lla nc e sy st em – – 7. 7d 7. 7d 7. 7d 5. 4d Fo cu s ar ea 4 : L eg is la ti o n a n d c o m m u n it y- b as ed s u rv ei lla n ce o f u se /s al e o f an ti m ic ro b ia l N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al in h um an h ea lth 7. 1 7. 1 7. 1 7. 1 7. 1 3. 2 N at io na l m on ito rin g sy st em s fo r in te nd ed u se o f an tim ic ro bi al in an im al s (s al es /u se ) 7. 2 7. 2 7. 2 7. 2 7. 2 4. 5. a N at io na l m on ito rin g sy st em s fo r pe st ic id e us e in p la nt p ro du ct io n, in cl ud in g an tim ic ro bi al p es tic id es , s uc h as b ac te ric id es a nd f un gi ci de s 7. 3 7. 3 7. 3 7. 3 7. 3 5. 2 C ou nt ry h as la w s an d re gu la tio ns o n pr es cr ip tio n an d sa le o f an tim ic ro bi al u se – – – – – 2. 8. 1 O pt im iz in g an tim ic ro bi al u se in h um an h ea lth 9. 1 9. 1 9. 1 9. 1 9. 1 3. 6 A do pt io n of A W aR e cl as si fic at io n of a nt ib io tic s in t he N at io na l Es se nt ia l M ed ic in es li st 9. 1. 1 9. 1. 1 3. 7 3. 7. 1 O pt im iz in g an tim ic ro bi al u se in t er re st ria l a ni m al h ea lth – – – – – 4. 11 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20236 Fo cu s ar ea a n d in d ic at o rs In d ic at o r co d e o f ea ch T rA C SS r o u n d 20 17 20 18 20 19 20 20 20 21 20 22 O pt im iz in g an tim ic ro bi al u se in a qu at ic a ni m al h ea lth – – – – – 4. 12 O pt im iz in g an tim ic ro bi al p es tic id es , s uc h as b ac te ric id es a nd fu ng ic id es u se in p la nt p ro du ct io n – – – 9. 3 9. 3 5. 6 Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an h ea lth c ar e 8. 1 8. 1 8. 1 8. 1 8. 1 3. 5 Bi os ec ur ity a nd g oo d an im al h us ba nd ry p ra ct ic es t o re du ce t he u se of a nt im ic ro bi al s an d m in im iz e de ve lo pm en t an d tr an sm is si on o f A M R in t er re st ria l a ni m al p ro du ct io n – – – – – 4. 9 Bi os ec ur ity a nd g oo d an im al h us ba nd ry p ra ct ic es t o re du ce t he u se of a nt im ic ro bi al s an d m in im iz e de ve lo pm en t an d tr an sm is si on o f A M R in a qu at ic a ni m al p ro du ct io n – – – – – 4. 10 G oo d m an ag em en t an d hy gi en e pr ac tic es t o re du ce d ev el op m en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng – – – – – 5. 5 Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n Pu bl ic at io n of N A P- A M R – – 5. 3 5. 3. 5. 3. 2. 8 Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t A n at io na l a ss es sm en t of r is ks f or r es id ue s of a nt im ic ro bi al co m po un ds a nd a nt im ic ro bi al -re si st an t pa th og en s in t he e nv iro nm en t – – – – 10 a 6. 1 C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to p re ve nt c on ta m in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t – – – – 10 b 6. 2 A s ys te m f or r eg ul ar m on ito rin g (p as si ve s ur ve ill an ce ) of a nt im ic ro bi al co m po un ds a nd t he ir m et ab ol ite s (o r re si du es ) an d re si st an t ba ct er ia or a nt im ic ro bi al r es is ta nc e ge ne s (A RG s) in w at er q ua lit y – – – – – 6. 3 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 7 Fo cu s ar ea a n d in d ic at o rs In d ic at o r co d e o f ea ch T rA C SS r o u n d 20 17 20 18 20 19 20 20 20 21 20 22 Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t M ul tis ec to ra l a nd O ne H ea lth c ol la bo ra tio n/ co or di na tio n 4. 1 4. 1 4. 1 4. 1 4. 1 2. 1 A m on ito rin g an d ev al ua tio n pl an f or t he n at io na l A M R ac tio n st ra te gi es 2. 3 b- g Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an – 4. 2 4. 2 4. 2 4. 2 2. 2 In fo rm at io n on t he u se o f da ta f ro m T rA C SS a t th e co un tr y le ve l – – – – – 2. 4a a nd b Th e nu m be r of c ou nt rie s ut ili zi ng r el ev an t an tim ic ro bi al co ns um pt io n/ us e da ta t o in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s – – – 7. 6 7. 6 2. 11 *T he in fo rm at io n is n ot a va ila bl e on T rA C SS . W e us ed o th er li te ra tu re t o pr ov id e in fo rm at io n on t hi s in di ca to r Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 20238 A n n ex 2 C o u n tr y p ro fi le s B an g la d es h ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t- so ur ce /a nt im ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /t ra cs s- 20 22 -b an gl ad es h. pd f? sf vr sn =7 81 4a 98 0_ 5& do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (iI nd ic at or 2 .6 , T rA C SS 20 22 ) – – Y es Y es Ba ng la de sh h ad in te gr at ed N A P- A M R w ith t hr ee e xi st in g ac tio n pl an s In te gr at in g N A P- A M R w ith ot he r ex is tin g pl an s ca n he lp a co un tr y ac hi ev e th e N A P go al s. It is im po rt an t fo r Ba ng la de sh to e xp an d in te gr at io n of N A P to ot he r ex is tin g pr og ra m m es Fo cu s A re a 2: R ai si n g A w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) C C C C Ba ng la de sh m ad e no p ro gr es s in t hi s se ct or , w hi ch is s til l a t a st ag e, w he re so m e aw ar en es s ac tiv iti es , a t lo ca l a nd / or s ub na tio na l l ev el s, a bo ut r is ks o f an tim ic ro bi al r es is ta nc e ar e ta rg et ed , b ut no t al l r el ev an t st ak eh ol de rs , b as ed o n st ak eh ol de r an al ys is To e nc ou ra ge B an gl ad es h to p la n an d im pl em en t th e aw ar en es s ra is in g ac tiv iti es o n a na tio na l l ev el fo r al l r el ev an t st ak eh ol de rs Tr ai ni ng a nd pr of es si on al e du ca tio n on A M R in t he f ar m in g/ ag ric ul tu re s ec to r (in di ca to r 5. 1, T rA C SS 20 22 ) B B B B Ba ng la de sh h ad n o pr og re ss w he re ta ilo re d ad h oc A M R tr ai ni ng c ou rs es w er e st ill a va ila bl e fo r at le as t tw o gr ou ps o f ke y st ak eh ol de rs To s ca le u p ta ilo re d ad h oc A M R tr ai ni ng c ou rs es t ha t in vo lv e m or e gr ou ps o f ke y st ak eh ol de rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 9 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 . N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e (in di ca to r 2. 13 , T rA C SS 20 22 ) – – – N o Ba ng la de sh h ad n ot e st ab lis he d or st ar te d th e im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce s ys te m f or A M R To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or A M R; te ch ni ca l a ss is ta nc e fr om W H O - SE A RO m ay b e ne ed ed . C ou nt rie s ut ili zi ng re le va nt a nt im ic ro bi al re si st an ce s ur ve ill an ce da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , Tr A C SS 2 02 2) – – – Y es Ba ng la de sh w as u si ng r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s. H ow ev er , i t st ill ha s lim ita tio ns s in ce it ju st c ov er s th re e se ct or s, in h um an , t er re st ria l a nd a qu at ic an im al s To e xp an d th e ut ili za tio n of A M R su rv ei lla nc e da ta f or d ec is io n- m ak in g in t he o th er s ec to rs Fo cu s ar ea 4 . R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) B B B D Ba ng la de sh s ta te d gr ad ua l p ro gr es s at th e st ag e w he re p re sc rib in g pr ac tic es an d an tib io tic u se a re m on ito re d in a na tio na l s am pl e of h ea lth -c ar e se tt in gs To e nh an ce t he im pl em en ta tio n of th e na tio na l m on ito rin g sy st em s fo r la rg er h ea lth -c ar e se tt in gs A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l E ss en tia l M ed ic in es li st ( in di ca to r 3. 7, T rA C SS 2 02 2) – B B B C ou nt ry h ad k no w le dg e ab ou t th e A W aR e cl as si fic at io n of a nt ib io tic s bu t ha s no t ye t ad op te d it To a do pt t he A W aR e cl as si fic at io n in t he N at io na l E ss en tia l M ed ic in es lis t Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202310 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 . I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in hu m an h ea lth c ar e (in di ca to r 3. 5, T rA C SS 20 22 ) A B C C Ba ng la de sh im pr ov ed in t hi s se ct or , w ith a n at io na l I PC p la n an d gu id el in e av ai la bl e, a nd s om e he al th -c ar e fa ci lit ie s im pl em en tin g it To im pr ov e by f ol lo w in g th e na tio na l I PC p ro gr am m e in ac co rd an ce w ith t he W H O IP C co re g ui de lin es , a nd im pl em en t th e na tio na l p la n an d gu id el in es a t al l h ea lth -c ar e fa ci lit ie s. G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – N /A A B Ba ng la de sh im pr ov ed b y ha vi ng s om e ac tiv iti es in p la ce t o im pr ov e G M P an d G H P To d ev el op a n at io na l p la n th at is ag re ed u po n in o rd er t o en su re ap pr op ria te a ni m al h us ba nd ry an d bi os ec ur ity p ro ce du re s, in ac co rd an ce w ith in te rn at io na l st an da rd s, a nd n at io na l g ui da nc e ad ap te d fo r im pl em en ta tio n at lo ca l f ar m a nd f oo d pr od uc tio n le ve ls Fo cu s ar ea 6 . R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n, im pl em en te d in t he c ou nt ry , i s la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 11 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 . L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al co m po un ds a nd t he ir m et ab ol ite s di sc ha rg ed to t he e nv iro nm en t (in di ca to r 6. 2, T rA C SS 20 22 ) – – Y es ( 6) /Y es bu t no t fu lly im pl em en te d (3 )/ N o (0 ) Y es ( 15 )/ N o (5 ) Ba ng la de sh c on si st en tly h ad le gi sl at io n an d/ or r eg ul at io ns t o pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al co m po un ds a nd t he ir m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e of t he s ub se ct or s To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns c on ce rn in g us in g liq ui d an d so lid w as te p ro du ct s fr om h um an s an d an im al s in ag ric ul tu re To s ug ge st c ou nt ry r eg ul at io n of p ro du ct s, c on ta m in at ed f ro m w as te f oo d, p la nt , o r an im al , w hi ch a re o ve r th e m ax im um re si du e lim it To a dv is e on c re at in g le gi sl at io n on w as te -w at er t re at m en t in a re as vu ln er ab le t o di sa st er s du e to ex tr em e w ea th er e ve nt s. Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an ( in di ca to r 2. 2, Tr A C SS 2 02 2) Y es ( 2) / N o (4 ) Y es ( 2) / N o (4 ) Y es (3 )/ N o (3 ) Y es ( 5) / N o (2 ) Ba ng la de sh w as a ct iv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in se ve ra l s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm b et w ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he p la nt h ea lth a nd f oo d pr od uc tio n se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202312 B h u ta n ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -b tn -2 02 2- co un tr y- pr of ile .p df ?s fv rs n= ac bf 7b 10 _6 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith o th er ex is tin g ac tio n pl an s or st ra te gi es ( in di ca to r 2. 6, Tr A C SS 2 02 2) – – N o Y es Bh ut an h ad in te gr at ed N A P- A M R w ith t hr ee o ut o f ei gh t ex is tin g ac tio n pl an s: O ne H ea lth s tr at eg y, N at io na l H ea lth S ec to r Pl an , a nd na tio na l a gr ic ul tu re d ev el op m en t pl an s an d po lic ie s In te gr at in g N A P- A M R w ith o th er ex is tin g pl an s ca n he lp a c ou nt ry ac hi ev e th e N A P go al s. It is im po rt an t fo r Bh ut an t o ex pa nd in te gr at io n of N A P to o th er ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) C C C C Bh ut an m ad e no p ro gr es s in t hi s se ct or , w hi ch w as s til l i n a st ag e, w he re s om e aw ar en es s ac tiv iti es , at lo ca l a nd /o r su bn at io na l l ev el , ab ou t ris ks o f an tim ic ro bi al re si st an ce w er e ta rg et ed , b ut n ot al l r el ev an t st ak eh ol de rs , b as ed o n st ak eh ol de r an al ys is Th er e is a n ee d fo r na tio nw id e, go ve rn m en t-s up po rt ed an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns , ta rg et in g al l o r th e m aj or ity o f pr io rit y st ak eh ol de r gr ou ps Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in t he fa rm in g/ ag ric ul tu re s ec to r (in di ca to r 5. 1, T rA C SS 20 22 ) A A A B Bh ut an s ta te d pr og re ss f ro m ha vi ng n o tr ai ni ng p ro vi si on on A M R fo r ke y st ak eh ol de rs to h av in g ta ilo re d ad h oc A M R tr ai ni ng c ou rs es f or a t le as t tw o gr ou ps o f ke y st ak eh ol de rs N ee d to e xp an d th e pr og ra m m e to m ak e co ur se s av ai la bl e fo r al l o r th e m aj or ity o f ke y st ak eh ol de rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 13 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , Tr A C SS 2 02 2) – – – Y es Bh ut an e st ab lis he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce s ys te m f or an tim ic ro bi al r es is ta nc e. H ow ev er , it on ly c ov er ed 2 s ec to rs in h um an an d an im al h ea lth To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e in t he ot he r se ct or s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 20 22 ) – – – Y es Bh ut an w as a lre ad y us in g re le va nt a nt im ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s. H ow ev er , i t st ill ha s lim ita tio ns s in ce it ju st c ov er ed 2 se ct or s in h um an a nd a ni m al he al th To u se r el ev an t an tim ic ro bi al re si st an ce s ur ve ill an ce d at a to in fo rm d ec is io n- m ak in g an d am en d po lic ie s in t he o th er se ct or s Fo cu s ar ea 4 . R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) C C C C Bh ut an c on si st en tly h ad t ot al s al es of a nt im ic ro bi al s m on ito re d at t he na tio na l l ev el o r so m e m on ito rin g at t he s ub na tio na l l ev el Th er e is a n ee d fo r pr es cr ib in g pr ac tic es a nd a nt ib io tic u se , w hi ch a re m on ito re d in a n at io na l sa m pl e of h ea lth -c ar e se tt in gs A do pt io n of A W aR e cl as si fic at io n of a nt ib io tic s in t he N at io na l E ss en tia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 2 02 2) – B B D Bh ut an im pr ov ed f ro m ju st h av in g kn ow le dg e to h av in g ad op te d th e A W aR e cl as si fic at io n of a nt ib io tic s in t he ir N at io na l E ss en tia l M ed ic in es L is t an d is m on ito rin g its a nt ib io tic c on su m pt io n an d re po rt in g it, a cc or di ng t o th e A W aR e cl as si fic at io n To in cl ud e A W aR e in it s an tim ic ro bi al s te w ar ds hi p pl an s (e .g . t re at m en t gu id el in es ) Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202314 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 . I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, Tr A C SS 2 02 2) C B B B Bh ut an h ad a n at io na l I PC pr og ra m m e or a n op er at io na l p la n av ai la bl e bu t no t im pl em en te d To d is se m in at e th e na tio na l I PC pr og ra m m e or o pe ra tio na l p la n th at h as b ee n de ve lo pe d G oo d m an ag em en t an d hy gi en e pr ac tic es t o re du ce d ev el op m en t an d tr an sm is si on o f A M R in fo od p ro ce ss in g (in di ca to r 5. 5, T rA C SS 2 02 2) – – B C Bh ut an h ad a n at io na l p la n ag re ed up on t o en su re G M P an d G H P, af te r pr ev io us ly o nl y ha vi ng s om e ac tiv iti es t o im pl em en t th os e tw o ta rg et s To m ai nt ai n th e na tio na l p la n ag re ed u po n to e ns ur e G M P an d G H P Fo cu s ar ea 6 . R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fo cu s ar ea 7 . L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, Tr A C SS 2 02 2) – – Y es ( 0) /Y es bu t no t fu lly im pl em en te d (0 )/ N o (8 ) Y es ( 0) / N o (1 7) Bh ut an h ad n o as pe ct s of le gi sl at io n or r eg ul at io n to p re ve nt co nt am in at io n of t he e nv iro nm en t, in cl ud in g al l 1 7 as pe ct s in t he en vi ro nm en t To d ev el op A M R po lic ie s an d ta rg et ed r eg ul at io ns t o re du ce en vi ro nm en ta l c on ta m in at io n fr om d is ch ar ge d an tim ic ro bi al s, an tim ic ro bi al c om po un ds , a nd m et ab ol ite s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 15 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an (in di ca to r 2. 2, T rA C SS 20 22 ) Y es ( 3) /N o (3 ) Y es ( 3) /N o (3 ) Y es ( 3) /N o (3 ) Y es ( 3) / N o (4 ) Bh ut an w as a ct iv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in s ev er al s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he a qu at ic an im al h ea lth , p la nt h ea lth , f oo d pr od uc tio n, a nd e nv iro nm en t se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202316 D em o cr at ic P eo p le ’s R ep u b lic o f K o re a ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -p rk -2 02 2- co un tr y- pr of ile .p df ?s fv rs n= 18 a1 e3 a9 _6 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith o th er ex is tin g ac tio n pl an s or st ra te gi es ( in di ca to r 2. 6, Tr A C SS 2 02 2) – – Y es Y es D PR K or ea h ad in te gr at ed N A P- A M R w ith ei gh t ou t of 1 3 ex is tin g ac tio n pl an s In te gr at in g N A P- A M R w ith ot he r ex is tin g pl an s ca n he lp a co un tr y ac hi ev e th e N A P go al s. It is im po rt an t fo r D PR K or ea t o ex pa nd in te gr at io n of N A P to ot he r ex is tin g pr og ra m m es Fo cu s A re a 2: R ai si n g A w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks an d re sp on se ( in di ca to r 2. 9, Tr A C SS 2 02 2) C C C D D PR K or ea h ad m ad e pr og re ss t o ha vi ng na tio nw id e, g ov er nm en t-s up po rt ed an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns , t ar ge tin g al l o r th e m aj or ity of p rio rit y st ak eh ol de r gr ou ps , u til iz in g ta rg et ed m es sa gi ng a cc or di ng ly w ith in se ct or s Ro ut in e, t ar ge te d, n at io nw id e, go ve rn m en t-s up po rt ed ca m pa ig ns f or u nd er st an di ng A M R ris k an d re sp on se w ith re gu la r m on ito rin g ne ed t o be im pl em en te d Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in t he fa rm in g/ ag ric ul tu re s ec to r (in di ca to r 5. 1, T rA C SS 2 02 2) B B C C D PR K or ea h ad m ad e pr og re ss o n ha vi ng ta ilo re d ad h oc A M R tr ai ni ng c ou rs es av ai la bl e fo r al l o r th e m aj or ity o f ke y st ak eh ol de rs Ro ut in el y av ai la bl e tr ai ni ng co ur se s in t he f ar m in g/ ag ric ul tu re s ec to r ne ed t o be ex pa nd ed n at io nw id e to c ov er a ll ke y st ak eh ol de rs Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at e st ab lis he d or st ar te d th e im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , Tr A C SS 2 02 2) – – – Y es D PR K or ea h ad n ot e st ab lis he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 17 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s (I nd ic at or 2 .1 2, T rA C SS 20 22 ) – – – Y es D PR K or ea h ad a lre ad y us ed r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s. H ow ev er , i t st ill h as lim ita tio ns s in ce it ju st c ov er s 3 se ct or s, in hu m an , t er re st ria l, an d aq ua tic a ni m al s To u se r el ev an t an tim ic ro bi al re si st an ce s ur ve ill an ce d at a to in fo rm d ec is io n- m ak in g an d am en d po lic ie s in t he o th er se ct or s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em fo r co ns um pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an h ea lth ( in di ca to r 3. 2, T rA C SS 2 02 2) B B C E D PR K or ea s ta te d si gn ifi ca nt p ro gr es s to ha vi ng d at a co lle ct ed a nd r ep or te d on a re gu la r ba si s (e ve ry y ea r/ tw o ye ar s) o n (a ) an tim ic ro bi al s al es o r co ns um pt io n at th e na tio na l l ev el f or h um an u se ; a nd ( b) an tib io tic p re sc rib in g an d ap pr op ria te / ra tio na l u se , i n a re pr es en ta tiv e sa m pl e of he al th f ac ili tie s, p ub lic a nd p riv at e To m ai nt ai n th e cu rr en t st at e of da ta c ol le ct io n an d re po rt o n a ro ut in e ba si s A do pt io n of A W aR e cl as si fic at io n of a nt ib io tic s in t he N at io na l E ss en tia l M ed ic in es L is t (in di ca to r 3. 7, Tr A C SS 2 02 2) – C C B D PR K or ea h as r eg re ss ed t o ha vi ng kn ow le dg e ab ou t th e A W aR e cl as si fic at io n of a nt ib io tic s bu t ha s no t ye t ad op te d it To e nc ou ra ge D PR K or ea t o ad op t A W aR e cl as si fic at io n of an tib io tic s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, Tr A C SS 2 02 2) C C C C D PR K or ea h ad im pr ov ed in t hi s se ct or , w ith a n at io na l I PC p la n av ai la bl e an d di ss em in at ed , w ith s el ec te d he al th -c ar e fa ci lit ie s im pl em en tin g it. To im pr ov e by f ol lo w in g th e na tio na l I PC p ro gr am m e in ac co rd an ce w ith t he W H O IP C co re g ui de lin es a nd im pl em en t th e na tio na l p la n an d gu id el in es at a ll he al th -c ar e fa ci lit ie s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202318 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s G oo d m an ag em en t an d hy gi en e pr ac tic es t o re du ce th e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng ( In di ca to r 5. 5, Tr A C SS 2 02 2) – B C C D PR K or ea im pr ov ed t o ha vi ng a n at io na l pl an a gr ee d up on t o en su re G M P an d G H P, a ft er p re vi ou sl y on ly h av in g so m e ac tiv iti es t o im pl em en t th os e tw o ta rg et s To im pr ov e cu rr en t pr og re ss by h av in g na tio nw id e im pl em en ta tio n of a p la n to en su re g oo d an im al h us ba nd ry an d bi os ec ur ity p ra ct ic es , a nd na tio na l g ui da nc e pu bl is he d an d di ss em in at ed Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, Tr A C SS 2 02 2) – – Y es ( 8) /Y es bu t no t fu lly im pl em en te d (0 )/ N o( 0) Y es (1 2) /N o (5 ) D PR K or ea h ad le gi sl at io ns a nd /o r re gu la tio ns t o pr ev en t co nt am in at io n of th e en vi ro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds , d es pi te la ck in g in s om e su bs ec to rs . To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns c on ce rn in g us in g liq ui d an d so lid w as te pr od uc ts f ro m a qu at ic a ni m al s in ag ric ul tu re To s ug ge st c ou nt ry r eg ul at io n of p ro du ct s co nt am in at ed f ro m w as te f oo d, p la nt , o r an im al , w hi ch a re o ve r th e m ax im um re si du e lim it To a dv is e cr ea tin g le gi sl at io n on w as te w at er in a re as v ul ne ra bl e to d is as te rs d ue t o of e xt re m e w ea th er a nd e ve nt s To p ro m ot e cr ea tio n of r eg ul at io n re la te d to t ra ns na tio na l a nd in te rc on tin en ta l t ra ns po rt a nd m ov em en t of f oo d, g oo ds , l iv e an im al s, a nd p eo pl e Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 19 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an (in di ca to r 2. 2, T rA C SS 2 02 2) Y es ( 2) / N o (4 ) Y es ( 2) / N o (4 ) Y es ( 5) /N o (1 ) Y es ( 5) / N o (2 ) D PR K or ea w as a ct iv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in se ve ra l s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he a qu at ic an im al a nd p la nt h ea lth s ec to rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202320 In d ia ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -in d- 20 22 -c ou nt ry - pr of ile .p df ?s fv rs n= e8 49 0f 94 _9 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith o th er ex is tin g ac tio n pl an s or st ra te gi es ( in di ca to r 2. 6, Tr A C SS 2 02 2) – – Y es Y es In di a ha d in te gr at ed N A P- A M R in to f ou r ou t of e ig ht e xi st in g ac tio n pl an s: O ne H ea lth S tr at eg y, N at io na l H ea lth S ec to r Pl an , c lim at e ch an ge a nd e nv iro nm en ta l pl an ni ng , a nd n at io na l f oo d sa fe ty st ra te gy a nd p ol ic ie s. In te gr at in g N A P- A M R w ith o th er ex is tin g pl an s ca n he lp a c ou nt ry ac hi ev e th e N A P go al s. It is im po rt an t fo r In di a to e xp an d in te gr at io n of N A P to o th er ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) – C C C In di a m ad e no p ro gr es s in t hi s se ct or , w hi ch is s til l i n a st ag e, w he re s om e aw ar en es s ac tiv iti es , a t lo ca l a nd / or s ub na tio na l l ev el , a bo ut r is ks o f an tim ic ro bi al r es is ta nc e ar e ta rg et ed , b ut no t al l r el ev an t st ak eh ol de rs , b as ed o n st ak eh ol de r an al ys is . Th er e is a n ee d fo r na tio nw id e, go ve rn m en t-s up po rt ed an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns ta rg et in g al l o r th e m aj or ity o f pr io rit y st ak eh ol de r gr ou ps Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in t he fa rm in g/ ag ric ul tu re s ec to r (in di ca to r 5. 1, T rA C SS 20 22 ) B A B B In di a ha d no p ro gr es s w he re in t ai lo re d ad h oc A M R tr ai ni ng c ou rs es a re s til l av ai la bl e fo r at le as t tw o gr ou ps o f ke y st ak eh ol de rs Th er e is a n ee d to e xp an d th e pr og ra m m e to m ak e co ur se s av ai la bl e fo r al l o r th e m aj or ity o f ke y st ak eh ol de rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 21 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , Tr A C SS 2 02 2) – – – Y es In di a es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce in t w o ou t of s ev en s ec to rs : i n hu m an h ea lth a nd t er re st ria l a ni m al s To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e in t he ot he r se ct or s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , Tr A C SS 2 02 2) – – – Y es In di a w as a lre ad y us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s. H ow ev er , i t st ill h as lim ita tio ns s in ce it ju st c ov er s 3 se ct or s, in h um an , t er re st ria l, an d aq ua tic a ni m al s To u se r el ev an t an tim ic ro bi al re si st an ce s ur ve ill an ce d at a to in fo rm d ec is io n- m ak in g an d am en d po lic ie s in t he o th er se ct or s Fo cu s ar ea 4 . R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) B D B B In di a m ad e no p ro gr es s an d st ay ed a t th e st ag e w he re in t he re is a s ys te m de si gn ed f or s ur ve ill an ce o f an tim ic ro bi al us e th at in cl ud es m on ito rin g na tio na l- le ve l s al es o r co ns um pt io n of a nt ib io tic s in h ea lth s er vi ce s To e nh an ce t he m on ito rin g of t ot al a nt im ic ro bi al s sa le s at th e na tio na l l ev el a nd /o r so m e m on ito rin g of a nt ib io tic u se a t th e su bn at io na l l ev el A do pt io n of A W aR e cl as si fic at io n of a nt ib io tic s in t he N at io na l E ss en tia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 2 02 2) – B B B C ou nt ry h ad k no w le dg e ab ou t th e A W aR e cl as si fic at io n of a nt ib io tic s bu t ha s no t ye t ad op te d it To a do pt t he A W aR e cl as si fic at io n in t he N at io na l Es se nt ia l M ed ic in es L is t Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202322 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, Tr A C SS 2 02 2) B B B C In di a im pr ov ed in t hi s se ct or , w ith a na tio na l I PC p ro gr am m e an d an op er at io na l p la n th at a re a va ila bl e, a nd na tio na l g ui de lin es f or h ea lth c ar e IP C ar e av ai la bl e an d di ss em in at ed . S el ec te d he al th f ac ili tie s ar e im pl em en tin g th e gu id el in es , w ith m on ito rin g an d fe ed ba ck in p la ce To im pr ov e by f ol lo w in g th e na tio na l I PC p ro gr am m e, in ac co rd an ce w ith t he W H O IP C co re g ui de lin es , a nd im pl em en t th e na tio na l p la n an d gu id el in es at a ll he al th -c ar e fa ci lit ie s G oo d m an ag em en t an d hy gi en e pr ac tic es t o re du ce d ev el op m en t an d tr an sm is si on o f A M R in fo od p ro ce ss in g (in di ca to r 5. 5, T rA C SS 2 02 2) – B B B In di a st at ed a d ec lin e w hi ch s ta ye d at th e le ve l w he re t he re a re n o sy st em at ic ef fo rt s to im pr ov e go od a ni m al hu sb an dr y an d bi os ec ur ity p ra ct ic es To d ev el op a n at io na l p la n th at is ag re ed u po n in o rd er t o en su re ap pr op ria te a ni m al h us ba nd ry an d bi os ec ur ity p ro ce du re s, in ac co rd an ce w ith in te rn at io na l st an da rd s, a nd n at io na l g ui da nc e ad ap te d fo r im pl em en ta tio n at lo ca l f ar m a nd f oo d pr od uc tio n le ve ls Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 23 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 0) /Y es bu t no t fu lly im pl em en te d (3 )/ N o (5 ) Y es ( 10 )/ N o (7 ) In di a co ns is te nt ly h ad le gi sl at io n an d/ or r eg ul at io ns t o pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds a nd th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e of th e su bs ec to rs To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns c on ce rn in g w as te w at er d is ch ar ge f ro m an im al a nd m an uf ac tu rin g si te fo r an tim ic ro bi al To s ug ge st c ou nt ry r eg ul at io n of c on ta m in at ed s ol id o r liq ui d w as te f ro m a ni m al a nd h um an , pr io r to u se in a gr ic ul tu re To a dv is e cr ea tin g le gi sl at io n on w as te w at er t re at m en t in a re as vu ln er ab le t o di sa st er s du e to o f ex tr em e w ea th er a nd e ve nt s To p ro m ot e cr ea tio n of re gu la tio n re la te d to o ve rs pr ay , dr ift , a nd le ac hi ng , f ol lo w in g pe st ic id e an d fe rt ili ze r ap pl ic at io ns Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an (in di ca to r 2. 2, T rA C SS 20 22 ) Y es ( 4) / N o (2 ) Y es ( 4) / N o (2 ) Y es ( 4) /N o (2 ) Y es ( 6) / N o (1 ) In di a w as a ct iv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in s ev er al su bs ec to rs To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he f oo d pr od uc tio n se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202324 In d o n es ia ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -id n- 20 22 -c ou nt ry - pr of ile .p df ?s fv rs n= 87 f7 63 46 _6 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (in di ca to r 2. 6, T rA C SS 20 22 ) – – Y es Y es In do ne si a ha d in te gr at ed N A P- A M R in to fiv e ou t of e ig ht e xi st in g ac tio n pl an s: O ne H ea lth s tr at eg y, W A SH , N at io na l A ct io n Pl an o n H ea lth S ec ur ity , n at io na l fo od s af et y st ra te gy a nd p ol ic ie s, a nd na tio na l a gr ic ul tu re d ev el op m en t pl an s an d po lic ie s In te gr at in g N A P- A M R w ith o th er ex is tin g pl an s ca n he lp a c ou nt ry to a ch ie ve t he N A P go al s. It is im po rt an t fo r In do ne si a to ex pa nd in te gr at io n of N A P to ot he r ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) D D D D In do ne si a m ad e no p ro gr es s in t hi s se ct or , w hi ch is s til l i n a st ag e w he re na tio nw id e, g ov er nm en t-s up po rt ed an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns t ar ge t al l o r th e m aj or ity o f pr io rit y st ak eh ol de r gr ou ps , u til iz in g ta rg et ed m es sa gi ng a cc or di ng ly w ith in se ct or s Ro ut in e, t ar ge te d, n at io nw id e, go ve rn m en t-s up po rt ed ca m pa ig ns f or u nd er st an di ng A M R ris k an d re sp on se w ith re gu la r m on ito rin g ne ed t o be im pl em en te d Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in th e fa rm in g/ ag ric ul tu re se ct or ( in di ca to r 5. 1, Tr A C SS 2 02 2) B B B B In do ne si a m ad e no p ro gr es s in t hi s se ct or , w hi ch is a t th e st ag e w he re ta ilo re d ad h oc A M R tr ai ni ng c ou rs es a re st ill a va ila bl e fo r at le as t tw o gr ou ps o f ke y st ak eh ol de rs To e xp an d th e pr og ra m m e fo r m ak in g co ur se s re la te d to fa rm in g/ ag ric ul tu re a va ila bl e fo r al l o r th e m aj or ity o f ke y st ak eh ol de rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 25 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , T rA C SS 2 02 2) – – – Y es In do ne si a es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce in o ne o ut o f se ve n se ct or s: in hu m an h ea lth To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e in t he ot he r se ct or s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 2 02 2) – – – Y es In do ne si a w as a lre ad y us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s. H ow ev er , i t st ill h as lim ita tio ns s in ce it ju st c ov er s 2 se ct or s, hu m an a nd t er re st ria l a ni m al s To u se r el ev an t an tim ic ro bi al re si st an ce s ur ve ill an ce d at a to in fo rm d ec is io n- m ak in g an d am en d po lic ie s in t he o th er se ct or s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) B B D D In do ne si a st at ed g ra du al p ro gr es s at t he st ag e w he re in p re sc rib in g pr ac tic es a nd an tib io tic u se a re m on ito re d in a n at io na l sa m pl e of h ea lth -c ar e se tt in gs To e nh an ce t he im pl em en ta tio n of t he n at io na l m on ito rin g sy st em s fo r la rg er h ea lth -c ar e se tt in gs A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l Es se nt ia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 20 22 ) – B C C C ou nt ry a do pt ed t he A W aR e cl as si fic at io n of a nt ib io tic s in t he ir N at io na l E ss en tia l M ed ic in es L is t To m on ito r its a nt ib io tic co ns um pt io n an d re po rt it , ac co rd in g to t he A W A Re cl as si fic at io n Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202326 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, T rA C SS 2 02 2) C C C C In do ne si a ha d im pr ov ed in t hi s se ct or , w ith a n at io na l I PC p la n av ai la bl e, ac co rd in g to t he W H O IP C c om po ne nt s To im pr ov e by f ol lo w in g th e na tio na l I PC p ro gr am m e, in ac co rd an ce w ith t he W H O IP C co re g ui de lin es , a nd im pl em en t th e na tio na l p la n an d gu id el in es at a ll he al th -c ar e fa ci lit ie s G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – D D D In do ne si a ha d na tio nw id e im pl em en ta tio n of a p la n to e ns ur e go od m an uf ac tu rin g (G M P) p ra ct ic es a nd g oo d hy gi en e pr ac tic es ( G H P) , a nd n at io na l gu id an ce p ub lis he d an d di ss em in at ed To m on ito r th e na tio nw id e pl an pe rio di ca lly Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 27 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 6) /Y es bu t no t fu lly im pl em en te d (2 )/ N o (0 ) Y es (1 0) / N o (7 ) In do ne si a co ns is te nt ly h ad le gi sl at io n an d/ or r eg ul at io ns t o pr ev en t co nt am in at io n of t he e nv iro nm en t w ith an tim ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e of th e su bs ec to rs To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns c on ce rn in g di sp os al o f m ed ic in e, an tim ic ro bi al a ge nt , a nd w as te - w at er d is ch ar ge f ro m a ni m al s. To s ug ge st c ou nt ry r eg ul at io n of c on ta m in at ed s ol id o r liq ui d w as te f ro m a ni m al s an d hu m an s pr io r to u se in a gr ic ul tu re To a dv is e cr ea tin g le gi sl at io n on w as te w at er t re at m en t in a re as vu ln er ab le t o di sa st er s du e to o f ex tr em e w ea th er a nd e ve nt s. T o pr om ot e cr ea tio n of r eg ul at io n re la te d to o ve rs pr ay , d rif t, a nd le ac hi ng , f ol lo w in g fe rt ili ze r ap pl ic at io ns Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an ( in di ca to r 2. 2, Tr A C SS 2 02 2) Y es ( 4) / N o (2 ) Y es ( 5) / N o (1 ) Y es ( 5) /N o (1 ) Y es (6 )/ N o (1 ) In do ne si a w as a ct iv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in se ve ra l s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he p la nt h ea lth se ct or Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202328 M al d iv es ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /t ra cs s- 20 22 -m al di ve s. pd f? sf vr sn =6 6c fc e6 1_ 5& d ow nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (in di ca to r 2. 6, T rA C SS 20 22 ) – – N o Y es M al di ve s ha s in te gr at ed N A P- A M R in to on e ou t of e ig ht e xi st in g ac tio n pl an s in O ne H ea lth s tr at eg y or O ne H ea lth m ec ha ni sm In te gr at in g N A P- A M R w ith o th er ex is tin g pl an s ca n he lp a c ou nt ry ac hi ev e th e N A P go al s. It is im po rt an t fo r M al di ve s to e xp an d in te gr at io n of N A P to o th er e xi st in g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) D D C C M al di ve s sh ow s a de cl in e at t he le ve l w he re t he re a re s om e aw ar en es s ac tiv iti es a t lo ca l a nd /o r su b- na tio na l le ve l a bo ut r is ks o f an tim ic ro bi al re si st an ce a nd a ct io ns t o ad dr es s it, ta rg et in g so m e bu t no t al l r el ev an t st ak eh ol de rs , b as ed o n st ak eh ol de r an al ys is Th er e is a n ee d fo r na tio nw id e, go ve rn m en t-s up po rt ed an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns , t ar ge tin g al l o r th e m aj or ity o f pr io rit y st ak eh ol de r gr ou ps Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in th e fa rm in g/ ag ric ul tu re se ct or ( in di ca to r 5. 1, Tr A C SS 2 02 2) A B A B M al di ve s ha s m ad e no p ro gr es s an d st ay s at t he le ve l w he re t ai lo re d ad h oc A M R tr ai ni ng c ou rs es a re a va ila bl e fo r at le as t tw o gr ou ps o f ke y st ak eh ol de rs Th er e is a n ee d to e xp an d th e pr og ra m m e to m ak e co ur se s av ai la bl e fo r al l o r th e m aj or ity o f th e ke y st ak eh ol de rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 29 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e (in di ca to r 2. 13 , T rA C SS 20 22 ) – – – N o M al di ve s ha s no t es ta bl is he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 2 02 2) – – – N o M al di ve s ha s no t ye t us ed r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s To s ta rt u si ng r el ev an t an tim ic ro bi al re si st an ce s ur ve ill an ce d at a to in fo rm d ec is io n- m ak in g an d am en d po lic ie s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) D B A A M al di ve s sh ow s a de cl in e at t he le ve l w he re t he re is n o na tio na l p la n or s ys te m fo r m on ito rin g us e of a nt im ic ro bi al s To c re at e a sy st em f or m on ito rin g an tim ic ro bi al u sa ge , i nc lu di ng tr ac ki ng n at io na l-l ev el s al es o r co ns um pt io n of a nt ib io tic s an d th e se ns ib le u se o f an tib io tic s in h ea lth ca re A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l E ss en tia l M ed ic in es li st ( in di ca to r 3. 7, T rA C SS 2 02 2) – C B C M al di ve s ha s im pr ov ed in t hi s se ct or an d at t he le ve l w he re in t he c ou nt ry ha s ad op te d th e A W aR e cl as si fic at io n of a nt ib io tic s in t he ir N at io na l E ss en tia l M ed ic in es L is t To m on ito r its a nt ib io tic co ns um pt io n an d re po rt it , ac co rd in g to t he A W A Re cl as si fic at io n Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202330 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, T rA C SS 2 02 2) B B A A M al di ve s sh ow s a de cl in e at t he le ve l w he re n o na tio na l I PC p ro gr am m e or op er at io na l p la n is a va ila bl e To d ev el op a n at io na l I PC pr og ra m m e or o pe ra tio na l p la n G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – B B A M al di ve s sh ow s a de cl in e at t he le ve l w he re in t he re w er e no s ys te m at ic ef fo rt s to im pr ov e go od m an uf ac tu rin g pr ac tic es ( G M P) a nd g oo d hy gi en e pr ac tic es ( G H P) ; n at io na l p la n ag re ed up on t o en su re g oo d m an uf ac tu rin g (G M P) a nd h yg ie ne p ra ct ic es ( G H P) , i n lin e w ith in te rn at io na l s ta nd ar ds ( e. g. C od ex A lim en ta riu s) To c on du ct s ys te m at ic e ff or ts t o im pr ov e G M P an d G H P Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 31 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 1) /Y es bu t no t fu lly im pl em en te d (0 )/ N o( 7) Y es ( 11 )/ N o (6 ) M al di ve s co ns is te nt ly h ad le gi sl at io n an d/ or r eg ul at io ns t o pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al co m po un ds a nd t he ir m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e of t he s ub se ct or s To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns c on ce rn in g w as te w at er di sc ha rg e fr om m an uf ac tu rin g si te fo r an tim ic ro bi al a nd d is po sa l o f fo od , p la nt o r an im al p ro du ct s, co nt am in at ed w ith a nt im ic ro bi al re si du es To p ro m pt t he c ou nt ry f or m ak in g re gu la tio n re la te d to m an ag em en t of r un of f an d so lid w as te f ro m sl au gh te rh ou se s To s ug ge st c ou nt ry r eg ul at io n of co nt am in at ed s ol id o r liq ui d w as te fr om a ni m al s an d hu m an s, p rio r to us e in a gr ic ul tu re Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an ( in di ca to r 2. 2, Tr A C SS 2 02 2) Y es ( 6) / N o (0 ) Y es ( 6) / N o (0 ) Y es ( 2) /N o (4 ) Y es ( 5) / N o (2 ) M al di ve s w as a ct iv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in se ve ra l s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm b et w ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of th e aq ua tic a ni m al h ea lth a nd f oo d pr od uc tio n se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202332 M ya n m ar ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -m m r-2 02 2- co un tr y- pr of ile .p df ?s fv rs n= ac 5d ca 15 _6 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (in di ca to r 2. 6, T rA C SS 20 22 ) – – Y es Y es M ya nm ar h as in te gr at ed N A P- A M R in to s ev en o ut o f ei gh t ex is tin g ac tio n pl an s, e xc ep t fo r cl im at e ch an ge a nd en vi ro nm en ta l p la nn in g In te gr at in g N A P- A M R w ith o th er e xi st in g pl an s ca n he lp a c ou nt ry a ch ie ve t he N A P go al s. It is en co ur ag ed f or M ya nm ar , t o in te gr at e N A P- A M R w ith c lim at e ch an ge a nd e nv iro nm en ta l pl an ni ng Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) D D D C M ya nm ar s ho w s at t he le ve l w he re t he re a re s om e aw ar en es s ac tiv iti es , a t lo ca l an d/ or s ub na tio na l l ev el , ab ou t ris ks o f an tim ic ro bi al re si st an ce a nd a ct io ns t o ad dr es s it, t ar ge tin g so m e bu t no t al l r el ev an t st ak eh ol de rs , ba se d on s ta ke ho ld er a na ly si s Th er e is a n ee d fo r na tio nw id e, g ov er nm en t- su pp or te d an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns , t ar ge tin g al l o r th e m aj or ity of p rio rit y st ak eh ol de r gr ou ps Tr ai ni ng a nd pr of es si on al e du ca tio n on A M R in t he f ar m in g/ ag ric ul tu re s ec to r (in di ca to r 5. 1, T rA C SS 20 22 ) B B C B M ya nm ar s ho w s at t he le ve l w he re t ai lo re d ad h oc A M R tr ai ni ng c ou rs es a re a va ila bl e fo r at le as t tw o gr ou ps o f ke y st ak eh ol de rs Th er e is a n ee d to e xp an d th e pr og ra m m e to m ak e co ur se s av ai la bl e fo r al l o r th e m aj or ity o f ke y st ak eh ol de rs Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 33 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e (in di ca to r 2. 13 , T rA C SS 20 22 ) – – – N o M ya nm ar h as n ot e st ab lis he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce s ys te m f or a nt im ic ro bi al re si st an ce C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 20 22 ) – – – N o M ya nm ar is n ot u si ng r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s To s ta rt u si ng r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm d ec is io n- m ak in g an d am en d po lic ie s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) A D A A M ya nm ar is a t th e st ag e w he re t he re is n o na tio na l pl an o r sy st em f or m on ito rin g us e of a nt im ic ro bi al s To c re at e a sy st em f or m on ito rin g an tim ic ro bi al us ag e, in cl ud in g tr ac ki ng n at io na l-l ev el s al es o r co ns um pt io n of a nt ib io tic s an d th e se ns ib le u se of a nt ib io tic s in h ea lth c ar e A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l E ss en tia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 2 02 2) – B B B C ou nt ry h as k no w le dg e of th e A W aR e cl as si fic at io n of an tib io tic s bu t no t ad op tin g it To a do pt t he A W aR e cl as si fic at io n in t he N at io na l E ss en tia l M ed ic in es L is t Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202334 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in hu m an h ea lth c ar e (in di ca to r 3. 5, T rA C SS 20 22 ) C C C C M ya nm ar s ta ys a t th e st ag e w he re a n at io na l IP C p ro gr am m e an d an op er at io na l p la n ar e av ai la bl e an d na tio na l g ui de lin es fo r he al th c ar e IP C a re av ai la bl e an d di ss em in at ed . Se le ct ed h ea lth f ac ili tie s ar e im pl em en tin g th e gu id el in es , w ith m on ito rin g an d fe ed ba ck in p la ce To im pr ov e by f ol lo w in g th e na tio na l I PC pr og ra m m e, in a cc or da nc e w ith t he W H O IP C co re g ui de lin es , a nd im pl em en t th e na tio na l pl an a nd g ui de lin es a t al l h ea lth -c ar e fa ci lit ie s G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – B D C M ya nm ar is a t th e le ve l w he re t he re is a n at io na l pl an a gr ee d up on t o en su re go od m an uf ac tu rin g (G M P) an d hy gi en e pr ac tic es ( G H P) , in li ne w ith in te rn at io na l st an da rd s (e .g . C od ex A lim en ta riu s) ; n at io na lly ag re ed u po n gu id an ce f or go od p ra ct ic es d ev el op ed a nd ad ap te d fo r im pl em en ta tio n, ac co rd in g to lo ca l f oo d pr oc es si ng a pp ro ac he s To m on ito r its a nt ib io tic c on su m pt io n an d re po rt it , a cc or di ng t o th e A W aR e cl as si fic at io n Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l-l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 35 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s –a nt im ic ro bi al co m po un ds a nd t he ir m et ab ol ite s di sc ha rg ed to t he e nv iro nm en t (in di ca to r 6. 2, T rA C SS 20 22 ) – – Y es ( 0) /Y es bu t no t fu lly im pl em en te d (3 )/ N o (5 ) Y es ( 3) / N o (1 4) M ya nm ar c on si st en tly h ad le gi sl at io n an d/ or r eg ul at io ns to p re ve nt c on ta m in at io n of t he e nv iro nm en t w ith an tim ic ro bi al s – an tim ic ro bi al co m po un ds a nd t he ir m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e of t he s ub se ct or s To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns re la te d to h um an s ew ag e tr ea tm en t an d m an ag em en t fo r liq ui d an d so lid w as te f ro m m ed ic al f ac ili tie s To s ug ge st c ou nt ry r eg ul at io n fo r di sp os al o f m ed ic in es o r an tim ic ro bi al a ge nt s fr om h um an s an d an im al s To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns co nc er ni ng w as te w at er d is ch ar ge f ro m a ni m al an d m an uf ac tu rin g si te f or a nt im ic ro bi al To p ro m pt t he c ou nt ry f or m ak in g re gu la tio n re la te d to m an ag em en t of r un of f an d so lid w as te f ro m s la ug ht er ho us es To s ug ge st c ou nt ry r eg ul at io n of p ro du ct s co nt am in at ed f ro m w as te f oo d, p la nt o r an im al s, w hi ch a re o ve r th e m ax im um r es id ue lim it To s ug ge st c ou nt ry r eg ul at io n of c on ta m in at ed so lid o r liq ui d w as te f ro m a ni m al s an d hu m an s, pr io r to u se in a gr ic ul tu re To a dv is e cr ea tin g le gi sl at io n on w as te w at er tr ea tm en t in a re as v ul ne ra bl e to d is as te rs d ue to o f ex tr em e w ea th er a nd e ve nt s. To p ro m ot e cr ea tio n of r eg ul at io n re la te d to o ve rs pr ay , d rif t, a nd le ac hi ng , f ol lo w in g pe st ic id e an d fe rt ili ze r ap pl ic at io ns To s ug ge st c re at io n of r eg ul at io n re la te d to tr an sn at io na l a nd in te rc on tin en ta l t ra ns po rt an d m ov em en t of f oo d, g oo ds , l iv e an im al s an d pe op le Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202336 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an ( in di ca to r 2. 2, Tr A C SS 2 02 2) Y es ( 6) / N o (0 ) Y es ( 6) / N o (0 ) Y es ( 6) /N o (0 ) Y es ( 7) / N o (0 ) M ya nm ar w as a ct iv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm b et w ee n al l r el ev an t se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 37 N ep al ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -n pl -2 02 2- co un tr y- pr of ile .p df ?s fv rs n= 92 0c b1 4e _5 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (in di ca to r 2. 6, T rA C SS 20 22 ) – – N o Y es N ep al h as in te gr at ed N A P- A M R in to t hr ee ou t of e ig ht e xi st in g ac tio n pl an s: O ne H ea lth s tr at eg y or O ne H ea lth m ec ha ni sm , W A SH , a nd n at io na l f oo d sa fe ty s tr at eg ie s an d po lic ie s In te gr at in g N A P- A M R w ith o th er ex is tin g pl an s ca n he lp a c ou nt ry ac hi ev e th e N A P go al s. It is im po rt an t fo r N ep al t o ex pa nd in te gr at io n of N A P to o th er ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) C C C C N ep al h as m ad e no p ro gr es s an d st ay s at th e le ve l w he re t he re a re s om e aw ar en es s ac tiv iti es a t lo ca l a nd /o r su bn at io na l l ev el ab ou t ris ks o f an tim ic ro bi al r es is ta nc e an d ac tio ns t o ad dr es s it, t ar ge tin g so m e bu t no t al l r el ev an t st ak eh ol de rs , b as ed o n st ak eh ol de r an al ys is Th er e is a n ee d fo r na tio nw id e, go ve rn m en t-s up po rt ed an tim ic ro bi al r es is ta nc e aw ar en es s ra is in g ca m pa ig ns , ta rg et in g al l o r th e m aj or ity o f pr io rit y st ak eh ol de r gr ou ps Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in th e fa rm in g/ ag ric ul tu re se ct or ( in di ca to r 5. 1, Tr A C SS 2 02 2) C B B B N ep al h as m ad e no p ro gr es s an d st ay s at t he le ve l w he re t ai lo re d ad h oc A M R tr ai ni ng c ou rs es a re a va ila bl e fo r at le as t tw o gr ou ps o f ke y st ak eh ol de rs Th er e is a n ee d to e xp an d th e pr og ra m m e to m ak e co ur se s av ai la bl e fo r al l o r th e m aj or ity of k ey s ta ke ho ld er s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202338 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , Tr A C SS 2 02 2) – – – N o N ep al h as n ot e st ab lis he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 2 02 2) – – – Y es N ep al u se d re le va nt a nt im ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s To m ai nt ai n th e us e of r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) A A B B N ep al h as m ad e no p ro gr es s an d st ay s at th e st ag e w he re t he re is a s ys te m , d es ig ne d fo r su rv ei lla nc e of a nt im ic ro bi al u se , t ha t in cl ud es m on ito rin g na tio na l-l ev el s al es o r co ns um pt io n of a nt ib io tic s in h ea lth s er vi ce s To e nh an ce t he m on ito rin g of t ot al a nt im ic ro bi al s al es a t th e na tio na l l ev el a nd /o r so m e m on ito rin g of a nt ib io tic u se a t th e su bn at io na l l ev el A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l Es se nt ia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 20 22 ) – B C C C ou nt ry h as a do pt ed t he A W aR e cl as si fic at io n of a nt ib io tic s in t he ir N at io na l Es se nt ia l M ed ic in es L is t To m on ito r its a nt ib io tic co ns um pt io n an d re po rt it ac co rd in g to t he A W aR e cl as si fic at io n Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 39 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, Tr A C SS 2 02 2) A A B B N ep al h as m ad e pr og re ss a nd c ur re nt ly st ay s at t he le ve l w he re a n at io na l I PC pr og ra m m e or a n op er at io na l p la n is av ai la bl e. N at io na l I PC a nd w at er , s an ita tio n an d hy gi en e (W A SH ) an d en vi ro nm en ta l he al th s ta nd ar ds e xi st b ut a re n ot f ul ly im pl em en te d To d is se m in at e th e na tio na l I PC pr og ra m m e or t he o pe ra tio na l pl an t ha t ha s be en d ev el op ed G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – B B B N ep al s ho w s a de cl in e, w hi ch s ta ye d at th e le ve l w he re t he re is t he n at io na l p la n ag re ed u po n to e ns ur e go od m an uf ac tu rin g (G M P) a nd h yg ie ne p ra ct ic es ( G H P) , i n lin e w ith in te rn at io na l s ta nd ar ds ( e. g. C od ex A lim en ta riu s) . N at io na lly a gr ee d up on gu id an ce f or g oo d pr ac tic es d ev el op ed a nd ad ap te d fo r im pl em en ta tio n, a cc or di ng t o lo ca l f oo d pr oc es si ng a pp ro ac he s To d ev el op a n at io na l p la n th at is a gr ee d up on in o rd er to e ns ur e ap pr op ria te a ni m al hu sb an dr y an d bi os ec ur ity pr oc ed ur es , i n ac co rd an ce w ith in te rn at io na l s ta nd ar ds , a nd na tio na l g ui da nc e ad ap te d fo r im pl em en ta tio n at lo ca l f ar m an d fo od p ro du ct io n le ve ls Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202340 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 0) /Y es bu t no t fu lly im pl em en te d (0 )/ N o (8 ) Y es ( 0) / N o (1 7) N ep al h as n o as pe ct o f le gi sl at io n or re gu la tio n to p re ve nt c on ta m in at io n of t he en vi ro nm en t, in cl ud in g al l 1 7 as pe ct s in t he en vi ro nm en t se ct or . To d ev el op A M R po lic ie s an d ta rg et ed r eg ul at io ns t o re du ce en vi ro nm en ta l c on ta m in at io n fr om d is ch ar ge d an tim ic ro bi al s, an tim ic ro bi al c om po un ds , a nd m et ab ol ite s Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an (in di ca to r 2. 2, T rA C SS 20 22 ) Y es ( 2) / N o (4 ) Y es ( 2) / N o (4 ) Y es ( 4) /N A (2 ) Y es ( 5) / N o (2 ) N ep al w as a ct iv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in s ev er al s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he p la nt h ea lth an d fo od p ro du ct io n se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 41 Sr i L an ka ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t- so ur ce /a nt im ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -t ra cs s- lk a- 20 22 -c ou nt ry - pr of ile .p df ?s fv rs n= e0 29 7f 69 _6 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : C o h er en ce o f N A P w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (in di ca to r 2. 6, T rA C SS 20 22 ) – – N o Y es Sr i L an ka h as in te gr at ed N A P- A M R in to th re e ou t of e ig ht e xi st in g ac tio n pl an s: W A SH , h ea lth s ec ur ity , a nd c lim at e ch an ge an d en vi ro nm en t. In te gr at in g N A P- A M R w ith ot he r ex is tin g pl an s ca n he lp a co un tr y ac hi ev e th e N A P go al s. It is im po rt an t fo r Sr i L an ka t o ex pa nd in te gr at io n of N A P to ot he r ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) E C C B Th er e ha s be en a d ec lin e ov er t he y ea rs in Sr i L an ka a nd c ur re nt ly a t th e st ag e w he re th er e ar e so m e ac tiv iti es t o ra is e aw ar en es s ab ou t ris ks o f an tim ic ro bi al r es is ta nc e an d ac tio ns t ha t ad dr es s it A w ar en es s ra is in g ca m pa ig n ne ed t o be e xp an de d to t ar ge t lo ca l o r su bn at io na l l ev el o f ac tiv ity t ha t in cl ud es r el ev an t st ak eh ol de rs Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in th e fa rm in g/ ag ric ul tu re se ct or ( in di ca to r 5. 1, Tr A C SS 2 02 2) B B B A Sr i L an ka s ho w s a de cl in e at t he le ve l w he re t he re is n o tr ai ni ng p ro vi si on o n A M R fo r ke y st ak eh ol de rs , e .g . a gr ic ul tu ra l ex te ns io n w or ke rs , f ar m er s, f oo d sa fe ty of fic er s, f oo d an d fe ed p ro ce ss or s an d re ta ile rs , e nv iro nm en ta l s pe ci al is ts Th er e is a n ee d fo r ta ilo re d ad h oc A M R tr ai ni ng c ou rs es av ai la bl e fo r at le as t tw o gr ou ps of k ey s ta ke ho ld er s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , T rA C SS 2 02 2) – – – N o Sr i L an ka h as n ot e st ab lis he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202342 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 2 02 2) – – – N o Sr i L an ka h as n ot y et u se d re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s To m ai nt ai n th e us e of r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) B A C A Sr i L an ka s ho w s a de cl in e at t he le ve l w he re t he re is n o na tio na l p la n or s ys te m fo r m on ito rin g us e of a nt im ic ro bi al s To c re at e a sy st em f or m on ito rin g an tim ic ro bi al u sa ge , in cl ud in g tr ac ki ng n at io na l- le ve l s al es o r co ns um pt io n of an tib io tic s an d se ns ib le u se o f an tib io tic s in h ea lth c ar e A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l Es se nt ia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 20 22 ) – N /A C B Sr i L an ka s ho w s a de cl in e w hi ch s ta rt ed a t th e le ve l w he re t he c ou nt ry h as a do pt ed th e A W aR e cl as si fic at io n of a nt ib io tic s in th ei r N at io na l E ss en tia l M ed ic in es L is t To a do pt t he A W aR e cl as si fic at io n in t he N at io na l Es se nt ia l M ed ic in es L is t Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, T rA C SS 2 02 2) C N /A D D Sr i L an ka h as m ad e pr og re ss a nd is cu rr en tly a t th e le ve l w he re a n at io na l I PC pr og ra m m e is a va ila bl e, a cc or di ng t o th e W H O IP C c or e co m po ne nt s gu id el in es , an d IP C p la ns a nd g ui de lin es im pl em en te d na tio nw id e; a ll he al th -c ar e fa ci lit ie s ha ve a fu nc tio na l b ui lt en vi ro nm en t (in cl ud in g w at er a nd s an ita tio n) a nd n ec es sa ry m at er ia ls a nd e qu ip m en t to p er fo rm IP C , as p er n at io na l s ta nd ar ds To e va lu at e an d pu bl is h co m pl ia nc e an d ef fe ct iv en es s on a r eg ul ar b as is s o th at p la ns an d gu id an ce a re u pd at ed in re sp on se t o m on ito rin g Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 43 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – B B B Sr i L an ka m ad e no p ro gr es s in t hi s se ct or , w hi ch is s til l a t a st ag e w he re s om e ac tiv iti es a re in p la ce t o de ve lo p an d pr om ot e go od m an uf ac tu rin g (G M P) a nd hy gi en e pr ac tic es ( G H P) To d ev el op a n at io na l p la n th at is a gr ee d up on in o rd er to e ns ur e ap pr op ria te a ni m al hu sb an dr y an d bi os ec ur ity pr oc ed ur es , i n ac co rd an ce w ith in te rn at io na l s ta nd ar ds , a nd na tio na l g ui da nc e ad ap te d fo r im pl em en ta tio n at lo ca l f ar m an d fo od p ro du ct io n le ve ls Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 0) /Y es bu t no t fu lly im pl em en te d (0 )/ N o (8 ) Y es ( 16 )/ N o (1 ) Sr i L an ka h ad le gi sl at io n an d/ or re gu la tio ns t o pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds a nd th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e of th e su bs ec to rs To e nc ou ra ge t he c ou nt ry t o dr af t re gu la tio ns c on ce rn in g di sp os al o f fo od , p la nt o r an im al pr od uc ts c on ta m in at ed w ith an tim ic ro bi al r es id ue s Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an ( in di ca to r 2. 2, Tr A C SS 2 02 2) Y es ( 4) / N o (2 ) Y es ( 5) / N o (1 ) Y es ( 6) /N o (0 ) Y es ( 6) / N o (1 ) Sr i L an ka w as a ct iv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e A M R N at io na l A ct io n Pl an , d es pi te la ck in g in se ve ra l s ub se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or s, w ith e nh an ce d en ga ge m en t an d in vo lv em en t of t he f oo d pr od uc tio n se ct or Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202344 Th ai la n d ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t-s ou rc e/ an tim ic ro bi al -re si st an ce /a m r-s pc -n pm /t ra cs s/ 20 22 /a nt im ic ro bi al -re si st an ce -tr ac ss -th a- 20 22 -c ou nt ry - pr of ile .p df ?s fv rs n= a2 09 65 9c _4 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith ot he r ex is tin g ac tio n pl an s or s tr at eg ie s (in di ca to r 2. 6, T rA C SS 20 22 ) – – Y es N o Th ai la nd d oe s no t ha ve p la ns o n in te gr at in g A M R w ith o th er e xi st in g ac tio n pl an s or s tr at eg ie s re la te d to O ne H ea lth s tr at eg y or O ne H ea lth m ec ha ni sm , W A SH , N at io na l H ea lth S ec to r Pl an , N at io na l A ct io n Pl an o n H ea lth S ec ur ity , cl im at e ch an ge a nd e nv iro nm en ta l pl an ni ng , n at io na l d ev el op m en t pl an s, na tio na l f oo d sa fe ty s tr at eg y, o th er s In te gr at in g N A P- A M R w ith o th er ex is tin g pl an s ca n he lp a c ou nt ry ac hi ev e th e N A P go al s. It is im pe ra tiv e fo r Th ai la nd t o st ar t w or ki ng o n in te gr at in g N A P in to ot he r ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) D E E E Th ai la nd h as m an ag ed t o ha ve r ou tin e, ta rg et ed , n at io nw id e, g ov er nm en t- su pp or te d ca m pa ig ns , i m pl em en te d to ra is e aw ar en es s of p rio rit y st ak eh ol de rs ac ro ss s ec to rs , w ith r eg ul ar m on ito rin g Th ai la nd a lre ad y re ac he d th e go al r el at ed t o ra is in g aw ar en es s of A M R ris k an d re sp on se Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in th e fa rm in g/ ag ric ul tu re se ct or ( in di ca to r 5. 1, Tr A C SS 2 02 2) C C C C Th ai la nd c on si st en tly p ro vi de d ta ilo re d ad h oc A M R tr ai ni ng c ou rs es t ha t ar e st ill a va ila bl e fo r al l o r th e m aj or ity o f ke y st ak eh ol de rs Ro ut in el y av ai la bl e na tio nw id e tr ai ni ng f or c ov er in g al l k ey st ak eh ol de rs n ee ds t o be es ta bl is he d Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 45 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s A re a 3. N at io n al A M R S u rv ei lla n ce S ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e (in di ca to r 2. 13 , T rA C SS 20 22 ) – – – Y es Th ai la nd h as e st ab lis he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce f or a ll ca te go rie s ex ce pt p la nt he al th To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e in p la nt he al th w hi le a ls o m ai nt ai ni ng ot he r se ct or s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 2 02 2) – – – Y es Th ai la nd h as a lre ad y us ed r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s in a ll se ct or s ex ce pt p la nt he al th To s ta rt u si ng r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm op er at io na l d ec is io n- m ak in g an d am en d po lic ie s in p la nt h ea lth w hi le a ls o m ai nt ai ni ng o th er se ct or s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) C B B E Th ai la nd h as s ho w n si gn ifi ca nt p ro gr es s by h av in g co lle ct ed a nd r ep or te d da ta on a nt im ic ro bi al s al es o r co ns um pt io n at t he n at io na l l ev el f or h um an u se a nd pr es cr ib in g an tib io tic a nd a pp ro pr ia te us e, in a r ep re se nt at iv e sa m pl e of h ea lth fa ci lit ie s, p ub lic a nd p riv at e, o n a re gu la r ba si s To m ai nt ai n th e cu rr en t st at e of da ta c ol le ct io n an d re po rt o n a re gu la r ba si s A do pt io n of A W aR e cl as si fic at io n of an tib io tic s in t he N at io na l E ss en tia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 2 02 2) – B C D Th ai la nd h as im pr ov ed , h av in g ad op te d th e A W aR e cl as si fic at io n of a nt ib io tic s in th ei r N at io na l E ss en tia l M ed ic in es L is t an d is m on ito rin g its a nt ib io tic c on su m pt io n an d re po rt in g it, a cc or di ng t o th e A W aR e cl as si fic at io n To in cl ud e A W aR e in it s an tim ic ro bi al s te w ar ds hi p pl an s (e .g . t re at m en t gu id el in es ) Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202346 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, T rA C SS 2 02 2) B C D D Th ai la nd h as im pr ov ed in t hi s se ct or , w ith a na tio na l I PC p la n av ai la bl e, a cc or di ng to t he W H O IP C c om po ne nt s, a nd im pl em en te d na tio nw id e To e va lu at e an d pu bl is h co m pl ia nc e an d ef fe ct iv en es s on a r eg ul ar b as is s o th at p la ns an d gu id an ce a re u pd at ed in re sp on se t o m on ito rin g G oo d m an ag em en t an d hy gi en e pr ac tic es to r ed uc e de ve lo pm en t an d tr an sm is si on o f A M R in f oo d pr oc es si ng (in di ca to r 5. 5, T rA C SS 20 22 ) – D D D Th ai la nd h as m ai nt ai ne d im pl em en ta tio n of a p la n to e ns ur e go od m an uf ac tu rin g (G M P) a nd h yg ie ne p ra ct ic es ( G H P) , an d na tio na l g ui da nc e pu bl is he d an d di ss em in at ed To m on ito r th e na tio nw id e pl an pe rio di ca lly Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 47 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 7) /Y es bu t no t fu lly im pl em en te d (0 )/ N o (1 ) Y es ( 10 )/ N o (7 ) Th ai la nd c on si st en tly h ad le gi sl at io n an d/ or r eg ul at io ns t o pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds a nd th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t, d es pi te la ck in g in s om e su bs ec to rs To e nc ou ra ge t he c ou nt ry fo r dr af tin g re gu la tio n re la te d to t ra ns na tio na l a nd in te rc on tin en ta l t ra ns po rt a nd m ov em en t of f oo d, g oo ds , l iv e an im al s, a nd p eo pl e To s ug ge st c ou nt ry r eg ul at io n of c on ta m in at ed s ol id o r liq ui d w as te f ro m a ni m al s an d hu m an s, p rio r to u se in ag ric ul tu re To a dv is e cr ea tin g le gi sl at io n on w as te w at er t re at m en t in a re as vu ln er ab le t o di sa st er s du e to o f ex tr em e w ea th er a nd e ve nt s. To p ro m ot e cr ea tio n of re gu la tio n re la te d to o ve rs pr ay , dr ift , a nd le ac hi ng , f ol lo w in g pe st ic id e an d fe rt ili ze r ap pl ic at io ns Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an ( in di ca to r 2. 2, Tr A C SS 2 02 2) Y es ( 6) / N o (0 ) Y es ( 6) /N o (0 ) Y es ( 6) /N o (0 ) Y es ( 7) / N o (0 ) Th ai la nd h ad c on si st en tly b ee n ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an a cr os s al l se ct or s To s tr en gt he n th e ex is tin g co or di na tio n m ec ha ni sm be tw ee n al l r el ev an t se ct or Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202348 Ti m o r- Le st e ht tp s: // cd n. w ho .in t/ m ed ia /d oc s/ de fa ul t- so ur ce /a nt im ic ro bi al -r es is ta nc e/ am r- sp c- np m /t ra cs s/ 20 22 /a nt im ic ro bi al -r es is ta nc e- tr ac ss -t ls -2 02 2- co un tr y- pr of ile .p df ?s fv rs n= 63 62 e7 a9 _8 & do w nl oa d= tr ue Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s Fo cu s ar ea 1 : N A P al ig n m en t w it h G A P- A M R C ou nt ry p la nn in g on A M R in te gr at ed w ith o th er ex is tin g ac tio n pl an s or st ra te gi es ( in di ca to r 2. 6, Tr A C SS 2 02 2) – – N o Y es Ti m or -L es te h ad p la nn ed o n A M R in te gr at ed w ith o th er e xi st in g ac tio n pl an s an d st ra te gi es , d es pi te o nl y be in g su cc es sf ul in t w o ou t of e ig ht s ec to rs In te gr at in g N A P- A M R w ith ot he r ex is tin g pl an s ca n he lp a co un tr y ac hi ev e th e N A P go al s. It is im po rt an t fo r Ti m or -L es te to e xp an d in te gr at io n of N A P to ot he r ex is tin g pr og ra m m es Fo cu s ar ea 2 : R ai si n g a w ar en es s Ra is in g aw ar en es s an d un de rs ta nd in g of A M R ris ks a nd r es po ns e (in di ca to r 2. 9, T rA C SS 20 22 ) D D D E Ti m or -L es te h as m an ag ed t o ha ve ro ut in e, t ar ge te d, n at io nw id e, go ve rn m en t-s up po rt ed c am pa ig ns , im pl em en te d to r ai se a w ar en es s ab ou t pr io rit y st ak eh ol de rs a cr os s se ct or s, w ith re gu la r m on ito rin g Ti m or -L es te a lre ad y re ac he d th e go al r el at ed t o ra is in g aw ar en es s of A M R ris k an d re sp on se Tr ai ni ng a nd p ro fe ss io na l ed uc at io n on A M R in t he fa rm in g/ ag ric ul tu re s ec to r (in di ca to r 5. 1, T rA C SS 20 22 ) A A A A Ti m or -L es te n ev er m an ag ed t o ha ve an y tr ai ni ng p ro vi si on o n A M R fo r ke y st ak eh ol de rs Th er e is a n ee d fo r ta ilo re d ad h oc A M R tr ai ni ng c ou rs es av ai la bl e fo r at le as t tw o gr ou ps of k ey s ta ke ho ld er s Fo cu s ar ea 3 : N at io n al A M R s u rv ei lla n ce s ys te m C ou nt rie s th at es ta bl is he d or s ta rt ed t he im pl em en ta tio n of a n in te gr at ed s ur ve ill an ce sy st em f or a nt im ic ro bi al re si st an ce ( in di ca to r 2. 13 , Tr A C SS 2 02 2) – – – Y es Ti m or -L es te h as e st ab lis he d or s ta rt ed th e im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or a nt im ic ro bi al re si st an ce f or h um an h ea lth , t er re st ria l an im al h ea lth , f oo d sa fe ty , a nd en vi ro nm en t To e st ab lis h or s ta rt t he im pl em en ta tio n of a n in te gr at ed su rv ei lla nc e sy st em f or an tim ic ro bi al r es is ta nc e in t he ot he r se ct or s Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 49 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s C ou nt rie s us in g re le va nt an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta t o in fo rm o pe ra tio na l de ci si on -m ak in g an d am en d po lic ie s (in di ca to r 2. 12 , T rA C SS 2 02 2) – – – Y es Ti m or -L es te h as a lre ad y us ed r el ev an t an tim ic ro bi al r es is ta nc e su rv ei lla nc e da ta to in fo rm o pe ra tio na l d ec is io n- m ak in g an d am en d po lic ie s in h um an h ea lth , te rr es tr ia l a ni m al h ea lth , a nd f oo d sa fe ty To u se r el ev an t an tim ic ro bi al re si st an ce s ur ve ill an ce d at a to in fo rm d ec is io n- m ak in g an d am en d po lic ie s in t he o th er se ct or s Fo cu s ar ea 4 : R at io n al u se o f an ti m ic ro b ia ls a n d s u rv ei lla n ce o f u se /s al e (c o m m u n it y- b as ed ) N at io na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th ( in di ca to r 3. 2, Tr A C SS 2 02 2) C E E C Ti m or -L es te f lu ct ua te d in it s na tio na l m on ito rin g sy st em f or c on su m pt io n an d ra tio na l u se o f an tim ic ro bi al s in h um an he al th , e ve nt ua lly h av in g to ta l s al es m on ito re d at t he n at io na l l ev el o r so m e m on ito rin g at t he s ub na tio na l l ev el Th er e is a n ee d fo r pr es cr ib in g pr ac tic es a nd a nt ib io tic u se , w hi ch a re m on ito re d in a na tio na l s am pl e of h ea lth -c ar e se tt in gs A do pt io n of A W aR e cl as si fic at io n of a nt ib io tic s in t he N at io na l E ss en tia l M ed ic in es L is t (in di ca to r 3. 7, T rA C SS 2 02 2) – B C D Ti m or -L es te h as im pr ov ed , h av in g ad op te d th e A W aR e cl as si fic at io n of an tib io tic s in t he ir N at io na l E ss en tia l M ed ic in es L is t, a nd is m on ito rin g its an tib io tic c on su m pt io n an d re po rt in g it, ac co rd in g to t he A W aR e cl as si fic at io n To in cl ud e A W aR e in it s an tim ic ro bi al s te w ar ds hi p pl an s (e .g . t re at m en t gu id el in es ) Fo cu s ar ea 5 : I n fe ct io n p re ve n ti o n a n d c o n tr o l, an d a n ti m ic ro b ia l s te w ar d sh ip In fe ct io n pr ev en tio n an d co nt ro l ( IP C ) in h um an he al th c ar e (in di ca to r 3. 5, Tr A C SS 2 02 2) B B D B Ti m or -L es te f lu ct ua te d in it s IP C in hu m an h ea lth c ar e, e ve nt ua lly h av in g na tio na l I PC p ro gr am m es o r op er at io na l pl an s, b ut t he se w er e no t fu lly im pl em en te d To d is se m in at e th e na tio na l I PC pr og ra m m e or t he o pe ra tio na l pl an t ha t ha s be en d ev el op ed Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 202350 Fo cu s ar ea a n d in d ic at o rs 20 19 20 20 20 21 20 22 Pr o g ra m m at ic is su e Pr io ri ty a ct io n s G oo d m an ag em en t an d hy gi en e pr ac tic es t o re du ce d ev el op m en t an d tr an sm is si on o f A M R in fo od p ro ce ss in g (in di ca to r 5. 5, T rA C SS 2 02 2) – A B A Ti m or -L es te h ad n o sy st em at ic e ff or ts t o im pr ov e G M P an d G H P To c on du ct s ys te m at ic e ff or ts t o im pr ov e G M P an d G H P Fo cu s ar ea 6 : R es ea rc h a n d in n o va ti o n In fo rm at io n on a ny r es ea rc h an d in no va tio n im pl em en te d in t he c ou nt ry is la ck in g. A f or um o f A M R- re le va nt r es ea rc h an d in no va tio n sh ou ld b e es ta bl is he d. A n at io na l l ev el r ep os ito ry o f A M R re se ar ch a nd in no va tio n sh ou ld b e cr ea te d. Fo cu s ar ea 7 : L eg is la ti o n a n d s u rv ei lla n ce f o r A M R in t h e en vi ro n m en t C ou nt ry h as le gi sl at io n an d/ or r eg ul at io ns * to pr ev en t co nt am in at io n of t he e nv iro nm en t w ith a nt im ic ro bi al s – an tim ic ro bi al c om po un ds an d th ei r m et ab ol ite s di sc ha rg ed t o th e en vi ro nm en t (in di ca to r 6. 2, T rA C SS 2 02 2) – – Y es ( 0) / Y es bu t no t fu lly im pl em en te d (0 )/ N o (8 ) Y es ( 0) / N o (1 7) Ti m or -L es te h as n o as pe ct o f le gi sl at io n or r eg ul at io n to p re ve nt c on ta m in at io n of t he e nv iro nm en t, in cl ud in g al l 1 7 as pe ct s in t he e nv iro nm en t se ct or To d ev el op A M R po lic ie s an d ta rg et ed r eg ul at io ns t o re du ce en vi ro nm en ta l c on ta m in at io n fr om d is ch ar ge d an tim ic ro bi al s, an tim ic ro bi al c om po un ds , a nd m et ab ol ite s Fo cu s ar ea 8 : O ve ra rc h in g c o o rd in at io n m ec h an is m s fo r O n e H ea lt h e n g ag em en t Se ct or s ar e ac tiv el y in vo lv ed in d ev el op in g an d im pl em en tin g th e A M R N at io na l A ct io n Pl an (in di ca to r 2. 2, T rA C SS 20 22 ) Y es ( 3) / N o (3 ) Y es ( 6) /N o (0 ) Y es ( 6) /N o (0 ) Y es ( 7) / N o (0 ) Ti m or -L es te h ad b ee n ac tiv el y in vo lv ed in de ve lo pi ng a nd im pl em en tin g th e N A P- A M R ac ro ss a ll se ct or s, e xc ep t in t he 20 19 r ou nd To e nc ou ra ge t he c ou nt ry t o in te ns ify t he p la nn in g an d im pl em en ta tio n of N A P- A M R Fourth p rogress analysis of im p lem entation of antim icrobial resistance action p lans in the W H O South-East A sia Region 2023 Fourth progress analysis of implementation of antimicrobial resistance action plans in the WHO South-East Asia Region 2023 This fourth progress analysis offers a comprehensive assessment of the implementation status of national action plans on antimicrobial resistance (NAP-AMR) in the WHO South-East Asia Region spanning the period from 2017 to 2022. The analysis encompasses eight crucial focus areas, each evaluated through existing WHO regional indicators designed to monitor AMR progress. Notably, 50% of the 62 indicators have been successfully implemented by Member States of the Region, signifying a positive trend over 2017–2022. However, challenges persist in several key areas. The analysis highlights disparities in the degree of awareness about AMR in countries. It highlights significant activities in aquatic animal health and food safety but only ad hoc training in the human health sector. National AMR surveillance systems are not yet fully integrated or operational in every Member State, posing challenges to informed decision-making. Regulatory frameworks for antimicrobial use and sale vary between countries, and some crucial sectors such as plant production lack monitoring systems. The implementation of infection prevention and control measures and antimicrobial stewardship in health-care settings remains uneven. Progress in research and innovation is distributed among multiple organizations, while several countries lack legislation on AMR in the environmental sector. Finally, while there is notable progress in coordination mechanisms for ‘One Health’ engagement, there are still gaps, particularly in plant health and food production sectors. To address these issues, the report recommends assistance to strengthen NAP-AMR implementation, multisectoral collaboration, data-driven decision-making, innovative research and robust monitoring at both national and subnational levels. 9 789290 210870