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No. 52, 22 December 2021

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Progress and challenges on the implementation of Antimicrobial Resistance (AMR) National Action Plans (NAPs) in the African region

Together with ReAct Africa, the South Centre organized a virtual conference from the 30th of November to the 3rd of December 2021 to assess the progress achieved on the implementation of the Global Action Plan on Antimicrobial Resistance (AMR) pandemic preparedness in the African Region. The four-day meeting looked at ongoing challenges in response to AMR, particularly in the face of the continuing pandemic and highlighted country progress and student-led actions to contain AMR.
On the first day of the conference, Dr. Mirfin Mpundu, Director of ReAct Africa, opened the event and welcomed the participants. The mission of ReAct is to have a world free from untreatable infections and enable collective action that ensures sustainable and equitable access to effective antibiotics for all. Dr. Mpundu noted that many challenges remain in the African region, including strengthening multisectoral engagement, regulatory systems, and surveillance structures. He also emphasized some critical opportunities in leveraging the COVID-19 response, including current financing and multisectoral collaboration that could be used in the AMR response.

Dr. Carlos Correa, Executive Director of the South Centre, welcomed the participants and affirmed the commitment of the South Centre to continue addressing AMR and support greater participation of civil society organizations (CSOs). He stressed that COVID-19 had shown the crucial need to strengthen health systems, increase capacity for infection, prevention and control and protect first-line health workers. He called for more resource mobilization for African countries to be able to address both COVID-19 and antimicrobial resistance.
Professor Otto Cars, founder and senior advisor of ReAct network, provided the keynote speech. He reiterated how critical it is to address AMR because curable diseases such as typhoid and gonorrhea are rapidly becoming difficult to treat. He also explained that it is challenging to address AMR because it is slow and invisible and it is not a disease, and it is complex and difficult to formulate a relatable narrative. He also noted an overreliance on the pharmaceutical industry to develop new drugs. Prof. Cars called for AMR to be framed as an ongoing pandemic and for AMR to be addressed with a systems view where the transformation of weak health and agricultural systems towards resilience is supported, and the need to increase global collaboration and coordination to fight AMR.
The conference paid tribute to three champions on AMR: Dr. (Mrs.) Martha Gyansa-Lutterodt, Ministry of Health of Ghana, Prof. Otto Cars and Prof. Carlos Correa.  
The first panel of the conference featured presentations by representatives of the regional offices of the World Health Organization (WHO), the Food and Agricultural Organization of the United Nations (FAO) and the World Organisation for Animal Health (OIE). It also had the participation of the Africa Centres for Disease Control and Prevention (Africa CDC) and the International Centre for Antimicrobial Resistance Solutions (ICARS).
During this session, the WHO highlighted the need to continue strengthening political commitment in African countries as some countries still don’t have national AMR plans and many countries are still unable to fund the implementation of their plans adequately. The OIE underscored their support in developing and implementing One Health national action plans and training of focal points for veterinary products, including the development of guidelines for veterinary professionals both in the private and public sectors. The FAO stressed how AMR is a challenge that includes changes in consumer habits. The Africa CDC emphasized that AMR presents an urgent threat to the health, security, and economic growth of countries in Africa and that no one organization or nation can manage or mitigate alone. 
ICARS presentation focused on the importance of implementation research on AMR. It emphasized how their efforts aim to partner with low and middle income countries (LMICs) to develop and test solutions to tackle AMR using implementation research to generate new evidence and support the translation of existing evidence into policies, programs, and practice.
Finance and Pandemic Preparedness
Day two of the conference focused on the issues of finance and pandemic preparedness. Dr. Viviana Muñoz Tellez, Coordinator of the Health, Intellectual Property and Biodiversity Programme of the South Centre, presented cross-cutting issues on the response to the COVID-19 pandemic and AMR. She highlighted the need for global coordination and to support infection, prevention, and control programs and emphasized the need to strengthen health systems and surveillance systems. She further stressed the need to increase capacity for sharing data and samples while at the same time ensuring access to medical countermeasures, including local production, supply, and delivery.  She also noted the mutual influence between infectious disease emergencies and AMR. Infectious diseases preparedness decreases the incidence of infections and, therefore, pressure for AMR. In contrast, a decrease in antimicrobial resistance reduces the risk of infectious outbreaks and provides better chances to contain upcoming outbreaks. Finally, she advanced that AMR should be part of the discussions for an international pandemic treaty, noting that the self-assessment tools for monitoring country compliance with the International Health Regulations (IHR) such as the Joint External Evaluation (JEE) already include AMR as a technical area and that inclusion of AMR in National Action Planning for Health Security (NAPHS) can also help to support NAPs on AMR and resource mobilization.
The panel on financing began with an overview of AMR financing challenges recalling the commitments made by the United Nations General Assembly political declaration in 2016, where countries agreed that funding should be made available to support the development and implementation of National Action Plans (NAPs), including surveillance and monitoring systems. The other international call for making financing available came from the recommendations of the UN Inter-agency Coordination Group on AMR in 2019. The recommendations called on governments, global, regional, national, bilateral, and multilateral financing and development institutions and banks, and private investors to systematically apply standards to assess risks and impacts related to AMR when making investments.
The panel had representatives from the World Bank, the WHO Trust Fund and the Fleming Fund. The World Bank explained that in terms of financing for AMR, there is availability for funding globally that needs to be mobilized. The bank is working on a country demand-based model, but there is still a gap in addressing what is needed.
The representative from the WHO Multi-Partner Trust Fund (MPTF) spoke about the complexity of the One Health response regarding AMR and their current efforts in directing their limited funds to the implementation of the national action plans on AMR. The MPTF is a joint approach between the Tripartite[1] Partners and the United Nations Environment Programme (UNEP) and works at the country, regional and global level with national governments and concerned stakeholders. It is currently supporting the UNEP and the Tripartite organizations to scale up efforts on One Health approaches to AMR.
The Fleming Fund discussed their ongoing support to 24 countries across Africa and Asia to build AMR surveillance capacity using the One Health approach. The Fleming Fund noted the importance of ensuring the quantity and quality of surveillance data to enable countries to act on AMR. The Fleming Fund started its work in 2016 and it has established many partnerships to support national surveillance systems.
The day closed with a presentation of a country experience with the example of Kenya regarding the financing of their national action plan presented by Dr. Evelyn Wesangula, Division of Patient and Health Workers Safety, Ministry of Health, Kenya.

Kenya’s national plan was developed in 2017, and to implement it, they had to seek funding from outside agencies and the national government. Some of the lessons they have learned in securing financial resources include the understanding that resources are scarce and that usually, there is a mismatch between donor priorities and country priorities. Also, they have found inadequate engagement in the decision-making process and that certain areas receive little or no support; therefore, these need to be considered. In terms of what can be done to increase access to finance, it is crucial to increase political support and stability in development and implementation, to identify and clearly define the AMR burden in the country and to understand the policy environment and formulation and implementation processes and establish multisectoral coordination mechanisms. Furthermore, developing realistic action plans to guide the process and to focus the support from development partners is also crucial.
Implementation of AMR National Action Plans
Day three of the conference focused on the experiences of implementation of AMR national action plans in the African region. The panel started with an overview from the WHO regional office, noting that to increase actions in AMR, there needs to be a multidisciplinary approach, and the leading organizations should unite and work together. The WHO also emphasized the importance of supporting the countries with implementing the NAPs and their support for awareness campaigns across many sectors, including the animal and the environmental sector.
The first country to share experiences regarding implementing their NAP and the impact of COVID-19 was Cote d’Ivoire. Before the COVID-19 pandemic, Cote d’Ivoire designed a One Health national platform and established a multisectoral NAP that was approved to combat AMR. They also developed over 15 guidelines and established five multisectoral technical committees with regular (bi-monthly) meetings.  The NAP focuses primarily on human health at 60%, 10% on environment and agriculture, and 25% on animal health.  During the onset of the COVID-19 pandemic, there was a suspension of face-to-face activities for six months, leading to a search for alternatives (online meetings, reduction of the number of face-to-face participants). This situation created challenges, including conflicting activities between AMR and COVID-19, the delay in implementation of AMR activities and resources directed to responding to the pandemic, and, therefore, reduction of AMR activities. However, they hope to resume activities and study the use of antimicrobials during the response to COVID-19 and the search for resources to increase the AMR activities.
The following country to present was Namibia. The presentation focused on the implementation of activities in the animal sector, particularly on increasing surveillance and systematic sampling at abattoirs, farms, and feedlots. The Directorate of Veterinary Services (DVS) monitors the antimicrobial use on farms bi-annually. Regarding advocacy, in all veterinary staff members' meetings, AMR is emphasized. Namibia has increased its AMR prevention by promoting timely vaccinations to animals which helps to reduce the chances of disease occurrence. The central veterinary laboratory also monitors pathogens in food and water for AMR. Namibia has also implemented a policy on the rational use of antimicrobials that discourages excess and indiscriminate use of antimicrobials in animal health. Namibia noted that even though the NAP has been endorsed, the implementation of activities is limited due to budget constraints. The COVID-19 pandemic has had serious impacts in the country, and, therefore, much of the resources have been channeled towards the control of the pandemic.
Egypt made a presentation focusing on antimicrobial stewardship. The Egyptian NAP was endorsed in 2019. Their NAP reflected the four objectives from the  WHO global action plan on AMR. The four strategic objectives include improving public awareness and strengthening skills, optimizing the use of antimicrobial medicines in human and animal health, strengthening their national One-Health surveillance efforts, and implementing Infection Prevention and Control (IPC) practices to prevent the spread of resistant pathogens.
Some of the challenges/opportunities encountered in implementing their NAP include enforcing laws and regulations that support the rational use of antimicrobials and the inclusion of AMR as a core component of undergraduate and postgraduate professional education, in-service training and certifications, and other continuing education programs. One of the lessons learned in the COVID-19 era is that this is an ideal time to start a conversation about AMR and to think about this delayed pandemic of drug resistance in the context of COVID-19. Another lesson is the direct impact of COVID-19 on AMR, including concerns of the increase in inappropriate antibiotic use in COVID-19 patients and that there is limited data in the AMR space in the region and a  need for better data collection.
Zambia's presentation highlighted its success in raising awareness, including AMR media award ceremonies and AMR publications. They have joined the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS), and surveillance sites increased from one in 2016 to three in 2020 and currently 5 in 2021. They have developed an integrated AMR surveillance data management system. Some of the lessons learned in implementing their NAP include the need for prioritisation and working with the resources they have and the value of collaborative, multisectoral partnerships.
A local example from Kenya of a health facility in Makueni county was also highlighted because of their work in implementing an antimicrobial stewardship and awareness program that included training at the hospital level. During the trainings, several gaps were identified at the hospital level, including poor optimization of empirical therapies - resulting in irrational prescriptions; poor microbial diagnostics - clinical and laboratory; lack of surveillance data to measure antibiotic use and quality of prescriptions; and the reduced use of reference guidelines for diagnosis and management of infectious diseases. These gaps were then addressed through the stewardship program, and significant improvements were observed.
After the presentation, the conference was officially closed, emphasizing some of the common challenges in implementing AMR NAPs, including lack of knowledge about the cost of implementing NAPs, the need to increase the participation of the environmental sector, increase resource mobilization and engage communities in owning the NAPs. Even though many countries in the region have NAPs in place, their implementation is still fragmented. However, it was also noted that to continue advancing the AMR agenda, NAPs must be country-owned. Also, countries would need to create a process for prioritization for NAP implementation. Resource mobilization is a critical component for implementation and therefore,   AMR should be part of the national and county sector expenditure frameworks and national budgets.
AMR Leadership Program for Tertiary Students in Africa
Day four of the conference was an opportunity to celebrate students in the AMR Leadership Program for Tertiary Students in Africa. This program aims to create AMR champions in the African region by targeting young people, particularly tertiary-level students. ReAct Africa is implementing this program in collaboration with Students against Superbugs (SAS). About 100 students were selected to join the program. The program included a variety of topics such as One Health situation in AMR; AMR and Universal Health Coverage; AMR in research; AMR awareness using art and literature, research, poetry, and other means. The students were encouraged to implement some of their learnings in their communities. During the sessions, a selection of the students highlighted their experiences in the program, including activities that they developed for the World Antimicrobial Awareness Week (WAAW).

[1] The tripartite organizations working on AMR include the Food and Agriculture Organization (FAO), the World Organisation for Animal Health (OIE) and the World Health Organization (WHO).

Author: Mirza Alas is a Consultant of the South Centre. 

SOUTH CENTRE NEWS ON AMR is an e-newsletter service of the South Centre providing news and information on issues relating to Antimicrobial Resistance.

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