Situational analysis of

antimicrobial resistance
in the South-East Asia Region,
2018
Report 2018

An update on two years of implementation

of national action plans

i
Situational analysis of
antimicrobial resistance
in the South-East Asia Region,
2018
Report 2018

An update on two years of implementation

of national action plans
Situational analysis of antimicrobial resistance in the South-East Asia Region, 2018
ISBN: 978-92-9022-702-1

© World Health Organization 2019

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CONTENTS
Acknowledgements vi
List of acronyms vii
Foreword ix
Executive summary xi
Background 1
Recent relevant initiatives and developments in the Region 2
Intercountry meetings to review situation of
NAP implementation in the Region 6

Results of situational analysis of NAP implementation 10

General trends in NAP implementation 10
Trends specific to focus areas 14
Conclusions 28

Way forward and recommendations 31

Key recommendations to address main challenges of
AMR containment in the Region 31
Way forward for WHO and its regional Triparte partners 34
Country profiles 36
Bangladesh 36
Bhutan 43
DPRK 49
India 55
Indonesia 62
Maldives 70
Myanmar 77
Nepal 83
Sri Lanka 90
Thailand 98
Timor-Leste 105
Annex 1: List of focus areas and indicators assessed 115

Annex 2: Situation analysis Tool 2018

(WHO Regional Office for South-East Asia Region) 117

Annex 3: List of participants 124

v
 Acknowledgements
The South East Asia Regional Office of WHO (WHO-SEARO) wish to express their
appreciation to all those whose considerable work in preparing for, and facilitating, the
meeting, and reviewing this report efforts made this publication possible. This was a
significant demonstration of the value of the Tripartite plus UNEP in working together
to understand the complexity of antimicrobial resistance and its management and the
inputs from the partners below is gratefully acknowledged.

FAO HQ

- Henk Jan Ormel, Senior Veterinary Policy Advisor

FAO Regional Office for Asia and the Pacific
- Katinka de Balogh, Senior Animal Health and Production Officer
- Mary Joy Gordoncillo, AMR Regional Surveillance Coordinator
OIE
- Pennapa Matayompong, Programme Coordinator, Sub-regional Representation for
South East Asia
- Pasang Tshering, Consultant, Regional Representation for Asia and the Pacific
UNEP Asia
- Kakuko Nagatani-Yoshida, Regional Coordinator for Chemicals, Waste and Air
Quality
- Masato Motoki, Environment and Health Officer
- Montira Pongsiri, Senior Research Associate
WHO HQ
- Elizabeth Tayler, Technical Officer, AMR Secretariat
- Pravarsha Prakash, Technical Officer, AMR Secretariat

The technical advice of Visanu Thamlikitkul, Director of WHO Collaborating Centre

for AMR Prevention and Containment at the Faculty of Medicine Siriraj Hospital,
Mahidol University and Viroj Tangcharoensathien, Senior advisor to the International
Health Policy Programme (IHPP), Ministry of Public Health in Thailand is gratefully
acknowledged.

The meeting would not have been possible without the financial support of the
United States Agency for International Development, USAID (Grant US -2016 1054
– Amendment 28 - One health surveillance of AMR in Asia) and the Government of
Canada (Grant arrangement between Canada DFATD and WHO – D004200 – Combating
Antimicrobial Resistance) and we are grateful for this but also the on-going technical
advice from Dan Schar, Senior Regional Emerging Infectious Diseases Advisor, USAID
and Sudarat Damrongwatanapokin Regional Animal Health Advisor, USAID.

Situational analysis of
vi antimicrobial resistance
in the South-East Asia Region, 2018
List of acronyms
AAW Antibiotic Awareness Week
AMR antimicrobial resistance
AMS AMR stewardship
AMSP AMR stewardship programme
AMU antimicrobial use
API active pharmaceutical ingredient
AR antibiotic residues
CDSCO Central Drugs Standard Control Organization
DRA drug regulatory authority
EPI expanded programme on immunization
EQAS external quality assurance system
ESBL extended-spectrum beta lactamases
EWS early warning system
FAO Food and Agriculture Organization
GAP global action plan
GAP-AMR global action plan on antimicrobial resistance
GDP good distribution practices
GLASS Global Antimicrobial Resistance Surveillance System
GMP good manufacturing practices
GPP good pharmacy practices
HAI health-care-associated infection
HiB haemeophilus influenza B
HIV human immunodeficiency virus
IEC information, education and communication
IPC infection prevention and control
JANIS Japanese Nosocomial Infection Surveillance System
LMIC lower-middle income country
MoH Ministry of Health
M&E monitoring and evaluation
MoU memorandum of understanding
NADFC National Agency of Drug and Food Control
NAP national action plan
NAP-AMR national action plan on antimicrobial resistance
NRA national regulatory authority

vii
 NGO nongovernmental organization
OTC over-the-counter
OIE World Organisation for Animal Health – Office International des
Epizooties
PCV pneumococcal conjugate vaccine
R&D research and development
SEA South-East Asia
SEARN South-East Asia Regional Network
SDG sustainable development goal
SOP standard operating procedures
ToR terms of reference
UHC universal health coverage
UNEP United Nations Environment Programme
USAID United States Agency for International Development
WASH water, sanitation and hygiene
WHA World Health Assembly
WHO World Health Organization

Situational analysis of
viii antimicrobial resistance
in the South-East Asia Region, 2018
 Foreword

Antimicrobial resistance (AMR) has been on the rise globally. One of the
biggest concerns in modern medical science relates to resistant bacteria, due
to which even common respiratory infections, skin sores and diarrhoea can
become untreatable and place millions at risk. Experts warn that if steps are
not taken by 2050, one in six deaths might be attributable to drug-resistant
strains of tuberculosis, malaria, human immunodeficiency virus (HIV) and
certain bacterial infections. If the current situation continues unchecked,
AMR could result in a decline of 1.1–3.8% in the annual global gross domestic
product (GDP), and could have a major impact on global poverty.

At the United Nations General Assembly in New York in September 2016,

global leaders committed themselves to fighting AMR. Despite the fact that
they had come together, challenges persisted as national health priorities
were influenced by different country contexts. Since 2010, WHO has taken
steps to further the work on AMR in the Region. A global Tripartite partnership
for One Health was signed with the Food and Agriculture Organization (FAO)
and World Organisation for Animal Health (OIE) to provide a strategic vision
and see to sharing of responsibilities to address health risks at the human–
animal–environment interface. This was reinforced with the signing of an
Memorandum of Understanding (MoU) in 2018, with details on combatting
health risks at the health-care-associated infection (HAI) interface in the
context of the One Health approach, and including AMR.

In the last two years, the work initiated in 2010 has gained momentum with
high-level advocacy meetings setting the stage for stakeholder engagement,
donor support and technical activities for AMR containment. A situation
analysis tool developed in 2016 provided technical guidance for assessing
the functionality of the measures and capacity to contain AMR in the Region.
This was followed up in 2018 with two intercountry meetings in Bangkok,
where Tripartite members and Member States reviewed implementation and
assessed the progress made in the two years since the last situation analysis
in 2016. This report provides a synthesis of the discussions and an update on
the status of the national action plans (NAP) in Member States.

More recently, the Interagency Coordination Group (IACG) on AMR,

co-chaired by the UN Deputy Secretary General and the WHO Director
General, recommended building a partnership that goes beyond the

ix
 Tripartite.i The renewed prioritization of this issue, along with binding
commitments at the national, regional and global levels, will see stronger
leadership and political buy-in, placing greater accountability for progress
on AMR with individual countries. While we commend the IACG initiative for
a global governance structure, we believe that global governance will need
a relay at the regional level, identifying clear actions and translating global
recommendations into implementation. We hope we can sustain funding to the
interventions above, with the support of valued partners such as the United
States Agency for International Development (USAID) and UK’s Fleming fund
to fight AMR and save millions of lives.

Poonam Khetraphal Singh

Regional Director
WHO South-East Asia Region

i
http://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_Future_global_governance_for_
AMR_120718.pdf

Situational analysis of
x antimicrobial resistance
in the South-East Asia Region, 2018
 Executive summary
Ever since antibiotics were developed
in the 1940s, scientists have warned
that their improper use will lead to
bacterial resistance. On the basis
of the data presented in WHO’s
Global Health Estimates, by the year
2050, about one in six deaths could
be due to drug-resistant strains
of tuberculosis, malaria, HIV and
bacterial infections.
WHO’s efforts to work with
Member States to develop
their national action plan on
antimicrobial resistance (NAP-
AMR)
Since 2010, WHO has worked with
FAO and OIE in a global Tripartite
partnership for One Health to
provide a strategic vision and ensure
sharing of responsibilities to address
health risks at the human–animal–
environment interface. The Tripartite
coordinated the development of a
common multipronged regional
action plan in support of countries,
highlighting priority issues of
governance and multisectoral
coordination, capacity-building, gaps
in knowledge and strengthening
of systems. The announcement
of the global action plan against
antimicrobial resistance (GAP-AMR)
in 2015 was followed by advocacy
initiatives at the global and regional
levels by WHO and the Tripartite,
calling for the development of
comprehensive NAPs-AMR that
were aligned to strategic objectives
and implemented using the One
Health approach. It also provided
technical support for developing and
monitoring the progress of Member
States with respect to their NAPs-
AMR.
Situational analysis of 2016
As a first step in implementing the
AMR prevention and containment
efforts in the Region, a situational
analysis was initiated by the
Regional Office in 2016. The findings
culminated in a roadmap providing
clear guidance on initiatives that
Member States need to put in
place to achieve sustainable AMR
containment.
By mid-2017, all 11 Members States
had prepared NAPs and initiated
programmes. These varied according
to each country’s context and
national health priorities. While the
higher-income countries focused
on emerging infectious disease
outbreaks and AMR, the lower-
income countries viewed AMR
as an abstract concept, looking
instead to strengthen local health
systems to address endemic and
‘neglected’ diseases. Not having
accurate national estimates on the
AMR burden limited many countries,
particularly those in the low- and
middle-income category (LMIC),
in the matter of making a case for
substantial investment in containing
AMR.
xi
 Bangkok meetings and situational
analysis of 2018
In 2018, two back-to-back
follow-up meetings were held
in Bangkok to assess progress
and identify gaps and challenges
in NAP implementation in the
Region and suggest actionable
recommendations. The meetings
brought together country-led
intersectoral teams, comprising
representatives from the national
drug regulatory authority (DRA),
national referral laboratory, AMR
stewardship programme (AMSP)
and national officers in charge
of the human and animal health
sectors and environment sectors
from the Member States, in addition
to technical experts from FAO,
OIE, United Nations Environment
Programme (UNEP) and WHO
collaborating centres from the
Region.
The situational analysis and review
of implementation was carried out
using the participatory methodology
of guided discussion and conducted
jointly by national stakeholders and
WHO in collaboration with FAO, OIE
and UNEP representatives. The
national stakeholders assessed
themselves with supporting evidence
and justification on each of the
indicators under individual focus
areas, documenting strengths,
challenges and implementation gaps.

Situational analysis tool of 2018

1. The advanced tool used for the situational analysis and monitoring of AMR was the same
as that used by the Regional Office in 2016.

2. The tool was used to conduct system-wide analysis of AMR prevention and containment
programmes, focusing on seven areas from the 2016 tool (NAP aligned with the GAP-
AMR governance; awareness-raising; national AMR surveillance system; rational use
of antimicrobials and surveillance of use/sales; infection prevention and control (IPC)
and AMR stewardship; research and innovation; and One Health engagement. Further,
it added the eighth focus area of overarching coordination mechanisms for One Health
engagement.

3. It assessed progress on 30 indicators as a proxy for strategic interventions/programmes

across eight focus areas and introduced 10 additional indicators.

4. Phase 3 or initial implementation was used as a cut-off for assessing progress. This
is because this is one of the most challenging phases for programmes, especially in
the context of developing countries, since it signifies an important shift from planning
and identification of resources (Phases 1 and 2) to the initiation of implementation with
political commitment and support (Phase 3 and above).

Situational analysis of
xii antimicrobial resistance
in the South-East Asia Region, 2018
Assessing the progress of a
country
The 2018 tool assessed the progress
of NAP-AMR implementation based
on 30 indicators as a proxy for
strategic interventions/programmes
across eight focus areas. These
included 20 initial indicators (from
the 2016 situational analysis tool)
and 10 newly introduced indicators.
For the purpose of analysis, Phase
3 or initial implementation was
used as the cut-off for assessing
the progress as it is an important
milestone that signifies an important
shift from planning and identification
of resources (Phases 1 and 2) to
initiation of implementation with
political commitment and support
(Phase 3 and above).
Country progress was defined by
the proportion of indicators that
reached Phase 3 and above and
was calculated for each country
(followed by the calculation of
median progress, i.e. median
of country progress) in 2016
and 2018. The progress against
individual indicators was assessed
as the number of countries that
achieved implementation of the
level of Phase 3 and above by
2018.
Results of the situational analysis,
2018
The situational analysis of 2018
revealed significant progress in the
implementation of NAPs across
different focus areas and their
indicators in the Member States in
the preceding two years.
Based on the original 20 indicators,
median country progress was
significantly higher at 55% in 2018
(i.e. 50% of the countries had at
least 55% of the 20 initial indicators
that reached Phase 3 and above);
progress against the same indicators
in 2016 was 25%. On the basis of
all 30 indicators (including the 10
new indicators introduced in the
situational analysis tool of 2018), the
median country progress in 2018 was
40%.
In terms of how the indicators
improved in countries, 17 out of
the 20 indicators assessed in 2016
showed progress in 2018. The
maximum progress was made in
sanitation and hygiene programmes
in community settings (10 countries
in 2018), raising of awareness
among the general public (nine
countries in 2018), education and
training (nine countries in 2018),
NAP-AMR and governance structure
(eight countries), regulations
dealing with antimicrobials and
active pharmaceutical ingredients
or APIs (eight countries in 2018),
strengthening of the national
laboratory network, surveillance of
antimicrobial use and sales among
humans, and regulation of over-
the-counter (OTC) sales (seven
countries for each indicator in 2018).
Implementation remained the same
in “IPC in health-care settings”,
whereas there was a decline in the
number of countries in the case of
“national AMR containment policy”
and “AMSP in health-care settings”,
mainly due to recalibration of earlier
assessments. None of the countries
was able to demonstrate initial
implementation of early warning
systems in the two years.
As for the indicators newly assessed
in 2018, none of the countries
had implemented national policy/
regulatory frameworks for the
controlled release of antibiotic
residues (AR) in the environment.
xiii
 Similarly, none had a platform for
sharing AMR data across sectors
or awareness and education
programmes for the environment
sector.
All Member States achieved >Phase
4 or full operations in at least one
indicator in 2018. Thailand emerged
as a leader, with 14 indicators in
Phase 4 and above. It was followed
by Sri Lanka (9), Bangladesh (7)
and Indonesia (6). The Democratic
People’s Republic of Korea (DPRK)
(1) and Timor-Leste (2) had the
least number of indicators in full
operation.
Some continuing challenges
The overall findings showed the
animal health sector has made
less progress across different
focus areas and indicators. Limited
systemic capacity of the animal
health sector and lack of resources
can explain some of the gaps in
progress. This could impact One
Health engagement and effective
multisectoral collaboration. The
environment sector, in particular,
is less integrated across all focus
areas and indicators, and this
probably reflects a lack of clarity in
the collaborative frameworks that
necessitate their involvement.
In a majority of the countries,
implementation of AMR surveillance
in the human health sector has
not been initiated so far. It is
lagging more in the animal and
environment sectors. Similarly, AMR/
antimicrobial use (AMU) surveillance,
IPC in health-care facilities, HAI
surveillance and AMSP in most
countries in the Region have failed
to reach initial implementation in the
last two years. None of the countries
Situational analysis of
xiv antimicrobial resistance
in the South-East Asia Region, 2018
started initial implementation of early
warning systems during this period.
An in-depth analysis revealed a lack
of policies, standards and guidelines
which, in turn, lead to an inability
to highlight the relevance of these
activities in the resource-constrained
Region.
A key challenge faced by countries
relates to having in place effective
operational plans and regulatory
frameworks that could be suitably
adapted to AMR containment efforts.
Most countries in the Region are yet
to put together a strategic research
agenda that is relevant to current
policies and programmes, and
address implementation challenges
facing AMR containment efforts.
Recommendations and next steps
Strengthening governance and
multisectoral collaboration is a
priority, as is expanding awareness
on AMR (emphasized as a continuous
effort targeting different sectors and
population groups as well as through
academic curricula and training for
students and working professionals).
To initiatite and improve standardized
and robust AMR/AMU surveillance
across sectors, it was agreed that
WHO and its Global Antimicrobial
Resistance Surveillance System
(GLASS), and the Tripartite partners
must extend support as a matter of
priority, providing technical support
and guidelines.
A key recommendation that
resonated with all Member States
was to standardize and implement
IPC and antimicrobial stewardship
programmes nationwide by involving
hospital personnel, NGOs and key
influencers in the community. To
avoid the irrational use and resale of
antimicrobials, it was also agreed by
all Member States that regulations
to monitor pharmacies and online
outlets would be necessary. Further,
checking the import of medical
products for public and animal health
sectors by promoting regulatory
cooperation in South East Asia
Regional Network (SEARN) that
is more acceptable and innovative
would strengthen AMR containment.
These efforts would then drive the
One Health agenda.
It was agreed that the regional
tripartite partners and UNEP
will continue to support the
implementation of NAPs-AMR
in Member States by providing
evidence-based technical guidance
customized for each country. Going
forward, the momentum thus
achieved will be sustained through
stronger multisectoral collaboration,
including the creation of platforms
that can enable joint planning,
exchange of surveillance information
and sharing of resources.
xv
 Background
Antimicrobial resistance is a global
public health concern that has
significant health and financial
consequences. The prevalence of
AMR been rising steadily and in
many parts of the developing world,
the levels of increase are considered
“dangerously high”. The developing
countries are more vulnerable than
others due to their large population,
coupled with a lack of financial,
technical and human resources
to deal with the high burden of
infectious diseases.
10 million deaths may be
attributed to AMR by 2050 at the
global level and nine million in
developing countries, with 4.7
million in Asia, 4.2 million in Africa
and 392,000 in Latin America.1
The 11 Member States of the Region
are Bangladesh, Bhutan, DPRK,
India, Indonesia, Maldives, Myanmar,
Nepal, Sri Lanka, Thailand and
Timor-Leste. They are lower-middle
income countries (LMICs), which
are home to 1.9 billion people.
Although the Region has made
steady social and economic progress,
a large proportion of the population
continues to live in poverty.
Inadequate housing and sanitation
accelerate person-to-person, and
environmental, spread of resistant
pathogens and genes.
1
Review of antimicrobial resistance. Tackling drug-resistant infections globally: final report and recommendations.
Chaired by Jim O Neil. May 2016 [http://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf]
2
One Health approach to tackle antimicrobial resistance in South-East Asia. Poonam Khetrapal Singh, regional
director BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3625 (Published 05 September 2017) Cite this as: BMJ 2017;358:
j3625
Antibiotics are widely used in the
Region for therapeutic and non-
therapeutic reasons in human
beings, animals, aquaculture and
agriculture, including for the
promotion of growth. This inevitably
leads to the presence of antibiotic
residues in the environment, paving
the way for bacteria to develop
resistance through selective
pressures. Qualitative risk analysis
suggests that this Region is probably
at the highest risk globally for the
emergence and spread of AMR.2
According utmost priority to the
issues related to AMR, the Region
has developed comprehensive
policies and adopted several Regional
Committee resolutions on the
prevention and containment of AMR.
These include:
i. A series of high-level advocacy
meetings held to help set the
stage for the engagement of
stakeholders, support from
donors and technical activities for
AMR containment.
ii. A situational analysis tool
prepared in 2016 to provide
technical guidance for assessing
functionality and capacity in
terms of governance, policy and
1
 systems available to contain AMR
(used in 10 of 11 Member States).
iii. The situational analysis was used
to create a regional roadmap to
help guide the Member States
in developing their national AMR
prevention and containment
programmes.
iv. A workshop was held in 2016,
for all Member States, to review
the progress of planning and
implementation status with
respect to NAP-AMR. This
was combined with in-country
review visits. The Regional
Office developed a roadmap to
assist Member States to develop
their national AMR prevention
and containment programmes
and to implement NAP. The
roadmap proposed five phases of
development based on activities
implemented as part of the NAP
(Fig 1).
v. Collaboration was initiated
with FAO and OIE as a follow-
up to the 2016 meeting and the
development of NAP-AMR to hold
intercountry meetings to:
– review the implementation of
NAP-AMR;
– identify challenges to the
containment of AMR;
– assess the usefulness of
the situational analysis
tool in supporting NAP
Situational analysis of
2 antimicrobial resistance
in the South-East Asia Region, 2018
implementation; and
– explore the flexibility of the
tool to expand and include
agriculture, aquaculture
and environmental sectors
in alignment with the One
Health approach.
Recent relevant initiatives
and developments in the
Region
After the announcement of the
GAP-AMR, SEA Region has taken
serious note of its high vulnerability.
Responding to the situation, it has
translated the GAP-AMR into a
public health priority and backed
it with strong advocacy and policy
initiatives. These developments have
highlighted the political commitment
of the regional leadership in this
area. There have been important
events and initiatives since the last
situational analysis, as shown in
Box 1. A multipronged strategic
approach has been adopted, and
there has been a wide range of policy
proclamations, advocacy meetings
and statements. Multisectoral
coordination mechanisms have
been put in place, efforts have been
made to raise awareness efforts, and
technical support has been provided
to countries for generating policy-
relevant evidence and monitoring of
AMR containment efforts.
Fig. 1. Roadmap for action on AMR in WHO SEA Region, 2016

3
 BOX 1. Special initiatives and developments in SEA Region in 2017–18

Policy statements

i. “Adopting an integrated approach to make progress towards universal health coverage (UHC) and
ensuring access to effective treatment of infectious diseases while reducing risk of AMR”: Outcome
of a high-level meeting on “UHC as a tool to combat infectious diseases” held on 30–31 May 2018 in
Tokyo, Japan.

ii. “Improving prevention, diagnosis and clinical management of sepsis and promoting AMR containment
initiatives”: adopting the 70th WHA resolution in May, 2017.

Technical support for policy relevant evidence

i. Participation in Global antimicrobial surveillance system (GLASS): Encouraging Member States to

participate in GLASS; nine out of 11 countries enrolled in GLASS and started to prepare for submission
of surveillance data.

ii. Scientific and literary work to support AMR containment: In 2017, a publication titled “Situation Analysis
on AMR in SEAR” was released during the 70th Regional Committee meeting at Maldives, serving
as baseline data for national AMR control programmes to measure progress. Other developments
included:

- DPRK followed Maldives’ example and undertook a situation analysis.

- Regional AMR risk assessment was conducted and the result was published in the British Medical
Journal in 2017, presenting initiatives from India, Indonesia and Thailand.

- Priority intervention areas were identified, and pilots initiated within the framework of the NAPs
on the basis of baseline risk assessment. The findings from these pilots will form the basis of
national level programms to strengthen AMR surveillance and control.

iii. WHO-led key projects undertaken proposed and approved:

- An extended-spectrum beta-lactamases (ESBL) pilot project was initiated in Indonesia in 2017 as

part of the regional integrated surveillance project. India and Nepal agreed to start the project
by 2018-19

- An environmental surveillance and study on the role and impact of AMR on the environment was
commissioned, on the basis of a recent WHO study: “Snapshot survey of AMR in East Kolkata
Wetlands, India”.

- Studies were conducted on a six-year retrospective analysis of antimicrobial consumption data in

several Member States to determine the extent and pattern of use of antibiotics.

iv. Adopting a regional approach: The approach was adopted through a SEARN platform that could help
control and regulate the quality of antibiotics sold in the Region in human and animal sectors.

v. Integrated surveillance: Proposing an integrated surveillance to be strengthened combining

surveillance in humans with animals and in the environment.

vi. Technical guidance: Extending technical guidance to build lab-supported human AMR surveillance in
Member States.

Situational analysis of
4 antimicrobial resistance
in the South-East Asia Region, 2018
Multisectoral coordination mechanisms

Developing NAP-AMR in all Member States: Available in WHO library at http://www.searo.who.int/entity/

antimicrobial_resistance/national-action-plans/en/.

Strengthening coordination mechanisms: Multiple sectors were drawn in to promote intersectoral

coordination at the national level and to coordinate bi-regional (SEA and Western Pacific) activities related to
AMR containment in collaboration with the Regional Tripartite members (FAO & OIE).

Constituting an AMR coordination group: In 2017, coordination mechanisms were established between
departments in the Regional Office, led by the Senior Advisor to the Regional Director with a view to enabling
comprehensive planning and engagement across sectors for AMR containment and utilizing the available
resources and expertise in the Region optimally.

Advocacy and awareness initiatives

i. Participating actively in a regional workshop on AMR in SEA, in Penang, Malaysia, on 26-28 March
2018: It provided a platform to share lessons and experiences on how Asian countries have responded
to the AMR crisis and how these can lead to evidence-based decisions and initiatives to tackle the
issue.

ii. Holding World Antibiotic Awareness Week: Since 2015, celebrations are held every November to
improve awareness and understand AMR through effective communication, education and training.

Key message in 2017: Seek advice from qualified health-care professional before taking antibiotics.

Key message in 2018: Think twice. Seek advice. Misuse of antibiotics puts us all at risk.

Monitoring AMR containment efforts

i. Completing AMR self-assessment process: All countries in the Region participated in a global self-
assessment process and the data was updated by June 2017.

5
 Intercountry meetings to
review situation of NAP
implementation in the
Region
The WHO Regional Office for South-
East Asia is committed to supporting
periodic situational analysis activities
across the Region. It also provides
technical support that may be
needed in the areas of surveillance,
laboratory capacity, human
resources, impact assessment and
research to combat AMR in close
coordination with Tripartite experts.
In the light of this commitment, two
back-to-back intercountry meetings
were organized from 23–27 July
2018 in Bangkok, Thailand. These
were held jointly with the Tripartite
partners (FAO and OIE) and UNEP to
review the implementation of NAPs
by the Member States. The meetings
sought to build momentum towards
the containment of AMR and a
subsequent reversal of trends.
General objective
• Monitor progress and address
gaps in the implementation of
-NAPs-AMR in the Region
Specific objectives
• To review progress on the
implementation of NAPs-AMR;
• To review progress in the
development of national
programmes for the containment
of AMR;
Situational analysis of
6 antimicrobial resistance
in the South-East Asia Region, 2018
Intercountry meetings that had
good representation used the
Guided Discussion approach
to undertake an exhaustive
review that was inclusive and
participatory. It built on the 2016
situational analysis to bring in
a fresh perspective with more
nuances and insights, enabling
Member States to identify areas
for strengthening cross-sectoral
collaboration at the national level
for AMR containment.
• To share good practices and
lessons learnt;
• To identify gaps, barriers and
challenges in the implementation
of AMR-NAPs and possible
solutions and enablers; and
• To make recommendations
for effective implementation,
considering the progress made,
and suggest additions to update
NAPs.
Methodology for situation analysis
of NAP implementation
The situation analysis, 2018 and
review of implementation was
carried out using the participatory
methodology of Guided Discussion.
Briefly, Guided Discussion is a
“transformative” approach to public
health research. As a participatory
Fig. 2. Review methodology adopted for conducting NAP implementation
Mul stakeholder Guided discussion
review
• Performed jointly by
naonal stakeholders
and WHO
• Naonal
stakeholders assess
themselves with
supporng evidence
and jusficaon
approach, it ensures the involvement
of all relevant stakeholders, both
marginal and dominant groups, and
enables them to voice their opinions.
Participation is empowering, i.e.
it leads to a participant-initiated
action agenda and empowerment to
participate in policy change.
Guided Discussion is particularly
useful after the participants have
gained knowledge and experience
on the topic of interest. In a Guided
Discussion, the facilitator stimulates
thought and “draws out” information
with the help of questions that have a
specific purpose and clear meaning.
The ideas, facts and agreements that
emerge as a result of the discussion
are recorded.
The implementation review in the
intercountry meetings was conducted
jointly by the national stakeholders
and WHO (the Regional Office and
country offices), in collaboration with
FAO, OIE and UNEP representatives.
The latter facilitated the exchange
with national stakeholders who
assessed themselves with supporting
evidence and justification on a set of
indicators and focus areas (Annex
1). This was done using a list of
core questions from the Situational
Themac analysis
• Elicits exchange • Ascertains the phase
between facilitators of implementaon
and stakeholders by focus area
through use of core • Idenfies and
quesons summarizes
• Consensus achieved strengths, challenges
on grading of phase and implementaon
of implementaon gaps
analysis tool (Annex 2) that was an
advanced version of the 2016 tool.'
Once a consensus was reached
between the national stakeholders
and facilitators on the level of
progress made in implementing
NAPs during 2017–2018, the phase
of implementation for that indicator
was ascertained and recorded. This
was followed by the documentation
of the strengths, challenges and
implementation gaps.
The use of the Guided Discussion
approach at the intercountry
meetings ensured that the
review was more inclusive and
participatory than the assessment
methodology of 2016. The
situational analysis in the latter was
carried out during in-country visits
by officials and consultants from
the Regional Office, as well as
experts and external consultants,
through dialogue with national
stakeholders. The involvement of
experts from FAO, OIE and UNEP
brought in a fresh perspective that
widened the horizons beyond the
Ministry of Health (MoH), enabling
countries to identify areas for
strengthening cross-sectoral
collaboration at the national level
for AMR containment.
7
 Tool used for situational analysis
and monitoring of AMR
The situation analysis tool of 2018
was an improvement over the one
used in 2016. As in the case of the
2016 assessment, the tool was used
to conduct a system-wide analysis of
programmes for the prevention and
containment of AMR.
Focus areas: The 2018 situational
analysis tool focused on eight areas.
Seven were included from the 2016
tool: (1) NAP being in line with
GAP-AMR governance; (2) raising
of awareness; (3) national AMR
surveillance system; (4) rational use
of antimicrobials and surveillance
of use/sales (community-based);
(5) infection, prevention control
and AMR stewardship; (6) research
and innovation; and (7) One
Health engagement. An additional
area, ‘Overarching coordination
mechanisms for One health
engagement’, was introduced in the
2018 tool.
Indicators: The 2018 tool assessed
the progress against 30 indicators as
a proxy for strategic interventions/
programmes across eight focus
areas. These included 20 old
indicators and 10 new introduced
indicators. The new indicators were:
one indicator under focus area 5 on
“Infection prevention and control”;
three indicators under focus area 7
on “One Health engagement”; and six
indicators under the newly introduced
focus areas 8 on “Overarching
coordination mechanism”. A list of
the 20 old and 10 newly introduced
indicators is given in Annex 1.
Situational analysis of
8 antimicrobial resistance
in the South-East Asia Region, 2018
Assessment of progress: For the
purpose of this report, Phase 3 or
initial implementation was used as
the minimum threshold for assessing
progress. Phase 3 is one of the most
challenging phases for programmes,
especially in the context of developing
countries. It is an important
milestone as it signifies a shift
from the planning and identification
of resources to the initiation of
implementation.
Only 20 indicators (from the
situational analysis tool, 2016)
were considered while calculating
the proportion for measuring the
progress of a country in 2016 and its
median progress between 2016 and
2018. DPRK was excluded from this
calculation as the country was not
a part of the situational analysis in
2016. To assess the status of country
progress in 2018, the proportion of
indicators that reached Phase 3
and above was calculated for all 30
indicators.
The progress of individual indicators
was assessed as the number
of countries that achieved an
implementation level of Phase 3 and
above in 2018. For indicators that
were assessed in 2016 (baseline), the
number of countries that were able
to achieve an implementation level
of Phase 3 and above in 2018 were
compared to the baseline.
Country progress was defined as
the proportion of indicators that
reached Phase 3 or above and
was calculated for each country
(followed by calculation of median
progress, i.e. median of country
progress in the years 2016 and
2018).
Participant profile: Country-led
intersectoral teams comprised
representatives, one each from the
national drug regulatory authority,
national referral laboratory and
AMSP, and national officers in-
charge of human health, animal
health and environmental sectors,
from all Member States of the
Region.
The technical experts included
those from FAO (Headquarters and
Regional Office for Asia and Pacific),
OIE and global and regional offices
of UNEP, two WHO collaborating
centres from the Region and all three
levels of WHO that facilitated and
coordinated the sessions. Partners
such as the United States Agency for
International Development (USAID),
Mott MacDonald for UK Fleming
Fund, Canada’s International
Development Research Centre (IDRC)
Asia Regional Office (New Delhi,
India), and International Health Policy
Programme of the Thai Ministry of
Public Health actively participated.
Limitations of the methodology
Two significant limitations were noted
in the methodology that was adopted.
To replace performance assessment based on the review of select participants by an assessment based
on the effectiveness of interventions, WHO is currently developing performance indicators to measure the
impact of AMR containment activities to support the monitoring of NAP implementation.
i. The analysis was primarily based
on group discussions between
national programme managers
with facilitators providing an
overview for each indicator.
The approach and tool provided
an opportunity to the national
stakeholders to present perceived
challenges and needs and for
them to discuss the justification
with external partners, such
as FAO, OIE and WHO, to
seek feasible and consensual
recommendations.
ii. Incremental phase-based
evaluation helped national
programme managers to gain
an understanding of progress
from one phase to the next
phase. The review was primarily
based on the understanding and
interpretation of the national
stakeholders. Though the group
involved in analysing the situation
was quite broad, it did not include
all stakeholders, like civil society,
NGOs, education sector experts
and likewise, who would have
had a bearing on the overall
assessment.
9
 Results of situational
analysis of NAP
implementation
The 2018 situational analysis
revealed significant progress in the
implementation of NAPs by Member
States in the preceding two years
across the seven focus areas. Since
face-to-face Guided Discussions
ensured greater in-depth
understanding of the situational
analysis tool as well as assessment
of the status of implementation
among the national stakeholders
there was consensus on revising
downward progress against some of
the indicators. The following sections
describe the progress made.
General trends in NAP
implementation
There were a few significant trends
in the implementation of NAPs, both
with respect to overall progress in
countries and to progress in focus
areas and specific indicators which
help draw lessons from the process.
Overall progress in countries
In 2016, Bhutan, Indonesia and India
reported the highest proportion of
indicators reaching Phase 3 or above
(country progress of 45%). Timor-
Leste had no indicator in Phase 3
and above (0% country progress);
the median of country progress was
at 25%. In contrast, when the same
indicators were assessed in 2018,
the evidence of progress was more
substantial, with median country
progress at 55%, ranging from
Situational analysis of
10 antimicrobial resistance
in the South-East Asia Region, 2018
country progress at 95% in Thailand
to 15% in Timor-Leste). Overall, 9 out
of 10 countries made progress in the
proportion of indicators in Phase 3
between and 2016 and 2018 (Fig. 3).
On the basis of the 30 indicators
(including the 10 additional
indicators), the median country
progress in 2018 was at 40%
(maximum country progress at 83.3%
in Thailand and minimum 16.7% in
Nepal and Timor-Leste), compared to
25% (Fig. 4)
Progress of focus areas and
indicators
Seventeen out of the 20 indicators
assessed in 2016 showed progress
in 2018 (Table-1). The maximum
progress in terms of the number of
countries in implementation Phase
3 and above was made in sanitation
and hygiene programmes in
community settings and establishing
a functional National Regulatory
Authority or Drug Regulatory
Authority (10 countries in 2018),
awareness among the general public
(nine countries in 2018), education
and training (nine countries in 2018),
NAP-AMR and governance structure
(eight countries), regulations of
finished products and APIs (eight
countries in 2018), national laboratory
network strengthening, surveillance
of use and sale in humans, regulation
of OTC sales (seven countries in
each indicator in 2018). The number
Fig. 3. Progress of NAP-AMR implementation, 2016–18
Progress of NAP AMR implementaon in SEAR (2016 18)

2016* 2018* 2018**

*Progress assessed for 20 indicators based on Situaon Analysis tool 2016; Situaon Analysis was not conducted in DPRK in 2016 and so progress not compared in 2018
** Progress assessed for 30 indicators (10 newly introduced indicators) based on Situaon Analysis tool 2016

Fig. 4. Progress of NAP-AMR implementation by country, 2016–18

Progress of NAP AMR implementaon, by country, SEAR (2016-18)
100
95

90
83.3
Proportion of indicators in phase 3 and above (%)

80
80

70
65
63.3
60 60
60 56.7
55
50
50 46.7
45 45 45
43.3
40.0 40 40.0
40
35
30.0 30.0 30.0 30
30
25 25 25
20 20
20 16.7 16.7
15 15
10
10

0 0 0
0
Bangladesh Bhutan DPRK* India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand TLS Median
progress

2016* 2018* 2018**

*Progress assessed for 20 indicators based on Situaon Analysis tool 2016; Situaon Analysis was not conducted in DPRK in 2016 and so progress not compared in 2018
** Progress assessed for 30 indicators (10 newly introduced indicators) based on Situaon Analysis tool 2016

11
 12
Table 1. Phases of indicators in eight focus areas for all Member States of the Region during the situational analysis review of AMR in 2018
Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

Situational analysis of
S. No. Focus area and subindicators
2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016

antimicrobial resistance
1 National AMR plan and governance
1.1 NAP in line with GAP-AMR 3 2 3 3 3 NA  3 2 2 3 4 2 3 2 2 2 4 3 5 3 2 2

in the South-East Asia Region, 2018

2 Raising awareness
2.1 Campaigns to raise public awareness 4 3 4 3 3 NA  2 2 4 3 3 2 3 2 2 2 4 2 4 2 4 2
2.2 Education and training strategies for professionals 3 1 3 2 2 NA  3 2 3 3 3 1 3 2 1 2 3 1 5 3 3 1
3 National AMR surveillance system
3.1 National human AMR surveillance 3 2 2 2 2 NA  3 2 2 2 2 2 2 2 4 3 4 3 5 3 2 1
3.2 National laboratory network strengthening 3 2 3 3 1 NA  4 2 1 1 2 1 4 2 3 3 5 2 5 4 1 1
3.3 Early warning systems 1 1 1 2 1 NA  2 2 1 NA 1 1 1 1 1 2 1 1 2 1 1 1
4 Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national AMR containment policy for control of 2   1  2  2  2  NA 2   3 2  4  2   2 1  1  1 2   2  2 3   2  2 1
human use of antimicrobials;AMR stewardship
4.2 National regulatory authorities or drug regulatory 4 3 4 5 3 NA  4 4 5 4 4 3 3 3 4 3 4 2 3 2 2 1
authorities
4.3 Surveillance of antimicrobial use and sales in 3 2 2 1 3 NA  3 3 3 3 3 2 2 2 1 3 3 1 4 2 2 1
humans
4.4 Regulation of finished antibiotic products and 4 3 4 4 3 NA  4 4 5 NA 4 2 2 2 2 2 3 2 4 2 1 2
active pharmaceutical ingredients (APIs)
4.5 Regulation of OTC sale and inappropriate sale of 4 3 5 5 1  NA 4 4 4 NA 4 2 2 2 2 3 4 2 4 2 2 1
antibiotics and APIs by pharmacies
5 Infection prevention and control and AMR stewardship programme
5.1 AMR stewardship programme in health-care 2 2 2 2 2 NA  1 3 3 3 1 1 2 2 1 2 2 1 4 3 1 1
settings
5.2 IPC programme in health-care setting 2 2 2 3 3 NA  3 3 3 3 2 2 2 3 1 1 4 3 3 2 1 1
5.3 National HAI and related AMR surveillance 2 2 2 4 3 NA  3 3 2 2 1 2 3 1 1 1 4 2 4 2 1 1
5.4 Sanitation and hygiene 4 1 5 5 5  NA 3 4 4 NA 4 2 2 3 4 2 4 4 4 3 3 2
5.5 Vaccination 4  NA 1 NA 1 NA  3 NA 2 NA 1 NA 4 NA 2 NA  3 NA  3 NA  4 NA 
6 Research and innovation
6.1 R&D and innovation on AMR prevention and 2 2 2 2 1 NA  2 2 2 2 2 1 3 2 1 1 2 1 4 1 1 1
containment and research funding
 Table 1 contd.
Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste
S. No. Focus area and subindicators
2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016 2018 2016
7 One Health engagement
7.1 A national AMR containment policy and 4 2 3 2 1  NA 2 2 3 2 1 2 1 1 1 2 4 3 3 2 1 1
regulatory framework for control and registration
of use in animal sector
7.2 National surveillance of AMR ,and use and sale of AMU-2  2 AMU-2  1 AMU-1  NA AMU-1   1 AMU-3 2 AMU-1   3 AMU-1  1  AMU-1   2 AMU-2   1 AMU-3 2  AMU-1  1 
AMR-2 AMR-2 AMR-1 AMR-2 AMR-3 AMR-1 AMR-1 AMR-2 AMR-3 AMR-3 AMR-1
antimicrobials at national level in the veterinary
sector
7.3 Biosecurity (infection prevention and control) in  3 2 2 2 3  NA 3 2 4 3  1 1 1 2 2 1 3 2 5 2 1 1
the animal sector
7.4 AMR awareness generation and education in the 2 2 3 2 1 NA  1 2 3 1 1 1 1 1 1 1 3 1 4 2 1 1
animal sector
7.5 A national AMR containment policy and 1 NA 1 NA 1  NA 1 NA 1  NA 1 NA 1  NA 1  NA 2  NA 2  NA 1  NA
regulatory framework to control release of AR
and AMR into the environment and management
there in
7.6 National surveillance of AR and AMR in waste 3 NA 1 NA 1  NA 1+ NA 1  NA 1  NA 1  NA 1  NA 1 NA  1+  NA 1  NA
water from manufacture and human/animal/fish
use and disposal in institutions and the home
7.7 Raising awareness on AMR and education in the 1 NA 1 NA 1 NA  1 NA 1 NA  2  NA 1  NA 1 NA  1 NA  2  NA 1  NA
environmental sector
8 Overarching coordination mechanisms for One Health engagement
8.1 Overarching AMR coordination mechanisms 4 NA  3  NA 2 NA  2 NA  1 NA  2 NA  2  NA 2 NA  2  NA 4 NA  1  NA
between all relevant sectors
8.2 Inclusion and engagement of all relevant sectors 2  NA 2  NA 1 NA  3   NA 2  NA 2  NA  2 NA  2   NA 2  NA 5  NA  3  NA
in the NAP-AMR
8.3 A platform and/or mechanism for sharing of 4  NA 2  NA 1 NA  1  NA 1  NA 1  NA 1  NA 1 NA  3 NA  3  NA 1  NA
AMU monitoring data from all relevant sectors
8.4 A platform and/or mechanism for sharing of AMR 2  NA 1 NA  1 NA  2 NA 2  NA 1  NA 2 NA  2  NA 2 NA  2  NA 1 NA 
surveillance data from al relevant sectors
8.5 AAW is nationally coordinated and celebrated, 4  NA 3  NA 1 NA  1  NA 1 NA  3 NA  5  NA 3  NA 2 NA  5  NA 3 NA 
with involvement of and contribution from all
relevant sectors
8.6 A mechanism for co-sharing of resources for AMR 1  NA 1  NA 1 NA  1 NA  1 NA 2 NA 1  NA 1 NA  3  NA  3  NA 1  NA
initiatives in the country

NA: Not assessed

1+ - Discussion in Phase 2 allocation inconclusive

13
 of countries achieving a level of
implementation of Phase 3 and above
remained the same in the indicator
on “IPC in health-care settings”,
whereas in the case of “national AMR
containment policy” and “AMSP in
health-care settings”, there was a
decline in the number of countries,
mainly due to recalibration of earlier
assessment. None of the countries
was able to demonstrate initial
implementation of early warning
systems in the two years.
Ten additional indicators were
introduced in the situational analysis
tool of 2018. Seven countries were
in Phase 3 and above with regard to
the implementation of the “nationally
coordinated AAW” and six countries
in “vaccination”. In three countries
each, “overarching coordination
mechanism”, “inclusion and
engagement of relevant sectors” and
“platform for sharing AMU data” were
at Phase 3 and above in 2018. None
of the countries had implemented a
national policy/regulatory framework
for the controlled release of AR and
AMR in the environment. Nor had
any of the countries established a
platform for the sharing of AMR data
across sectors or initiated awareness
and education programmes for the
environment sector.
All Member States were able to
achieve > Phase 4 or full operations
with regard to at least one indicator
in 2018. Thailand was the leader,
with 14 indicators in Phase 4 and
above, followed by Sri Lanka (10),
Bangladesh (7) and Indonesia (6);
DPRK (1) and Timor-Leste (2) had
the least number of indicators in full
operation.
Situational analysis of
14 antimicrobial resistance
in the South-East Asia Region, 2018
Trends specific to focus
areas
Focus area 1: NAP in line with the
GAP-AMR (Fig. 5)
Indicator 1.1: NAP in line with the
GAP-AMR/level of governance
Five Member States (45%), namely,
Bangladesh, Bhutan, DPRK, India,
and Myanmar have developed their
NAP in line with the GAP-AMR,
including operational strategies
with defined activities and budgetary
provisions (Phase 3).However, though
India has a NAP, the federal nature
of the country requires the drawing
up of state action plans. These are
still being developed for the priority
states to initiate decentralized
implementation, Kerala being one of
the first to develop an action plan.
Fig. 5. Focus area 1: NAP in line
with GAP-AMR
9
8
8
7
No of countries (> phase 3)
6
5
4
4
3
2
1
0
2016 2018
In Indonesia, the AMR working
group has been established and
its NAP is under development
(Phase 2).1 In Nepal, the NAP has
been prepared in line with the GAP-
1
On the basis of its discussion with the facilitators,
the national team from Indonesia proposed a phased
revision from Phase 3 in 2016 to Phase 2 in 2018 for this
indicator.
AMR and is awaiting endorsement India and Nepal, few government-
by the government (Phase 2). Timor led activities were conducted in
Leste has developed a NAP-AMR, different parts of the country with a
which includes an operational plan view to raise awareness of AMR. This
with defined activities and their resulted in the stage of programme
respective budgets (Phase 2). Both installation even as initiatives to
Sri Lanka and Maldives have made raise awareness were being planned
significant progress in rolling out (Phase 2).
their NAP-AMR and scaled up
activities across their respective Indicator 2.2: Education and training
countries (Phase 4). In Thailand, strategies for professionals
ongoing efforts have helped attain
a phase of sustainable operations Content for training on AMR and
(Phase 5). related issues has been included in
continuous professional development
Focus area 2: Raising awareness courses for health-care professionals
(Fig. 6) and induction training organized
by the eight Member States (73%)
Indicator 2.1: Awareness campaigns of Bangladesh, Bhutan, India,
directed at the public Indonesia, Maldives, Myanmar, Sri
Lanka and Timor-Leste (Phase 3).
Fig. 6. Focus area 2: raising
awareness Nepal: Proposals for the revision of
10 the medical curriculum to include
9 9
9 AMR-related content are under
No of countries (> phase 3)

8
7 consideration (Phase 1)2
6
5
4 DPRK: This indicator is in the phase
3
3
2 of programme installation since
2
1
plans for professional training have
0 been developed and proposals have
Awareness to Education &
public training for
been made for the initiation of annual
professionals training courses for health workers
2016 2018 on AMR (Phase 2).

In six Member States (55%), namely, Thailand: Concepts related to AMR

Bangladesh, Bhutan, Indonesia, Sri have been incorporated in the pre-
Lanka, Thailand and Timor-Leste, service training of all relevant cadres
there were nationwide, government- across sectors. Such training is
led antibiotic awareness campaigns, regularly conducted as continuing
targeting both the public and health professional development courses
professionals. The activities for for all health-care professionals, and
this indicator were in the phase the performance is monitored and
that entailed full operation (Phase evaluated (Phase 5).
4). In three Member States (27%),
i.e., DPRK, Maldives and Myanmar,
campaigns and activities to raise
2
Following deliberations at the workshop, the phase for
awareness were conducted on this indicator was revised from Phase 2 in 2016 to 1 in
a limited scale (Phase 3). In the 2018, primarily for want of a clearly developed strategy
for training health professionals.
remaining two Member States (18%),

15
 Focus area 3: National AMR
surveillance system (Fig. 7)
Indicator 3.1: National human AMR
surveillance
The system of national human AMR
surveillance is well established and
functional for monitoring AMR trends
accurately and in a timely manner
in Nepal and Sri Lanka (Phase 4). In
Thailand, national AMR surveillance
is regularly assessed and adjusted,
and has been contributing data
meaningfully to GLASS (Phase 5).
Standardized national surveillance
is operational at a limited number
of sites in Bangladesh and India
(Phase 3). As for the other six
Member States (55%), i.e. Bhutan,
DPRK, Indonesia, Maldives, Myanmar
and Timor-Leste, guidelines have
been developed for human AMR
surveillance, but implementation is
limited due to various constraints
of skilled human resources, access
to funds and data management
(Phase 2).
Indicator 3.2: Strengthening of
national laboratory network
In Bangladesh, Bhutan and Nepal,
the national AMR reference
Fig. 7. Focus area 3: national AMR surveillance system
8
7 not been established (Phase 1) in
7 nine of the 11 (82%) Member States.3
No of countries (> phase 3)
6 India and Thailand have developed
5
5 plans for implementing early
4
3 3
3
2 initiated (Phase 2).
1
0 0
0
National AMR National Laboratory Early warning system
surveillance (humans) network
2016 2018
Situational analysis of
16 antimicrobial resistance
in the South-East Asia Region, 2018
laboratory is functional, the Clinical
and Laboratory Standards Institute
(CLSI) guidelines have been adopted
as a reference standard and a quality
assured laboratory network is
operational at selected sites that are
participating in the external quality
assurance system (EQAS) (Phase 3).
In India and Myanmar, a repository
system and national EQAS have been
set up at all surveillance sites (Phase
4). The laboratory network comprises
laboratories both from the public
and private sectors nationwide.
Research is an integral component
of laboratory surveillance, there
being an established infrastructure,
equipment and human resources
dedicated to research-related
activities. These positive steps helped
Sri Lanka and Thailand to attain
a stage of sustainable operations
(Phase 5). In Indonesia and Timor-
Leste, no national laboratory
network has been established for
AMR surveillance in the human
sector, in the case of DPRK, there is
limited information on international
standards and antimicrobial
sensitivity testing. Thus, the latter
three Member States (27%) continue
in the stage of exploration and
adoption (Phase 1).
Indicator 3.3: Early warning systems
Early warning systems (EWS) have
warning of emerging AMR, in line
with international standards and
pilot projects for EWS that have been
Focus area 4: Rational use of
antimicrobials and surveillance
3
Bhutan and Nepal agreed to revise the phase of
progress from Phase 2 in 2016 to Phase 1 during 2018.
of use/sale [community-based]
(Fig.8)
Indicator 4.1: A national AMR
containment policy for control of
human use of antimicrobials
A total of eight Member States (73%)
are in the process of implementing
the national AMR containment
policy for control of the human use
of antimicrobials (Phase 2). The
national antimicrobial containment
policy is under development in
Myanmar (Phase 1). A national
policy and guidelines for regulated
use of antimicrobials are yet to
be developed in Nepal (Phase 1).
Thailand is currently focusing on the
multidisciplinary expansion of the
national policy with the potential to
scale-up nationally (Phase 3).
India is yet to initiate the
implementation of its National
AMR containment policy (Phase 2),
while efforts are ongoing in
Indonesia to initiate nationwide
implementation (Phase 2). In Nepal,
the national guidelines and policy for
Fig. 8. Focus area 4: rational use of antimicrobials and surveillance of use/sale
12
No of countries (> phase 3)
10
8 7
6
4 3
2
2 1
0
National AMR
containment
policy; AMSP
(humans)
antimicrobial containment are yet to
be developed (Phase 1).4
Indicator 4.2 National regulatory
authorities
National regulatory authorities
(NRA) are fully operational (Phase 4)
in six (55%) Member States and
nationwide activities and outcomes
are regularly shared with programme
managers. There is a need to
strengthen the NRAs in DPRK,
Myanmar and Thailand, as these are
in a phase of initial implementation
(Phase 3). In Thailand, tools for
quality assurance are in place and
inspection is implemented, but the
capacity for the enforcement of
policies and regulation is limited.
Timor-Leste needs to focus on NRA
strengthening and capacity-building
(Phase 2). In Indonesia, the National
Agency of Drug and Food Control
(NADFC) ensures compliance with
4
India revised its implementation phase from Phase 3
in 2016 to Phase 2 in 2018; Indonesia revised its
implementation phase to Phase 2 in 2018 from Phase 4
in 2016; and Nepal assessed its implementation in 2018
as Phase 1 compared to Phase 2 in 2016.
10
8
7 7
4
3
NRA/DRA Surveillance of Regulation of Regulation of
use and sales finished products OTC sales
(humans) and APIs
2016 2018
17
 good manufacturing, distribution
and pharmacy practices, in addition
to evaluating safety, efficacy and
quality aspects. These steps point
towards the effective implementation
of the programme with sustainable
operations (Phase 5). In Bhutan, the
NRA is fully operational but yet to
ensure sustainability. The country
aims to strengthen and build the
capacity of the NRA at the national
level through regulatory cooperation
with SEARN (Phase 4).5
Indicator 4.3 Surveillance of
antimicrobial use and sale among
humans
Six Member States (55%) are
reported to have established
a surveillance mechanism for
antimicrobial use (AMU) and sales
among humans that includes framing
a policy and organizing a task force
for the collection of production
data (Phase 3). Bhutan, Myanmar
and Timor-Leste are beginning to
implement surveillance mechanisms
for AMU (Phase 2). Nepal is yet to
develop a surveillance mechanism
(Phase 1), while Thailand’s
surveillance mechanism is fully
functional (Phase 4).
Indicator 4.4: Regulation of finished
antibiotic products and active
pharmaceutical ingredients
The regulation of finished antibiotic
products and APIs is fully operational
(Phase 4) in five Member States
(45%). Myanmar and Nepal continue
to develop regulations, as was the
situation in 2016 (Phase 2), while
DPRK is in the process of rolling
out regulations at the national
level (Phase 3). Sri Lanka already
has regulations in place, though
5
Bhutan revised its implementation phase from Phase 5
in 2016 to Phase 4 in 2018.
Situational analysis of
18 antimicrobial resistance
in the South-East Asia Region, 2018
some areas such as inspection is
limited, due to the lack of resources
(Phase 3). The NADFC in Indonesia
has reportedly attained the highest
performance standards with
sustainable operations (Phase 5).
Indicator 4.5: Regulation of OTC and
inappropriate sale of antibiotics and
APIs by pharmacies
The regulation of OTC and
inappropriate sale of antibiotics and
APIs by pharmacies has attained
a state of full operation in six
Member States (55%). In Bhutan,
the regulations are fully operational
nationwide, with regular monitoring
and evaluation of implementation
(Phase 5). Myanmar, Nepal
and Timor-Leste are currently
developing structures and making
provisions for the allocation of
resources to implement regulations
on a nationwide scale. Strategic
planning is in place for capacity
building and the allocation of a
budget to conduct activities (Phase
2). In DPRK, a beginning has been
made to identify potential barriers
in the implementation framework
(Phase 1).6
Focus area 5: Infection prevention
control and AMR stewardship
programme (Fig. 9)
Indicator 5.1: AMR stewardship
programme in health-care settings
India, Maldives, Nepal and Timor-
Leste were found to be in the
initial stages of establishing an
AMSP in health-care settings
(Phase 1). Bangladesh, Bhutan and
Myanmar continue to establish their
programmes, as was the case in
2016 (Phase 2), while DPRK and Sri
6
Nepal revised its implementation phase from Phase 3
during 2016 to Phase 2 in 2018.
 Fig. 9. Focus area 5: infection prevention and control and AMR stewardship programme
12
10
No of countries (> phase 3)
8
6 5
4 3
2 2
2
0
AMSP in
healthcare
settings
* New indicator introduced in situational analysis tool, 2018
Lanka have completed their core
set of activities and are focused on
implementing the programme with
a potential to scale it up nationally
(Phase 2). Specifically, Sri Lanka
has developed national guidelines
on IPC and geared infection control
units in hospitals to support IPC
activities by conducting the training
of staff regularly. In DPRK, guidelines
are available in health facilities for
prescribing antimicrobials only after
testing for susceptibility, which is
conducted at each provincial hospital.
Besides, the prevention of infection in
health-care settings is a part of the
national strategy. Indonesia continues
to establish the programme in select
health-care settings (Phase 3), as in
2016, while Thailand has scaled up its
activities nationwide and progressed
to full operations (Phase 4).7
Indicator 5.2: IPC programme in
health-care settings
Bangladesh, Bhutan, Maldives and
Myanmar are focused on establishing
IPC in health-care settings, with
7
India and Nepal revised their implementation phase to
Phase 1 from Phase 3 and Phase 2, respectively, in 2016.
10
6
5 5 5
0
IPC in HCS National HAI Sanitation & Vaccination*
surveillance Hygiene
2016 2018
the potential to scale up nationally
(Phase 2).8 DPRK, India, Indonesia
and Thailand have implemented
IPC programmes in health-care
settings across a limited number of
sites in the country (Phase 3). In Sri
Lanka, nationwide surveillance for
methicillin-resistant staphylococcus
aureus bacteraemia, hand hygiene,
lower segment caesarean surgery
with quarterly reporting of data to
provincial hospitals indicate full
operation of the IPC programme in
health-care settings (Phase 4). Nepal
and Timor-Leste are in the process
of identifying potential barriers and
setting up systems and frameworks
to initiate IPC in health-care settings
and combat AMR (Phase1).
Indicator 5.3: National HAI and
related AMR surveillance
Bangladesh, Bhutan and Indonesia
are establishing national-level
programmes for hospital-acquired
infection (HAI) and AMR surveillance
(Phase 2). Three Member States
(27%), i.e. Maldives, Nepal and
8
Bhutan and Myanmar revised phase-grading from
Phase 3 in 2016 to Phase 2 in 2018.
19
 Timor-Leste, are in the stage of
initial exploration and the adoption
of this indicator (Phase1), while
DPRK, India and Myanmar have
already attained the stage of initial
implementation (Phase 3).9 In Sri
Lanka, bacteriological testing of food
and water samples is conducted
regularly, along with well-established
national surveillance of water quality;
also, mechanisms are in place
to ensure compliance with hand
hygiene that is reported regularly to
the central authorities (Phase 4). In
Thailand, HAI surveillance has been
set up, with regular reporting on AMR
(Phase 4).
Indicator 5.4: Sanitation and hygiene
Bhutan and DPRK have well
established WASH and waste
disposal programmes (Phase 5).
Six Member States (55%), i.e.
Bangladesh, Indonesia, Maldives,
Nepal, Sri Lanka and Thailand, have
adopted large-scale nationwide
sanitation and hygiene activities to
combat AMR, and are in the phase of
full operation (Phase 4). In Thailand,
potable tap water supplies are
available in health-care facilities, and
campaigns on sanitation and hygiene
are conducted at regular intervals.
India and Timor-Leste have still not
engaged in nationwide sanitation and
hygiene activities that are relevant to
reverse AMR trends (Phase 3).10
Indicator 5.5: Vaccination
This indicator was added to the
situational analysis tool to ensure
a renewed focus on vaccination as
9
Bhutan revised its implementation phase from Phase 4
in 2016 to Phase 2 in 2018, and Maldives from Phase 2 in
2016 to Phase 1 in 2018.
10
India revised its implementation phase from Phase 4
in 2016 to Phase 3 in 2018, and Myanmar from Phase 3 in
2016 to Phase 2 in 2018.
Situational analysis of
20 antimicrobial resistance
in the South-East Asia Region, 2018
a strategy to curb AMR. It has been
observed that vaccine technology
is available but is underused
for the prevention of bacterial
infections, particularly those
caused by organisms resistant to
antimicrobials. Bhutan, DPRK and
Maldives are currently exploring the
inclusion of pneumococcal conjugate
vaccine (PCV) in their respective
routine immunization schedules
(Phase1). Indonesia and Nepal
are now beginning to implement
the inclusion of PCV in routine
immunization (Phase 2). Three
Member States (27%), i.e. India, Sri
Lanka and Thailand, have included
PCV in their expanded programme
on immunization (EPI) schedule
(Phase 3), and three other Member
States (27%), i.e. Bangladesh,
Myanmar and Timor-Leste, have
introduced PCV nationwide (Phase 4).
Focus area 6: Research and
innovation (Fig. 10)
Indicator 6.1: R&D and innovation on
AMR prevention and containment (+
research funding)
Six Member States (55%),
Bangladesh, Bhutan, India,
Indonesia, Maldives and Sri Lanka,
have plans to foster research and
development and innovation on
AMR prevention and containment. A
strategic research agenda has been
developed and policies planned to
support research that assists the
implementation of NAP-AMR, along
with funding from various national
and international resources tapped
for conducting research (Phase 2).
The Member States (27%) of DPRK,
Nepal and Timor-Leste are yet to
develop specific policies related
to research and development and
innovation for AMR containment and
prevention (Phase 1). In Myanmar,
the existing policies and structures
support activities related to research
on the prevention and containment
of AMR (Phase 3), while in Thailand,
research is integral to supporting
evidence-based policy decisions.
The country has well-established
infrastructure, equipment, skilled
manpower and funds for research
and development from domestic and
international donors (Phase 4).
Fig. 10. Focus area 6: research
and innovation
10
No of countries (> phase 3)
8 Inadequate infrastructure, the
6
4
2 procedures have contributed to
0
0 varying levels of AMR containment
2016
Focus area 7: One Health
engagement (Fig. 11)
Indicator 7.1: A national AMR
containment policy and regulatory
framework for control of use for
animals, and their registration for
use
The DPRK, Maldives, Myanmar,
Nepal and Timor-Leste are yet to
develop a national AMR containment
policy and a regulatory framework for
control of the use of antimicrobials
in the veterinary sector (Phase 1).
India has planned a drug regulatory
authority for the veterinary sector and
issued an advisory for prudent use
of antimicrobials for the treatment
of animal diseases (Phase 2).
Bhutan, Indonesia and Thailand have
progressed from Phase 2 to Phase 3
by developing a regulatory framework
and initiating the implementation of
AMR containment in the veterinary
sector. As for Bangladesh, the
country’s legal framework prohibits
the use of antimicrobials in animal
feed, and the classification of the use
of antimicrobials includes drugs for
limited use in “watch and reserved”
category. In Sri Lanka, the regulatory
framework closely monitors the
importation of antimicrobials and
ensures that licensing is renewed
periodically. Bangladesh and Sri
Lanka have made efforts to bring this
indicator in a phase of full operation
in the last two years (Phase 4).11
absence of skilled manpower, and
gaps in operational guidelines and
2
laboratory standard operation
2018
activities in most of the Member
States in the Region.
Indicator 7.2: National surveillance
of AMR and use and sales of
antimicrobials at national level in
the veterinary sector
AMR surveillance in the veterinary
sector has been initiated in
accordance with the national plans
in Indonesia, Sri Lanka and Thailand
(Phase 3). National plans have
been developed, but with limited
capacity for implementation of
AMR surveillance in Bangladesh,
Bhutan and India (Phase 2). No
national policy/guidelines have been
developed for AMR surveillance in the
veterinary sector in DPRK, Maldives,
Myanmar, Nepal and Timor-Leste,
resulting in a stage of exploration and
adoption of this indicator (Phase 1).
However, project-based AMR
11
Nepal revised its implementation phase from Phase 2
in 2016 to Phase 1 during 2018.
21
 Fig 11. Focus area 7: One Health engagement

7
No of countries (> phase 3)

6
6
5
5
4
4
3
3
2
1 1 1 1
1
0 0 0 0 0 0
0
National AMR National Biosecurity in AMR National AMR National AMR
containment surveilance for animal sector awareness and containment surveillance of awareness and
policy and AMR & AMU education policy and AR & AMR in education
regualtions (animals) (animal sector) regualtions for wastewater* (environment
(animals) controlled sector)*
release of AR
& AMR
(environment)*

2016 2018

surveillance is ongoing in Myanmar.12 of sales and AMU in the animal

In Maldives, though the AMR
containment policy includes AMR
surveillance in animals, no activities
have been conducted so far due to
limited infrastructure, the absence
of skilled manpower, and gaps in
operational guidelines and laboratory
standard operation procedures.
Five Member States (45%), i.e. DPRK,
India, Maldives, Myanmar and Timor-
Leste, are yet to develop guidelines
for the surveillance of AMU. Also,
monitoring guidelines for sales in
the veterinary sector are yet to be
developed (Phase 1).13 Though the
NAP outlines AMU surveillance and
monitoring activities in Myanmar,
these are yet to be initiated. There
is limited capacity for surveillance
12
The Myanmar Pig Partnership, funded by the Zoonoses
and Emerging Livestock Systems (ZELS) and led by the
University of Cambridge, is an interdisciplinary research
project exploring the disease risk accompanying the
changing pig production and consumption patterns in
Myanmar. It covers AMR and AMU.
13
Maldives revised its implementation phase from
Phase 3 in 2016 to Phase 1 in 2018.
sector in four Member States
(36%), i.e. Bangladesh, Bhutan,
Nepal and Sri Lanka (Phase 2). In
Indonesia, surveillance of sales,
distribution and use of antibiotics
is limited, but surveys for antibiotic
sales based on antibiotic import
data and antibiotic production data
are conducted (Phase 3). Thailand
has set up national surveillance of
the use and sale of antimicrobials
in the veterinary sector, and the
information is shared annually
with the OIE, on the basis of sale
estimates of antimicrobials in the
veterinary sector (Phase 3).
Indicator 7.3: Biosecurity (IPC) in the
animal sector
Three Member States (27%), i.e.
Maldives, Myanmar and Timor-
Leste, are beginning to explore and
adopt measures to install national
biosecurity practices in the animal
sector (Phase I). Another three

Situational analysis of
22 antimicrobial resistance
in the South-East Asia Region, 2018
Member States (27%), i.e. Bhutan,
DPRK and Nepal, are establishing
a programme, though there is
no specific department that can
assume the exclusive responsibility
of biosecurity in the animal sector
(Phase 2). Bhutan has developed
standard operating procedures
(SOPs) for government-manned
farms, but there are no guidelines
for small/ backyard farms so far.
Also, the policy for vaccination in the
animal sector is yet to be developed.
A manual on biosecurity is available
in Nepal and training sessions are
conducted for farmers, as well as
technicians, in the veterinary sector.
Barring Bangladesh, none of
the Member States were found
to have a policy or regulatory
framework that could help control
the release of AR/AMR surveillance
in waste water from antibiotic
manufacturers/ homes (Phase 1).
The DPRK has implemented
biosecurity guidelines and
established systems to monitor
compliance, although the guidelines
do not specifically address AMR. Both
India and Sri Lanka have developed
policies, guidelines and strategies
for biosecurity in the animal sector,
and are expanding these by scaling
up activities nationwide (Phase 3).
In India, training programmes and
workshops are organized regularly
to strengthen the implementation
of biosecurity measures. The
biosecurity manual is followed
both by public and private sector
farms, even though no guidelines
for backyard poultry exist in India.
The biosecurity audit process
has been developed in India, but
its implementation is limited. In
Sri Lanka, vaccines such as the
Salmonella vaccine are available
free of charge for backyard poultry
handlers. In addition, guidelines for
outbreak response are in existence
to support biosecurity in the animal
sector.
Following avian influenza outbreaks
in the past, significant investments
have been made in Indonesia to
strengthen biosecurity in the animal
sector, especially with technical
and financial support from FAO and
USAID. In Indonesia, biosecurity
is fully operational in the animal
sector (Phase 4) as guidelines, policy
and training manuals have been
developed and implemented with
regular audit being conducted for
large-scale farms. There has been
an advancement of biosecurity in
Thailand, with regular and sustained
activities for IPC being conducted in
the animal sector (Phase 5).
There were various levels of
success in different countries.
Some had adopted measures
to instal biosecurity practices in
the animal sector and developed
SoPs for government-manned
farms, with guidelines for small/
backyard farms. Others had
undertaken training to strengthen
the implementation of biosecurity
measures and conducted regular
audits for farms.
Indicator 7.4: Education on AMR
in the animal sector and raising
awareness
It was observed that no strategies/
policies have been developed
to initiate systematic efforts for
comprehensive awareness of
23
 AMR amongst professionals in the
veterinary sector in six (55%) Member
States, i.e. DPRK, India, Maldives,
Myanmar, Nepal and Timor-Leste
(Phase1).
In Bangladesh, strategies to create
awareness have been developed (but
not implemented) to include training
of health-care professionals in the
animal sector (Phase 2). Bhutan,
Indonesia and Sri Lanka (27%) have
incorporated concepts related to
AMR in continuing professional
development programmes and
developed specific programmes
for awareness among veterinary
professionals (Phase 3). Campaigns
to generate awareness have been
conducted using a multisectoral
approach, along with revisions in the
curriculum in veterinary sector in
Thailand (Phase 4).
Indicator 7.5: A national AMR
containment policy and regulatory
framework to control release of AR
and AMR into the environment and
management therein
Engagement and involvement of
the environment sector has been
found to be inadequate across
the Region and most Member
States are beginning to include the
environment aspect to strengthen
multidisciplinary participation under
the One Health approach.
Sri Lanka and Thailand have a
national AMR containment policy and
a regulatory framework to control
the release of AR and AMR into
the environment and management
therein (Phase 2). All other Member
States are still in the process of
Situational analysis of
24 antimicrobial resistance
in the South-East Asia Region, 2018
developing policies and regulations
(Phase 1). In Sri Lanka, the national
waste management policy has been
drafted to include all regulations and
guidelines, including waste water
treatment by manufacturing units
and hospitals. A central environment
authority has been established for
the implementation of the regulations
and an environment impact
assessment has been conducted.
In Thailand, the existing policies
address AMR in the environment and
there are well-established standards
of surface water testing and of waste
water effluents from industries and
the municipal wastewater system.
Indicator 7.6: National surveillance
of AR and AMR in waste water
The release of resistance-driving
chemicals into the environment is
increasingly being recognized as
a cause of the spread of clinically
relevant antibiotic resistance. This
has made it imperative to monitor
and control the disposal of AR in the
environment and to have a system of
surveillance of AMR in wastewater
from drug manufacturing units,
institutions, homes and waste water
plants. Thus, an additional indicator
was added to the situation analysis
tool in 2018.
In Bangladesh, policies are in place
for monitoring waste and waste
water from antibiotic manufacturing
units but these are yet to expanded
to include specific indicators
for assessing the quantum of
antimicrobials in waste generated by
human/animal use (both terrestrial
and aquatic) (Phase 3).
Indicator 7.7: AMR awareness
generation and education in the
environmental sector
An additional indicator to monitor
the progress on AMR awareness
generation in the environmental
sector was included in the situational
analysis tool . It was observed that
no communication strategies have
been developed in nine Member
states (82%) (Phase 1) to generate
comprehensive awareness on
environmental safety in the AMR
context. In Maldives, the national
AMR containment policy addresses
issues pertaining to awareness and
education for the environment sector
(Phase 2) In Thailand, a specific
policy for waste management has
been developed, primarily for the
pharmaceutical sector. This was
preceded by a core set of activities
including the development of
guidelines and standards and
identification of resources for the
implementation and monitoring of
the programme (Phase 2).
Focus area 8: Overarching
coordination mechanisms for One
Health engagement (Fig. 12)
Addressing the rising threat
of AMR requires a holistic and
multisectoral (One Health) approach.
To assess progress on One Health
engagement, an additional subset
of indicators was added to the
situational analysis tool developed
by the Regional Office. The phase of
progress related to each indicator was
reviewed by national stakeholders
in close coordination with Tripartite
experts during the workshop.
Indicator 8.1: Overarching AMR
coordination mechanism
Apart from Timor-Leste and
Indonesia, which do not have any
formal multisectoral governance or
coordination mechanism (Phase 1),
all Member States have established
multisectoral working groups. Six
Member States have multisectoral
working groups/coordination
committees under government
leadership (Phase 2). Bhutan has
progressed to holding regular
meetings, with defined reporting
mechanisms for the multisectoral
group (Phase 3). Bangladesh and
Thailand have functional multisectoral
committees with advanced objectives,
including the development of
restrictions on critically important
antimicrobials (Phase 4).
Indicator 8.2: Inclusion and
engagement of all relevant sectors
in the NAP-AMR
In seven (64%) Member States,
namely Bangladesh, Bhutan,
Indonesia, Maldives, Myanmar,
Nepal and Sri Lanka, the NAP-AMR
includes relevant sectors (Phase
2)." In both India and Timor Leste,
NAP-AMR provides for the inclusion
and engagement of relevant sectors
to facilitate One Health engagement.
In DPRK, there is an absence of
multisectoral involvement due to
the lack of awareness, but the issue
is now beginning to draw attention
(Phase 1). In Thailand, multisectoral
coordination, with the inclusion
and engagement of all the relevant
sectors, has attained a phase of
sustainable operation (Phase 5).
25
 Fig. 12. Focus area 8: Overarching coordination mechanisms for One Health engagement

8
7
7

6
No of countries (> phase 3)

4
3 3 3
3
2
2

1
0 0 0 0 0 0 0
0
Overarching Inclusion and Platform for Platform for Nationally Co-sharing of
coordination engagement sharing AMU sharing AMR coordinated resources for
mechanism* of relevant data* data* AAW* AMR
sectors* initiatives*

2016 2018

*New indicator introduced in situational analysis tool, 2018

Indicator 8.3: A platform and/ Indicator 8.4: A platform and/

or mechanism for sharing AMU or mechanism for sharing AMR
monitoring data surveillance data

In seven Member States (64%), there In seven Member States (64%),

is no formal platform or mechanism
for the sharing of AMU monitoring
data from all the relevant sectors
(Phase 1). In Bhutan, there are
defined reporting mechanisms for
multisectoral groups that serve as
platforms for the sharing of AMU
monitoring data amongst the relevant
sectors (Phase 2). In Sri Lanka and
Thailand, a platform for the sharing
of AMU data amongst the relevant
sectors is clearly defined and
functional (Phase 3). Bangladesh
has a well-developed platform and
mechanism for the sharing of AMU
monitoring data (Phase 4).
i.e. Bangladesh, India, Indonesia,
Myanmar, Nepal, Sri Lanka
and Thailand, defined reporting
mechanisms for multisectoral groups
have been established and serve
as a platform for sharing of AMR
surveillance data amongst relevant
sectors (Phase 2). The remaining four
Member States (36%), Bhutan, DPRK,
Maldives and Timor-Leste, do not
have a formal mechanism for sharing
of AMR surveillance data (Phase 1).

Situational analysis of
26 antimicrobial resistance
in the South-East Asia Region, 2018
Indicator 8.5: AAW is nationally
coordinated and celebrated with
involvement and contributions from
all relevant sectors exists
Antibiotic Awareness Week (AAW)
is nationally coordinated and
celebrated, with the involvement of
and contributions from all relevant
sectors in five Member States
(45%), i.e. Bhutan, Maldives, Nepal,
Thailand and Timor-Leste (Phase 3).
DPRK, India and Indonesia are yet to
establish multisectoral coordination
amongst all relevant sectors for AAW
(Phase1). In Bangladesh, involvement
of and contribution from all sectors
are fully operational (Phase 4). In
Myanmar and Thailand, nationally
coordinated AAW celebrations are
in an advanced stage, with regular
feedback, monitoring and evaluation
(Phase 5).
Indicator 8.6: Mechanisms for
co-sharing of resources for AMR
initiatives exist
The mechanisms for co-sharing of
resources for AMR initiatives are
still being discussed and explored in
eight Member States (73%) (Phase 1).
After establishing the initial core set
of activities, Maldives is beginning
to instal co-sharing of resources
for AMR initiatives amongst various
stakeholders (Phase 3). In Sri Lanka,
activities for co-sharing of resources
for AMR initiatives have been
undertaken and are at the stage of
initial implementation (Phase 3).
27
 Conclusions
Inspite of the fact that the SEA Region
has been identified as the region with
the highest potential burden of AMR,
it has not gained significant traction
in policy and/or programmatic areas.
As a result, systemic responses to
AMR as a public health issue have
been largely neglected. However,
the announcement of the GAP-
AMR in 2015, followed by a series of
advocacy initiatives at the global and
regional levels, especially by WHO
and the other Tripartite partners, has
brought the issue to the forefront in
the Region.
The 2015 GAP-AMR called for the
development of comprehensive
NAP-AMRs aligned with its strategic
objectives and implemented using
the One Health approach. As the first
step in the implementation of the
AMR prevention and containment
efforts in the Region, a situational
analysis of AMR containment
efforts was initiated by the WHO
Regional Office in 2016. The findings
of the situational analaysis were
incorporated in a roadmap for
AMR prevention and containment
The 2018 situational analysis highlighted the continuing
challenges that need to be addressed as a priority by the
Member States and the technical agencies that support
implementation of their NAP-AMR.
Going forward, the momentum that has been generated
will be sustained only if there is multisectoral collaboration,
including the establishment/ availability of platforms that
enable joint planning, exchange of surveillance information
and sharing of resources.
Situational analysis of
28 antimicrobial resistance
in the South-East Asia Region, 2018
in the Region. These publications
subsequently formed the basis for
the development of most of the NAP-
AMRs in the Member States.
By mid-2017, all 11 Members States
had prepared their NAPs and initiated
programmes based on them. The
follow-up inter-country meetings in
2018 helped assess progress and
identify gaps and challenges in
implementation and made actionable
recommendations.
Overall, the discussions pointed
towards significant progress in
AMR prevention and containment
initiatives in the Region in the last
two years. The progress made in
initiating the programmes was
confirmed by the change in median
progress between 2016 and 2018,
notably in terms of ongoing advocacy
and political commitment.
It emerged that interventions
aligned with existing efforts, such as
sanitation and hygiene programmes,
demonstrated better results. Also,
spreading awareness, imparting
education/training and fostering
collaboration across sectors during
AAWs were easier and quicker,
even though the quality, extent and
robustness of these initiatives was yet
to be established through systematic
monitoring and evaluation.
Enabling regulatory frameworks,
that are suitably adapted to the
needs of AMR, are essential to
containment efforts. The SEA
Region has traditionally responded
to public health issues, especially
those dealing with use of medicines/
medicinal products, with regulation
heavy responses. So, not surprisingly,
the progress made in implementing
NAPs in the last two years, again
indicates focus on regulations in the
context of AMR and AMU (regulation
of antibiotics and APIs and OTC
sales). However, in most cases,
implementation posed challenges
and what will be required is effective
operational plans that will help
overcome these implementation
challenges.
Investments have been made over
the years to strengthen public health
laboratories in disease surveillance
and these have provided an
important launch pad for initiating a
laboratory network in most countries.
Finally, progress has been made in
establishing governance mechanisms
as part of the NAP-AMRs, forming
the basis for future advancement and
consolidation of multisectoral and
collaborative action.
Qualitative differences were seen
in the level of success achieved
by the Member States, with a
few recording higher levels of
implementation over the two years
between analyses (Phase 4 and
above). This provided an opportunity
for learning from experiences
within the Region. While Thailand
made progress across all focus
areas and indicators, the strategic
research agenda developed by it is
emerged as a good practice model.
Sri Lanka paid attention to their
environmental sector making it a key
stakeholder in AMR containment.
Further, it stood firm on making
its public health system stronger,
resulting in improved sanitation/
hygiene, vaccination and effective
implementation of regulations.
Effective multisectoral coordination
(One Health) was well exemplified
in Bangladesh, and so is it’s more
modern pharmacy regulation
system. India stood out for its robust
regulatory frameworks as well as
community awareness initiatives in
the area of sanitation by launching a
massive cleanliness mission across
the country fixing accountabilities
and involving multiple layers of
society. Stewardship was successfully
implemented in Bhutan as were
high intersectoral coordination
and strong political will. Further,
these were characterised by
well-defined policies/guidelines,
regulatory systems and budgetary
provisions for AMR containment
efforts. Indonesia did a fine job
in consolidating its regulatory
frameworks and a robust biosecurity
system for the animal sector. It
also succeeded in mobilizing the
community by creating awareness
on the smart use of medicines.
Infection prevention and control in
support of AMR containment through
sanitation/ hygiene interventions
and vaccination proved to be a
major strength in DPRK, Myanmar
and Timor-Leste. DPRK carried
out a nationwide coverage of safe
water and sanitation and hygiene,
while Myanmar put together
systematic efforts in the area of
capacity building of professional
and paraprofessionals in addition
to enforcing strong pharma related
regulations. Good results were
seen thanks to strong multisectoral
coordination and synergy at the inter
and intra departmental level. Nepal’s
introduction of vaccination and good
coverage ensured effective infection
prevention. In Thailand, a strong and
quality assured laboratory network
and strong set of regulations provided
29
 a deterrent to any kind of misuse.
although OTC antibiotics can still be
available in some locations. Strong
political will and commitment were
seen in Timor-Leste where greater
government ownership translated
into systematic and regular launch
of awareness campaigns targeting
different community groups.
In general, there has been less
progress across different focus
areas and indicators in the animal
health sector. This could impact One
Health engagement and effective
multisectoral collaboration. The
limited systemic capacity of the
animal health sector, typical of the
Region, and a lack of resources
could explain some of these gaps
in progress. The environmental
sector, in particular, is less
integrated across all focus areas
and indicators. This is probably a
reflection of the lack of clarity in
the collaborative frameworks that
necessitate its involvement. Limited
conclusive evidence on the role of
the environment in the emergence
and spread of AMR could also be
a reason for weaker advocacy. The
newly introduced focus areas with
respect to overarching collaborative
mechanisms brought out some of
these gaps.
The situation analysis revealed
that in a majority of the countries
in the Region, the implementation
of AMR surveillance has not been
initiated so far. While this is true
of the human health sector, it is
even more so in the animal and
environment sectors. Other areas
of concern are IPC in health-care
facilities, HAI surveillance and AMSP,
in which most of the countries in the
Region have failed to reach initial
implementation in the last two years.
Situational analysis of
30 antimicrobial resistance
in the South-East Asia Region, 2018
An in-depth analysis revealed lack of
awareness, policies, standards and
guidelines, which lead to the inability
to highlight the relevance of these
issues in the resource-constrained
SEA Region. In addition, there is a
lack of political will to support these
important functions. WHO GLASS
and other Tripartite partners would
need to support surveillance, with
technical backing and guidelines, on
priority.
None of the countries has
taken steps towards the initial
implementation of early warning
systems. Globally, this critical
function for AMR surveillance,
containment and spread has suffered
due to a lack of clarity on goals and
standards. Recent efforts by WHO
should help provide more clarity in
this regard.
The GAP-AMR has identified research
and innovation as a key strategic
objective so that evidence can be
generated to guide current and future
containment efforts. However, as has
been demonstrated in many areas
of public health, health research is
often disconnected with the needs
of policymakers and programme
managers. Most countries in the
Region are yet to put together a
strategic research agenda that
is relevant to the current policies
and programmes and address
implementation challenges in the
way of AMR containment efforts in
the Region. The discussions clearly
pointed towards the need for greater
clarity on research strategies. The
research agenda proposed and being
pursued by Thailand provides a good
template for research priorities
that are in line with the local needs
and ensure a strong One Health
collaborative focus.
 Way forward and
recommendations
The roadmap proposed by the
Regional Office in 2016 provides clear
guidance on the steps and initiatives
that the Member States need to take
to achieve sustainable programmes
for AMR containment. Depending
on their respective readiness and
existing capacities, they can set
their own agenda and pace, with a
common vision and understanding
of the good practices that need to
be achieved as a result of different
initiatives outlined in their NAP-
AMR. Having strong operational plans
with inbuilt monitoring and evaluation
would be critical in ensuring
progress and a degree of coherence
in this complex multisectoral
and multistakeholder issue. On
the basis of the present situation
analysis, 2018, the intercountry
meetings identified country-specific
recommendations (See Section on
Country Profiles).
Key recommendations to
address main challenges
of AMR containment in the
Region
Strengthen governance and
multisectoral collaboration: Given
its global health implications, AMR
must be kept high on the agenda of
policy-makers. There continues to
be a need to strengthen governance
and multisectoral collaboration in all
Member States, with a special focus
on non-human sectors. At the same
time, the Member States must learn
from each other’s experience and good
practices from other Regions. The
following measures must be taken.
• Strengthen policy frameworks to
provide an enabling environment
to make AMR a priority public
health issue. Place special focus
on dedicated funding for AMR
containment, especially from
national sources when global
momentum has settled.
• Map the resources available
in the Member States, develop
operational plans and establish
mechanisms for co-sharing
resources for AMR initiatives.
• Integrate monitoring and
evaluation in the implementation
plans as the programme and
AMR interventions get scaled up,
since it is important to calibrate
response and keep pace with
global developments and needs.
Expand awareness of AMR and
related issues: While this has turned
out to be a low-hanging fruit for
Member States in the Region, as
demonstrated by the rapid scale-
up of initiatives for generating
awareness, their quality and impact
are yet to be assessed. There have
been similar challenges when
dealing with the general public,
farmers and professional groups. In
order to ensure that programmes for
raising awareness have the desired
31
 impact and are able to promote the
prudent use of antibiotics in society
as a whole, the following priorities
must be set for the Region.
• Continue efforts to increase
awareness of AMR and related
issues among different target
groups, focusing specially on
non-human sectors, to ensure
their buy-in and commitment.
• Develop and implement a
comprehensive strategy to raise
awareness amongst the public
and professionals involved
in the human, animal and
environmental health sectors.
• Promote the prudent use
of antimicrobials among
professionals of different sectors
by enhancing the focus on AMR
in the curriculum and training
for continuous professional
development courses.
• Adopt a multisectoral approach
by involving the marine,
agricultural and environment
sectors in generating awareness
of the efficient management of
waste water in the context of
AMR.
• Public and professional
awareness (and knowledge,
attitude and practice) should be
assessed on a regular basis to
guage the level of understanding
the impact of awareness-raisng
activities (response - behaviour
change) and the successful/
unsuccessful fatures of
awareness campaigns.
Situational analysis of
32 antimicrobial resistance
in the South-East Asia Region, 2018
Step up AMR surveillance across
sectors: AMR surveillance needs
to be strengthened. Besides, the
availability of national guidelines that
are aligned to international standards
must be ensured. Surveillance
should be bolstered by taking definite
steps that include the following.
• Introduce information
management systems using
information technology to
improve the efficiency of
surveillance systems.
• Ensure the availability of
trained human resources and
infrastructure while focusing on
quality assurance to attain the
highest performance standards
in laboratory-supported AMR
surveillance across sectors.
• Enhance the molecular detection
capacity of the laboratory
network, and explore the use
of advanced software for data
analysis and alert generation to
set up EWS.
Standardize and implement IPC
and antimicrobial stewardship
programmes: IPC and AMSP are
cirtical interventions to reduce the
use and prevent the emergence of
AMR. In addition to ensuring that
national guidelines are available, the
following measures should be taken.
• Integrate AMSP, IPC and
surveillance of hospital-acquired
infections in health-care facilities
by ensuring high standards of
service delivery.
• Strengthen the implementation
of WASH practices nationwide
and enhance the involvement of
NGOs and local opinion leaders
to build awareness and promote
infection control measures in the
community.
Ensure rational use of
antimicrobials and surveillance of
use/sale: The use and sale of AMA
have been traditionally supported
through enabling regulations in the
countries of the Region. However,
these frameworks need to be suitably
adapted so as to respond to the
emerging needs related to AMR.
Some of the priorities for the Region
should be as follows.
• Build the NRA’s capacity to review
dossiers and registration of
antibiotics; conduct post-market
surveys for quality assurance
of the antibiotics available;
and implement regulations on
finished products and APIs.
• See to it that the organizational
structure and capacity of the NRA
is able to regulate pharmacies to
meet the requirements of NAP.
Increase the NRA’s capacity to
monitor the consumption and use
of antibiotics in humans through
online sales, etc.
• Promote regulatory cooperation
in the SEARN on AMR for the
import of medical products
(medicines, devices and
diagnostics) and laboratory
network.
Support implementation with
standards and guidelines: In addition
to strengthening regulatory capacity
and frameworks, special focus is
required for strengthening capacity
for the implementation of various
interventions and programmes.
Two important intial steps would,
therefore, be as follows.
• Develop and implement
standards and guidelines to
support the implementation of
the programme and ensure the
quality of response.
• Work on strengthening the
priority areas for the Region, i.e.
surveillance; IPC, including HAI;
and AMSP.
Make implementation research
more acceptable and innovative:
It is imperative to recognize the
wider interpretation of research
and innovation in the context of the
Region. While countries like India
and Thailand can boast of significant
R&D capacity with expertise in areas
such as the development of newer
molecules, vaccine candidates and
diagnostic platforms, the priority
for most countries in the Region
clearly appears to be implementation
research. The following steps
are recommended in relation to
implementation research.
• Prioritise strategic research
agendas that can strengthen
AMR containment programme
delivery.
33
 • Include other priorties that
have the potential to impact the
assessment of AMR containment
initiatives with a special focus on
economic burden from evolving
AMR.
Drive One Health agenda with
investments and engagement
across sectors: Special efforts are
needed to accelerate interventions
in non-human sectors and building
their capacities for a meaningful
engagement in the multisectoral
response. This is true in particular of
the environment sector, which has
so far remained on the margins. The
following steps are recommended in
this regard.
• Invest in strengthening
surveillance of AMR, AMU and AR
and regulatory capacity across
sectors, at national and regional
levels. This will help check the
import of plants, animals and
antimicrobials that tend to cross
unmanned international borders
easily.
• Generate necessary evidence and
enable frameworks to support
interventions as part of the effort
to encourage implementation
research.
Way forward for WHO and its
regional Triparte partners
To facilitate the implementation of
NAPs, WHO and its regional Tripartite
partners formed a Regional
Tripartite Coordination Team to
coordinate integrated support to
Member States in technical guidance,
advocacy, monitoring and fund-
raising.
Situational analysis of
34 antimicrobial resistance
in the South-East Asia Region, 2018
Concerted efforts have been made
to reach out to UNEP and explore
specific collaborations on the
implementation of policies and
regulatory frameworks governing
the use of antimicrobial agents,
and laboratory networks for the
surveillance of resistance to and
rational use of antimicrobials. These
efforts cover all levels across diverse
sectors, including human and animal
health, agriculture, food safety and
environment.
As a flagship priority for the Region,
the Regional Office will continue, with
the help of the Tripartite partners, to
support the implementation of the
NAP-AMR in Member States. It will:
• provide support through
evidence-based technical
guidance customized for each
Member State;
• collaborate and review
implementation status and
measure progress in each
Member State using the
situational analysis tool
developed by the Regional Office;
• document technical support to
the Member States and seek
opportunities to document proof
of evidence for advocacy and
fund-raising;
• strengthen collaboration and
sharing of information with
partners and WHO collaborating
centres;
• identify and collaborate with
Member States that are willing
to undertake interventions within
their NAPs and demonstrate
measurable outcomes or impact;
• respond to Member States’
requests to update AMR-NAPs,
especially to include One Health
approaches and to enhance the
animal, crop, aquaculture and
environment dimensions of the
AMR threat;

• strengthen a One Health

partnership with the regional
offices of OIE and FAO to combat
AMR.

Intercountry meeting to review

implementation of national action
plans on AMR, Bangkok, Thailand,

23–25 July 2018 Bhutan, Democratic

Peoples’ Republic of Korea, Maldives,
Nepal, Sri Lanka and Timor-Leste,
25 – 27 July 2018: Bangladesh, India,
Indonesia, Myanmar and Thailand

35

Bangladesh
Focus area and
indicators
1. National AMR plan and governance
1.1 NAP in line
with GAP-AMR/
governance issue
2. Raising awareness
2.1 Awareness
campaigns for the
public
2.2 Education and
training strategies
for professionals
Situational analysis of
36 antimicrobial resistance
in the South-East Asia Region, 2018
Country profiles
Phase, Phase, Justification/ comments
2016 2018
2 3 The NAP is in line with the GAP-
AMR, developed and approved at
the ministerial and Secretariat
level. There is a functional
multisectoral AMR national
steering committee and national
technical committee, with
defined terms of reference of
various stakeholders.
3 4 Nationwide government-led
campaigns, targeting public and
professionals, are conducted
during the AAW. Awareness-
raising activities are conducted
primarily during the AAW
and there is limited focus on
the generation of awareness
throughout the year.
1 3 The specific topic of AMR
is in the process of being
introduced in pharmacists’/
medical curriculums. AMR
training is conducted for health
professionals.
Recommendations
Enforce policies and regulations to
support smooth implementation
of NAP-AMR. Ensure inbuilt
mechanism for monitoring
and evaluation, along with
adequate budgetary provisions
in operational plans developed
for various AMR containment
activities.
Promote collaboration among all
relevant stakeholders to conduct
nationwide campaigns for the
generation of awareness of AMR
among the population.
Develop specific communication
strategies targeting behavioural
change and make plans to
evaluate the impact of activities
for raising awareness. Bangladesh
should consider revising
the medical and veterinary
curriculums to focus on AMR
issues. Design and implement
specific courses for continuous
professional development of
health experts both in the human
and animal sector.
 Focus area and Phase, Phase, Justification/ comments Recommendations
indicators 2016 2018
3. National AMR surveillance system
3.1 National human 2 3 National guidelines and SOPs for For further expansion and
AMR surveillance human AMR surveillance have nationwide adoption of human
been prepared. National human AMR surveillance, it is essential
AMR surveillance is in place to develop an accountability
and there are plans to expand framework with a reporting
the network nationwide. Data mechanism, and ensure the
collection and regular training availability of adequate funds for
are conducted to strengthen AMR activities across various
surveillance. sectors.
3.2 Strengthening of 2 3 The national reference laboratory Focus on capacity-building
national laboratory follows the CLSI as a reference for laboratory diagnostics
network standard and supports the and ensure the availability of
laboratory network. Conventional infrastructure and adequate
microbiological methods reagents. Standardize laboratory
are followed in laboratory surveillance by establishing
diagnostics and the laboratory national external quality
network; molecular methods assurance mechanisms.
are yet to be adopted. National
external quality assurance has
not been established.
3.3 Early warning 1 1 No EWS has been established for Plan to establish an EWS
systems AMR bacteria. and consider developing the
molecular detection capacity of
the laboratory network supporting
AMR surveillance.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 1 2 An AMSP has been planned and Develop comprehensive AMSP
AMR containment is under development. guidelines, covering training
policy for control material and tools to monitor
of human use of antimicrobial use in the human
antimicrobials; AMR health sector.
stewardship
4.2 NRA/ DRA 3 4 The NRA is fully functional and a Promote regulatory cooperation
national drug policy is in place. on AMR in SEARN for the import
of medical products, and quality
assurance of the laboratory
network. Develop an API analysis
system.

37
 Focus area and Phase, Phase, Justification/ comments Recommendations
indicators 2016 2018
4.3 Surveillance of 2 3 Guidelines have been developed Develop a national AMR
antimicrobial use to survey AMU in humans. containment policy and establish
and sale among Antimicrobial manufacturing an AMU monitoring system
humans data is collected under regular to control AMU in humans.
monitoring by the DRA. Expedite the completion of the
antimicrobial consumption survey
and develop operational plans
to monitor the use and sale of
antimicrobials in the human
health sector.
4.4 Regulation of 3 4 The NRA is fully functional and Provide adequate human and
finished antibiotic inspection is carried out, but the financial resources to strengthen
products and APIs capacity for the enforcement of the regulatory capacity of the
the regulations is limited. NRA to conduct pre- and post-
marketing surveillance, and
enforce regulations on finished
products and APIs to support
GMP.
4.5 Regulation 3 4 A model pharmacy regulation To regulate inappropriate sale
of pharmacies system is in place and document of antibiotics and APIs, consider
regarding OTC sale list of drugs for OTC sale. The advanced IT solutions to manage
and inappropriate national drug policy provides referral, prescription and the
sale of antibiotics for sale of antimicrobials on drug-dispensing system.
and APIs prescription only; however,
there is limited capacity for the
enforcement of regulation.
5. Infection prevention and control and AMR stewardship programme
5.1 AMSP in health- 2 2 There is a national IPC/ Develop coherence and an
care setting AMR operational plan, but integrated AMSP, IPC and
implementation is limited surveillance of HAI.
for want of SOPs, guidelines
and protocols, and laboratory
capacity for antimicrobial
sensitivity testing.
5.2 IPC programme 2 2 There is a national infection Develop policy and guidelines
in health-care control committee and national for AMSP and strengthen the
setting IPC guidelines are under laboratory capacity for AMR/AMU
development. surveillance in the human health
sector.
5.3 National HAI 2 2 HAI surveillance has been Develop policy/guidelines and
and related AMR initiated in a few public and build capacity for HAI. Expand this
surveillance private facilities. across the country in a step-wise
manner.

Situational analysis of
38 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase, Justification/ comments Recommendations
indicators 2016 2018
5.4 Sanitation and 1 4 There is a national campaign to To strengthen sanitation and
hygiene improve sanitation and hygiene hygiene activities, focus should
in communities through the be placed on expanding the
WASH programme. Data on implementation of the WASH
access to safely managed water programme.
are available.
5.5 Vaccination NA 4 PCV and haemeophilus influenza The Member States should
B (HiB) vaccine are included in consider developing a vaccination
the expanded programme of policy in the context of AMR
EPI. Typhoid vaccine is not. The prevalence and practices.
national indicators for vaccine
coverage are good.
6. Research and innovation
6.1 R&D and 2 2 Policies have been framed Encourage R&D and innovation for
innovation on AMR and there are plans to foster generation of evidence to support
prevention and research and innovation on AMR. the effective implementation of
containment and NAP-AMR.
research funding
7. One Health engagement
7.1 A national AMR 2 4 The national drug policy Develop an AMR containment
containment policy addresses AMR and a legal policy and tools to implement
and regulatory framework prohibits the use of and monitor AMR containment
framework for antimicrobials in animal feed. in the animal sector. Ensure that
control and Regulatory frameworks have there are adequate funds for AMR
registration of use in been implemented with some containment in the veterinary
animals monitoring but the capacity for sector.
enforcement is limited.
7.2 National 2 AMU-2 Guidelines have been developed Develop operational plans for
surveillance of AMR, AMR-2 to survey antimicrobial use in the antimicrobial use and sales in
and use and sales of human and animal sectors. The the animal sector. Strengthen the
antimicrobials in the capacity for surveillance of AMU inspection system for monitoring
veterinary sector and AMR is limited. the implementation of the AMR
containment policy in the animal
sector.
7.3 Biosecurity (IPC) 2 3 Biosecurity measures have been Develop guidelines to support
in the animal sector initiated in the poultry sector biosecurity measures in other
following bird flu outbreaks. animal sectors; and enhance
awareness in and diagnostic
support for the veterinary sector.
7.4 AMR awareness 2 2 Strategies have been formulated Formulate strategies targeting
generation and to raise awareness among different groups engaged
education in the veterinary professionals. Experts in animal handling, with an
animal sector from the human and animal emphasis on behavioural change
sectors are involved in training for prudent AMU in animals.
health-care professionals.

39
 Focus area and Phase, Phase, Justification/ comments Recommendations
indicators 2016 2018
7.5 A national AMR NA 1 Under the National Regulations, There is a need to expand policies,
containment policy policies are in place for have an operational plan including
and regulatory monitoring waste/waste water monitoring and evaluation (M&E)
framework to from antibiotic manufacturers. system to assess AMR and AR
control release of It is mandatory to process load in waste and waste water
AR and AMR into waste before releasing it into generated by all relevant sectors.
the environment the environment. Effluent
and management treatment plants are compulsory
therein and expired antimicrobials
are destroyed by incineration.
However, there is no specific
policy aimed at reducing AR and
AMR in environment.
7.6 National NA 3 Policies are in place for Develop national policy directed
surveillance of monitoring waste and at reduction of AR and AMR waste
AR and AMR in waste water from antibiotic generation supported by operation
waste water from manufacture under the National plans to assess AR/ antimicrobial
manufacture and Regulatory of Drugs. Need to load in waste and wastewater
use in the human, expand policies, operational plan from relevant sectors.
animal and fish including M&E system to all
sectors and disposal relevant sectors such as human,
by institutions and animal and fisheries.
homes
7.7 AMR awareness NA 1 There is no policy/ strategy Develop a communication strategy
generation and on AMR in waste to ensure for awareness generation and
education in the environmental safety. The education in the environmental
environmental NRA policies focus on the sector.
sector safe disposal of waste from
manufacture. Guidelines are in
place for the management of
hospital waste.
8. Overarching coordination mechanisms for One Health engagement 
8.1 Overarching NA 4 There is a multisectoral national Strengthen the existing
AMR coordination steering committee as well as coordination mechanism
mechanism a national technical committee between all relevant sectors,
on AMR, led by the MoH, with with enhanced engagement and
defined terms of reference (ToR) involvement of the environment,
for various stakeholders. food safety, education,
aquaculture, and animal and
human health sectors.

Include and engage all relevant

sectors in NAP-AMR.

Situational analysis of
40 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase, Justification/ comments Recommendations
indicators 2016 2018
8.2 Inclusion and NA 2 The NAP-AMR engages human No specific recommendation
engagement of all health, animal health, drug
relevant sectors in administration for humans
the NAP-AMR and animals, plant health, civil
society, and the private sector
(primarily pharmaceutical and
chemists’ associations), and
WASH.
8.3 A platform and/ NA 4 The NRA monitors AMU Establish coordinated
or mechanism in the human and animal mechanisms for AMR/AMU
for sharing AMU sectors. A multisectoral expert surveillance and ensure
monitoring data committee is leading a survey on the implementation of AMR
from all relevant antimicrobial consumption. containment across the relevant
sectors sectors.
8.4 A platform and/ NA 2 An interministerial secretariat Provide a platform for sharing
or mechanism for One Health is in place, but monitoring data regularly with
for sharing AMR there is a need to strengthen national and international
surveillance data the involvement of various stakeholders across all sectors
from all relevant stakeholders.Though there is an to ensure evidence-based policy
sectors AMR surveillance mechanism decisions.
for the human sector, there is
none for the animal sector. The
food safety surveillance system
is functional.
8.5 AAW is nationally NA 4 AAW is celebrated annually with Conduct an assessment of the
coordinated and multisectoral participation, impact of awareness generation
celebrated with including scientific seminars activities, with the involvement
involvement of and targeting experts from of and contributions from all
contributions from various sectors. Campaigns relevant sectors. Promote active
all relevant sectors are organized regularly for participation of various sectors
awareness generation among to ensure that AAW is nationally
pharmacists supporting the coordinated and celebrated.
human and animal sectors.
8.6 A mechanism NA 1 Trainings organized by the To identify resources and establish
for the co-sharing of health sector for capacity- a mechanism for the co-sharing
resources for AMR building of experts from various of resources for AMR initiatives.
initiatives sectors and awareness building
activities, funded by MoH, for all
stakeholders are some initiatives
under the mechanism of co-
sharing resources.

41
 Fig 13: The figure shows an average of phase-grading for all indicators

National AMR plan and Governance

Awareness raising
National AMR Surveillance system
Rational use of antimicrobials and surveillance of Use/Sale
Infection Prevention Control & AMR Stewardship program
Research and innovation
One health engagement
Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

The modern pharmacy regulation system established by the country has

been identified as a good practice in the Region. Under this system, a
comprehensive list of drugs for OTC sale is regulated under the national drug
policy that provides for the sale of antimicrobials only on prescription.

Situational analysis of
42 antimicrobial resistance
in the South-East Asia Region, 2018
Bhutan
Focus area and Phase, Phase,
Justification/comments
indicators 2016 2018
1. National AMR plan and governance
1.1 NAP in line 3 3 A comprehensive NAP for 2018–
with GAP-AMR/ 2023, in line with GAP-AMR, was
governance issue launched during November 2017.
Budgetary provisions have been
made for AMR activities in the
12th Five-year Plan (FYP).
2. Raising awareness
2.1 Awareness 3 4 Nationwide awareness week
campaigns for the is observed, with television
public campaigns, talk shows,
animation and pamphlets, to
enhance the awareness of AMR
among the general public at
large.
2.2 Education and 2 3 The inclusion of AMR-related
training strategies issues in induction training
for professionals for health professionals and
in modules on the rational
use of drugs are strategies
implemented for awareness
of AMR. Efforts are ongoing to
modify the medical curriculum
by incorporating details on AMR/
AMS.
3. National AMR surveillance system
3.1 National human 2 2 Guidelines have been prepared
AMR surveillance but implementation is limited
due to the scarcity of skilled
manpower, funds and capacity
for data management.
Recommendations
Continue to maintain strong
political will and commitment
to support AMR activities. There
should be adequate budgetary
provisions in the FYP. Build
further on ownership of AMR
implementation by regulatory
authorities.
Consider developing a strategic
plan to evaluate antibiotic literacy
and behaviour among the public
through a baseline survey,
followed by a targeted campaign
to enhance awareness.
Take measures to revise and
update all health professional
curriculums with a focus on AMR/
AMS; also include guidance on
competency evaluation.
To understand the impact of
AMR on the population and
monitor trends in AMR, it is
crucial to set up systems for
linking microbiological and
epidemiological findings. The
Member States should consider
using systems such as WHONET
for robust data collection
and analysis. There is a need
to streamline data-sharing
modalities to ensure regular
and timely availability of all
information with policy-makers.
43
 Focus area and Phase, Phase,
Justification/comments Recommendations
indicators 2016 2018
3.2 Strengthening of 3 3 The national AMR reference To maintain the highest standards
national laboratory laboratory is functional, with in laboratory procedures, the
network a quality-assured laboratory Member States should focus on
network at a few centres, and capacity-building of laboratory
selected sites are participating in staff and data-handling experts.
EQAS. The CLSI for standardized
microbiological laboratory
procedures are being followed.
GLASS enrolment is under
progress.
3.3 Early warning 2 1 Efforts are ongoing to establish There is a need for expertise to
systems EWS, prepare a list of priority develop EWS and verify identified
AMR bacteria and verify AMR organisms at the earliest.
identified AMR organisms at the
earliest.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 2 2 An AMSP has been established There is a need to expedite
AMR containment only at the national hospital and the finalization of the existing
policy for control its expansion to other AMR/AMU AMSP national antibiotic policy
of human use of sentinel sites is limited due to and ensure that M&E tools are
antimicrobials; AMR the scarcity of trained human included in the AMSP guidelines.
stewardship resources. There is a need to
expedite the finalization of the
existing AMSP national antibiotic
policy and ensure that M&E
tools are included in the AMSP
guidelines.
4.2 NRA/ DRA 5 4 Tools for quality assurance & Promote regulatory cooperation in
registration of antibiotics is in South East Asia Regional Network
place along with post marketing (SEARN) in AMR for importing
surveillance to monitor sale medical products and ensuring
and distribution of antibiotics. regulatory cooperation in labs.
However, there remains limited Strengthen regulatory registration
capacity for enforcement of capacity of NRA to register,
policies and regulation undertake post marketing
surveillance and testing of
antimicrobials.
4.3 Surveillance of 1 2 National policy or plan Develop NRA capacity through
antimicrobial use on surveillance of use of data analysis for monitoring
and sale among antimicrobials have been antibiotic consumption and use
humans developed and approved but are
yet to be fully implemented. PPS
in few hospitals are conducted
twice a year to capture the
seasonal variations.

Situational analysis of
44 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/comments
indicators 2016 2018
4.4 Regulation of 4 4 Regulatory authority and
finished antibiotic systems of regulation on
products and APIs import, manufacture, sale
and distribution of antibiotics
is in place and inspection
is implemented . However,
capacity for enforcement of
policies and regulation is limited
by and inspection coverage
restricted due to resource
constraints
4.5 Regulation 5 5 System for regulating sale and
of pharmacies distribution of antibiotics from
regarding OTC sale pharmacies is in place and
and inappropriate inspection is fully implemented.
sale of antibiotics This however does not
and APIs completely stop illegal entry
of medicines through porous
borders
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 2 2 Strong regulatory frameworks
care setting are being established and plans
are in the offing to establish in
referral hospitals. Antibiotics are
prescribed only by physicians
with reserved antibiotics having
limited access; national essential
medicine list available. Training
/ sensitization of physicians
is being done and awareness
in public domain stepped up.
However, porous borders allow
ready availability of antibiotics
5.2 IPC programme 3 2 IPC programme and capacity
in health-care plans implemented and a
setting National IPC committee
in place. Monitoring and
reporting formats are being
used and guidelines on waste
management shared. WASH
assessment in health facilities
has also been done on priority
basis.
Recommendations
Develop regulatory cooperation
through SEARN for access
to quality products and boost
capacity building of NRA along
with advocacy to implement
regulation for dossier evaluation
in antibiotic products and GMP
inspection
Capacity building for NRA
to be stepped up besides
providing adequate human and
financial resources for control
of sale of antibiotics including
e-pharmacies
Stronger regulation needed for
drugs brought across the border
by members of the public. This
should be backed by ongoing
awareness programmes and
activities
Training and certification for
dedicated ICNs to be done in
a uniform manner along with
regular IPC audits. Feedback
from IPC professionals must feed
into hospital/health-care facility
designs and results from KAP
studies on hand hygiene etc to
help refine existing protocols.
45
 Focus area and Phase, Phase,
Justification/comments Recommendations
indicators 2016 2018
5.3 National HAI 4 2 HAI surveillance (for Dedicated, trained/ certified
and related AMR pneumonias, UTIs and blood IPC nurses are the need of the
surveillance stream infections) including hour. Lab capacity strengthening
point prevalence surveys must continue and data analysis
conducted in select national evaluated from time to time.
and regional hospitals, but is
not fully standardised and data
too is not analyzed completely.
Meanwhile, the vital role of IPC
is emphasised with every HCF
(IC Nurse) encouraged to report
monthly in real time according to
defined criteria.
5.4 Sanitation and 5 5 HCF have programmes for Monitoring of water quality
hygiene WASH and waste disposal fully is undertaken, but can be
implemented nationwide, but strengthened further
not specifically in the context of
AMR.
5.5 Vaccination NA 1 Vaccine coverage is 96% in Impact must be measured on
general population. And PCV several counts
13 launched, but plan is to
implement it in 2019
6. Research and innovation
6.1 R&D and 2 2 NAP has provisions for R&D, Full targeted research proposals
innovation on AMR but there is limited financial on baseline data on AMR and
prevention and resource allocation. There is a AMU and other proposals related
containment and strong need for research work to AMR should be prepared to
research funding to be more structured and support implementation of NAP,
targeted to benefit the overall while seeking funding support
implementation of NAP. from and collaboration with
other institutes for such research
proposals.
7. One Health engagement
7.1 A national AMR 2 3 The Medicine Act of Bhutan, Assess status of AMR surveillance
containment policy 2003 and Bhutan Medicines system in animal sector and
and regulatory Rules and Regulation, 2012 develop structured national AMR
framework for require that all medicines, surveillance plan for the sector,
control and including antimicrobials which with a focus on coordinated
registration of use in are imported into the country, policy on usage of critical
animals are registered with DRA/NRA. It antibiotics among both humans
also classifies all antimicrobials and animals. Develop specific
as prescription-only drugs. training programmes for para-
Regulatory enforcement is in professionals on AMU and AMR.
place and is carried out by the
regulatory authority. Thus initial
implementation policies and
regulatory frameworks have
been implemented, but there is
limited capacity for monitoring
registration and AMU.

Situational analysis of
46 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/comments Recommendations
indicators 2016 2018
7.2 National 1 AMU-2 Limited information is Assess the status of the
surveillance of AMR, AMR-2 available on the use and sale of AMR surveillance system in
and use and sale antimicrobials at the national the animal sector, develop a
of antimicrobials in level in the veterinary sector. structured national AMSP for the
veterinary sector According to the national policy, animal sector, with a focus on
information on the use of coordinated policy on the use of
antimicrobials in the veterinary critical antibiotics, both among
sector has been annually humans and animals. Develop
contributed to the OIE database specific training programmes for
since 2015. para-professionals on AMU and
AMR.
7.3 Biosecurity (IPC) 2 2 Biosecurity policies, guidelines Reinforce biosecurity policies,
in animal sector and strategies have been guidelines and strategies. Follow
developed, but these are more this with training of individuals
generic and do not cover all handling animals in the private
aspects of IPC in animal sector. and government sectors.
Consider establishing/ assigning
clear responsibility to biosecurity
department.
7.4 AMR awareness 2 3 Guidelines for the use of Develop specific training
generation and antibiotics in livestock were programmes for para-
education in animal developed in 2017. A national professionals on AMU and
sector consultative and awareness AMR. There is a need to develop
workshop on AMR for livestock messages and channels of
was conducted. The College delivery for the generation of
of Natural Resources is the awareness, specifically amongst
apex centre for training para- farmers.
professionals who support
veterinarians in animal sector
activities.
7.5 A national AMR NA 1 There is no specific policy to Develop policies and targeted
containment policy control the release of AR and strategies on AMR in waste
and regulatory AMR into the environment. The to ensure the safe disposal
framework to existing guidelines for waste of pharmaceuticals in the
control release of water and waste disposal environment.
AR and AMR into do not specify indicators for
the environment assessing quantum of disposed
and management pharmaceuticals in waste
therein generated by human/animal use.
7.6 National NA 1 Guidelines for waste water Develop policies and targeted
surveillance of and waste disposal do not strategies on AMR in waste
AR and AMR in specify indicators for assessing to ensure the safe disposal
waste water from the quantum of disposed of pharmaceuticals in the
manufacture and pharmaceuticals in waste environment.
use in the human, generated by human/animal use.
animal and fish Also, there is no specific policy
sectors and disposal to control release of AR and AMR
by institutions and into the environment.
homes

47
 Focus area and
indicators
7.7 AMR awareness
generation and
education in
environmental
sector
8. Overarching coordination mechanisms for One Health engagement
8.1 Overarching
AMR coordination
mechanism between
all relevant sectors
8.2 Inclusion and
engagement of all
relevant sectors in
NAP-AMR
8.3 A platform and/
or mechanism for
sharing of AMU
monitoring data
from all relevant
sectors
8.4 A platform and/
or mechanism for
sharing of AMR
surveillance data
from all relevant
sectors
Situational analysis of
48 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/comments Recommendations
2016 2018
NA 1 There is a need to recognize the Foster the inclusion of the
importance of the environment environment sector in the
sector by framing policies implementation of NAP and
or targeted communication involve the environment sector in
strategies to ensure the safe the AMR network.
disposal of pharmaceuticals in
the environment.
NA 3 An Inter-Ministerial One Health To ensure smooth implementation
committee (IMCO) has been of AMR activities, build synergies
set up, but it is yet to be fully and further strengthen
operationalized. The AMR intersectoral coordination.
technical committee has two
subcommittees – one each for
animal and human health. Both
report to IMCO. Detailed ToR of
the technical AMR committee
are to be developed.
NA 2 The health sector leads the work To ensure smooth implementation
on AMR in accordance with NAP of AMR activities, build synergies
and engages other sectors, such and further strengthen
as agriculture, wildlife, plant life intersectoral coordination.
and education. The involvement
of environment, food and
other relevant sectors is under
consideration.
NA 2 AMU monitoring data is Develop integrated monitoring
informally exchanged between and surveillance mechanisms for
the human health and antimicrobial surveillance, as well
animal health sectors during as use and sale of antimicrobials
technical committee meetings in human, animal and plant
conducted quarterly. The animal sector.
health sector data, based on
procurement information,
is submitted annually to the
OIE. No data specific to AMR
in animal health is currently
available.
NA 1 AMR surveillance data is Develop integrated monitoring
generated for human health, but and surveillance mechanisms for
not systematically shared with antimicrobial surveillance, as well
other relevant sectors. There is as use and sales of antimicrobials
no AMR surveillance data from in human, animal and plant
the animal sector. sector.
 Focus area and Phase, Phase,
Justification/comments Recommendations
indicators 2016 2018
8.5 AAW is nationally NA 3 The AAW is nationally Build ownership and strengthen
coordinated and coordinated by the health coordination amongst various
celebrated with sector and has been celebrated stakeholders during AAW
involvement of and annually with the involvement of celebrations.
contribution from all the agriculture sector since 2016.
relevant sectors
8.6 A mechanism NA 1 There is an informal system Member States should identify the
for co-sharing of of resource-sharing for AMR resources available and develop
resources for AMR initiatives, such as jointly operational plans and establish
initiatives conducting laboratory training a mechanism for co-sharing of
both for human and animal resources for AMR initiatives.
health. However, there is no
documented agreement on co-
sharing of resources available.

Fig. 14: Situational analysis of progress in AMR prevention and containment in Bhutan, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

The high-level intersectoral coordination between the agriculture, human

and animal health sectors is impressive. The performance statdards of the
laboratory network to support AMR surveillance in the veterinary sector are
high.

A strong political will and commitment to reverse AMR trends is evident from
the well-defined policy guidelines, ownership by regulatory authorities and
adequate budgetary provisions to support AMR implementation.

49
 DPRK
Focus area and
indicators
1. National AMR plan and governance
1.1 NAP in line
with GAP-AMR/
governance issue
2. Raising awareness
2.1 Awareness
campaigns for the
public
2.2 Education and
training strategies
for professionals
3. National AMR surveillance system
3.1 National human
AMR surveillance
Situational analysis of
50 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
NA 3 The NAPis in line with GAP-AMR
and has been developed with
defined activities. A national
multisectoral committee on AMR
has been established. Budgetary
provisions have been made but
lack dedicated fund allotment.
NA 3 National-level awareness
campaigns have been launched,
using locally developed
materials.
NA 2 Plans for professional training
have been developed and
training courses for health-care
workers are conducted annually.
NA 2 National guidelines have been
developed for AMR surveillance
in the human sector, but these
are not aligned with international
standards. Data analysis from
ongoing AMR surveillance needs
to be strengthened.
Recommendations
Enhance engagement and
involvement of all relevant sectors
and ensure that the NAP-AMR
is endorsed by all concerned
ministries. To operationalize the
AMR coordination committee
with a multisectoral approach,
it is essential to develop an
accountability framework with a
reporting mechanism and ensure
sustainable funds.
Advocacy for AMR containment
with high-level policy-makers is
the need of the hour to enhance
political will and commitment.
It is recommended that
communication strategies for the
public be developed on the lines
of the latest global information
and internationally available
standardized IEC material be
translated into the local language.
Develop awareness programmes,
trainings and workshops, on
the basis of the latest global
information on AMR, for
individuals engaged in human
health, food safety, agriculture,
environment and other relevant
sectors.
Strengthen the national
guidelines for AMR surveillance
in accordance with international
standards. Encourage the use of
the software WHONET for efficient
data management and analysis.
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
3.2 Strengthening of NA 1 A national reference laboratory To support human AMR
national laboratory has been established, but it is surveillance, establish a national
network not in line with international laboratory network, introduce and
standards and lacks guidelines adapt international standards and
for antimicrobial sensitivity guidelines, focus on capacity-
testing. AMR surveillance with building of laboratory staff and
limited quality control measures develop quality control systems
is operational at a few health- with EQA.
care facilities.
3.3 Early warning NA 1 There is no EWS. Develop plans to establish an
systems EWS for emerging resistance on a
national scale.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national NA 2 The national AMSP policy is to Organize stewardship activities
AMR containment be finalized and the essential into a comprehensive AMSP.
policy for control medicine list needs to be Develop standard treatment
of human use of revised. guidelines for the use of
antimicrobials; AMR antibiotics with technical support
stewardship from WHO and consider adapting
the AWARE framework to refine
and revise the essential medicine
list. Improve access to and
availability of drugs nationwide.
4.2 NRA/DRA NA 3 NRA is existing and operational Develop regulatory cooperation in
SEA regulatory network for AMR
and strengthen national medical
products quality assurance of
antibiotics through SEARN
4.3 Surveillance of NA 3 Estimation of needs has been Develop and adapt WHO standard
antimicrobial use carried out at facility level as part Guidelines and capacities on
and sale among of national drug management analysis of antibiotic sales/
humans system although no data has consumption data and production
been collected so far on sales of annual reports. There is a
and consumption at national level suggestion that WHO could
due to lack of technical capacity support capacity building in
and standard guidelines for developing standard tools
surveillance of AMU

4.4 Regulation of NA 3 NRA regulates all aspects of Capacity building must be

antibiotic products antibiotic manufacture, import,
and APIs storage and sales despite lack
of capacity including human and
physical resources
strengthened to implementNRA
functions. Also greater access to
the SEA regulatory network for
technical support and cooperation
would go a long way in improving
the overall national system

51
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
4.5 Regulation NA 1 Government supplies drugs Enable availability and effective
of pharmacies to facilities and pharmacies; prescription guidelines for
regarding OTC and drugs are centrally procured. antibiotics in public sector by
inappropriate sale of All facilities and pharmacies developing regulations and
antibiotics and APIs are government owned, hence guidelines for monitoring OTC
ensures quality. However, sale sales and establishing a system
of drugs without prescription for analysing data on sales
remains a challenge

5. Infection prevention control and AMR stewardship programme

5.1 AMSP in health- NA 2 There is no AMR stewardship There is need to organise
care setting programme in HCS though stewardship activities into
guidelines are available in systematic policies, programmes
health facilities for prescribing and guidelines as comprehensive
medicines. Only doctors can AMSP. Also, laboratory support to
prescribe them and they are all inform clinical decision making
trained in clinical management for AMU has to be enhanced
guidelines. Decision for use
of antibiotic use is based on
antibiotic susceptibility test
at provincial hospitals. More
sophisticated antibiotics are
available at higher level facilities
and prevention of infections in
HCS is part of national strategy
5.2 IPC programme NA 3 National IPC policy, committee Strengthen data analysis, training
in health-care and guidelines are available of infection prevention staff and
setting and used to train professionals. use of information technology.
Every hospital has an Infection Strengthen laboratory capacity
control committees that for AST from provincial level
investigate episodes of infectious and above – training in standard
diseases outbreaks and techniques, infrastructure.
report to MoPH. Twice a year Surveillance data must be
monitoring and inspection of analysed regularly.
IPC activities is conducted by
MoPH. Surveillance data too
is available. However, data not
analysed to inform decision
making

Situational analysis of
52 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
5.3 National HAI NA 3 Guidelines are available for Strengthen laboratory capacity
and related AMR HAI surveillance by site of for AST from provincial level
surveillance infection/unit/ settings in and above – training in standard
place in provincial and other techniques, infrastructure and
referral hospitals. Data on HAI improve national oversight
is collected regularly but not all for reporting structures and
surveillance data is analysed harmonisation of standards
hence making it difficult
to inform decision making
processes. Further, there is
limited laboratory support for
infectious disease diagnosis and
AST
5.4 Sanitation and NA 5 Complete nationwide coverage Maintaining the high level
hygiene has been ensured with respect of coverage with continuous
to sanitation and hygiene and campaigns and ensuring funding
safe water supply in institutions, for WASH programmes will
hospitals, communities and ensure long term sustainability
schools. This is seen as a and results
success model that can be
replicated and upscaled across
the country
5.5 Vaccination NA 1 PCV vaccination is not available/ Raise the issue of PCV
introduced in DPRK. However, introduction with partners
influenza vaccine is included in and explore possibility of PCV
the EPI programme introduction through WHO
Country office/GAVI/other sources
6. Research and innovation
6.1 R&D and NA 1 A research and development Build research agenda in NAP
innovation on AMR team of professionals has and develop research capacity
prevention and been constituted as part of the for surveillance to track the use
containment and national AMR multisectoral of antibiotics in humans and
research funding committee, though it does not animals.
focus on AMR surveillance in
the animal and human sectors.
The research priority is to
develop traditional medicines as
alternatives to antimicrobials.

53
 Focus area and
indicators
7. One Health engagement
7.1 A national AMR
containment policy
and regulatory
framework for
control and
registration of use in
animals
7.2 National
surveillance of AMR,
and use and sale
of antimicrobials in
veterinary sector
7.3 Biosecurity (IPC)
in animal sector
7.4 AMR awareness
generation and
education in animal
sector
Situational analysis of
54 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
NA 1 There is no policy or regulatory
framework for the control and
registration of use in animals
exists.
NA 1 There are no policy or guidelines Same as 7.1
for surveillance of AMR in the
animal sector. The national
guidelines for AM sales/use in
the animal sector are not aligned
with OIE.
NA 3 General guidelines for
biosecurity in the animal
sector are implemented, and
there are regular reporting
mechanisms and a system to
monitor compliance. National
epizootic disease monitoring
with specimen referral systems
have been operationalized.
NA 1 No activities for raising
awareness regarding AMR have
been planned in the animal
sector.
Recommendations
Through the network of
development partners (FAO/
OIE), align guidelines for
antimicrobial sale and use
in the veterinary sector with
international standards and
focus on capacity-building
for the enforcement of drug
regulations in the animal sector.
Build awareness among animal
health sector professionals and
the Member States on the use
of the tool developed by FAO
for communication on AMR.
Include AMR and prudent use of
antimicrobials in the curriculums
for human and animal health.
Strengthen laboratory support
for AMR surveillance in the
animal sector. It is important
to develop standard protocols
and methodology for laboratory
diagnostics in accordance with
international guidelines, and
focus on capacity-building and
quality assurance to attain the
highest performance standards.
Same as 7.1
Same as 7.1
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.5 A National AMR NA 1 There is no policy or regulatory Enhance the engagement of
containment policy framework to control the the environment sector, define
and regulatory release of AR/ AMR into the standards for the release and
framework to environment. management of antimicrobials
control release of in the environment, and link the
AR and AMR into existing policies with AMR-related
the environment issues.
and management
therein
7.6 National NA 1 The existing environment Same as 7.5
surveillance of protection policy does not
AR and AMR in include AMR. No guidelines have
waste water from been developed for surveillance
manufacture and of AR/AMR in waste and
use in the human, environment.
animal and fish
sectors and disposal
by institutions and
homes
7.7 AMR awareness NA 1 No specific policies have been Same as 7.5
generation and developed to address AMR-
education in related environmental issues.
environmental
sector
8. Overarching coordination mechanisms for One Health engagement
8.1 Overarching NA 2 A national AMR coordination Ensure the inclusion and
AMR coordination committee has been established, engagement of all relevant
mechanism between involving the relevant sectors, sectors, including human and
all relevant sectors including health (human and animal health, agriculture,
animals), drug regulatory aquaculture, food safety,
authorities, environment, environment and education, along
education, food safety, quality with active participation of the
control and mass media. civil society and media. It is vital
to have a functional overarching
AMR coordination mechanism in
place.
8.2 Inclusion and NA 1 The NAP-AMR engages Same as 8.1
engagement of all stakeholders from various
relevant sectors in sectors, such as human health,
NAP-AMR animal, environment, education,
quality control committees for
medicine, food and mass media.
8.3 A platform and/ NA 1 Information on AMU in human Data on AMU and consumption
or mechanism for health facilities is collected should be shared regularly
sharing of AMU annually. No data are available amongst all relevant sectors,
monitoring data for AMU in the animal sector with national and international
from all relevant and there is no mechanism for stakeholders to enable evidence-
sectors sharing data across sectors. based policy decisions and to
track AMR transmission.

55
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
8.4 A platform and/ NA 1 There is no sharing of AMR It is the need of the hour to develop
or mechanism for data across various sectors. A platforms for sharing data from
sharing of AMR framework is being identified for AMR surveillance in human and
surveillance data sharing information under the veterinary sectors to assess the
from all relevant NAP-AMR. magnitude of AMR in the country,
sectors identify gaps in AMR containment
activities and develop operational
plans to address challenges.
8.5 AAW is nationally NA 1 No AAW has been observed. Develop communication strategies
coordinated and However, it is planned to conduct using standardized information,
celebrated with a nationally coordinated AAW education and communication
involvement of and with contributions from various (IEC) material for generation of
contribution from all stakeholders. awareness on antimicrobials and
relevant sectors behavioural change. AAW should
be nationally coordinated, with the
involvement of and contribution
from all sectors.
8.6 A mechanism NA 1 No specific resources have Identify resources to implement
for co-sharing been identified for AMR. WASH AMR containment activities and
resources for AMR and IPC initiatives have been explore sharing of resources
initiatives identified for co-sharing of across ministries for organizing
resources to conduct AMR- key activities on a rotational basis.
related activities.

Fig 15: Situational analysis for progress on AMR prevention and containment at DPRK in 2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

Good practice

Access to a safely managed water supply and nationwide coverage of

sanitation and hygiene as well as WASH practices constitute a successful
model. These steps have enabled the country to achieve a considerable
level of advancement in the implementation of preventive measures. These
achievements underscore the role of these steps in combating an AMR
situation that is evolving by the day.

Situational analysis of
56 antimicrobial resistance
in the South-East Asia Region, 2018
India
Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
1. National AMR plan and governance
1.1 NAP in line 2 3 The NAP is in line with the GAP-
with GAP-AMR/ AMR, governance mechanisms
governance issue on AMR have been established
and a phased approach has been
adopted for implementation,
beginning with surveillance.
2. Raising awareness
2.1 Awareness 2 2 Some government-led activities
campaigns for the have been conducted in parts of
public the country to raise awareness
of AMR.
2.2 Education and 2 3 AMR forms a part of continuous
training strategies professional development
for professionals courses for health-care
professionals. The Medical,
Nursing and Pharmacy Council
has been set up to review
medical training and curriculum.
3. National AMR surveillance system
3.1 National human 2 3 An AMR surveillance network,
AMR surveillance including a large number of
tertiary hospitals in the public
sector and a limited number
of private hospitals, has been
established. It contributes data
to GLASS. The surveillance
is yet to be sensitive and
representative. Also, its
contribution to GLASS is limited.
Recommendations
There is a need for stronger
advocacy with policy-level
decision-makers to allocate
separate funds for AMR activities
in different sectors.
Develop a national strategy for
mass awareness and conduct a
survey to assess the impact of
the awareness campaigns on the
knowledge, attitude and practices
of the public. The efficacy of the
redline campaign, an innovative
approach for antimicrobial
containment in India, should be
evaluated. There is a need for
secure sustainable funds and
political commitment to support
generation of awareness across
all sectors.
To build awareness of the
containment of AMR among
professionals of the human
health sector, it is recommended
that awareness programmes,
workshops and training for basic
health staff be reviewed and
developed. As the topic of AMR is
included in the curriculum and
continuous professional training,
it is important to develop a
competency framework as a way
forward.
For human AMR surveillance to
be representative of the country,
include additional sites to the
surveillance network. Member
States should consider capacity-
building in data management and
expand the use of WHONET.
57
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
3.2 Strengthening of 2 4 A national laboratory network Develop standardized protocols
national laboratory has been established. The for laboratory diagnostic
network CLSI has been adopted as methodology and quality
the reference standard and assurance procedures. Organize
EQAS has been set up at all training for the laboratory
surveillance sites. network supporting AMR
containment
3.3 Early warning 2 2 A list of priority AMR bacteria Operationalize EWS, develop a
systems has been drawn up and national repository of AMR strains
molecular methods are and set up auto-generation of
available. However, reporting to alerts, using a real-time IT-based
GLASS-EAR is still in the initial AMR data management platform.
phase.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 3 2 A national policy for the Develop national guidelines for
AMR containment containment of AMR has been antimicrobial stewardship. This
policy for control developed and an AMSP planned. should include monitoring tools to
of human use of assess the impact of training and
antimicrobials; AMR explore web-based training and
stewardship resources to conduct nationwide
training on stewardship.
4.2 NRA/ DRA 4 4 The Drug Controller General Promote regulatory cooperation
of India and Central Drugs on AMR in SEARN for imports
Standard Control Organization of medical products (medicines,
(CDSCO) is the NRA. Tools devices and diagnostics) and
for quality assurance and regulatory cooperation in
registration of antibiotics are laboratory network.
in place, and inspection is
implemented. However, the
capacity for enforcement of
policies and regulation is limited.
4.3 Surveillance of 3 3 Sales of antimicrobials at the To establish AMU surveillance
antimicrobial use national level have not been in the human health sector, it is
and sales among monitored. Monitoring of use is crucial to develop a national AMU
humans limited to few facilities that are monitoring system with technical
not representative. assistance from the development
partners. Member States should
consider organizing a national
workshop on surveillance of
antibiotic consumption using the
tool prepared.
4.4 Regulation of 4 4 The CDSCO is the regulatory Enhance engagement with the
finished antibiotic authority. Inspection is department of pharmaceuticals
products and APIs implemented, but there is and get the CDSCO to conduct an
limited capacity for enforcement assessment to generate evidence
of policies and regulation. on the quality of drugs, and to
support good microbiological
practices.

Situational analysis of
58 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
4.5 Regulation 4 4 The CDSCO is the regulatory Strengthen the regulatory
of pharmacies authority in place. Inspection capacity of the NRA to implement
regarding OTC sale is implemented, but there is regulation of OTC sales and
and inappropriate limited capacity for enforcement inappropriate sale of antibiotics
sale of antibiotics of policies and regulation. and enforce regulations
and APIs pertaining to finished products
and APIs.
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 3 1 There is no national Prepare national guidelines for
care setting comprehensive policy for AMR an IPC programme, and integrate
stewardship. Standard treatment AMSP and HAI surveillance with
guidelines and IPC guidelines the IPC programme in health-
have been developed. care facilities. Build the capacity
of nursing staff so that they can
successfully implement the IPC
programme nationwide. The
Member States should work
towards convergence of the
surveillance conducted for AMR,
AMU and HAI.
5.2 IPC programme 3 3 A national patient safety Same as 5.1 above
in health-care framework /IPC is implemented
setting in selected health-care facilities.
5.3 National HAI 3 3 Few public and private facilities Same as 5.1 above
and related AMR have HAI surveillance and share
surveillance data with bodies at the national
level.
5.4 Sanitation and 4 3 Policies/ campaigns to improve For the promotion of sanitation
hygiene sanitation and hygiene are and hygiene, it is advisable to
implemented on a limited scale. strengthen the implementation of
Data on safely managed water WASH through IPC arrangements
supply or sanitation services at health facilities. Emphasize
exist, but there is not much promotion, along with M&E of
access to these. the Swacch Bharat Abhiyaan
and Kayalap, which have been
recognized as good practices.
Member States should promote
routine immunization and include
AMR as a topic of discussion
for the immunization technical
advisory group.
5.5 Vaccination NA 3 PCV 13 has been implemented Continue routine immunization
partially under Mission activities across the nation and
Indradhanush. Typhoid and expand the PCV vaccination
PCV are used extensively in the programme to areas with a high
private sector. burden of disease.

59
 Focus area and
indicators
6. Research and innovation
6.1 R&D and
innovation on AMR
prevention and
containment and
research funding
7. One Health engagement
7.1 A national AMR
containment policy
and regulatory
framework for
the control and
registration of use in
animals
7.2 National
surveillance of AMR,
and use and sale
of antimicrobials
at national level in
veterinary sector
Situational analysis of
60 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
2 2 The NAP outlines research and
development policies. There
are various R&D activities
under way, in collaboration
with international agencies and
development partners.
2 2 A national plan on AMU has been
developed by the DRA for the
veterinary sector. A regulatory
framework for the registration of
products and AMU in the animal
sector has been developed, but
is not being implemented.
1 AMU1; There are no policy/ guidelines
AMR2 for surveillance of antimicrobial
sales and AMU. There is a
limited capacity for AMR
surveillance in the animal
sector. An Indian network of
fisheries and animal research
on AMR has been established.
There are plans to outline SOPs
and methodologies for AMR
surveillance in the animal sector.
Recommendations
Develop an AMR research
consortium to strengthen
partnerships with research/
academic institutions, civil
society and other stakeholders,
for resource mobilization and
the development of evidence-
based policies. The research
activities to focus on impact the
assessment of AMR containment
initiatives to support NAP-AMR
implementation.
Develop a regulatory framework
under the Drugs and Cosmetics
Act to control the use of
antimicrobials in the animal
sector. To initiate national
surveillance of AMU and sale in
the veterinary sector, advocate
establishing a drug supply
chain from the manufacturer to
distribution outlets. This should
also include import information.
To support AMR surveillance
in the veterinary sector, it is
imperative to build the capacity
for laboratory diagnostics, build
on the infrastructure available
and ensure the management of
data.
Same as 7.1 above
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.3 Biosecurity (IPC) 2 3 A biosecurity manual is being To ensure biosecurity in the
in animal sector followed by public and limited animal sector, it is essential to
private facilities in the animal develop a national biosecurity
sector, particularly the poultary manual with good husbandry
set-up. Training for the animal practices, ensure monitoring
sector, such as the fisheries compliance and harmonize
department, is well established. national AMR containment
An online reporting mechanism activities.
has been developed.
7.4 AMR awareness 2 1 There is no national strategy for Develop a strategy and guidelines
generation and the generation of awareness of on raising awareness among
education in animal AMR in the animal sector. The veterinarians of the prudent
sector veterinary curriculum has been use of antimicrobials. Align
modified to include topics in awareness campaigns with
microbiology that emphasize regulatory framework. Focus on
AMR. There are limited activities the use of mass communication
for raising awareness, such as techniques and the social media
training for veterinarians. platform to reach farmers in
far-flung areas. Initiate the
inclusion of AMR-related issues
in the curriculum for veterinary
professionals.
7.5 A national AMR NA 1 Biomedical waste management Expedite the finalization of
containment policy guidelines exist and guidelines to standards to control the release of
and regulatory reduce AR in industrial effluent AR and AMR into the environment
framework to are under way. No regulations and include the same in the
control release of have been developed to control national AMR containment policy.
AR and AMR into AR emissions from antimicrobial Review private sector initiatives
the environment manufacturers, hospitals and and involvement in reducing AR in
and management waste-water treatment plants. effluents.
therein
7.6 National NA 1+ The policy guidelines are weak National surveillance of AR and
surveillance of and evidence linking AMR and AMR in waste water requires
AR and AMR in the environment is limited. establishing a national authority
waste water from for the containment of AMR and
manufacture and bridge the gap in impact of AMR
use in the human, in the environment.
animal and fish
sectors and disposal
by institutions and
homes

61
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.7 AMR awareness NA 1 There are no targeted Create awareness of efficient
generation and communication strategies on management of biological waste
education in AMR in waste. Guidelines for AR products, including manure, in
environmental monitoring are being developed. the context of AMR containment.
sector Strengthen community-level
management of the disposal
system for unused/expired
antimicrobials on farms and in
households.
8. Overarching coordination mechanisms for One Health engagement
8.1 Overarching NA 2 A multisectoral AMR steering To establish multisectoral
AMR coordination committee and a national committee for overarching
mechanism exists authority for the containment of AMR coordination by engaging
between all relevant AMR have been established with all relevant stakeholders
sectors the participation of the relevant including environment, food
sectors, including human and safety, agriculture and WASH
animal health, food safety, programme across the country
environment and the civil society. including at State level.
8.2 Inclusion and NA 3 The NAP-AMR provides for Same as 8.1
engagement of all the inclusion and engagement
relevant sectors in of relevant sectors such as
NAP-AMR food, animal husbandry, dairy,
fisheries, environment, civil
society and education and
research development.
8.3 A platform and/ NA 1 There is no mechanism for To develop multisectoral
or mechanism sharing AMR surveillance data integrated monitoring and
for sharing AMU from all the relevant sectors. The surveillance mechanisms for the
monitoring data NAP-AMR plans to monitor AMU use and sale of antimicrobials
from all relevant at the national and state levels. in the human, animal and plant
sectors sectors.
8.4 A platform and/ NA 2 In the human health sector, To enable evidence-based policy
or mechanism a system is in place for AMR decisions, it is of paramount
for sharing AMR surveillance. In the animal importance to streamline data
surveillance data health and food sectors, AMR flow and develop platforms for
from all relevant surveillance is in the intial phase the regular sharing of AMR
sectors of establishment. There is no surveillance and AMU/sales data
platform for the sharing of data with all national and international
between sectors. stakeholders across all relevant
sectors.

Situational analysis of
62 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and
indicators
8.5 AAW is nationally
coordinated and
celebrated with
involvement of and
contributions from
all relevant sectors
8.6 A mechanism
for co-sharing of
resources for AMR
initiatives
Phase, Phase,
Justification/ comments Recommendations
2016 2018
NA 1 AAW is celebrated primarily Build synergies amongst all
in the human health sector. the relevant sectors to organize
There are plans to establish a nationally coordinated AAW
linkages with WASH, animal and with a focus on standardized
evironment sectors. and uniform communication
strategies aimed at behavioural
change.
NA 1 No formal mechanism has been Member States to map available
established for the co-sharing of resources, develop operational
resources for AMR initiatives in plans and establish mechanism
the country. for the co-sharing of resources
for AMR initiatives.

Fig 16: Situation analysis of progress in AMR prevention and containment in India, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

The Swachh Bharat Abhiyaan (Clean India Mission), Kayalkalp (rejuvenation) and Swach Swasth
Sarvatra (war against impurity) initiatives of the Government of India have been highlighted as
good practices for spreading awareness and knowledge of AMR. These activities encourage
behavioural change among different audiences and the active engagement of all sections of
society for effective promotion of hygiene and IPC programmes. The concept of marking a red
line on antibiotic packages to curb OTC sale is considered a model for creating awareness on the
dangers of taking antimicrobials without prescription, especially in countries with non-existent or
weakly enforced laws pertaining to OTC sale of drugs.

63
 Indonesia
Focus area and
indicators
1. National AMR plan and governance
1.1 NAP in line
with GAP-AMR/
governance issue
2. Raising awareness
2.1 Awareness
campaigns among
the public
2.2 Education and
training strategies
for professionals
3. National AMR surveillance system
3.1 National human
AMR surveillance
Situational analysis of
64 antimicrobial resistance
in the South-East Asia Region, 2018
Phase Phase
Justification/ comments
2016 2018
3 2 The NAP is in line with GAP-AMR
and developed with multisectoral
collaboration, in line with the
One Health approach, supported
by WHO, FAO and OIE.
3 4 Public awareness campaigns on
the prudent use of antimicrobials
have been conducted with a
focus on health professionals
working in the human and
animal health sectors. The
dissemination of information
and educational material for
increasing public awareness and
knowledge, through the print,
electronic, and social media
have been conducted nationwide.
AAW is organized regularly by
the MoH, with support from
development partners in the
health sector.
3 3 AMR has been included
in scientific seminars of
professional associations,
workshops, and training and
technical assistance sessions for
health-care professionals.
2 2 Guidelines have been developed
but not fully implemented. The
availability of quality data and
analysis is limited.
Recommendations
To strengthen the NAP-AMR
operational plan, it is crucial to
build an M&E framework. There
is a need for stronger advocacy
with policymakers to allocate
separate funds for AMR activities
in different sectors.
Efforts should be made to
continue and expand the public
awareness campaign at the
community level and evolve a
methodology to assess the impact
of public awareness campaigns
regularly. Member States to
conduct a baseline impact
evaluation of public awareness
campaigns on AMR in 2019 .
To educate and train
professionals catering to
human health, include AMR in
the curriculum for all health
professionals, including
pharmacists, technicians,
nurses and focus on AMR during
all trainings and continuous
professional development
courses.
Develop a policy for the
surveillance of AMR in the human
health sector, with a focus on
monitoring systems and data
analysis at the national level.
 Focus area and Phase Phase
Justification/ comments
indicators 2016 2018
3.2 Strengthening of 1 1 No national network has
national laboratory been developed. The national
network veterinary product assay
laboratory conducts AMR
surveillance of livestock.
3.3 Early warning NA 1 There is no AMR-specific EWS.
systems Disease-specific warning
systems (for TB, HIV) have been
developed.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 4 2 A national AMSP has
AMR containment been planned and is under
policy for control development. There is a list
of human use of of essential medicines and a
antimicrobials; AMR national formulary which places
stewardship restrictions on AMU in health-
care facilities.
4.2 NRA/ DRA 4 5 The NADFC conducts pre-
and post-market control of
antimicrobial medicines as part
of quality assurance activities.
The NADFC enforces GMP, good
distribution practices (GDP)
and good pharmacy practice
(GPP), particularly to ensure
quality standards production,
distribution and management
of medicines in health-care
facilities. There is a cyber patrol
to control online sales of drugs.
Recommendations
There is a need for establishing
a laboratory network with a
designated national reference
laboratory that supports
laboratory diagnostics
nationwide. It is recommended
that international standards of
AMR detection, including external
quality assurance for laboratory
surveillance, be adopted.
Develop a plan to establish
an early warning system for
emerging resistance on a
national scale and expand the
list of priority AMR bacteria to
include organisms identified from
specimens apart from blood.
To strengthen the implementation
of the AMSP nationwide, update
the guidelines on AMU. Explore
the introduction of prescription
audit, feedback mechanisms and
expansion of the AMSP to private
health-care facilities.
Promote regulatory cooperation
on AMR in SEARN for the import
of medical products (medicines,
devices and diagnostics) and
regulatory cooperation in the
laboratory network. Ensure
the availability of adequate
financial resources and trained
manpower at the NRA for optimal
performance and support the
implementation of NAP-AMR.
65
 Focus area and Phase Phase
Justification/ comments
indicators 2016 2018
4.3 Surveillance 3 3 The sale of antimicrobials at
of AMU and sale the national level is not being
among humans monitored. Monitoring of AMU
is limited to a few facilities that
are not representative. It is
conducted in a few puskesmas
as an indicator of the rational
use of medicines for two
diseases – non-pneumonia
ARTI and acute diarrhoea, and
regularly reported to the MoH.
4.4 Regulation of NA 5 A regulatory authority and
finished antibiotic system are in place, and
products and APIs regulation is fully and effectively
implemented.
4.5 Regulation NA 4 A regulatory authority and
of pharmacies system are in place. Inspection
regarding OTC sale is implemented, but there
and inappropriate is limited capacity for the
sale of antibiotics enforcement of regulation.
and APIs
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 3 3 There are no national policy/
care setting guidelines on stewardship.
National IPC/AMR plan aligned.
IPC/AMR plans implemented in
a limited number of health-care
settings.
5.2 IPC programme 3 3 An IPC programme is
in health-care implemented in select health-
setting care facilities. It includes the
rational use of antibiotics,
guidelines, standard and
transmission precautions,
education and training, HAI
surveillance and capacity-
building plans.
5.3 National HAI 2 2 Few public and private facilities
and related AMR have HAI surveillance. Data are
surveillance not centralized at the national
level .
Situational analysis of
66 antimicrobial resistance
in the South-East Asia Region, 2018
Recommendations
To establish AMU surveillance
in the human health sector, it is
essential to develop the national
AMU monitoring system with
technical assistance from the
development partners.
Strengthen the NRA’s capacity
to maintain regulatory control of
finished antibiotic products, APIs
and OTC sales of antibiotics.
Finalize regulations for online
sale of medicines and continue to
expand the community movement
on the smart use of medicines
programme.
Develop a national policy on
AMSP, allocating an adequate
budget and using sufficient
human resources for nationwide
implementation.
In consultation with technical
experts, prepare guidelines
on training and a reporting
system for data management,
and integrate IPC with AMSP in
health-care setting.
Prepare specific technical
guidelines for HAI and
standardize HAI-related AMR
surveillance in the country. To
support HAI surveillance, it is
essential to set up a laboratory
network with close monitoring
and supportive supervision to
maintain the highest performance
standards.
 Focus area and Phase Phase
Justification/ comments Recommendations
indicators 2016 2018
5.4 Sanitation and NA 4 A policy /WASH campaign to The Member States should
hygiene improve sanitation and hygiene strengthen their sanitation and
is implemented at a large scale. hygiene campaign, consider
Data on safely managed water a detailed survey on WASH in
supply or sanitation services health-care settings and build
exist, but access to these data is advocacy for the nationwide
medium. expansion of the WASH
programme.
5.5 Vaccination NA 2 PCV has been introduced in Continue routine immunization
some provinces of the country. activities across the nation
In general, there is vaccination and conduct evidence-based
coverage of more than 90%. expansion of the PCV vaccination
programme to provinces with a
high disease burden.
6. Research and innovation
6.1 R&D and 2 2 Policies have been planned and Strengthen coordination and
innovation on AMR the existing structure proposes collaboration amongst various
prevention and to foster research and innovation stakeholders and laboratory
containment and on AMR. networks to formulate a coherent
research funding R&D policy and ensure the
availability of technical and
financial funds, to conduct
targeted research focused on
AMR.
7. One Health engagement
7.1 A national AMR 2 3 Policies and regulations have The Member States may consider
containment policy been established on AMU including the assessment of
and regulatory in the livestock and animal biosecurity measures during
framework for health sector, but there is routine inspections.To focus on
control and limited capacity for monitoring biosecurity in the animal sector,
registration of use in registration and AMU. it is suggested that awareness
animals campaigns be conducted
for small-scale farmers,
and concepts of biosecurity
be included in continuous
professional development
courses for veterinarians and
audit learning after training.
Ensure sustainability by providing
adequate human and financial
resources.

67
 Focus area and Phase Phase
Justification/ comments Recommendations
indicators 2016 2018
7.2 National 2 AMU-3 Surveillance of the sale, Same as 7.1 above
surveillance of AMR, AMR-3 distribution and use of antibiotics
and use and sale is limited and not yet integrated.
of antimicrobials in Surveys of antibiotic sales were
veterinary sector based on data on the import and
production of antibiotics, while
no comprehensive correlation
survey has been conducted
between sales data and usage
data. A national strategy is being
developed on AMR surveillance
in the veterinary sector and
capacity-building.
7.3 Biosecurity (IPC) 3 4 Continuous professional Same as 7.1 above
in animal sector development in AMR and
alternative biosecurity measures
and regular audit of learning are
being carried out. Though M&E
mechanisms are functional,
their contribution is suboptimal
for improving the capacity
of the system and ensuring
sustainability.
7.4 AMR awareness 1 3 AMR awareness programmes Stronger advocacy with
generation and have been developed and piloted academia is requied for the
education in animal in some pre-service veterinary generation of AMR awareness
sector training and a few special in the animal sector so that the
courses for veterinary faculty, subject of AMR is included in
both in the public and private the curriculum and continuous
sectors, among farmers and professional development
stakeholders from the poultry courses for veterinarian and
association. farming professionals. Adopt
a multisectoral approach
by involving the marine
and agricultural sectors to
generate awareness of efficient
management of waste water in
the context of AMR.
7.5 A national AMR NA 1 There is no national policy Review the existing regulations
containment policy to reduce antimicrobial on solid waste and waste water
and regulatory contamination of the management to control the
framework to environment and no regulations release of AR /AMR into the
control release of controlling AR emissions have environment. Advocate the
AR and AMR into been developed. integral role of the Ministry of
the environment Environment in developing policy
and management and a regulatory framework
therein for AMR containment and
management.

Situational analysis of
68 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase Phase
Justification/ comments Recommendations
indicators 2016 2018
7.6 National NA 1 Though the environment sector Strengthen community-level
surveillance of is engaged in AMR activities, management of the antimicrobial
AR and AMR in there are no regulations on disposal system of unused
waste water from AR and AMR monitoring in the antimicrobials at the farm or
manufacture and environment. household level.
use in the human,
animal and fish
sectors and disposal
by institutions and
homes
7.7 AMR awareness NA 1 No policies/communication Enhance the engagement of
generation and strategies have been the environment sector and
education in the developed to limit the disposal link the existing policies with
environmental of antimicrobials in the AMR-related issues to make
sector environment and to monitor the evidence-based policy decisions.
impact of AMR in waste. The Member States should
conduct national surveillance
with technical support from
development partners to generate
a country profile of AR and AMR
in the environment and identify
indicators for monitoring AR and
AMR in waste water form all
relevant sectors.
8. Overarching coordination mechanisms for One Health engagement
8.1 Overarching NA 1 There is no policy for the To enhance multisectoral
AMR coordination regulation of multisectoral collaboration, involvement and
mechanism between coordination. The NAP outlines engagement of all relevant
all relevant sectors a multisectoral coordination sectors, there is a need to set up
mechanism, but it is yet to be a coordination committee and
implemented. have the NAP-AMR endorsed by
the government.
8.2 Inclusion and NA 2 NAP-AMR provides for inclusion Same as 8.1
engagement of all and engagement of various
relevant sectors in sectors, including the human
NAP-AMR health, animal health, food
safety, civil society and trade
sectors, along with private sector
engagement.
8.3 A platform and/ NA 1 There is no regulation policy/ Develop multisectoral integrated
or mechanism mechanism/ platform for monitoring and surveillance
for sharing AMU sharing AMU data among the mechanisms for the use and sale
monitoring data relevant sectors. of antimicrobials in the human,
from all relevant animal and plant sectors.
sectors

69
 Focus area and
indicators
8.4 A platform and/
or mechanism
for sharing AMR
surveillance data
from all relevant
sectors
8.5 AAW is nationally
coordinated and
celebrated with the
involvement of and
contributions from
all relevant sectors
8.6 A mechanism
for co-sharing of
resources for AMR
initiatives
Situational analysis of
70 antimicrobial resistance
in the South-East Asia Region, 2018
Phase Phase
Justification/ comments
2016 2018
NA 2 There is no existing mechanism
for sharing AMR surveillance
data from all relevant sectors.
The Ministry of Agriculture
conducts AMR surveillance of
livestock and data from the
national reference laboratory
is shared with the central
government.
NA 1 AAW activity is nationally
coordinated, but there is
no multisectoral integrated
approach.
NA 1 There is no sharing of resources
for AMR initiatives. To conduct
AMR activities, budget provisions
are made by the MoH, but there
is no dedicated fund for AMR
activities in the Ministry of
Agriculture.
Recommendations
To enable evidence-based policy
decisions, it is of paramount
importance to streamline data
flow and develop platforms
for regular sharing of AMR
surveillance data with all national
and international stakeholders
across all relevant sectors. Focus
on finalizing the tricycle project.
Build synergies amongst all
relevant sectors to organize
a nationally coordinated
AAW. To ensure standardized
communication, it is suggested
that messages prepared by the
Tripartite at the international
level are adapted to the country’s
context.
The Member States should
identify available resources,
develop operational plans and
establish a mechanism for the
co-sharing of resources for AMR
initiatives.
Fig 17: Situational analysis of progress in AMR prevention and containment in Indonesia, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

An average of phase-grading for all indicators in different focus areas is shown in the figure purely for pictorial representation.

Good practice

The remarkable performance of the NADFC in pre- and post-market control

of antimicrobials as part of quality assurance activities is one of the good
practices highlighted in Indonesia. The NADFC ensures the quality of
antimicrobials by routine inspection of production and distribution facilities,
including pharmacies and health-care facilities, and by testing samples
in NADFC laboratories, both in central and provincial offices. The NADFC
regulatory enforcement in the areas of import, export, production, distribution
and use of finished antibiotic products and APIs ensures compliance with
GMP, GDP and GPP, particularly as far as the management of the safety,
efficacy and quality of medicines is concerned. There is a strong system of
pharmacovigilance, with adverse drug reactions being reported to the NADFC
through e-meso application.

Another good practice that deserves special mention is the community

movement, the “smart use of medicines programme”, which emphasizes the
prudent use of AMR by enhancing awareness among pharmacists and the
community regarding the sale of antibiotics only on prescription.

71
 Maldives
Focus area and
indicators
1. National AMR plan and governance
1.1 NAP in line
with GAP-AMR/
governance issue
2. Raising awareness
2.1 Awareness
campaigns for the
public
2.2 Education and
training strategies
for professionals
3. National AMR surveillance system
3.1 National human
AMR surveillance
Situational analysis of
72 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
2 4 The NAP is in line with GAP-
AMR. Budgetary provisions have
been made for all activities in
the standard budget of the MoH.
A national AMR multisectoral
coordination committee, with
technical subcommittees,
has been established and
is functional. A high-level
ministerial steering committee
for AMR has been approved.
2 3 Nationwide awareness
campaigns have been conducted
annually since 2015. There are
plans for a nationwide survey to
assess the knowledge, attitudes
and practices of health-care
workers and the public at large.
1 3 AMR is included in the
curriculum of nurses, laboratory
technicians and pharmacists.
2 2 The data available from
standardized surveillance
initiated at a few tertiary
hospitals are limited. Standard
operating procedures and
guidelines for a nationwide
surveillance system are under
development.
Recommendations
Prioritize the endorsement
of NAP-AMR by all ministries
concerned, including agriculture,
fisheries and environment, along
with the animal and human
health sectors. Step up targeted
advocacy with policy-level
decision-makers to mobilize
resources and create synergies
with the existing programmes for
AMR containment.
Consider undertaking a
knowledge, attitudes and
practices survey to have
baseline information on AMR
awareness among the public.
Develop targeted communication
strategies for behavioural change
with specific M&E framework.
Explore using the social media for
advocacy and consider appointing
an ambassador to promote the
cause of AMR among the public.
Develop a specific curriculum
for health-care professionals,
including experts in the fishery,
plant and environment sectors.
Strengthen the IT sector to
support national human AMR
surveillance.
 Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
3.2 Strengthening of 1 2 A national network of 20
national laboratory laboratories in a 4-tier health-
network care system is planned. A
national reference laboratory
has been identified, standard
operating procedures are
in place for diagnostics in
accordance with the CLSI
guidelines. Capacity for the
molecular identification of AMR
bacteria is not developed. A
quality framework including
EQAS is under way.
3.3 Early warning 1 1 There is no EWS.
systems
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 2 2 The national AMSPhas
AMR containment been planned and is under
policy for control development.
of human use of
antimicrobials; AMR
stewardship
4.2 NRA/DRA 3 4 Tools for quality assurance
and registration of antibiotics
are in place and inspection
implemented, but the capacity
for the enforcement of policies
and regulation is limited.
4.3 Surveillance 2 3 The monitoring of antimicrobial
of AMU and sale sales at the national level has
among humans not been implemented. The
monitoring of use is irregular
and limited to a few facilities that
are not representative.
4.4 Regulation of 2 4 A regulatory authority and
finished antibiotic system are in place and
products and APIs inspection is implemented, but
the capacity for the enforcement
of policies and regulation is
limited.
4.5 Regulation 2 4 A regulatory authority and
of OTC sale and system are in place and
inappropriate sale of inspection implemented, but the
antibiotics and APIs capacity for the enforcement of
by pharmacies policies and regulation is limited.
Recommendations
Build capacity of the laboratory
network supporting AMR,
with a focus on developing
standardized methods and quality
control procedures. Establish
mechanisms for regular and
timely sharing of microbiological
findings with programme experts
and build a stronger coordination
between laboratory and
programme staff.
Build capacity for the molecular
verification of identified AMR
organisms to establish EWS.
Expedite the implementation of
the AMSP. Consider the inclusion
of prescription audit and establish
a drug therapeutic committee at
hospitals.
Ensure availability of adequate
financial resources and trained
manpower for the Food and
Drug Authority to support the
implementation of the NAP-AMR
optimally.
Identify resources for capacity
building and establishing
systematic surveillance of AMU
and sales in humans.
Strengthen capacity of NRA to
implement regulation of OTC and
inappropriate sale of antibiotics
and enforce regulations on
finished products and APIs.
Same as 4.4.
73
 Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 1 1 A national AMSP has been
care setting planned and is under
development. The national AMR
containment policy is in the final
stage of endorsement.
5.2 IPC programme 2 2 A national patient safety and
in health-care infection control committee has
setting been established in the MoH.
Though guidance documents
for infection prevention are
available, they need to be
formally endorsed, so are not yet
implemented.
5.3 National HAI 2 1 A national AMR containment
and related AMR policy has been developed,
surveillance but is yet to be endorsed by all
stakeholders.
5.4 Sanitation and 2 4 Training and awareness-
hygiene raising sessions on sanitation
and hygiene are conducted in
the community at large scale
for diseases such as flu and
diarrhoea. Access to safe
water is ensured for the entire
population.
5.5 Vaccination NA 1 Plans are under way to introduce
PCV in 2018. A low incidence
of typhoid was reported by the
disease surveillance system, so
typhoid vaccination is not being
considered.
6. Research and innovation
6.1 R&D and 1 2 Policies have been framed and
innovation on AMR the existing structure has a plan
prevention and to foster R&D.
containment and
research funding
Recommendations
Expedite the preparation of
national guidelines for the
IPC programme and integrate
AMSP and HAI surveillance with
the IPC programme at health-
care facilities. Set up drug and
therapeutics committees in
hospitals and plan trainings for
capacity-building or retaining
and/or recruiting of infection
control specialist.
A national committee needs to
be set up to elaborate policy and
strengthen laboratory capacity
to support IPC in health-care
setting.
Establish a specific HAI
surveillance system with
guidelines, including M&E
aspects.
Strengthen the surveillance of
waste water for microbial content
and antibiotic residue. Promote
WASH activities nationwide.
Introduce PCV as planned.
Promote R&D to understand
the baseline AMU/AMR
status in the country. Develop
innovative measures to reduce
contamination by cross-border
microorganisms.

Situational analysis of
74 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7. One Health engagement
7.1 A national AMR 2 1 There is no national policy or Streamline data generated
containment policy plan to reduce AMU in the animal from AMR/AMU surveillance
and regulatory or fisheries sector. The national and develop mechanisms for
framework for AMR containment policy is in the systematic data sharing with
the control and final stage of endorsement. national and international
registration of stakeholders.
animal use
7.2 National 3 AMU-1 There is no system for collecting Member States should establish a
surveillance of AMR, AMU-2 data on AMU in animals. No mechanism for the collection and
and use and sale of reports have been submitted to analysis of data on AMU in the
antimicrobials in the the OIE on AMU in the animal veterinary sector at the national
veterinary sector sector due to the non-availability level.
of data. The AMR containment
policy includes AMR surveillance
in animals. However, no activities
have been conducted for
want of infrastructure, skilled
manpower, guidelines and SOP
for laboratory activites in the
animal sector. The laboratory
capacity with respect to food and
water is limited. An aquaculture
centre with laboratory facilities is
being developed.
7.3 Biosecurity (IPC) 1 1 There are no AMR-specific Biosecurity guidelines specific
in animal sector biosecurity policies, though to AMR in the animal sector,
general guidelines on biosecurity including aquaculture, should be
(for poultry, small ruminants developed. The Member States
but not aquaculture) have should consider the inclusion
been developed and partially of biosecurity measures in
implemented. inspection services and visits.
7.4 AMR awareness 1 1 The national AMR containment Continue advocacy and awareness
generation and policy (in final stage of activities for farmers, pet owners
education in animal endorsement) focuses on the and health professionals in
sector education of farmers, food veterinary sector.
handlers and the food industry.
The draft agriculture policy
addresses AMR awareness
among farmers.

75
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.5 A national AMR NA 1 A national AMR containment With the aid of technical
containment policy policy is in the final stage of assistance, develop solutions
and regulatory endorsement. There is no for waste management and
framework to national framework to control the release of AR and AMR in
control release of release of AR and AMR into the environment .
AR and AMR into environment and management
the environment therein.
and management
therein
7.6 National NA 1 The ministry of environment is Develop mechanisms for the
surveillance of part of the national coordinating disposal of waste generated
AR and AMR in committee on AMR. Mechanisms from AMU to ensure
waste water from need to be developed for the environmental safety. Link the
manufacture disposal of waste generated from existing environmental policies
and use in the AMU to ensure environmental and regulations with AMR
human,animal, fish safety. containment.
sectors and disposal
by institutions and
homes
7.7 AMR awareness NA 2 The national AMR containment Increase the involvement of
generation and policy addresses awareness and fisheries, farmers and school
education in education of the environment students to enhance the
environmental sector. No targeted strategies generation of awareness and
sector have been developed for education in the environmental
environmental safety. sector.
8. Overarching coordination mechanisms for One Health engagement
8.1 Overarching NA 2 A national AMR coordination Develop collaborative
AMR coordination committee was established mechanisms with relevant
mechanism between in 2016. It comprises stakeholders to build legal
all relevant sectors subcommittees on education, framework for controlling
awareness, surveillance, AMU, antimicrobial use in agriculture,
research and innovation, and aquaculture and veterinary sector.
an expert group on IPC, which
includes representatives from
the private sector. AMR steering
committee approved with
ministerial level participation
from education, environment,
agriculture and fisheries, finance
and health sectors.

Situational analysis of
76 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
8.2 Inclusion and NA 2 The NAP-AMR provides for the Same as 8.1
engagement of all inclusion and engagement of the
relevant sectors in health, education, environment,
NAP-AMR agriculture and fisheries,
finance, food safety sectors and
WASH.
8.3 A platform and/ NA 1 Estimates on AMU in the Establish mechanisms for the
or mechanism human sector can be made systematic sharing of AMR
for sharing AMU by extrapolation of the import surveillance/ AMU monitoring
monitoring data database as all medicines are data among all relevant
from all relevant imported.. stakeholders.
sectors
8.4 A platform and/ NA 1 AMR surveillance data from Same as 8.3
or mechanism a few tertiary hospitals have
for sharing AMR been shared on WHONET. No
surveillance data structured surveillance set up
from all relevant for animal, fisheries, agriculture,
sectors food and environmental sector.
8.5 AAW is nationally NA 3 AAW is nationally coordinated Build ownership and strengthen
coordinated and and celebrated with the coordination amongst various
celebrated with involvement of all sectors, stakeholders during AAW
involvement of and including education, celebrations.
contributions from environment, agriculture and
all relevant sectors fisheries, finance and health.
Events for human health are
scheduled even beyond AAW.
8.6 A mechanism NA 2 The initial mapping of The Member States should map
for co-sharing of responsibilities and identification available resources, develop
resources for AMR of stakeholders was conducted, operational plans and establish a
initiatives but as a mapping of financial mechanism for the co-sharing of
resources was not carried resources for AMR initiatives.
out, there is no co-sharing of
resources for AMR initiative.

77
 Fig 18: Situational analysis of progress in AMR prevention and containment in Maldives, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas purely for pictorial representation.

Good practice

Among the good practices that can reverse AMR trends in Maldives are the
efforts towards capacity-building of professionals and para-professionals in
the human health sector. Apart from modifying the curriculum for nurses,
laboratory technicians and pharmacists, the country organizes continuing
medical education courses focused on AMR for health-care professionals
every week. The efforts to check the use of illegal veterinary drugs, especially
in private set-ups, should go a long way in curbing the indiscriminate use
of antimicrobials. The adoption of quality management systems as per ISO
9000:2015 for the regulation of medicines is another good practice.

Situational analysis of
78 antimicrobial resistance
in the South-East Asia Region, 2018
Myanmar
Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
1. National AMR plan and governance
1.1 NAP in line 2 3 A NAP has been developed
with GAP-AMR/ in line with the GAP- AMR. A
governance issue national multisectoral AMR
steering committee and national
technical committee have been
established and are functional.
2. Raising awareness
2.1 Awareness 2 3 Nationwide activities on AMR
campaigns for the awareness generation are
public conducted for the public through
collaborative efforts of the
human health and veterinary
sectors.
2.2 Education and 2 3 AMR topics are included in
training strategies some pre-service, in-service and
for professionals other continuing professional
development training courses for
human health professionals.
3. National AMR surveillance system
3.1 National human 2 2 Few AMR surveillance sites
AMR surveillance have been established and
registered in GLASS. Strengthen
surveillance data management
training conducted in WHONET
while AMR surveillance
guidelines are yet to be
developed .
3.2 Strengthening of 2 4 A national reference laboratory
national laboratory has been set up with the CLSI
network as a refence standard and to
support laboratory network. The
repository system and national
EQAS have to be established.
Recommendations
The Member States should
link the existing organizational
structure with the operational
plans, and ensure an inbuilt
framework for M&E and adequate
resources.
Develop a national strategy for
comprehensive awareness of
AMR. This should include a survey
to assess baseline information on
AMR. Secure sustainable funds
and support from ministries
other than health for conducting
campaigns and generating
awareness of evolving AMR.
Conduct awareness programmes,
training and workshops for all
health professionals. There is
a need for continuous medical
education programmes to keep
professionals up to date. Proritize
building of AMR concepts for in-
service health professionals and
revise the medical curriculum to
focus on AMR.
Strengthen human AMR
surveillance, streamline data
management and set up a
mechanism for regular and
timely sharing of human AMR
data with hospitals and national/
international stakeholders.
To achieve and maintain the
highest standards in laboratory
performance, the Member States
should establish laboratory
accreditation practices and
ensure the availability of the latest
CLSI guidelines in the nation’s
laboratory network.
79
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
3.3 Early warning 1 1 No EWS are available. Develop an early warning
systems system with the use of the
latest technology to support
epidemiological data analysis and
to build the molecular diagnostic
capacity of the laboratory
network.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 1 1 There is no policy pertaining to Promote regulatory cooperation
AMR containment AMR containment and control in SEARN on AMR for import in
policy for control of human use of antimicrobials. medical products, and quality
of human use of There is no policy on AMR assurance of laboratory network.
antimicrobials; AMR stewardship either. Develop an API analysis system.
stewardship Strengthen the regulatory
capacity of the NRA to implement
regulations on OTC and
inappropriate sale of antibiotics,
and enforce regulations on
finished products and APIs.
4.2 NRA/ DRA 3 3 The enforcement activities of Same as 4.1
the NRA are weak due to limited
capacity and resources.
4.3 Surveillance 2 2 There are no guidelines on the Same as 4.1
of AMU and sale surveillance of the use and/ or
among humans sale of antimicrobials in humans.
4.4 Regulation of 2 2 An NRA, with limited functional Same as 4.1
finished antibiotic capacity, has been established
products and APIs for oversight.
4.5 Regulation 2 2 Regulation of pharmacies Same as 4.1
of pharmacies regarding OTC and the
regarding OTC and inappropriate sale of antibiotics
inappropriate sale of is in place, but there is limited
antibiotics and APIs capacity for implementation.
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 2 2 There is no national AMR Develop AMR stewardship policy/
care setting stewardship policy. The SOPs, guidelines; and organize training/
guidelines and protocols are workshops to promote the
weak and not available at all concept of AMR stewardship in
health facilities. health-care settings.
5.2 IPC programme 3 2 National IPC guidelines have Establish an IPC programme
in health-care been developed, and all hospitals with a dedicated trained staff at
setting have a hospital infection control the national level and strengthen
committee. They also have the hospital infection control
basic IPC facilities, including committees.
laboratory support. The
implementation of IPC guidelines
is limited due to constraints of
human resources.

Situational analysis of
80 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
5.3 National HAI 1 3 Limited surveillance is being Consider the development of
and related AMR conducted in some health-care a national policy, allocating
surveillance facilities in accordance with the adequate human resources and
SOPs and guidelines developed funds to ensure the sustainability
for HAI surveillance. of activities initiated under HAI
and related AMR surveillance.
5.4 Sanitation and 3 2 WASH activities are conducted in Enhance compliance with
hygiene communities. There are limited sanitation and hygiene activities
data on safe water supply and promoted nationwide under the
sanitation services. WASH programme.
5.5 Vaccination NA 4 PCV 13 has been included in Advocacy is required to link AMR
the EPI programme since 2016. and vaccination practices.
There are no plans to include the
Typhoid Vi vaccine.
6. Research and innovation
6.1 R&D and 2 3 The NAP outlines research and Establish a technical working
innovation on AMR development activities for AMR group to develop operational
prevention and surveillance. Several research research plans that support the
containment and activities have been undertaken, implementation of NAP-AMR.
research funding but a fully operational AMR- Mobilize resources to ensure
oriented research programme is sustainable funds for R&D and
yet to be implemented. innovation.
7. One Health engagement
7.1 A national AMR 1 1 There is no national policy to Develop a policy/ guidelines
containment policy reduce AMU in the animal or for AMR and AMU surveillance
and regulatory fisheries sector. in the animal sector. Identify
framework for resources, ensure the availability
control and of infrastructure and organize
registration of use in training for initiating AMR
animals surveillance in the veterinary
sector. Expedite the finalization
of animal feed under drug law
to provide a legal framework for
the use of antimicrobials in the
animal sector.
7.2 National 1 AMU-1 Project-based AMU/AMR Same as 7.1
surveillance of AMR, AMR-1 surveillance is being conducted
and use and sale in a limited manner. There is no
of antimicrobials in policy/guidelines for AMU/AMR
veterinary sector surveillance. The draft animal
feed law is yet to be finalized.
The NAP outlines surveillance
and monitoring activities,
however these are yet to be
implemented.

81
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.3 Biosecurity (IPC) 2 1 Biosecurity policies, strategies Develop a biosecurity policy.
in the animal sector and guidelines have not been Finalize and endorse guidelines
prepared. on animal husbandry practices
with a focus on backyard as well
as commercial farms.
7.4 AMR awareness- 1 1 There is no national strategy Create awareness of AMU and
generation and for comprehensive awareness AMR among animal handlers.
education in animal generation in veterinary services.
sector
7.5 A national AMR NA 1 There is no national policy Review current regulations on
containment policy to reduce antimicrobial waste water control and initiate
and regulatory contamination of the a survey to assess the status of
framework to environment. Guidelines antibiotic residue and AMR at
control release of and SOPs for health-care different locations in the country.
AR and AMR into waste management include
the environment pharmaceutical waste
and management management, but these are not
therein yet focused on AR or AMR.
7.6 National NA 1 No provision for monitoring AR Develop guidelines to enhance the
surveillance of AMR and AMR in the environment. The engagement of the environment
in waste water from Ministry of Natural Resources sector in the surveillance of AR
manufacture and and Environmental Conservation and AMR in waste water from
use in the human, is yet to be involved in AMR various sources.
animal sectors activities.
and disposal by
institutions and
homes
7.7 AMR awareness NA 1 There is no policy or targeted The involvement and engagement
generation and communication strategy on AMR of the Ministry of Natural
education in in waste for the public at large. Resources and Environment
environmental Conservation is imperative for
sector comprehensive AMR containment
efforts.
8. Overarching coordination mechanisms for One Health engagement 
8.1 Overarching NA 2 Here is an overarching AMR Make the participation of various
AMR coordination coordination mechanism, with a sectors more organized by
mechanism between national multisectoral steering avoiding duplication of activities
all relevant sectors committee, national coordination by various committees.
committee and technical working
groups which are established
and functional.

Situational analysis of
82 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
8.2 Inclusion and NA 2 The human health, animal Engagement of the environment,
engagement of all health, plant health, food plant and food sectors should be
relevant sectors in production, food safety, strengthened.
NAP-AMR environment, WASH, trade and
private sectors, as well as the
civil society are included and
engaged in the implementation
of the NAP-AMR.
8.3 A platform and/ NA 1 There is no policy, mechanism or Set up a platform for the regular
or mechanism for platform for the sharing of AMU sharing of data among the
sharing of AMU data among the relevant sectors. relevant sectors for evidence-
monitoring data based decision making at the
from all relevant national and international levels.
sectors
8.4 A platform and/ NA 2 Project-based AMR surveillance Human health surveillance data
or mechanism for is conducted in the veterinary should be regularly shared with
sharing of AMR sector. AMR surveillance all the relevant sectors. Animal
surveillance data activities are limited in the health surveillance should be
from all relevant human health sector. There is established at the national level
sectors no mechanism/ platform for the and pilot projects in the veterinary
sharing of data among various sector should be scaled up for
sectors. animal health surveillance to be a
nationwide activity.
8.5 AAW is nationally NA 5 The health sector leads For AAW, operationalize the
coordinated and awareness activities, with technical group formed and
celebrated with contributions from other relevant enhance the engagement
involvement of and sectors (agriculture, livestock, of sectors such as plant,
contributions from irrigation, WASH, education, environment and defence in
all relevant sectors information and defence) for various activities.
the general public and health
professionals at the national
level. Agriculture sector
contributed by organizing field
trips to enhance understanding
of AMR.
8.6 A mechanism NA 1 A mechanism for the co-sharing Map the resources available to
for co-sharing of resources is yet to be developed. develop operational plans and
resources for AMR establish a mechanism for the
initiatives co-sharing of resources for AMR
initiatives.

83
 Fig 19: Situational analysis of progress on AMR prevention and containment in Myanmar, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

The coordination among all stakeholders exhibited during the celebration

of the AAW is remarkable. The multisectoral governance and coordination
mechanisms are exemplary. Each sector has a clearly defined role while
conducting activities under the able guidance and leadership of the national
government.

Situational analysis of
84 antimicrobial resistance
in the South-East Asia Region, 2018
Nepal

Focus area and Phase, Phase, Justification/comments Recommendations

indicators 2016 2018
1. National AMR plan and governance
1.1 NAP in line 2 2 A draft NAP-AMR is under review Expedite the endorsement of the
with GAP-AMR/ for alignment with the GAP- NAP-AMR by the government on
governance issue AMR. It will include operational priority.
plans and detail activities for all
sectors, that is human, animal,
food and environment.
2. Raising awareness
2.1 Awareness 2 2 Some government-led activities, The Member States will adapt
campaigns for the including AAW, are conducted the internationally available
public in parts of the country to raise messages on AMR to suit the
awareness of AMR. country’s context. To assess the
baseline understanding of AMR
concepts among the public, it is
recommended that a knowledge,
attitude and practice survey be
conducted, and the gaps identified
be addressed by formulating
strategies in coordination with the
National Health Education and
Information Centre.
2.2 Education and 2 1 There is no policy/ strategy It is imperative to prepare
training strategies for the training of health training material with specific
for professionals professionals. The curriculum information on AMR for induction
of medical universities is under training and continuous
revision to focus on AMR. professional development
courses for professionals in
the human health, animal and
plant health, and environment
sectors . Procedures for the
revision of curriculum for all
health professionals to include
information on AMR stewardship
must be expedited.
3. National AMR surveillance system
3.1 National human 3 4 Standardized human AMR Human AMR surveillance sites
AMR surveillance surveillance has been initiated should be expanded so as to
at a limited number of sites. be representative of the entire
Data management needs to country. Conduct structured
be strengthened to ensure training of laboratory experts and
timeliness and completeness, data managers, and establish
and regular analysis. strong coordination between
programme managers and
laboratory surveillance to support
human ARM surveillance.

85
 Focus area and Phase, Phase, Justification/comments Recommendations
indicators 2016 2018
3.2 Strengthening of 3 3 The national public health There is a need to build
national laboratory laboratory has been identified as technical expertise in laboratory
network the national reference laboratory. diagnostics, strengthen
A quality assured laboratory laboratory infrastructure, develop
network of both public and standardized protocols/guidelines
private sector facilities has been and augment data management
established at limited sites. capacity.
3.3 Early warning 2 1 There is no system in place for Establishing an EWS requires
systems AMR bacteria. capacity-building of the national
reference laboratory in molecular
detection and developing a
repository of organisms.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 2 1 There is no national policy, A national antibiotic policy needs
AMR containment plan or regulations for the use to be framed and treatment
policy for control and sale of antimicrobials. A guidelines developed for the
of human use of national list of essential drugs is prescription of antimicrobials at
antimicrobials; AMR available and standard treatment different levels of health facilities.
stewardship protocols are followed for some
diseases (TB, malaria, HIV,
leprosy).
4.2 NRA/ DRA 3 4 An NRA/DRA system has been Ensure the availability of
set up for oversight, but it is not adequate financial resources and
fully functional. trained manpower at the NRA
so that it performs optimally and
supports the implementation of
NAP-AMR.
4.3 Surveillance 3 1 There are no guidelines for To establish AMU surveillance
of AMU and sale surveillance of the use and/or in the human health sector, it is
among humans sale of antimicrobials. crucial to develop a national AMU
monitoring system with technical
assistance from the development
partners.
4.4 Regulation of 2 2 Regulation is limited. However, Strengthen the NRA’s capacity
finished antibiotic strategic planning is under for dossier review and antibiotic
products and APIs way for capacity-building and registration, conducting post-
appropriate budgeting. market survey for quality
assurance of antibiotics,
regulating finished products and
APIs and prohibiting OTC sale of
antibiotics.
4.5 Regulation 3 2 Regulation is limited. However, Same as 4.4
of pharmacies strategic planning is under
regarding OTC and way for capacity-building and
inappropriate sale of appropriate budgeting.
antibiotics and APIs

Situational analysis of
86 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase, Justification/comments
indicators 2016 2018
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 2 1 There is no national AMR
care setting stewardship policy, or
operational plan available or
approved.
5.2 IPC programme 1 1 There are no national IPC
in health-care policy, guidelines and action
setting plans to mandate IPC in health-
care settings. Infection control
committees have been set up
in all hospitals, but standard
treatment guidelines are not
available.
5.3 National HAI 1 1 There is no policy in this sphere.
and related AMR The national plan and guidelines
surveillance to mandate hospitals for HAI
surveillance are limited. Few
public and private hospitals have
HAI surveillance, and there is no
mechanism for centralized data
reporting.
5.4 Sanitation and 2 4 A policy on improving sanitation
hygiene and hygiene is implemented on
a large scale, with campaigns
being held regularly.
5.5 Vaccination NA 2 The PCV 10 and HiB vaccines
are part of the national
immunization programme, while
the introduction of the typhoid
vaccine is in the pilot phase.
6. Research and innovation
6.1 R&D and 1 1 The NAP plans to foster R&D on
innovation on AMR AMR but no technical committee
prevention and or working group has been
containment and formed to support it. Also,
research funding there are no dedicated funds to
promote innovation.
Recommendations
A prerequisite to strengthen
the AMSP is to update the
essential drug list and list of
drugs included in social health
insurance programmes. It is
imperative to incorporate AMR
stewardship concepts in training
courses specifically for health
professionals and implement
AMSP on priority in hospital
management.
To formulate a national policy,
it is essential to develop
standard treatment protocols
for nationwide implementation,
strengthen infrastructure and
establish IPC committeein health
facilities.
To assess magnitude of HAI in
the country and address barriers
in reporting, HAI surveillance
coordinated by the national
infection control committee
should be established.
The Member States should
strengthen the sanitation and
hygiene campaign and routine
immunization activities across the
nation.
Consider the development of a
vaccination policy in the context of
AMR practices.
Ensure the availability of funds
to conduct targeted research
focused on AMR.
87
 Focus area and
indicators
7. One Health engagement
7.1 A national AMR
containment policy
and regulatory
framework for
the control and
registration of use in
animals
7.2 National
surveillance of AMR,
and use and sales
of antimicrobials in
veterinary sector
7.3 Biosecurity (IPC)
in animal sector
Situational analysis of
88 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase, Justification/comments Recommendations
2016 2018
2 1 There is no national policy It is imperative to develop
or plan to reduce AMU in standardized protocols and
veterinary/ fisheries sector. A methodology for laboratory
regulatory framework has been diagnostics, build on the
developed for the control and available infrastructure and
registration of use in the animal ensure data management. The
sector, but it has not been Member States should prepare
implemented. protocols to monitor the use
and sale of antimicrobials in the
animal sector and ensure timely
sharing of data with national
and international stakeholders.
Engage the National Veterinary
Council in developing a policy on
communication strategies and
disseminating information in the
veterinary sector using the mass
media. Develop surveillance
guidelines and build the capacity
of laboratories in the veterinary
sector, and ensure biosecurity
measures.
2 AMR 1; There are no policy/ guidelines Same as 7.1
AMU 2 for AMR surveillance, and the
use and sales of antimicrobials
in the veterinary sector at the
national level. The central
veterinary laboratory has been
identified as the coordinating
laboratory for AMR surveillance.
The information shared with the
OIE global database on the use
of antimicrobials in the animal
sector is primarily based on
the supplies/sales data on the
import of antibiotics.
1 2 Biosecurity strategies and Same as 7.1
guidelines have been developed.
Training is conducted to build the
capacity of farmers, and owners
of commercial poultry farms and
hatcheries as per the directives
of the ministry of Agriculture.
 Focus area and Phase, Phase, Justification/comments Recommendations
indicators 2016 2018
7.4 AMR awareness 1 1 There is no policy and no Same as 7.1
generation and systematic effort has been
education in animal made to raise AMR awareness.
sector Awareness activities are
conducted by different
stakeholders but no concerted
effort has been made.
7.5 A national AMR NA 1 There is no specific regulation/ Enhance the engagement of
containment policy national policy to control the the environment sector and link
and regulatory release of antibiotic residue and existing policies with AMR-related
framework to AMR into the environment. Nor is issues. The involvement of the
control release of there any regulation or policy for environment sector is critical to
AR and AMR into a water management system. establish national surveillance
the environment of AR and AMR in wastewater
and management from all relevant sectors. There is
therein strong need to develop a policy to
control antibiotic residue in food
and the environment.
7.6 National NA 1 There is no national policy for Same as 7.5
surveillance of surveillance of AR/AMR in waste
AR and AMR in and the environment. An ad hoc
waste water from study is being conducted for
manufacture and antibiotic levels in fisheries.
use in the human,
animal and fish
sectors and disposal
by institutions and
homes
7.7 AMR awareness NA 1 The environment sector does Same as 7.5
generation and not have a specific strategy on
education in the generation of awareness
environmental and education on AMR. It is not
sector included in AMR-related policy
committees.
8. Overarching coordination mechanisms for One Health engagement 
8.1 Overarching NA 2 A national AMR coordination The composition of multisectoral
AMR coordination committee has been established, committee established for
mechanism between but needs to be modified, overarching AMR coordination
all relevant sectors considering the federal context must be reviewed so that it has
and administrative restructuring, nationwide representation, in
to make it more inclusive, with the context of administrative
all relevant stakeholders . restructuring in the country.
Ensure the inclusion and
engagement of stakeholders from
all relevant sectors.

89
 Focus area and
indicators
8.2 Inclusion and
engagement of all
relevant sectors in
NAP-AMR
8.3 A platform and/
or mechanism for
sharing of AMU
monitoring data
from all relevant
sectors
8.4 A platform and/
or mechanism
for sharing AMR
surveillance data
from all relevant
sectors
8.5 AAW is nationally
coordinated and
celebrated with
involvement of and
contributions from
all relevant sectors
8.6 A mechanism
for co-sharing of
resources for AMR
initiatives
Situational analysis of
90 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase, Justification/comments
2016 2018
NA 2 The NAP-AMR is under review
for alignment with GAP-
AMR and representativeness
in the federal context. A
national AMR multisectoral
committee has been proposed
with representation from the
ministries of food, environment,
education, information
technology and finance, and
the National Health Research
Council, civil society and private
sector.
NA 1 There is no policy/ mechanism/
platform for the sharing of AMU
data among the relevant sectors.
No information on AMU is
available from the human health
sector for want of guidelines.
Limited information related to
the animal sector is gathered
from procurement data. There is
no sharing mechanism.
NA 2 There is a platform for the
sharing of data on animal health
with the national reference
laboratory for human health.
NA 3 AAW is celebrated jointly by
the human and animal health
sectors in collaboration with FAO
and WHO. Most activities are
conducted in Kathmandu.
NA 1 There are no provisions for
sharing resources for AMR
initiatives across ministries. The
MoH allocates funds for AMR
activities from its annual budget.
Recommendations
Same as 8.1
The Member States should
streamline data flow and develop
platforms for the regular sharing
of information across all sectors
to establish the transmission
pathways of AMR. There is a
need to outline a strategy for
data management at the national
level, both for AMU and AMR
surveillance, and for sharing with
all national and international
stakeholders to enable evidence-
based decision-making at all
levels.
Same as 8.3
Build synergies among all
relevant sectors for a nationally
coordinated AAW and plan
activities spread across the entire
calendar year.
Stronger advocacy is needed with
policy-makers for the allocation
of dedicated funds for AMR
activities. Explore the feasibility
of resource-sharing across the
relevant sectors.
Fig 20: Situational analysis of progress in AMR prevention and containment in Nepal, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

The PCV-10 vaccine was introduced in routine immunization in 2015.

The coverage of PCV primary and secondary doses reached 90% and 88%,
respectively, and that of the booster/third dose reached 80% in 2017. The Hib
vaccine was introduced as part of a pentavalent vaccine in 2009, and the
coverage of pentavalent 3 was 90% in 2017 (WHO-UNICEF estimates).

91
 Sri Lanka
Focus area and
indicators
1. National AMR plan and overnance
1.1 NAP in line
with GAP-AMR/
governance issue
2. Raising awareness
2.1 Awareness
campaigns for the
public
2.2 Education and
training strategies
for professionals
Situational analysis of
92 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
3 4 The NAP has been developed
in line with the GAP-AMR
and makes provision for the
National Advisory Committee on
AMR and NAP implementation
strengthening team. An
operational plan characterized
by a multisectoral approach is
being rolled out and scaled up,
covering defined activities with
their respective budgets.
2 4 A nationwide, government-led
antibiotic awareness campaign
targeting the public and
professionals was organized
by the health sector. Baseline
data on AMR awareness among
the public has been collated
through a study conducted in the
community regarding knowledge,
attitudes and practices.
1 3 The topic of AMR has been
included as a core component of
the service training programmes
of all health-care professionals
(doctors, pharmacists, nurses,
veterinarians) and incorporated
in the in-service continuing
professional development
programmes for veterinary
surgeons and extension officers.
For in-service laboratory
technicians, an external quality
assurance programme based
on AMR detection has been
developed. The inclusion of
AMR in the medical and school
curriculums has been proposed.
Recommendations
To strengthen the implementation
of NAP-AMR, ensure that it
is endorsed by all ministries
concerned, including environment
and food safety, along with
the human and animal health
sectors. Develop a regular
monitoring framework for the
assessment of the impact of AMR
surveillance systems.
Continue with activities for the
generation of awareness among
the public and evaluate the
effectiveness of the campaigns
with a focus on behavioural
change. Consider external
evaluation for the assessment of
impact. The Member States may
conduct studies among farmers
to identify the existing practices
and customize communication
strategies accordingly.
Education and training
programmes should continue to
focus on building AMR concepts
with regular updates. Develop
strategies to monitor and
evaluate the quality of workshops/
courses/ training conducted
for laboratory technicians,
nurses and other paramedical
professionals and experts.
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
3. National AMR surveillance system
3.1 National human 3 4 The surveillance programme is Continue with the ongoing
AMR surveillance designed in line with the Global activities related to human AMR
Antimicrobial Surveillance surveillance and document
System. The use of WHONET has progress in an annual report.
been introduced for surveillance Build capacity for data
and data collection, but there is management, expand the use of
no contribution of data to GLASS. WHONET and contribute regularly
Capacity-building programmes to GLASS.
to monitor AMR trends
accurately are under way. Deputy
Dir. Gen. of Health Services (LS)
is recognized as the National
Coordinating Centre.
3.2 Strengthening of 2 5 A nationwide laboratory Strengthen laboratory-supported
national laboratory network has been established. human AMR surveillance, build
network It comprises 25 laboratories in technical expertise and progress
the private and public sectors, towards accreditation standards
the Medical Research Institute in laboratory performance.
serving as the national reference
laboratory. The laboratory
network has adopted the CLSI
as the performance standard
and participates in the national
external assurance programme.
It has recently enrolled in GLASS
and is likely to initiate data-
sharing soon.
3.3 Early warning 1 1 No EWS has been established. To establish an EWS, enhance
systems the capacity of the laboratory
network for molecular detection
and explore the use of advanced
software for data analysis and
alert generation.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national A national AMSP has Implement the national AMSP,
AMR containment been planned and is being adopt the WHO essential
policy for control developmed. National guidelines medicine list and build capacities
of human use of have been framed on empiric to develop curriculum and
antimicrobials; AMR 2 2 antimicrobial therapy and the conduct specialized trainings on
stewardship DGHS has issued a circular on AMSP. Participate in Regional
the restricted use of antibiotics. collaboration and the exchange of
‘Red Light Antibiotics' are information on antimicrobials.
available guidance documents.

93
 Focus area and
indicators
4.2 NRA/DRA
4.3 Surveillance
of AMU and sale
among humans
4.4 Regulation of
finished antibiotic
products and APIs
4.5 Regulation
of pharmacies
regarding OTC and
inappropriate sale of
antibiotics and APIs
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health-
care setting
5.2 IPC programme
in health-care
setting (HCS)
Situational analysis of
94 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
2 4 The NRA is fully operational.
Tools for quality assurance and
the registration of antibiotics
are in place. Inspections are
conducted, but the capacity for
the enforcement of policies and
regulations is limited.
1 3 Monitoring of the sale of
antimicrobials at the national
level has not been implemented.
Monitoring of AMU is limited
to a few facilities that are not
representative. A national
antibiotic consumption survey
covering all provinces is under
way.
2 3 There is a regulatory authority
and a system for oversight with
a limited functional capability.
APIs of registered local products
are permitted to be imported
through a licence system.
2 4 There is a regulatory authority
and a system. Inspection is
implemented, but the capacity
for the enforcement of regulation
is limited. OTC dispensing of
medicines is prohibited.
1 2 There is a national IPC/AMR
policy and an operational plan.
However the SOps are weak,
and guidelines and protocols,
which need to be updated, are
not available at all hospitals. Red
light Antimicrobial prescriptions
defined under AMSP and is
included in guidance document.
3 4 A national advisory committee on
IPC has been set up and national
guidelines on IPC based on the
WHO core component are being
framed. An infection control
manual and local guidelines are
used by the infection control
committees in hospitals.
Recommendations
Promote regulatory cooperation
on the import of medical
products and AMR in SEARN;
ensure quality assurance of the
laboratory network and develop
an API analysis system.
Develop a national AMR
containment policy and establish
a national AMU monitoring
system to control the use of
antimicrobials in humans.
Expedite the completion of the
national survey on antibiotic
consumption.
Provide adequate human and
financial resources to strengthen
the regulatory capacity of the
NRA to conduct pre- and post-
marketing surveillance and
enforce regulations on finished
products and APIs.
To regulate the inappropriate sale
of antibiotics and APIs, consider
advanced IT solutions to manage
the referral, prescription and
drug dispensing systems.
Ensure the availability of SOPs
and guidelines, and strengthen
the laboratory capacity at health-
care facilities to support the
national AMSP.
Provide adequate human and
financial resources for the
IPC programme in health-
care settings and evaluate
the implementation status
periodically.
 Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
5.3 National HAI 2 4 Many public and private facilities
and related AMR are conducting HAI surveillance
surveillance and centralized data on HAI from
several hospitals are available,
but the capacity for detection
and data analysis is limited.
5.4 Sanitation and 4 4 The policy on improving
hygiene sanitation and hygiene is
implemented on a large scale,
with regular campaigns. There
are data on safe water supply
and sanitation services, and
access to them is medium.
5. Infection prevention control and AMR stewardship programme
5.5 Vaccination NA 3 Two types of pneumococcal
vaccines (PCV 10 & 13 and
PPSV23) are available in the
private sector, but not included
in the EPI schedule. Typhoid
vaccines are given to food
handlers and to the general
public during outbreaks.
The vaccines available are Vi
polysaccharide vaccine and Ty21
capsule for oral administration.
The inclusion of vaccines in
the EPI schedule is based on
periodic review of disease
burden.
6. Research and innovation
6.1 R&D and 1 2 Policies have been framed and
innovation on AMR it is proposed that the existing
prevention and structure will foster research
containment and and innovation on AMR in both
research funding the human and animal sectors.
Recommendations
Conduct HAI surveillance in
tandem with human AMR/AMU
surveillance in health-care
facilities.
Promote measures to enhance
compliance with sanitation and
hygiene standards and collect
baseline data to confirm the
status of safe water supply across
the country.
Advocate for the inclusion of
PCV in routine immunization and
monitor trends of AMR to update
disease burden estimates for
evidence-based introduction of
vaccines.
Plan targeted research projects
to provide baseline data on AMR/
AMU in the human, animal and
environment sectors to support
implementation and M&E of NAP-
AMR. There is a need to explore
and approach national and
international funding agencies
for sustainable funds to conduct
research activities.
95
 Focus area and
indicators
7. One Health engagement
7.1 A national AMR
containment policy
and regulatory
framework for
the control and
registration of use in
animals
7.2 National
surveillance of AMR,
and use and sale
of antimicrobials in
veterinary sector
7.3 Biosecurity (IPC)
in animal sector
7.4 AMR awareness
generation and
education in animal
sector
Situational analysis of
96 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
3 4 A policy has been framed and
a plan implemented. There is
some capacity for monitoring,
but the capacity fo enforcement
is limited.
1 AMU There is limited capacity for
-2; surveillance of the sale and
AMR use of antimicrobials in the
-3 animal sector. Aggregated data
of active ingredients based on
import data, licence data as all
registration data are shared with
the OIE.
2 3 Training on AMR and alternative
biosecurity measures has
been started for professionals
in the animal sector. The
existing policies, strategies and
guidelines focus primarily on
poultry farming.
Awareness programmes
have been developed and
undergraduate curriculums
revised to include AMR. AMR has
also been incorporated in in-
1 3
service/ continuing professional
development programmes for
veterinary surgeons, para-
professionals (diploma-holders)
and extension officers.
Recommendations
Add into a national AMR
containment policy a support
national surveillance of AMU
and sales, in the veterinary
sector. It is important to prepare
national guidelines for the
collection, analysis and timely
sharing of data on AMR and AMU
with national and international
stakeholders across all relevant
sectors.
The Member State should
conduct systematic assessment
of the AMR surveillance system,
build laboratory capacity and
ensure the availability of funds
to continue AMR containment
initiatives in the veterinary sector.
To strengthen biosecurity
measures, harmonize guidelines
across the animal sector,
introduce an audit system that
is applicable to different kinds of
livestock and evaluate the impact
of generating awareness in the
veterinary sector.
Create awareness among animal
handlers on AMU and AMR using
mass media channels and social
media platforms.
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.5 A national AMR NA 2 A national policy to reduce Develop guidelines to
containment policy antimicrobial waste generation enhance the engagement of
and regulatory has been formulated and the environment sector and
framework to approved. Regulations implement the national policy on
control release of are in place to control AR waste management. It is crucial
AR and AMR into emissions from antimicrobial to establish surveillance of AR
the environment manufacturers, hospitals and and AMR in waste water from the
and management waste-water treatment plants. human and animal sectors.
therein Environmental protection policy
(licence) is renewed annually
and environmental impact
assessment is mandatory for
new projects.
7.6 National NA 1 Environment is not included Same as 7.5
surveillance of in the NAP-AMR. Though not
AR and AMR in specific to AMR, a fully functional
waste water from programme on waste-water
manufacture and management exists.
use in the human,
animal and fish
sectors and disposal
by institutions and
homes
7.7 AMR awareness NA 1 The environment sector is Environmental awareness
generation and not involved in AMR-specific programmes should include
education in activities. messages on AMR. There is a
environmental need to link AMR with the existing
sector environment protection licensing
system in the country.
8. Overarching coordination mechanisms for One Health engagement 
8.1 Overarching NA 2 Overarching AMR coordination Strengthen the coordination
AMR coordination has been ensured by mechanism between all
mechanism between establishing a national advisory relevant sectors with enhanced
all relevant sectors committee on AMR and the NAP engagement and involvement
implementation strengthening of the environment, food safety,
team on the basis of a education, aquaculture, and
multisectoral approach. animal and human health
sectors.

97
 Focus area and
indicators
8.2 Inclusion and
engagement of all
relevant sectors in
NAP-AMR
8.3 A platform and/
or mechanism for
sharing of AMU
monitoring data
from all relevant
sectors
8.4 A platform and/
or mechanism for
sharing of AMR
surveillance data
from all relevant
sectors
8.5 AAW is nationally
coordinated and
celebrated with
involvement of and
contributions from
all relevant sectors
8.6 A mechanism
for co-sharing of
resources for AMR
initiatives
Situational analysis of
98 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments Recommendations
2016 2018
NA 2 The NAP-AMR includes various Same as 8.1
sectors, though the level of
engagement of each sector is
different. The various sectors
involved in NAP-AMR are
human health sector including
pharmaceutical , dental,
professional college associations
and medical education,
agriculture and livestock
including veterinary council,
plant health, food production and
food safety, private sector and
some aspects of WASH.
NA 3 Information pertaining to AMU Establish coordinated
monitoring is available from mechanisms for AMR/AMU
the human health and animal surveillance and implement AMR
health sectors, which share containment across relevant
data intermittently. The national sectors. Provide a platform for
steering committee helps in the sharing of monitoring data
the sharing of information on regularly with national and
AMU among the human health, international stakeholders across
animal health and plant sectors. all sectors to ensure evidence-
However, there is no formal based policy decisions.
mechanism of data-sharing
between all the relevant sectors.
NA 2 AMR surveillance in human Same as 8.3
health sector has been
streamlined. Mechanisms
have been developed for AMR
surveillance in the animal health
sector, but not fully implement.
In the environmental sector,
AMR surveillance is in the initial
stages of establishment.There
is no mechanism for the sharing
of AMR surveillance data among
different sectors.
NA 2 AAW activities are led by the Carry out impact assessment of
human health sector, with the activities for the generation of
involvement of the animal health, awareness conducted with the
food safety and environment involvement of and contributions
sectors. However, national level from all relevant sectors.
coordination is weak.
NA 3 There is no established Identify resources and establish a
mechanism for the co-sharing of mechanism for the co-sharing of
resources for AMR initiatives in resources for AMR initiatives.
the country.
Fig 21: Situational analysis of progress in AMR prevention and containment in Sri Lanka, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

Of all the good practices in the country, the foremost is the National Medicinal
Registration Authority, which ensures that all medicines, medical devices, etc.
are safe, efficacious and of acceptable quality. Another good practice is the
drug registration policy, which calls for the submission of the availability of
stocks and information pertaining to the quantity of antimicrobials imported
for the yearly renewal of the import licence. In addition, a well-established
system for the distribution of all medical supplies ensures timely and regular
availability of medicines in all hospitals in the public sector.

The focus on the environmental sector is commendable. Environmental

impact assessment is mandatory for new projects as well as for the annual
renewal of the environmental protection licence (a regulatory/legal tool under
the provision of the national Environmental Act (license scheme). Though
not specific to AMR, there is a fully functional programme on waste water
management that may serve as a model for cross-learning for other countries
in the Region.

99
 Thailand
Focus area and
indicators
1. National AMR plan and governance
1.1 NAP in line
with GAP-AMR/
governance issue
2. Raising awareness
2.1 Awareness
campaigns for the
public
2.2 Education and
training strategies
for professionals
3. National AMR surveillance system
3.1 National human
AMR surveillance
Situational analysis of
100 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
3 5 An operational plan is being
rolled out and scaled up. It
outlines defined activities
with their respective budgets.
However, implementation
and sustained coverage are
challenges.
2 4 Nationwide, government-led
campaigns are held to raise
awareness of antibiotics among
the public and professionals.
3 5 AMR has been incorporated
in the pre-service training
programmes for all relevant
cadres. Regular continuing
professional development
training is conducted for health
professionals.
3 5 A national AMR surveillance
programme is functional to
monitor AMR trends accurately
and in a timely fashion. It has
been contributing data to
GLASS since 2017. The National
Antimicrobial Resistance
Surveillance Centre (NARST) has
been functional since 1997.
Recommendations
For sustainable coverage and
successful implementation of
NAP-AMR, it is crucial to build
an M&E framework. Ensure that
the NAP-AMR prepared by health
ministry is fully endorsed by all
relevant stakeholders.
Adopt a nationally coordinated
multisectoral approach for
mass awareness. Prepare a
national strategy for awareness
generation with mechanisms
to assess the impact of
the awareness generation
campaigns on the public. Focus
on communication risk analysis
to avoid miscommunication,
especially in the animal sector.
Continue the implementation
of the existing education
and training strategies for
professionals in the human and
animal health sectors.
To strengthen human AMR
surveillance, increase the number
of sites contributing to GLASS,
improve the efficacy of the
information management system
and promote the utilization of
the data by policy-makers and
health-care providers.
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
3.2 Strengthening of 4 5 The laboratory network Strengthen laboratory-supported
national laboratory comprises 97 laboratories AMR surveillance and maintain
network nationwide from the public and technical expertise by regular
private sectors. The National capacity-building. Build
Institute for Health (NIH) serves international collaboration to
as the national reference provide opportunities for cross-
laboratory. This, as well as a learning by sharing experience,
few network laboratories, have knowledge and technologies.
ISO151189 certification, which
ensures the maintenance of the
highest standards of quality.
EQA measures are in place and
operated by NARST. Research is
the core mandate of the NIH and
research-related activities are
supported by well-established
infrastructure, equipment,
human resources and budget.
3.3 Early warning 1 2 The systems planned for early Set up a national committee
systems warning of emerging AMR are in to establish EWS as per
line with international standards. international standards.
Pilot projects for EWS have been
initiated in a few hospitals (not in
place yet)
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 2 3 A national AMSP has been Expedite the finalization of the
AMR containment developed. It includes tools to national antibiotic policy. The
policy for control implement and monitor progress policy should cover treatment
of human use of and impact. guidelines, including prescription
antimicrobials; AMR requirements, and restrictions
stewardship on sales by private pharmacies.
Intensify multidisciplinary
capacity-building for AMSP in
hospitals.
4.2 NRA/ DRA 2 3 Tools for quality assurance Promote regulatory cooperation
and registration of antibiotics in SEARN on AMR for the
are in place and inspection is import of medical products and
implemented, but the capacity regulatory cooperation in the
for the enforcement of policies laboratory network.
and regulation is limited.

101
 Focus area and
indicators
4.3 Surveillance
of AMU and sale
among humans
4.4 Regulation of
finished antibiotic
products and APIs
4.5 Regulation
of pharmacies
regarding OTC sale
and inappropriate
sale of antibiotics
and APIs
5. Infection prevention control & AMR stewardship programme
5.1 AMSP in health-
care setting
5.2 IPC programme
in health-care
setting
5.3 National HAI
and related AMR
surveillance
5.4 Sanitation and
hygiene
Situational analysis of
102 antimicrobial resistance
in the South-East Asia Region, 2018
Phase, Phase,
Justification/ comments
2016 2018
2 4 Mechanisms are in place for
the regular collection of data on
antimicrobial sale at the national
level. AMU data are collected by
a few health-care facilities, but
it is not a representative sample.
The linking of AMU data analysis
with the national laboratory-
based AMR surveillance is weak.
2 4 A regulatory authority and
system are in place and
inspection is implemented but
the capacity for the enforcement
of policies and regulation is
limited.
2 4 A regulatory authority and
system are in place and
inspection is implemented, but
the capacity for the enforcement
of policies and regulation is
limited.
3 4 The national policy and
operational plan are weak. SOPs,
guidelines and protocols, with
limited updates, are available at
only some hospitals.
2 3 The IPC programme and
capacity-building plans have
been implemented in select
health-care facilities with limited
monitoring. A national IPC plan/
policy is under development.
2 4 The IPC programme and
capacity-building plans have
been implemented nationwide .
3 4 The policy on improving
sanitation and hygiene is
implemented on a large scale
through regular campaigns.
Recommendations
Develop operational plans to
conduct regular surveillance
of AMU and sale in the human
sector. Complete the antibiotic
consumption survey in the human
sector and share results to
support policy decisions.
Strengthen the capacity of the
NRA for dossier review and
antibiotic registration; conducting
post-market surveys for quality
assurance, and implementing
regulations on finished products
and API.
Promote regulatory cooperation
in SEARN on AMR for the
import of medical products and
regulatory cooperation in the
laboratory network.
Finalize guidelines, monitoring
tools and mechanisms for
systematic feedback of laboratory
findings to physicians.
Ensure adequate resources,
including hospital infrastructure
for the isolation of patients upon
the detection of AMR.
Focus on capacity-building of
infectious disease experts, nurses
and pharmacists to support the
surveillance of HAI.
Standardize reporting and
collation of data on hand hygiene
to strengthen the sanitation and
hygiene practices.
 Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
5.5 Vaccination PCV 13 is not mandatory under
the EPI schedule. A cost- benefit
 NA 3 analysis is planned for evidence
generation and stronger
advocacy.
6. Research and innovation
6.1 R&D and 1 4 The NAP outlines a plan to foster Continue research activities to
innovation on AMR R&D and innovation on AMR
prevention and prevention and containment.
containment and Funds have been secured from
research funding domestic and international
donors.
7. One Health engagement
7.1 A national AMR 2 3 Policies and/or regulatory
containment policy frameworks have been
and regulatory implemented, but there
framework for is limited capacity for the
registration and monitoring of registration and
control of use in AMU in the animal sector.
animals
7.2 National 2 AMU-3 A national surveillance
surveillance of AMR AMR-3 system for the use and sale
and use and sales of antimicrobials in the
of antimicrobials in veterinary sector has been
veterinary sector set up. Guidelines on the
collection of AMU data need to
be developed. Information is
shared annually with the OIE on
the basis of estimates of sales of
antimicrobials.
7.3 Biosecurity (IPC) 2 5 The national guidelines have
in animal sector limited reference to biosecurity.
They outline disease control,
disinfection check and standard
farm care for large-scale
commercial farms, industries
and biosecurity measures for
slaughter houses. It is proposed
to include AMR in the existing
guidelines.
7.4 AMR awareness 2 4 The curriculum for veterinary
generation and training has been revised
education in animal to include AMR. Awareness
sector generation campaigns with a
multisectoral approach and a
focus on the animal sector are
being conducted.
Recommendations
Consider the inclusion of PCV in
the EPI schedule on the basis of
a disease burden assessment
and in the context of AMR
containment.
support the implementation of
the NAP-AMR.
Develop collaborative
mechanisms among
multisectoral stakeholders and
ensure adequate resources to
implement veterinary legislation
and policy for AMR containment
in the animal sector.
Strengthen the existing AMR
surveillance by reviewing
guidelines to involve food
production, food safety and
veterinary R&D. Develop
guidelines on AMU data collection
in the animal sector, including
aquaculture, to establish a
national surveillance of the use
and sale of antimicrobials.
Develop guidelines on animal
rearing without antibiotics.
Enhance awareness and
diagnostic support and formulate
a registration system for backyard
farming.
Continue the implementation
of the existing education
and training strategies for
professionals.
103
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.5 A national AMR NA 2 There is no national policy Develop a regulatory framework
containment policy on AR and AMR disposal in to control the release of AR
and regulatory the environment. However, and AMR in the environment.
framework to the release of AR from There is a need to address the
control release of manufacturing units is well knowledge gap regarding the
AR and AMR into regulated by the existing cumulative long-term impact of
the environment policies. releasing AMR organisms into the
and management environment (both terrestrial and
therein marine systems).
7.6 National NA 1+ Although there are mechanisms Same as 7.5
surveillance of for monitoring the environment,
AR and AMR in these are not AMR-specific .
wastewater from
manufacture and
use in the human,
animal and fish
sectors and disposal
by institutions and
homes
7.7 AMR awareness NA 2 A policy and targeted Focus on raising AMR awareness,
generation and communication strategies have and organize trainings and
education in been formulated primarily for workshops for professionals in
environmental the management of waste from the environment sector.
sector the pharmaceutical sector.
Quality surveillance of surface
water is conducted quarterly
for coliform count, but it is not
related to AMR.
8. Overarching coordination mechanisms for One Health engagement 
8.1 Overarching NA 4 The One Health approach is Strengthen the overarching AMR
AMR coordination followed at all levels of the AMR coordination mechanism between
mechanism between governance structure, such all relevant sectors and include
all relevant sectors as the national AMR strategic the plant and agriculture sectors.
committee and multisectoral
working groups for planning and
implementation.
8.2 Inclusion and NA 5 The NAP-AMR includes and Same as 8.1
engagement of all engages various sectors,
relevant sectors in including human health, animal
NAP-AMR health, agriculture, environment,
food safety, food production,
WASH, trade and civil society for
the containment of AMR.

Situational analysis of
104 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
8.3 A platform and/ NA 3 Databases of wholesale and Establish a platform and/or
or mechanism for production of antimicrobials in mechanism for the sharing of
sharing of AMU the human and animal health AMR and AMU monitoring data
monitoring data sectors are available. The from all the relevant sectors.
from all relevant system allows monitoring of Review AMU in plant and
sectors AMU data. THAISAC is a platform agriculture sectors in the context
developed for the sharing of of the AMR containment policy.
AMU monitoring data between
the human and animal health
sectors. The animal sector has
a mechanism for an AMU data
repository (ICT system). However,
the contribution from various
stakeholders is suboptimal.
There is limited involvement of
the plant and agriculture sectors
in collating AMU data.
8.4 A platform and/ NA 2 In the human health sector, a Same as 8.2
or mechanism pathogen surveillance system
for sharing AMR has been functional for the past
surveillance data two decades. AMR surveillance
from all relevant data are available in the animal
sectors sector, but not shared regularly
across sectors. Information is
disseminated during meetings in
an ad hoc manner.
8.5 AAW is nationally NA 5 AAW is nationally coordinated Promote the generation of
coordinated and and celebrated with the awareness of antimicrobials,
celebrated with involvement of the human sustain collaboration between the
involvement of and health, animal health, human and animal health sectors
contributions from environment, agriculture and and include other sectors to
all relevant sectors plant sectors, and NGOs. sustain activities outside of AAW.
Activities are conducted
thorough out the year to promote
rational use in the community.
8.6 A mechanism NA 3 One Health approach is applied
for co-sharing of to all levels of AMR governance
resources for AMR structure such as National AMR
initiatives strategic committee and working
groups with multisectoral
planning and implementation.

105
 Fig 22: Situational analysis of progress in AMR prevention and containment in Thailand, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

Several remarkable activities have been undertaken to curb AMR in the human
sector. There is a well-defined laboratory network, comprising 97 laboratories
and a national reference laboratory, with state-of-the-art diagnostic facilities,
standard guidelines, and external quality assurance. The capacity-building
activities undertaken are good practices for AMR containment. Another set of
activities which deserve special mention relate to the maintenance of very high
standards sanitation and hygiene, and water supply, particularly the availability
of potable water in health-care facilities. The enforcement of the ban on the
irrational use of antimicrobials in the animal sector to promote growth is
commendable.

Situational analysis of
106 antimicrobial resistance
in the South-East Asia Region, 2018
Timor-Leste
Focus area and Phase, Phase,
Justification/ comments
indicators 2016 2018
1. National AMR plan and governance
1.1 NAP in line 2 2 The NAP-AMR, which is line
with GAP-AMR/ with GAP-AMR, includes
governance issue an operational plan with
defined activities and their
respective budgets. A national
multisectoral AMR committee
has been established.
2. Raising awareness
2.1 Awareness 2 4 Nationwide, government-led
campaigns for the awareness campaign are held.
public These target the public and
professionals. Survey conducted
to assess the awareness
of AMR among the public
and IEC material has been
developed for the rational use of
antimicrobials.
2.2 Education and 1 3 Awareness for health
training strategies professionals conducted
for professionals on policy. Guidelines have
been developed for AMR-
specific education/training for
professionals.
3. National AMR surveillance system
3.1 National human 1 2 Guidelines have been developed
AMR surveillance but are not fully implemented.
Only limited quality data
are available and there are
problems related to analysis and
representativeness.
3.2 Strengthening of 1 1 There is no national network.
national laboratory
network
Recommendations
To implement the NAP-AMR,
it is recommended a national
multisectoral committee
with adequate resources be
established. To ensure political
commitment and ownership by
the country, it is important to
have a NAP-AMR endorsed by the
government.
Develop methodology to evaluate
the impact of the campaigns
conducted among the public to
raise awareness of AMR.
Formulate a policy and guidelines
for the revision of the curriculum
and induction training as well
as continuous professional
development courses on the
prudent use of antimicrobials in
the human and animal health
sectors.
Strengthen policies and
regulations to enforce
implementation of the existing
guidelines and ensure a robust
data analysis system to address
the gaps in monitoring and
evaluation.
It is essential to build a laboratory
network with an identified
national reference laboratory,
adopt standard diagnostic
guidelines, establish quality
assurance measures, and build
capacity for data management
using WHONET.
107
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
3.3 Early warning 1 1 EWS are not established for AMR Set up EWS for the rapid
system bacteria. detection of AMR organisms and
a database to provide information
on AMR risk on a real-time basis,
using advanced IT software.
4. Rational use of antimicrobials and surveillance of use/sale (community-based)
4.1 A national 1 2 There are plans to develop a There is a need to develop an
AMR containment national AMSP. AMSP. A national antibiotic
policy for control policy with definite treatment
of human use of guidelines, including norms for
antimicrobials; AMR prescription at health facilities,
stewardship and restrictions on sales at
private pharmacies needs
to framed. Provide adequate
human, financial and technical
resources for implementation
of antimicrobial stewardship
programme .
4.2 NRA/ DRA 1 2 There is an NRA/DRA with Promote regulatory cooperation
a limited capacity. Strategic with SEARN on AMR for the
planning is in place for capacity- import of medical products and
building and appropriate regulatory cooperation between
budgeting. laboratories.
4.3 Surveillance 1 2 A national policy and plan on Enable the organizational
of AMU and sales surveillance of antimicrobials structure and capacity of the
among humans is being formulated. Limited NRA to regulate pharmacies to
surveillance is conducted in meet the requirements of the
select facilities and national NAP. Also, build the capacity of
level sales also survey on AMR the NRA for monitoring AMU in
consumption done. humans.
4.4 Regulation of 2 1 There is no official regulation It is essential to strengthen the
finished antibiotic of import, export, production, capacity of the NRA for regulating
products and APIs distribution and use of finished registration, dossier review, and
antibiotic products and APIs. regulating finished antibiotic
products and APIs. Develop
capacity of NRA and advocacy
to implement regulation for
antibiotic policy .
4.5 Regulation 1 2 There is national drug Policy, Same as 4.4
of pharmacies which prohibits the sale
regarding OTC sale of antimicrobials without
and inappropriate prescription, but implementation
sale of antibiotics is limited.
and APIs

Situational analysis of
108 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
5. Infection prevention control and AMR stewardship programme
5.1 AMSP in health- 1 1 There is no national AMSP or Develop a policy and guidelines
care setting operational plan. for the AMSP and strengthen the
capacity of laboratories for the
surveillance of AMR/AMU in the
human health sector.
5.2 IPC programme 1 1 There is no national policy, It is crucial to establish an IPC
in health-care guidelines or action plans to committee and strengthen IPC
setting mandate IPC in health-care training in health-care facilities.
settings.
5.3 National HAI 1 1 No policies limited to national Develop policy/guidelines and
and related AMR plan and guidelines to mandate build capacity for HAI surveillance
surveillance hospitals for HAI surveillance. and expand across country in a
stepwise manner.
5.4 Sanitation and 2 3 The policy on improving Focus on expanding the
hygiene sanitation and hygiene has been implementation of the WASH
implemented on a limited scale. programme.
Data on safe water supply and
sanitation services exist, but
access is low.
5.5 Vaccination NA 4 PCV was introduced in Consider developing plans for the
the routine immunization sustainability of immunization
programme in 2017. There are services beyond GAVI, the vaccine
no plans for including the HiB alliance. Support and continue
and typhoid vaccines in the EPI the use of PCV.
schedule.
6. Research and innovation
6.1 R&D and 1 1 Build capacity and secure funds
innovation on AMR There are no policies fostering for research activities to provide
prevention and research and innovation on the baseline information for AMR/
containment and prevention and containment of AMU in the relevant sectors to
research funding AMR. support the implementation of the
NAP-AMR.
7. One Health engagement
7.1 A national AMR 1 1 There is no national policy Develop a national AMR
containment policy or plan to reduce AMU in the containment policy and regulatory
and regulatory animal and fisheries sectors. framework for the control
framework for and registration of AMU in the
control and animal sector. Follow up and
registration of use in finalize the draft legislation
animals and policy. Also, develop
collaborative mechanisms among
multisectoral stakeholders for
the containment of AMR in the
veterinary sector .

109
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.2 National 1 AMU-1 There are no activities on the Establish AMR surveillance
surveillance of AMR AMR-1 surveillance of AMU and AMR in in the animal health sector,
and use and sale of the veterinary sector. There is supported by a quality assured
antimicrobials in the a national veterinary laboratory laboratory network and a robust
veterinary sector that can handle bacterial data analysis mechanism with
isolation, but not for AST. They the cooperation of international
have SOPs for some bacteria but experts. Tripartite experts should
not all. review the existing laboratory
capacity to support surveillance.
The National Directorate of
Veterinary Services has plans to
develop policies and guidelines
for AMU, and the collection of
sales data.
7.3 Biosecurity (IPC) 1 1 There are no biosecurity policies, There is a need to develop
in animal sector strategies or guidelines. guidelines, policy and protocols
for biosecurity in the animal
sector, including backyard farms
and commercial establishments.
7.4 AMR awareness 1 1 Awareness-generation activities Consider technical assistance
generation and are conducted mostly under from Tripartite experts to identify
education in the the MoH with the engagement the extent of AMR in various
animal sector of the animal health sector. sectors and customized approach
However, there are no messages to be adopted to reduce the risk
specifically targeted at animal of AMR.
health professionals or farmers.
7.5 A national AMR NA 1 There is no national policy Develop AMR containment
containment policy on reducing antimicrobial policy and regulatory framework
and regulatory contamination of the to control antimicrobial
framework to environment. contamination of the environment
control release of and engage the ministries
AR and AMR into of commerce, industry and
the environment environment to initiate AMR
and management surveillance of waste water and
therein solid waste from all relevant
sectors. Conduct research to
assess baseline data on AR and
AMR from different sources.
7.6 National NA 1 Weak national policy and Same as 7.5
surveillance of guidelines for the surveillance
AR and AMR in of AR/AMR in waste and
waste water from the environment. Though
manufacture and the environment sector is
use in human, included in the national AMR
animal and fish committee and is part of
sectors and disposal the NAP, no surveillance of
by institutions and AMR contamination of the
homes environment is conducted.

Situational analysis of
110 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus area and Phase, Phase,
Justification/ comments Recommendations
indicators 2016 2018
7.7 AMR awareness NA 1 There are no policies or targeted It is essential to develop
generation and communication strategies on guidelines on the safe disposal
education in the AMR in waste. of waste water and expired drugs
environmental in the context of generating
sector awareness of AMR in the
environmental sector.
8. Overarching coordination mechanisms for One Health engagement 
8.1 Overarching NA 1 The NAP-AMR mandates a Expedite the setting up of
AMR coordination multisectoral coordination the coordination committee
mechanism between committee at the national level and task force for building an
all relevant sectors and a task force to conduct AMR overarching AMR coordination
activities. The process of setting mechanism among all relevant
up the committee and task force sectors. Ensure the inclusion
is under way. and engagement of all relevant
sectors, particularly the
environment and plant sectors.
8.2 Inclusion and NA 3 The NAP-AMR includes and Same as above
engagement of all engages various sectors,
relevant sectors in including human health,
NAP-AMR agriculture, veterinary, food
safety and trade, NGOs, WASH
and the private sector.
8.3 A platform and/ NA 1 No mechanism has been Develop an integrated mechanism
or mechanism for developed for the sharing of data for the sharing of AMR and AMU
sharing of AMU from all the relevant sectors. monitoring data from all relevant
monitoring data Limited data on AMU are sectors, particularly the human
from all relevant available from the human health and veterinary sectors. Consider
sectors sector, but none from the animal a sentinel survey across different
sector. sectors, integrated environment
with agriculture.
8.4 A platform and/ NA 1 The AST in human health Enhance the involvement of and
or mechanism for supports the diagnostics and contributions from all relevant
sharing of AMR treatment methodology. No sectors for the generation of
surveillance data organized AMR surveillance is awareness of AMR.
from all relevant conducted in the human health
sectors and animal sectosr. There is no
mechanism for sharing data
among the relevant sectors .
8.5 AAW is nationally NA 3 AAW is nationally coordinated Build synergies among all
coordinated and and celebrated with the relevant sectors to organize a
celebrated with involvement of the human and nationally coordinated AAW.
involvement of and animal health sectors and
contributions from targets the public at large along
all relevant sectors with professionals in the human
health sector.
8.6 A mechanism NA 1 Funds are available for AMR Identify resources and initiate
for co-sharing of activities, but there is no co- sharing of these for AMR
resources for AMR mechanism for the co-sharing of initiatives.
initiatives resources.

111
 Fig 23: Situational analysis of progress in AMR prevention and containment in Timor-Leste, 2016–2018

National AMR plan and Governance

Awareness raising

National AMR Surveillance system

Rational use of antimicrobials and surveillance of Use/Sale

Infection Prevention Control & AMR Stewardship program

Research and innovation

One health engagement

Overarching coordination mechanisms for One Health Engagement

- 1.00 2.00 3.00 4.00 5.00

2016 2018

The figure shows an average of phase-grading for all indicators in different focus areas, purely for pictorial representation.

Good practice

A strong political will and commitment to reverse AMR trends is evident from
the progress in raising awareness and ownership by government authorities.
One of the unique measures undertaken to strengthen the awareness of the
rational use of antimicrobials is the use of specially designed labels to mark
all imported antimicrobials.

Situational analysis of
112 antimicrobial resistance
in the South-East Asia Region, 2018
Annexures

113
 Annex 1: List of focus areas and
indicators assessed

Focus area Indicator 2016 2018

Focus area 1: National AMR 1.1 NAP in line with GAP Y Y
plan
Focus area 2: Raising 2.1 Awareness to public Y Y
awareness
2.2 Education and training for professionals Y Y
Focus area 3: National AMR 3.1 National AMR surveillance (humans) Y Y
surveillance system 3.2 National laboratory network (humans) Y Y
3.3 Early warning system Y Y
Focus area 4: Rational 4.1 National AMR containment policy; AMSP (humans) Y Y
use of antimicrobials and 4.2 NRA/DRA Y Y
surveillance of use/sales
(community-based) 4.3 Surveillance of use and sales (humans) Y Y
4.4 Regulation of finished products and APIs Y Y
4.5 Regulation of OTC sales Y Y
Focus area 5: IPC and AMSP 5.1 AMSP in health-care settings Y Y
5.2 IPC in health-care settings Y Y
5.3 National HAI surveillance Y Y
5.4 Sanitation and hygiene Y Y
5.5 Vaccination N Y
Focus area 6: Research and 6.1 R&D and innovation Y Y
innovation
Focus area 7: One Health 7.1 National AMR containment policy and regulations Y Y
engagement (animals)
7.2 National surveillance for AMR and AMU (animals) Y Y
7.3 Biosecurity in animal sector Y Y
7.4 Awareness and education regarding AMR (animal Y Y
sector)
7.5 National AMR containment policy and regulations for N Y
controlled release of AR and AMR (environment)
7.6 National surveillance of AR and AMR in waste water N Y
7.7 Awareness and education regarding AMR N Y
(environment sector)

115
 Focus area Indicator 2016 2018
Focus area 8: Overarching 8.1 Overarching coordination mechanisms N Y
coordination mechanisms
8.2 Inclusion and engagement of relevant sector N Y
for One health engagement
8.3 Platform for sharing AMU data N Y
8.4 Platform for sharing AMR data N Y
8.5 Nationally coordinated AAW N Y
8.6 Co-sharing of resources for AMR initiatives N Y

Situational analysis of
116 antimicrobial resistance
in the South-East Asia Region, 2018
 Focus Indicators/ Exploration and Program Initial Full operation Sustainable
Areas Phases adoption installation implementation operation
NAP In line No Action Plan AMR working group GAP-aligned Action plan Action plan includes
with GAP-AMR or no national established and Action plan* includes operational plan
multisectoral National action plan including operational being rolled out
committee or underway operational plan plan being & scaled up with
AMR committee with defined rolled out & defined activities and

Plan
established but activities and scaled up respective budget
involving one respective with defined
ministry budget available activities and

1. National AMR Action

respective
budget
Awareness Government Some government- Nationwide, Nationwide, Program has a
campaigns to not involved in led activities in government- government- strategy to change
the public awareness- parts of the country led antibiotic led antibiotic behaviour and can
raising activities to raise awareness awareness awareness measure impact
on antibiotic about AMR and campaign campaign of the programme
resistance actions to address it targeting targeting in public and
the general public AND professionals
public OR professionals
professionals**
Education No policy or Relevant policies AMR in some AMR in some AMR incorporated
and training strategy developed but ad- pre service pre service into pre service
strategies for hoc training courses training and/or training and/ training for all
professionals in some disciplines some special or some relevant cadres.
courses special Regular continuing

2. Awareness raising
OR courses professional
Continuous AND development
professional Continuous
development professional
and regular development
audit of learning and regular
audit of
learning
Annex 2: Situation analysis Tool 2018 (WHO
Regional Office for South-East Asia Region)

117
 Situational analysis of
Focus Indicators/ Exploration and Program Initial Full operation Sustainable
Areas Phases adoption installation implementation operation

118 antimicrobial resistance

National No capacity for Guidelines Standardized Surveillance National AMR

in the South-East Asia Region, 2018

human AMR AMR laboratory developed but not national AMR in place and surveillance
surveillance and/or limited fully implemented – surveillance functional regularly assessed
reporting; or limited quality data in place and to monitor and adjusted; and
no surveillance and analysis and/ representative AMR trends contributing to
guidelines representativeness of country but accurately GLASS
limited number and timely
of op. sites but no
contributing
data to
GLASS*
National No national A national network Nat. Ref. Lab A national Lab network
Laboratory network with testing identified and network of established, EQA
Network developed according to the quality assured EQA health measures in place,
strengthening international laboratory laboratories and demonstrated
standards is networks developed in capacity of reference
planned developed most /ALL lab for research
only at few surveillance
surveillance sites
sites

3. National AMR surveillance system

Early warning No system System planned, System is Demonstrated Demonstrated
systems in place or in keeping with implemented in functional functional capacity
planned international pilot mode, or capacity: data and proof of
standards if implemented centralised response from
on a national and analysed detection
scale either not with reports
fully functional
(not sensitive
to reportable
events)
 Focus Indicators/ Phases Exploration and Program installation Initial Full operation Sustainable operation
Areas adoption implementation
A national AMR No/weak national policy National AMS National AMS AMSP implemented by A national AMSP for
containment & plan, regulations for Programme (AMSP) Programme (AMSP) relevant institutions. control of human use of
policy for control antimicrobial use and planned and under is developed Regulations for antimicrobials implemented
of human use of availability development Including tools antimicrobial use and and enforced >2 years
antimicrobials; AMR to implement availability implemented
Stewardship (AMS) and monitor AMS in limited capacity
progress & impact
National Regulatory No official NRA/DRA NRA/DRA with limited NRA/DRA system Tools for quality Competent and functional
Authorities (NRA) or existing with limited capacity but strategic set up for oversight assurance & registration NRA/DRA with capacity to
or Drug Regulatory capacity planning in place for but not fully of antibiotics in place and ensuring/enforcing antibiotic
Authorities (DRA) capacity building and functional inspection implemented quality standards and
appropriate budgeting but limited capacity for taking measures against
enforcement of policies substandard products and
and regulation Inspecting pharmacies
Surveillance of No guidelines for National policy & plan Monitoring sales On a regular basis (every On a regular basis (every
antimicrobial use surveillance of use on surveillance of of antimicrobials year/two-years) sales year/two-years) sales data at
(AMU) and sales in and/or sales of use of antimicrobials at national level data at national level are national level are collected
humans antimicrobials under development or not implemented. collected. and
developed & approved Monitoring of use Use data in individual AMU surveys are conducted
but not implemented limited to few health-care facilities are in a representative sample
(surveillance in facilities that are not collected from a small & of facilities & translated
individual facilities and representative and not representative sample. into actions. And links with
national level sales) irregularly No established analysis national AMR surveillance
with national AMR lab- data analysed and reported
based surveillance
Regulation of No official regulation Regulation with limited Regulatory authority Regulatory authority Regulatory authority and
finished antibiotic on import, export, capacity but strategic and system set up and system in place and system in place and are fully
products and active production, distribution planning in place for for oversight with a inspection implemented and effectively implemented
pharmaceutical and use of finished capacity building and limited functional but limited capacity for
ingredients (APIs) antibiotic products and appropriate budgeting capability enforcement of policies
APIs or existing with and regulation
limited capacity
Regulation of No official regulation on Regulation with limited Regulatory authority Regulatory authority Regulatory authority and

4. Rational use of antimicrobials and surveillance of use/sale (community-based)

pharmacies on over over the counter sale capacity but strategic and system set up and system in place and system in place and are fully
the counter sale and and inappropriate sale planning in place for for oversight with a inspection implemented and effectively implemented
inappropriate sale of of antibiotics and APIs capacity building and limited functional but limited capacity for
antibiotics and APIs appropriate budgeting capability enforcement of regulation

119
 Focus Indicators/ Exploration and Program installation Initial implementation Full operation Sustainable operation
Areas Phases adoption
AMR No national AMR A national IPC/AMR National IPC/AMR plan- Nat. IPC/AMR plan- IPC/AMR measures and
stewardship stewardship policy, policy, or operational aligned IPC/AMR plans aligned IPC/AMR plans the effectiveness is widely

Situational analysis of
program in or operational plan is plan, is available but implemented in limited are implemented in about implemented and regularly
Health-care available or approved weak SOPs, guidelines number of HCS all HCS evaluated and shared

120 antimicrobial resistance

setting and protocols not

in the South-East Asia Region, 2018

available to all hospitals
(limited updates)
IPC program No national IPC policy, A national capacity IPC programme and IPC program and IPC capacity building and
in guidelines or action building programme, capacity building plans capacity building plans programme effectiveness
health-care plans to mandate IPC or operational plan, implemented in selected implemented nationwide are regularly evaluated and
setting in HCS is developed; SOPs, HCS shared
(HCS) guidelines and protocols
developed and available
But not implemented
National No policies, limited Few public and private Few public and private Centralised data on HAI Monitoring and response
HAI and national plan and facilities have HAI facilities have HAI from several hospitals but frameworks established
related AMR guidelines to mandate surveillance but data not surveillance and share data with limited data analysis to identify critical HAI
surveillance hospitals for HAI centralized at national with national level and detection capacity events, especially related to
surveillance level emergence of AMR indicator
bacteria against critical drugs
Sanitation No policy or campaign Policy or campaign on Policy or campaign to Policy or campaign to Policy or campaign to improve
and Hygiene on sanitation and sanitation and hygiene improve sanitation and improve sanitation and sanitation and hygiene is
hygiene in institutions in institutions or in hygiene implemented in hygiene is implemented implemented with M&E
or in communities. communities in place. limited scale. at large scale. mechanism.

No data on safely Limited data on safely Data on safely managed Data on safely managed Access to safely managed
managed water supply managed water supply water supply or sanitation water supply or sanitation water supply or sanitation

5. Infection prevention control & AMR stewardship programme

or sanitation services or sanitation services services exist but access services exist and access services high
low medium
Vaccination No formal campaign Formal campaign to Formal campaign to Formal campaign to Formal campaign to enhance
on sanitation enhance on sanitation & enhance on sanitation & enhance on sanitation & on sanitation & hygiene and
& hygiene and hygiene and vaccination hygiene and vaccination is hygiene and vaccination vaccination is implemented in
vaccination being developed implemented in small scale is implemented in large large scale & associated with
scale M&E system
 Focus Indicators/ Phases Exploration and Program installation Initial Full operation Sustainable operation
Areas adoption implementation
R&D and innovation No policies fostering Policies planned and Presence of policies Research consortium, Government-led research
on AMR prevention research environment existing structure has a and investments to dynamic research outputs related to AMR
and containment (+ although capacity exists plan to foster research foster research and programmes are ongoing global research agenda
Research funding) for research and innovation on AMR innovation on AMR thanks to government- led
agenda

innovation
6. Research and

121
 7. One Health engagement contd.

Situational analysis of
Focus Indicators/ Phases Exploration and Program installation Initial Full operation Sustainable operation

122 antimicrobial resistance

Areas adoption implementation

in the South-East Asia Region, 2018

A national AMR No national policy to National policy to Evidence of Policy or regulations Policy or regulations
containment policy reduce antimicrobial reduce antimicrobial implementation of implemented with some implemented with adequate
and regulatory contamination into waste generation policy or regulations capacity for monitoring capacity for monitoring and
framework to environment. developed and approved. but limited capacity but no enforcement for enforcement
control release of for monitoring capacity
AR and AMR into No regulations Regulations in
the environment controlling AR place controlling
and management emissions from AR emissions
therein antimicrobial from antimicrobial
manufacturers, manufacturers,
hospitals or wastewater hospitals or wastewater
treatment plants treatment plants
National No/weak national Policy and guidelines Some capacity and Some data analysis of AR/ Comprehensive approach
surveillance of policy and guidelines in place but limited data generated AMR in different waste of surveillance with
AR and AMR in for surveillance of AR/ capacity for surveillance from AR/AMR generation or environment coordinated analysis with
wastewater from AMR in waste and in any AR/AMR waste generation locations human and animal
manufacture and environment waste generation or or environment
human/animal/fish environment location locations
use and disposal in

7. One Health engagement

institutions and the
home
AMR awareness No policies or targeted Policies or targeted AMR in some pre- Continuous professional Assessment of the
generation & communication communication service training development and regular understanding by
education in the strategies on AMR strategies developed and/or some audit of learning (for professionals/ technicians,
environmental in waste or only (for institutions listed in special courses (for institutions listed in Phase and impact of, education
sector planned (for antibiotic Phase Exploration and institutions listed in Exploration and Adoption) programmes on
manufacturers, Adoption) Phase Exploration performance
hospitals, wastewater and Adoption)
treatment institutions,
farmers)
 Focus Indicators/ Phases Exploration and Program Initial implementation Full operation Sustainable operation
Areas adoption installation
8.1 Overarching No formal Multisectoral Multisectoral working Joint working on issues Integrated approaches used
AMR coordination multisectoral working group(s) group(s) is (are) functional, including agreement to implement the national
mechanism is existing governance or or coordination with clear terms of reference; on common objectives, AMR action plan
between all relevant coordination committee on regular meetings, and funding including restriction of
sectors* mechanism AMR established for working group(s). Activities use of critically important
exists with Government and reporting/accountability antimicrobials
leadership arrangements are defined
8.2 Inclusion and No formal Multisectoral Multisectoral working Joint working on issues Integrated approaches used
engagement of all multisectoral working group(s) group(s) is (are) functional, including agreement to implement the national
relevant sectors in the governance or or coordination with clear terms of reference; on common objectives, AMR action plan.
NAP-AMR coordination committee on regular meetings, and funding including restriction of
mechanism AMR established for working group(s). Activities use of critically important
exists with Government and reporting/accountability antimicrobials
leadership arrangements are defined
8.3 A platform and/ Nothing Ad-hoc Data from different sectors Compatible data from Fully integrated platform
or mechanism for collected and intermittently sectors collected separately with combined data that is
sharing of AMU shared but collated, shared and fed back to sectors
monitoring data from discussed in meaningful
all relevant sectors format with a coordination
exist mechanism to facilitate this
8.4 A platform and/ Nothing Ad hoc- Data from at least two sectors Systems looking at Fully integrated system
or mechanism for uncoordinated, and shared and discussed transmission pathways covering all priority
sharing of AMR project based with compatible tools and with compatible tools pathogens with consistent
surveillance data from which covers protocols for relevant sectors and protocols for relevant methodology for QA and
all relevant sectors surveillance in to enable examination of sectors data from human, animal
exist multiple sectors transmission pathways and environment sectors
developed and tested
8.5 AAW is nationally Not-coordinated Coordinated AAW AAW implemented jointly in AAW implemented jointly in Coordinated campaign
coordinated and messaging two sectors more than two sectors beyond AAW i.e. continuous
celebrated with
involvement and

8. Overarching coordination mechanism for One Health engagement

contributions from all
relevant sectors
8.6 A mechanism No mapping of Method to identify Core elements i.e committee, Other key interventions Coordinated mechanism for
for co-sharing of resources. existing resources etc. resources identified and costed resource allocation between
resources for AMR sectors is functional
initiatives in the
country exist
*Sectors actively involved in developing and implementing the AMR National Action Plan include among others human health, animal health (terrestrial and aquatic), plant health,
food production, food safety, environment, WASH, trade, private sectors and civil society

123
 Annex 3: List of
participants

Back-to-back intercountry meetings were held to review the implementation

of the national action plans on antimicrobial resistance in Bangkok, Thailand,
in July 2018.

Meeting 1: 23–25 July 2018: Bhutan, DPR Korea, Maldives, Nepal,

Sri Lanka and Timor-Leste

Meeting 2: 25–27 July 2018: Bangladesh, India, Indonesia,

Myanmar and Thailand

Bangladesh Pema Yangzom

Programme Officer
Sarwar Jahan Pia Health-care and Diagnostic Division
Assistant Chief Department of Medical Services
National Control Laboratory Thimphu
Directorate General of Drug Administration Email: pyangzom@health.gov.bt
Dhaka
Email: jahan.sarwat@yahoo.com Nirmal Kumar Thapa
Animal health specialist
Md Razibul Habib National Center for Animal Health
Superintendent of Drugs Department of Livestock, Ministry of
Directorate General of Drug Administration Agriculture and Forests
Dhaka Thimphu
Email: mrhjewel@gmail.com Email: nkthapa08@hotmail.com
Md Mahbub Hossain Tashi Dendup
Superintendent of Drugs Regulatory Officer
Directorate General of Drug Administration Drug Regulatory Authority
Dhaka Thimphu
Email: mhossainbmb@gmail.com Email: tdhendup@dra.gov.bt
Bhutan DPR Korea
Raghunath Sharma Han Jong Ryol
Laboratory officer Senior officer
Jigme Dorji Wangchuck National Referral State Hygiene Control Board
Hospital Ministry of Public Health
Thimphu Pyongyang
Email: regunathsharma959@yahoo.com
Hong Sun Gil
Thupten Tshering Vice-Director
Senior pharmacist Veterinary and Anti-Epizootic Institute
Jigme Dorji Wangchuck National Referral Ministry of Agriculture
Hospital Pyongyang
Thimphu
Email: thuptent@idwnrh.gov.bt

Situational analysis of
124 antimicrobial resistance
in the South-East Asia Region, 2018
Kang Song Guk National Officer-in-Charge,
Section chief Human, Animal and Environment Centre
Central Medication Research Institute for R&D of Biomedical and Basic Health
Medical Science Academy Technology
Pyongyang NIHRD, Ministry of Health
Jakarta
Mun Hye Son Email: dyaharmiriana@gmail.com
Section chief
National Regulatory Authority Yurike Elisa Dewi
Pyongyang Head of veterinary drug quality section
Veterinary Drug Sub-directorate,
Jon Song Hui Directorate of Animal Health
Official Directorate General of Livestock and
Department of External Affairs Animal Health Services
Ministry of Public Health Ministry of Agriculture
Pyongyang Republic of Indonesia
Kim Se Hun Jakarta
Senior officer Email: yedewie@yahoo.com
Department of Medicine Management Nani H. Widodo
Ministry of Public Health Head of subdivision and nursing services
Pyongyang Directorate of Referral Health
India Ministry of Health
Jakarta
Lata Kapoor Email: naniwidodo@gmail.com
Joint Director (Specialist Grade)
National Centre for Disease Control Nanang Yunarto
Directorate General of Health Services, National Laboratory Representative
Sham Nath Marg Centre for R&D of Biomedical and Basic
Delhi Health Technology
Email: lata.kapoor@gov.in National Institute of Health Research and
Development
Arti Bahl Jakarta
Joint Director – Epidemiology Division Email: nayunandesba@yahoo.com
National Centre for Disease Control
Directorate General of Health Services, Erie Gusnellyanti
Sham Nath Marg Head of section of rational use of drug
Delhi promotion
Email: artichitkara@rediffmail.com Directorate of Pharmaceutical Services
Ministry of Health
Adhiraj Mishra Jakarta
Livestock officer Email: erie.gn@gmail.com
Department of Animal Husbandry, Dairying
and Fisheries Joan Aprilla Arland
Ministry of Agriculture and Farmers’ GDP lead inspector,
Welfare NADFC
Government of India Jakarta
New Delhi Email: joan.arland@yahoo.com
Email: adhiraj123@yahoo.com Hanny Musytika
Indonesia Head of section for standardization of safety
and efficacy of new drugs,
Harry Parathon Biological Products and Investigational New
Chief Drugs,
Committee for Antimicrobial Resistance NADFC
Control Jakarta
Ministry of Health, Republic of Indonesia Email: hanny.musytika@gmail.com
Jakarta
Email: hparathon@yahoo.com Maldives

Dyah Armi Riana Fathimath Reesha

Laboratory technologist
National Referral Laboratory representative
Male
Email: reesha7935222@gmail.com

125
 Shreefa Adam Manik Syaw Wynn
Director General Veterinary officer
Ministry of Health Livestock, Breeding and Veterinary
Male Department
Email: shareefa@health.com.mv Ministry of Agriculture, Livestock and
Irrigation
Ismail Ajmal Yangon
Environmental Analyst Email: dr.sn.wynn.12005@gmail.com
Ministry of Environment
Male Nepal
Email: ismail.ajmal@environment.gov.mv
Salina Manandhar
Aishath Mohamed Senior veterinary doctor
Deputy Director-General, Pharmaceuticals Vetenary Public Health Office
National Drug Regulatory Authority Tripureswar
Male Kathmandu
Email: aishathmohamed@health.gov.mv Email: Smanandhar76@yahoo.com

Ibrahim Sujau Runa Jha

Consultant in medicine
Male
Email: i-shaujau@hotmail.com
Aminath Shafia
Director-General
Ministry of Fisheries and Agriculture
Male
Email: shafia.aminath@fishagri.gov.mv
Myanmar
Khin Nyein Zan
Consultant microbiologist
National Health Laboratory
Department of Medical Services
Yangon
Email: ihdmoh@mptmail.net.mm
Wutt ye Tin Maung
Assistant director
National Health Laboratory
Department of Medical Services
Yangon
Email: wuttye84@gmail.com
Director
National Public Health Laboratory
Department of Health Services
Kathmandu
Email: runa75jha@yahoo.com
Bibek Kumar Lal
Deputy Director-General
Department of Health Services
Kathmandu
Email: bibeklal@outlook.com
Sangita Shah
Drug administrator
Ministry of Health and Population
Kathmandu
Email: sangitashah295@gmail.com
Satish Kumar Deo
Clinical pharmacologist
Tribhuvan University Teaching Hospital
Kathmandu
Email: satdeo@gmail.com
Sri Lanka

Aye Lwin B V S H Beneragama

Assistant director (CEU) Acting additional secretary (Medical
Department of Public Health Services)
Naypyitaw Ministry of Health, Nutrition and Indigenous
Email: ayelwin169@gmail.com Medicine
Colombo
Kyi Kyi Swe Email: sbeneragama@hotmail.com
Medical officer
National Tuberculosis Control Programme R M Monika Nandani
Mandalay Pharmacist
Email: drkyikyiswe1986@gmail.com Medical Research Institute
Colombo
Zaw Myo Latt Email: rmn.nmra@gmail.com
Medical officer (CEU)
Department of Public Health
Naypyitaw
Email: zawmyolatdr@gmail.com

Situational analysis of
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in the South-East Asia Region, 2018
K Jayathilake
Consultant clinical microbiologist
Sri Jayawardenapura General Hospital
Colombo
Email: kjayatilleke@gmail.com
S S P Silva
Director, Veterinary Research Institute
Peradeniya
Email: susil_vri@yahoo.com
P M Mahinda Gunarathne
Director, Policy Planning and Monitoring
Ministry of Mhaweli Development and
Environment
Email: pmmgun@yahoo.com
Thailand
Suchart Chongprasert
Director
Bureau of Drug Control
Food and Drug Administration
Ministry of Public Health
Bangkok
Email: drsurchart@gmail.com
Nithima Sumpradit
Pharmacist, professional level
Bureau of Drug Control
Food and Drug Administration
Ministry of Public Health
Bangkok
Email: nithima@fda.moph.go.th
Weerawat Manosuthi
Acting medical officer
Bamrasnaradura Infectious Diseases
Institute
Department of Disease Control
Ministry of Public Health
Bangkok
Email: idweerawat@yahoo.com
Julaporn Sirnha
Veterinarian, senior professional level
Animal Feed and Veterinary Products
Control
Department of Livestock Development
Ministry of Agriculture and Cooperatives
Bangkok
Email: Julaporn19_dld@yahoo.com
Kingdao Intarukdach
Environmentalist, senior professional level
Water Quality Management Bureau
Pollution Control Department
Ministry of Natural Resources and
Environment
Bangkok
Email: Kingdao78@hotmail.com
Noppavan Janejai
Medical scientist, senior professional level
National Institute of Health
Department of Medical Sciences
Bangkok
Email: Noppavan.j@dmsc.mail.go.th
Timor-Leste
Mario Amaral
AMR national focal point
Veterinary Diagnostic Laboratory
Dili
Email: amaralmario@yahoo.com
Frederico Amaral
AMR national focal point
Veterinary Diagnostic Laboratory
Dili
Email: fredy13@yahoo.com
Delfim da C X Ferreira
National Director
Pharmacy and Medicine
Dili
Email: delfim_costa@gmail.com
Suzana Soares Hendriques
AMR national focal point
Ministry of Health
Dili
Email: suzanasoares06@gmail.com
Florbela Viana
AMR national focal point
National Laboratory
Dili
Email: florbelaviana@yahoo.com
Feliciano da Conceicao
AMR national focal point
Ministry of Agriculture and Fisheries
Dili
Email: maularavets@yahoo.com
Temporary Advisers
Visanu Thamlikitkul
Director
WHO Collaborating Centre for AMR
Prevention and Containment
Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok
Thailand
Email: visanu.tha@mahidol.ac.th
Wantana Paveenkittiporn
Head
WHO Collaborating Centre for AMR
Surveillance and Training
National Institute of Health, Nonthaburi,
Thailand
Nonthaburi
Email: wantana.p@dmsc.mail.go.th
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 Siriraj Hospital
Pinyo Rattanaumpawan
WHO Collaborating Centre for AMR
Prevention and Containment
Faculty of Medicine, Siriraj Hospital,
Mahidol University
Thailand
Email: pinyohiso@yahoo.com
Rujipas Sirijatuphat
WHO Collaborating Centre for AMR
Prevention and Containment
Faculty of Medicine, Siriraj Hospital,
Mahidol University
Thailand
Email: rujipas.sir@mahidol.ac.th
Special Invitees
Viroj Tangcharoensathien
Senior advisor to the International Health
Policy Programme (IHPP)
Ministry of Public Health
Bangkok
Email: viroj@ihpp.thaigov.net
FAO
Katinka de Balogh
Senior Animal Health and Production
Officer
Food and Agriculture Organization
Regional Office for Asia and the Pacific
39 Phra Atit Road, Phranakon
Bangkok
Email: Katinka.DeBalogh@fao.org
Mary Joy Gordoncillo
AMR Regional Surveillance Coordinator
Food and Agriculture Organization
Regional Office for Asia and the Pacific
39 Phra Atit Road, Phranakon
Bangkok
Email: Mary.Gordoncillo@fao.org
Henk Jan Ormel
Senior veterinary policy advisor
Animal Health Service
Food and Agriculture Organization
Italy, Rome
Email: HendrikJan.Ormel@fao.org
OIE
Pennapa Matayompong
Programme Coordinator
World Organization for Animal Health
C/o Department of Livestock Development
Bangkok
Email: p.matayompong@oie.int
Pasang Tshering
Consultant
OIE Regional Representation for Asia and
the Pacific
Email: p.tshering@oie.int
Situational analysis of
128 antimicrobial resistance
in the South-East Asia Region, 2018
Other agencies/ NGOs/ donors
Kakuko Nagatani-Yoshida
Regional Coordinator for Chemicals, Waste
and Air Quality
UN Environment Asia and the Pacific Office
Room #0208, Wing A, 2nd Floor,
The United Nations Building
Rajadamnern Nok Avenue, Dusit
Bangkok 10200, Thailand
Email: kakuko.nagatani@unep.org or
nagatani-yoshida@un.org
Masato Motoki
Environment and health officer
Asia and the Pacific Office Economy Division
UN Environment
UN Building, Rajadamnern Nok Avenue,
Bangkok 10200, Thailand
Email: masato.motoki@un.org
Montira Pongsiri
Senior research associate, Planetary Health
Science Policy
Cornell University, College of Veterinary
Medicine
Department of Population Medicine and
Diagnostic Sciences
Atkinson Center for a Sustainable Future
Faculty Fellow
Bangkok, Thailand
Email: mjp329@cornell.edu
Sudarat Damrongwatanapokin
Regional Animal Health Advisor
Office of Public Health, US Agency for
International Development
Regional Development Mission, Asia
Athenee Tower
Wireless Road, Lumphini, Pathum Wan
Bangkok 10330
Email: sdamrongwatanapokin@usaid.gov
Anchalee Jatapai
Global Health Security and Development
Advisor
Office of Public Health, US Agency for
International Development
Regional Development Mission, Asia
Athenee Tower, Wireless Road, Lumphini,
Pathum Wan
Bangkok 10330
Email: ajatapai@usaid.gov
WHO country AMR focal points
Anuj Sharma
National professional officer (AMR and
Laboratories)
WHO Country Office India
Email: sharmaan@who.int
Benyamin Sihombing
National professional officer
WHO Country Office, Indonesia
Email: sihombingb@who.int
Mya Yae Mon Supaporn Wongsrichai
National professional officer Veterinarian, Professional level
WHO Country Office, Myanmar Bureau of Quality Control of Livestock
Email: yeemonm@who.int Products; BQCLP
Email: paw_dld@yahoo.com
Samuel Reuben
Technical officer (Emergency Preparedness) WHO secretariat
WHO Country Office, Nepal
Email: samuelr@who.int Prof Tjandra Aditama
Senior Advisor to Regional Director
Richard Brown WHO Regional Office for South-East Asia
WHO Country Office, Thailand Email: aditamat@who.int
Email: brownr@who.int
Sirenda Vong
Observers Programme Area Manager
Health Information Management and Risk
Arlyne A. Beeche Assessment
Senior programme specialist WHO Regional Office for South-East Asia
Agriculture and Environment Email: vongs@who.int
International Development Research
Center, Asia Regional Office Manish Kakkar
Jor Bagh, New Delhi Medical Officer
India Health Information Management and Risk
Email: abeeche@idrc.ca Assessment
WHO Regional Office for South-East Asia
Nareerut Pudpong, Researcher Email: kakkarm@who.int
Email: nareerut@ihpp.thaigov.net
David Sutherland
Sunicha Chanvatik, Researcher Consultant, Tripartite Secretariat
Email: sunicha@ihpp.thaigov.net Health Information Management and Risk
Angkana Sommanustaweechai, Researcher Assessment
Email: angkana@ihpp.thaigov.net WHO Regional Office for South-East Asia
Email: sutherlandda@who.int
Wanwisa Kaewkhankhaeng, Research
assistant Oo Moe
Email: wanwisa@ihpp.thaigov.net Medical officer
Health Information Management and Risk
Parinda Seneerattanaprayul, Coordinator Assessment
Email: parinda@ihpp.thaigov.net WHO Regional Office for South-East Asia
Email: moo@who.int
Sukanya Numsawat
Email: pharmatug@hotmail.com Elizabeth Tayler
Technical Officer, AMR Secretariat
Raththar Benchapalanon WHO Headquarters, Geneva
Email: raththar.b@gmail.com Email: taylere@who.int
Kulsumpun Krobanan Pravarsha Prakash
Email: kulsumpunmew@gmail.com Technical Officer
Sirima Punnin WHO Headquarters, Geneva
Email: sirima.punnin@gmail.com Email: prakashpra@who.int

Sasi Jaroenpoj Klara Tisocki

Veterinarian, expert level
Division of Animal Feed and Veterinary
Products Control
Department of Livestock Development
Ministry of Agriculture and Cooperatives
Thailand
E mail: sasijaroenpoj@yahoo.com
Thammarath Sujit
Veterinarian, senior professional level
Bacteriology and mycology section
National Institute of Animal Health (NIAH)
50/2 Kasetklang, Ladyao, Chatuchak,
Bangkok 10900 Thailand
Email: thammarathh@hotmail.com
Regional Adviser - Essential Drugs and
Other Medicines
WHO Regional Office for South-East Asia
Email: tisockik@who.int
Manisha Shridhar
Regional Adviser - Intellectual Property
Rights and Trade & Health
WHO Regional Office for South-East Asia
Email: shridharm@who.int
Kuldeep Sharma
Executive Assistant
Health Information Management and Risk
Assessment
WHO Regional Office for South-East Asia
Email: sharmak@who.int

129