Confidential: For Review Only · In 2013, attempt to establish the National AMR Coordinating Unit...

Confidential: For Review O

nly

National strategic plan on antimicrobial resistance (2017-

2021): a new chapter addressing AMR challenges in

Thailand

Journal: BMJ

Manuscript ID BMJ.2016.035864.R1

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the Author: 24-Dec-2016

Complete List of Authors: Sumpradit, Nithima; Food and Drug Administration of Thailand, Wongkongkathep, Suriya; Ministry of Public Health Poonpolsup, Sitanan; Ministry of Public Health Janejai, Noppavan; Ministry of Public Health Paveenkittiporn, Wantana; Ministry of Public Health Boonyarit, Phairam ; Ministry of Public Health Jaroenpoj, Sasi; Department of Livestock Development Kiatying-Angsulee, Niyada; Drug System Monitoring and Development Center Kalpravidh, Wantanee; Food and Agriculture Organization of the United Nations, Regional Office for Asia and the Pacific Sommanustweechai, Angkana; International Health Policy Program,

Tangcharoensathien, Viroj; International Health Policy Program

Keywords: Thailand, Antimicrobial resistance, National strategy on AMR, National action plan on AMR, Political commitment, Global Action Plan on AMR, Low and middle income countries, Developing countries

https://mc.manuscriptcentral.com/bmj

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BMJ Analysis Section

National strategic plan on antimicrobial resistance (2017-2021):

a new chapter addressing AMR challenges in Thailand

Nithima Sumpradit1, Suriya Wongkongkathep

2, Sitanan Poonpolsup

1, Noppavan Janejai

3, Wantana

Paveenkittiporn3, Phairam Boonyarit

4, Sasi Jaroenpoj

5, Niyada Kiatying-Angsulee

6, Wantanee

Kalpravidh7, Angkana Sommanustweechai

8, Viroj Tangcharoensathien

8

1 Food and Drug Administration, Ministry of Public Health

2 Department of Traditional and Alternative Medicines, Ministry of Public Health

3 Department of Medical Sciences, Ministry of Public Health

4 Office of Permanent Secretary, Ministry of Public Health

5 Department of Livestock Development, Ministry of Agriculture and Cooperatives

6 Drug System Monitoring and Development Center, Faculty of Pharmacy, Chulalongkorn University

7 Food and Agriculture Organization of the United Nations

8 International Health Policy Program, Ministry of Public Health

Background Concerns over antimicrobial resistance (AMR) has dated back to Sir Alexander Fleming in his 1945

Nobel Prize statement.1 Since then, AMR situation deteriorates. Indeed, it is even worse when the

pipeline of new antimicrobial molecules dried out which leads to the post-antibiotic era, when

simple infection can kill as effective antimicrobials are not available. Additionally, the collapse of

modern medicine is foreseeable where surgeries and chemotherapy cannot be operated due simply

to lack of effective antimicrobials.2

Substantial evidence indicates AMR causes significant health and economic burden. Globally, it

causes approximately 700,000 deaths yearly. Failing to tackle AMR will cause 10 million deaths by

2050 and the highest death toll of 4.7 million is forecast for Asia.2 In Thailand, AMR causes

approximately 38,000 deaths yearly and an economic burden of 1,200 million USD (1 USD = 35

Bath).3

Addressing AMR challenges require clear guidance and effective intersectoral actions at all levels.

The Global Action Plan on AMR (GAP-AMR), adopted by the 68th

World Health Assembly (WHA),

serves as a blueprint to guide WHO member states develop their National Action Plan on AMR.

The need for a national AMR strategy in Thailand was driven by two major forces: increased AMR

prevalence and the country’s commitment to join forces with other nations to mitigate its global

health threats. This paper aims to describe rationale, context, process and key actors involved in the

development of National Strategic Plan on AMR (NSP-AMR), identifies implementation challenges in

order to draw lessons for national and international audiences.

Historical evolution of AMR prevention and containment Thailand has several initiatives addressing AMR. The 1967 Drug Act ensures the quality and controls

the distribution of antimicrobials; infection prevention and control in health facilities was initiated

since 19714 and the national AMR surveillance system in human was launched in 1998

5. Several

policies promote appropriate antimicrobial use. For example, the Antibiotics Smart Use Program to

reduce unnecessary antibiotic use for certain clinical conditions in outpatient departments, clinics,

pharmacies and communities results in favorable outcomes; it was then up-scaled to a national

policy6; the Drug Use Evaluation program ensures appropriate use of expensive, broad spectrum

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antimicrobials; and the Antibiotic Awareness Day Campaign led by civil society organization creates

public awareness.

Despite these actions, the increased trend of AMR prevalence in human and emergence of AMR in

food animals call for effective and comprehensive system to address AMR in human and animals. In

1996, a draft national policy on AMR was driven by infectious expert in a technical report of the

annual Health Systems Research Institute conference (HSRI)7. Unfortunately this premature policy

without stakeholder involvement was not implemented.

In the 2010s, AMR was addressed “as one of the elements” of two national strategies: National Drug

Development Strategy 2012-2016 emphasizing rational use of antimicrobials and National Strategic

Plan on Emerging Infectious Disease 2013-2016 focusing on prevention and containment of AMR

using One-Health approach. Both strategies had their own AMR subcommittees where some

subcommittee members are overlapped. However, there is no platform for information-sharing and

collaboration between the two subcommittees.

In 2013, attempt to establish the National AMR Coordinating Unit in the Ministry of Public Health

(MOPH), led by an infectious expert with no due process of multi-sectoral involvement, though

gaining strong policy support, political changes in 2014 aborted that initiative.

Historical evolution offers a few lessons. The problem streams and expert contributions are not

strong enough to mobilize full commitment by line government agencies which have legal mandates.

AMR, a small component in national strategies, is easily overlooked. Several patchy initiatives did

not address AMR in a systematic manner, not able to upscale and sustainable.

National and global context leading toward NSP-AMR Significant global advocate in 2014 boosts national AMR actions. Two global events are; first, the

adoption of resolution WHA 67.25 in 2014 calling for the development of GAP-AMR for which later

WHA 68.7 in 2015 adopted the GAP-AMR requesting WHO member states to develop their national

action plans within two years. Second, the Global Health Security Agenda (GHSA) was launched in

February 2014 where Thailand serves as a contributing country on AMR action package. Thailand

actively engaged in several global health agenda on AMR which concertedly raise AMR agenda to a

high level meeting at the 2016 United Nations General Assembly (UNGA). Together with other

global health partners, these events synergistically pave the way to “Political Declaration of the High-

Level Meeting of the UNGA on Antimicrobial Resistance” in September 20168.

At the national level, 2014 also marks a significant change in MOPH policy environment. Political

changes in 2014 led to the change of health minister and duty reassignment of MOPH executives.

An author (SW), in charge with Global Health, had endorsed a list of eight Global Health priorities,

including AMR. In translating policy into actions, in October 2014 the MOPH in collaboration with

National Health Security Office (NHSO) and the Drug System Monitoring and Development Center

(DMDC), a civil society organization, convened a consultative meeting with multi-sectoral partners

including the Ministry of Agriculture and Cooperatives (MOAC) and others to share information on

AMR, their current activities and identified required actions. Evidence shows there is no NSP-AMR to

guide directions and national coordinating mechanism which facilitates inter-sectoral actions. Lack

of AMR awareness in the public and policy makers exacerbates the problems. Furthermore, most

AMR stakeholders have limited knowledge about AMR situations and actions beyond their territory

and specific expertise. To enable effective collaboration, a technical report “Landscape of AMR

situations and Actions in Thailand” was published to promote understanding among AMR

stakeholders regarding the whole picture of AMR situations, actors and actions in Thailand.9

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Development of the NSP-AMR The AMR Coordination and Integration Committee (AMR-CIC), tasked to coordinate and develop the

NSP-AMR, was appointed by the MOPH through an Order on 6 May 2015, two weeks preceding

adoption of GAP-AMR by WHA 68.

Development process

It took 16 months from May 2015 to August 2016 with full participation of and engagement by

multi-stakeholders. After the AMR-CIC meeting in June 2015, a consultative workshop in August

2015 engaging more than 120 participants from public, private, academic and civil society sectors

from human, animal, crop and environmental health contributed to the draft contents of NSP-AMR.

The draft NSP-AMR has gone through several rounds of public consultation including through a

public hearing session in the 8th

National Health Assembly (NHA) in December 201510

. In April-May

2016, the formal public hearing process was conducted via two channels: the public hearing forum

supported by seven organizations, especially by National Health Commission Office (NHCO) engaging

approximately 200 multi-stakeholders and the written comments from related sectors. Through

these processes, the draft of NSP-AMR was finalized by July 2016. Finally, through a joint submission

by MOPH and MOAC to the Cabinet, it was endorsed by a Cabinet resolution in August 2016. Box 1

describes the milestones of NSP-AMR development in synchronize with the global AMR movement.

Box 2 details the chronologies of NSP-AMR development process.

-----------------------------------------------

Boxes 1 and 2 about here

-----------------------------------------------

NSP-AMR Key contents

The contents of NSP-AMR are guided by two concepts: ‘One Health’ approach which recognizes the

interconnectivity across human, animal and environmental health; and ‘Triangle that Moves the

Mountain’ concept11

which describes the synergistic endeavor (the triangle) to overcome extremely

difficult challenges (the mountain) through the active movement and collaboration among three key

actors who represent different categories of social engagement: politicians (for political

commitment), technocrats (contributing to evidence) and civil society (contributing to social learning

and movement).

Also three guiding principles shape its contents a) action oriented with measurable goals and targets

by implementing the NSP-AMR in stepwise manner leading toward continued advancement; b)

synergistic efforts which orchestrate and promote coherence of the existing policies, processes and

actions across relevant stakeholders; and c) political engagement to ensure effective and

sustainable implementation.12

The Prime Minister hand-on experiences at the high level meeting of

the UN General Assembly on AMR in September 2016 gives a strong boost of political commitments

to AMR.

The NSP-AMR goal is to reduce morbidity, mortality and economic impacts, it sets the 2021 targets

of 50% reduction in AMR morbidity; 20% and 30% reduction in antimicrobial consumption in human

and animal respectively; 20% increase in public knowledge on AMR and awareness of appropriate

use of antimicrobials and the capacity of the national AMR management system is increased to level

4 according to the WHO Joint External Evaluation Tool of International Health Regulation (2005).12,13

Box 3 summarizes the six strategic actions.

-----------------------------------------------

Box 3 about here

-----------------------------------------------

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Factors contributing to NSP-AMR development Reflections from hand-on involvement of the authors throughout the whole processes of NSP-AMR

development, a few factors contribute to NSP-AMR development are identified.

Prime movers: Characteristics and Commitment

A critical number of multi-sectoral prime movers whose characteristics are synergistic is a positive

enabling factor, for example leadership with authority, technical competency, management,

communication and human skills. Also their high commitment to a share vision and willingness to

endure hardships with passions are winning combinations. When the actors who are expected to be

the implementers of the strategy had fully engaged and involved in drafting NSP-AMR, the

ownership of the NSP-AMR will promote effective program implementation.

Reconciliation of different interests and expectations

AMR engages a good number of actors ranging from human and animal health to agriculture and

global health; each has own interests and expectations. This makes multi-sectoral collaboration

complicated. The reconciliation is achieved through several ways such as information sharing,

understanding roles of different actors, and steering towards a common vision of AMR.

Planning, implementation and evaluation: an interlinked process

In the process of developing NSP-AMR, implementation and evaluation are planned together where

responsible agencies are identified. This type of planning process enhances the likelihood of

effective implementation. The developing process was guided by local and international evidence

taking resource availability and contexts into account to ensure practicality and sustainability.

Identifying lead implementing agencies is straightforward based on their legal mandates and

missions, except the fifth strategic action on increasing public awareness. Despite numerous public

awareness initiatives and campaigns, there is no clear lead agency to coordinate this issue nationally

Also challenges remain on orchestrating different strategic actions by various agencies to achieve

the NSP goals. The fifteen pre-existing AMR related policies were taken into account in the

development of NSP-AMR in order to ensure coherence and synergies. Box 4 shows the lead

implementing agencies in MOPH and MOAC engaging in NSP-AMR development.

---------------------------------------------

Box 4 about here

---------------------------------------------

The International Health Policy Program (IHPP), a quasi-independent research agency of the MOPH,

had agreed to work with NSP implementing agencies to support monitoring and evaluation of NSP-

AMR. IHPP and partners are responsible for a major program on Surveillance of Antimicrobial

Consumption in human and animals. This program will contribute to regular report similar to works

by the European Surveillance of Antimicrobial Consumption-network14

and European Surveillance of

Veterinary Antimicrobial Consumption15

. Additionally, through the strong partnership with National

Statistic Office of Thailand (NSO), NSO had agreed to include an AMR module into the 2017 Health

and Welfare Survey questionnaire where 27,000 national representative households would be

numerated. The contents of the module are similar to the Euro Barometer16

in order to facilitate

international comparison. It is planned that the biennial Health and Welfare Survey will include AMR

module for regular monitoring.

Recently, the 2017-2021 WHO Country Cooperation Strategy (CCS) had included AMR program as

one of the five flagships funded by several Thailand agencies apart from WHO. All these ongoing

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monitoring works will be hosted by WHO CCS AMR program. See box 5 summary of potential M&E

mechanisms.

-----------------------------------------------

Box 5 about here

-----------------------------------------------

Convergence between top-down and bottom-up approaches

In parallel with NSP-AMR development, civil society organizations (led by DMDC) and the Infectious

Disease Association of Thailand proposed “integrated approaches to address antibacterial resistance

crisis” as an agenda item of the 8th National Health Assembly (NHA) in 2015. This is a bottom-up

participatory public policy process through inclusive engagements by government sector, the

academic, private and people sectors across all 77 provinces of Thailand17

. The NHA resolution on

AMR was adopted in December 2015. The NHA process increases public awareness on AMR. The

government stakeholders driven NSP-AMR and the grass root level driven NHA resolution are

synergies of top-down and bottom-up combination.

Synergies: Inside-Out and Outside-in momentum

Prominent global contributions of Thailand to address AMR are, for example, as Chairperson of G77

supporting the political declaration on AMR during UNGA 2016, as co-founder of the Alliance of

Champions fighting against AMR in 2015, a lead organizer on behalf of Foreign Policy Global Health

countries to convene the ministerial side event on AMR at the 68th

WHA and a contributing country

in GHSA-AMR action package. Global Health contributions reinforce political commitments by Prime

Minister, Health Minister and Agriculture Minister to further support AMR as a common national

agenda. We observe the synergistic momentum between inside-out, the contribution by Thailand to

global AMR agenda shaping; and outside-in, the contribution from the global commitment to

country affirmative actions and sustained commitment.

Implementing NSP: some foreseeable challenges

Lead agency on promoting public awareness on AMR

There is unclear which agency will lead the promotion of public knowledge on AMR and appropriate

use of antimicrobials despite a vast number of responsible agencies engaging in these activities.

There are still dialogues whether it should be managed by the government sector, people sector or

else.

Governance mechanisms on AMR implementation

A National Committee on AMR will be appointed by Prime Minister as a national, multi-sectoral

governance body for directing, coordinating and overseeing NSP-AMR implementation and

evaluation. It is possible that evolving situations of NSP-AMR implementation may lead to policy

dialogue in establishing a national coordinating unit on AMR. However, regardless of types of

governance body, it is important to note that the complex natures of AMR and effective

collaboration across stakeholders will remain a major challenge. The AMR governance mechanisms

need to be adjusted to address challenges such as the dynamic networks of non-liner interactions

among AMR stakeholders, changes in political contexts and the emergences of new entities

regarding AMR situations and actions.

The ways forward Between September and December 2016 is a preparatory phase for NSP-AMR implementation. Key

activities include, for example, the establishment of the National Committee on AMR as the national

governance and coordinating body, the development of the operational plan on AMR as a blueprint

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guiding implementation by lead agencies and set up budgetary plans for the next five years, and the

establishment of NSP-AMR monitoring and evaluation systems.

Conclusions Thailand has committed to and fought against AMR for decades despite no national action plan. The

NSP-AMR opens new space and platform for cross sectoral actors to synchronize their actions. Due

process of extensive engagement of and ownership by relevant stakeholders, who are NSP-AMR

implementers, in the drafting of NSP-AMR, paves strong foundation towards successful NSP

implementation.

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Key messages

Lessons learn from developing NSP-AMR

• A critical number of multi-sectoral prime-movers, from policy and technical levels who are also

implementers, having fully involved in the NSP-AMR drafting processes, not only ensures the

relevance of NSP-AMR but supports ownership in the downstream implementation.

• Reconciliation of different interests and expectations across multi-sectoral stakeholders can be

achieved by promoting a common understanding on AMR, use of evidence on effective

interventions and steering towards a common vision of AMR.

• Envisioning implementing agencies and monitoring and evaluation mechanisms embedded in

the planning processes support smooth implementation

• Synergies support successful policy formulation, implementation and monitoring and

evaluation, such as (a) line agency driven NSP-AMR and bottom-up approach through National

Health Assembly resolution increases public awareness and relevance of NSP-AMR; (b) inside-

out, through Thailand efforts in shaping global AMR agenda and outside-in, where global AMR

momentum boosts country affirmative actions and sustained commitment

Competing interests: We have read and understood BMJ policy on declaration of interests and have

no relevant interests to declare.

Contributors and sources: All authors conceived the structure of the article. NS wrote the first draft.

All authors contributed to and endorse the final version. NS is guarantor of the article.

Corresponding author: Nithima Sumpradit. Email address: [email protected]

Acknowledgement: Drafting NSP-AMR received contributions from numerous colleagues including

Praphon Angtrakool, Theerasak Chuxnum, Thitipong Yingyong, Varavoot Sermsinsiri, Chutima

Akaleephan, Chariya Sangsajja, Varaporn thientong, Narumol Sawanpanyalert, Woraya Luang-on,

Noppharat Mongkhalangkun, Thanabadee Rodsom, Thanida Harintharanon, Somnuk Temwuttiroj,

Julaporn Srinha, Mintra Lukkana, Songkhla Chulakasian, Thitiporn Laoprasert, Jiraporn

Kasornchandra, Boonmee Sathapatayavong, Kumthorn Malathum, Visanu Thamlikitkul, Pisonthi

Chongtrakul, Kanchana Kachintorn, Panthep Rattanakorn, Direk Limmathurotsakul, Pitak

Santanirand, Preecha Montakantikul and Phatchara Ubonsawat. Special thanks to National Health

Commission Office of Thailand, National Health Security Office, Healthcare Accreditation Institute

(Public Organization), Thai Health Promotion Foundation, Health Systems Research Institute,

International Health Policy Program, Drug System Monitoring and Development Program, Food and

Agriculture Organization of the United Nations and World Health Organization

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Box 1 The milestones of NSP-AMR development: synergies between global engagement and

national actions

Na

tio

na

l a

ctio

ns

• 2012 AMR as part of

the National Drug

Development

Strategy 2012-2016

• 2013 AMR as part of

the National

Strategic Plan on

Emergent Infectious

Diseases 2013-2016

• 8 Oct Multi-

sectoral meeting

to map roles of

agencies and

develop an

integrated

framework on

AMR

• Dec 2014- Jan

2015 Informal

meetings between

MOPH and MOAC

• 6 May Appointment of

AMR-CIC to develop NSP-

AMR

• Aug Multi-sectoral

brainstorming workshop for

NSP-AMR development

• Nov AMR-CIC launched a

full report on ‘Landscape

of AMR situations and

actions in Thailand’

• Dec NHA resolution

“integrated approaches to

address antibacterial

resistance crisis”

• 18 Jan Revision of

AMR-CIC by having a

MOPH and MOAC

joint secretariat team

• Apr-May Public

hearing of the draft

NSP-AMR1

• 25 Jul A joint

submission of NSP-

AMR by MOPH and

MOAC to the Cabinet

• 17 Aug The NSP-AMR

was endorsed by the

cabinet resolution

Prior to 2014 2014 2015 2016

Glo

ba

l co

nte

xt

an

d e

ng

ag

em

en

t b

y T

ha

ila

nd

• Sep 2011 Jaipur

Declaration on

AMR

• Dec 2011 World

Health Day on

AMR

• Nov AMR as a

flagship priority

identified by

SEARO Regional

Director

• 20 May WHA resolution

on GAP-AMR

• 26 May OIE resolution on

Combating AMR and

promoting the prudent use

of antimicrobial agents in

animals

• Jun FAO resolution on

AMR in food and

agriculture

• Nov World Antibiotic

Awareness Week

• 16 Apr Communiqué of

Tokyo Meeting of

Health Ministers on

AMR in Asia

• 21 Sep Political

Declaration of the

High-Level Meeting of

the UNGA on

Antimicrobial

Resistance

• Sep Thailand as a

contributing

country on AMR

in GHSA

• 8 May Thailand hosted a

regional GHSA meeting

consisting of AMR session

• 19 May Thailand is co-

founding the Alliance of

Champions fighting

against AMR established

at WHA 68th

• 19 May Thailand

organized the ministerial

side event on AMR during

WHA 68th

on behalf of

FPGH countries

• Thailand serves as the

Chair of G77

AMR – Antimicrobial Resistance; CIC – AMR Coordination and Integration Committee; FAO – Food and Agriculture

Organization of the United Nations; FPGH – Foreign Policy and Global Health; GAP-AMR – Global Action Plan on

Antimicrobial Resistance; GHSA – Global Health Security Agenda; MOAC – Ministry of Agriculture and Cooperatives; MOPH

– Ministry of Public Health; NHA – National Health Assembly; NSP-AMR – National Strategic Plan on Antimicrobial

Resistance; OIE - World Organisation for Animal Health; SEARO – WHO South-East Asia Regional Office; WHA – World

Health Assembly; WHO – World Health Organization; UNGA – United Nations General Assembly

Note: 1 This process is mandated by the Office of Prime Minister Regulation on Public Hearing.

Modified from: National Action Plan on Antimicrobial Resistance 2017-2021 Thailand: at a glance (2016)

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Box 2 The chronologies of NSP-AMR development process

Phase 1 Preparation

8 Oct 2014 First consultative meeting among AMR-related stakeholders to share information and analyze AMR

situations and actions

Host agencies: MOPH, NHSO and DMDC

Dec 2014-Jan

2015

Informal consultative meetings between MOPH and MOAC to explore options for integrated work

5 Feb 2015 MOPH executive meeting endorsed a proposal on a multisectoral committee on AMR to draft NSP-

AMR

Phase 2 Planning and generating technical evidences

6 May 2015 AMR-CIC was appointed by the MOPH ministerial order to develop the NSP-AMR

20 May WHA 68.7 resolution adopted GAP-AMR requesting member states to develop NAP-AMR in line with

GAP-AMR within 2 years, an external environment enabling national actions.

23 Jun 2015 First meeting of AMR-CIC set the guiding principles and key responsible agencies to be a focal point

for developing each AMR strategy

Aug 2015 Project on the development of NSP-AMR supported by WHO

18-19 Aug 2015 Brainstorming workshop on NSP-AMR engaging over 120 participants from all sectors

Phase 3 Drafting NSP

24 August 2015 Second meeting of AMR-CIC set up the drafting groups for each strategy

Sep-Nov 2015 Drafting group meetings to develop contents of NSP-AMR

Oct 2015 Turnover of high level positions in MOPH results in change of Chair of AMR-CIC but the whole

processes continued

Dec 2015 NHA resolution on integrated approaches to address antibacterial resistance crisis

Public consultative forum regarding the drafted NSP-AMR during the NHA session

Launch a technical report on ‘Landscape of AMR situations and actions in Thailand’

Jan 2016 Revision of AMR-CIC on a new Chair and a MOPH/MOAC Joint Secretariat team

18 Feb 2016 Third AMR-CIC meeting planning for public hearing and a joint MOPH/MOAC proposal of NSP-AMR

to the cabinet

Phase 4 Public hearing

22 Apr 2016 Public hearing forum on NSP-AMR engaging around 200 participants from all sectors

Hosting agencies: NHCO in collaboration with MOPH, MOAC, Thai Health Promotion Foundation,

DMDC, IHPP, FAO and WHO

Apr-May 2016 Public hearing official letter on NSP-AMR from MOPH to relevant agencies

1 Jun 2016 MOPH high level meeting agreed to extend the length of NSP-AMR from 3 to 5 years according to

recommendations from public hearing

May-Jun 2016 Drafting group meetings to revise the draft NSP-AMR based on public hearing results

Phase 5 Finalization and submission for cabinet approval

21 Jun 2016 Fourth AMR-CIC meeting endorsed the draft NSP-AMR and requested the Secretariat team, in

consultation with committee members, to make final refinements and submit for cabinet

considerations by July 2016

25 Jul 2016 The MOPH and MOAC joint submission of NSP-AMR to the Cabinet

17 Aug 2016 The NSP-AMR 2017-2021 was approved by the cabinet

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Box 3: An overview of the NSP-AMR

Vision:

Reduction of mortality, morbidity and economic impacts from AMR

Mission:

Establish policies and national multi-sectoral mechanisms which support effective and sustained AMR

management system

Goals:

1. 50% reduction in AMR morbidity

2. 20% reduction in antimicrobial consumption in human

3. 30% reduction in antimicrobial consumption in animal

4. 20% increase in public knowledge on AMR and awareness of appropriate use of antimicrobials

5. Capacity of the national AMR management system is increased to level 4 as measured by the WHO’s

Joint External Evaluation Tool (JEE) for International Health Regulations (2005)

Strategic actions

1. AMR surveillance system using ‘One Health’ approach

2. Regulation of antimicrobial distribution

3. Infection prevention and control and antimicrobial stewardship in humans

4. AMR prevention and control and antimicrobial stewardship in agriculture and companion animals

5. Public knowledge on AMR and awareness of appropriate use of antimicrobials

6. Governance mechanisms to implement and sustain AMR actions

Box 4: Lead implementing agencies in MOPH and MOAC in NSP-AMR Development

Ministry of Public Health Ministry of Agriculture and Cooperative

• Department of Disease Control

• Department of Medical Sciences

• Department of Medical Service

• Department of Health Service Support

• Department for Development of Thai

Traditional and Alternative Medicine

• Food and Drug Administration

• Office of Permanent Secretary

• Department of Fisheries

• Department of Livestock Development

• Department of Agricultural Extension

• National Bureau of Agriculture

Commodity and Food Standard

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Box 5 A summary of potential M&E programs for the NSP-AMR

M&E mechanism Responsible agencies Funding

agencies

M&E of overall NSP-AMR

Monitor mid-term progress in 2019

and end-term achievements in 2022

of NSP-AMR implementation

CCS-AMR Program1

FDA and IHPP

To be identified

M&E by goal

1 Reduction in AMR morbidity To be identified To be identified To be identified

2 Reduction in antimicrobial

consumption in human

Surveillance of

Antimicrobial

Consumption and CCS-

AMR program

IHPP, FDA, DLD2, NDA

team3, Faculty of

Veterinary, Mahidol

University

HSRI, CCS-AMR

program

3 Reduction in antimicrobial

consumption in animal

4 Increase of public knowledge on

AMR and awareness of

appropriate use of antimicrobials

Biennial Health and

Welfare Survey and

CCS-AMR program

NSO in collaboration

with IHPP and DMDC

NSO

5 Capacity of the national AMR

management system is improved

to level 4

CCS-AMR Program

FDA and IHPP To be identified

Notes: 1 The CCS-AMR Program is in process of proposal development.

2 Department of Livestock

Development, 3 National Drug Account (NDA) team consists of experts from Faculty of Pharmacy from four

universities: Chulalongkorn University, Konkean University, Silpakorn University and Prince of Songkha

University.

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References

1. Fleming A. Penicillin: Nobel Lecture, December 11, 1945.

http://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf.

Accessed 28 September, 2016.

2. O’Neill J. Review on antimicrobial resistance. Antimicrobial resistance: Tackling a crisis for

the health and wealth of nations2014.

3. Pumart P, Phodha T, Thamlikitkul V, Riewpaiboon A, Prakongsai P, SuponLimwattananon.

Health and economic impacts of antimicrobial resistance in Thailand. Journal of Health

Systems Research. 2012;6(3):352-360.

4. Danchaivijitr S. Nosocomial Infection Control in Thailand J Infect Dis Antimicrob Agents.

1993;10:49-51.

5. World Health Organization Regional Office for South-East Asia. Southeast Asia Regional

Strategy on Prevention and Containment of Antimicrobial Resistance 2010-2015. 2010;

http://www.searo.who.int/entity/antimicrobial_resistance/BCT_hlm-407.pdf. Accessed 27

October, 2014.

6. Sumpradit N, Chongtrakul P, Anuwong K, et al. Antibiotics Smart Use: a workable model for

promoting the rational use of medicines in Thailand. Bulletin of the World Health

Organization. 2012;90:905-913.

7. Sirinawin S. Antimicobial use and antimicrobial resistance in Thailand. Bangkok: Health

Systems Research Institute; 1996.

8. United Nations. Draft political declaration of the high-level meeting of the General Assembly

on antimicrobial resistance. 2016; http://www.un.org/pga/71/wp-

content/uploads/sites/40/2016/09/DGACM_GAEAD_ESCAB-AMR-Draft-Political-

Declaration-1616108E.pdf Accessed 29 September, 2016.

9. Sumpradit N, Suttajit S, Poonplosup S, Chuancheun R, Prakongsai P. Landscape of

Antimicrobial Resistance Situations and Action in Thailand. Bangkok: World Health

Organization; 2015.

10. National Health Commission Office of Thailand. Home without AMR - a public hearing on a

drafted Thailand Strategic Plan on Antimicrobial Resistance. In the 8th National Health

Assembly. 21 December 2015;

http://www.sem100library.in.th/opac/Catalog/BibItem.aspx?BibID=b00012761. Accessed 28

September, 2016.

11. Wasi P. Triangle that moves the mountain” and Health Systems Reform Movement in

Thailand. Human Resources for Health Development Journal. 2000;4(2):106-110.

12. Ministry of Public Health, Ministry of Agriculture and Cooperatives, National Health

Commission Office of Thailand, et al. National Strategic Plan on Antimicrobial Resistance

2017-2021 Thailand: at a glance. 2016.

13. World Health Organization. Joint external evaluation tool: International Health Regulations

(2005). Geneva, Switzerland: WHO Document Production Services; 2016.

14. European Centre for Disease Prevention and Control. Surveillance of antimicrobial

consumption in Europe 2012. 2014;

http://ecdc.europa.eu/en/publications/Publications/antimicrobial-consumption-europe-

esac-net-2012.pdf. Accessed 28 September, 2016.

15. European Medicines Agency. European Surveillance of Veterinary Antimicrobial

Consumption, 2014. 'Sales of veterinary antimicrobial agents in 26 EU/EEA countries in

2012'. 2014;

http://www.ema.europa.eu/docs/en_GB/document_library/Report/2014/10/WC500175671

.pdf. Accessed 28 September, 2016.

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16. Special Eurobarometer 445: Antimicrobial Resistance. 2016;

http://data.europa.eu/euodp/en/data/dataset/S2107_85_1_445_ENG. Accessed 28

September, 2016.

17. Rasanathan K., Posayanonda T., Birmingham M., 2012;1:87-96. TV. Innovation and

participation for healthy public policy: the first National Health Assembly in Thailand. Health

Expectations. Health Expectations. 2012;15:87-96.

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BMJ Analysis Section

National strategic plan on antimicrobial resistance (2017-2021): a

new chapter in addressing AMR challenges in Thailand Nithima Sumpradit1, Suriya Wongkongkathep2, Sitanan Poonpolsup1, Noppavan Janejai3, Wantana

Paveenkittiporn3, Phairam Boonyarit

4, Sasi Jaroenpoj

5, Niyada Kiatying-Angsulee

6, Wantanee

Kalpravidh7, Angkana Sommanustweechai

8, Viroj Tangcharoensathien

8

1 Food and Drug Administration, Ministry of Public Health 2 Department of Traditional and Alternative Medicines, Ministry of Public Health

3 Department of Medical Sciences, Ministry of Public Health

4 Office of Permanent Secretary, Ministry of Public Health 5 Department of Livestock Development, Ministry of Agriculture and Cooperatives

6 Drug System Monitoring and Development Center, Faculty of Pharmacy, Chulalongkorn University

7 Food and Agriculture Organization of the United Nations 8 International Health Policy Program, Ministry of Public Health

Word counts 1982

Boxes 4

Figure 1

References 12

Burden of antimicrobial resistance Antimicrobial resistance (AMR) is a serious health threat causing approximately 700,000 deaths

globally per year.1 The impact could be worse if the pipeline of new antimicrobial molecules dried

out leading to the post-antibiotic era, when simple infection can kill as effective antimicrobials are

not available. Specifically, it is estimated that failing to tackle AMR will cause 10 million deaths a year

and cost up to US$ 100 trillion by 2050.1

In Thailand, AMR also causes high burden on health and economic. A study estimates 88,000 AMR

attributed morbidity and 38,000 mortalities in 2010; resulting in 1,200 million USD (1 USD = 35 Baht)

economic loss.2 Box 1 describes AMR prevalence and antimicrobial use.

<Box 1 here>

The main drivers for the emergence and spread of AMR in Thailand are, for example, ineffectiveness

of infection prevention and control in healthcare settings, limited scope of AMR surveillance in

human and lack of systematic surveillance in agriculture settings, failure in contain overuse of

antimicrobial use in human and non-human especially ineffective law enforcement to control

antimicrobial distribution and poor awareness on AMR.

Responses to AMR: a review of past experiences Past responses to AMR challenges, described in Box 2 are inadequate; mostly focused on rational

use of antibiotics in human with little attention to the animal sector. AMR driven by infectious

experts without addressing health systems, law and regulation as well as due process of engaging all

relevant stakeholders proved not successful. Different patchy initiatives do not coordinate well,

human AMR profiles are not fully used to change prescription decision.

<Box 2 here>

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Previous AMR responses offer a few lessons. First, the problem streams driven by experts are not

strong enough to mobilize full commitment by line government agencies which have legal mandates.

Second, AMR, a small component in several national strategies is easily overlooked and lack of

coordination. Third, several patchy initiatives cannot address AMR in a holistic manner where

collective forces to combat AMR are limited. Finally experts’ focus on hospital infection prevention

and control, where community, farmers, practitioners and veterinarians who drive overuse and

abuse of antibiotics are inadequately mobilized to collectively address AMR.

In 2016, the National Strategic Plan on Antimicrobial Resistance 2017-2021 (NSP-AMR) was endorsed

by the Cabinet as the first national comprehensive strategy; having legal status to enforce and

coordinate implementation of AMR.

This paper draws lessons on how multi-sectoral collaborations are mobilized for NSP-AMR, discusses

how NSP-AMR is translated into actions, and identifies potential implementation challenges and

solutions. This study provides lessons for national and international audiences on their journeys in

addressing AMR.

Toward a comprehensive strategy on AMR 2014 is a pivotal year where attempts to address AMR challenges are more strategic and

comprehensive. Four factors contribute to successful development of AMR strategy.

Knowing the landscape and complex nature of AMR

Due to the complexity of AMR, most stakeholders do not have comprehensive knowledge and

actions beyond their territory and expertise. Thus, in October 2014 the Ministry of Public Health

(MOPH) convened a stakeholder meeting to review experiences and map AMR landscape and

actions in Thailand. Though actions are extensive, they are fragmented and lack of directions. The

awareness on urgency and severity of AMR, in the general public and policy makers is low. The

landscape analysis suggested the need for a national strategic plan to consolidate efforts across

stakeholders with clear strategic directions.3

Engaging stakeholders

In line with the whole-society engagement principle stated in Global Action Plan on AMR (GAP-

AMR)4, Thailand applied both top-down and bottom-up approaches in engaging a wider group of

stakeholders to drive AMR agenda. The bottom-up approach facilitates changes via the National

Health Assembly (NHA) forum which is a bottom-up participatory public policy process through

inclusive engagements by government sector, the academic, private and people sectors across all 77

provinces of Thailand.5 The NHA resolution on AMR was adopted in December 2015. The process of

drafting a NHA resolution on AMR had created the public awareness on AMR at the grass-root level.

The top-down approach facilitates system changes through the state agencies’ legal authorities such

as the uses of policy, regulations and guidelines. In August 2015, supported by WHO Country

Office for Thailand and other Thai multi-sectoral partners the AMR Coordination and Integration

Committee (AMR-CIC) (described below) convened a brainstorming workshop engaging more than

120 key stakeholders from public, private, academic and civil society sectors from public health,

animal, agriculture and environment who provided inputs to NSP-AMR.

Gaining political support

The AMR-CIC was appointed by the MOPH two weeks prior to the adoption of GAP-AMR by the 68th

session of World Health Assembly (WHA). This multi-sectoral coordinating structure was tasked to

develop the NSP-AMR. The NSP-AMR development process took 16 months from May 2015 to

August 2016 with full participation of and engagement by multi-stakeholders. The draft NSP-AMR

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has gone through several rounds of public consultation including through a public hearing session in

the 8th NHA. Through these processes, the draft NSP-AMR was concluded and jointly submitted by

MOPH and Ministry of Agriculture and Cooperatives to the Cabinet; it was endorsed by a Cabinet

resolution in August 2016. A summary of NSP-AMR 2017-20216 is presented in Box 3.

< Box 3 here >

Joining forces with regional and global actors

Thailand global health role on AMR synergistically support national AMR movement. Contributions

of Thailand to address AMR at regional and global level are prominent; for example, as Chairperson

of G77 supporting the political declaration on AMR during UNGA 2016, as co-founder of the Alliance

of Champions against AMR in 2015, a lead organizer on behalf of Foreign Policy Global Health

countries to convene the ministerial side event on AMR at the 68th WHA and a contributing country

in AMR action package in the Global Health Security Agenda. Additionally, AMR is one of the WHO

South East Asia Region flagships in 2014 in responses to 2011 Jaipur Declaration on AMR. These

combined contributions reinforce political commitments by Prime Minister, Health Minister and

Agriculture Minister to further support AMR as a common national agenda. We observe the

synergistic momentum between “inside-out”, the contribution by Thailand to global AMR agenda

shaping; and “outside-in”, the contribution from the global commitment to country affirmative

actions and sustained commitment.

Translating NSP-AMR into actions: intersectoral actions and monitoring September to December 2016 is a preparatory phase for NSP-AMR implementation. A conceptual

framework emerged in Figure 1 depicts the role and contributions by different stakeholders to a

successful implementation.

< Figure 1 here >

Successful NSP-AMR implementation requires effective intersectoral actions which are guided by

evidence and regular monitoring of progresses. Thus, implementation and evaluation for NSP-AMR

has been planned altogether where responsible implementing agencies are identified along the way

of planning.

Program Implementation

According to the framework, successes in reductions in antimicrobial use in human and animals

(Goals 2, 3), and infection prevention and control in health facilities, may contribute to halting or

reversing AMR prevalence and morbidities (Goal 1). The increase in awareness on AMR and proper

use of antimicrobial (Goal 4) in the general public and among farmers will enhance the likelihood for

overall reduction in antimicrobial consumption (Goals 2, 3). The Goal 5 aims at improving the AMR

management systems in line with the requirements in the WHO Joint External Evaluation tool (JEE

tool) of International Health Regulation 20057; it will facilitate the achievement of Goals 1-4 and

sustain the effective improvement of the AMR management systems.

To achieve these five targets, it requires a critical mass of health, veterinary and non-health

professionals as well as relevant local actors in the ‘front line’ settings (e.g., hospitals, clinics,

pharmacies, veterinary settings, animal farms and crop production sites) to change their practices,

and reduce the antibiotics exposure and selection pressure on the emergence of AMR pathogens. At

this frontier, labeled as ‘battle field’ (see Figure 1) requires inter-sectoral actions through collective

actions by local actors, central agencies and strategic partners to drive effective NSP-AMR

implementation and achieve NSP-AMR goals.

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Winning the different battle fields in Figure 1 needs to be strategic. In November 2016, a workshop

to develop the operational plans (2017-2021) under NSP-AMR was held as a platform for cross-

sectoral partners consisting of central agencies and strategic actors to integrate their operational

plans on AMR. Priority activities are, for example, the Prime Minister to appoint the National

Committee on AMR as a major governing mechanism for NSP-AMR implementation, strengthening

regulations to control antimicrobial distribution for human, animal and agriculture use, and mobilize

the Global Antimicrobial Resistance Surveillance System to strengthen the national system on AMR

surveillance.

Program Monitoring

The Royal Thai Government-World Health Organization Country Cooperation Strategy Program on

AMR 2017-2021 (CCS-AMR program) will serve as a platform for NSP-AMR monitoring and

evaluation (M&E). The program covers three areas of works: monitor and evaluate NSP-AMR

implementation and generate the publicly available biennial report on AMR prevalence,

antimicrobial consumption and public awareness, strengthen M&E platforms and develop new ones

when needed, and strengthen capacity in generating evidence for effective NSP-AMR

implementation. Both NSP-AMR implementation and CCS-AMR programs are synchronized in the

same 5-year timeframe.

NSP-AMR implementation: potential challenges and solutions Several potential implementation gaps are identified and actions to minimize the gaps are proposed.

First, there is a need for strengthening M&E system, especially AMR morbidity and antimicrobial

consumption in human and animal. Although the efforts to establish these systems and assessment

of data structure find it feasible to do so, the major challenge is the quality, reliability and

fragmentation of available databases. Significant investments in technically and financially are

needed.

Second, NSP-AMR implementation is at an infancy stage; it is vulnerable and requires sustainable

and strong policy support. However, uncertainty of policy and political continuity due to frequent

turn-over of high-level policy makers could affect the degree of political commitment, budget

allocation for NSP-AMR implementation and the establishment of permanent structure such as the

National Coordinating Center on AMR to oversee, support and coordinate NSP-AMR in the long run.

Third, current capabilities of the country to address AMR holistically are still far short of achieving

the NPS-AMR goals. Thus, the capacity development model of Individual, Node (organization),

Network and Enabling environment (or INNE model)8 together with the JEE tool

7 should be jointly

applied.

Fourth, AMR is also included in other national policies (see Box 4). Policy coherence, effective

communication and collaboration across actors responsible for these policies are needed.

< Box 4 here >

Fifth, multi-sectoral action is complex as each has own interests and expectations. A shared vision on

AMR across stakeholders is critical9; it has been gradually acquired through the process of NSP-AMR

development. The reconciliation of conflicts and expectations are very crucial for trust building. It

can be improved through several ways such as information sharing, engaging in joint projects or

missions, understanding roles of different actors, and steering towards a common vision of AMR.

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Finally, input and process may not automatically translate into output and outcomes as intended in

Figure 1. Complex nonlinear relationships are foreseen where unpredictable emerging challenges

are major risks that the program needs to overcome. To mitigate these challenges, the innovative

concepts such as theory of changes10

and developmental evaluation11

should be applied to

understand if the middle parts in result chains, such as determinants of bottlenecks, unforeseen

barriers are addressed and timely removed. These concepts acknowledge that change processes are

no longer seen as linear, but feedback loops contribute to change managements. The implementers

should keep vigilance and monitor progresses closely and immediate interventions are introduced to

change course of actions to achieve the NSP-AMR goals.

Conclusions Thailand has committed to and fought against AMR for decades despite no national action plan. The

NSP-AMR opens new space and platform for cross-sectoral actors to synchronize their actions

through a shared vision. Although the due process of extensive engagement of and ownership by

relevant stakeholders pave a strong foundation towards effective implementation; implementation

challenges still remain. Thus, adaptive learning while implementing NSP that is guided by evidence

from M&E platform will enhance the likelihood of successful implementation.

Key messages

• NSP-AMR development is based on four steps: knowing the landscape, engaging stakeholders,

gaining political support and joining forces with regional and global actors.

• ‘Inside-out’ and ‘outside-in’ momentum enables a country to shape global AMR agenda and

simultaneously boosts country’s affirmative actions and sustained commitment.

• A multi-sectoral bottom-up and top-down approach widens stakeholders’ engagement and

ownership in addressing AMR issues.

• The NSP-AMR implementation gaps can be addressed by innovative concepts such as theory of

changes and developmental evaluation together with JEE tools and evidence from M&E

platform.

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Competing interests: The corresponding author has read and understood BMJ policy on declaration

of interests and has no relevant interests to declare.

Contributors and sources: All authors conceived the structure of the article. NS wrote the first draft.

All authors contributed to and endorse the final version. NS is guarantor of the article.

Corresponding author: Nithima Sumpradit. Email address: [email protected]

Acknowledgement: Drafting NSP-AMR received contributions from numerous colleagues including ,

Visit Tangnapaporn, Praphon Angtrakool, Sukanya Jearapong, Theerasak Chuxnum,

Thitipong Yingyong, Varavoot Sermsinsiri, Chutima Akaleephan, Chariya Sangsajja, Varaporn

thientong, Narumol Sawanpanyalert, Woraya Luang-on, Noppharat Mongkhalangkun, Thanabadee

Rodsom, Thanida Harintharanon, Somnuk Temwuttiroj, Julaporn Srinha, Mintra Lukkana,

Songkhla Chulakasian, Thitiporn Laoprasert, Jiraporn Kasornchandra, Boonmee Sathapatayavong,

Kumthorn Malathum, Visanu Thamlikitkul, Pisonthi Chongtrakul, Kanchana Kachintorn,

Panthep Rattanakorn, Direk Limmathurotsakul, Pitak Santanirand, Preecha Montakantikul and

Phatchara Ubonsawat

Special thanks to National Health Commission Office of Thailand, National Health Security Office,

Healthcare Accreditation Institute (Public Organization), Thai Health Promotion Foundation, Health

Systems Research Institute, International Health Policy Program, Drug System Monitoring and

Development Program, Food and Agriculture Organization of the United Nations, and World Health

Organization

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Box 1 Situation of AMR and antimicrobial consumption in Thailand

AMR profile

- Important AMR pathogens are, for example, Imipenem-Resistant Acinetobacter spp.

Imipenem-Resistant Pseudomonas aeruginosa, Vancomycin-Resistant Enterococci,

Carbapenem-Resistant Enterobacteriaceae, Extended-spectrum beta-lactamase-producing

Enterobacteriaceae, Multidrug-resistant tuberculosis and Extensive Drug resistant

tuberculosis

- Between 2000 and 2014, the prevalence of imipenem resistant P. aeruginosa and

Acinetobacter spp. had increased from 10% to 22% and from 14% to 65%, respectively.

Source: National Antimicrobial Resistance Surveillance Center, Thailand

Antimicrobial consumption

- There are approximately 5,200 antibiotic products registered with Thai FDA, of which two

thirds are for human use and the remaining for animal uses.

- For human use, antimicrobial products accounts for 50% of the total drug values.

Approximately 15-20% of antimicrobial values are of antibiotics.

- In 2009, values of antibiotic production and importation were 315 million USD while

cardiovascular and cancer drugs were 260 and 225 million USD, respectively.

- Pennicillins, Cephalosporins and Carbapenems are top three consumption values.

Source: Food and Drug Administration, Thailand

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Box 2 Past experiences addressing AMR:

• Infectious Prevention and Control Program and National AMR Surveillance Center were

launched in 1970s and 1998, respectively.

• Antibiotics Smart Use Program launched 2007; financial incentive introduced in 2009

supported no use of antibiotics in certain clinical conditions not required antibiotics.12

• AMR was addressed as a small component of two strategies: National Drug Development

Strategy (2012-2016) emphasizing rational use of antimicrobials; and National Emerging

Infectious Disease Strategy (2013-2016) focusing on containment of AMR using One-Health

approach.

• Introduction of draft national AMR policy driven by infectious experts in 1996 was not

adopted into policy as there was no due process of stakeholder involvement.

• Another attempt by infectious experts in 2013 to establish National AMR Coordinating Unit

in the MOPH did not get through, as no due process of multi-sectoral involvement.

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Box 3: A summary of the NSP-AMR 2017-2021

Vision: Reduction of mortality, morbidity and economic impacts from AMR

Mission: Establish policies and national multi-sectoral mechanisms which support effective and

sustained AMR management system

Goals:

1. 50% reduction in AMR morbidity

2. 20% reduction in antimicrobial consumption in human

3. 30% reduction in antimicrobial consumption in animal

4. 20% increase in public knowledge on AMR and awareness of appropriate use of

antimicrobials

5. Capacity of the national AMR management system is increased to score 4 as measured by

the WHO’s Joint External Evaluation Tool for International Health Regulations (2005)

Strategies

1. AMR surveillance system using ‘One Health’ approach

2. Regulation of antimicrobial distribution

3. Infection prevention and control and antimicrobial stewardship in humans

4. AMR prevention and control and antimicrobial stewardship in agriculture and companion

animals

5. Public knowledge on AMR and awareness of appropriate use of antimicrobials

6. Governance mechanisms to implement and sustain AMR actions

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Box 4 National policies related to AMR

• National Strategic Plan on AMR 2017-2020

• National Health Assembly Resolution 8.5 on Integrated approaches to address antibacterial

resistance crisis (2015)

• National Emerging Infectious Disease Strategy 2017-2020

• National Drug Development Strategy 2012-2016

• National Strategic Plan on International Health Regulation (2005) 2017-2021

• National Operational Plan on AMR 2015-2018 under the Communicable Disease Act 2015

• National Operational Plan on Infection Prevention and Control 2015-2018 under the

Communicable Disease Act 2015

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Confidential: For Review Only11

Local actors @ Battle field(fighting against the system inertia)

50% reduction of AMR morbidity

20% reduction of antimicrobial use in human

30% reduction of antimicrobialuse in animals

Stable or decreasing

trends of AMR

ImpactGoals

20% increase in public

awareness on AMR & AM use

Measures for ambulatory care and pharmacies� Disease prevention� Antimicrobial use� …

Measures for agriculture and companion animals� Disease / Infection

Prevention and Control� AMR surveillance� Antimicrobial use� …

Measures for IPD� AMR surveillance� Infection Prevention and

Control� Antimicrobial stewardship� ...

Healthcare settings and clinics (Human & animals)

Farms, Agriculture sites, Feed mills

Laboratories for Antimicrobial residues and AMR

Strategies 1-6 of NSP-AMR

Governance mechanism of NSP-AMR implementation

and evaluation

Central agencies and Strategic partners

(consolidating efforts and actions for NSP-AMR implementation)

Coordinating Committee on AMR

Program Management team of CCS-APR program

RTG-WHO Country Cooperation Strategy program on Antimicrobial Resistance (CCS-AMR Program)

� Area of Work 1 M&E of NSP-AMR implementation� M&E by 5 goals � Mid-term review & end-term achievement evaluation� Biennial report on AMR situation and actions

� Area of Work 2 Strengthening M&E platforms /systems and developing one if needed

� Area of Work 3 Building capacity for evidence generation including mapping expertise, research gaps. priority setting for research, training etc.

Integration of operational plans of central agencies and strategic partners with an engagement of local actors

AMR management system achieves score 4 of JEE tool

AMR Coordinating Center

� Coordinating & monitoring strategies 1-5 implementation

� Data warehouse� Providing technical support for policy & media and international coordination

� Managing research and M&E

Sub-steering committee of CCS-AMR program

Executive committee of RTG-WHO CCS Program

Pharmacies

Measures for the public� Disease prevention� Health literacy on AMR

and antimicrobial use� …

Others� Monitoring AMR and

antimicrobial residues in food & environment

� …

National Committee on AMR

Slaughterhouses & Food outlets

Other settings� Pharmaceutical

industry� Communities� …

Figure 1. Conceptual framework of NSP-AMR implementation and evaluation

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References

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Review on antimicrobial resistance 2014.

2. Pumart P, Phodha T, Thamlikitkul V, Riewpaiboon A, Prakongsai P, Limwattananon S. Health

and economic impacts of antimicrobial resistance in Thailand. Journal of Health Systems

Research. 2012;6(3):352-360.

3. Sumpradit N, Suttajit S, Poonplosup S, Chuancheun R, Prakongsai P. Landscape of

antimicrobial resistance situations and actions in Thailand 2015.

4. World Health Organization. Global Action Plan on Antimicrobial Resistance. 2015.

http://apps.who.int/iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1.

Accessed 7 December, 2016.

5. Rasanathan K, Posayanonda T, Birmingham M, Tangcharoensathien V. Innovation and

participation for healthy public policy: the first National Health Assembly in Thailand. Health

Expectations. 2012;15:87-96.

6. Ministry of Public Health, Ministry of Agriculture and Cooperatives, National Health

Commission Office of Thailand, et al. National strategic plan on antimicrobial resistance

2017-2021 Thailand: at a glance 2016.

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(2005). Geneva, Switzerland: WHO Document Production Services; 2016:

http://apps.who.int/iris/bitstream/10665/204368/1/9789241510172_eng.pdf Accessed 18

August 2016.

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9. Costa AL, Kallick B, editors. Assessment in the learning organization: shifting the paradigm.

VA: Association for Supervision and Curriculum Development; 1995.

10. Rogers P. Theory of change, methodological briefs: impact evaluation 2. 2014;

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and Use. New York: Guilford Press; 2011.

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promoting the rational use of medicines in Thailand. Bulletin of the World Health

Organization. 2012;90:905-913.

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Confidential: For Review Only

Local actors @ Battle field (fighting against the system inertia)

50% reduction of AMR

morbidity

20% reduction of antimicrobial use in human

30% reduction of antimicrobial use in animals

Stable or decreasing

trends of AMR

Impact Goals

20% increase in public

awareness on AMR & AM use

Measures for ambulatory care and pharmacies Disease prevention Antimicrobial use …

Measures for agriculture and companion animals Disease / Infection Prevention and Control AMR surveillance Antimicrobial use …

Measures for IPD AMR surveillance Infection Prevention and Control Antimicrobial stewardship ...

Healthcare settings and clinics (Human & animals)

Farms, Agriculture sites, Feed mills

Laboratories for Antimicrobial residues and AMR

Strategies 1-6 of NSP-AMR

Governance mechanism of NSP-AMR implementation

and evaluation

Central agencies and Strategic partners (consolidating efforts and actions for NSP-AMR implementation)

Coordinating Committee on AMR

Program Management team of CCS-APR program

RTG-WHO Country Cooperation Strategy program on Antimicrobial Resistance (CCS-AMR Program)

Area of Work 1 M&E of NSP-AMR implementation M&E by 5 goals Mid-term review & end-term achievement evaluation Biennial report on AMR situation and actions

Area of Work 2 Strengthening M&E platforms /systems and developing one if needed

Area of Work 3 Building capacity for evidence generation including mapping expertise, research gaps. priority setting for research, training etc.

Integration of operational plans of central agencies and strategic partners with an engagement of local actors

AMR management system achieves

score 4 of JEE tool

AMR Coordinating Center

Coordinating & monitoring strategies 1-5 implementation

Data warehouse Providing technical support

for policy & media and international coordination

Managing research and M&E

Sub-steering committee of CCS-AMR program

Executive committee of RTG-WHO CCS Program

Pharmacies

Measures for the public Disease prevention Health literacy on AMR and antimicrobial use …

Others Monitoring AMR and antimicrobial residues in food & environment …

National Committee on AMR

Slaughterhouses & Food outlets

Other settings Pharmaceutical industry Communities …

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Confidential: For Review Only · In 2013, attempt to establish the National AMR Coordinating Unit...

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