Health Policy

Response to antimicrobial resistance in South-East Asia Region

Benyamin Sihombing,a,∗ Rajesh Bhatia,b Rahul Srivastava,c Tjandra Yoga Aditama,d Ramanan Laxminarayan,e and Suman Rijalf
a
Antimicrobial Resistance Unit, Department of Communicable Diseases, WHO South-East Asia Region, New Delhi, India
b
Former Director Communicable Diseases, WHO SEARO, New Delhi, India
c
Regional Director Office, WHO South-East Asia Region, New Delhi, India
d
YARSI University, Jakarta, Indonesia
e
Center for Disease Dynamics, Economics & Policy, Washington, USA
f
Department of Communicable Diseases, WHO South-East Asia Region, New Delhi, India

Summary The Lancet Regional

Health - Southeast
Antimicrobial resistance (AMR) inflicts significant mortality, morbidity and economic loss in the 11 countries in the WHO
Asia 2023;18: 100306
South-East Asia Region (SEAR). With technical assistance and advocacy from WHO, all countries have developed their
Published online 29
respective National Action Plans on AMR that are aligned with the Global Action Plan. Historically, the WHO Regional October 2023
Office has been proactive in advocacy at the highest political level. The past decade has seen an enhancement of the https://doi.org/10.
country’s capacity to combat AMR through national efforts catalyzed and supported through several WHO initiatives at all 1016/j.lansea.2023.
levels—global, regional and country levels. Several countries including Bangladesh, India, Indonesia, Nepal, Sri Lanka and 100306
Thailand have observed a worrying trend of increasing drug resistance, despite heightened awareness and actions. Recent
AMR data generated by the countries are indicative of fragmented progress. Lack of technical capacity, financial resources,
weak regulatory apparatus, slow behavioural changes at all levels of the antimicrobial stewardship landscape and the
COVID-19 pandemic have prevented the effective application of several interventions to minimize the impact of AMR.

Copyright © 2023 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND IGO license
(http://creativecommons.org/licenses/by-nc-nd/3.0/igo/).

Keywords: AMR Global Action Plan; AMR National Action Plan; AMR surveillance; Advocacy; One Health;
Antimicrobial Stewardship

Introduction decrease of up to 3.8% in global exports, with a dimin-

Antimicrobial resistance (AMR) is a significant growing ishing of livestock production by 7.5% per cent per year.
global concern since it results in close to 1.27 million It will also result in an increase in healthcare-related
deaths annually, and importantly this trend continues to costs of US$1 trillion by 2050.4
rise globally.1 If no remedial action is taken, it is esti- The threat of mortality, morbidity and economic loss
mated the mortality attributable to AMR could rise to 10 associated with AMR poses an additional burden on
million globally and this would mean a cumulative loss countries already grappling with challenges associated
of US$100 trillion to the global economy by 2050.2 AMR with infectious disease prevention and treatment.5
poses a major hurdle to achieving Universal Health Countries in the WHO South-East Asia Region fall in
Coverage and health-related goals in the Sustainable this category. WHO risk assessment surveys have pro-
Development Goals (SDG) framework. Beyond Goal 3, jected 389,000 deaths attributed to AMR in South Asia.1
AMR is central to several other SDGs, for example, SDG The SEA Region has taken pioneering steps to identify
1 (no poverty), SDG 2 (zero hunger) and SDG 8 (decent the threat and develop cogent response strategies to
work and economic growth).3 AMR is now being address AMR. As early as 2011, health ministers of
recognized as a global health security threat. We have countries in the Region adopted the Jaipur Declaration for
witnessed in this interconnected world that resistant Prevention and Control of Antimicrobial Resistance which
superbugs could easily spread across borders and make called for a concerted action against AMR.6 It indicated an
many treatable infections untreatable. early realization of the challenge even though the Region
The adverse impacts of AMR go beyond the health at that time was not fully equipped to address it. In 2014,
sector and the well-being of people, it has serious ram- the regional response to AMR got a boost when it was
ifications also for economic well-being. According to a identified as one of the Flagship Priority areas for the
World Bank report, AMR shall be responsible for a WHO SEARO Region.7 Since then, WHO has been
providing guidance to Member States on improved
implementation of AMR national action plans (NAPs).
DOIs of original articles: https://doi.org/10.1016/j.lansea.2023.100303, This has resulted in a multisectoral ‘One Health’ approach
https://doi.org/10.1016/j.lansea.2023.100304, https://doi.org/10.1016/j.
lansea.2023.100307, https://doi.org/10.1016/j.lansea.2023.100302
covering human health, animal health, plant and food
*Corresponding author. chains, food safety and the environment. At the 2015
E-mail address: [email protected] (B. Sihombing). regional committee meeting in Timor-Leste, member

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 Health Policy

states passed a key resolution for steadfast political trends across countries.12 Importantly, the available
commitment and multisectoral coordination to tackle data clearly shows an increasing trend in hospital-
AMR.8 Next, a regional strategy to support the develop- associated infections.13,14 However, the data is not na-
ment and implementation of AMR National Action Plans tionally representative as most samples were drawn
was finalized to guide countries in strengthening their from tertiary care hospitals.
national AMR prevention and containment programmes.9 Reports from Bangladesh, Nepal and Sri Lanka
The SEARO is implementing activities to contain indicate a high level of resistance to beta-lactams espe-
AMR in line with the following five strategic objectives cially due to the presence of extended-spectrum beta-
derived from the Global Action Plan launched in 2015 lactamase (ESBL) producing pathogens.15–17 Data from
by WHO in collaboration with Food and Agriculture India have shown an increasing trend of resistance as
Organization and World Organization for Animal well18 Imipenem susceptibility of E. coli has dropped
Health (founded as OIE).10 These objectives are: steadily from 86% in 2016 to 64% in 2021 and that of
Klebsiella pneumoniae dropped steadily from 65% in
• To improve awareness and understanding of anti- 2016 to 43% in 2021. Resistance to carbapenems in
microbial resistance through effective communica- Acinetobacter baumannii was recorded as 87.5% in the
tion, education and training; year 2021. Methicillin-resistant S. aureus (MRSA) rates
• To strengthen the knowledge and evidence base are increasing from 2016 to 2021 (28.4%–42.6%). In
through surveillance and research; Indonesia, in accordance with the SDG indicator, the
• To reduce the incidence of infection through effective proportion of ESBL-producing E. coli was 57.7% among
sanitation, hygiene and infection prevention measures; the total E. coli-induced bloodstream infections.19 In
• To optimize the use of antimicrobial medicines in children, in Myanmar, high rates of carbapenem resis-
human and animal health; and tance were noted for E. coli (48%), K. pneumoniae (42%),
• To develop the economic case for sustainable invest- and Acinetobacter sp. (59%).20 Lim et al., in 2016 esti-
ment that takes account of the needs of all countries mated that 19,122 of 45,209 (43%) deaths in Thailand
and to increase investment in new medicines, diag- among patients with hospital-acquired infection were
nostic tools, vaccines and other interventions. due to multidrug-resistant bacteria, representing excess
mortality caused by resistant pathogens.21
This article focuses on progress made by the Mem-
ber States of the WHO South-East Asia Region in con-
taining AMR and WHO’s strategic support in taking the Progress in national action plans
AMR agenda forward. The article also states the present WHO Regional Office for the South-East Asia region
and future challenges and efforts needed to move for- has been conducting situational analysis and moni-
ward in achieving the 2030 goal. toring of AMR using the Regional Office tool to analyse
AMR prevention and containment.
Three self-assessment surveys have been conducted
Disease burden that have taken place (2016–2017, 2017–2018, 2018–2019)
Globally, more people die due to reasons related to AMR to assess the progress of 31 indicators as a proxy for
than HIV/AIDS or malaria. In the SEA Region, 4 million strategic interventions/programmes across eight focus
people died in 2019 due to sepsis as an immediate or in- areas.22,23 All 11 countries in the South-East Asia Region
termediate cause of death.11 Of these deaths attributed to have developed and endorsed respective National Action
sepsis, 62% were caused by bacterial infections.11 The Plans (NAPs) in line with the Global Action Plan.21 Eight
remaining 38% were caused by other pathogens such as Member States have updated their NAPs as the initial
viruses, fungi, and parasites. Out of the deaths due to NAPs period ended in 2022. These NAPs were developed
bacterial infections, between 0.39 and 1.41 million people with the technical assistance of the WHO.
died because of bacterial AMR.11 Table 1 shows the The implementation of NAP has been fragmented
composition of infection-related deaths, including AMR, in and varies from country to country as well as within-
the Member States of the WHO South-East Asia Region. country.20 The 2018–2019 situational analysis revealed
In 2020, two AMR indicators were included in the significant progress in the implementation of NAPs
monitoring framework of the SDGs. These indicators across different focus areas in the SEAR Member States
monitor the proportion of bloodstream infections in the preceding three years (Figs. 1 and 2).22 The self-
(BSIs) due to Escherichia coli which is resistant to assessment done by the countries in the WHO survey
third-generation cephalosporins and methicillin- showed that >90% of SEAR countries had started
resistant Staphylococcus aureus (MRSA).12 Data avail- implementing NAPs with 27% actively monitoring the
ability for these indicators has improved over implementation.22 The progress in the implementation
2017–2020. Table 2 shows the progress in the SDG of NAPs, as expressed by the median values of the
indicators in the region. The available data shows a percentage of indicators with an implementation status
persisting level of AMR in the Region with varying phase of 3 and above, found in the third situational

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Countries Sepsis Bacterial infections Resistance (associated) Resistance (attributable)

Bangladesh 229,144 161,912 98,779 26,193
Bhutan 1138 760 464 124
DPR Korea 38,937 27,552 16,178 4131
India 2,990,000 1,790,000 1,040,000 297,036
Indonesia 444,880 302,592 133,753 34,530
Maldives 261 182 97 25
Myanmar 113,088 78,905 40,233 11,170
Nepal 55,803 37,826 23,204 6413
Sri Lanka 22,088 15,452 8815 2300
Thailand 134,738 82,573 43,885 10,775
Timor Leste 2574 1610 667 154

Source: AMR. IHME. 2019. https://www.healthdata.org/antimicrobial-resistance.

Table 1: Composition of infection-related deaths in Member States of WHO South-East Asia Region.

analysis in 2021 for all countries in the Region was 64%, Awareness and understanding
compared to 40% in 2018 and 16% in 2016.22 None of Improving awareness and understanding of AMR is
the countries showed any slide in the implementation critical not only for health professionals and veterinar-
status during 2021 compared with the situational anal- ians but also for the general public. Since 2015, WHO
ysis in 2018. The progress in the animal and agricultural has observed World Antimicrobial Awareness Week
sectors was found to lag compared with the human (WAAW) from 18 to 24 November every year.24 Every
sector, while progress in the environmental sector was year, the WHO Regional Office and country offices
the least among all the sectors.22 organize a series of events to harness momentum
Out of 11 countries in WHO South-East Asia, nine around tackling AMR and fueling behaviour change the
countries—Bangladesh, Bhutan, DPR Korea, India, programmes feature talk shows, social media events,
Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste campaigns and community events at schools, univer-
—were already functioning One Health coordination sities, and other locations. Government agencies, health
mechanism.22 In Indonesia, presidential instruction institutions, and other stakeholders, also spearheads
No. 4/2019 supports the development of a fully func- initiatives on WAAW campaign.
tional cross-sectoral coordination mechanism for AMR In 2021 and 2022, activities during WAAW expanded
control, which also demonstrates the strong commit- across sectors and included a ‘Go Blue’ campaign under
ment of the Indonesian government to ensure the the theme ‘Spread Awareness, Stop Resistance’.25 As
implementation of an integrated AMR approach part of this campaign, important public buildings
through a partnership of several sectors.22 around the world chose to immerse themselves in blue

Country The proportion of bloodstream infections due to

E. coli resistant to third-generation cephalosporin Methicillin resistant S. Aureus
Year 2017 2018 2019 2020 2017 2018 2019 2020
Bangladesh naa 70 93.1 71.43 na na na 0
Bhutan na na 56.78 53.93 na na 20.79 11.67
DPR Korea na na na na na na na na
India 75.11 78.83 80.81 86.81 52.5 63.1 60.61 64.66
Indonesia na 71.88 70.14 75.63 na 52.3 39.85 36.24
Maldives na na na na na na na na
Myanmar na 84.91 77.78 80.56 na 74.1 55.61 50.97
Nepal na 65.33 77.27 72.97 na 55.6 na 79.01
Sri Lanka na 67.67 63 61.92 na na 55.99 53.29
Thailand 41.72 36.42 37.26 39.4 16.7 11.3 12.43 10.63
Timor Leste na na na 61.54 na na na na
a
na—Not Assessed/Not available. Source: WHO 2020: SDG Target 3.d.2.

Table 2: Status of SDG Indicators for AMR in countries of the South-East Asia Region (2017–2020).

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Fig. 1: The proportion of indicators with implementation phase 3 or above in each country from 2016 to 2021. Source: Third progress
analysis of implementation of antimicrobial resistance national action plans in the WHO South-East Asia Region 2022.

colour. In all 11 countries (100%), the governments Agricultural Organization (FAO), WOAH (World Orga-
regularly led education campaigns on AMR to raise nization for Animal Health) and WHO to reflect the
awareness in the public, this was an increase from the multisectoral nature of AMR, was expanded to include
situation in 2018 (81%).22 the UN Environment Programme (UNEP). This was to
facilitate additional environmental aspects of AMR in
Monitoring and surveillance the frameworks of action. This will hence evolve into
In 2022, the Regional Tripartite Coordination, Quadripartite Coordination (FAO, WOAH, UNEP and
embodied by participating UN agencies Food and WHO) from 2022 onwards. All Member States have

Na onal surveillance of AMR, and use and sales of an microbials 6

3
in the veterinary sector 1

A na onal AMR containment policy and regulatory framework for 7

5
control and registra on of use in animals 1

Regula on of pharmacies regarding OTC sale and inappropriate 9

7
sale of an bio cs and APIs 4

10
Regula on of finished an bio c products and APIs 8
3

10
Surveillance of an microbial use and sale among humans 7
3

11
NRA/ NMRA 10
7

A na onal AMR containment policy for control of human use of 7

1
an microbials; AMR stewardship 2

8
AMSP in health-care se ng 5
3

Phase 2021 Phase 2018 Phase 2016 0 2 4 6 8 10 12

No of countries (>Phase 3)

Fig. 2: Progress in the country’s response to contain AMR (2016–2021). Source: Third progress analysis of implementation of antimicrobial
resistance national action plans in the WHO South-East Asia Region 2022.

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participated in all the self-assessment surveys conducted GLASS provides a standardized approach to the
so far.26 collection, analysis, interpretation and sharing of data by
The Third One Health Situational Analysis 2021 re- countries and seeks to actively support capacity building
ported progress in all eight focus areas and indicators.27 and monitor the status of existing and new national
More countries started implementing actions under surveillance systems. It promotes a shift from surveil-
these indicators – the national AMR plan and gover- lance approaches based solely on laboratory data to a
nance, raising awareness, national AMR surveillance system that includes epidemiological, clinical, and
system, rational use of antimicrobials and surveillance population-level data.
of use/sale including and AMS, IPC, research and Inappropriate use of antibiotics is rampant in the
innovation, One Health engagement and overarching Region and is a major contributor to antimicrobial
coordination mechanisms for One Health engage- resistance but data on antibiotic use and consumption
ment.28 However, no progress was observed with AMR are scant.30 The median value of the overall consump-
awareness generation and education on AMR in the tion of antimicrobials is 16.6 (range, 12.3–31.2) Defined
environmental sector, and the implementation of an Daily Dose (DDD) per 1000 inhabitants per day while
AMR early warning system (EWS), wherein almost none for three countries in WHO South-East Asia (Bhutan,
of the countries managed to start a national programme Maldives and Nepal) it was 15.3 (range, 9.5–57.4)
in these areas during the situational analysis in 2021, (Fig. 3). Countries reporting from SEA Region also
2018 and 2016 (Fig. 2).27 showed significant variations in the usage of antimi-
WHO support for strengthening surveillance is to crobial drugs.31 India consumes a large volume of
provide technical assistance to expand sentinel sites to broad-spectrum antibiotics that should ideally be used
generate nationally representative and good-quality sparingly. The total DDDs consumed in 2019 was 5071
AMR data. By 2021, 10 of 11 countries in the Region million (10.4 DDD/1000/day).32 While consumption of
had initiated AMR surveillance in the human sector human antimicrobials in Thailand in 2017 was 75.68
(Table 2). By September 2022, all Member States in DDD/1000 inhabitants/day.32 Hoque et al., in 2020
SEAR got themselves enrolled in the Global AMR Sur- observed the widespread availability of antimicrobials
veillance System (GLASS) and 6 Member States enrolled without prescription in Bangladesh.33 All countries in
in GLASS- antimicrobial consumption (AMC). India has the WHO Eastern Mediterranean Region reported a
initiated a multi-site surveillance system for AMR based consumption 31.8 [range, 29.4–53.6] and where six Eu-
on the standard protocols29 (Box 1). ropean countries is 15.3 [range, 9.2–30].34 In the United

Box 1.
A case study of AMR surveillance networks in India.

India commenced AMR surveillance in 2013 and has gradually expanded this activity under two networks: organized by the Indian Council of Medical Research (ICMR) and the National
Centre for Disease Control (NCDC).
ICMR initiated Antimicrobial Resistance Surveillance and Research Network (AMRSN) in 2013 to monitor trends in the antimicrobial susceptibility profile of clinically important bacteria
and fungi limited to human health. The pathogens included in surveillance align with the WHO Priority List of Pathogens (2017) and are Enterobacteriaceae causing sepsis, Gram-
negative non-fermenters, enteric fever pathogens, diarrheagenic bacterial organisms, Gram positives: staphylococci and enterococci and fungal pathogens. AMRSN includes six nodal
centres–one for each pathogenic group, and 16 regional centres located in tertiary care health facilities.27

NCDC runs another AMR surveillance network in India, called NARS-Net. The network currently has 35 labs in 26 states/UTs. These labs submit AMR surveillance data on seven priority
bacterial pathogens of public health importance: Klebsiella spp., Escherichia coli, Staphylococcus aureus, Enterococcus spp., Pseudomonas spp., Acinetobacter spp., Salmonella enterica serotypes
Typhi and Paratyphi.16
The major drawback with both networks is data generated by their surveillance systems is not truly representative of the AMR burden in the country since data is primarily from patients
who have had prior antimicrobial therapy from tertiary care hospitals and not from communities.

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Total consumpon of anbacterials expressed as

DDD per 1000 inhabitants per day

Bhutan (2020)

Maldives (2019)

Nepal (2018)

0 10 20 30 40 50 60 70

Fig. 3: Total consumption by antimicrobial classes in three countries of WHO SEA Region in 2020, expressed as DDD per 1000 in-
habitants per day. Source: WHO. Global antimicrobial resistance and use surveillance system (GLASS) report: 2022. WHO Geneva, 2022.

Kingdom, there were 18.2 DDD per 1000 inhabitants in noticeable in developing countries like Ethiopia, where
2019.35 In a comprehensive study showed that high rates regulation strategies are too weak.39,40 Despite the rise in
of antibiotic consumption were seen in North America, antibiotic consumption, access to antibiotics continues
Europe and the Middle East. Total antibiotic consump- to be a concern, and delays in access to antibiotics cause
tion rates showed a nearly ten-fold variation between more fatalities than antibiotic resistance.41 Across the
countries, ranging from as low as 5.0 DDD to 45.9 DDD developing countries, antibiotic overuse exists side-by-
per 1000 population per day. Between 2000 and 2018, side with lack of access. There are millions of people
global antibiotic consumption rates increased by 46% in low- and middle-income countries who remain
(from 9.8 to 14.3 DDD per 1000 population per day). deprived of antibiotics contributing heavily to the ma-
While in the high-income countries, consumption rates jority of world’s annual 5.7 million antibiotic-
remained stable between 2000 and 2018, in low- and preventable deaths. The dilemma between excess of
middle-income countries, there was a 76% increase antibiotics leading to AMR and access to needy needs to
observed between 2000 and 2018.36 They also found a be balanced out.2,42
rise in the irrational use of antibiotics across sectors and The South-East Asia Regulatory Network (SEARN)
consequent contamination of the environment and responsible for supporting the regulation of medical
spread of resistance. Procurement of antibiotics through products, including medicines, vaccines, medical de-
over-the-counter (OTC) sale is widespread in Myanmar. vices and diagnostics across the Region, is now poised to
More than half of the participants (58.5%) purchased play a more active role in surveillance, detection and
antibiotics without a prescription, mainly from medical regulatory action on substandard and falsified antimi-
stores or pharmacies (87.9%). A disproportionately crobials, and hence help to address AMR. Comprehen-
higher use of broad-spectrum and Watch category sive strengthening of NRAs through direct WHO
antibacterial was observed in the private sector in Sri support and SEARN is likely to yield productive results.
Lanka.32 About 97% of retailers dispensed unnecessary
antimicrobials in diarrhoea, and only 3% suggested Infection prevention and control
evaluation by a physician in Nepal.37 Self-medication There is a strong need to reduce the overall burden of
with antibiotics was found to be widespread in bacterial infections including in high risk settings vis
Bangladesh (45.7%). Inappropriate antibiotic use is a health facilities or animal farms. All efforts including
pertinent problem in LMICs where regulatory frame effective IPC in health settings, personal hygiene, vacci-
works are weak. Inappropriate antibiotic use in LMICs nation and hand washing have profound impact on
is a multifaceted problem that cuts across clinical and reducing infectious diseases.43 Safer hospitals mean fewer
veterinary medicine and agriculture.38 Globally, over infections and every infection prevented is an antibiotic
50% of antibiotics are sold without a medical prescrip- avoided. The pooled prevalence of HAIs was estimated to
tion. Although over the counter sale of antibiotics is be 9.0% in the WHO South-East Asia Region, according
common in the developed world, this practice is more to a systematic review published in 2015.44

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In 2015, responding to the need for attention to encompasses interventions designed to promote the
patient safety in the Member States of the South-East optimal use of antibiotics, including selection, dosing,
Asia Region, the WHO Regional Office launched the route, and duration of administration and is a critical
Regional Patient Safety Strategy 2016–2025.45 It element of curbing and preventing AMR.
included IPC as one of the six strategic objectives, i.e., WHO continued to support countries in updating
improve the structural systems to support quality and national Essential Medicines Lists by incorporating es-
efficiency of health care and place; patient safety at the sentials of WHO’s Access-Watch-Reserve (AWaRe)
core of all levels of health care; assess the nature and classification for antimicrobials.48 Antimicrobials have
scale of harm to patients and establish a system of been grouped into these three categories, with recom-
reporting and learning at the national level; ensure a mendations on when each category should be used. It
competent and capable workforce that is aware and also includes the details of 258 antibiotics along with
sensitive to patient safety; prevent and control health their pharmacological classes, anatomical therapeutic
care-associated infection; improve implementation of chemical codes and WHO essential medicine list status.
global patient safety campaigns and strengthen pa- WHO recommended country-level targets of at least
tient safety in all health programmes; and strengthen 60% of total antibiotic consumption being from the
capacity for and promote patient safety research. Access group of antibiotics.49,50
Since then, countries are implementing the strategy By 2022, Bhutan, Indonesia, Maldives, Nepal, Timor
with some particularly focusing on IPC. Consequent Leste and Thailand had adopted the AWaRe categoriza-
to the formulation of National Action Plans, a national tion into their national EMLs.51 Other countries are also
infection prevention and control (IPC) programme or planning to use this strategy. To improve the affordability
operational plan is available in all countries of the of medicines, all SEAR Member States employ some
WHO South-East Asia Region. However, four of the aspect of a policy to control the prices of medicines and
countries in the Region are not fully implementing devices and to contain pharmaceutical expenditure.
it.46 Only three of the countries had an IPC pro- Antimicrobial stewardship (AMS) plans are being
gramme supported by plans and guidelines imple- implemented in countries across the Region with WHO
mented nationwide. 50.0% of the countries had a support. These aim to optimize the use of antimicro-
dedicated budget for IPC. In six of the countries, bials, improve patient outcomes, reduce AMR and
there was a mandate to produce IPC national healthcare-associated infections, save healthcare costs
guidelines.45 overall, and lead by example for other sectors. WHO has
WHO initiated policy dialogue and technical assis- developed tools to assist AMS activities at the healthcare
tance on improving infection prevention and control facility level in low- and middle-income countries, which
(IPC) which continued even during the COVID-19 have helped to advance implementation at the national
pandemic. Adopting IPC guidelines, including WASH, level as well as within healthcare facilities and clinical
was a key feature of the technical support provided by practice. AMR has been included or is in the process of
WHO to strengthen IPC in the Member States. WHO being included, in medical, nursing and pharmacy
supported the development of fit-for-service dashboards curricula in several countries in the SE Asia Region.52
to strengthen policy advocacy. In addition, training This has been achieved by engaging ministries of
packages and guidance documents were made available health, education, and universities. Technical support
to Member States for capacity building on IPC and to has been provided to the Region’s countries to develop
deal with associated challenges like the emergence of national antimicrobial stewardship (NAMS) policies.
new variants of concern.
An interesting example of improvement is the
implementation of IPC tailored to the local situation in Discussion
Cox’s Bazar area in Bangladesh. In collaboration with Globally, AMR would have been the third leading GBD
WHO and relevant partners, local authorities and teams cause of death in 2019, on the basis of the counterfactual
established IPC committees and IPC focal persons in of no infection.53 WHO-conducted risk assessments
137 healthcare facilities in the Rohingya camps and all have shown, the Region is likely the most at-risk part of
eight sub-district referral healthcare facilities, used the world as about 30% of AMR attributable deaths are
checklists for IPC assessments, and undertook the occurring in the Region.1,11,52 The WHO South-East Asia
training of trainers to create local expertise.47 Region is particularly affected due to the rapid intensi-
fication of food-production systems, loosely regulated
Antimicrobial stewardship access to antimicrobials, poor awareness, widespread
Irrational use of antibiotics is well recognized to be one irrational prescribing and self-medication, and an
of the main drivers of AMR.48 WHO has been strongly abundance of substandard-quality or counterfeit
advocating for prescribers and users to assure optimal drugs.54,55 All these factors combined with a high prev-
utilization of these agents. It has extended continuous alence of infectious diseases and weak healthcare sys-
support to strengthen antimicrobial stewardship, which tems drive the AMR in the Region.56

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Much has been done in the Region to counter this recognized antimicrobial resistance as one of the top 10
increasing burden of AMR. One such intervention was most urgent global health threats.60 This led to intensi-
WHO’s advocacy for putting the right policy for AMR fied efforts to tackle AMR at global and national levels.
control. National Action Plan is a strategic tool for AMR Thereafter, the pandemic substantially hampered the
containment with the objective to guide stakeholders for progress towards containing AMR, especially the
integrated responses against AMR through the identi- implementation of AMR national action plans. Ongoing
fication of priority areas for work and collaboration. It is responses for multiple health emergencies hindered the
a result of political momentum facilitated by the coor- regular work on AMR particularly on strengthening the
dinated efforts of WHO.10 While all Member States of AMR surveillance system. Further, prolonged intensive
the WHO South-East Asia Region have developed na- care stays, high mortality rate, diagnostic and prognostic
tional multisectoral action plans, implementation re- uncertainty and concern for secondary bacterial in-
mains a challenge. Only a few countries report that their fections has led to frequent empiric antibacterial use
NAP is being implemented effectively or have allocated during the pandemic, thus leading to increase AMR.61
financing in their national budgets for AMR pro- Nevertheless, the COVID-19 pandemic has highlighted
grammes.22,57 By 2022, none of the countries had costed the vulnerability of healthcare systems in controlling
the AMR programmes so that adequate budget can be infectious disease threats and increased awareness of
marked. Bangladesh and Bhutan have effectively the importance of planning for emerging infections and
implemented training on the National Action Plan maintaining robust infection control. The pandemic has
Budgeting and Costing Tool to increase country capacity generated opportunities that should be seized to harness
on the use of the tool to help build and cost an opera- positive effects on the management of antimicrobial
tional plan for their NAP.57 In addition, an e-learning resistance.62
course is being developed to complement the virtual/ Leadership and technical support play a crucial role
face-to-face trainings and to ensure greater dissemina- in implementing action plans at global and national
tion and use at country level. Limited technical capacity levels and the policymakers understand and rely on
within different programmes of MOH and related sec- statistics and data generated and implied for local level
tors hinders the efficient implementation of NAP or national levels. However, at present, most of the AMR
despite political commitment at the highest level.57 The statistics are still global, with limited AMR data at the
Member States have a dependency on WHO and donor national or subnational level.63,64 This creates an oppor-
partners to move forward in areas like manpower, tunity to lobby for more research at a national level to
technical expertise, and funding support. Advocacy ef- generate data to measure AMR burden, accounts for the
forts in the field of Antimicrobial Resistance (AMR) patient pathway within the healthcare setting, and
have indeed faced challenges in achieving optimal po- strengthens diagnostic stewardship and laboratory
litical and financial responses. Several factors contribute practice that can be used to advocate for government
to this situation are lack of Awareness on AMR in the buy-in and support.
general public compared to other health issues, lack of There is a human behaviour component in all as-
robust AMR data locally, as a "silent pandemic" nature pects of AMR since antibiotics are solely handled and
of AMR makes it harder to rally urgent responses, used by human beings. Doctors prescribe and public
competing with global health priorities (pandemics, consumes while veterinarians prescribe and administer
non-communicable diseases, and poverty) and stake- antimicrobials to animals.65–68 Lack of awareness cam-
holder fragmentation. paigns and use of ineffective communication tactics in
AMR solutions can result in considerable economic the Region which primarily comprises of countries in
benefits with long-term effects, both in terms of LMICs, warrants for increased public awareness to
addressing AMR and broader health priorities.58 For mitigate AMR.57 Eliminating misconceptions about an-
instance, a modelling study done in Japan has shown tibiotics being “magic bullets requires behavioural
that 18 new antimicrobials can be developed over next change among both antimicrobial prescribers and users.
the 10 years with a collective investment of $78 billion Further, the development of resistance is a natural
by G7 countries.59 Such an investment will have a return process of adaptation of bacteria in reaction to antibi-
on-investment ratio of 6:1 for Japan’s share of invest- otics. This meant that antibiotics had a limited lifespan
ment. The ROI shall increase to 28:1 if the timeframe is from the very beginning.69,70 This should have been
extended to 30 years. The global ROI could be much explicitly made known to the public, humans and doc-
higher, at 27:1 over 10 years and 125:1 over 30 years. tors at the inception of antibiotics. This was the first
The number of lives saved across the world shall be missed opportunity towards mitigation of AMR,
518,000 at the end of 10 years and 9.9 million by the end through communication targeting awareness and hu-
of 30 years.59 However, such modelling studies have not man behaviour.
yet been done in the regional context. The quality and consistency of AMR surveillance
Before the coronavirus disease 2019 (COVID-19) data are limited for the Region. Currently, there are
pandemic, the World Health Organization (WHO) several networks which contribute to AMR surveillance

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in South-East Asia.57 However, there is huge geographic need to take this down to the Regional, national and sub-
heterogeneity in terms of data quality and availability. national level. Advocating and promoting by WHO and
Surveillance in the Region is primarily driven by few other UN agencies, One Health approach has been stated
healthcare facilities contributing data with a number of in G20 Health Ministers’ Meeting where G20 member
eligible patients not being tested and a lack of quality of nations commit to address antimicrobial resistance
laboratory services, hence it cannot be generalized for (AMR) comprehensively using the One Health approach.
national representation. Overall, a large knowledge gap This involves enhancing coordination and governance
exists due to a weak surveillance. Though AMR research across sectors, advancing research and development,
in the Region is focused on burden and patterns of improving infection prevention and control, ensuring
resistance, yet nationwide surveillance is lacking. More clean water, sanitation, and hygiene, raising awareness
research is needed to discover new antibiotics and about AMR, and promoting responsible use of antimi-
develop rapid diagnostic tests. Investment in research crobials. This includes preserving existing treatments
and national surveillance of resistant pathogens must be through antimicrobial stewardship, increasing surveil-
prioritised.71 Support for Member States in sharing lance of AMR and antimicrobial usage, utilizing surveil-
AMR and AMC data with GLASS and in taking up a lance data for policy decisions, developing new
standardized approach for the collection and analysis of antimicrobials guided by prioritization lists, and ensuring
AMR data at the global and regional level as well as equitable access for everyone, including through
utilising those data for policy-informed decisions. While community-based efforts. The third One Health situa-
the need for research and development of new di- tional analysis 2021 has shown that the environment
agnostics is paramount, rigorous implementation of sector has made less progress across different focus areas
currently available, and affordable, IPC interventions in and indicators of AMR in the Region. The limited sys-
human and animal sectors can yield good results even temic capacity of the environmental sector and lack of
in a short period. resources can explain some of the gaps in progress.
As AMR, which is a complex challenge that spans Further, the environment sector is less integrated into
across various sectors, including healthcare, agriculture, AMR response, and this probably reflects a lack of clarity
environment, and policy-making, global architecture and in the collaborative frameworks that necessitate their
governance are essential in organising a multi-sectoral involvement.57 This could impact One Health’s engage-
response to the problem. Organisations with a global ment and effective multisectoral collaboration. A
mandate, such as the World Health Organization strengthened One Health response will help in building
(WHO), Food and Agriculture Organisation (FAO), and connections and communication channels across sectors
World Organisation for Animal Health (OIE), offer plat- to ensure collaboration on research and development as
forms for international cooperation initiatives and augurs well as the implementation of programs, policies and
well for intersectoral coordination. In 2019 the World legislation.
Health Organization (WHO), Food and Agriculture
Organisation (FAO), and World Organisation for Animal
Health (OIE) partnered up to utilize Antimicrobial Conclusions
Resistance Multi-Partner Trust Fund to combat AMR. The 71st session of the UN General Assembly identified
The Antimicrobial Resistance MPTF, which consists of AMR as a dominant global health concern, placing it
global/regional and country components, lessens the high on the agenda of national policymakers, interna-
threat of AMR by sponsoring transformative and creative tional organizations and financial institutions in devel-
practises that assist national governments in putting the oped and developing countries. Being a flagship
"One Health" concept into practise and maintaining it. programme in the South-East Asia Region, WHO has
Indonesia and Bangladesh received the fund for the proactively supported countries through enhanced
purpose of tackling AMR at the national levels with advocacy and augmented technical capacity. WHO is
backstopping support from WHO, FAO, WOAH and committed to support all Member States in developing
UNEP became a co-signatory of the Fund in 2021, and implementing National Action Plan on AMR. Using
enhancing the understanding of the critical environ- the information from monitoring and surveillance data
mental dimensions of AMR. The Quadripartite Organi- will capture the country stage to stimulate effective and
zations—FAO, UNEP WHO, and WOAH—developed sustainable multisectoral response on AMR. It is
the One Health Joint Plan of Action (2022–2026) which essential to recognize that these plans entail a journey
consist of six interdependent action tracks, including rather than an immediate fix. By acknowledging the
AMR to provide a framework for action and propose a set need for phased activities over years, we are setting a
of activities the four organizations and upstream policy realistic expectation for the time and effort required.
and legislative advice and technical assistance, to help set Prioritizing interventions that can be universally adop-
national targets and priorities across the sectors for the ted now is a smart approach, as their success can inspire
development and implementation of One Health legis- and pave the way for others to join the fight against
lation, initiatives and programmes. There is an urgent AMR.

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Moving forward, the next decade is critical for accel- regulatory action on substandard and falsified antimi-
erating action on AMR. The Member States of the WHO crobials need to be strengthened across Member States
South-East Asia Region need to prioritize the AMR na- in order to check the practice of irrational and sub-
tional action plans and allocate adequate financial re- standard use of antibiotics.22,72,73 Irrational use of anti-
sources for their implementation. The integration of biotics in animal sector can be minimized through
these plans with primary health care and health emer- legislation. Some countries have initiated major activ-
gencies holds the key. The first step in this direction is to ities on the aspect of supplementing animal feed with
cost the AMR programmes at national levels and mobi- antibiotics. There has been significant work in mini-
lize resources—both foreign and domestic resources. mizing irrational use of antibiotics in animal feed in
The current funding mechanisms face notable limi- Bangladesh as one of the drivers of AMR. India has also
tations when it comes to generating the necessary vol- issued government orders to discontinue use of anti-
ume of funds and ensuring a steady flow of resources. biotic supplemented animal feed. These should be used
This can impede the ambitious goals set out in the na- as foundations for development and implementation of
tional action plans. It’s crucial to explore alternative effective legislations. Strengthening infection preven-
approaches such as cost-sharing and direct funding to tion and control (IPC) measures and antimicrobial
bridge this gap. Addressing resource needs a compre- stewardship is of paramount importance in the Member
hensive gap analysis to identify where the shortfalls lie States workplan to mitigate the growing threat of anti-
and how they can be effectively covered. Methodological biotic resistance and ensure the continued effectiveness
challenges related to costing need also be addressed, of our antibiotics.74 The adoption of AWaRe categori-
including whether to use financial units of costing. The zation by the Member States is also critical for the
challenges in current drug development initiatives are proper implementation of NAP. As the Region faces
multifaceted and can impact the timely creation of multiple threats to AMR, multisectoral, multidisci-
effective treatments. Clinical trial capacities and regu- plinary and multi-institutional efforts are needed to
latory frameworks play a pivotal role in this scenario. address AMR holistically. Therefore, the ‘One Health’
These challenges can result in delays, higher costs, and approach that connects the human, animal and envi-
potential roadblocks in bringing new antimicrobials to ronmental sectors is considered vital to addressing
market. Addressing these limitations requires collabo- AMR, particularly for the Region. The Quadripartite
rative efforts between stakeholders, including govern- Organizations—FAO, UNEP WHO, and WOAH—
ments, pharmaceutical companies, and regulatory developed the One Health Joint Plan of Action
agencies, to streamline processes, incentivize research, (2022–2026) which consist of six interdependent action
and establish adaptive regulatory pathways that ensure tracks, including AMR to provide a framework for action
safety while expediting drug development. Despite and propose a set of activities the four organizations and
concerted advocacy efforts, achieving optimal political upstream policy and legislative advice and technical
and financing responses remains a challenge. This can assistance, to help set national targets and priorities
be attributed to a variety of factors, including competing across the sectors for the development and imple-
priorities, limited awareness about the gravity of AMR, mentation of One Health legislation, initiatives and
and the complex nature of policy change. Moreover, programmes.75 This has been voiced in the G20 Lombok
securing political commitment and sustainable funding Policy Brief which emphasized support to low- and
for AMR initiatives requires ongoing dedication and middle income countries to strengthen One Health
engagement from a diverse range of stakeholders, approaches to pandemic prevention, preparedness and
including health organizations, governments, private response including AMR as a silent pandemic.76
sectors, and civil society. Building a stronger case for In the coming time, to make AMR interventions
AMR’s impact on public health, economies, and global more effective, a more comprehensive and program-
security can enhance the likelihood of eliciting more matic approach is needed, putting people and their
robust political and financial responses. Rather than needs at the centre of the AMR response.
creating separate plans for preparedness, leveraging
existing initiatives such as TB and AMR surveillance can Contributors
offer a more cohesive and efficient approach. By inte- BS: reviewing, data validation, editing the draft.
RB: developed the methodology, writing the original draft, editing.
grating AMR surveillance efforts within broader TYA: reviewing and editing.
pandemic preparedness strategies, synergies can be RL: reviewing and editing.
achieved in terms of resource utilization, expertise SR: supervision, reviewing.
sharing, and overall effectiveness. This interconnected RS: reviewing, editing.
approach recognizes the interdependence of various
Declaration of interests
health challenges and the need for a unified response.
The views expressed in the submitted article are of the authors and not
This not only optimizes resource allocation but also an official position of the institution to which they are affiliated. The
enhances the overall readiness to combat emerging authors except RL and SR are affiliated with WHO SEARO. The author
health threats. Further–surveillance, detection and declares no conflict of interest.

10 www.thelancet.com Vol 18 November, 2023

 Health Policy

Acknowledgement reporting period-January to December 2020. New Delhi. National

The authors would like to acknowledge the national antimicrobial pro- Programme on AMR Containment National Centre for Diseases
grams of ministries of health, in-country partners, and the WHO Control Directorate General of Health Services, Ministry of Health
and Family Welfare Government of India; 2021. Available at:
country offices of the South-East Asia Region.
https://ncdc.gov.in/showfile.php?lid=811. Accessed May 21, 2023.
19 Puspandari N, Sunarno S, Febrianti T, et al. Extended spectrum
beta-lactamase-producing Escherichia coli surveillance in the hu-
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