In 2017, a Joint External Evaluation of core capacity to implement the International Health Regulations (2005) was conducted in South Sudan to identify, prepare and respond to public health events of international concern, including antimicrobial resistance (AMR). The report showed gaps in various technical areas, such as lack of formal structures for multisectoral approaches, including communication and coordination among relevant One Health stakeholders; no national action plan on AMR; and “no capacity” (score 1) for detection of AMR, surveillance of AMR-related infections, prevention and control of health care-associated infection, and antimicrobial stewardship. In 2020, the South Sudan National Action Plan for Health Security (NAPHS) 2020-2024) was developed in response to the recommendations of the Joint External Evaluation for national capacity for health security in the One Health, whole-of-government approach. The NAPHS was the basis for the South Sudan national action plan (NAP) on AMR, ensuring a national multisectoral approach. The six steps for implementing NAPs are illustrated in Fig. 1.
Fig. 1. Six steps for sustainable implementation of an AMR NAP (1).
The Republic of South Sudan National Action Plan on Antimicrobial Resistance 2023-2028 (NAP 1.0), developed in 2023, included an operational plan for comprehensive interventions and both multisectoral and sector-specific actions for the AMR response, in line with the Global action plan on AMR (2). NAP 1.0 was developed by multisectoral, collaborative consultation under the leadership of the Ministry of Health in collaboration with the ministries of Livestock and Fisheries, Environment and Forestry, Wildlife and Tourism and Conservation, with other relevant AMR stakeholders, such as the Medical Corps of the Ministry of Defence Veterans Affairs, the WHO Country Office in South Sudan, the South Sudan Center for International Programs, the African Centre for Disease Control, the WHO Regional Office for Africa, the Food and Agriculture Organization of the United Nations and the World Organisation for Animal Health.
The national AMR secretariat in South Sudan coordinated development of the NAP, including organizing workshops for national stakeholders and agencies and implementing and technical partners between April and May 2023. The first workshop was held to review and validate an AMR situational analysis, which included mapping of AMR stakeholders, identifying strengths, weaknesses, opportunities and threats and providing recommendations on priorities in various sectors to be included in NAP 1.0. During a further workshop on the NAP, the stakeholders elaborated a strategic plan, a detailed operational plan and a plan for monitoring and evaluation. The stages of development of the NAP are outlined in Fig. 2.
Fig. 2. Development of the South Sudan AMR NAP 2023-2028
Guidelines, including the WHO implementation handbook for national action plans on antimicrobial resistance: guidance for the human health sector (1) and Antimicrobial resistance: a manual for developing national action plans were consulted for technical guidance (3). Other strategies and plans that include AMR, such as the NAPHS, were also reviewed to identify priorities, gaps and recommendations to be included in NAP 1.0, as South Sudan is in the early stages of its AMR activities.
The five strategic objectives of NAP 1.0 are:
- to improve awareness and understanding of AMR through effective communication, education and training;
- to strengthen knowledge and evidence through surveillance and research;
- to reduce the incidence of infection through effective sanitation, hygiene and infection prevention;
- to optimize the use of antimicrobial medicines in human and animal health; and
- to prepare an economic case for sustainable investment that accounts for the needs of all countries and for increased investment in new medicines, diagnostic tools, vaccines and other interventions.
Costing the South Sudan NAP on AMR
To cost the South Sudan NAP, consultations were held on use of the WHO costing and budgeting tool for national action plans on antimicrobial resistance (4) with the South Sudan national AMR secretariat and representatives of the three levels of WHO (headquarters, the Regional Office for Africa and the South Sudan WHO Country Office). Virtual and in-person training in use of the WHO costing and budgeting tool was provided on 2-4 May 2023 for coordinators selected from the ministries of Health, Livestock and Fisheries, Environment and Forestry, and Wildlife Conservation and Tourism. Other participants were from the Medical Corps Unit of the Ministry of Defense Veterans Affairs, other WHO partners, the Center for International Programs South Sudan and the Food and Agriculture Organization of the United Nations. Training was conducted in order to build national capacity in use of the tool so that the team could cost the operational plan for NAP 1.0 (Fig. 3).
Fig. 3. Training of costing coordinators in South Sudan
The trained costing coordinators were divided into five groups, each responsible for costing one NAP strategic objective. The groups included stakeholders from ministries, sectors and technical areas. The operational plan outlined the strategic interventions, activities, sub-activities, implementation steps and the lead implementing agencies, which is a prerequisite for costing the plan with the WHO tool. Once each group had costed the activities in its strategic objective, the modules were consolidated into the costed 5-year operational plan, with costing dashboards (Fig. 4). The AMR secretariat convened a 1-day workshop to finalize the costing, review the costed activities and validate the distribution of cost per ministry. The WHO AMR NAP Helpdesk was consulted on any issues that arose during training, costing and technical validation of the completed costing.
Fig. 4. Summary distribution of percentages of costs by ministry
The total cost of the 5-year plan is US$ 11 818 591, distributed as follows:
- creation of awareness and education on AMR: US$ 2 705 710
- surveillance, laboratory activities and knowledge: US$ 4 407 252
- infection prevention and control: US$ 1 460 242
- AMR stewardship: US$ 1 362 493
- research and development of an investment case: US$ 1 882 895
“We are grateful for having training on this WHO Tool for Costing for the first time. It is indeed a very important tool that we can use for not only AMR but also our other national plans, and this will greatly facilitate better planning. After the training, we even have experts among our own team who have been leading their groups. I believe we very capable of costing our own operational plan and we can proceed with finalizing the AMR NAP and submitting it for endorsement. This is a very big success for South Sudan,” commented Abe Lojuan, National AMR focal person.
South Sudan is in the early stages of its AMR response, one of its priorities being to strengthen multistakeholder coordination and engagement in a One Health, country-led approach. NAP 1.0 provides an AMR governance structure integrated into the country’s One Health governance in the Office of the Cabinet Affairs Ministers to ensure high-level political commitment and alignment with national priorities. The multistakeholder consultative workshops for NAP development and costing established multistakeholder coordination and engagement.
The costing exercise offered an opportunity to identify activities that could readily be implemented jointly and ensured that the costs of the activities were realistic. As the costs of activities are distributed according to each lead implementing agency, with progress in NAP implementation and monitoring, the implementers can use the tool to update and track which activities are funded and any funding gap that will require additional resource mobilization and avoid duplication. The South Sudan AMR NAP 2023-2028 has been finalized and will be submitted for endorsement (Fig. 5).
Fig. 5. South Sudan National Action Plan on Antimicrobial Resistance 2023-2028
Costing of NAP 1.0 was supported by the WHO Country Office, the WHO Regional Office for Africa and WHO headquarters. Financial contributions were made by the African Centre for Disease Control, the Federal Ministry of Health, Germany, and the governments of Saudi Arabia and the United Kingdom of Great Britain and Northern Ireland (UK Aid/ Fleming Fund).
- WHO implementation handbook for national action plans on antimicrobial resistance: guidance for the human health sector. Geneva: World Health Organization; 2022 (https://www.who.int/publications-detail-redirect/9789240041981).
- Global action plan on antimicrobial resistance. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/item/9789241509763).
- Antimicrobial resistance: a manual for developing national action plans. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/item/9789241549530).
- WHO costing and budgeting tool for national action plans on antimicrobial resistance. Geneva: World Health Organization; 2021 (https://iris.who.int/bitstream/handle/10665/346344/9789240036901-eng.pdf?sequence=1).