National Effort on Containment of AMR in Nepal

Ms. Usha Tandukar is a Senior Drug Administrator within the Quality Standard and Regulation Division at Nepal’s Ministry of Health and Population.

Antimicrobial resistance (AMR)

Antimicrobial resistance (AMR) is one of the major public health issues that challenges the remarkable success of modern medicine. Global and national evidence shows that AMR will continue to be a leading cause of death if not tackled in time.

According to the Institute for Health Metrics and Evaluation (IHME) paper titled Global Burden of Bacterial Antimicrobial Resistance 1990–2021: A Systematic Analysis with Forecasts to 2050, an estimated 21.36 million people who died globally in 2021 had sepsis either as the immediate cause of death or as part of the chain of events leading to their death, based on data from 204 countries and territories.

As per this study, 4.71 million people who died suffered from drug-resistant infections such as lower respiratory, bloodstream, and intra-abdominal infections, and 1.14 million deaths were directly caused by AMR. It is projected that 39 million people are expected to die from AMR between 2025 and 2050.

In Nepal, 6,000 lives have been lost each year since 1990 due to AMR. In 2021, there were an estimated 4,710 deaths attributable to AMR and 19,600 deaths associated with AMR. The largest number of deaths associated with AMR in 2021 occurred among those aged 70+ in the country. In 2021, across 204 countries, Nepal had the 60th highest age-standardized mortality rate associated with AMR.

Coordinated efforts at the global, regional, and national levels have significantly strengthened the policy landscape, creating a more supportive environment for the prevention and control of this pressing issue.

Recognizing the threat early on, health ministers from the South-East Asia Region, including Nepal, signed the Jaipur Declaration on Antimicrobial Resistance in 2011 (WHO SEARO, 2011).

In May 2015, the 68th World Health Assembly endorsed the Global Action Plan on Antimicrobial Resistance (GAP-AMR), based on the “One Health” approach, recognizing that antimicrobial resistance is not only a human health issue but also closely linked to animal health and the environment. The GAP emphasizes the importance of multi-sectoral involvement in addressing the problem of AMR.

In 2016, the global commitment to combat AMR was further strengthened by the high-level meeting on AMR at the United Nations General Assembly, in which global leaders reiterated their commitment to act on AMR through a political declaration that was adopted as a UN General Assembly resolution (UN, 2016).

In Nepal, various policy documents, including the National Health Policy, 2076 (2019), the Fifteenth Five-Year Plan (fiscal year 2019/20–2023/24), the National Animal Health Policy, 2078, and the Sixteenth Five-Year Plan (fiscal year 2024/25–2028/29) issued by the Government of Nepal, have highlighted AMR as a prime public health issue requiring urgent action. The Nepal Health Sector Strategy 2015–2020 also identified AMR as a public health challenge. To address the One Health issue, the “One Health Strategy, 2076” (2019) was endorsed by the Council of Ministers.

Several acts across the One Health sectors have provided a legislative framework for the control of AMR in human, animal, and food sectors. The Public Health Service Act, 2075 (2018), as well as the Drug Act, 2035, prohibit the sale or distribution of antibiotics without a medical prescription. The Food Hygiene and Quality Act, 2081 (2024) and the Animal Slaughterhouse and Meat Inspection Act, 2055 (1999) provide standards for maintaining the quality of consumables, including food and meat.

To contain AMR, a multisectoral National Action Plan (NAP) has been developed in coordination with relevant sectors and stakeholders and approved by the Ministerial Council on 26th February 2024. This document identifies five strategic priorities for the NAP-AMR, aligned with GAP-AMR:

1. Improve awareness and understanding of AMR through effective communication, education, and training.
2. Strengthen knowledge and evidence related to AMR through surveillance and research.
3. Reduce the incidence of infection through effective infection prevention and control.
4. Optimize the use of antimicrobial agents in the human, animal, and food sectors.
5. Ensure sustainable resources for the containment of AMR and promote investment in research and innovation.

Each strategic priority has its own focus areas, with various strategic interventions proposed. Within each priority and focus area, interventions include key activities and outputs with timelines for completion—short-term (within 1 year), medium-term (1–3 years), and long-term (3–5 years). Altogether, 123 activities are outlined in the NAP-AMR.

Two major committees, the National Steering Committee and the National Technical Working Committee, have been proposed for implementing this action plan at the national level. The plan also allows for the formation of other committees based on strategies, priorities, sectors, and the three tiers of government to ensure coordination and collaboration. A comprehensive and integrated approach at the national, provincial, and local levels has been established to address AMR, with resources expected to be managed jointly by the three tiers of government, development partners, and non-governmental organizations.

The primary objective of the NAP-AMR is to ensure the rational and optimal use of antimicrobials across “One Health,” reduce the burden of AMR, and emphasize multi-sectoral coordination, collaboration, and communication. The plan aims to improve awareness and understanding of AMR in Nepal, reduce inappropriate antimicrobial consumption, and optimize antimicrobial use. It is expected to enhance infection prevention and control (IPC), initiate Antimicrobial Stewardship Programs (AMSP) in healthcare facilities at both community and hospital levels, and contribute substantially to AMR containment.

The NAP is also expected to strengthen coordination and cooperation among “One Health” stakeholders, aiding patient management, reducing morbidity and mortality, and supporting the achievement of SDGs and Universal Health Coverage. Implementation requires joint efforts from all One Health sectors, including professional organizations, academia, civil society, media, and consumer groups.

Key Regulatory and Policy Interventions Addressing Antimicrobial Resistance in Nepal:

Ban on Non-Recommended Antibiotic Combinations: On August 9, 2023, during its 55th meeting, the Drug Advisory Committee (DAC) under the Department of Drug Administration (DDA) prohibited the import, sale, distribution, and manufacture of antibiotic combinations not recommended by WHO. A decision was also made to include a Red Line on the packaging of antibiotics and all antimicrobials.

Restriction on Antibiotics in Poultry Feed: The Ministry of Agriculture and Livestock Development (MoALD) published a quality standard document for poultry feed in the Nepal Gazette on May 29, 2023, prohibiting the use of antibiotics in poultry feed.

Ban on Colistin for Animal Use: At its 50th meeting on August 20, 2019, the DAC prohibited the registration, import, sale, distribution, and manufacture of Colistin for veterinary use, recognizing its critical importance in human medicine.

Hospital-Level Circular from MoHP: On July 11, 2022, the Ministry of Health and Population (MoHP) issued a circular to all hospitals, mandating several antimicrobial stewardship measures:

Revision of the Cardex system to include the indication, start date, review date, and stop date for every antimicrobial prescribed.

Avoid use of WHO’s “not recommended” antibiotics.

Initiation of Antimicrobial Stewardship Programs (AMSP) in healthcare facilities.

Ms Usha Tandukar

She is a Senior Drug Administrator in the Quality Standard and Regulation Division of the Ministry of Health and Population, Nepal. She serves as the Member Secretary of the National Technical Working Committee on AMR (NTWC-AMR). She holds a Master’s degree in Industrial Pharmacy from Kathmandu University and is an executive member of Women in Science and Technology (WIST). She is registered with the Nepal Pharmacy Council and is a Life Member of the Nepal Pharmaceutical Association (NPA).