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Policy  –  Develop a plan

Evaluate progress

Monitoring and evaluation through analysis and reporting of quality indicators is an integral part of any health policy.

Evaluation of the national action plan

In order to ensure that implementation of the national action plan on antimicrobial resistance occurs as planned, continuous monitoring is important. Results should be fed back to government parties and members of the stakeholder platform in a timely manner and in a format that can be interpreted and used by the respective party. Periodic evaluation is important to understand if goals are being accomplished and to identify aspects that may need improvement.

Develop a monitoring and evaluation plan

When monitoring health reforms, assessments of the level of inputs (financial, human, and logistics), the dynamics, processes and the outputs of implementation are in focus. Evaluation then assesses the extent to which the policy’s different activities has achieved the outcome and impact objectives. In other words, if the policy has had the effect it intended and what could be addressed and improved.

Often evaluation is done by measuring indicators, however, in addition, the collection of descriptive data can be helpful to give a comprehensive view of the extent to which changes are occurring. When developing a monitoring and evaluation framework, the multisectoral coordinating group should consider:

  • What is the specific aim(s) of the policy/intervention?
  • What measure(s) monitor the policy implementation process?
  • What measure(s) would show progress in achieving stated aims?
  • How to collect and record such data?
  • Who will analyze and interpret the data?
  • How does the results of such data then influence stakeholders and/or policy?

Annual target plans

One way of increasing the likeliness of actual implementation is to set up annual target plans. Such target plans helps in planning for short and long term goals of the policy and to go from policy into action. Moreover, they can serve as important tools for budget planning and allocation. It is advisable that the annual target plans also include clear and measurable indicators to allow monitoring and evaluation of the process.

Annual targets in the White House National Action Plan for Combating Antibiotic-resistant Bacteria

In their National Action Plan from 2015, the US government set up five larger general goals to address antibiotic resistance. These have several attached objectives, each containing 1, 3 and 5-year milestones that define clear targets. An example is Objective 5.3 that was written in the following way:

Develop a mechanism for international communication of critical events that may signify new resistance trends with global public and animal health implications.

Milestones:

Within one year:

  • CDC will work with TATFAR partners to develop a common U.S.-E.U. system for sharing and analyzing bacterial resistance patterns for pathogens identified as urgent and serious threats in Table 1.
  • HHS/OGA, USDA, FDA and CDC will work with TATFAR partners to address TATFAR Recommendation #18, which calls for the formation of an international working group to identify key knowledge gaps about transmission of drug-resistant bacteria in animals and the use of antibiotics in animal agriculture.

Within three years:

  • CDC will work with WHO and other partners to develop a secure website for real-time sharing of international surveillance data on antimicrobial resistance in order to facilitate early warning and notification of significant events to WHO, regional and international disease surveillance networks (e.g., European Centre for Disease Prevention and Control), and IHR. These efforts will make use of data-sharing practices developed by the U.S. and TATFAR (see above). Steps include developing terms of reference, assessing IT requirements, and identifying mechanisms for validating and sharing information.
  • CDC will deploy the website in partnership with the international community and will help test, monitor, evaluate, and improve its utility.
  • USDA will identify next steps in addressing knowledge gaps about development and spread of antibiotic resistance in animals, based on the conclusions of the work group formed in fulfillment of TATFAR Recommendation #18 (see above).

Within five years:

  • CDC and other U.S. agencies will help ensure access to – and full participation by – public health authorities in all WHO member countries.
  • USDA will engage TATFAR and other regional partners in sharing information about drug-resistance trends with implications for animal health.”

Even though indicators are not clearly stated, the milestones provide targets to be fulfilled. The full plan can be found here.

Measurement and indicators

An essential part of the planning of the monitoring and evaluation plan is the development of adequate indicators. It is important that indicators represent the progress towards implementing the activity or achieving the outcome. Indicators used to monitor implementation of the antibiotic resistance policy can be divided into different groups:

Indicator Groups for Monitoring and Evaluation:

Indicator Group Description Example(s)
Input Indicators measuring resources used/needed in implementing policy Financial cost of:

  • Infrastructure
  • Human resources
  • Consumables
Process Indicators measuring action points relating to programme implementation
  • Working groups formed
  • Training sessions held
  • Launch of public awareness campaign
Output Indicators measuring the number or presence of intended products/outputs
  • Number of infection control programs initiated
  • Dosages of antibiotics distributed
Outcome Indicators that assess the quantity and quality of the policy implemented
  • Decrease of inappropriate use of antibiotics in agriculture or veterinary medicine
  • Decrease in targeted drug-resistance infections
Impact Indicators assessing the achievement of longer term goals relating to broader policy aims
  • Health Status of the population
  • Reduced risk of pandrug resistance

Implementation plan, indicators and targets for WHO South East Asia’s Regional strategy on prevention and containment of antimicrobial resistance (2010-2015) :

The WHO SEARO regional strategy 2010-15 recognized the need for a wide range of activities to contain antimicrobial resistance and the need for commitment from a wide variety of players. The strategy states that endorsement by all countries of the region is needed for sustained action. It provides an implementation framework with suggestions of activities that could be included together with a list of suggested indicators and targets. Many of these regional indicators could be transferable to the national level. The strategy and the different indicators were followed up in regional meetings and workshops where country reports on current status and progress were presented.

In MEASURE you can find specific tools and resources for measuring various aspects of antibiotic resistance and use (suc point prevalence survey protocols and knowledge, attitudes, beliefs and practices questionnaires):

Analyzing and communicating results

Data collected from monitoring and evaluation efforts should be analyzed by the multisectoral coordinating group and additional key stakeholders.

Results from monitoring indicators (such as input and process indicators) can inform discussions related to future implementation strategies, whilst results from evaluation indicators (such as output, outcome or impact indicators) can also be used in future resource allocation decisions. Information for both sets are needed, as a failure of impact may be due to a failure in implementation.

Results should be fed back to collaborating partners and interested stakeholders, especially management. Communication methods and content should be tailored to the audience, and reporting should be transparent to promote confidence in the national action plan. Positive progress should be acknowledged and public recognition should be made of the contributions and successes of all partners involved in the project. Affirmation of hard work will provide incentive for stakeholders to continue to be involved in the process.

Selected Resources

Resource Description 
Monitoring and evaluation of the global action plan on antimicrobial resistance: framework and recommended indicators Guidance with indicators. Framework to help obtain and analyze standardized data to assess the success of the global action plan on antimicrobial resistance (GAP) and inform operational and strategic decisions on resistance at both national and global levels. Recommends indicators to be compiled on a national level as well as indicators to be collected on a global level from secondary sources.
FAO Antimicrobial Resistance Policy Review and Development Framework Guide from FAO to help decision-makers and technical staff to review, develop and implement national policies on antimicrobial use and resistance in food animal production. Covers both AMR-specific and AMR-relevant policies. The Framework is designed to help countries review and update their national policies and provides examples from countries that facilitate effective national responses to AMR. Developed for governments in Asia and the Pacific.
Building Coalitions for Containing Antimicrobial Resistance: A Guide Guidance by SIAPS offers guidance on how to formulate and implement a plan and evaluate outcomes. Also provides a number of templates and sample interview forms that can be adapted for different local contexts. The chapter “Monitor and evaluate” gives an overview of the M&E process with country examples. An older version is available in Spanish and French.
ECDC, EFSA and EMA Joint Scientific Opinion on a list of outcome indicators as regards surveillance of antimicrobial resistance and antimicrobial consumption in humans and food-producing animals Indicators. Suggestion of outcome indicators with a ‘One Health’ perspective to support assessment of progress made in the implementation of actions against antibiotic resistance in EU Member States. Provides rationale for selection, describes methodology, and provides example of calculation of indicators. Established by European health and food safety agencies. Examples: Human medicine: proportion of Escherichia coli bacteria resistant to third-generation cephalosporins. Veterinary medicine: proportion of E. coli in food-producing animals that are susceptible or resistant to a number of antibiotics.
Country monitoring and evaluation guidance Guidance from WHO to policy makers and health practitioners on how to strengthen the monitoring, evaluation and review of national health strategies. See for example “Monitoring, evaluation and review of national health strategies: a country-led platform for information and accountability, available in English, French and Spanish.
Guidelines for Monitoring and Evaluation of Health Sector Reforms in the African Region Guideline published by the WHO’s Regional Office for the African Region. It offers guidance to member states on how to integrate M&E into the process of health care planning. It also provides a background to health sector reform implementation and proposes a conceptual framework for identifying key questions and indicators for monitoring and evaluating of these reforms.
1.
The White House. National Action Plan for Combating Antibiotic-Resistant Bacteria [Internet]. US Governement; 2015 [cited 2015 Apr 22]. Available from: https://www.cdc.gov/drugresistance/us-activities/national-action-plan.html
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Food and Agriculture Organization of the United Nation - FAO. Antimicrobial Resistance Policy Review and Development Framework [Internet]. 2018 [cited 2019 Jul 1]. Available from: http://www.fao.org/emergencies/resources/documents/resources-detail/en/c/1154167/
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SIAPS. Building Coalitions for Containing Antimicrobial Resistance: A Guide. Submitted to the US Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services Program. Arlington, VA: Management Sciences for Health. [Internet]. 2017 [cited 2018 Mar 14]. Available from: http://siapsprogram.org/publication/building-coalitions-for-containing-antimicrobial-resistance-a-guide/
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World Health Organization - WHO, Food and Agriculture Organization of the United Nation - FAO, World Organisation for animal health - OIE. Monitoring and evaluation of the global action plan on antimicrobial resistance: framework and recommended indicators [Internet]. World Health Organization; 2019 [cited 2019 Jun 18]. Available from: https://apps.who.int/iris/handle/10665/325006
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ECDC, EMA Committee for Medicinal Products for Veterinary Use (CVMP), EFSA Panel on Biological Hazards (BIOHAZ). ECDC, EFSA and EMA Joint Scientific Opinion on a list of outcome indicators as regards surveillance of antimicrobial resistance and antimicrobial consumption in humans and food-producing animals. EFSA Journal [Internet]. 2017 Oct 1;15(10):n/a-n/a. Available from: http://onlinelibrary.wiley.com/doi/10.2903/j.efsa.2017.5017/abstract
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Monitoring, evaluation and review of national health strategies: a country-led platform for information and accountability. [Internet]. Geneva, Switzerland: World Health Organization - WHO; 2011. 49 p. Available from: http://www.who.int/healthinfo/country_monitoring_evaluation/documentation/en/
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World Health Organization - WHO. Child Health and Development - Indicators [Internet]. [cited 2015 Apr 22]. Available from: http://www.emro.who.int/child-health/research-and-evaluation/indicators/All-Pages.html
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World Health Organization - WHO. Guidelines for Monitoring and Evaluation of Health Sector Reforms in the African Region [Internet]. WHO AFRO; [cited 2015 Apr 22]. Available from: http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=2216
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WHO Regional Office for South-East Asia. Regional strategy on prevention and containment of antimicrobial resistance [Internet]. World Health Organization; 2010. Available from: http://www.searo.who.int/entity/antimicrobial_resistance/rev_regional_strategy_on_amr.pdf?ua=1