In order to implement National Action Plans (NAPs) on antimicrobial resistance (AMR), those making funding decisions need to understand how much activities will cost, what is already being funded, and how to leverage additional funding. Sierra Leone was the first country to pilot test the prototype WHO costing and budgeting tool resulting in a fully costed two-year operational plan for its’ National Action Plan on AMR. The lessons learned from the pilot along with additional pilots in Paraguay, Jamaica and Somalia were instrumental in finalizing the WHO costing and budgeting tool for national action plans on AMR, which was launched in October 2021. Funding for the pilot was provided by the Kingdom of Saudi Arabia and the Government of the United Kingdom of Great Britain and Northern Ireland (UK aid/ Fleming Fund).
The aim of the WHO costing and budgeting tool is to support countries, through a participatory process, to turn their AMR plans into action by enabling the costing of priority activities. In addition to costing individual activities, the tool also enables the insertion of existing funding and the identification of funding gaps. A pre-requisite to using the costing tool is to have a time-bound operational plan in place with prioritized activities.
The process
The process for piloting the prototype WHO Costing and Budgeting Tool for National Action Plans on AMR was initiated in Sierra Leone in December 2020 with support of the three levels of WHO (headquarters (HQ), regional office for the African region (AFRO) and the Sierra Leone country office). Following an initial meeting of the Sierra Leone AMR multisectoral governance mechanism, twelve costing coordinators were nominated from the Ministry of Health and Sanitation, the Ministry of Agriculture and Forestry, and the Ministry of Environment through the Environment Protection Agency to undertake the pilot and subsequent development of the first costed operational plan for Sierra Leone’s National Action Plan on AMR. The training of the costing coordinators on the prototype tool took place through a three day hybrid (both virtual and in-person) training in January 2021.
“The tool is user friendly and allowed me to easily navigate and find the information I needed…” (Anthony Daniel Foday, senior Public Health Superintendent, Ministry of Health and Sanitation, Sierra Leone and lead costing coordinator)
“The costing exercise provided an opportunity for multi-sectoral stakeholders to have a more granular insight into the NAP leading to prioritization of activities guided by likely impact of the intervention and feasibility in a resource limited setting.” (Gerald Shambira, consultant, Sierra Leone WHO country office)
Technical personnel from several Ministries, Departments and Agencies with support from WHO and FAO assisted in developing a detailed implementation plan for the prioritized activities, including unit costs and quantities. The costing tool readiness checklist was instrumental in ensuring all of the prerequisites for costing were undertaken. The training of the national costing coordinators in January was also key in enabling the correct utilization of the costing and budgeting tool when costing of the two-year National Action Plan for Sierra Leone. Moreover, initial IT challenges with generation of costing and funding dashboards – owing to Excel version compatibility – was resolved during the training.
Fig. 1. The 12 costing coordinators from Sierra Leone
Following the costing tool training workshop, a national workshop to prioritize activities for the two-year operational plan to be costed took place in February 2021 with assistance from the Sierra Leone WHO country office. Activities were prioritized according to expected impact of the activity and feasibility (ease/difficulty of implementation including cost). From an initial list of activities, 111 activities under 56 objectives were prioritized. Subsequently, using the WHO costing and budgeting tool, the costing coordinators developed a fully costed two-year operational plan for Sierra Leone with a total cost of 2.146 million USD which was presented to the AMR multisectoral governance mechanism in May 2021 (Fig. 2).
Fig. 2. Process for developing the Sierra Leone costed AMR operational plan
The costed plan will support Sierra Leone in enhancing resource mobilization efforts for the implementation of the prioritized activities to accelerate action on AMR in the country. The multisectoral governance mechanism is currently seeking endorsement by the government of the finalized two year costed AMR operational National Action Plan. In addition, the costed plan is already being used to mobilize resources from domestic and external donors and implementing partners.
“We found the tool very easy to use. The costing exercise provided us an opportunity to develop a two-year costed National Action plan that highlights key priority activities with high impact. The exercise also assisted with AMR resource allocation and will be used to mobilize additional funding for AMR activities. As a country, we are excited that Sierra Leone was selected for the pilot of this tool – this means that Sierra Leone will always do it when it comes to addressing AMR issues!” (Dr. Joseph Sam Kanu, Deputy Manager, National Disease Surveillance Programme, Ministry of Health and Sanitation, Sierra Leone and AMR Focal Point, Sierra Leone)
Delivering the training in the midst of COVID-19
To ensure smooth delivery of the training on the WHO costing and budgeting tool while COVID-19 restrictions were in place was a challenge. However, the three levels of the WHO (WHO HQ, AFRO and the Sierra Leone WHO country office) worked closely together to deliver a hybrid (both virtual and in-person) training to the 12 costing coordinators. To this end, the WHO country office trained staff co-facilitated the training in-person while the lead external trainers connected virtually. The adoption of such a hybrid modality has resulted in a successful outcome while ensuring robust institutional sustainability and adherence to the COVID-19 restrictions.
Fig. 3. Opening Session of AMR Operational Plan Development in Makeni, Sierra Leone
“The tool was user friendly and allowed easy navigation. The accompanying guide was brief and provided information for easy trouble shooting. We managed to assist the Ministry of Health and Sanitation in developing a detailed two-year implementation plan for the selected activities, including unit costs and quantities.” (Anna Maruta, Infection control specialist, AMR Team lead, Sierra Leone WHO country office)
Lessons learned
Sierra Leone adopted a step-wise approach in developing their costed two-year operational National Action Plan. Involvement of many different ministries, departments and agencies and the prioritization of activities to be included in the operational plan using a One Health approach, through a multisectoral workshop, was key. This allowed the multisectoral governance mechanism to identify country priority activities to implement in 2021-22 through a participatory approach. Furthermore, it was agreed to include detailed implementation steps in the operational plan, which made the costing of the activities easier. The WHO costing and budgeting tool was then used to calculate real costs (related to each activity) and identify funding gaps.
The use of the One Health approach in selecting the 12 costing coordinators from the human health, animal health, agriculture and environment sectors means that expertise on the use of the tool has been shared to the various sectors. The sectors now have a pool of experts on the use of the tool for future costing and budgeting exercises.