This study included 77 national action plans on AMR from the WHO Member States, available in the WHO library of AMR national action plans. This selection included countries from every WHO region: AFR (n = 13), EMR (n = 16), EUR (n = 14), RAM (n = 8), SEAR (n = 11), and WPR (n = 15). The income level of these countries covered: LIC (n = 9), LMIC (n = 24), UMIC (n = 20), and HIC (n = 24). Most national action plans were published in 2017 (n = 32), following 2018 (n = 15) and 2019 (n = 15). The Supplementary File 1 provides an overview of all national action plans included in this study.

Information on vaccination

Vaccination was mentioned in 67 out of 77 national action plans (87%) across all WHO regions, see Fig. 2. Ten countries, in WHO EUR (n = 4), SEAR (n = 3), WPR (n = 2), and EMR (n = 1), did not mention (human) vaccination at all in their national action plans, while all countries in the WHO African Region (n = 13) and American Region (n = 8) have included vaccination. Seventeen countries reported information on the effect of specific vaccines on AMR, with 10 national action plans covering multiple vaccines as shown in Table 2. The mean number of vaccines described in the 17 AMR plans is 2.18 (95% CI 1.59 – 2.76; Med = 2; SD = 1.13). All LIC countries (n = 9) include vaccination, however only one LIC country (Afghanistan) also mentions specific vaccines in its national action plan. One LIC (11%), five LMIC (21%), two UMIC (10%), and nine HIC (38%) include specific vaccines.

Fig. 2

World map of AMR national action plans including vaccination

Table 2 Overview of 17 out of 77 national action plans that include specific vaccines

Of the 67 national action plans that highlighted vaccination, 33 countries (49%) developed specific indicators to promote vaccination (and specify the value of vaccination on AMR prevention and control) while 34 countries (51%) merely mentioned vaccination as an example. Table 3 shows this data specified for each vaccine.

Table 3 Total of 17 national action plans discussing vaccination, either as indicator or exampleCountry comparison

We noticed that AMR national action plans overlap (e.g. textual overlap) with other plans across WHO regions and income groups, focusing on objectives on vaccination and specific vaccines included in the plans (e.g. Objective 4.6.1.3 of the Afghanistan and Indian national action plan is identical). Countries include more objectives on vaccination (43%) compared to specific vaccines (22%). Table 4 presents these results for each WHO region.

Table 4 Vaccination (objectives and specific vaccines) included in 77 AMR national action plans by WHO region

Figure 3 shows the inclusion of objectives on vaccination or specific vaccines (e.g. PCV, influenza vaccine, Hib vaccine, TCV, measles and/or rotavirus vaccination) in 77 national action plans, specified by country income level. Details on the 33 countries that include objectives on vaccination can be found in Supplementary File 1.

Fig. 3

Vaccination (objectives and specific vaccines) included in 77 AMR national action plans by income level

We assessed the association between income and vaccination using multilevel logistic regression and found that an increase of income is accompanied by a lower probability of including specific vaccines in AMR plans (OR = .77; p = .18; 95% CI .52-1.13). We found a weaker association, non-significant as well, in the opposite direction between income and the probability of including vaccination objectives in action plans; here an increase in income is accompanied by a slightly higher probability (OR = 1.05; p = .74; 95% CI .78-1.43). The multilevel model shows that regional variation is larger when it comes to the inclusion of specific vaccines in national action plans compared to objectives on vaccination (see Supplementary File 2).

Key components of national action plans

For this analysis we excluded 7 plans published in 2015, before publication of the 2016 WHO manual for developing national action plans. Out of the remaining 70 action plans, 21 (30%) included no key components and 19 (27%) included all key components (with 10 out of 19 countries in WHO EMR). Most countries include an operational plan (57%), followed by a strategic plan (47%) and M&E plan (40%). Table 5 shows the total number of plans that include a key component (i.e. component is specifically mentioned in the text) per income level and WHO region, although these key components are often not related to promoting or strengthening vaccination. In total, 11 strategic plans, 11 operational plans and 7 M&E plans include a specific objective or activity on vaccination. Only five AMR plans (7%) included all key components, including cost and funding, with a focus on vaccination.

Table 5 Key components included in 70 national action plans published after 2016Strategic plan

The strategic objectives in national action plans are not always specified in the strategic plan, as less than half of the 70 AMR plans (n = 33; 47%) included a strategic plan. The other 37 plans presented the objectives or strategies to tackle AMR throughout the text, focusing mainly on awareness, surveillance, infection prevention and control, antibiotic stewardship, and research and innovation. These main objectives are similar to the Global Action Plan on AMR, with additional country-specific objectives.

As based on the Global Action Plan, the following objectives were recurring in the AMR national action plans: (1) increase national awareness and understanding of AMR, (2) enhance national surveillance of AMR, (3) reduce the incidence of infections and contain the spread of antimicrobial-resistant organisms through effective IPC (e.g. sanitation and hygiene), (4) optimize the appropriate use of antimicrobials in humans, animals and agriculture, and (5) increase investment in research and development (R&D) for new antibiotics, vaccines, tools and other interventions.

Vaccination was often referred to in objectives related to infection prevention and control (strengthen, improve and promote vaccination programs: 67%) and research and innovation (prepare economic arguments for sustainable investment in new drugs, diagnostics and vaccines: 52%). Out of the 33 strategic plans, 11 plans (33%) included the promotion of vaccination or strengthening of vaccination programs as a strategic objective.

Operational plan

An implementation and operational plan was included in 40 out of 70 national action plans (57%). For each activity and sub-activity (what), these plans include a responsible entity (who), a timeline (when), and indicators, milestones or targets (how). Most operational plans are included in WHO EMR and AFR (see Table 5). Promoting or strengthening vaccination is a specific activity included in the implementation and operational plan of 11 national action plans (16%).

Costs and funding

Of the 70 national action plans published after 2016, costs and funding were described in 23 plans (33%). The costs or estimated budget often, but not always, included a source of funding and are described for each objective and activity. Costs and/or funding is described for five objectives and activities specifically related to promoting vaccination, included in the national action plans of Eritrea, Libya, Nigeria, Tanzania and Tunisia (WHO EMR and AFR).

Monitoring and evaluation plan

Twenty-eight countries (40%) included a M&E plan. For each activity and sub-activity, the plan describes the indicator, method and targets (by year). Only seven national action plans (10%) described monitoring and evaluation of objectives related to promoting or strengthening vaccination coverage: Eritrea, Nigeria, Pakistan, Sierra Leone, Tanzania, Tunisia and Zimbabwe (WHO EMR and AFR).