## 1 Introduction  
Antimicrobial stewardship (AMS) has been recommended as a key strategy for optimising the use of antimicrobials and reducing the global threat of antimicrobial resistance (AMR) [1]. AMS programmes have evolved in different healthcare settings [2; 3; 4], but most relevant research has been conducted in high-income countries, whose healthcare systems are supported by a political commitment to AMS and substantial financial investments [4]. Learning from high-income countries needs to be shared and adapted for low- and middle-income countries (LMICs). The initial successes provide evidence for the effectiveness of shared learning approaches [1; 5; 6; 7; 8; 9; 10]. A key requirement for the success of shared learning appears to be the engagement and empowerment of frontline staff, who need to be equipped with the skills and tools to carry out AMS effectively.  
In 2019, [PERSON] et al. [11] developed a global checklist of the core elements of hospital AMS programmes. The checklist collates information from published literature, the previously developed core elements of AMS programmes, and their accompanying checklist items. However, the authors themselves identified a number of shortcomings of their tool, for example, stating '... most of these checklist items may not currently exist in most hospitals in low-income countries' and suggesting 'These seven core elements and their related 29 checklist items could be adapted and adopted locally depending on factors such as clinical setting and resource availability' [11] p. 23. Subsequent efforts have addressed these suggestions and focused on developing more appropriate materials for the LMIC context [12]. In October 2019, the WHO published a toolkit of essential national core elements for AMS programmes in LMICs. This was supplemented by a 28-item checklist of essential healthcare facility core elements for AMS programmes in LMICs, differentiating between the 'basic' and 'advanced' elements [12]. The development of materials for LMIC healthcare settings was an initial step toward more contextualised AMS approaches.  
This study takes another step toward increasing the suitability and acceptance of standardised AMS tools in LMIC settings in several different ways:  
1. Our focus on Sub-Saharan Africa (specifically Tanzania, Zambia, Uganda, and Ghana) offers a further local adaptation of the materials.
2. Our unique methodological approach uses elements of co-creation through the strong involvement of local hospital representatives during a Delphi consensus procedure.  
3. We extended the number of checklist items to capture the more nuanced differences in the AMS elements. Additionally, we incorporate open-ended questions within the AMS checklist to allow for more reporting flexibility.
4. We provide an initial evaluation of the checklist's effectiveness by using it to measure the outcomes of an AMS intervention programme.  
The checklist was developed as part of the 'Commonwealth Partnerships for Antimicrobial Stewardship' (CwPAMS) programme, funded by UK aid Fleming Fund and jointly managed through the Tropical Health and Education Trust (THET) and the Commonwealth Pharmacists Association (CPA) [13; 14; 15; 16]. The CwPAMS programme ran from inception in September 2018 until June 2021 and was set up to support 12 health partnerships between teams of volunteers (including pharmacists and specialist nurses) from the UK's National Health Service (NHS) Trusts and higher education institutes and health workers in four African countries (Tanzania, Zambia, Uganda, and Ghana). The CwPAMS programme provided the perfect setting for developing the AMS checklist because the existing project infrastructure enabled the easy identification of representative healthcare workers to be included in the consensus process. Given CwPAMS' efforts in running AMS interventions, the project further allowed us to test the success of the newly developed checklist.