Antimicrobial resistance (AMR) is no longer a distant scientific concern; it is an immediate systems crisis. Globally, bacterial AMR was associated with 4.71 million deaths in 2021, including 1.14 million deaths directly attributable to resistant infections. If current trends persist, AMR could claim up to 10 million lives annually by 2050 – outstripping cancer as a cause of mortality.
India sits at the centre of this crisis. It is among the world’s largest consumers of antibiotics and as a major global supplier of active pharmaceutical ingredients. This dual role makes AMR not only a public health challenge but also a structural vulnerability with global spillovers.
AMR is often framed as a problem of misuse–over-prescription, patient non-compliance, or weak awareness. These factors matter, but they do not explain why resistance continues to rise even where policies and controls exist. The deeper problem is institutional fragmentation. Antibiotics are produced, prescribed, financed, and disposed of across systems that do not share accountability, allowing resistant organisms to emerge and spread faster than they can be contained.
A Perfect Storm of Drivers
Antimicrobial resistance thrives not simply because antibiotics are misused, but because the systems that govern their use, and disposal operate in isolation. India’s high burden of infectious diseases – tuberculosis, diarrhoeal, respiratory infections – sustains constant antibiotics demand, yet prescribing practices remain weakly regulated. Antibiotics are frequently used for viral infections, sold over the counter despite prescription controls, and consumed through incomplete treatment courses. Irrational fixed-dose combinations further increase the likelihood that resistant strains survive and spread.
Clinical misuse, however, explains only part of the persistence of resistance. Antibiotic residues from pharmaceutical manufacturing and human excretion enter water bodies through inadequately treated effluents and wastewater. Resistant bacteria and genes have been detected in urban sewage and downstream ecosystems, while veterinary antibiotics used in livestock production persist in soils and food chains. These pathways ensure that resistance generated in one domain does not remain confined to it.
Once in the environment, resistance genes circulate across water, food chains, and ecological systems. Bacteria can exchange these genes, allowing resistance acquired in one setting to surface in another. AMR is therefore not confined to prescribing practices. It is the cumulative result of fragmented governance across health care, agriculture, industry, and environmental regulation.
Emergence Avoidance vs Transmission Avoidance
To break this cycle, policy must act on two distinct but interdependent fronts. The first is emergence avoidance – reducing the creation of new resistance. This requires rational prescribing, restricting over-the-counter sales, strengthening antimicrobial stewardship in hospitals, expanding vaccination to reduce unnecessary antibiotic demand, and regulating irrational drug combinations. Every inappropriate prescription increases the likelihood that resistant strains survive and spread.
The second front is transmission avoidance – limiting the spread of resistant organisms once they emerge. This depends on timely laboratory detection, effective infection prevention and control practices, sanitation, wastewater treatment, and biosecurity in agriculture. Resistant bacteria move across hospitals, communities, farms, and ecosystems; containment breaks down when transmission pathways remain open.
Progress on one front without the other is self-defeating. Curtailing misuse without improving hygiene allows resistant strains to circulate, while improving sanitation without rationalising prescribing accelerates the emergence of new variants.
AMR control therefore fails not because tools are unavailable, but because reducing emergence and limiting transmission require coordinated action that existing policy responses treat separately.
Policy Architecture Exists – But Enforcement Lags
India is not without a policy response to antimicrobial resistance. The National Policy for Containment of AMR (2011) and the subsequent National Action Plan aligned the country with the World Health Organization’s (WHO’s) Global Action Plan. Regulatory steps followed: Schedule H1 restricted key antibiotics to prescription-only sales, the Indian Council of Medical Research established a national AMR surveillance network, antimicrobial stewardship programmes were piloted in tertiary hospitals, and irrational fixed-dose combinations were prohibited.
At the subnational level, several states – including Kerala, Madhya Pradesh, Delhi, Andhra Pradesh, and Rajasthan – have launched State Action Plans for Containment of AMR. A sentinel surveillance model, which monitors selected laboratories to generate representative resistance data, has been adopted as a pragmatic alternative to comprehensive nationwide monitoring.
On paper, this architecture appears comprehensive. In practice, however, these instruments operate in parallel rather than as a single system. Prescribing controls, surveillance, infection prevention, and environmental oversight are governed by separate institutions, with limited feedback between them.
As a result, enforcement varies widely across states, laboratory capacity differs sharply, resistance data from public and private facilities remain poorly integrated, and environmental compliance in pharmaceutical manufacturing is inconsistently monitored. The framework exists; sustained coordination and accountability do not.
States as Proof of Concept
State-level experience shows that outcomes change when responsibility for antimicrobial use, surveillance, and infection control is institutionally aligned rather than dispersed.
In Kerala – where antibiotics account for nearly 20 percent of total use – hospital-based stewardship programmes and strengthened infection control protocols have led to reductions in high-end antibiotic prescribing, shorter hospital stays, and lower treatment costs. Systematic monitoring of priority pathogens in tertiary facilities has improved prescribing accountability.
Madhya Pradesh has pursued a complementary strategy, introducing hospital-specific antibiograms – resistance profiles that guide doctors toward appropriate therapies – while linking infection control measures with improved wastewater management.
The lesson is not that AMR can be eliminated at the state level, but that institutional design matters. These cases do not offer a scalable solution by themselves, but they establish a proof of concept: coordination changes behaviour even in the absence of new technologies or expanded budgets.
Embedding AMR into Universal Health Coverage
AMR control cannot succeed as a standalone effort. Fragmented governance of prescribing, surveillance, infection control, and environmental regulation leaves no institution responsible for closing the loop between evidence and action; India’s universal health coverage (UHC) architecture provides the framework to do so.
The WHO’s Global Action Plan on AMR identifies five priorities – awareness, surveillance, infection prevention, rational use, and sustainable investment. These are not specialised interventions; they are core functions of a health system. Embedding AMR control within UHC frameworks allows these functions to be coordinated through routine financing and oversight, rather than pursued as parallel initiatives.
India’s publicly financed health expansion creates an operational entry point. Large schemes such as the Ayushman Bharath Pradhan Mantri Jan Arogya Yojana generate high volumes of utilisation data and already shape provider behaviour through reimbursement rules. Integrating digital prescription records into claims processing would allow antibiotic use to be monitored systematically. Linking reimbursement to condition-specific treatment guidelines – aligned with the WHO’s Access, Watch, and Reserve classification – would create direct incentives for rational prescribing. Surveillance data could then feed back into both clinical guidance and payment design, closing a loop that currently remains open.
This health-system alignment does not exhaust the AMR challenge. System-wide controls – phasing out non-therapeutic antibiotic use in livestock, enforcing wastewater treatment standards in pharmaceutical clusters, and strengthening laboratory accreditation – remain essential complements.
But without institutionalising AMR within UHC mechanisms, these efforts remain fragmented. With it, antimicrobial stewardship becomes part of routine system design rather than an external campaign – linking evidence to incentives, and intent to outcomes
Governance Is the Frontier
India has already built much of the formal architecture to tackle AMR. The challenge now is to translate policy intent into sustained coordination. That shift – from isolated interventions to system design – is the real frontier. It lies in making institutional alignment as central to health policy as drug discovery itself – and in recognising that resilience against resistance is a function of governance, not chance.
