Antimicrobial resistance (AMR) poses a significant challenge, with bacterial, protozoal and fungal infections often overlooked compared to viral ones.
India's high antibiotic consumption necessitates stringent controls akin to narcotics regulation.
The proposed Controlled Antimicrobials framework aims to integrate digital infrastructure to monitor prescriptions and reduce misuse.
It was anticipated and remains true that a virus acts quickly and visibly, and can be managed, whereas antimicrobial resistance in protozoa, bacteria, and fungi persists subtly, progresses slowly and poses the greatest challenge to address.
While multipronged actions have been ongoing, including standards, regulations, policy support and technical interventions, the big impact expected is elusive.
So what can be done to change public behaviour to achieve desired results? Holistic approaches are complex to design, implement and monitor. Hence its proposed to take a different pathway this time.
The approach so far included limiting prescriptions unless sensitivity tests demand, standardised treatment regimens, over-the-counter (OTC) sales ban, personal hygiene, lowering cost of molecular diagnostics, vaccine development and its funding. Newer approaches include next-generation antibiotics, bacteriophage therapy and CRISPR/Cas-based antibacterial strategies will all the approaches simulated using artificial intelligence.
The question is, do we expect it to really make the big impact needed? Chronic conditions are often ignored until it’s too late, unless we have a situation like the glucagon-like peptide-1 treatment for diabetes and obesity, which have now become the top-selling medications, even surpassing anti-cancer drugs.
The core issue remains easy access in low- and mid-income countries. Unless there is immediate dispensing control on antibiotics like that done for drugs under the Narcotic Drugs and Psychotropic Substances (NDPS) Act, this will continue.
The case is being made because India is among the highest consumers of antibiotics globally, with widespread OTC sales and irrational prescriptions. Fluoroquinolones, cephalosporins and carbapenems are often used without culture sensitivity, driving resistance.
The NDPS Act has successfully restricted access to high-risk substances through licensing, documentation, and penal provisions. A similar framework for Schedule H1 and critical antimicrobials could enforce accountability and traceability.
Risk-based control of antimicrobials in India is designed through a tiered framework that classifies drugs according to their spectrum, clinical importance and potential for resistance.
At the highest level, Tier 0 includes the most restricted group of antibiotics, comprising Group A and B multidrug-resistant or extensively drug-resistant tuberculosis drugs such as bedaquiline.
Tier 1 encompasses reserve group antibiotics like colistin and carbapenems, which require stringent NDPS-level (Narcotic Drugs and Psychotropic Substances) control.
Tier 2 covers the watch group of antibiotics, including fluoroquinolones and third-generation cephalosporins, which are semi-restricted and require electronic prescriptions.
Finally, Tier 3 consists of the access group drugs such as amoxicillin, which remain under monitoring but are not restricted for regular use.
The implementation of the Controlled Antimicrobials framework could follow a phased approach. Phase 1 would begin as a pilot program in five high-burden states identified for widespread antimicrobial misuse. This stage would emphasise establishing prescription traceability and antimicrobial stewardship protocols within the Ayushman Bharat Digital Mission, ensuring foundational digital infrastructure and compliance.
In Phase 2, the initiative could expand nationwide, embedding antimicrobial controls into platforms like eSanjeevani, private electronic medical records and pharmacy point-of-sale systems to enable seamless prescription monitoring and enforcement across public and private sectors.
Phase 3 would then focus on creating real-time data linkages with the Indian Council of Medical Research’s Antimicrobial Resistance Surveillance Network and the Central Drugs Standard Control Organization. This final stage would enable dynamic resistance mapping, continuous policy feedback, and adaptive regulatory actions in response to emerging antimicrobial resistance patterns.
The National Action Plan on Antimicrobial Resistance (NAP-AMR) 2.0 (2021–2025) outlines six key strategic priorities aimed at containing AMR in India through a One Health approach. These include strengthening surveillance, improving stewardship, expanding awareness, tightening regulation, enhancing sanitation and infection control and promoting innovation and research. The plan seeks to connect human, animal, and environmental health responses under a unified regulatory and institutional framework.
Under the first priority, One Health surveillance will be expanded by strengthening ICMR-AMRSN and integrating it with antimicrobial monitoring systems in the animal, food and environmental sectors. Interoperable data platforms will be developed to link human, veterinary and environmental AMR information while supporting state-level surveillance units and sentinel sites.
The second strategic area focuses on improving antimicrobial stewardship (AMS) by institutionalising AMS programmes across all tertiary and secondary care hospitals. These should advicate for mandatory infection control committees, antibiotic policy audits and widespread promotion of prescription audits and electronic prescribing in both public and private settings.
The third priority emphasises awareness and education through targeted information, education and communication campaigns for prescribers, pharmacists, farmers and the general public. AMR content will be integrated into the curricula of medical, veterinary and nursing institutions, while community engagement will be strengthened through non-governmental organisations and local governance bodies.
The fourth area of focus is to reinforce regulatory frameworks. This can be done by enforcing Schedule H1 compliance, restricting OTC sales of critical antimicrobials, developing digital prescription tracking and pharmacy audit systems and regulating antibiotic use in food-producing animals by prohibiting growth promoters and prophylactic usage.
Improving sanitation, hygiene and infection prevention and control (IPC) forms the fifth pillar. To achieve this, it is imperative to integrate AMR goals into national programmes such as the Swachh Bharat Abhiyan, Jal Jeevan Mission and National Health Mission. This priority includes strengthening IPC standards in both human and veterinary health facilities and expand wastewater surveillance and effluent treatment protocols, particularly in pharmaceutical manufacturing and healthcare sectors.
Finally, promoting research and innovation should be the sixth strategic focus. This involves funding research and development for rapid diagnostic tools, novel antimicrobials and alternative therapies such as phage therapy. Support must also be extended to operational research on AMR drivers and behavioural change. Alongside, public–private partnerships and global collaborations such as those under the Global AMR Surveillance System and the Fleming Fund need to be encouraged.
While the AMR 2.0 is comprehensive and builds on the learnings from AMR 1.0, public figures need to speak about it consistently to instil a responsible behaviour in every citizen.
The country needs to put its full force behind the above cohesive and enforceable strategy that regulates essential antimicrobials with the same rigour applied to narcotics. This should involve integrating digital tracking and tiered access mechanisms, introducing much-needed accountability, reducing inappropriate use and strengthening the implementation of NAP-AMR 2.0 priorities.
However, regulatory discipline alone will not deliver sustainable change. The pivotal transformation will occur only when antimicrobial resistance becomes part of public consciousness — discussed openly by leaders, reflected in consumer behaviour and recognised as seriously as lifestyle diseases such as diabetes or cancer. Turning this invisible biological crisis into a visible social concern is key to achieving long-term, measurable progress.
Dharmesh Kharwar is an independent director and strategy advisor. Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth.