[Answered] Analyze the governance challenges and institutional gaps fueling the ‘silent crisis’ of Antimicrobial Resistance (AMR) in India. In light of a drying antibiotic pipeline, evaluate the policy measures required to regulate antibiotic overuse while ensuring future health security.

Introduction

By 2026, Antimicrobial Resistance (AMR) has emerged as India’s ‘silent pandemic’, with ICMR and IHME data showing rising resistance to last-resort antibiotics, threatening routine healthcare, surgeries, and public health security.

AMR as a Governance Failure, Not Merely a Medical Problem

1. From clinical issue to systemic crisis, AMR in India reflects deep governance and institutional deficits rather than isolated clinical misuse.
2. Despite Schedule H1 regulations, weak enforcement and fragmented oversight have allowed irrational antibiotic consumption to flourish across human, animal, and environmental interfaces.

Governance and Institutional Gaps Fueling AMR

1. Regulatory Weakness and Enforcement Deficit: India formally restricts over-the-counter sale of critical antibiotics, yet studies show widespread non-prescription access, especially in rural and peri-urban areas. The absence of pharmacist accountability and poor inspection capacity undermine regulatory intent, exemplifying implementation failure.
2. Diagnostic Deficiency and Empirical Prescribing: Limited access to rapid diagnostics at the primary healthcare level forces physicians into empirical, broad-spectrum antibiotic use. RBI-style data transparency exists for finance, but health systems lack equivalent real-time surveillance architecture for infections and resistance patterns.
3. Fragmented Surveillance Architecture: ICMR’s AMR surveillance network covers only around 25 tertiary hospitals, producing skewed, high-resistance data. Unlike Japan’s JANIS model (2,000 hospitals), India lacks a nationally representative, interoperable surveillance grid, weakening evidence-based policymaking.
4. Environmental and Pharmaceutical Externalities: Poor wastewater treatment near pharmaceutical clusters such as Hyderabad and Baddi creates resistance hotspots. Environmental regulation remains weak, allowing antibiotic residues to select resistant organisms, a classic case of   unpriced by policy.
5. Behavioural and Cultural Misuse: Self-medication for viral illnesses, reliance on informal providers, and prophylactic prescribing reflect low antibiotic literacy. AMR is driven largely by human behaviour, not merely animal antibiotic use.

The Drying Antibiotic Pipeline: A Structural Market Failure

1. Innovation Stagnation: WHO (2024) reports that most antibiotics in development lack novel mechanisms of action. Pharma firms face poor returns due to short treatment durations and stewardship-driven restricted use—an archetypal market failure requiring state intervention.
2. Dependence on Toxic Last-Resort Drugs: India increasingly relies on drugs like Colistin, once abandoned due to toxicity. Resistance to such “last lines” reflects a broken pharmaceutical buffer, risking a post-antibiotic era where minor infections become fatal.

Evaluating Policy Measures for Future Health Security

1. Strengthening Antibiotic Stewardship: Kerala’s decade-long antimicrobial stewardship programme demonstrates that rational prescription, clinician training, and phased OTC restrictions work better than abrupt bans. Stewardship must be institutionalised nationwide through mandatory hospital antibiotic policies.
2. Scaling Diagnostics and Surveillance: Expanding free diagnostics under the National Health Mission and deploying rapid tests at PHCs can shift care from empirical to evidence-based treatment. A nationwide AMR data grid, akin to JANIS, is essential for predictive governance.
3. Reforming Pharmaceutical Innovation Policy: India must deploy pull incentives—market entry rewards, public procurement guarantees, and public-private partnerships—to revive antibiotic R&D. The success of vaccine missions shows state-led innovation is feasible.
4. Operationalising the One Health Framework: NAP-AMR 2.0 (2025–29) must integrate human health, veterinary regulation, food safety (FSSAI residue norms), and environmental governance, recognising the gut microbiome as a reservoir of resistance genes.
5. Balancing Access and Excess: The core dilemma lies in ensuring antibiotic access for vulnerable populations while preventing misuse. This requires calibrated regulation, not prohibition—aligning public health ethics with constitutional duties under Article 47.

Conclusion

Public health is constitutional governance. Echoing PM Modi’s warnings, India must treat AMR as a security threat—combining stewardship, innovation, and One Health to protect future generations.