Disclaimer: This post is for academic purposes only. Please read the original document if you intend to use them for clinical purposes.
Antimicrobial Resistance (AMR) is a pressing global public health crisis, identified by the WHO as one of the top ten threats to humanity and described as a “silent pandemic.” India faces a dual challenge: ensuring rational antibiotic access to treat infections while simultaneously curbing overuse to prevent worsening resistance. In response, the Government of India has developed the National Action Plan (NAP) on AMR 2.0 for the period 2025-2029. This comprehensive strategy builds upon the foundations of the first NAP (2017-2021), addressing its implementation gaps, such as limited ownership by non-health sectors and the absence of a dedicated coordinating authority. NAP-AMR 2.0 is distinguished by its robust “Whole of Government” and “One Health” approach. It integrates specific, budgeted, and time-bound action plans from over 20 ministries and departments, ensuring sectoral ownership and sustained funding.
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1. Challenge:
AMR occurs when microbes like bacteria, viruses, and fungi evolve to resist the medicines used to treat them, rendering common infections difficult or impossible to cure. This phenomenon jeopardizes modern medical advancements, increases mortality, prolongs hospital stays, and escalates healthcare costs.
a) Global:
AMR is a global crisis with severe repercussions. A 2021 Global Burden of Disease study estimated that 1.14 million deaths were directly attributable to bacterial AMR, with an additional 4.71 million deaths associated with it. If current trends continue, the global toll could reach 10 million deaths annually by 2050, with cumulative economic losses of up to $100 trillion. The burden is disproportionately severe in low- and middle-income countries (LMICs), including the South Asia region.
b) India:
India’s situation is complex, marked by both the need for increased rational antibiotic use and the urgent requirement to curb widespread misuse and overuse.
i) Trends in Human health:
- High Resistance Rates: Surveillance data from the National Centre for Disease Control (NCDC) and the Indian Council of Medical Research (ICMR) show high resistance levels, particularly in Gram-negative bacteria. Resistance to third-generation Cephalosporins exceeds 65% in pathogens like Eschirichia coli and Klebsiella pneumoniae.
- Pathogen Profile: E. coli is the most commonly isolated pathogen, primarily from urine samples. Carbapenem resistance is rising, with Acinetobacter species showing 66% resistance in blood isolates.
- Fungal Threat: Invasive fungal infections are a growing concern, with multidrug-resistant Candida auris emerging as a significant healthcare-associated pathogen, particularly in ICUs, where it is associated with high mortality rates (46-75%).
- Antimicrobial Consumption: A multi-centric survey found that antibiotic use prevalence in hospitals was 71.9%. Alarmingly, 57% of prescriptions were for antibiotics in the WHO “Watch” group, which have higher resistance potential, and only 6% of patients were on definitive therapy, indicating vast empirical use.
ii) Trends in Animal health, Fisheries, and Food:
The misuse and overuse of antimicrobials in food-producing animals is a major driver of AMR. Globally, 73% of all antimicrobials sold are used in animals raised for food.
- Surveillance Findings: The Indian Network for Fishery and Animal Antimicrobial Resistance (INFAAR) reports high resistance rates in food animals. Poultry isolates exhibit significantly higher resistance to multiple antibiotics compared to other livestock. Penicillin resistance in S. aureus is widespread (over 70%).
- Regulatory Action: In response to these threats, the government has taken steps such as prohibiting the use of colistin as a growth promoter in food-producing animals. The Food Safety and Standards Authority of India (FSSAI) has also prohibited 19 antibiotics in meat and fishery products and set tolerance limits for 43 others.
2. Evolution:
NAP-AMR 2.0 is an evolution of India’s national strategy, incorporating lessons from the first plan implemented from 2017 to 2021.
a) Achievements of NAP-AMR 1.0 (2017-2021):
The first action plan laid a critical foundation for AMR containment in India. Key achievements include:
- Awareness: Development and dissemination of media material on judicious antimicrobial use.
- Surveillance: Strengthening of national AMR surveillance networks like NCDC’s NARS-Net and ICMR’s AMRSN, and initiation of human antimicrobial consumption surveillance.
- Infection Control: Launch of the National Guidelines on Infection Prevention and Control (2020) and national initiatives like “KAYAKALP” to improve hygiene in public health facilities.
- Regulation: Strengthening the enforcement of Schedule H and H-1 rules to curb over-the-counter antibiotic sales and banning colistin in animal feed.
- Sub-national Action: Launch of State Action Plans for Containment of AMR (SAP-CAR) in seven states: Kerala, Madhya Pradesh, Delhi, Andhra Pradesh, Sikkim, Gujarat, and Rajasthan.
b) Lessons learned:
The implementation of NAP-AMR 1.0 faced following challenges:
- Limited Ownership: Non-human health sectors had limited ownership and participation.
- Lack of Coordination Body: The proposed National Authority for Containment of AMR (NACA) was never constituted, leaving a void in inter-sectoral coordination and monitoring.
- Impact of COVID-19: The pandemic stalled implementation progress from 2020-2022.
c) Development of NAP-AMR 2.0 (2025-2029):
The development of NAP-AMR 2.0 was initiated in 2022. A series of national consultations were held with experts across human health, research, environment, and animal husbandry sectors. NITI Aayog played an instrumental role in bringing together 20 ministries and departments for brainstorming sessions to ensure a “Whole of Government” approach. This process resulted in each key stakeholder ministry preparing and committing to a specific, budgeted action plan, ensuring clear ownership, sustained funding, and accountability.
3. Strategy:
The core of NAP-AMR 2.0 is a comprehensive strategy with a clear vision, goal, and a framework of six strategic objectives designed to be implemented with a “One Health” approach.
- Vision: To create a sustainable ecosystem for humans, animals, plants, and the environment by preventing AMR emergence and transmission through an evidence-based “One Health” approach.
- Goal: To protect the health of all life forms through improved awareness, strengthened laboratory capacity, infection prevention, appropriate antimicrobial use, effective research, and robust coordination.
Six Strategic Objectives:
The national strategy is operationalized through six interconnected strategic objectives, each with detailed sub-objectives and activities.
| Strategic Objective | Key Focus Areas and Activities |
| 1. Improve Awareness and Understanding | – Conduct Knowledge, Attitude & Practices (KAP) studies among stakeholders. – Create a central repository of Information, Education, and Communication (IEC) materials. – Develop and implement sustained communication campaigns using Behaviour Change Communication (BCC) strategies. – Revise curricula for health, veterinary, and school education to include AMR and IPC. |
| 2. Strengthen Laboratory Capacity | – Strengthen and expand quality-assured microbiology labs for AMR detection at national, state, and district levels – Establish standardized digital documentation systems (e.g. LIMS) for surveillance. – Strengthen surveillance of AMR in animal husbandry, fisheries, food, and the environment. – Develop capacity for targeted surveillance of antimicrobial residues in food and the environment. |
| 3. Reduce Incidence of Infection | – Develop and implement a National IPC program for all tiers of healthcare. – Strengthen surveillance of Healthcare-Associated Infections (HAIs). – Promote community infection prevention through WASH (Water, Sanitation, and Hygiene) and vaccination programs. – Implement biosecurity and IPC programs in veterinary settings and farms. – Ensure effective management of waste from healthcare facilities, farms, and pharmaceutical industries. |
| 4. Optimize Use of Antimicrobial Agents | – Strengthen and enforce regulations (Schedule H & H1) to prevent over-the-counter sales of antibiotics. – Develop and implement evidence-based standard treatment guidelines for humans and animals. – Establish and expand Antimicrobial Stewardship (AMSP) programs in all healthcare facilities. – Establish a national surveillance system for Antimicrobial Consumption (AMC) and Use (AMU). – Phase out the use of antibiotics for growth promotion in livestock and fisheries. |
| 5. Promote Research and Innovations | – Define research priorities for new diagnostics including Point-of-Care tests (POCT), therapeutics, and vaccines. – Build a mission-mode program through the India AMR Innovation Hub (IAIH) to nurture and deploy innovations. – Fund research to estimate the morbidity, mortality, and economic impact of AMR in India. – Investigate AMR transmission pathways across human, animal, and environmental sectors. |
| 6. Strengthen Governance and Collaborations | – Establish dedicated AMR coordination units within each key ministry/sector for effective monitoring. – Create a high-level Inter-sectoral Coordination Committee for oversight and review. – Strengthen India’s international collaborations and leadership on AMR. – Support all states and UTs in developing and implementing their own State Action Plans for Containment of AMR (SAP-CAR). |
4. Commitment:
The “Whole of Government” approach is evidenced by the direct commitments from key ministers, highlighting cross-sectoral collaboration and ownership.
5. Governance, Monitoring, and Evaluation:
NAP-AMR 2.0 incorporates a robust governance and monitoring framework to ensure accountability and track progress effectively.
a) Governance and Monitoring:
- High-Level Oversight: A high-level inter-ministerial committee under the Member (Health), NITI Aayog, will conduct bi-annual reviews of the plan’s implementation.
- Research Coordination: The office of the Principal Scientific Adviser (PSA) will coordinate and monitor the action plans of science and research ministries to prevent duplication.
- Nodal Ministry Coordination: The Ministry of Health & Family Welfare (MoHFW) will host an Intersectoral Coordination Committee and a Technical Advisory Group to monitor progress.
- Sectoral Monitoring: Each key ministry {e.g. MoHFW, MoFAHD (Ministry of Fisheries, Animal Husbandry & Dairying), MoAFW(Ministry of Agriculture & Farmers Welfare)} will establish a dedicated unit to monitor the implementation of its own action plan.
- Digital Dashboard: A national monitoring dashboard will be established on the NITI Aayog website to provide real-time progress updates from all stakeholder ministries and departments.
b)Evaluation:
The success of NAP-AMR 2.0 will be measured against specific outcomes using Key Performance Indicators (KPIs).
| Expected Outcome: | Key Performance Indicators (KPI): |
| Improved awareness and capacity | – Percentage increase in awareness among key stakeholders. – Number of professional curricula incorporating AMR topics. – Number of personnel trained on AMR/IPC. |
| Strengthened surveillance | – Number of quality-assured laboratories for AMR detection. – Number of facilities enrolled in national AMR surveillance networks. |
| Reduced infection rates | – Number of facilities implementing national IPC programs. |
| Optimized antimicrobial use | – Number of facilities with functional AMSP programs. – Number of facilities enrolled in AMC surveillance. |
| Fostered research and innovation | – Number of operational research projects initiated/completed. – Number of new diagnostics, therapeutics, or vaccines developed. |
| Strengthened governance | – Number of inter-sectoral coordination meetings held. – Number of SAP-CAR developed and implemented with dedicated funding. |
