National Action Plan On Antimicrobial Resistance

The National Action Plan on Antimicrobial Resistance (NAP-AMR) is India’s strategic framework aimed at containing and managing the growing threat of antimicrobial resistance through a coordinated, multisectoral approach. Launched in April 2017 by the Ministry of Health and Family Welfare (MoHFW), it aligns with the World Health Organization’s (WHO) Global Action Plan on AMR (2015) and embodies the One Health principle, recognising the interconnectedness of human, animal, and environmental health. The NAP-AMR serves as a blueprint for guiding national efforts to reduce misuse of antimicrobials, strengthen surveillance, improve infection control, and promote research and innovation.

Background and Rationale

Antimicrobial resistance has emerged as a critical global health challenge due to the widespread and inappropriate use of antibiotics, antivirals, antifungals, and antiparasitics in humans, animals, and agriculture. India bears one of the world’s highest burdens of drug-resistant infections, including multi-drug resistant tuberculosis (MDR-TB), methicillin-resistant Staphylococcus aureus (MRSA), and carbapenem-resistant Enterobacteriaceae.
Contributing factors include over-the-counter antibiotic sales, self-medication, irrational prescriptions, unregulated use in livestock, and inadequate sanitation. Recognising the threat to public health and economic stability, India initiated the NAP-AMR to establish a unified response, integrating actions across ministries, sectors, and scientific disciplines.

Objectives of the NAP-AMR

The National Action Plan on AMR (2017–2021) outlines the following broad objectives:

1. Improve awareness and understanding of AMR through effective communication, education, and training.
2. Strengthen knowledge and evidence by establishing robust surveillance of antimicrobial use and resistance across human, animal, food, and environmental sectors.
3. Reduce the incidence of infection through improved sanitation, hygiene, and infection prevention measures.
4. Optimise the use of antimicrobial agents in human and animal health through stewardship programmes and regulatory frameworks.
5. Promote investment in research and innovation for new diagnostics, drugs, vaccines, and alternative therapies.
6. Strengthen leadership and intersectoral collaboration at national and international levels.

These objectives are structured to ensure sustainable containment of AMR and align with India’s broader public health goals under the National Health Policy 2017.

The One Health Approach

A core feature of the NAP-AMR is its One Health framework, which integrates human health, animal health, agriculture, and the environment. This holistic approach acknowledges that resistant microorganisms can move between humans, animals, and ecosystems via food, water, and soil.
Key stakeholders include the:

• Ministry of Health and Family Welfare (MoHFW) – coordination and implementation.
• Ministry of Agriculture and Farmers’ Welfare (MoAFW) – regulation of veterinary antimicrobial use.
• Ministry of Environment, Forest and Climate Change (MoEFCC) – environmental surveillance and waste management.
• Indian Council of Medical Research (ICMR) and Indian Council of Agricultural Research (ICAR) – research and data generation.
• State Governments – local execution and monitoring.

Strategic Priorities and Interventions

The NAP-AMR defines six strategic priorities with corresponding interventions and targets:

1. Improving Awareness and Understanding of AMR:
   • Nationwide campaigns to promote rational antibiotic use among healthcare providers and the public.
   • Integration of AMR education into medical, nursing, veterinary, and pharmacy curricula.
   • Collaboration with media and civil society for behaviour change communication.
2. Strengthening Knowledge and Evidence through Surveillance:
   • Expansion of the AMR Surveillance and Research Network (AMRSN) led by the ICMR.
   • Establishment of national reference laboratories for human, veterinary, and environmental AMR data.
   • Participation in the Global Antimicrobial Resistance Surveillance System (GLASS) for international data sharing.
3. Reducing the Incidence of Infection:
   • Promotion of infection prevention and control (IPC) programmes in hospitals.
   • Strengthening of vaccination coverage, including pneumococcal and influenza vaccines.
   • Improved water, sanitation, and hygiene (WASH) under Swachh Bharat Abhiyan.
4. Optimising the Use of Antimicrobial Agents:
   • Implementation of Antimicrobial Stewardship Programmes (AMSPs) in hospitals to guide rational prescribing.
   • Regulation of antimicrobial sales through enforcement of Schedule H1 under the Drugs and Cosmetics Rules (2014).
   • Banning of certain antibiotics as growth promoters in livestock and poultry.
   • Development of national guidelines for antibiotic use in both human and veterinary medicine.
5. Promoting Research and Innovation:
   • Funding for development of rapid diagnostic tools to identify resistant infections.
   • Support for public–private partnerships to develop new antimicrobials and vaccines.
   • Research into traditional and alternative therapies, including phage therapy and herbal medicine.
6. Strengthening Leadership and Intersectoral Collaboration:
   • Formation of an Intersectoral Coordination Committee (ISC) chaired by the Secretary of Health.
   • State-level AMR Action Plans modelled on the national framework.
   • International collaboration with WHO, FAO, and OIE (now WOAH).

Implementation Mechanism

The NAP-AMR is implemented through a multilayered coordination system involving:

• National AMR Secretariat (MoHFW): Oversees planning, implementation, and monitoring.
• National Centre for Disease Control (NCDC): Acts as the nodal technical agency for AMR surveillance.
• ICMR and ICAR: Conduct research and maintain laboratory networks.
• State Governments: Adapt national guidelines into local action plans.

Funding is provided under the National Health Mission (NHM) and through international collaborations such as the Fleming Fund (UK) and the Global Health Security Agenda (GHSA).

Key Achievements

Since its launch, the NAP-AMR has led to several significant outcomes:

• Establishment of over 30 AMR surveillance laboratories across India under ICMR and NCDC.
• Ban on the use of colistin as a growth promoter in animals (2019).
• Implementation of infection control and antimicrobial stewardship guidelines in major tertiary hospitals.
• Development of the National Guidelines for Infection Prevention and Control (2020).
• Increased awareness through national observances such as the World Antimicrobial Awareness Week (WAAW).
• Integration of AMR objectives into India’s National Health Policy and National Livestock Policy.

Challenges and Limitations

Despite commendable progress, the implementation of NAP-AMR faces persistent challenges:

• Uneven enforcement of regulations on antibiotic sales and veterinary use.
• Limited laboratory capacity and shortage of trained microbiologists in rural areas.
• Inadequate data integration between human, animal, and environmental surveillance.
• Low public awareness about rational antibiotic use.
• Financial and infrastructural constraints in state-level execution.
• Slow pace of innovation in developing new antimicrobials and diagnostics.

Effective AMR containment requires stronger governance, capacity building, and sustained political commitment.

Future Directions and NAP-AMR 2.0

Building upon the first plan (2017–2021), India is developing a revised National Action Plan on AMR (NAP-AMR 2.0) to guide actions from 2025 onwards. The proposed updates focus on:

• Strengthening state-level action plans (SAP-AMRs) for decentralised implementation.
• Integrating digital data systems for real-time AMR surveillance.
• Expanding AMR research and innovation hubs.
• Enhancing collaboration with environmental and wastewater management sectors.
• Promoting sustainable financing models for AMR containment.

These efforts aim to align India’s response with the Global AMR Framework (2024–2034) being developed by WHO and partner organisations.