On 26th September 2024, nations gathered at the United Nations General Assembly’s high-level meeting on Antimicrobial Resistance (AMR) and resolved to “invest in the present, to secure the future.” Given the threat posed by the rapid rise of antimicrobial-resistant bacteria to health, this is a laudable resolution. It is thus an opportune moment to gauge the extent and nature of India’s investment in combating the threat of AMR: How much is being invested? Where are these funds being directed? And critically, how are they being used on the ground? 

AMR, which renders antibiotics less effective, has loomed large in India's health policy for over a decade—and for good reason. It makes infections harder to treat, driving up healthcare costs, prolonging illnesses, and tragically, increasing deaths, especially among the most vulnerable: children and the elderly. 

Twelve years ago, AMR began to garner attention and was featured in the Indian health policy. From 2012 to 2017, a dedicated AMR containment program (National Program for Containment of AMR) coordinated by the National Centre for Disease Control (NCDC) received substantial financial support: INR 112 crores for five years. This program's key elements were AMR surveillance, monitoring antimicrobial use, and fostering awareness among healthcare providers and the public on the judicious use of antibiotics. 

But despite initial progress, it prima facie appears that the Indian government has dropped the ball on AMR– budgetary allocations have fallen precipitously and rendered diffuse as the program was moved under the broad umbrella of One Health. 

However, since 2017, a reading of budgetary allocations indicates that the status of AMR has undergone a palpable change. From being a stand-alone program that was geared to move in mission mode, AMR has now been clubbed together with other neglected diseases. 

Currently clubbed under the budget head ‘Establishment and Strengthening of NCDC Branches and Health Initiatives Inter-Sectoral coordination for preparation and control of ZoonoticDiseases and other neglected tropical diseases surveillance of Viral Hepatitis AntimicrobialResistance,’ the budgets fluctuate from 2012 - 25.

While we do not know what proportion of the budget is dedicated to fighting antimicrobial resistance, what we do see is that the budget under this rather broad head fell by 99.4% between 2016 - 17 and 2017 - 18 from Rs 22.4 crore to Rs 0.13 crore. The 2017 - 2019 period saw a rise in the budget by 22.9 crores; however, in 2020 it fell by 42.7% to Rs 13.2 crore rising in 2021 and 2022 only to fall again in 2023 by 27.2%. The revised budget for 2023 - 24 is 27.52 crores and the estimated budget for 2024 - 25 is 52 crores. While an upward trend can be discerned in more recent times, the percentage of the funds that are earmarked for AMR continues to be at large. 

While the 2017 Indian National Action Plan (NAP) for Antimicrobial Resistance (AMR) aims to address critical policy and regulatory issues related to antibiotic use through the One Health approach, its implementation has been sluggish, most likely on account of its dependence on the coordinated efforts from all stakeholders to metamorphose into action. 

This is better illustrated, as merely four of twenty - eight Indian states have launched their state action plan (SAP): Kerala has launched KARSAP, Madhya Pradesh has launched MP-SAPCAR, Delhi has launched SAPCARD and Andhra Pradesh has launched APACAR. Given the size of India's Population and its federal governance structure, implementing sub-national action plans is critical for effectively containing antimicrobial resistance. 

In a high AMR impact scenario, the global community, particularly countries with large resource-deficit populations stand to face the fire as an additional 24 million people would be pushed into poverty, with a disproportionate occurrence in low and middle-income countries. An increased AMR-related mortality and morbidity would not just decrease the size of the workforce but also impact its overall efficiency. Further, reduced labour supply can be accounted for in terms of unpaid care work, as people take a longer time to recover, experience a reduced quality of life and a greater likelihood of death.

While the World Bank models estimate that under a low burden of antimicrobial resistance health costs could increase by $330 billion, under a high-burden situation this increase could amount to $1.2 trillion (The World Bank, 2017). 

Kamini Walia, presently leading the Antimicrobial Resistance Initiative at ICMR, suggests several low-hanging fruits that can be introduced with fewer resources and costs to healthcare settings. These include intravenous to oral conversions, de-escalation and therapeutic substitution, and formulary restriction. 

Going forward, if we are indeed to take steps to ‘secure the future’ we need to make transparent the finances that will be harnessed to combat AMR and build policy momentum by picking the low-hanging fruit. Only then will the commitments made in New York last month translate into the action that we so urgently need.

The writers are with Ramalingaswami Centre on Equity and Social Determinants of Health, Public Health Foundation of India, Bengaluru.