Enhanced focus on environmental AMR in NAP 2.0 needed for an inclusive healthcare sector

Dr Anil Agrawal, Member of Parliament, Rajya Sabha, and a Member of the Health and Family Welfare Parliamentary Committee emphasises that while we celebrate the advancements made in the provision of healthcare services, it is equally important to acknowledge the simultaneous challenges posed by a trifecta of disease burdens: infectious diseases, noncommunicable diseases, and the emergence of novel pathogens driving epidemics and pandemics. Within this complex landscape, Antimicrobial Resistance (AMR) emerges as an additional threat, operating at the intersection of these three burdens

In the past 8 years, the foundation of the Indian healthcare system has been strengthened due to the implementation of progressive reforms by the Narendra Modi government. Guided by the vision of Sabka Sath Sabka Vikas, these reforms have aimed to improve the accessibility, affordability, and quality of healthcare services. One significant initiative is the Pradhan Mantri Jan Arogya Yojana (PMJAY) – world’s largest health insurance scheme, fully financed by the government. This scheme provides a cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalisation across both public and private empaneled hospitals. Additionally, the government has established a unified digital health infrastructure for the country, leveraging unique IDs, registry systems, and data analytics. The commendable pro-people initiatives undertaken by the government have received accolades and praise from various quarters.

While we celebrate the advancements made in the provision of healthcare services, it is equally important to acknowledge the simultaneous challenges posed by a trifecta of disease burdens: infectious diseases, noncommunicable diseases, and the emergence of novel pathogens driving epidemics and pandemics. Within this complex landscape, Antimicrobial Resistance (AMR) emerges as an additional threat, operating at the intersection of these three burdens.

AMR arises when bacteria, viruses, fungi, and other pathogens undergo genetic changes as a response to selection pressure, enabling them to evade the effects of antimicrobial drugs. This natural process is accelerated by the excessive use of antimicrobials (such as antibiotics, antifungals, antivirals, antimalarials, etc.), leading to the loss of effectiveness of crucial medications. The threat of AMR became more evident during the recent COVID-19 crisis, which witnessed widespread misuse of antibiotics. This crisis highlighted the urgent need for a robust regulatory ecosystem to regulate the sale of antimicrobials for human consumption.

AMR is considered one of the top 10 global health threats. In 2019 alone, 1.27 million deaths worldwide were directly attributed to AMR, and this number could reach 10 million deaths annually by 2050.[1] Furthermore, it is estimated that AMR could wipe out USD 100 trillion from the global gross domestic product (GDP) by 2050.[2] Addressing such a grave threat requires collective and collaborative action from all stakeholders.

The Narendra Modi Government swiftly introduced a National Action Plan (NAP) for AMR for the five-year period of 2017-2021, following the release of the Global Action Plan on AMR by the World Health Organization (WHO). The NAP outlined priorities for the curtailment of AMR in the animal, human and environmental ecosystems. Over the course of the first five years of the NAP, various initiatives have been taken like the bans on certain antibiotics in farms and animals, launch of the “red line” campaign to prevent the indiscriminate consumption of antibiotics, and the strengthening of the AMR surveillance network of the Indian Council of Medical Research (ICMR) amongst many others.

The completion of the first five-year period of the NAP prompts a moment of introspection. As the Union of Ministry of Health and Family Welfare (MoHFW) develops NAP 2.0, the learnings from the first iteration of the NAP should be given careful consideration. The recent Inter-Sectoral Coordination Committee meeting on AMR has identified enhanced convergence among diverse stakeholders as a significant lesson learned. The meeting was chaired by the Union Health Secretary and partner ministries and departments were urged to work together. They highlighted the importance of awareness, surveillance, prevention, stewardship, and research and development to effectively counter the menace of AMR in animals, humans, and the environment.

The current NAP has seen greater emphasis on animal and human aspects of AMR. However, it is crucial to recognize the equal importance of addressing challenges related to environmental pollution and environmental AMR, which have been underemphasised in comparison. Therefore, NAP 2.0 should prioritize addressing these issues. Stakeholders must recognize the significance of preventing the discharge of effluents from farms, factories, healthcare facilities, and pharmaceutical manufacturing from adversely affecting the environment and creating AMR hotspots. Proactive measures should be taken, and a framework stipulating the maximum permissible limit of antibiotic residues in effluent discharge should be established.

The government has demonstrated its commitment to the development of an inclusive healthcare sector by introducing initiatives like PMJAY, as well as the Production-Linked Incentive (PLI) scheme for the pharmaceutical sector, with a substantial financial outlay of Rs 15,000 crores over six years as part of the Atmanirbharta (self-reliance) initiative. However, it is equally important for the various stakeholders including the pharmaceutical companies to recognize their responsibilities and actively contribute to combating AMR.

AMR presents a shared concern that affects each and every one of us. It is crucial for individuals to commit to taking antibiotics only with a prescription for their own safety and the safety of all. Measures should be taken to educate agriculturists about the dangers of antibiotic misuse for growth and production. Further, groups working at the grassroot levels can play a significant role in this regard. By combining these initiatives with other concerted efforts, and by collaborating and working in unison, we can effectively curb the spread of AMR and safeguard the effectiveness of antimicrobials for the future.

References

[1] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext

[2] https://www.worldbank.org/en/news/press-release/2016/09/18/by-2050-drug-resistant-infections-could-cause-global-economic-damage-on-par-with-2008-financial-crisis