The world is on the verge of entering a dangerous post-antibiotics era where common infections may become untreatable and antimicrobial resistance or AMR may become the leading cause of premature deaths. While an estimated 7,00,000 people die annually due to AMR, reports suggest that the number of deaths may reach upto 10 million by 2050.
Unlike diseases like malnutrition and diarrhea that mostly affect the poor, AMR is a public health problems that is a threat to all communities in different parts of the world regardless of their economic status. However, this threat is greater in low- and middle-income countries that have weak sanitation and health infrastructure.
Political commitment to combat antimicrobial resistance has increased significantly since 2015, when the 68th World Health Assembly endorsed the Global Action Plan on antimicrobial resistance. Consequently, many countries started drafting and committing to National Action Plans against AMR. On April 19, 2017, the ‘Inter-Ministerial Consultation on AMR containment’ led by India’s health ministry announced the finalisation of India’s comprehensive and multi-sectoral National Action Plan. India’s plan is robust and involves different ministries to tackle the problem under the one health agenda. It can show results if properly implemented. But is there a danger of this document becoming another Indian plan that is excellent on paper but useless without political and financial commitment towards implementation?
As strong as National Action Plans are in terms of prescribing rational use of antimicrobials, infection control practices and related public health measures, without strong health systems these measures will have limited impact on AMR in developing countries.
In the absence of a proper regulatory environment, the higher dependence on the private health sector is associated with increased AMR due to frequent overuse of antibiotics. In Brazil, an emerging economy similar to India, the higher density of private health clinics is associated with higher antimicrobial consumption despite stronger restrictions of over-the-counter sales that have curtailed misuse of antibiotics available over the counter.
But overuse of antibiotics is only one of many factors contributing to AMR. Global AMR maps show greater resistance in low- and middle-income countries, especially India, despite the fact that their per capita antibiotic use is not as much as the high income countries. Recently published research in the Lancet has uncovered underlying reasons. An analysis of 73 countries showed that the reduction of antibiotic consumption alone will not be enough to control AMR. AMR was found increase with lower health expenditure, worse infrastructure – especially sanitation infrastructure – and even poorer governance that allows corruption.
India’s public health budget including both centre and state expenditure is a measly 1.3% and massive out of pocket spending results in millions getting poorer every year. Despite its much-publicised Swachh Bharat Abhiyan, India has the biggest urban sanitation crisis with most open defecators at 41 million people.
Health care vs health coverage
The recently released draft of Global Framework for Development and Stewardship to Combat Antimicrobial Resistance rightly mentions the key principle in stewardship policies – “Universal health care provides the best enabling framework for addressing AMR in the human health sector”. However, in most countries including India, universal health care is replaced by an insurance-driven, privately provisioned universal health coverage. Most of these insurance coverage schemes like the recently launched Pradhan Mantri Jan Aarogya Yojana, only cover hospital-based care. Private facilities contracted under the scheme may continue to irrationally prescribe antibiotics. At the same time, neglecting outpatients may also be given unnecessary antibiotics over the counter. Irrational use of antibiotics for viral diarrhoea and respiratory tract infections are already common.
Moreover, the PMJAY’s dependence on private provisioning of health on public money may lead to further neglect of the public health systems while. Thus, the plans to counter AMR may fail if the health budget is not increased and if the public health system continues to be weak.
Lack of access
Another important dimension critical to AMR control in India is the access-excess dilemma. Even with irrational antibiotic use is a growing public health threat, India still faces an old problem of shortages of essential antibiotics needed to treat common illnesses. The 2017 edition of the World Health Organisation’s list of essential medicines carefully proposes three groups of antibiotics – access, watch and reserve. The access group includes first or second choice antibiotics for at least one of the reviewed syndromes, which should be widely available, affordable and quality-assured. The watch group antibiotics have a higher resistance potential and are recommended as first or second choice treatments only for a specific, limited number of indications; whereas, the reserve group antibiotics are “last resort” option that should be used for highly specific patients and settings, when all alternatives have failed.
But access is often jeopardised in the current environment where intellectual protection and profitability are prioritised over human health. For example, stock outs of benzathine penicillin have been common since 2015. Benzathine penicillin is an access group antibiotic used to treat a number of infections including gonorrhea and syphilis. In Delhi alone, there have been problems in treating these two diseases in the last few months due to shortages of the antibiotic. On one hand resistant Neisseria gonorrhoea is a high priority pathogen that has developed resistance to existing drugs and requiring research and development of new antibiotics. On the other hand, unavailability of penicillin is contributing to more resistance. Due to high public health value, the manufacturers of penicillin and other antibiotics cannot be allowed to simply stop the production without prior notice. The government must ensure ways of keeping up production and supply of these vital antibiotics in its National Action Plan.
What India needs to do to tackle the threat of AMR is to have a health-in-all policy with the necessary regulatory tools combining health and social equity goals with economic development. A lot needs to be done to provide adequate sanitation, water quality and other infection prevention practices with better access to quality antibiotics to break the cycle of lack of access and growing resistance. If not, trying to implement any action plan like mopping the floor while the faucet is open.
The writer is an Assistant Professor of Community Medicine, at JN Medical College, AMU, Aligarh and a member of the People’s Health Movement, which is a member of Antimicrobial Resistance Coalition.