Policy Needed Against Antimicrobial Resistance

We have written this opinion piece after witnessing a troubling incident near a local pharmacy in Kathmandu. As we passed by, a young man in his 20s casually requested Azithromycin — a broad-spectrum antibiotic known for its long half-life — without a prescription. He said, “Brother, can you give me Azithromycin? I feel like I have tonsillitis.” Without hesitation, the pharmacist over-the-counter dispensed Azithromycin, treating it as casually as any ordinary household item. This seemingly routine exchange underscores a far more urgent public health crisis in Nepal: the unchecked antibiotic misuse and the escalating threat of Antimicrobial Resistance (AMR).

AMR is a global health catastrophe, silently eroding treatment efficacy that has revolutionised medicine since the penicillin discovery in 1940. It escalates manageable infections into life-threatening conditions, severely straining healthcare systems in low-income countries like Nepal, where healthcare infrastructure struggles to meet even basic medical needs. Irrational antimicrobial uses across human, veterinary, agriculture, and environment sectors have accelerated the emergence of resistant pathogens. AMR, a "silent pandemic," has caused 36 million deaths since 1990, equating to three deaths per minute, and could lead to 1.9 million deaths annually by 2050, totaling 39 million deaths from 2025 to 2050.  

Economic cost

The World Bank estimates AMR could shrink the global economy by $1 trillion by reducing GDP by 3.8 per cent and pushing an additional 28.3 million into extreme poverty by 2050. In 2019, AMR ranked 52nd globally and 2nd in South Asia for age-standardised AMR mortality, with 23,000 associated and an additional 6,400 attributed deaths, threatening healthcare, socio-economic stability, and sustainable development. A 2021 Nature Scientific Reports revealed 79 per cent of respondents in Nepal purchased over-the-counter antibiotics without prescriptions, violating Section 17 of Nepal’s 'Drugs Act 1978, ' which mandates prescription-only dispensing. However, weak enforcement and regulatory oversight have allowed this practice to persist. 

While the "One Health (OH)" approach promotes cross-sectoral collaboration in human, veterinary, agricultural, and environmental health, conflicting interests undermine its effectiveness. For instance, the poultry industry’s reliance on antimicrobials for productivity conflicts with public health efforts to reduce antibiotic consumption. Recognising the AMR gravity, Nepal has taken some policy measures, including signing the 'Jaipur Declaration in 2011' and formulating the 'National AMR Containment Action Plan 2016. However, implementation has been weak, and progress has remained limited. The recently endorsed 'National Action Plan on AMR (NAP-AMR) 2024-2029' represents a step forward. However, resource limitations and policy fragmentation hinder its effective execution.

To combat AMR effectively, Nepal must prioritise healthcare infrastructure investment, enhance public health awareness, and implement stringent antimicrobial stewardship. The recently introduced 'National Antibiotic Treatment Guidelines 2023' for humans and animals must be swiftly integrated into both public and private healthcare settings. Furthermore, the 'National Health Policy 2019' recognises AMR as a public health challenge, necessitating its full and formal implementation within the broader NAP-AMR framework.

The 'National Drug Policy 1995' urgently needs revision to regulate antimicrobial quality, manufacturing, distribution, and waste management while addressing substandard medicines and preventing illegal cross-border transport of unregistered drugs. The 'Drugs Act 1978', though providing legal authority to regulate antimicrobial use, is outdated and lacks necessary provisions for effective NAP-AMR implementation under a OH approach, highlighting Nepal’s urgent need for practical, and enforceable policy measures.

Strengthening AMR surveillance is vital for tracking resistance trends, requiring better digital data systems, informed policymaking, and independent regulatory bodies to enforce guidelines, monitor progress, and address gaps. Moreover, local governments should be empowered to implement AMR containment strategies at the grassroots level. Raising public awareness is another critical component. AMR-related education should be integrated into school curricula. Engaging community leaders can dispel misconceptions about antimicrobial use and foster behavioral change. Additionally, continuous training for healthcare professionals in antimicrobial stewardship and rational prescribing practices is imperative.

Over-the-counter antimicrobial dispensing without prescriptions must be strictly prohibited, and antimicrobial use in OH sectors must adhere to standardised guidelines. Healthcare professionals engaged in improper antimicrobial prescriptions — whether due to personal gain or unethical practices — must be held accountable through regulatory monitoring. Public awareness against antimicrobial self-medication should be intensified to drive behavioral change at the community level. An extensive network of community health workers (FCHVs, CHWs) can be leveraged to combat AMR more effectively. Engaging mothers’ groups, schoolteachers, and pupils across all 753 local governments can instill rational antimicrobial use in the community. Furthermore, the NAP-AMR should be adapted to local contexts through multi-sectoral collaboration. Establishing standardized antimicrobial treatment protocols in community hospitals is crucial for ensuring antimicrobial usage consistency.

Political Will

Combating AMR demands strong leadership, political commitment, and evidence-based policies. The 'One Health Strategy 2019' reflects Nepal’s constitutional mandate to safeguard citizens’ health and welfare, underscoring the importance of multi-sectoral collaboration to address global health challenges, including AMR. However, political will and effective governance are essential for translating policy into action. The government must prioritise AMR as a national health security threat, allocating resources for containment, enforcing regulations, enhancing surveillance, and integrating evidence-based awareness into public health initiatives.

Containing AMR will require a concerted effort underpinned by stringent policy enforcement and an unwavering commitment to safeguarding public health. If effectively implemented, AMR containment policies will serve as an ‘AMRIT’— an Ambrosia — preserving the efficacy of life-saving medicines for next generations.  

(Authors are researchers at the Nexus Institute of Research and Innovation (NIRI) specialising in the field of AMR.)