By Arunima Rajan

Healthcare Executive takes a close look at the global threat of Antimicrobial Resistance, uncovering how Kerala’s bold Operation AMRITH tackles this invisible enemy head-on and what lessons other states can draw from Kerala’s proactive approach.

It was a typical Monday morning at Jan Aushudhi Kendra in Mooledom, a small town in Kottayam, Kerala, when an elderly couple approached the pharmacist, Aniyamma, for antibiotics. Unlike in many other parts of India, where such requests might be filled without a second thought, Aniyamma stood firm. Without a prescription, she calmly refused to sell the antibiotics, despite their insistence. Such a scene is rare, even in big cities like Mumbai, where a WhatsApp message to a neighbourhood pharmacist is often enough to procure antibiotics. But in Kerala, actions like Aniyamma’s reflect a state-led commitment to responsible antibiotic use and rigorous antimicrobial resistance (AMR) management.

Crucial pieces of the Puzzle

This commitment has been formalised through Operation AMRITH, launched in January 2024 by Kerala’s drug control department. The mission is clear: to eliminate the over-the-counter sale of antibiotics without prescriptions by the end of the year. Surprise inspections will be carried out in pharmacies across the state, with strict penalties for those selling antibiotics without a doctor’s prescription. The public is encouraged to report violations, empowering communities to participate actively in curbing antibiotic misuse. Pharmacies are also required to display notices stating that antibiotics will not be sold without a prescription and to maintain records of all sales.

The 2018 Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) report underscores Kerala’s role as a substantial consumer of pharmaceuticals, with annual drug expenditures nearing ₹20,000 crore. Antibiotics make up 20% of this total—a figure that points to their critical role in healthcare and the ongoing concerns over their extensive use. Yet, due to focused efforts by the state government, antibiotic sales have reportedly declined by ₹1,000 crore over the past year, according to recent news reports.

India’s battle with AMR sits at a critical crossroads. Widespread misuse of antibiotics and weak infection control have created fertile ground for drug-resistant infections. Yet amidst this crisis, Kerala has charted an alternative path. In 2018, the state launched India’s first state-led AMR action plan, the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP), testing an approach that could potentially transform AMR management across the nation.

The Role of the Antibiogram

A crucial tool in Kerala’s AMR strategy is the antibiogram—a healthcare resource that maps bacterial pathogens and their responses to antibiotics. This data helps doctors select effective treatments and track resistance trends. Kerala published its first antibiogram in 2022, becoming the first state in India to do so under the KARSAP framework. The state now aims to produce district-level antibiograms, which would allow Kerala to monitor AMR patterns across both primary and secondary hospitals, creating a comprehensive statewide view.

Kerala’s hub-and-spoke model for AMR surveillance is a practical setup: central labs with advanced facilities act as hubs, connected to smaller district labs, or spokes. This system lets local labs handle routine tests, while more complex cases are sent to the central hubs. The idea is to improve AMR tracking right down to the district level, enabling each area to contribute to district-specific antibiograms. It’s a smart approach that helps Kerala monitor antibiotic resistance patterns statewide, making data more accessible and actionable across the healthcare system.

Regulating Antibiotic Access Through Clear Rules

India’s Drugs and Cosmetics Act requires prescriptions for antibiotics listed under Schedules H and H1, aiming to limit over-the-counter sales. Yet, with unclear definitions, some antibiotics are still accessible without a prescription. Kerala’s AMR strategy takes a firmer stance, working to tighten these controls and promote safer antibiotic use across the state.

A Localised Solution for a Nationwide Problem

What sets Kerala’s approach apart is its decentralisation. KARSAP extends from the state to the grassroots, covering every district and block with local AMR committees—191 in total by 2023. “Decentralisation ensures that AMR strategies respond to the specific needs of each district,” says KS Harshith, consultant at Aster RV Hospital. By harnessing local insights, Kerala has adapted a state-level plan to work effectively at the community level, tailoring AMR efforts to Kerala’s unique landscape and strengthening on-the-ground public health interventions.

For a nation as diverse as India, this model could provide a pathway. States across India could replicate the framework, adapting it to their own healthcare landscapes to prioritise community-cantered, locally responsive health policies rather than broad, centralised regulations.

Reining in Antibiotic Access Through Regulation

At the core of Kerala’s model is strict regulation around antibiotics. “Antibiotics shouldn’t be sold over the counter,” emphasises Neha Rastogi Panda, consultant in infectious diseases at Fortis Memorial Research Institute. “When antibiotics are too easy to access, people misuse them—taking them for the wrong reasons, stopping treatments midway, or even using them for viral infections they can’t treat.” By limiting antibiotics to prescriptions, Kerala aims to curb misuse at the root, reducing the chance for resistance to build.

With over a million AMR-related deaths in India in 2019 alone, Rastogi stresses that Kerala’s approach could make a difference. “Kerala’s model can significantly combat AMR by establishing stringent regulations on antibiotic sales, enforcing robust surveillance across human, animal, and environmental health, and driving public awareness,” she says. Kerala’s strategy engages not only healthcare providers but pharmacists and the general public in a shared responsibility to curb antibiotic misuse. It’s a model of accountability that, if replicated, could act as a vital check on AMR’s rise.

Building Awareness from the Ground Up

One of Kerala’s defining moves has been its investment in awareness and prevention. KARSAP reaches beyond the healthcare sector, engaging communities to encourage rational antibiotic use and improve hygiene practices. This kind of public health literacy could be powerful on a national scale. “Community education is a powerful tool, not just against AMR but across public health challenges,” explains Harshith. Such strategies could serve as essential preventive layers, building resilience against AMR and other infections alike.

Strengthening AMR Data and Surveillance Systems

Data underpins Kerala’s AMR policy. With granular tracking of resistance patterns across the state, Kerala quickly identifies high-resistance areas, tailoring responses as needed. “Collecting and analysing data on AMR shows where resistance is growing, so efforts can be targeted where they’re needed most,” explains Rastogi. For a vast and diverse nation like India, a similar system could be transformative, helping states coordinate efforts and make data-informed interventions.

The WHO’s 95% Access Goal: A National Challenge

Kerala’s initiatives also align with global goals, including the WHO’s objective for 95% access to essential antibiotics. While this goal aims to reserve last-resort drugs for severe cases, achieving it requires tackling behaviour-driven challenges. “Patients often expect antibiotics for every illness, even viral ones,” Rastogi notes. “Public awareness campaigns are essential to educate people on when antibiotics are necessary and when they’re not.” Kerala’s efforts show that behaviour change is a critical component of AMR policy, demanding consistent public education to shift expectations and foster responsible use.

A State-Led Blueprint for India

Kerala’s approach highlights the potential of a state-led model in tackling complex health challenges like AMR. By decentralizing decision-making and accountability, Kerala empowers communities to take ownership of AMR solutions, a strategy that may be especially valuable

for states with dense urban populations like Maharashtra, Delhi, and Karnataka. A localised approach could also help each state tailor strategies to its unique healthcare landscape, offering an alternative to a one-size-fits-all national policy.

Resilience Through Community Action

The COVID-19 pandemic temporarily slowed Kerala’s AMR efforts, but by 2021, the state had revived its initiatives, demonstrating the importance of resilience in public health. For other states, Kerala’s experience underscores the need for stable funding, political commitment, and adaptability to manage unexpected disruptions. As the threat of AMR continues to grow, nimble, community-driven approaches that integrate awareness, prevention, and resilience will be essential to the fight.

Strict adherence to AMRITH’s protocols is still a work in progress. For example, the recent directive to dispense antibiotics in blue envelopes—a move aimed at emphasising careful use—is yet to be fully adopted across the board. “I did hear about the rule about the blue cover, but we haven’t started doing that yet. I heard the notification has just come; I think they will enforce it by November 5th. Even if 10 percent of pharmacies flout the rules, many don’t give antibiotics without a prescription,” says Keerthi, a pharmacy owner in Kottayam.

Kerala’s model offers a promising framework, but its success serves as more than just a blueprint. For India, it represents a starting point for a more inclusive, adaptive approach to AMR, one that empowers states to lead their own health solutions while remaining aligned with a broader, national goal of reducing antimicrobial resistance.

The AMRITH Model: Lessons for Rest of India