Authors: Vidhi Singh, Nimisha Droach ABSTRACT Background:  AMR has long stopped being a background clinical concern. It is now a direct threat to healthcare systems and national economies, and India sits at a particularly difficult intersection of high antibiotic consumption, variable health infrastructure, and limited regulatory reach. Two policy instruments were introduced to address this — the National Action Plan on Antimicrobial Resistance (NAP-AMR) and the Schedule H1 Regulation — though how well either has worked on the ground remains an open and contested question. Objective: This paper examines where NAP-AMR and Schedule H1 are falling short in practice and traces how those enforcement failures, surveillance gaps, poor inter-agency coordination, and limited stewardship capacity have produced measurable economic damage — for patients, hospitals, and India’s broader economy. Methods: A qualitative secondary data analysis was conducted using academic literature, surveillance reports, and policy documents from WHO, NCDC, ICMR, and the Ministry of Health and Family Welfare. Results: A consistent pattern emerged: surveillance systems are too heavily concentrated in urban tertiary hospitals, coordination between the Centre and the states is fractured, stewardship programmes are understaffed, and antibiotics continue to be sold without prescriptions despite Schedule H1. Treatment costs have risen as a result, hospital stays have lengthened, and families — particularly lower-income ones — are bearing financial burdens they cannot absorb. Conclusion: Tightening enforcement, digitising prescription records, expanding surveillance beyond tertiary facilities, and protecting households from catastrophic out-of-pocket costs are priorities India cannot continue to defer. INTRODUCTION AMR has moved well past the point of being a specialist clinical concern. The resistance crisis is reshaping healthcare economics, threatening basic medical procedures, and — in a country with India’s population size and disease burden — doing so at a scale that should alarm policymakers far beyond the health ministry. India’s position in this story is not incidental. It is one of the world’s largest consumers of antibiotics. Urbanisation has outpaced sanitation infrastructure in many parts of the country. The public health system, though large, is deeply uneven in capacity. The burden of infectious disease remains substantial. These factors don’t simply coexist; they interact and reinforce one another, accelerating resistance. Highly drug-resistant strains are now documented across Indian hospitals, and the practical consequences are real — routine surgeries carry added infection risk, neonatal care has become more clinically complex, and cancer treatment outcomes are increasingly compromised by resistant co-infections. Two major regulatory interventions were put in place to counter this. Schedule H1 came into force in 2014, covering 24 antibiotic classes including the most clinically critical ones. Dispensing requires a valid doctor’s prescription, and pharmacies must maintain three years of purchase and sales records. The purpose was to create accountability where there had been almost none. NAP-AMR provided the longer-horizon strategic architecture. Designed around One Health principles, it set goals for surveillance expansion, professional and public awareness campaigns, and antimicrobial stewardship programme development in hospitals. On paper, the two instruments work in tandem — Schedule H1 supplying the regulatory teeth, NAP-AMR supplying the strategic framework. The reality on the ground is considerably more complicated. The policies themselves are not the core problem. The gap lies in execution, and that gap is wide. Across Indian states, implementation has been uneven. Antibiotics listed under Schedule H1 are still regularly obtained without prescriptions in many communities. Stewardship programmes are largely absent from primary and secondary care settings. Surveillance data is dominated by large urban teaching hospitals and reflects little of what is happening in rural areas or primary care. This review examines those gaps from two angles. Policy Implementation Gaps and Regulation Challenges: Why does over-the-counter antibiotic dispensing persist even where legal restrictions apply? How do staffing shortages and missing diagnostic infrastructure outside major cities erode compliance? What does the published evidence say about the distance between what Schedule H1 requires and what pharmacies actually do? Economic Implications of India’s AMR Policies: Drug-resistant infections cost more to treat — more days in hospital, more expensive drugs, more tests. In India, where most healthcare spending is out-of-pocket, those extra costs don’t get absorbed by insurance; they fall directly on patients. This section maps that financial burden and examines what it means for lower-income households, hospitals managing constrained budgets, and India’s broader economic position. The aim is to connect weak implementation to real-world harm in a way that is useful for policymakers. Understanding precisely where and how enforcement breaks down is a prerequisite for designing fixes that actually hold. Theoretical Framework This study draws on Public Policy Implementation Theory as its interpretive lens. The theory’s core argument is straightforward but often overlooked in practice: whether a policy succeeds depends on how it is operationalised, not merely how it is designed. Institutional capacity, governance arrangements, resource availability, cross-sector coordination, enforcement quality, and the actual behaviour of stakeholders — these are the variables that determine what policies achieve. Applied to NAP-AMR and Schedule H1, this framework focuses attention on the structural and institutional factors that have limited their impact, and helps explain why the gap between policy intent and public health reality has persisted for over a decade. RESEARCH METHODOLOGY Research Design The study uses a qualitative research design built on secondary data analysis, focused on India’s AMR policy framework with particular attention to NAP-AMR and Schedule H1. Governance, regulatory enforcement, antimicrobial stewardship, and surveillance served as the core analytical dimensions. Where quantitative data from national surveillance reports and published studies added clarity — on treatment costs, antibiotic consumption trends, or the measurable effects of specific interventions — that evidence was drawn into the analysis.  Study Area Context  The research centres on India’s healthcare system, examining how AMR policies have been implemented across hospitals, pharmacies, surveillance networks, and public health institutions. It also addresses the economic consequences of those policies, including rising healthcare expenditure and the financial pressures on patients and institutions. Participants and Sampling No human participants were involved. Sources were selected through purposive sampling based on their direct relevance to AMR, NAP-AMR, Schedule H1, stewardship, surveillance, and the