'Mind the gaps': stakeholder perspectives on addressing antimicrobial resistance in the environment in the Indian context.

Background: There is growing global awareness of the pivotal role environmental factors, including pharmaceutical manufacturing waste, play in the development and spread of antimicrobial resistance (AMR). India bears one of the highest burdens of AMR globally and possesses a substantial manufacturing sector, but limited insight is available on how to practically mitigate environmental AMR-related risk in this context.

Objective: To understand the barriers and opportunities in managing manufacturing waste for addressing AMR in the environment from the perspectives of stakeholders in India.

Methods: We conducted semi-structured interviews with a range of stakeholders from government, industry, and civil society following a stakeholder mapping and analysis process within the Indian context. We also undertook a series of stakeholder events to inform the study.

Results: Our findings indicate that 1) Policy action is fragmentary and there are economic and capacity gaps that have implications for industry behaviours; 2) A One Health approach to addressing AMR in the environment requires leadership and that means AMR prevention needs to be institutionalised within government for them to steer, facilitate and coordinate; and 3) There is a need to enhance knowledge amongst policymakers in India about AMR in the environment, and robust 'evidence' is required to foster policy change.

Conclusions: The study underscores the need for a multifaceted strategy to address the contribution of pharmaceutical manufacturing waste to AMR in the environment in India. Greater prioritisation of AMR, stakeholder collaboration, and capacity building are essential to overcoming the challenges identified.