Social (In)equities and Ethical Challenges: Role of Information Practices in Antimicrobial Resistance in India


Antimicrobial resistance has been described as a "slow-moving Tsunami" and one of the top global health threats that affect social groups inequitably especially in LMICs. This paper analyses social inequities and ethical implications related to antibiotic use in India and how information systems can help mitigate them. India is a global AMR hotspot, showing relative policy inertia in addressing this grand challenge. The paper describes two interconnected streams of work. One, it takes an ecosystem perspective to understand inequities in practices around prescription, dispensing, and consumption of antibiotics. Two, it analyzes the potential role of the digital in trying to address these inequities. As result, the paper identifies four key determinants of social inequity and their ethical implications. Next, the paper identifies the opportunities and challenges in applying digital to address these inequities. This paper thus seeks to make an important contribution to IS research on an area of immense societal value, particularly in informing how the potential of the digital can be effectively materialized.

Amuasi, John H., Tamara Lucas, Richard Horton, and Andrea S. Winkler. 2020. “Reconnecting for Our Future: The Lancet One Health Commission.” Lancet (London, England) 395(10235):1469–71. doi: 10.1016/S0140-6736(20)31027-8.
Anand, S. 2002. “The Concern for Equity in Health.” Journal of Epidemiology and Community Health 56(7):485–87. doi: 10.1136/jech.56.7.485.
Barker, Anna K., Kelli Brown, Muneeb Ahsan, Sharmila Sengupta, and Nasia Safdar. 2017. “Social Determinants of Antibiotic Misuse: A Qualitative Study of Community Members in Haryana, India.” BMC Public Health 17(1):1–9. doi: 10.1186/s12889-017-4261-4.
Birgand, G., L. S. P. Moore, C. Bourigault, V. Vella, D. Lepelletier, A. H. Holmes, and J. C. Lucet. 2016. “Measures to Eradicate Multidrug-Resistant Organism Outbreaks: How Much Do They Cost?” Clinical Microbiology and Infection 22(2):162.e1-162.e9. doi: 10.1016/j.cmi.2015.10.001.
Braveman, P., Arkin, E., Orleans, T., Proctor, D., Acker, J., & Plough, A. (2018). What Is Health Equity? Behavioral Science & Policy, 4(1), 1-14. -
Cars O, Jasovsky, D. (2015) Antibiotic Resistance (ABR) - No Sustainability without Antibiotics: Brief for Global Sustainable Development Report.
Chakraborty, D., Ahmad, M. S., & Seth, A. (2017, November). Findings from a Civil Society Mediated and Technology Assisted Grievance Redressal Model in Rural India. In Proceedings of the Ninth International Conference on Information and Communication Technologies and Development (Pp. 1-12).
Chan, M. (2016). WHO Director-General Briefs UN on Antimicrobial Resistance. Dr Margaret Chan, Director.
Chaudhry, D., & Tomar, P. (2017). Antimicrobial Resistance: The next BIG Pandemic. Int J Community Med Public Health, 4(8), 2632-6.
Datye, Vinita, Karina Kielmann, Kabir Sheikh, Deepali Deshmukh, Sucheta Deshpande, John Porter, and Sheela Rangan. 2006. “Private Practitioners’ Communications with Patients around HIV Testing in Pune, India.” Health Policy and Planning 21(5):343–52. doi: 10.1093/heapol/czl021.
General, R. (2011). Census Commissioner. Census of India, 2011. - Google Search.” Retrieved November 8, 2021g
Government of Himachal Pradesh. (2017) Order to Conduct Prescription Audit, Department of Health & Family Welfare; Retrieved from:
Heyman, Gabriel, Otto Cars, Maria-Teresa Bejarano, and Stefan Peterson. 2014. “Access, Excess, and Ethics—towards a Sustainable Distribution Model for Antibiotics.” Upsala Journal of Medical Sciences 119(2):134–41. doi: 10.3109/03009734.2014.904958.
Holloway, B., Mathur, A., Pathak, A., & Bergström, A. (2020). Utilisation of Diagnostics in India: A Rapid Ethnographic Study Exploring Context and Behaviour. BMJ Open, 10(11), E041087.
Jamrozik, Euzebiusz, and Michael J. Selgelid. 2020. “Drug-Resistant Infection: Causes, Consequences, and Responses.” Pp. 3–18 in Ethics and Drug Resistance: Collective Responsibility for Global Public Health, Public Health Ethics Analysis, edited by E. Jamrozik and M. Selgelid. Cham: Springer International Publishing.
John, T. J., Dandona, L., Sharma, V. P., & Kakkar, M. (2011). Continuing Challenge of Infectious Diseases in India. The Lancet, 377(9761), 252-269.
Kapur, S., Gehani, M., Kammili, N., Bhardwaj, P., Nag, V., Devara, S. M., & Sharad, S. (2019). Clinical Validation of Innovative Optical-Sensor-Based, Low-Cost, Rapid Diagnostic Test to Reduce Antimicrobial Resistance. Journal of Clinical Medicine, 8(12), 2098.
Khan, A. A., & Banu, G. K. K. R. (2013). Antibiotic Resistance and Usage-A Survey on the Knowledge, Attitude, Perceptions, and Practices among the Medical Students of a Southern Indian Teaching Hospital. Journal of Clinical and Diagnostic Research: JCDR, 7(8), 1613-1616.
Klein, E. Y., Van Boeckel, T. P., Martinez, E. M., Pant, S., Gandra, S., Levin, S. A., ... & Laxminarayan, R. (2018). Global Increase and Geographic Convergence in Antibiotic Consumption between 2000 and 2015. Proceedings of the National Academy of Sciences, 115(15), E3463-E3470
Kotwani, A., Joshi, J., & Lamkang, A. S. (2021). Over-the-Counter Sale of Antibiotics in India: A Qualitative Study of Providers’ Perspectives across Two States. Antibiotics, 10(9),
Kotwani, A., Wattal, C., Joshi, P. C., & Holloway, K. (2012). Irrational Use of Antibiotics and Role of the Pharmacist: Insight from a Qualitative Study in New Delhi, India. Journal of Clinical Pharmacy and Therapeutics, 37(3), 308-312.
Kotwani, A., Wattal, C., Katewa, S., Joshi, P. C., & Holloway, K. (2010). Factors Influencing Primary Care Physicians to Prescribe Antibiotics in Delhi India. Family Practice, 27(6), 684-690.
Laxminarayan, R., & Chaudhury, R. R. (2016). Antibiotic Resistance in India: Drivers and Opportunities for Action. PLoS Medicine, 13(3), E1001974.
Laxminarayan, Ramanan, Precious Matsoso, Suraj Pant, Charles Brower, John-Arne Røttingen, Keith Klugman, and Sally Davies. (2016). “Access to Effective Antimicrobials: A Worldwide Challenge.” The Lancet 387(10014):168–75. doi: 10.1016/S0140-6736(15)00474-2.
Levy, M., Lanamäki, A., & Hirschheim, R. (2020). Robust Action Strategies in a Connected but Unequal World: Revisiting American Pragmatism for Social Justice Focused Research in Information Systems. Communications of the Association for Information Systems, 47(1), 42
Library of National Action Plans.” (2021) Retrieved November, 2021s (
Littmann, Jasper, and A. M. Viens. (2015). “The Ethical Significance of Antimicrobial Resistance.” Public Health Ethics 8(3):209–24. doi: 10.1093/phe/phv025.
Loan, G. M., Gosh, D., & Mehta, J. (2020) Preliminary Assessment of Antibiotic Prescription Practices & Patterns Newly Developing Medical College at Himachal Pradesh, India.
Marmot, M., & Bell, R. (2010). Health Equity and Development: The Commission on Social Determinants of Health. European Review, 18(1), 1-7.
Mendelson, M., & Matsoso, M. P. (2015). The World Health Organization Global Action Plan for Antimicrobial Resistance. SAMJ: South African Medical Journal, 105(5), 325-325.
Murshid, M. A., & Mohaidin, Z. (2017). A Systematic Review of the Influence of Medical Representatives and Promotional Tools on Prescribing: A Comparison between Developed and Developing Countries. International Journal of Pharmaceutical and Healthcare Marketing.
Nations, United. n.d. “Universal Declaration of Human Rights.” 2021. United Nations. Retrieved November 11, 2021 (
NSS 75th Round, (2017 -2018). Government of India, Ministry of Statistics and Program Implementation, National Statistical Office, India.
O’Neill, J. (2016). Tackling Drug-Resistant Infections Globally: Final Report and Recommendations - Google Search.” Retrieved November 8, 2021
Porter, G., Kotwani, A., Bhullar, L., & Joshi, J. (2021). Over-the-counter sales of antibiotics for human use in India: The challenges and opportunities for regulation. Medical Law International, 21(2), 147-173.
Sahay et al., (2020) “Designing for Scale: Strengthening Surveillance of Antimicrobial Resistance in Low Resource Settings.” Springerprofessional.
Saint, V., Mohsenpour, A., Mühling, C., & Bozorgmehr, K. (2020). Exploring Equity, Gender, and Social Determinants Aspects of Antimicrobial Resistance: Scoping Review. European Journal of Public Health, 30(Supplement_5), Ckaa166-707.
Saner, R., Yiu, L., & Nguyen, M. (2020). Monitoring the SDGs: Digital and Social Technologies to Ensure Citizen Participation, Inclusiveness and Transparency. Development Policy Review, 38(4), 483-500.
Savoldi, A., Carrara, E., & Tacconelli, E. (2020). Gross National Income and Antibiotic Resistance in Invasive Isolates: Analysis of the Top-Ranked Antibiotic-Resistant Bacteria on 2017 WHO Priority List—Authors’ Response. Journal of Antimicrobial Chemotherapy.
Sen, A. (1999). Commodities and Capabilities. OUP Catalogue.
Sen, A., Ahmed, S., & Peter, F. (2004). Why Health Equity. In : (Pp. 21-33). Oxford University Press.
The Charter of Patient Rights. (2019) | National Human Rights Commission India.” Retrieved November 11, 2021ah (
The Drugs and Cosmetic Act and Rules (1940) Ministry of Health & Family Welfare, Government of India.”
Wadhwa, M. (2021). Revamping of Public Health Surveillance System in India.
World Health Organisation. (2008) “WHO Commission on Social Determinants of Health, & World Health Organization. (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. World Health Organization.
World Health Organization. (2014). Antimicrobial Resistance: Global Report on Surveillance. World Health Organization.
World Health Organisation (2018). “WHO Report on Surveillance of Antibiotic Consumption: 2016-2018 Early Implementation.
World Health Organisation, (2021) "No Time to Wait: Securing the Future from Drug-Resistant Infections.” Retrieved November 10, 2021y (
World Health Organisation (2021a) “Global Database for the Tripartite Antimicrobial Resistance (AMR)”. Retrieved November 11, 2021 (
IssueVol 5, No 4 (2021) QRcode
AMR Information system Inequity Ethics Digital Surveillance Antibiotics information practices India

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Thakral Y. Social (In)equities and Ethical Challenges: Role of Information Practices in Antimicrobial Resistance in India. Health Tech Ass Act. 2022;5(4).