The Economics of Antibiotics - Part 4: What Does the Antibiotics Market of the Future Look Like?

Article by: Isobel Firth, Mikel Berdud, Simon Brassel, Adrian Towse and Lotte Steuten
This article was commissioned by Pfizer Inc. Content was written by OHE Consulting Ltd with technical review from Pfizer Inc.
The previous three blogs explained why market failure means we are lacking new antibiotics, how the UK is taking the lead to overcome that market failure with a Netflix-style subscription payment model for antibiotics, and what other G20 countries need to do to stimulate antibiotic development. In this fourth and final blog in our AMR series, we set out a positive scenario for tackling antibiotic resistance, and contemplate other possibilities.
International collaboration prevails
If the US pull incentive mechanism is implemented through the PASTEUR Act, the EU develops a pull incentive for antibiotics and the G7 commitments to implementing pull incentives are realised then a strong signal will be sent to companies that their investment in the development of antibiotics will be rewarded [1]. Over time, evidence will accumulate that volume-delinked payment models better align incentives for stewardship and innovation than traditional volumed-linked models. Either individually or in collaboration, enough countries will pay for antibiotics using delinked payment models to meet the global pull incentive needed to bring antibiotics to market.
Collaboration to secure a large enough economic incentive is necessary but not sufficient. International cooperation is also needed to agree and update priority lists of the most needed and most valuable antibiotics to ensure that research is focussed on on international priorities instead of local ones [2]. Importantly, it cannot take each country another 10 years to implement their version of the best delinked solution. Action is needed now.
A sustainable antibiotic market is developed
R&D investment will be stimulated in the short term as more countries become involved in a global pull incentive. A healthy antibiotics market has, however, to be sustained in the long term, as antibiotic resistance is a natural mechanism that will continue even as new antibiotics are developed. Incentives for continued investment are therefore vital.
We will learn with experience which pull mechanisms are most effective at providing the incentives needed. In our view, an incentive mechanism has a better chance of stimulating a long-term market for antibiotics if rewards are linked to the value of antibiotics developed. By linking payment to value, companies will be incentivised to develop the highest value product possible to address increasing resistance to existing treatments.
As described in the previous blogs, the development of value frameworks that are feasible to implement is a vital piece of the jigsaw for incentivising more effective new drugs. There are different mechanisms to link value assessment to a pull reward, and not all of them require a full value assessment like the one conducted by NICE for the NICE-NHS AMR model [3]. While this model has shown that implementation of the STEDI framework is possible, other countries will have their own approaches to implementing STEDI frameworks [4].
Low- and middle-income countries have reliable access to antibiotics
The discussion so far has focussed on the actions of a small number of the world’s richest countries. Yet antibiotic resistance is likely to disproportionately impact the majority of the world’s population living in low- and middle-income countries (LMICs)5. The World Health Organisation (WHO), among others, has signalled the importance of ensuring LMIC countries have access to both existing and novel antibiotics, while stewardship is protected6.
Initiatives like the Global Antibiotic Research & Development Partnership (GARDP) developing treatments for drug-resistant infections, and WHO SECURE aim to support sustainable access to antibiotics for LMICs [2]. Building on this concept, organisations like GAVI and the WHO could oversee the joint procurement and supply of antibiotics using a similar model to the COVAX Facility used to purchase COVID-19 vaccines. Taking learnings from COVID-19, an access mechanism enhanced with education and other tools, including diagnostics, could ensure the appropriate use of novel antibiotics globally. Companies also have a role to play in ensuring access to novel antibiotics in LMIC countries. With combined action valuable new antibiotics could then be shared equitably around the world [2].
A bright future is not guaranteed
The bright future we paint is possible, but it is not our current trajectory. Antibiotic resistance will not overwhelm the world quickly and simultaneously in the way that COVID-19 did, causing loss of life and economic damage so visible that it compelled action from policymakers to support innovation for vaccines and therapeutics. Many call antibiotic resistance the ‘silent pandemic’ because the moment of crisis is creeping up on us mostly undetected [2]. We will only realise we should have acted sooner when hospitals are full of people with untreatable infections and the fundamentals of modern medicine, like surgery and chemotherapy, result in high death rates from infection.
Disjointed action will likely fail to prevent antibiotic resistance from increasing. Therefore, international and intergovernmental organisations like the WHO and a G20 Ministerial Health Declaration are essential to coordinating efforts across countries. Knowledge generated from countries further along in implementing pull incentives, like the UK, will help other countries design their mechanisms. Sharing knowledge of how to implement a pull mechanism is particularly crucial given their complexity and novelty. Despite the initial design hurdle, pull mechanisms such as the subscription model are today’s best strategy for building a sustainable antibiotic market in the future because they send a strong signal to developers to invest in antibiotic development.
While the pandemic exposed so painfully that nobody is safe until all are safe, it also demonstrated how joint global action can work. But it takes time and resources. While we painted a bright picture of the future, laying its foundation must start today.
The Economics of Antibiotics blog series
In this four-part series, we discuss the economics of antimicrobial resistance to understand the relevance of the NICE-NHS England AMR model and explore the questions that remain about the delinked model:
  1. G7 Finance Ministers, 2021. G7 Finance Ministers’ Statement on Actions to Support Antibiotic Development. [online] Available at: [Accessed 16 Aug. 2022].
  2. WHO, 2022. Expanding Sustainable Access to Antibiotics (SECURE). [online] Available at: [Accessed 10 Jul. 2022].
  3. NICE, 2022. NICE reaches important milestone in the UK’s efforts to tackle antimicrobial resistance. | News and features | News | NICE. [online] Available at: [Accessed 08 Sep. 2022].
  4. Outterson, K. and Rex, J.H., 2020. Evaluating for-profit public benefit corporations as an additional structure for antibiotic development and commercialization. Translational Research, 220, pp.182–190. 10.1016/j.trsl.2020.02.006.
  5. Antimicrobial Resistance Collaborators, 2022. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet, 399(10325), pp.629–655.
  6. Access to Medicine Foundation, 2022. Lack of access to medicine is a major driver of drug resistance. How can pharma take action? [online] Available at: [Accessed 06 Sep. 2022].
PP-UNP-GLB-0508; September 2022

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