“We will implement purchasing arrangements for new antimicrobials that de-link the price paid for antimicrobials from the volumes sold, monitor and evaluate impact, and advocate for the wider use of these ‘subscription models’ in other countries.”

As NICE notes, investing in new antimicrobials is not “commercially attractive” because of the necessarily strict controls and restrictions of use for the purpose of avoiding AMR exacerbation. As already stated, it’s an ROI consideration. Thus, the UK Government’s 2019 national action plan for AMR was meant to test how to incentivise companies to invest in new antimicrobials – utilising a rather different model from that used for other medicines. Together with NHS England, NICE ran a pilot project testing an innovative approach that pays companies a fixed annual fee for antimicrobials. Sums were based primarily on a health technology assessment of their value to the NHS, instead of volumes used.

Certainly, eyes will be on England from other nations, and other similar models are duly in the pipeline abroad. What is paramount, though, is that global endeavours are undertaken: no man is an island, and no one country can ameliorate the worldwide AMR situation alone. Indeed, if G20 countries rolled out payments based on their percentage share of the global market – remember, England is a mere 2%-3% of that share – this would act as a significant global “pull incentive”, even without LMICs making a contribution.

As the ABPI’s value & access policy director, Paul Catchpole, notes: “All countries globally, particularly the G7 and G20 nations, need to make their own contributions, collectively, to add up to significant amounts of money that will make antibiotic research more commercially attractive to stimulate development.”

To this end, across the pond, the US proposed the PASTEUR (Pioneering Antimicrobial Subscriptions To End Upsurging Resistance) Act in 2021, similarly operating as a subscription-type model. However, it has not been passed, despite the 2023 bill lowering the suggested funding from $11 billion to $6 billion. Back on the Continent, the EU is contemplating a transferable exclusivity voucher (TEV), based on a reward system, whereby developing a critically needed drug (e.g., an antibiotic) in turn extends the patent a pharmaceutical company has on another drug. Recent analysis by the Center for Global Development found that the new EU antimicrobial incentive programme could save some 20,000 lives and deliver $15.5 billion in total benefits, with – importantly – an ROI of 4:1 over the next decade.

European countries adopting such an approach to fit their national systems include Sweden, which has implemented a revenue guarantee for five antimicrobials active against Priority 1 pathogens on the WHO priority pathogen list, while Germany and France have both developed an adjusted reimbursement system for antibacterials, allowing larger payment to companies. 

While it remains to be seen as to how effective the uptake of this “pull incentive” Netflix-style subscription model across the international map will be, what remains certain is that the antibacterial market is broken, that the antibiotic pipeline needs a cash incentive for an R&D interest boost, and that AMR is not going anywhere anytime soon. While countries broadly support the concept, the question that also lingers is which new antimicrobials will be most suitable for a “subscription” or “pull incentive” approach. 

Rex and Outterson might have stated that antibacterials should be thought of as the “fire extinguishers” of medicine, but – in a world where we yet battle infectious diseases such as COVID and mpox in multiple variants – what type of fire, and at what cost, will it take to drive nations down a suitable, if not fully perfect, payment model path and arrest AMR before it becomes truly unstoppable?