To Push or To Pull? In a Post-COVID World, Supporting and Incentivizing Antimicrobial Drug Development Must Become a Governmental Priority

Abstract

The COVID-19 pandemic has refocused attention worldwide on the dangers of infectious diseases, in terms of both global health and the effects on the world economy. Even in high income countries, health systems have been found wanting in dealing with the new infectious agent. However, the even greater long-term danger of antimicrobial resistance in pathogenic bacteria and fungi is still under-appreciated, especially among the general public. Although antimicrobial drug development faces significant scientific challenges, the gravest challenge at the moment appears to be economic, where the lack of a viable market has led to a collapse in drug development pipelines. There is therefore a critical need for governments across the world to further incentivize the development of antimicrobials. Most incentive strategies over the past decade have focused on so-called "push" incentives that bridge the costs of antimicrobial research and development, but these have been insufficient for reviving the pipeline. In this Perspective, we analyze the current incentive strategies in place for antimicrobial drug development, and focus on "pull" incentives, which instead aim to improve revenue generation and thereby resolve the antimicrobial market failure challenge. We further analyze these incentives in a broader "One Health" context and stress the importance of developing and enforcing strict protocols to ensure appropriate manufacturing practices and responsible use. Our analysis reiterates the importance of international cooperation, coordination across antimicrobial research, and sustained funding in tackling this significant global challenge. A failure to invest wisely and continuously to incentivize antimicrobial pipelines will have catastrophic consequences for global health and wellbeing in the years to come.

Keywords: One Health; access; antimicrobial resistance; global health policy; market failure; push and pull incentives.

Figure 1

Summary of the different R&D stages and pharmaceutical industry costs involved in the development of a new therapeutic. Estimates of costs are taken from Paul et al. (2010) (marked *, modeled capitalized costs per launch of a new molecular entity) and Rex 2020 (marked †, specifically for antibiotics for the first five years postapproval). Recent estimates put the capitalized cost of bringing a new antibiotic to market at around $1.3 billion.^, However, a figure that is often overlooked is the cost postapproval, which for antibiotics is estimated to be $250–500 million over the first five years that the drug is on the market.

Figure 2

Estimates of global deaths due to AMR, including future predictions, and deaths due to treatable infections caused by lack of access to effective antimicrobials. Data based on the O’Neill (AMR related) and CDDEP reports.^, Current COVID-19 related deaths are provided for context, approximately a year into the crisis; data retrieved from Worldometer on 15th December 2020.

Figure 3

Global coordination is needed to solve the market failure crisis in antimicrobials and to balance access versus stewardship requirements across the globe. Continuous dialogue and reflective learning across nations will be critical for combatting the myriad policy challenges of AMR at a global level.