The world has a right and a shared responsibility to secure antibiotics globally so that it can continue to be effective
Photo: iStock_ On October 18, 2023, global experts at a webinar organised by Delhi-based think tank Centre for Science and Environment (CSE) discussed the challenges and possibilities around antibiotics or any aspect of antimicrobial resistance becoming a global public good.
The webinar was the third The Antibiotic Webinars series being conducted to discuss the antibiotic pipeline and access crisis. Earlier in July this year, CSE had published an assessment on the ongoing crisis in Down To Earth.
The pipeline of new antibiotics continues to be weak and there is a need for critical reforms to stimulate the antibiotic innovation ecosystem for a sustainable and equitable antibiotic access, according to a CSE assessment published in July 2023 in Down To Earth.
This also included the possibility of considering antibiotics as a ‘global public good’ so that they are treated differently from other drugs in terms of resource and development and access.
Key experts who spoke at the webinar included Gavin Yamey, director, Center for Policy Impact in Global Health, Duke Global Health Institute, the United States; Anna Sjöblom, director, ReAct Europe, Sweden; Kerri Elgar, senior policy analyst, Development Co-operation Directorate, OECD, France; Franck Berthe, The Pandemic Fund Secretariat, Washington DC, US; Rohit Malpani, senior advisor, GARDP. It was moderated by Amit Khurana, director, Sustainable Food Systems programme, CSE.
The concept of global public goods was discussed at length during the webinar. It is not new, but presently there is a renewed interest in this concept. This is because of the wide array of emerging trans-national health challenges, which, if not acted upon timely, will not only cost lives but also adversely impact the economy.
There is a need for international collective action for health to address these challenges. While the cost of investing in these actions could be large, the return on investment is quite high. Discussions and debate around global public goods is also gaining momentum.
The conventional definition of global public goods is narrow and has its own challenges. Commonly a global public good is understood as being non-rival (if one person consumes it, this does not reduce its availability to others) and non-excludable (no one can be denied access).
But this definition does not capture the full array of health actions that are collectively required to address wider supra-national health challenges. More definitional clarity is needed.
There are alternative ways to look at how global public goods can be defined. This includes, for instance, the concept of common goods. As per the World Health Organization, ‘common goods for health’ are public goods or have large social externalities and thus will not arise through market forces alone. Therefore, they require both public financing and public action. This concept has emerged based on the observed failures (surveillance, leadership, advocacy) exposed by Ebola, SARS, Zika and other communicable diseases as well as by other health and environmental risk factors.
Another concept is ‘global functions’, which capture the broad array of activities critical in preparing for and responding to transnational challenges. These include supplying global public goods, managing cross border externalities (such as AMR response) and exercising leadership.
In terms of funding, there has been an increased amount of spending over time on health through development budgets, in particular infectious diseases. It is difficult to measure flows going to AMR. This is more so in case of low- and middle-income countries, which are most impacted with respect to health challenges.
Subsequently expenditure on national government priorities has dropped. It is also imperative to know the use and mobilisation of domestic resources, such as in areas like pandemic prevention and preparedness, AMR and One Health.
Antibiotics do not fit the conventional definition of global public goods. But there could be different dimensions or characteristics which could fit. This can include patents for an antibiotic shared in an open patent pool, AMR containment, aspects linked to antibiotics such as supply, appropriate use, registration, affordability and presentation. Awareness, surveillance, wash and IPC could also be framed as global public goods.
Existing financing models like the push and pull incentives have limitations when looked at from a global public good perspective. Pull incentives like subscription models operational in the United Kingdom or being planned in the US, for instance, may not work in LMICs unless effective mechanisms are developed that enable these countries to pay. Antibiotics will otherwise remain as only a regional good or a national public good. It will also not drive innovation.
Even if subscription mechanisms developed in different countries are applied globally, the priorities that would guide developers would be those countries who can pay the most.
Another pull mechanism which could be linked to creation of global public goods effectively is a prize (such as a “milestone prize” during clinical development or an end-stage prize / market exclusivity reward for a product when it comes to market). But this can happen provided the right conditions are in place such as a company willing to give up its intellectual property in exchange for a prize, affordability is ensured and supply is enough.
Push incentive like GARD-P face concerns such as whether companies and public sector are willing to share or license their compounds to GARDP to take forward its development, what is the territory provided in case license is available, is the product developed in the right presentation that is required in LMICs.
There are also challenges associated with considering antibiotics as global public goods. It is therefore important to look at AMR containment issues more holistically and address aspects like access to clean water, infection prevention, appropriate antimicrobial use in agriculture which is linked to better human and sustainable development.
Similarly, an AMR lens on investments in areas such as water and sanitation, livestock and agriculture, healthcare systems and strengthening public health systems needs to be applied. Putting too much emphasis on the antibiotics-global public good linkages can have limitations like ‘tragedy of the commons’ and ‘free rider problem’.
The world's people have a shared responsibility to secure this resource globally so that it can continue to be effective. It is also a right as people should have access to it when needed. Global collaborative action and global governance is crucial for addressing cross border threats such as AMR. This could be expedited through measures like a binding agreement, putting more accountability on government, and strengthening existing AMR governance models.
In addition, compulsory financing at the country level can also be explored. This could involve innovative financing mechanisms such as global taxes, along the lines of the airline tax which have earlier helped Unitaid generate resources for global health.
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