Leveraging Purchasing Systems to Ensure Access, Stewardship, and Innovation: A Landscape Review of Current and Potential Market Structures for Antimicrobials

This working paper aims to synthesise existing research and thinking on how antimicrobials are procured and ways to improve the current purchasing system. It examines interventions designed to improve innovation, access, and stewardship of antimicrobials and seeks to lay the foundation for a new CGD working group, A New Grand Bargain for Antimicrobial Procurement: Improving Purchasing Systems to Enhance Access, Stewardship, and Innovation for Antimicrobials in Low- and Middle-Income Countries (LMICs). We conducted a systematic review of academic and grey literature and identified 141 papers. We also interviewed 28 stakeholders with a broad range of expertise in this field. Key findings include: • The literature is overly focused on high-income countries (HICs). Whilst 51 percent of papers mention an LMIC (72/141), fewer than 10 percent exclusively focus on LMICs (14/141). Also, just 12.5 percent of papers with listed authors (16/128) have any authors based in an LMIC. LMIC- and HIC-based groups have very different priorities, as evidenced in both the interviews and the literature. Those in the former group focus more on access to drugs, while the latter are more concerned about innovation. Both groups highlighted stewardship as a priority. • There is broad agreement that a new purchasing system is needed for antimicrobials in LMICs. Although the literature lacks consensus about the best way to reform purchasing systems, interview findings suggest a more recent coalescence around subscription models in HICs. In these models, purchasers pay annually for a drug, regardless of how many units are needed. The National Health System in the United Kingdom is currently piloting such a system with two drugs, and the US Congress is considering its own version with the PASTEUR Act. There is less clarity on the optimal system for LMICs. • There is insufficient research on how to implement policies and—with the exception of the GAIN Act, a 2012 piece of US legislation that grants an additional five years of exclusivity for qualifying antimicrobials—a dearth of research evaluating previously implemented initiatives.