A New Grand Bargain to Improve the Antimicrobial Market for Human Health

Final Report of the Center for Global Development's Working Group

By Anthony McDonnell, Katherine Klemperer, Morgan Pincombe, Rachel Silverman Bonnifield, Prashant Yadav, and Javier Guzman

Every year, antimicrobial resistance (AMR) directly causes 1.27 million deaths and is associated with an additional 3.7 million deaths. 

Low- and middle-income countries bear the brunt of this burden, accounting for nearly 90 percent of the direct death toll and over 99.5 percent of AMR–related deaths among children under five. 

Already, more people die directly from AMR than from HIV/AIDS, malaria, or any one form of cancer other than lung cancer. 

And the problem of AMR is only growing: Without effective antibiotics, it has been estimated that 10 million people a year could die from AMR—equivalent to the annual death toll from all cancers. 

Some life-saving surgeries and treatments, including transplants, will not be possible because the risks from these procedures will be too high without effective antibiotics.

Tackling AMR requires global consensus and action on many fronts.

Creating an antimicrobial market that ensures adequate innovation, access, and stewardship is key to fighting AMR.

Improving infection prevention and control, increasing surveillance, and reducing antibiotic use in agriculture are also critical.

Progress has been made to garner political commitment to tackle AMR, including through high-level commitments at the 2015 World Health Assembly and the 2016 UN General Assembly.

More than 170 National Action Plans (NAPs) were developed to formalize government responses to AMR.

New R&D initiatives have been created (such as CARB-X, GARDP, and the AMR Action Fund), and some countries have started to pilot new ways to value and procure antibiotics, including the United Kingdom’s subscription model and Japan’s pilot for a revenue guarantee system.

Surveillance systems have been improved through the Fleming Fund, and better data for decision making are available via the R&D Hub. 

These policies and commitments are laudable, but collective action problems still stand in the way of realizing a new international approach to the antimicrobial market.

Fewer than 20 percent of NAPs have been fully funded and implemented.

The pipeline of innovative antibiotics is insufficient to tackle the challenge of AMR, and the funding gap for early-stage product development is at least $250 million a year

Building on its previous research and analysis on AMR, in 2022, CGD launched the working group A New Grand Bargain to Improve the Antimicrobial Market for Human Health to examine policy options to drive global action against AMR.

We outline the principles of a Grand Bargain that we believe all stakeholders can and should sign up to during the UN General Assembly's High-Level Meeting on AMR in 2024.

Balancing antimicrobial innovation, access, and stewardship

The current market for antimicrobials fails to spur research and development (R&D), ensure access to new and existing products, and protect against overuse.

These three objectives—innovation, access, and stewardship—must be balanced to ensure sustainability and equity. Global commitment and action are needed to overcome collective action problems and realize a new market structure for antimicrobials.

Three factors needed for a sustainable antimicrobial market


without stewardship, speeds resistance and undermines innovation


constrains access and undermines innovation without a balanced policy


unjust without access, wasteful without stewardship

Innovation, Access, and Stewardship

Three factors needed for a sustainable antimicrobial market


without stewardship, speeds resistance and undermines innovation


constrains access and undermines innovation without a balanced policy


unjust without access, wasteful without stewardship

Inadequate innovation

The R&D pipeline for antimicrobials is—and for decades has been—dry.

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The number of new antibiotics approved by the US Food and Drug Administration fell from 16 in 1983–87 to 3 in 2008–12—a decline of 81 percent.

Resistance buildup is outpacing innovation, and the innovation agenda does not sufficiently reflect the needs of low- and middle-income countries.

Methods to assess the value of antimicrobial treatments fail to adequately value all benefits derived from antimicrobials. As a result, renumeration is insufficient to encourage innovation, and market entry in many countries is limited.

Analysis conducted as part of this working group offers a new assessment framework that can integrate LMIC priorities, including affordability, accessibility, ease of administration, heat stability, and wide applicability. 

Amidst persistent challenges, some recent positive developments have occurred in antimicrobial innovation. Payouts contingent on R&D success (“pull incentives”) have been piloted in the United Kingdom and Sweden and proposed in the United States, Japan, Canada, and the European Union. Estimates suggest that the domestic return on such investments would be as high as 28:1.

Further implementation of these mechanisms, coupled with higher levels of “push funding” (upfront funding for R&D) are needed to fill the significant remaining gaps in the innovation pipeline.

Inadequate access

Inadequate access to existing and new antimicrobials is a leading cause of death from AMR infections and a key priority in the AMR response in LMICs.

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Alongside the moral imperative to expand access to essential medicines, widespread availability of essential treatments is needed to help decrease transmission and limit inappropriate use of other antimicrobials used when first-line treatments are inaccessible, reducing the risk of diseases spreading to the whole world.

Most antibiotics are off-patent. Manufacturers of these drugs face thin margins and minimal incentives to invest in supply chain flexibility and resiliency. Shortages of amoxicillin—a key off-patent medicine—were recorded in late 2022 and early 2023 in 80 percent of the 35 countries for which the World Health Organization (WHO) had data.

Greater supply chain resilience is needed, but collective action problems disincentivize procurers from paying the price.

Initiatives such as the partnership created by the pharmaceutical company Shionogi, the Global Antibiotic Research and Development Partnership (GARDP), and the Clinton Health Access Initiative (CHAI) to ensure the successful rollout of their novel antibiotic cefiderocol and efforts by the Global Drug Facility to roll out safe, effective, and affordable tuberculosis treatments provide lessons and potential models for future interventions to address access issues for off-patent and on-patent treatments.

Inadequate stewardship

The current market for antimicrobials contains structural failures and perverse incentives that undermine stewardship, contribute to higher levels of inappropriate use, and drive up resistance rates.

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Stewardship refers to the appropriate use of antimicrobials to ensure that their efficacy is maintained over time.

Adequate stewardship measures must be imposed to support appropriate use of Reserve and Watch category drugs, as defined by the WHO’s AWaRe classification.

Prescription policies and reporting databases could be leveraged to strengthen stewardship, but they must allow countries sufficient flexibility to sustain and expand access to antibiotics at a level commensurate with local disease burden.

Countries need targets for antimicrobial usage that are measurable (to facilitate accountability) and absolute (so that they can be tailored to national circumstances).

Six Recommendations

from CGD’s working group A New Grand Bargain to Improve the Antimicrobial Market for Human Health

This report presents recommendations on increasing the availability of critically needed drugs, creating incentives to develop new ones, and reducing market pressures to misuse or oversell the drugs.

It provides one political and five operational recommendations.

The political recommendation outlines why it is both possible and in everyone’s interest to overcome the collective action problems inherent in dealing with market failures in the antimicrobial market through a global agreement.

The five operational recommendations describe actions countries could take to begin to implement such a deal.


1. Establish a new “Grand Bargain” in the antimicrobial market for human health

View the infographic.

Countries should negotiate and agree on a new political understanding (or Grand Bargain) on antimicrobials at the UN General Assembly High-Level Meeting on AMR in 2024.

A Grand Bargain is both achievable and in everyone’s interest. It should set out standards and commitments for countries, international organizations, and the pharmaceutical industry to ensure the adequate functioning of antimicrobial procurement systems.

It should ensure that countries protect antimicrobials from unnecessary use, contribute toward R&D for new treatments, and ensure that essential antibiotics reach people who need them, including by creating a system that facilitates the distribution of drugs in countries not well served by current systems.

International organizations—which include UN bodies like the WHO, international finance institutions like the World Bank, and regional health organizations like the African Centres for Disease Control and Prevention—have a role to play in coordinating and monitoring the system. Industry should commit to conducting research on new treatments, including those that meet the needs of LMICs, and ensure equitable access to drugs in exchange for a system that engenders adequate renumeration and supports appropriate distribution.


2. Implement a Sustainable Access Hub that ensures antimicrobials reach the people who need them

View the infographic.

A sustainable access hub (or hubs) should be established to address issues in the antimicrobial market, including demand fragmentation and low volumes, that contribute significantly to access challenges, especially in low- and middle-income countries.

The hub would serve primarily as a backstop to facilitate access to essential antimicrobials and diagnostics in settings where the market is currently failing. It could be a global entity or a series of regional initiatives; its functions could be handled by one organization or divided among and led by several.

Six key functions would help deliver on the hub’s goals:

  • supporting procurement of an essential portfolio of antimicrobials and diagnostics
  • facilitating registration and distribution of these products
  • shaping the antimicrobial market as a large procurer
  • improving the tracking of global antimicrobial consumption
  • ensuring that purchasers meet the WHO’s stewardship and access standards
  • managing or supporting financial and technical assistance for resource-constrained countries to implement stewardship and surveillance systems.


3. Ensure innovation is properly valued and meets the needs of LMICs

High-income countries (HICs) should implement funding systems, including push and pull incentives, that attract investment for treatments that meet the needs of all countries.

To better guide global innovation, the WHO should employ new methods to determine the Priority Pathogen List and develop target product profiles (TPPs) that better reflect the disease burden in, and priorities of, LMICs. Procurement decisions in all countries should be guided by assessment frameworks that adequately assess the value of antimicrobial innovation.

This report outlines an assessment framework designed to be flexible enough to accommodate local contexts, needs, and preferences.


4. Strengthen regional regulatory processes

Robust regional approaches to regulating antimicrobials could streamline the approval of clinical trials; reduce the time to issue marketing authorization while guaranteeing consistent standards for safety, efficacy, and quality; and improve post-marketing vigilance and surveillance.

Regional regulatory approaches would enhance resource utilization, especially in low-income countries (LICs), where mature, functional systems and regulatory capacity are limited.

In addition to expanding timely access to antimicrobials, regional approaches could support regional procurement.


5. Control and track the unnecessary use of antimicrobials

Countries should enact policies to reduce unnecessary use and develop robust tracking systems to measure the impact of such policies. Control policies should be tailored to the type of antimicrobial and include a prescription policy for Reserve (and where appropriate Watch) category antimicrobials.

These policies should be coupled with a reporting database for Reserve antibiotics and be underpinned by robust data systems and access to diagnostics. Such a system for controlling and tracking antimicrobial usage will be a critical step in the implementation of the Grand Bargain.

These systems should also be built with access in mind so that they track when essential antibiotics are not available to treat patients.


6. Set targets to track progress on innovation access, and stewardship goals

Specific, measurable, achievable, relevant, and timebound targets are essential to implementing any international agreement on tackling AMR. Countries could set them at the High-Level Meeting on AMR at the 2024 UN General Assembly.

These targets could include (a) the percentage of people with justified need who are able to access effective and affordable antimicrobials, (b) the justified level of antimicrobial consumption in each country, and (c) the number of innovative new products in the antimicrobial pipeline.

This report identifies methodologies that could be used to set targets. To support implementation, countries could also receive guidance, technical assistance, and, in resource-constrained environments, the funds to help meet the targets.

Overview of the proposed Grand Bargain to Improve the Antimicrobial Market for Human Health

The Grand Bargain

A path to effective, affordable, and accessible antimicrobials

High-income country governments

In return for a system that ensures sustainable access to effective antimicrobials:

  • Adequately fund research and development
  • Support and conduct clinical trials
  • Facilitate global access to essential diagnostics and antimicrobials
  • Protect drugs from unnecessary use
  • Adequately fund National Access Plans
  • Domestically and in low-income countries
  • Support the creation of a sustainable access hub for antimicrobials

Low- and middle-income country governments

In return for a system that ensures sustainable access to effective antimicrobials:

  • Support and conduct clinical trials
  • Collect and report data on resistance
  • Protect drugs from unnecessary use
  • Reduce unnecessary barriers to access and stewardship
  • Adequately fund National Action plans
  • Support the creation of a sustainable access hub for antimicrobials

International organizations

  • Coordinate between countries and ensure commitments are followed
  • Set global targets for access, innovation and stewardship of antimicrobials
  • Monitor resistance rates and antimicrobial consumption
  • Provide finance and technical advice to governments to implement goals

Pharmaceutical industry

In return for a system that adequately remunerates research and removes barriers to selling antimicrobials in LMICs:

  • Undertake research and development in critical areas that meet all countries needs
  • Protect drugs from unnecessary use
  • Manufacture antibiotics in an environmentally sustainable way
  • Improve production standards and supply chains globally
  • Ensure drugs are available in all countries

A Sustainable Access Hub

that ensures reliable access to and stewardship of essential antimicrobials and diagnostics where the market currently fails


Sustainable Access Hub



Ensure access

Every year, antimicrobial resistance (AMR) directly causes 1.27 million deaths and is associated with an additional 3.7 million deaths. 

Reduce inappropriate use of antimicrobials

by providing diagnostics, financial and technical assistance, and reducing incentives to oversell

Help countries track and report

consumption data to WHO's GLASS platform

Reduce shortages

by shaping markets and forecasting and aggregating demand, tracking suppliers' capacity and stockpiling where necessary

Reduce prices

of medicines through pooled procurement and multi-year contracts