A 2017 OECD report, ‘Tackling Wasteful Spending on Health’, warns that one-fifth of health expenditure makes no or minimal contribution to good health outcomes. It’s alarming news – especially at a time when public budgets worldwide are under pressure. Governments could spend significantly less on healthcare and still improve patients’ health.
Inappropriate use of antimicrobial medicines is both wasteful and one of the biggest threats to clinical care, as it encourages the development of antimicrobial resistance (AMR). Many of the achievements of modern medicine, including surgical procedures and the care of premature new-borns, are intrinsically based on our ability to prevent and cure infections. All these medical achievements may be swept away by AMR if action is not promptly taken. From 2014 to 2016 the United Kingdom carried out a comprehensive and independent AMR review. The review panel, chaired by economist Jim O’Neill, estimated that up to ten million people worldwide may die by 2050 due to six common diseases whose resistance is growing.
AMR also puts healthcare budgets and the whole economy under stress. Patients developing resistant infections are more difficult to treat. Each patient costs up to an additional US$40,000 due to increased medicalisation and additional time spent in hospital. This figure is likely to double once indirect costs such as absence from work are considered.
So where are we going wrong? Microorganisms can learn how to withstand attacks by drugs. By using antimicrobials incorrectly, we are helping them to do this more quickly. Fundamentally, we are making two mistakes.
“Since 2000, only five new classes of antibiotics have been put on the market ‒ none targets the deadliest bacteria”
First, our consumption of antimicrobials is largely ineffective. In some countries we consume too many antibiotics – the largest category of antimicrobials – and often for the wrong reasons. About half of all the antibiotics prescribed by healthcare facilities in OECD countries do not meet medical prescription guidelines. The extensive use of antibiotics in agriculture sustains the growth of AMR: worldwide, up to 70% of antibiotics are given to animals, often for no other reason than to make them grow more quickly. Conversely, some less wealthy countries consume too few antimicrobials because people cannot afford to buy them when needed. About 600,000 children under five are estimated to die of pneumonia in low- and middle-income countries because they do not have access to effective antibiotics.
To promote the effective use of antimicrobials, alternative interventions are needed. They include those triggering behavioural changes (such as stewardship programmes and educational interventions) and organisational changes (the use of diagnostic tests or delayed prescriptions), as well as economic incentives (like pay-for-performance schemes). Countries should strengthen their efforts and upscale successful local actions to the national level.
Second, the way in which we give incentives for research and development (R&D) into new antimicrobials is flawed, creating a huge threat for the future. The last major new class of antibiotic was discovered in 1987 but the approval of novel therapies has fallen eight-fold since then. Since 2000 only five new classes of antibiotics have been put on the market. None targets the deadliest bacteria.
This lack of innovation is largely due to market failure that also triggers ineffective use: the (wrong) incentives to make large use of antimicrobials. Industry seeks adequate return on investment, so has an interest in selling a lot of pills, thereby triggering ineffective use, or increasing the price, which limits access and affordability. Any newly-developed drug would need to be restricted to prevent diseases from becoming resistant to the new antimicrobials. For the pharmaceutical industry, this means that investment in other therapeutic categories is far more appealing. Innovation in antimicrobials suffers as a result.
“Up to 70% of antibiotics are given to animals, often for no other reason than to make them grow more quickly”
We need to identify innovative economic approaches to address the lack of sufficient investment in the antimicrobial R&D pipeline, from the early research phases to the commercialisation of the final product. New incentives to promote an effective use of newly-developed antimicrobials are also badly needed. This means ensuring that access to the drug is granted when and where it is needed and that we have in place strong actions to prevent ineffective use.
The good news is that the world has woken up to the challenge. It is now widely recognised that there is no time to waste: we need to step up global efforts to tackle AMR before it becomes uncontrollable. At the Elmau and Ise-Shima summits in 2015 and 2016, G7 countries committed to tackle the issue, as did G20 leaders in Hangzhou in 2016. Leaders called on the OECD, the World Health Organization, the United Nations’ Food and Agriculture Organization, and the World Organisation for Animal Health to support them.
Health ministers from the 35 OECD countries and their counterparts from Colombia, Costa Rica, India, Indonesia, Kazakhstan, Lithuania, Peru, Saudi Arabia and South Africa met in January in Paris under the chairmanship of the UK’s Secretary of State for Health, Jeremy Hunt. They discussed AMR as part of the broader agenda of tackling ineffective spending in healthcare systems and managing the innovation process in medical technology. Together with other international organisations, the OECD is working to support G20 countries in tackling the issue.
Breaking the vicious circle that has led to the emergence of AMR will be crucial. It will require action in many ways, including rational use and good surveillance in the animal and human sector, and in promoting the development of new antimicrobials. We cannot afford to put off the issue much longer. The stakes are high: the benefits of success and, crucially, the risks of failure are enormous for our economies and societies.
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