For example, as part of a new payment pilot, the United Kingdom extended its typical cost-effectiveness framework to include Stedi, an acronym for reducing the collateral damage by focusing on a wider (S)pectrum of antibiotics, the reduction in (T)ransmission, the (E)nablement of other treatments, the indirect benefits of preserving other antibiotics due to (Diversity) and the (I)nsurance value of having more last-line treatments.

Noting, however, that the Stedi value profile for any one antibiotic is highly context-dependent and may trade off one element against another, the framework continues to evolve as the pilot continues.

Secondly, as we encourage the development of new antibiotics, we should also discourage their use until absolutely needed in order to delay the onset of resistance. In theory, “pull incentives” work best with stewardship when reimbursement to antibiotic manufacturers can be separated, or de-linked, from sales volumes.

De-linking is a relatively radical mindset change, but is currently being explored globally.

Between 2020 and 2022, the Public Health Agency of Sweden ran a pilot study of a partially delinked scheme where the state guaranteed a minimum annual revenue to antibiotic manufacturers, which in turn stock-piled and delivered their antibiotics within specified time limits. This scheme has been relatively successful, allowing Sweden to gain access to several new antibiotics earlier than their European peers.

Elsewhere, the UK is currently testing a fully delinked “Netflix-style” subscription model in which selected antibiotic producers are reimbursed with a fixed pre-determined amount each year for access to a new antibiotic, regardless of the number of doses actually prescribed.

WHAT ARE REALISTIC NEXT STEPS FOR SINGAPORE?

Continuing with and even expanding Singapore’s robust antimicrobial stewardship is not an option, but a necessity.

In Singapore, our Agency for Care Effectiveness evaluates the value of new drugs and medical devices. As international best practices for assessing the full value of new antibiotics evolve, our process and methods should also evolve, as well as supporting the underlying research agenda for antimicrobial resistance more broadly.

In general, “pull incentives” only have a significant chance of achieving their aim only if multiple countries including large economies participate.

Although any such scheme we implement will have little impact on its own in shifting the needle towards incentivising future antibiotic development, Singapore is well respected on the world stage and provides important regional thought leadership.

We should explore and contextualise such incentives for antibiotic development, and ensure that we are well placed to implement them should there be a significant global move towards enacting such strategies.

Monitoring international movements in financing and forming a pragmatic evidence-based view of regional aids and barriers to implementation is an important dimension of preparedness that a vision of good stewardship must now begin to embrace.

ABOUT THE AUTHORS:

Professor Hsu Li Yang is vice-dean of global health at Saw Swee Hock School of Public Health (SSHSPH), National University of Singapore (NUS). Associate Professor Wee Hwee Lin is the Director for the Centre for Health Intervention and Policy Evaluation Research at SSHSPH. Professor Joanne Yoong is the founder and CEO of Research For Impact, Singapore as well as adjunct faculty at Yong Loo Lin School of Medicine, NUS.