In the last two years, we have seen billions in investment rapidly prioritised to get vaccines and treatments for COVID-19 into clinical use. In contrast, response to the pandemic-level health burden of Antimicrobial Resistance (AMR) remains acutely underfunded.

A recent study estimated 1.27 million annual deaths due to antibacterial AMR; 80 per cent of which are in low- and middle-income countries (LMICs).

Conventional economic incentives no longer function in antibiotic markets despite estimates that AMR could cause 10 million deaths per year and cut global GDP by 3.8% by 2050. Overuse of antibiotics in the COVID-19 response is expected to exacerbate this burden. 

In recent decades, antibiotic markets have become increasingly commercially unattractive and many large pharmaceutical firms have withdrawn completely from antibiotic production. Several biotech innovators have gone bankrupt trying to develop ‘new’ antibiotics as commercialisation is non-viable — considering the USD 1.5 billion estimated cost of developing a new antibiotic versus USD 16 million in revenue (US median). Coupled with downward pressure from health systems on prices for generic ‘old’ formulations, the result is a global shortage of these critical medicines, often termed the ‘fire extinguishers of medicine’.

Without ensuring commercial viability of old compounds, the world loses manufacturing capacity, supply chains become more concentrated and drug shortages exacerbated. Shortages accelerate AMR as less appropriate often broad-spectrum alternatives are used in clinical practice.

Without effective and available old and new antibiotics, the capabilities of modern medicine are threatened, risking pre-penicillin era mortality. Various attempts at push and pull incentives, new reimbursement models and a private sector fund to support research and development (R&D) are welcome initiatives but the scale of underfunding needs more urgent remediation and must support both old and new antibiotic markets.

Across the value chain, stewardship concerns discourage misuse, so price and volume must be divorced to enable antibiotics to be valued appropriately as the "fire extinguishers" that health systems need. Cost- or value-based new pull incentives have recently been proposed but these must go further than R&D to guarantee the long-term viability of manufacturing capacity with geographically diversified sources of active pharmaceutical ingredients.

With LMICs bearing the highest burden of AMR, access and affordability must also be built in to ensure global availability of antibiotics for WHO priority pathogens. These last two pandemic years have demonstrated that when funders (public and private), regulators and governments co-operate, innovation can be accelerated.

Human and animal health, and our natural environment depend on urgent scientific, financial and policy innovation to support sustainable antibiotic markets. For the sake of our planet, our health – the priorities of World Health Day 2022 – global access to antibiotics and other AMR countermeasures must be made a funding priority.