Global Health Security Summary
Aligning Incentives for
Antibiotic Development
and Use with Public
Health Needs: First
Roundtable on
Antimicrobial
Resistance
2 October 2013
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
INTRODUCTION
This was the first of a series of meetings organized by the Centre on Global Health Security at
Chatham House to address the problem of antimicrobial resistance. A series of roundtables and a
conference are envisaged to address, in particular, the following key issues:

What new efforts by governments and stakeholders in the developing and developed
world are needed for global antimicrobial conservation? What obstacles constrain
effective action? How can they be addressed?

What are the most efficient ways of stimulating new drug development for long-term
sustainability? What has been tried? What is most likely to work? What does this mean
for government policies?

How do we address antibiotic use in the food and agriculture sector (including
fisheries)? How do we promote cross-sectoral collaboration? What are the obstacles?
How can they be overcome?
The underlying purpose of these consultations is to influence actions by governments and policymakers in global and multilateral fora such as the World Health Organization (WHO), the World
Organization for Animal Health (OIE), the Food and Agriculture Organization (FAO) and the
Transatlantic Taskforce on Antimicrobial Resistance (TATFAR), and in national governments (e.g.
through policies to promote long-term sustainability). Possible outcomes include contributing to the
content of agreements in the WHO, the OIE, the FAO and other organizations on global actions to
combat resistance and recommendations to national governments on stewardship and incentives
for drug development.
This first roundtable was convened to address the second point above. It brought together a broad
range of senior participants from industry, regulators, research organizations and civil society. The
meeting was chaired by John-Arne Røttingen of the Norwegian Institute of Public Health and
Harvard University. Participants are listed in Annex 1.
CONTEXT
As resistance to antibiotics continues to grow, there is a well-recognized misalignment between the
incentives for the development of new antibiotics and the clinical need for them. The returns from
investment in antibiotic research and development (R&D) are perceived as too small. The number
of large multinational companies researching antibiotics has fallen drastically in the last 20 years
and few new antibiotics have been developed. Apart from the poor economic return, there are
particular scientific challenges in developing antibiotics. And companies complain that regulatory
requirements are uncoordinated and disproportionate, and correspondingly costly, which
compounds the problem of inadequate returns.
In terms of use, there are various clinical issues that militate against using antibiotics in a rational
way (i.e. to treat an identified bacterial disease with the right antibiotic at the right dose). The
psychology of the patient-clinician relationship, inadequate access to speedy diagnostic tools, overthe-counter sales, inappropriate use of antibiotics for viral illnesses and sub-standard drugs with
too little active ingredient are among the reasons why antibiotic resistance develops faster than it
should. Moreover, the financial incentives for providers or payers often do not discourage
inappropriate use and may in fact instead encourage misuse (such as salaries based on number of
prescriptions filled). Higher prices have been suggested not just as a way to incentivize research
but also to discourage unnecessary use. However, higher prices could put antibiotics out of reach
of poorer populations and increase the costs to health systems in higher-income countries.
This summary was compiled by Charles Clift, Senior Consulting Fellow at the Centre on Global
Health Security at Chatham House
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
The purpose of the roundtable was to contribute to the drafting of a roadmap outlining the steps
necessary to promote appropriate incentives for development and use in national and international
policy circles.
SESSION 1: INTRODUCTION AND BACKGROUND
Kevin Outterson introduced his background paper: ‘Antibiotic Delinkage Models: New Business
Models to Prevent an Antibiotic Apocalypse’. This paper describes the various proposals that have
been made to stimulate new antibiotic development based on delinking the return to producers
from the volume of their sales. This would mean that companies would not be incentivized to
maximize sales in ways that could accelerate the development of resistance. A summary of the
various proposals is at Annex 2.
In discussion the importance of improving diagnostics to foster appropriate use was emphasized
by several participants. In addition, improved diagnostics could significantly lower the costs of
clinical trials by allowing accurate targeting of patients for inclusion. Ways to stimulate diagnostic
development, such as prizes for instance, therefore needed to be considered.
Several participants took issue with the idea in the paper that only a few new ‘high quality’
antibiotics should be prioritized, rather than incentivizing a larger number of so-called ‘follow-on’ or
‘me too’ drugs. It was contended that this misunderstood the R&D process, which is difficult to
focus in the way proposed; and that follow-on innovation was very important in improving the
quality of ‘first in class’ drugs and for market competition. For example, there had been four
generations of cephalosporins – with each generation addressing a new unmet need. Additionally,
innovators face uncertainty until late stage clinical trials regarding the potential impact of a new
antibiotic. There have also been instances where unsuccessful antibiotics (such as vancomycin)
are later found to be more valuable due to new public health threats. By limiting the reward to only
game-changing antibiotics, there was concern that this would limit the overall amount of R&D
investment. But there was general agreement that rewards should be larger for those antibiotics
that have the largest potential impact or add to the resistance profile of products available.
SESSION 2: FOCUS ON INCENTIVES FOR DEVELOPMENT DELINKED FROM
VOLUME OF SALES
Initial presentations focused on three possible delinkage models. One idea was that, up to the end
of Phase 2, the funding would be worked via a public/private partnership, not dissimilar from what
often happens now (e.g. through the Innovative Medicines Initiative (IMI) or the US Biomedical
Advanced Research and Development Authority (BARDA)). Then, at the Phase 3 start decision
there would be a contract with the purchaser (usually a government). That would be a long-term
contract of up to 20 years. Under that contract, the manufacturer would commit to supply as little or
as much of that antibiotic as the purchaser required, based on public health considerations. The
manufacturer would not be involved in the distribution of that antibiotic, its promotion or education
about it. These would be entirely up to the purchaser. Purchasers could then utilize incentives to
reward appropriate use by providers and prescribers, including where providers could pay a
variable fee for antibiotics (or a class) depending on their record of appropriate use (or infection
rates in hospitals).
Another presentation focused on the Rewarding Antibiotic Development and Responsible
Stewardship (RADARS) model. In this model (applicable to the US health care system), public and
private payers reimburse hospitals for the incremental costs of qualified infectious disease products
(for example as defined in the US Generating Antibiotic Incentives Now (GAIN) Act) above and
beyond existing diagnosis-related group payments (DRGs). Payments would only be made if drugs
are prescribed in accordance with a preapproved stewardship programme. Guaranteed minimum
payments for a period of five years would be paid to the innovator pharmaceutical company
irrespective of the volume sold. During this period, promotion by the pharmaceutical company
would be prohibited. After five years the guaranteed minimum payments would cease but the
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
incremental payments would continue for an additional five years to further reward innovators who
produce particularly innovative products and/or accurately address the most troubling resistance
trends.
Another participant set out a proposal for global model that treated new antibiotics as global public
goods requiring special treatment (see Figure 1). Under this initiative a sizeable fund would be
established at a global level that would manage the whole spectrum of activities from discovery to
the market. The fund would offer a variety of incentives for innovation, from grants to prizes tied to
development milestones or end products and contract manufacturing with the private sector on a
cost-plus basis. But against this the intellectual property would be held either by a suitable body
such as the WHO, the Medicines Patent Pool, or similar. This needs to happen at the UN, or in any
case, global level because the intellectual property would need to extend to all countries of the
world and require a licence in perpetuity. The idea would also be to fully harness the innovative
capacity of middle income countries and to provide medicines of assured quality through a new
regulatory mechanism.
Figure 1. Proposed Initiative: New Antibiotics as Global Public Goods.
Other participants outlined the model of public-private partnership utilized by the IMI with member
companies of the European Federation of Pharmaceutical Industries and Associations (EFPIA),
and emphasized the need for new incentive structures both in drug development and use. The role
of small and medium enterprises (SMEs) as important innovators should not be ignored in this
context. The use of the European Commission’s SME funding instruments has demonstrated that it
is possible to mobilize SMEs in this area of research.
Issues raised in discussion included the following.

Delinkage could provide a promising means to increase R&D in antibiotics by removing
the disincentives inherent in the limited market prospects for new antibiotics. But there
was also a realization that to implement delinkage models will require significant
stakeholder input and effort, ensuring long-term coordination. From the innovator
perspective common characteristics that were important for any delinkage model were
the magnitude of the reward for innovation (which needed to be in line with other
therapeutic areas) and its predictability. Delinkage was not just a new way of rewarding
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
R&D but needed to offer returns sufficient to offset the risks inherent in the R&D
process. Offering a generous return might be a good investment in terms of costs
saved down the line, akin to an insurance policy against having no effective antibiotics
in a health crisis.

Application of delinkage to promote appropriate use raised a number of issues. A key
one was price. In developed countries it might be possible to charge a very high price
to deter inappropriate use without burdening the patient but this would not, in most
participants’ opinion, be appropriate in developing country settings where most people
met costs from their own pocket. At the same time price as a barrier is probably less
important in a developed country where use can be more properly regulated and
enforced, whereas price as barrier was seen by some as a potential mechanism to
avoid inappropriate use in private sector providers and from over the counter sales.

Ensuring access in low-and-middle-income countries (LMICs) to both existing and new
antibiotics required special attention. It seemed likely that far more people died in
developing countries through lack of access to antibiotics than as a result of
resistance. The cost of goods for novel hospital intravenous antibiotics might be as
much as $50–100 per day, which was not affordable in LMICs. LMICs might benefit
from the spill-over effects, meaning that some or many high income economies will be
willing to finance the development of novel antibiotics and LMICs will benefit from the
novel antibiotics at accessible prices.

The use of public-private partnerships on the lines of the IMI or BARDA, which enable
risk-sharing between private and public sectors, should be considered as one model.
The experience from the IMI so far had demonstrated the ability to attract cofunding
from companies, including the engagement of new companies. It was noted by some
that these should not be considered as subsidies if they involved significant investment
by companies that they otherwise would not have made.

The possibility of models similar to orphan drug legislation in the United States and EU,
which had been successful in attracting company attention to drugs for smaller patient
populations, was discussed. But it was questioned by some whether this model, often
involving (very) high prices for the specified indication, was cost-effective and
appropriate in the case of antibiotics.

Drug company pay-for-performance incentives (where innovators are reimbursed for
the actual impact of the new antibiotic or diminished resistance) were deemed too risky
since innovators are often uncertain until late stage trials of the real potential of a new
antibiotic. By contrast, pay-for-performance between payers and providers/prescribers
is a more viable approach.

Surveillance of hospital or community behaviour and resistance levels was deemed to
be a task of the payers and the public health system and should be independent of the
company innovation process.
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
SESSION 3: INTEGRATING INCENTIVES FOR DEVELOPMENT WITH
INCENTIVES FOR CONSERVATION
One presenter suggested a number of feasible performance measures that could aid conservation.
For instance whether or not antibiotics were prescribed using an algorithm rather than guesswork,
or what percentage of prescriptions was based on a diagnostic test. Encouraging more diversity in
antibiotic use would also be positive – gonorrhoea has become very difficult to treat because the
same drug was used repeatedly. The notion could also be applied to encouraging diversity in R&D
programmes. There could also be rewards to producers, for example for working with diagnostic
developers on combination products.
A second presenter argued that delinkage should not be seen as a cure-all. The causes of
inappropriate use were many and setting clear rules and guidelines on company behaviour in
respect of information and marketing was important but only part of the picture. There needed to be
a clear set of rules for all the players, both producers and providers. The presenter also
emphasized that developers need ‘good prices, accelerated access and support from regulators’.
He saw health technology assessment practices emphasizing cost-effectiveness and value for
money (particularly in Europe) as a threat to development, given that drugs were approved simply
on the principle of non-inferiority.
A third presenter noted that there was already a lot of money going into push funding. The issue
was therefore the right mix of push and pull funding to develop new products and also ensure the
right conditions for both conservation and access. In addition the effectiveness of R&D could be
enhanced by greater cooperation in terms of shared platforms and more collaborative working.
In discussion the following issues were raised.

The extent to which incentives for conservation and development could be integrated.
Could the rewards to companies be determined by the extent of appropriate use of
their products, rather as rewards to companies in some current schemes (‘managed
entry’) were predicated on the demonstrated effectiveness of their products in use?
Probably not but delinkage removed the incentive for aggressive marketing of
products.

In the same vein using pricing to incentivize appropriate use thought by many not to be
the right approach, particularly in developing countries. Universal solutions, applicable
across diverse countries, would be difficult.

In a delinked scheme, at what point in the development cycle would a contract with a
company be made, e.g. before or after marketing approval? The return needed to be
attractive to attract private investment in development, but that needed to be on the
basis that investors shared the scientific and market risk equitably. Similarly the
rewards on offer needed to be related to the likely overall health impact.

Marketing and promotion was very costly so a system that removed that cost for a
product was in itself an incentive for R&D as well as a contribution to decreasing
inappropriate use.

The only reliable data on direct health impact was generated in Phase 3 – once on the
market the randomness of the data was lost. And a new antibiotic would almost
certainly look bad if principally used with very sick patients as a last resort.

It was noted that the discussion focused on hospital use, but it was also contended that
in reality most consumption and the development of resistance probably occurred
elsewhere. This included also use in the food and agriculture sector. There was much
that was not fully understood about what was driving resistance. The possibility of
companies providing sales data free to public health authorities was raised. By this
means any suspected overconsumption could be monitored.

The potential value of combinations of antibiotics in combating the development of
resistance was considered. There were particularly difficult issues in their development
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
for antibiotics, including demonstrating their impact on the development of resistance.
On the other hand experimenting with different combinations of existing drugs could be
a means to extend their useful life, as well as potentially increasing efficacy. But the
regulatory system was predicated on demonstrating safety and efficacy, not the
potential impact on resistance development. The latter regulatory approach has not
been fully explored and could present some challenges.

The need for regulatory harmonisation was re-emphasized as a means of reducing the
cost of obtaining marketing approval in multiple territories with differing requirements
for approval.
SESSION 4: ELEMENTS OF A ROADMAP
The first presenter attempted to summarize the key issues raised. Use in food and agriculture had
been very briefly alluded to but the implications of antibiotics being used far more widely than that
needed to be taken into account. Solutions in high- and low-income countries were likely to be very
different with respect to the priorities for maintaining access and conservation. The importance of
diagnostic development in conjunction with new antibiotic development had been emphasized.
Perhaps a separate but linked roadmap was required for diagnostics. The diversity of antibiotic use
policies, even from hospital to hospital in the same country, had been highlighted – so global
guidelines on use would be hugely challenging, but international guidelines that can be nationally
and locally adapted may be appropriate. The focus in the discussion had been on incentives for the
private sector but incentives for academic and public sector researchers were also important. The
diversity of the different actors and their different motivations needed to be considered. The view of
antibiotics as global public goods and a possible global fund was brought up as an interesting
possibility. It was also imperative to engage emerging economies. For that reason a UN initiative
might be appropriate. As regards incentives for conservation and use, key issues would be
measurability and what can be incentivized. Rules needed to be devised governing both the
behaviour of companies as well as users of the product.
The second presenter, focusing on LMICs, noted, first, that antibiotics were introduced in highincome countries when infectious disease levels had already declined as a result of improvements
in living conditions. By contrast, in LMICs antibiotics were currently being used as a stop-gap
measure in the absence of sustained improvements in living conditions and general hygiene and
infection control. The fact that antibiotics were being used to the extent they were arose from
multiple failures in prevention. Reducing the demand for antibiotics therefore required attention to
improvements in water, sanitation and the other determinants of high levels of infection, as well as
more use of vaccination. Second, there were huge disparities in access in developing countries,
which had implications for pricing. The presenter argued that there should be affordable access to
the most commonly used antibiotics, but other antibiotics (e.g. daptomycin) could be rationed
through price outside hospital settings. Third, the issue of agricultural use and the development of
cross-resistance was particularly important in developing countries. Fourth, the innovative potential
of emerging economies should be mobilized. The public and private sectors in developing countries
needed to be brought into a global strategy to tackle resistance. Fifth, in countries associated with
the Global Antibiotic Resistance Project (GARP), there was now much greater interest in tackling
resistance. The time was ripe to involve them in the global effort.
The third presenter, focusing on developed countries, thought that new models should be applied
in the first instance in the United States and Europe. Note needed to be taken of successful models
such as for orphan drugs and product development partnerships for neglected diseases, and the
measures taken to accelerate adoption in developing countries (e.g. through GAVI and the AMC
mechanism). Was more push-type funding (e.g. beyond BARDA and the IMI) required? As regards
delinkage models, a five-year guaranteed payment might be long enough to provide an additional
incentive for companies, but short enough for the payer not to be locked into an arrangement that
turned out to have little value.
A paying model could be similar to the Patient-Centred Outcome Research Institute (PCORI) in the
United States, which is funded by a levy on each insured person. The possible relevance of orphan
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
drug-type exclusivities in a delinkage model needed further exploration. The outcome of the
previous session seemed to confirm that companies had limited ability to directly affect stewardship
other than through restrained marketing. These issues should be considered as part of a wider
structure centred on the payer-provider relationship.
In discussion some themes were reiterated. The issue of the huge variation of practices and
guidance on antibiotic use between prescribers was reiterated. Even so, Sweden, for instance, had
succeeded in reducing antibiotic use in children by 60 per cent. The other issue was the unrealism
of pursuing an R&D strategy that would result in just a few ‘high quality’ drugs. It was asserted that
drug development did not work like this.
Discussion centred on preparing a summary of general principles that might govern new business
models for conservation and use. These included the desirability of an integrated approach,
encouraging delinkage and better conservation models, taking account of the marked differences in
what might be required in low and high income countries (see Annex 3). These provoked much
debate and it was clear that focusing on the details of particular schemes elicited a variety of
responses that reflected differences in the interests and ideology of stakeholders, as well as the
complexity of the issues that were being addressed. However, a majority of participants agreed on
the need to move forward with designing and assessing ‘Delinkage Plus’ models where
innovators/pharmaceutical companies are rewarded for the innovation and R&D investments
through predictable mechanisms and not incentivized by price levels and volumes, and where
purchasers/payers are responsible for suitable conservation strategies and appropriate regulations,
guidance and incentives for providers and prescribers.
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
ANNEX 1: PARTICIPANTS
Christine Årdal
Norwegian Institute of Public Health
Brendan Barnes
EFPIA
Esteban Burrone
Medicines Patent Pool
Daniel Burgess
Rempex Pharma
Otto Cars
ReAct
Marco Cavaleri
EMA
Charles Clift
Centre on Global Health Security
Stefan Elbe
Sussex University
Ed Godber
H-Labs
David Heymann,
Centre on Global Health Security
Andrew Jack
Financial Times
Marie-Paule Kieny
WHO
Ramanan Laxminarayan
Public Health Foundation of India
Rohit Malpani
MSF
Line Matthiessen
European Commission
Kevin Outterson
Boston University
David Payne
GSK
Laura Piddock
Antibiotic Action, University of Birmingham
Sadie Regmi
University of Manchester
John Rex
AstraZeneca
John-Arne Røttingen
Norwegian Institute of Public Health
Adrian Towse
Office of Health Economics
Patrick Vink
Cubist Pharmaceuticals
Anna Zorzet
ReAct
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
ANNEX 2: DIFFERENT DELINKAGE MODELS
Delinkage Models
Model
Description
Advantages
Problems
Patents
Owned By
Payer
Licenses
Payers buy an annual
license to have access to
the antibiotic; actual
antibiotics are delivered at
marginal cost; companies
retain the patent
Full delinkage possible;
competitive pricing if
multiple payers are in
the market; government
participation not required
Higher transaction costs (annual
contracts required between each
payer and each manufacturer);
private payers will not want to
increase overall antibiotic
reimbursement; coordination will
be difficult
Private
RADARS
Payers top-up the hospital
DRG for innovative
antibiotic; government
pays company significant
prizes, reduced by
company sales receipts;
net effect could be full
delinkage if the
guaranteed payment is
large
Increased certainty for
companies (existing
reimbursement is
retained should the prize
fail to materialize);
conditions increased
reimbursement on
effective stewardship
Hospital-based and US-centric
Private
GSK
Fully delinked; predictable
revenue stream. Long
term contract with
purchaser at Phase 3
start.
Incentivizes new
antibiotic innovation with
appropriate use.
Manufacturer not
involved in distribution
/promotion and will
provide as little or as
much as purchaser
needs.
Requires risk and significant
financial commitment by
purchaser
Private
Patent
Buy-out
Prize
Funds
Purchase of national
patent rights by a
government; actual
antibiotics are provided by
the government; could
also be voluntary
Full delinkage; one
transaction per molecule
per country; government
can manage the
molecule for long-term
public health
Difficult to negotiate appropriate
price; political risk
Public
Strategic
Antibiotic
Reserve
(SAR)1
For particularly important
molecules that are not
needed yet, a patent
buyout or multi-year
license to keep the drug
off the market until needed
clinically
Saves very important
molecules for a rainy
day; will be rarely used
Akin to paying farmers not to
farm (Conservation Reserve
Programme); pricing will be
large and difficult to negotiate
Public
Antibiotic
Health
Impact
Fund
(AHIF)2
Governments create a
fund that will pay for the
actual health impact of the
antibiotic including
stewardship; company
participation is entirely
voluntary
Pays for human health
impact on a global basis;
companies retain their
patents; AHIF provides a
nexus for coordination
Requires significant up-front
financial commitment from
governments; measurement of
the relative health impact will
have significant financial impact
for the companies
Private
1 Kesselheim, A.S. and Outterson, K., ‘Fighting Antibiotic Resistance: Marrying New Financial Incentives to Meeting Public
Health Goals’, Health Affairs, 29 (9), 2010; Kesselheim, A.S. and Outterson, K., ‘Improving Antibiotic Markets for Long Term
Sustainability’, Yale Journal of Health Policy, Law and Ethics, 11 (1), 2011.
2 Outterson, K., Pogge, T. and Hollis, A., ‘Combatting Antibiotic Resistance Through the Health Impact Fund’, in Cohen, G.I.
(ed.), The Globalization of Health Care: Legal and Ethical Issues (Oxford University Press, 2013).
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
Hybrid Models
Model
Description
Advantages
Problems
Patents
Owned By
P4P
Keeps existing
reimbursement system
intact; company receives a
very significant top-up
payment for achieving
defined quality goals
relating to appropriate use
and resistance
Easier startup; can be
contractual or by statute;
extension of existing
‘pay for performance’
initiatives; can directly
support hospital
infection control
Not delinkage, but linkage with a
quality payment that may fail to
address underlying problems;
will need to be an order of
magnitude larger than existing
quality incentives in order to
attract new capital to the sector;
companies may not want
stewardship responsibilities
Private
Conditional
Grants
Push funding provides
non-dilutive capital,
conditioned on advance
agreement to meet
stewardship goals
Piggybacks stewardship
on government grants
(IMI, NIH, BARDA)
Increases company uncertainly
about revenue stream unless the
financial terms and
commitments are clear at time of
grant
Private
LPAD Plus
LPAD with stewardship
commitments, marginal
cost sales & a significant
prize
Similar to prize funds
Similar problems to conditional
grants and prizes
Private
The various models can also be arranged based on the ownership of the intellectual property rights
(IPRs).
IPR Ownership in Antibiotic Delinkage and Hybrid Models
Delinkage
Hybrid
Private IPR
RADARS; Payer Licenses; GSK; AHIF
P4P; Conditional Grants; LPAD
Plus
Buy-out by
governments/payers
Patent Buy-out Prize Funds; SAR
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Aligning Incentives for Antibiotic Development and Use with Public Health Needs: First Roundtable on
Antimicrobial Resistance
ANNEX 3
1. General principles

Goal – lowest achievable clinical failure rate

To do this we need an integrated approach:

Health-needs (including BOD) driven innovation

Stewardship balanced with access

Infection control and surveillance

Public awareness (visibility of ABR and usefulness of diagnostics)

Greater stimulation for innovation (in antibiotics, diagnostics, vaccines, delivery, etc.)
with delinkage
2. Delinkage components

Delink revenues from sales volumes

Improve total innovation incentives, including predictability, for antibiotics

Encourage long-term co-ordination by stakeholders

Preserve access without regard to ability to pay
3. Conservation models

Business models for diagnostics (including companion)

Improved and measurable practices for use

Public awareness

Delinkage models for industry (where there is no promotion)

Payer/provider incentive systems for improved use (taking account of differing national
health systems)

Business models for combination therapies, conservation and infection control
4. Models for high-income countries

Delinkage Plus (business models coupled with conservation strategies, including
follow-ons)

Reluctance to require:

Payment for health outcomes/institutional behavior

Payment for diminishing resistance
5. Models for LMICs

Positive spillovers (from HIC R&D)

Products should be priced for accessibility but how to regulate use of new antibiotics?

Access provisions built into delinkage models

More work is needed here
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