Economies of resistance

ABSTRACT

The social organisation of economic life plays a pivotal role in assembling many emerging and enduring health problems. Yet throughout the recent history of global health challenges, an emphasis on the influence of economic systems has frequently been sidelined in favour of research that interrogates the behavioural and/or cultural dimensions of these problems. The global crisis of antimicrobial resistance provides a striking example of this trend, with analysis frequently and increasingly focusing on behavioural or technological fixes – for example, the need for responsible use of remaining antimicrobial drugs, or for revived efforts to identify new antimicrobial agents – while at times glossing over the market logics that reproduce the problem itself. With a few notable exceptions, the economic headwinds that shape the current antimicrobial resistance (AMR) scene have been largely decentred in scholarly discussions. In this article, we argue for a critical sociology of economies of resistance, contributing to burgeoning efforts to understand how economic structures both shape the acceleration of AMR and undermine the development of drug and diagnostic solutions.

KEYWORDS:

• antibiotic resistance
• antimicrobial resistance
• diagnostics
• drug pipeline
• marketisation

Introduction

Antimicrobial resistance (AMR) – whereby bacteria or other microbes develop resistance to the medicines used to kill them – has recently been identified as one of the ten greatest threats to global health (World Health Organization [WHO], 2019b). In 2019, bacterial AMR alone was associated with an estimated 4.95 million deaths worldwide, including 1.27 million deaths for which it was directly responsible (Antimicrobial Resistance Collaborators [ARC], 2022). Yet this critical global challenge has, for the most part, failed to attract sufficient economic investment to even slow its pace (Luepke et al., 2017). Novel drug development and antimicrobial optimisation (enabled by innovative diagnostic solutions) remain two key priorities of AMR amelioration according to key international stakeholders (World Health Organization [WHO], 2015), but they each face significant headwinds. For instance, few new drugs reach the market, and promising options are frequently lost when companies fold or abandon their development citing limited profit potential (Coukell, 2020; Luepke & Mohr, 2017). Antimicrobial stewardship (AMS) attracts negligible economic support, while diagnostic innovations (which could pin-point resistant microbes more quickly and enable drug use optimisation) often prove either unprofitable to develop, or too costly to implement (World Health Organization [WHO], 2021). As such, AMR remains a ‘poor performer’ in the global health arena despite a clear trajectory toward pan-resistance and the critical threat this presents to routine medicine and human health more broadly (D’Abramo, 2021).

The role of economic factors in underwriting these failures has received comparatively little attention to date, with attention instead focusing on the need for behavioural, cultural and organisational change. As those few scholars offering a critical analysis of these economic dynamics have noted, however (e.g. Glover et al., 2023; Hall et al., 2019; Singer et al., 2019, 2020), the commercial logics of drug and diagnostic development – including the vested interests and lobbying activities of private companies therein – play a pivotal role in shaping the field.

The above exceptions notwithstanding, insofar as the financial dimensions of AMR are discussed in the field more broadly, researchers still predominantly focus on documenting the reverberating economic impacts of (for example) AMR-related morbidity, mortality and lost capacity for routine medical interventions (e.g. Taylor et al., 2014). Analyses of this kind attest that the economic costs of AMR are significant and are rising (Dadgostar, 2019; Fowler et al., 2021; Lu et al., 2020). While valuable, such discussions at times abstract these specific costs away from the broader economic structures and taken-for-granted commercial logics that drive willingness (or otherwise) to invest in AMR solutions. This has fostered a less-than-comprehensive, and at times even uncritical, reading of the evolving economic challenges in relation to AMR.

In this article, we offer an empirically informed critical sociological analysis of some of the economic dynamics that shape the current AMR scene, with a focus on drug and diagnostic development. Drawing on interviews with industry stakeholders, Australian hospital executives and clinicians, and representatives of peak global health and humanitarian bodies, we underline the prevailing and interconnected market logics that shape the AMR scene and unravel solutions – particularly in well-resourced Global North contexts. In presenting this analysis, we join with other critical AMR scholars in calling for both a redoubling of research on the economic dynamics shaping accelerating AMR, and an urgent reconsideration of the temporally limited and return-based economic scene within which AMR solutions are currently being developed (Hofer, 2019).

The marketisation of health

Within international global health scholarship, there has been a growing emphasis on the importance of recognising prevailing economic conditions and their profound, accelerating and often deleterious impact on human health (Sell & Williams, 2020). While there have been many contributions to these debates, of particular importance here are those that have emphasised forms of prioritisation and de-prioritisation that occur in marketised health contexts (Timmermans & Almeling, 2009). Marketisation at its broadest refers to the introduction of competition into the delivery of goods and services. Common mechanisms of marketisation include deregulation and liberalisation (including the removal of state-imposed price controls to allow ‘freer’ competition between providers), as well as the outsourcing of traditionally public responsibilities to private companies to deliver these services on a competitive basis. Marketisation thus frequently coexists with forms of privatisation that see state-owned infrastructures of care wholly or partially transferred into private hands, providing the wealthy with a new area of investment and resource accumulation, while relaxing (short-term) financial burdens on the state (Huffschmid, 2009). Even when the state retains ownership, the marketisation of healthcare sees services structured as and functioning like (quasi) businesses, accountable to boards and funders, and beholden to (often short-term) budget imperatives. In this context, healthcare, in many nations, has gradually been transformed into a commodity to be packaged, marketed, bought and sold. The patient, for their part, has been ‘reimagined’ as an autonomous consumer, responsible for ‘choosing’ and procuring the goods and services they require to achieve optimal health (Gabe et al., 2015).

Health marketisation is often packaged using the lexis of ‘modernisation’, ‘efficiency’ and ‘consumer choice’. Across the globe, many governments have, to varying degrees, marketised their health systems in a purported effort to increase healthcare quality and rein in costs (Krachler & Greer, 2015; White & Collyer, 1997). The logic, here, is that fostering competition between healthcare providers will lead providers to deliver better and more affordable goods and services, so as to attract patient-consumers (and/or additional funding) on a competitive basis. Much of the evidence suggests, however, that the so-called free market – at least as currently materialised – is ill-equipped to deliver solutions to many health challenges, and in fact contributes to the entrenchment and reproduction of health inequalities in many instances (Collyer & White, 2011). Notions of an unwieldy and ineffectual public sector are routinely leveraged to rationalise marketisation across contexts and health systems (Krachler et al., 2021), yet these market actors are themselves highly constrained by structures of profitability and short-term monetary accountability that frequently prevent dexterous action (Timmermans & Almeling, 2009). Indeed, marketisation can contribute to significant gaps in the availability of ‘niche’ (read, financially unlucrative) goods and services, as well as heightened health inequalities as access to treatment is mediated by ability to pay (White & Collyer, 1997).

In the context of AMR, such dynamics have recently been explored by scholars whose research has shown that AMR is assembled, at least in part, through the systems and structures of late capitalism – including the transformation of health services in line with prevailing market values (Chandler, 2019; Hinchliffe et al., 2018). Allied dynamics, including the rise of consumerist sensibilities, are illustrative of the ripple effects of markets at the interpersonal level. In fact, the turn toward consumerism, associated with the proliferation of market models of healthcare, has been shown to make it more difficult for medical professionals to withhold antibiotics from patient-consumers in both hospitals and primary care settings, even when these drugs are not clinically required (Kohut et al., 2020). Such dynamics have also been shown to interplay with other meso and macro factors including those of scarcity and structural vulnerability in low- and middle-income countries (LMICs) (Broom, Peterie, Kenny, Broom, et al., 2023). Equally, marketisation interplays with – or perhaps acts to fuel – the rise of managerialism in healthcare contexts. As we show below, within the marketised milieu, health executives – operating as quasi or actual business executives, charged with balancing budgets and beholden to financial imperatives – must make crude calculations concerning ‘what care is financially viable or cost effective’ (Kirby et al., 2018, p. 382).

These (evolving) logics of healthcare marketisation also permeate the pharmaceutical and diagnostics industries that underwrite drug and diagnostic development, including the development of essential antimicrobials and optimisation-enabling technologies. The broader scene of drug development can be a lucrative business. At the end of 2021, for example, the global pharmaceutical market was valued at US$1,42 trillion (Statista, 2021). This global pharmaceutical industry is dominated by transnational companies that work aggressively to minimise cost and maximise profit (Pogge, 2005; Tobbell, 2011). Many of these companies routinely lobby policymakers and governments – agitating for market interventions that serve their commercial interests (see Glover et al., 2023). The prioritisation of profit within the sector has been associated with a range of deleterious social and environmental impacts, including environmental degradation and labour exploitation associated with low-cost manufacturing in LMICs (Lübbert et al., 2017). Furthermore, this focus on profit means significant health needs are frequently left unmet, as companies choose not to invest in drugs or other technologies that are unlikely to deliver strong financial returns. As Lexchin (2016, p. 6) notes, ‘the best interests of the pharmaceutical companies do not necessarily coincide with what is best for the entire country and for public health writ large’.

These insights and others like them are important for understanding how AMR is produced through the contours of economic life, yet they continue to receive limited take-up in mainstream discussions of AMR. In this article, we build on this research by arguing that accelerating AMR is exacerbated by the logics (and failures) of marketisation. While our empirical focus is on stalled research and development (R&D) vis-à-vis both new antimicrobial drugs and new diagnostic technologies, we show how this problem of a ‘dry pipeline’ is shaped by economic logics within and beyond private industry – including those that contribute to failed stewardship efforts in marketised hospital settings. We thus show that key efforts to combat AMR are being curtailed and unravelled by an overarching and cross-sector over-reliance on the ‘free market’ as an arbiter of human and societal health.

Methods

Data collection and sample

In this article, we draw insights from our ongoing program of research on the social, political and economic drivers of AMR (Broom et al., 2021; Broom, Peterie, Kenny, Broom, et al., 2023; Broom, Peterie, Kenny, Ramia et al., 2023) to explore and illuminate these dynamics. Specifically, we present findings from qualitative interviews conducted between 2018 and 2022 with a diverse range of stakeholders in the AMR space. Our focus, in this article, is on the economic factors that shape AMR’s assembly in the Global North. In particular, we explore how the economic logics of the present – as manifest in both industry and healthcare contexts – constrain efforts to curb AMR through critical R&D.

Data collection for the study involved in-depth, semi-structured interviews with stakeholders responsible for combating AMR in both industry and clinical settings. Participants (n = 62) included a wide range of industry stakeholders (including pharmaceutical and diagnostic company representatives), Australian hospital executives and clinicians (including nurses, general practitioners, pharmacists, surgeons, oncologists, neurologists, sexual health clinicians and consultants), and representatives of peak global health and humanitarian organisations located in the US, the UK and Europe. Interviews were conducted face-to-face or via video conference by Alex Broom, Michelle Peterie and Katherine Kenny, and ranged between 30 and 60 minutes in duration. Interviews were audio-recorded and transcribed verbatim. Identifying information was removed from the transcripts to preserve study participants’ privacy. Interviews were guided by questions about participants’ perceptions and direct experiences of AMR, their efforts to develop and implement AMR solutions, and any support or headwinds they faced working to do so. Together, participants provided a multistakeholder view of accelerating AMR as manifest across organisational contexts, including its embeddedness in prevailing economic logics. Ethics approval for this research was provided by the relevant Local Health Services Ethics Committee/s and/or The University of Sydney’s Human Research Ethics Committee.

Data analysis

The methodology for this project draws on the interpretive traditions within sociology and, specifically, on Charmaz’s (1990) approach to social analysis. The aim was to achieve a detailed understanding of the varying positions adhered to, and to locate these within a spectrum of broader underlying beliefs and/or agendas. Data analysis was based on four questions adapted from Charmaz’s (1990) approach: what is the basis of a particular experience, action, belief, relationship, or structure; what do these assume implicitly or explicitly about particular subjects and relationships; of what larger process is this action/belief and so forth a part; and what are the implications of such actions/beliefs for particular actors/institutional forms? The approach used was developmental, in that knowledge generated in the early interviews was challenged, compared with, and built on by later ones. We approached the analysis of the interviews thematically, seeking to retain nuance by documenting atypical cases, conflicts, and contradictions within the data. Finally, we revisited the literature and sought out conceptual tools that could be employed to make sense of the patterns that had emerged from the data.

In what follows, we bring empirical findings from these interviews into conversation with broader insights from the critical social science AMR literature, showing how the economic logics of the present – and their various manifestations across industry and healthcare – unravel drug and diagnostic development. Critically, our analysis draws not only on the perspectives of industry stakeholders and those personally involved in R&D, but also on the perspectives of other stakeholders – including hospital executives, clinicians and peak global health and humanitarian representatives – who form part of the broader ‘ecosystem’ in which private industry operates in the Global North.

Findings

Valuable, but not profitable

The development of new antimicrobial drugs and rapid point-of-care diagnostic technologies are key priorities in the global AMR solutions agenda. The reduced reliability of many antimicrobials has fuelled calls for new drugs to be developed. Equally, the AMS agenda has seen point-of-care and rapid testing for resistant organisms upscaled internationally – both to facilitate a targeted scale-back in the use of antimicrobial drugs that have no effect other than to increase resistance, and to enable the re-use of older antimicrobials that may still be effective in treating some (non-resistant) infections. New and improved AMR diagnostics have also been advanced as a way of visualising the AMR problem across services and nations, so that targeted interventions can be made. In the context of prevailing economic structures, however – where most such R&D is undertaken by private interests – issues of profitability (or lack thereof) shape what is and is not possible in terms of novel drug and diagnostic development.

A key issue here, as represented by the industry stakeholders who participated in our study, is that developing novel drugs and diagnostics in response to AMR is often not profitable. While the historical medical leaps delivered by antimicrobials attest to the enormous value that these drugs afford societies, social value does not necessarily equate with market value. As one industry representative noted,

My commercial counterparts are basically saying, ‘well I get it, there’s a medical need for it. But how much are you going to sell? And how much can we charge? How much is a customer going to pay?’ (Industry Representative, USA, 2022)

As private businesses operating on a for-profit basis, pharmaceutical and diagnostic companies are reluctant to invest in even critical medical technologies if they cannot guarantee their financial viability. As one diagnostic scientist put it, most large companies simply ‘won’t take the risk. If it’s not a $5 billion product, they’re not going to do it’ (Diagnostics Scientist, Australia, 2022).

A recurring theme in industry participants’ interviews concerned the ‘problem’ of price point, and how the low sale price of antimicrobials and associated diagnostic technologies compromised industry investment by reducing the potential for cost recovery and profit. From a diagnostics industry perspective, the low price of antimicrobials was doubly problematic because it both limited revenue from antimicrobial sales, and reduced demand for diagnostics – despite their value in an era of optimisation.

It’s a complete market failure, right? Because the cost of antibiotics is so low and so as a function of that, the diagnostics have to also be relatively inexpensive, because the treatment pathway, the total cost to the patient is limited. […] [I]f you take oncology as a good example, when you are determining whether a drug is going to benefit that patient or not, the cost of the drug is fifty, maybe a hundred times more expensive than the cost of the diagnostic to determine whether or not that patient will benefit. And in that scenario the calculation is very easy, right? The cost of the drug at the back end determines what you’re willing to pay for the diagnostic at the front end, because you can eliminate a number of people where it’s just not going to be effective for them. So, it’s worth it in that calculus. But when you come to antimicrobials, because they are so ubiquitous, they are so cheap. It’s almost like, well, if I don’t do the diagnostic, and I give this person an antimicrobial, it’s not really going to come back to bite me. (Industry Representative, Australia, 2022)

Yet, as several participants observed, price point is not something that can be adjusted without risking adverse consequences. For industry participants, the key danger associated with raising prices was a market one: it threatened to tarnish the company’s reputation with publics and politicians, and consequently curb sales. Global health stakeholders, in contrast, stressed the ethical implications of raising prices. The financial accessibility of essential drugs and diagnostics is vital for health justice (Berman et al., 2022), and the world’s poor already struggle to access such products (Fojo & Grady, 2009). As one humanitarian worker told us, many essential drugs and diagnostics are already prohibitively expensive for healthcare services in LMICs.

[T]he decision could be we don’t scale up today, but in one year time, or we cannot afford to use it in 100% of the patient, but just in 50%, or things like that. So indeed, it is a bit of an issue. […] [The organisation is always advocating for] access to diagnostics, vaccines and medicines, and always discussing to have reduced price for low- and middle-income countries. (Humanitarian Worker, Europe, 2022)

Questions of price point were thus a focus of tension and tussle in many interviews.

The problem industry participants’ reflections ultimately pointed to, however, was not the low sale price of antimicrobials and associated technologies per se, but the extent to which antimicrobial and diagnostic development has become financially unviable. With antimicrobial and diagnostic innovation revenue often insufficient to cover the costs of antimicrobial and diagnostics research, development and commercialisation (Boluarte & Schulze, 2022), investment in this area has all but stalled. Large pharmaceutical and diagnostic companies were described as having abandoned the AMR market entirely, and participants noted that the smaller biotech companies now responsible for 80% of antibiotic development were feeling the strain of these financial pressures (Emanuel, 2015). As one diagnostic scientist told us,

[I]f you actually have a look at the world, and you have a look at what is out there in terms of [AMR technologies], there’s actually bugger all. […] [I]t also tells you what the big companies are actually thinking. You know what I mean? If they thought it’s there and it’s sort of a low hanging fruit and a place where a commercial entity can make some money, there would be more people in the game, I guess. I guess it speaks to the fact that it’s not that easy. It’s [AMR is] really important obviously, which is why we are all believers. But it’s not that easy. I mean, [our company] has to make money or we can’t pay our staff. We all go home again if we don’t make money out of it, which is the hard, cold, commercial fact. (Diagnostics Scientist, Australia, 2022)

Speaking to these ‘hard, cold, commercial facts’, several study participants cited companies that had been financially injured by their decisions to invest in AMR. In 2019, for instance, Melinta Therapeutics filed for bankruptcy (Coukell, 2020); in April the same year, Achaogen did the same. Both companies had been actively involved in antimicrobial R&D and had been among the few pharmaceutical companies to release new antibiotics onto the market in the preceding years (Coukell, 2020; Dall, 2019). Stories of this kind recurred in our interviews and clearly functioned as fables in the industry, warning companies against taking undue risks.

Market strength and the paradox of stewardship

One under-recognised factor that industry participants identified as contributing to the perceived financial unviability of AMR solutions concerned the uneasy relationship between AMR R&D and the ‘optimisation’ agenda. AMS programs – that is, institutional efforts to encourage better prescribing/management of remaining antimicrobial resources through tracking, reporting, education and intervention – are a mainstay of the global optimisation agenda (World Health Organization [WHO], 2019a), having been embraced (at least in policy) by international entities such as the World Health Organisation (WHO), as well as local governments attempting regulatory change (Anderson et al., 2019). For industry representatives involved in R&D, antimicrobial stewardship presented a paradox. Most obviously, efforts to preserve effective antimicrobials by limiting use were seen as reducing drug sales (see Hall et al., 2019). Less straightforwardly, the stewardship agenda also represented a potential new market for diagnostic innovation, as technologies that allowed clinicians to quickly and accurately diagnose pathogens and resistance therein were essential to improve prescribing. Investment in AMS programs thus had contradictory effects and were viewed by some industry stakeholders as a market opportunity.

Despite this promise industry participants noted that the seemingly superficial way in which AMS was often implemented undermined confidence in this diagnostic market. As one industry representative explained,

The other challenge with AMR, in particular, is that you have a very cheap methodology currently to address the problem. And so, having a very cheap standard of care – which is not great, but ‘good enough’ – makes it very difficult for companies to invest this significant amount of money required in order to recognise a return on that investment. (Industry Representative, Australia, 2022)

While diagnostic technologies had the potential to play an important role in stewardship, the perceived reality of only partial commitment to this agenda undermined industry investment.

This notion of ‘good enough’ care – in this context, doing the bare minimum to curb AMR in healthcare settings – aligned with the perspectives of many Australian hospital executives, whose reflections shed additional light on the role of economic factors in unravelling AMR solutions. Despite the importance of good management of remaining antimicrobials for the sustainability of the healthcare system, executive participants stressed that government regulatory structures around AMR typically sought to hold healthcare providers to minimal standards of improvement vis-a-vis antimicrobial use (Broom et al., 2021). In this context, the benefits judiciousness would deliver were neither made visible nor financially rewarded.

If you were saying we’re doing this [AMS] purely from a quality perspective, or if we are meeting a minimum standard or a state benchmark or we’re doing okay against our peers, there’s very little drivers to push us any harder other than [that]. Well, the other thing is, have we got some cost savings or efficiencies to find here? […] No one in the political sphere, et cetera, is looking for exceptional care at the moment. They just want any care for the hundreds and thousands of people waiting for access to care. (Hospital Executive, Australia, 2022)

From the perspective of these executives, the resulting institutional failures to invest in AMS programs were in part a failure to recognise the financial benefits these programs might deliver (through, for example, fewer infections, fewer multidrug-resistant organisms, healthier patients, quicker recoveries, and lower health services costs). As one executive told us, ‘I don’t think that [the financial cost of resistance] is quantifiable in a way that an organisation like this could interpret at the moment […] I don’t think we’ve got the sophistication to speak to that’ (Hospital Executive, Australia, 2022).

Significantly, these participants noted that they were themselves beholden to economic objectives that curtained their efforts to implement robust stewardship programs. Insofar as healthcare institutions function as businesses – beholden to budgetary pressures, reporting requirements and (public or private) funder priorities – many leaders struggle to justify the financial investment genuine optimisation requires (Broom et al., 2021; Broom, Peterie, Kenny, Ramia et al., 2023). Indeed, several participants posited that financial incentive structures within the (increasingly marketised) Australian healthcare system at times encourage unnecessary antimicrobial consumption by attaching institutional income to clinician activity. As one hospital executive and clinician explained,

So, if I’m in private practice and somebody comes in and [… I have] kids at private schools and got to pay the mortgage and pay the beach house and blah, blah. There is an incentive there to earn, but I’m not paid anything for trying not to do that, for practicing in a preventative way. Everything points towards if I do some activity, like I put a patient in hospital, then it generates activity to the hospital, the anaesthetist has got a job, the theatre nurse has got a job. […] So now we just yawn and scratch ourselves if someone gets an infection postpartum, because we just think, ‘We’ll give them antibiotics’, and then generally that’s going to fix the problem. But eventually it mightn’t, if we’ve got nothing left, so what are we going to do? (Hospital Executive/Clinician, Australia, 2022)

What we see in this executive/clinician’s reflection – as well as in other interviewees’ accounts – is that even well-resourced healthcare systems provide limited (if any) monetary incentive for the better management of antimicrobials. In fact, suboptimal use is effectively remunerated through activity-based funding, which rewards clinicians and their institutions for (over)treating. The effects of such dynamics for AMS are clear, but – as industry representatives stressed – they also have the under-recognised consequence of undermining industry investment in R&D.

The lure of more lucrative markets

While most industry stakeholders perceived both AMR drug and diagnostic development as financially unviable in the current market system, there was also a clear comparative dimension to their appraisals which underlined industry’s overarching interest in profit maximisation. Most industry participants noted (either explicitly or implicitly) that greater profit could be achieved in other areas of R&D. As one participant put it,

It’s hard for organisations to take the risk when they are responsible for losing. […] We stand to lose this much money, or we stand to lose this reputation, whatever it is – time that we could spend on other projects […] that becomes a very simple calculation. (Industry Representative, Australia, 2022)

As this participant intimated in their reference to ‘other projects’, a key factor stalling development surrounding AMR is the greater profit companies can achieve by developing drugs and diagnostics to address other medical needs. That is, the issue is not purely financial sustainability, but also the comparative potential for profit in one market vis-à-vis another.

One distinctive feature of the antimicrobial scene that shapes these calculations is the time-limited nature of a company’s return-on-investment. On the one hand, new antimicrobial drugs necessarily have a limited shelf-life, as microbes will eventually develop resistance to them. Where this process once took an average of 21 years to occur, accelerating resistance means microbes are now beginning to develop resistance within just one year of a new drug’s introduction (Makary et al., 2021). On the other hand, the optimisation efforts described above mean that new drugs would ideally be rarely prescribed in the early years of availability, to conserve these drugs until older equivalents become ineffective. This pattern of low early sales, followed by a (temporary) increase in demand several years later, does not sit well with the existing drug patent system, where drug developers have only the first few years after a drug’s release to recoup investment costs before cheaper generics become available. Estimates suggest that approximately 88% of revenue from antibiotic sales currently goes to non-patent holders, meaning companies that invest in antimicrobial R&D receive only 12% of revenue for the products they developed (Hall et al., 2019, p. 64).

In the context of diagnostic development, similar issues arise concerning comparative profit margins. As one diagnostic scientist explained, diagnostics to detect cancers are significantly more lucrative than equivalent tests to identify infectious diseases and resistance therein. Sexually transmitted infection (STI) diagnostics are a case in point:

If you go say into the oncology space, […] it costs you more to get those tests to market, but you can then sell those tests for a lot more money. Some of the breast cancer screening tests […] Some of them are $3,000. So, here we’re talking about the STI market. They can sell basic Chlamydia/gonorrhoea tests for $1.50 in Australia. That’s the price. That’s well and truly under cost of goods. (Diagnostics Scientist, Australia, 2022)

Available statistics confirm the scale of this issue. In 2019, Hall and colleagues observed that ‘eleven of the twelve most recent oncology drugs approved by the FDA [Food and Drug Administration] each cost more than [US]$100,000 per year’ (63). Fojo and Grady (2009) similarly analysed four oncology drugs and found that patients paid an average of US$47,000 for each month that the treatment extended their lives (see also Hall et al., 2019). As the above diagnostics scientist observed, these pricing discrepancies guide present and future development in the pharmaceutical and diagnostics industry, channelling resources into addressing some illnesses and not others (Falagas et al., 2006). A basic premise within the ‘free market’ is that R&D choices are made in line with a business case.

The industry conception of antimicrobials (and associated technologies) as inherently low return is understandable given the strong headwinds developers face. As numerous participants told us, even companies that recognise the importance of AMR as a global issue frequently struggle to justify investment in this area. This conception, however, also reflects an endemic short-term and siloed monetary scene. Lucrative cancer therapeutics, for example, are only viable to the extent that efficacious antibiotics are available to treat infections in patients with compromised immune systems.

I’m dreading the day when we start to see Tazocin [a particular antimicrobial] resistance, because that seems to be pretty much the go-to sort of first drug for febrile neutropenia in most centres these days. So, when Tazocin resistance develops, then I think that’s going to be potentially a very significant issue. Some of our patients on chemotherapy are frequent flyers. They’re often coming back with febrile neutropenia. The other classic example is the patient who’s got a biliary tree cancer or a pancreatic cancer who comes in with repeated episodes of biliary tree sepsis, and they’re the ones I certainly see as going to the risk of resistance in the future. (Clinician, Australia, 2018)

The reticence, on the part of industry, to accept the immediate costs associated with curbing resistance speaks to the short-termism of much investment culture. It also reveals a collective action problem, where companies are unable to rationalise the short-term costs associated with addressing AMR, in part because the long-term gains such investments would yield (with respect to the viability of the healthcare system more broadly) would be shared by their competitors. In this context, questions of return-on-investment – sometimes couched in the language of fairness and free-riders – come to the forefront. The problem facing industry thus emerges as one of both value and values. The logic of the market and its guiding principle of competition works against collaboration and solidarity, presenting structural barriers and disincentives even to companies genuinely motivated to combat AMR.

Conclusion: addressing market failures

Rising resistance is often framed as a problem of antimicrobial wastage, diminishing discoverable antimicrobial resources, and/or poor visibility of the problem. Yet each of these explanatory modes evades the broader economic scene – logics which assemble these prevailing conditions. In fact, AMR exists in – and is reproduced through – financial (dis)incentives and market logics, as governments and international actors seek to mobilise around an issue that is struggling to gain traction in an increasingly marketised system.

Markets, of course, are not inherently bad. In the context of human health, the marketisation of healthcare has arguably created some efficiencies, consistencies and improvements through the introduction of benchmarking, standardised models of reimbursement, and broad safety and quality assurance mechanisms that serve to improve standards (Ghandour et al., 2022). Certainly, this is the orthodox argument made by proponents of healthcare marketisation (Krachler & Greer, 2015; White & Collyer, 1997). In its starkest form, however, a market model of healthcare provision induces temporal vulnerabilities as the provision of healthcare becomes untethered from binding notions of the public good. Healthcare providers run as businesses beholden to budget bottom lines, and healthcare itself is transformed into a commodity (available to some but not necessarily to others). Equally, R&D is constrained by crude financial calculations that stall or prevent important work that might deliver considerable benefits to human health. The development of AMR in this (literally and figuratively) ‘mutating’ environment is a clear example of the risks associated with such a model, as are the various ways (outlined above) that theoretically viable solutions are being undone at the level of economic logics and priorities.

It goes without saying that reconfiguring marketised systems is more complex than simply pulling new or additional ‘market levers’. Yet it is also clear that ‘the market’ and its logics, as currently configured, are poorly placed to address the present reality of systemic, industry-wide de-prioritisation of AMR solutions. New approaches are urgently needed.

Some work has been done in the last decade to weave financial incentives into the development of new antimicrobials in an effort to ‘nudge’ private, corporate interests toward more intensive research and innovation (Luepke et al., 2017). This work has been driven by the market reality (outlined above) that commercial returns for developing antimicrobial drugs are incommensurable with business interests. Analysis by the Boston Consulting Group, for example, found that a minimum incentive of US$2.3 billion over 10 years was needed to support a single antimicrobial drug through development (Boluarte & Schulze, 2022). Such ‘solutions’ have also been championed by industry stakeholders with a vested interest in maximising private profit. As Glover et al. (2023, p. 205) note, voices advocating for other solutions ‘tend to be crowded out (both numerically and discursively) by those lobbying for solutions that match their self-interest such as greater public subsidies for the development of diagnostics and new antibiotics’. Failing to support private industry, these stakeholders have cautioned, may result in significant harm to the economy and society.

There is ongoing discussion among researchers, non-government entities and governments concerning how such incentive programs might work. Possible push incentives include research grants, tax credits and/or public-private partnerships that reduce overheads and support companies to research and develop new therapeutics and diagnostics (Luepke et al., 2017). Possible pull incentives include the provision of financial rewards or prizes that can be paid to companies – either immediately or over time – when they develop a viable new product (Hall et al., 2019; Neri et al., 2019). Such rewards would effectively function to de-link a product’s financial viability from its market performance and could be linked to priority areas to guide development to address the most pressing needs.

Beyond direct remuneration, other pull incentives have also been posited. For example, drug developers might be given extended market exclusivity when they develop new antimicrobial drugs, which would allow them more time to recoup development costs before generic alternatives enter the market (Luepke et al., 2017). There are even calls for such benefits to be transferable between products, so that a company that develops a valuable antibiotic, for example, might be rewarded with extended market exclusivity on another product of their choosing – for example, a lucrative cancer treatment they also developed (Luepke et al., 2017). Such an approach might encourage the larger pharmaceutical companies that have abandoned AMR to return to the field as a way of increasing profit in other parts of their businesses. It might also better recognise the dependency of medical subfields such as oncology on continued access to viable antimicrobials.

Using public funds to underwrite private profit, however, is not the only or (arguably) the most ethical way to address weaknesses in the drug and diagnostic pipeline. Singer et al. (2019, p. 3) make a compelling argument against solutions that continue the logic of commercial drug development, instead proposing a ‘radical change to the current paradigm of antimicrobial development and manufacture’. The model they offer – ‘a joint, internationally-funded antimicrobial development Institute that would fund permanent staff to take on the role previously assigned to pharmaceutical companies’ (Singer et al., 2019, p. 3) – bypasses many of the problems associated with the current market system. Perhaps most notably, it makes important inroads vis-à-vis global justice (Pogge, 2005) by ensuring a country’s access to AMR solutions is not predicated upon its ability to subsidise investment or ensure a lucrative private market (Berman et al., 2022).

Glover et al. (2021) similarly advance a Networked Institute Model to support antimicrobial R&D by providing a permanent public infrastructure for clinical drug trials and small-scale production. Such an approach, they argue, would allow the public sector to take on ‘high-risk, high-public reward projects that have not gained commercial traction’ (Glover et al., 2021, p. e637), without precluding the possibility of industry involvement.

Whatever model is ultimately adopted, the failures of the current market system must be taken seriously if AMR is to be addressed in a way that is effective, sustainable and socially just.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was funded by Australian Research Council (ARC) [grants IH190100021 and LP170100300]. Katherine Kenny was supported by ARC fellowship [DE22101498].