Outcomes-Based Financing as a Tool to Curb AMR in LMICs
Summary
In 2024, PATH committed to develop and pilot an outcomes-based financing (OBF) mechanism to incentivize antimicrobial stewardship (AMS) efforts specifically in low- and middle-income countries (LMIC) to support and improve human health. This mechanism aims to address the underlying infrastructure and health systems gaps in order to achieve a comprehensive stewardship approach. It also focuses on incentivizing health provider networks in LMICs to pilot innovative business models and service delivery approaches that prevent, undo, or counteract the economic and social incentives driving the overuse or incorrect use of antibiotics. In partnership with the governments of Senegal and Tanzania, PATH will undertake research to develop contextual understanding of the overuse or misuse of antibiotics and current infrastructure and capacity gaps underpinning the AMS program. They will subsequently design and pilot an OBF instrument to address these challenges with the potential to directly impact more than 25,000 lives by 2026 and hundreds of thousand more if taken to scale.
Approach
PATH commits to developing and piloting an outcomes-based financing (OBF) mechanism to incentivize antimicrobial stewardship (AMS) efforts specifically in LMICs to support and improve human health. This mechanism will not only aim to address the underlying infrastructure and health systems gaps necessary for a comprehensive stewardship approach but will focus on incentivizing health provider networks in LMICs to pilot innovative business models and service delivery approaches that prevent, undo, or counteract the economic and social incentives driving the overuse or incorrect use of antibiotics in LMIC settings.
As part of these efforts, PATH will undertake research in Senegal and Tanzania to develop contextual understanding of economic and social incentives currently driving overuse or misuse of antibiotics and current infrastructure and capacity gaps underpinning AMS program. This research will focus on validating and characterizing the drivers of antibiotic misuse at health facilities within target catchment areas, identifying OBF inventions that would counteract antibiotic misuse, and assess the feasibility, estimate costs, and identify potential risks of OBF interventions. Subsequently, PATH will also leverage their trusted relationships with partners, AMR stakeholders, and country governments to co-design and pilot an OBF instrument which is expected to reach 25,000 patients across both countries.
The team commits to methodically understanding the impacts and risks of implementing novel solutions through IRB approved research protocols and working with experts to identify potential risks and mitigation strategies and avoid the introduction of perverse incentives. The governments will not have any financial exposure associated with the success or failure of the pilot program and if the threshold of success is not met, there will be no obligation to scale the project.The impact resulting from this initiative is decreased misuse of antibiotics, improved market fundamentals and effectiveness of current and future antibiotics, and reduced mortality and morbidity associated with AMR.
Action Plan
Phase 1: Develop contextual understanding of market incentives currently driving misuse of antibiotics and current infrastructure and capacity gaps underpinning AMS programs in Senegal and Tanzania.
2024 Q3: Institutional Review Board (IRB) approvals received for study in Senegal and Tanzania
2024 Q4: Conduct study and disseminate preliminary research findings
Phase 2: Design OBF instrument to support optimal use of antibiotics and socialize with key partners, stakeholders, and funders.
2024 Q3: First iteration of OBF instrument designed
2025 Q1: Final iteration of OBF instrument designed based on research results and stakeholder engagement
Phase 3: Pilot OBF instrument
2025 Q1: Pilot implementation plan co-developed with ministries of health in Senegal and Tanzania.
2025 Q2: IRB approvals to conduct pilot implementation study in Senegal and Tanzania received.
2025 Q3: Facility recruitment and training completed; Pilot implementation study initiated
2026 Q2: Pilot implementation study completed; data analysis and findings disseminated with local stakeholders and global AMR community.
The learnings from the pilot implementation study will determine the feasibility of scale up. Accordingly, the team will advocate for the development of a central financing facility to support scale up of the intervention.
Background
Antimicrobial resistance (AMR) , caused by overuse or inappropriate use of antibiotics, has emerged as one of the leading public health threats of the twenty-first century. AMR threatens the ability to treat common infections by reducing or eliminating the effectiveness of antibiotics against bacteria. It is estimated that 1.3 million lives are lost annually due to AMR and this toll is expected to increase to 10 million lives per year by 2050 (Lancet, 2022) .
The burden of AMR is greatest in low and lower-middle income countries (LMICs) with sub-saharan Africa carrying the highest burden. (Lancet, 2022) . In LMIC settings, AMR is not only a public health threat but is also associated with several negative health outcomes at an individual level including increased ICU admissions and prolonged hospital stays (Kraker, 2023) .
Current guidance around country-level AMR reduction is largely clinical in nature, however, various financial and behavioral motivations have been well documented to drive overuse of antibiotics.(Li, 2023; Belachew, 2021) Stewardship efforts have not addressed these drivers which reflects an underappreciation of the market forces that contribute to misuse.
While incentive structures to reduce AMR have been explored and successfully implemented in high-income countries such as the United Kingdom (Aliabadi, 2021) and Japan (Okubo, 2023) , limited investments have been made in exploring similar models in LMICs.
Outcomes-based financing (OBF) is an incentive system which could complement stewardship activities by more directly addressing the behavioral and financial drivers of misuse. OBF allows donors and implementers to direct the attention of service providers to desired outputs and outcomes of stewardship efforts versus the traditional focus of donor grants on upfront inputs. The growing burden of AMR necessitates innovation and novel solutions to be explored and implemented.
Progress Update
Partnership Opportunities
PATH and the Bay Area Global Health Alliance seek financial resources for this commitment, in particular Phase 3: pilot implementation. As OBF is still a novel tool in global health, coordination and socialization across a highly diverse set of funders including impact investors, outcome funders, and traditional donors is required. The team also seeks expertise from OBF implementers and Monitoring and Evaluation specialists., PATH will leverage and offer its deep expertise in global health and AMR and its experience in implementing stewardship efforts globally and specifically in Senegal and Tanzania. They will leverage their trusted relationship with partners, AMR stakeholders, and most importantly country governments to carry out this work. PATH will offer best practices in designing and conducting evidence-based programming that is patient-centric and impactful. The Bay Area Global Health Alliance will offer its expertise in multi sectoral partnerships and alliance management to raise awareness and mobilize resources for successful implementation of this commitment.