The Not-So-Invisible Hand of “Stewardship,” Within and Beyond Antibiotics: Implications of Non-Monetary Pharmaceutical Controls for Access to Medicines

One of the main drivers of antimicrobial resistance is the misuse and overuse of antimicrobials. However, lack of access to antimicrobials causes a large mortality burden and can also contribute to the spread of resistant infections. Policies to control use therefore need to tread a careful balance between preventing inappropriate use and enabling necessary use. Such stewardship policies are often considered unique to the field of antimicrobials but are in fact ubiquitous across drug classes. This paper considers how learnings from the use of control policies in other areas of medicine can be translated into lessons for antimicrobial stewardship policy design. We describe the rationale(s) behind imposing controls on medicines and catalogue a list of control policy options, considering the potential impact of each policy on access and stewardship goals. We then offer two deep dives on specific policy levers—prescription policy and mandatory reporting/databases—to demonstrate how stewardship policies work in practice. We conclude with learnings and recommendations for policymakers when formulating and reviewing policy, both for antibiotics specifically and for all drug classes more broadly.