With rigorous economic research and practical policy solutions, we focus on the issues and institutions that are critical to global development. Explore our core themes and topics to learn more about our work.
In timely and incisive analysis, our experts parse the latest development news and devise practical solutions to new and emerging challenges. Our events convene the top thinkers and doers in global development.
The growth and global spread of infections resistant to almost all known antibiotics is a huge looming threat. A recent study estimates up to 10 million lives could be lost each year by 2050, with enormous economic impact. Antimicrobial resistance could reverse progress made against big global killers such as HIV, malaria and tuberculosis. Even common surgery could carry a lethal risk of infection. CGD work examines the incentives, innovation, and impetus needed to ensure collective action to produce a new generation of antibiotics, and encourage their widespread development and use.
By WHO’s World Alliance for Patient Safety
In 2008, the World Alliance for Patient Safety, the World Health Organization’s (WHO) patient safety programme, announced its 3rd Global Patient Safety Challenge: Tackling Antimicrobial Resistance. The work will build upon the previous work of WHO, particularly the Global Strategy for Containment of Antimicrobial Resistance published in 2001. The new project, under the leadership of David Heymann and Didier Pittet, will facilitate an international coalition to address the threat to patient safety posed by antimicrobial resistance.
The work will be undertaken in two stages. During the initial ‘foundation’ period in 2008 and 2009, five expert working groups are meeting to formulate a WHO Global Work Plan for Antimicrobial Resistance. In 2010, WHO will launch the ‘challenge’ component, encouraging all member states to sign up to an intervention, or a focused bundle of interventions, to reduce the threat of resistance.
The readers of this feature guest column will be more aware than most of the patchwork nature of issues surrounding antimicrobial resistance. At a first international consultation in July 2008, at WHO Headquarters in Geneva, it was agreed that the 3rd Patient Safety Challenge will concentrate on five key action areas:
Animal husbandry, aquaculture and agriculture including the examination of the regulation of antimicrobial use in food production processes.
Infection control including the promotion of simple and effective interventions to reduce transmission of resistant microbes in both hospital and community settings.
Rational drug use and regulation including access, quality, and misuse of antimicrobial agents.
Research and development of efficient and affordable diagnostic methods to support rapid targeted treatment and new antimicrobial agents including vaccines and alternative therapies.
Surveillance including developing laboratory capacity and the development of a long-term strategy to collect and report high quality data in a systematic fashion.
In November 2008, expert working groups were formed. They will meet again this month to finalize first drafts of chapters in the Global Work Plan. These chapters will summarize current knowledge, highlight gaps in understanding, and suggest intervention priorities. It is hoped that this Work Plan will act as a tool for advocacy at the national level, but also suggest a series of practical interventions that individual countries can adopt.
It is anticipated that these expert working groups will address antimicrobial resistance with a particular focus on antibacterial resistance. This will be complemented by expertise from well-established disease specific programmes at WHO such as HIV, Malaria and Tuberculosis.
In conjunction with these efforts, WHO will work to estimate the global burden of antimicrobial resistance.
The exact interventions that form the focus of the third challenge are still under discussion, and will be decided through a wide consultative process. The aim is to capture one intervention, or a small number of interventions, that together create an iconic focus for the international movement to reduce the threat of resistance.
WHO appreciates the difficult nature of this task. Attempts to tackle this multifactoral and deeply complex issue have been tried before and have often failed. However, it is hoped that the current approach, drawing on the experience of a wide community of experts, and aiming for practical interventions for member states to adopt, will start to turn the tide against the growing threat of resistance.
To learn more, please visit our website or email us at:
Back to the March, 2009 Newsletter
By Prashant Yadav, Professor of Supply Chain Management, MIT-Zaragoza International Logistics Program
Drug resistance is threatening our ability and the resources required to treat infectious diseases in developing countries. Countering drug resistance involves complex tradeoffs between a number of activities¹. In order to formulate robust and effective strategies against resistance emergence, we need a clear understanding of the incentives of all health system actors and how these incentives interact to drive (socially-optimal² or not) behavior.
The DRWG recently commissioned a study to better understand how incentive structures might cause resistance. Findings confirmed the hypothesis that many actors across the supply chain deviate from making socially-optimal decisions. We identified three possible explanations for these deviations:
Actors sometimes lack the necessary knowledge and information to make socially-optimal choices (informational blind-spots)
Actors can often negatively affect others by their decisions (incentive misalignments arising from failure to internalize all costs)
Short-term choices are not always consistent with long-term socially-optimal outcomes (incentive misalignments arising from faulty future vs. current reward discounting)
An example of the latter is when actors are rewarded as a result of good immediate outcomes (e.g. providing prompt treatment or ensuring lower stock outs of drugs) rather than for good (socially desirable) long-term decisions (e.g. educating patients and the general community about the importance of infection control and preventive methods or maintaining an assortment of drugs that may lead to decreased resistance). In these cases, different rewards or incentives may be found to encourage the socially-optimal choices.
A more challenging example stems from the lack of incentives for manufacturers to discover and develop drugs for neglected diseases and how these incentives affect resistance emergence. Manufacturers of innovative drugs, vaccines and to some extent diagnostic technologies are dependent upon a decision-model which is driven primarily by immediate market opportunities and estimated risks of technology failure. Using this model, higher risks of failure combined with a small market size have deterred companies from developing new classes of anti-infective products. Somehow, the potential market must be expanded or the risk of failure reduced – or both – before new anti-infective product development will become sufficiently attractive to manufacturers.
Large generic manufacturers have recently started moving into the pharmaceutical innovation business – perhaps with their eyes on larger markets. They tend to have very little research experience, however, and usually don’t know how to bring a new product to market. Such companies are increasingly willing to get on the learning curve by purchasing the rights to late or mid- stage anti-infectives, which research-based pharmaceutical companies do not find attractive due to small revenue potential and high marketing costs. This re-aligns the discouraging incentive structure, as generic companies clearly have an incentive to leverage small revenue products to gain experience with obtaining marketing approval.
The DRWG has made it a top priority to focus on aligning these various incentives for the prevention and containment of resistance. We continue to research and consult on this topic of vital importance, and there will certainly be more on incentives to come. Stay tuned!
1. For example, development of new products, ensuring treatment heterogeneity, guaranteeing systemic availability and affordability of the right drugs, making certain drugs are high-quality, and enforcing compliance, adherence and rational use
2. Where “socially optimal” refers to the set of decisions at each stage in the health care supply chain that minimizes the emergence of drug resistance within society as a whole without compromising access to medicines
Braving freezing temperatures and gusty winds, hundreds of development experts and members of the policy community packed a Washington hotel ballroom for a panel discussion on the outlook for global development policy in the new Obama administration, just four days before the inauguration of the new U.S. president.
On the panel were David Gergen, senior political analyst for CNN, editor-at-large at U.S. News and World Report, and advisor to four presidents; CGD president Nancy Birdsall; and CGD senior fellows Steve Radelet, Vijaya Ramachandran, and David Wheeler. CGD’s Lawrence MacDonald was panel moderator.
Gergen, a member of CGD’s board of directors, saw both opportunities and risks for greater attention to development under the new administration. On the one hand, new president Barack Obama has first-hand experience of poverty in developing countries, having lived as a child in Indonesia. On the other hand, Gergen said, Obama faces a crowded policy agenda and the immense fiscal demands of responding to a global financial crisis.
“We have an incoming president who will embrace development and accept some sacrifices to further the development agenda,” Gergen said. He added, however, that an anticipated flood of countercyclical spending to stimulate the economy would be followed by extremely tight budgets, possibly squeezing out development initiatives.
Birdsall responded that it is precisely in such a situation that sound policy ideas, such as those offered in CGD’s newest book, The White House and the World: A Global Development Agenda for the Next U.S. President, are most valuable
Discussion with David Gergen on Obama's Development Policy (video)
White House and the World (book)
White House and the World (briefs)
“I would ask the president to be a champion for development,” said Birdsall. “It’s not just about foreign aid. It’s about using all the tools that the United States has, including trade as a development policy, how to deal with climate change, how to maximize the development benefits of bringing the private sector to Africa, and how to think across the board about the relevance of development in making Americans more prosperous,” she said.
Panel members suggested ways that the United States could have a big positive impact on the economies of poor countries by making policy changes that also benefit Americans and cost relatively little in budgetary terms.
Ramachandran, author of a forthcoming book on ways to improve the business climate in Africa, outlined how the United States can help to foster private-sector investment to address the continent’s chronic infrastructure shortages, especially roads and power. For example, she said, U.S. companies are leaders in small-scale renewable power that could provide off-grid electricity to rural Africans.
Wheeler, an expert on development and environmental issues, said that his conversations with senior officials in China and India have convinced him that they are prepared to act to reduce their countries’ greenhouse gas emissions—provided that the United States first moves aggressively to reduce its own emissions, which on a per-capita basis are many times higher.
Radelet, who served as a senior official in the U.S. Treasury under both Democratic and Republican administrations, and is co-chair of the Modernizing Foreign Assistance Network or MFAN, urged the administration to create a National Strategy for Global Development. This would provide the basis, he said, for a grand bargain between the legislative and executive branches on modernizing U.S. foreign assistance, including new legislation to replace the burdensome and outdated Foreign Assistance Act of 1961.
Gergen said that these and other ideas in The White House and the World were “critically important for the future of the world and for redesigning American international policy.”
During a lively audience Q&A session, topics included trade, migration, corruption, and the U.S. response to humanitarian crises.
Summing up, Gergen said “Obama is incredibly strategic. This is a man who thinks long-term.”
Birdsall interjected: “That is why Obama can be a champion for development.”
“That’s exactly right,” Gergen responded.
By Paul Nunn, Coordinator, TB/HIV and Drug Resistance, World Health Organization, Geneva
The Drug Resistance Working Group organized two “pre-consultation” meetings in Paris on October 18th to take advantage of the 39th World Union Conference on Lung Health taking place at the same time.
Participants were interested by the similarity of events that gives rise to resistance across diseases - TB is not different. They expressed concern at how use of drugs for other conditions might be exacerbating drug resistance in TB, including the formation of extensively drug resistant TB (XDR-TB). Examples of this include widespread empirical use of fluoroquinolones for conditions such as community-acquired pneumonia and chronic diarrhea, especially in individuals with HIV infection. These were possible drivers of the recent XDR-TB outbreak in KwaZulu Natal, South Africa.
Participants also voiced concerns about TB drug quality which many felt is another of the key drivers of drug resistance. There is some evidence for concern from the 1990s, when several fixed dose combinations of rifampicin, isoniazid and ethambutol and pyrazinamide were found to have insufficient quantities of bio-available rifampicin. Ensuring the quality of medicines is crucial for the prevention of resistance.
While prequalification by WHO and its partners has been developed for ARVs, it has not been well applied to TB drugs, especially the 2nd line drugs used to treat MDR-TB. Ensuring that practitioners prescribe correctly is a challenge for the generally weak regulation systems that exist in high TB burden countries. Both these issues are expected to be major areas of discussion at the upcoming meeting on "Global Tuberculosis Control and Patient Care: a Ministerial meeting of high MDR and XDR-TB burden countries" in Beijing, China, April 1-3, that is being organized by the World Health Organization, the Ministry of Health of the Peoples Republic of China and the Bill & Melinda Gates Foundation. Analytical work currently underway in preparation for the meeting will model future scenarios for MDR and XDR-TB with a stagnant global response, compared to one with greater investment, and will also look at the financial and economic costs of drug-resistant TB.
Participants in the CGD consultations agreed that the increase in antimicrobial resistance serves as a clear call for more widespread, accurate and timely drug resistance surveillance. While TB drug resistance surveillance appears to be rather more advanced than that for other diseases; in fact, all diseases, TB included, need much better systematic surveillance. As technologies develop, they open up the possibility of synergies between diseases - for TB, HIV and many bacteria, resistance can now be detected by genetic-based tests, which, in the case of TB at least, significantly shorten the time required for diagnosis. A recommendation might be to create molecular diagnostics laboratories that could serve as a common platform for diagnosing resistance across several major diseases.
Consistent with the DRWG’s interest in this area, there are new signs of interest in laboratory capacity-strengthening from donors. For example, WHO and the International AIDS Society are collaborating to establish the HIV Resnet, a global HIV drug resistance surveillance network. Additionally, a small group of malaria experts has been working to consider how a global network (called the proposed World Antimalarial Resistance Network (WARN)) might operate, to bring together clinical, molecular, in vitro and pharmacological data on drug efficacy and drug resistance to malaria. The expert group wants to develop WARN in a manner that builds local capacity in data analysis and presentation in developing countries and facilitates widespread access to information.
In the TB realm, a Global Laboratory Initiative (GLI) was proposed to and endorsed by the Stop TB Coordinating Board in October 2007, and has recently been upgraded to the status of a Working Group within the Stop TB Partnership. The Partnership is actively seeking integration of improved micro-biological laboratory services including resistance testing and smear microscopy into a broader strategy of laboratory strengthening in hospital and primary care. This will require a broad approach to reforming the laboratory system, focusing particularly on microbiological capacity for monitoring drug resistance (including other antibiotics beyond TB).
Additionally, the World Bank announced (at the Paris meeting) a regional laboratory strengthening effort of US$ 140 million, which will seek Board approval during the second half of 2009. Promoting a global public goods approach, this initiative’s primary proposed objective is to improve access, quality and efficiency of TB diagnostic services, (which remains heavily neglected), using an integrated approach to laboratory strengthening. Cross-disease efforts to strengthen laboratories are still not the norm, but there seems to be an increased interest in this area and growing recognition of potential economies of scale and greater health benefits as cross-disease resistance spreads.
There’s a lot of attention being paid to the counterfeit drug trade at the moment. Former President of France, Jacques Chirac, recently chaired a meeting with West African leaders to discuss how to crack down on counterfeiting. Meanwhile, the Wellcome Trust and the American Pharmaceutical Group held an Opinion Formers' conference on counterfeit medicines (presentations here); the International Federation of Pharmaceutical Manufacturers and Associations produced a brief on the issue; and Roger Bate has continued to draw attention to counterfeits and other drug quality issues in developing countries, including through his book Making a Killing. And this is all on top of the WHO-hosted IMPACT initiative on counterfeits, which started in 2006.
The DRWG’s consultation draft report proposes eight recommendations for global action on drug resistance. We will continue refining these recommendations so that the final report prioritizes the most effective and feasible actions for global organizations to take against drug resistance. To do this, we need your input here. To get you started, we have listed below some of the important questions we are still exploring about what works to combat resistance. We welcome your responses.
Recommendation #1: Develop a multi-disease laboratory and surveillance system to confirm and track the emergence and spread of drug‐resistant strains of disease.
What are the pros and cons of deploying lab capacity across diseases, compared to more disease specialized labs? Could the use of molecular technology increase overall capacity? What are the most cost-effective ways to build such capacity?
Which types of drug resistance data are most needed to inform effective drug/health policy development?
What are the best ways to share drug resistance information with those who need it, including through the internet and social media? Would a drug resistance data 'one stop internet shop' help, and if so, what kinds of resources/services should it offer?
Recommendation #2: Support regional networks of drug regulators to protect drug efficacy.
Which are the best examples of functioning and sustainable regional regulatory networks within and outside of public health? What factors make them work?
How are they funded, and what do they cost?
What should be the main functions of regional drug regulatory networks supported by governments and donors?
Recommendation #3: Develop uniform industry standards and procedures to measure and monitor drug resistance.
What steps can manufacturers take to improve the rational use of drugs and diagnostics and reduce opportunities for resistance emergence?
What would it cost manufacturers to meet standards established for drug resistance such as those indicated in question 1, and how could developing country manufacturers be supported to do so?
How can major purchasers of drugs and diagnostics be incentivized to select products that meet post-marketing standards that reduce drug resistance potential?
Recommendation #4: Create a web‐based marketplace to share resistance‐specific research and technological innovations across diseases.
What prevents resistance-related technologies from moving along the R&D pathway? How might a web-based 'marketplace' address these blockages?
Who is most likely to use a web-based marketplace, and what kinds of information should it be designed to share?
What kind of facilitation would be needed for the marketplace to work? What would it cost to sustain the marketplace?
How could the marketplace attract (a) developing country researchers, (b) developed country researchers, and (c) donors, investors, and late-stage developers?
Recommendation #5: Establish systematic resistance‐specific training and education for pharmacy workers.
How can global, sustained, and systematic education and training be made available to pharmacy workers? Which organizations could develop and update resistance-specific materials suitable in different countries and regions?
What would education and training cost for start-up and maintenance? Who might provide short-term and longer-term funding?
What is the potential for using web-based training methods?
Recommendation #6: Scale up accreditation of drug dispensers and provide incentives for high quality dispensing practices.
What tools (checklists, guidelines, etc.) and incentives are effective mechanisms to improve rational drug dispensing and use?
What minimum basic services and standards are needed in a “core drug dispensing model” for accreditation, and how could this model be sustainably implemented in developing countries?
How much do existing accreditation programs cost? Who might fund their expansion?
Recommendation #7: Hold an international drug‐resistance and development conference (IDRDC) to catalyze institutional communities against resistance.
Who should participate in the IDRDC conference?
What should an IDRDC conference accomplish?
How frequently should an IDRDC be held and how should it be linked to other global medicine and infectious disease events?
Recommendation #8: Strengthen the International Health Regulations (IHR) in language and practice as they apply to drug resistance.
What are the existing barriers to using the IHRs to combat drug resistance?
What steps would better enable the WHO to act against drug resistance?