Incentivizing Antimicrobial Stewardship through Outcomes-Based Financing
This project aims to combat antimicrobial resistance (AMR)—a growing global health threat disproportionally affecting low- and middle-income countries—by co-creating and piloting an outcomes-based financing (OBF) mechanism to strengthen antimicrobial stewardship (AMS). Without addressing these behavioral and market forces, new tools will be exposed to the same patterns of misuse and hence risk the same lack of effectiveness. A successful OBF intervention can address these challenges in complementary ways to AMS efforts.
The first two phases of this work were made possible through financial support from Pfizer’s Accord for a Healthier World Initiative.
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Advancing and increasing access to quality and appropriate diagnostics that improve the health outcomes of people and communities in low-resource settings.
We work to ensure all countries have the staff, systems, and supplies they need to prevent, detect, and respond to disease outbreaks and emerging health threats.
For two decades we have worked alongside the Senegalese government, health care workers, private-sector companies, and other stakeholders to strengthen health systems and improve health equity across Senegal. From improved abilities to detect and respond to disease outbreaks to stronger supply chains for vaccines and medicines, we are seeing the impact of our efforts on behalf of the Senegalese people.
Since 2005, PATH has collaborated with the government of Tanzania to improve public health and save lives through the development, support, and scale-up of innovative approaches and technologies that improve health outcomes and strengthen health systems.
About the project
Phase 1: Laying the Foundation
Phase 1 focused on developing a deep contextual understanding of the factors shaping antibiotic use in Senegal and Tanzania. This included identifying the market incentives driving the misuse of antibiotics, as well as mapping the infrastructure and capacity gaps limiting the effectiveness of existing Antimicrobial Stewardship (AMS) programs. These insights helped to inform the design of a targeted, outcomes-based approach to strengthening AMS efforts in both countries.
Methodology and results:
Prospective patient and health care provider interviews were conducted in each country to validate and characterize the drivers of antibiotic misuse at public and private facilities in Dakar and Dar es Salaam as well as identify potential OBF interventions that would counteract these drivers. Twenty-nine facilities were included in total, across which 98 providers and 199 patients were interviewed. The key findings from the research highlighted several areas where leveraging novel financing mechanisms (e.g., OBF) could affect system-level change. Notably, we confirmed that current practices are not always aligned with national guidelines. For example, many pharmacists in the private sector dispense antibiotics without a prescription, and many clinicians are willing to prescribe an antibiotic without a confirmed lab test result. Patients likewise face many challenges in seeking optimal care, conflicting with stewardship efforts and creating incentives for patients to directly approach pharmacies. We found that clinic wait time and visit cost were major barriers in seeking clinical care, incentivizing deviation from the appropriate care pathway.
Phase 2: Designing the instrument
Building off the findings in Phase 1, PATH and Social Finance International aimed to design an outcomes-based financing instrument to support the optimal use of antibiotics in Senegal and Tanzania. The OBF instrument is being socialized and validated by key partners, stakeholders, and funders to ensure alignment and gather feedback for successful implementation.
The ambition of the AMS Outcomes Fund is to support the innovation and testing of AMS interventions using outcomes-based finance as a mechanism to fund and sustain improved AMS outcomes. Through the fund, flexible innovation funding is provided to support AMS programs working with facilities along the referral pathway to improve prescribing, dispensing, and testing behaviors in Senegal and Tanzania. If a program delivers pre-agreed outcomes, as laid out by the fund, follow-on funding is disbursed to expand delivery of the intervention on the basis of outcomes.
The funded interventions will focus on delivering behavior change outcomes that measure adherence to optimal antimicrobial stewardship protocols at the clinic, hospital, or pharmacy level, as laid out in government guidance. However, they will receive flexible funding to deliver a program of work they deem to be the most effective way of delivering the behavior change outcomes.
It will build partnerships with a shared vision for impact to:
- Direct flexible funding toward innovative programming aligned around target outcomes (e.g. improving the following of prescription protocols), and allowing for local delivery to be adapted based on specific needs and challenges faced by health care facilities and laboratories.
- Learn and build evidence on what innovative programs work through data-driven performance management, and scale them through outcomes-funding to improve AMS practices.
- Minimize funding fragmentation, by aligning government and global funders around clear outcomes targets rather than specific programmatic activities.
The AMS Outcomes Fund hopes to build an evidence-base for effective interventions with an aim to facilitate adoption at scale of proven interventions by government over time.
Phase 3: Implementation
Phase 3 will rely on PATH’s strong partnership with local governments to launch and manage the OBF instrument in health care facilities. More information on this phase and how to help us grow this initiative can be found below.
Get involved
Support is needed to continue this exciting initiative. Engagement from funders and partners interested in co-designing a solution will be critical to successfully demonstrating how OBF can enhance AMS efforts, providing a sustainable response to one of the most persistent public health challenges of our time.
Contact
Neha Agarwal