As antimicrobial resistance (AMR) continues to rise despite global attention and investments, a new research effort is shedding light on one of its root causes — and proposing a novel way forward. At a recent Clinton Global Initiative (CGI) Deeper Dive Session, PATH — together with Pfizer, the Bay Area Global Health Alliance, and Social Finance International — shared early-phase research findings aimed at understanding the drivers of antibiotic misuse and presented an innovative financing design approach to incentivize the correct use of antibiotics. The session aimed to raise awareness and engage potential partners around a next-phase pilot to test outcomes-based financing (OBF) as a new tool to drive more sustainable and effective stewardship.
Despite increased global attention and significant investment, antimicrobial resistance (AMR) continues to rise, posing a growing threat to health systems and communities globally. Projections estimate up to 10 million annual deaths due to AMR by 2050. In many low- and middle-income countries (LMICs), misuse and overuse of antibiotics remain widespread, underscoring the need for new models to address the problem at scale.
“While there’s great work in surveillance and research for AMR, there is very little focused on service delivery and what’s actually driving prescribing decisions and use,” said Kellen Thomas, disease programs lead on Pfizer’s Accord for a Healthier World team. “That’s why we partnered with PATH and the Bay Area Global Health Alliance to better understand the service delivery gaps and the economic and behavioral drivers behind antibiotic misuse and overuse.”
Quick Summary
The proposed approach centers on outcomes-based financing (OBF), a model that aligns funding with measurable outcomes, shifting the focus from inputs to desired outcomes and providing local healthcare providers with the flexibility to innovate in order to more directly address market and behavioral challenges. A defining feature of this initiative is its emphasis on country leadership in Tanzania and Senegal from the outset, ensuring that solutions are locally-led and grounded in the specific context of each health system.
New, initial findings from PATH’s research reveal that in Senegal and Tanzania, 45-58% of patients obtain antibiotics directly from pharmacies without a prescription. This bypasses diagnostics and clinical care, fueling unsafe antibiotic use and resistance. Economic pressures, long wait times, and limited access to diagnostics drive patients to bypass clinical evaluation, increasing the risk of resistance. The issue is especially acute in the private sector, where fewer than 20% of pharmacists refer patients to clinicians; this finding points to a need for stronger public-private partnerships to improve prescribing and dispensing practices.
Outcomes-based financing could be a key to improve how antibiotics are prescribed, tested, and dispensed. Many current interventions yield clear outputs, but it’s unclear if they drive better practices and outcomes. None have been shown to consistently change behavior across the full patient journey. To close that gap, Social Finance International has designed the Antimicrobial Stewardship (AMS) Outcomes Fund. The fund would provide upfront grants and financing to pilot interventions that meet specific outcomes—like boosting antibiotics dispensed with a valid prescription—using real-time data to adapt and improve delivery. If the programs deliver verified outcomes, then they receive further funding to expand their reach, with a long-term goal for governments to adopt and integrate effective programs into national AMR strategies, paving the way for sustainable funding. While still in its early stages, the Outcomes Fund represents a promising model—one that will require committed investment to move from design to reality.
“This is a relatively novel approach to antimicrobial stewardship,” continued Neha Agarwal, senior director of strategy at PATH. “And with anything novel, it takes a consortium of partners to move the needle forward.” As the initiative moves deeper into the pilot implementation phase, PATH is calling on diverse stakeholders and funders to help shape its future.
More on the research and proposed approach follow.
The Current System: Built for Inputs, Not Outcomes
PATH’s phase one research in Senegal and Tanzania uncovered major challenges in the health system that lead to delays or problems in how antibiotics reach patients.
“Roughly half of the places where patients are getting their antibiotics is directly from a pharmacy, and this is without a prescription,” said Rebecca Green, research officer at PATH. “They haven’t seen a clinician, and the pharmacist is still willing to dispense.” In Senegal, 45% of patients reported obtaining antibiotics directly from pharmacies, while in Tanzania, that figure rose to 58%. This is a problem because it bypasses diagnostic testing and clinical evaluation, undermining efforts to ensure antibiotics are used safely and effectively, and increasing the risk of resistance.
Underlying these behaviors are economic pressures and structural delays, such as long wait times and cost barriers, which make it difficult for patients to follow the optimal care pathway, (i.e., the patient journey, or best practices and steps for diagnosing, evaluating, and disbursing or not disbursing antibiotics to patients).
“Forty-nine percent of clinicians are willing to prescribe antibiotics if a lab result is taking longer than expected,” Green added. “Forty-one percent of pharmacists say it is okay to dispense antibiotics without a prescription.”
“It’s happening more frequently in the private sector [in privately owned pharmacies, as opposed to government clinics and other entities],” continued Green. PATH’s research found that fewer than 20% of private sector pharmacists refer patients to a clinician when they present without a prescription, compared to public facilities where providers adhere well to the protocols. There is a potential need for more public-private partnerships, to establish better protocols and bridge the gaps in prescribing and dispensing behaviors seen among public versus private clinics and pharmacies.
The New Approach: Outcomes-Based Financing to Realign Incentives
“There is a real opportunity — and need — to improve prescribing, testing, and dispensing behaviors,” said Saskia Thomas, manager at Social Finance International. “OBF approaches are well placed to facilitate this, but it’s a shift from the status quo in health systems to transition from focusing on inputs to outcomes.”
According to PATH’s research in Tanzania and Senegal, many current interventions, such as patient-level information campaigns and providing support to government stakeholders to refine prescribing protocols, are important and achieve well-defined outputs. However, there is a lack of clarity as to how these interventions are leading to better practices within the system, and as such better AMR outcomes. So far, no single effort has been proven to drive consistent behavior change across the full patient journey — from diagnosis to treatment to dispensing.
Social Finance International is proposing an AMS Outcomes Fund to address this gap by using OBF to test the effectiveness of interventions, with a commitment to sustaining and scaling approaches that successfully deliver pre-defined outcomes. The fund, which still needs investors before establishment, would provide upfront grant funding to pilot programs that are focused on improving specific AMS outcomes, such as increasing the percentage of antibiotics dispensed with a valid prescription at private pharmacies.
“Implementers will use performance management to learn and adapt service delivery in real time, based on the data and insights collected,” Saskia Thomas explained. “Progress toward the agreed outcomes will be assessed from the start, and if those outcomes are delivered, funding will be released by the Outcomes Fund to support continued delivery or expansion to additional facilities, helping to drive change across the system.”
The ultimate goal is for governments to take ownership. “The AMS Outcomes Fund hopes to set the stage for government ownership and future funding,” continued Saskia Thomas. “This structure helps build an evidence base that governments can use to support the adoption of effective programming in their national action plans for AMR going forward.”
Country Ownership and Pathways to Scale
The Ministries of Health in both Senegal and Tanzania have played a central role across all phases of the project, from protocol approvals and site selections to co-developing context-appropriate interventions aligned with national AMR strategies.
“The Ministry of Health [in Senegal] provided early alignment and ensured ethical oversight of the project. The ethics committee helped give feedback and recommendations to formalize our research scope and facilitate buy-in at the senior level,” said Papa Sokhna, senior technical officer at PATH. “We organized a dissemination workshop with ministry experts to validate the findings and co-develop interventions and incentives that fit the Senegal context. The ministry’s engagement has been consistent and strategic, helping ensure the OBF design is grounded in local realities.”
There was similar collaboration with the Tanzanian Ministry of Health, which streamlined approvals and supported data collection. “Thanks to strong collaboration with the Ministry of Health, our research went smoothly,“ shared Fred Boniphace, senior IT technician at PATH. “Stakeholders appreciated and were excited about our research, but emphasized the need for sustainability.” One additional suggestion was to offer in-kind incentives—such as training or mentorship programs—to help support long-term behavior change.
Building the Future of AMR Stewardship Together
“We’re getting closer and closer to this abstract idea being a reality. We still have some way to go, particularly with respect to design and financing, but there is progress,” Kellen Thomas said. “We wanted to use this session to share this project, and provide an opportunity for other partners to join us in this work.”
PATH and its partners are actively seeking insights from across sectors to ensure the model is both practical and scalable. That includes understanding how outcomes-based financing might align with different organizational priorities and how implementation strategies can be designed with sustainability in mind, and identifying potential funding and design partners.
“We hope this approach might support and align with multi-sectoral efforts to combat AMR. Our long-term vision is that we’d be able to scale up at a national level and also think about a global facility that would facilitate outcomes-based financing as a general mechanism to support AMR efforts,” concluded Agarwal.
Learn more about the CGI Commitment to Action here.