A new AMR Benchmark report was released during the annual World Economic Forum in Davos in January 2020. This was the second report since the Access To Medicines Index Foundation started their engagement in the field of antimicrobial resistance in 2016. While this new AMR Benchmark uncovers some truly concerning facts on company behavior, these findings are often not framed in a way that makes their significance clear. This brief ReAct assessment tries to put these findings in context and comments on the AMR Benchmark’s approach.
The stated intention of the AMR Benchmark report is to guide and incentivise pharmaceutical companies to do more to tackle drug-resistance and provide investors interested in investing in a more ethical and sustainable manner, with a guide to how the pharmaceutical industry “manages risks and opportunities” in the field of AMR. By doing a peer to peer comparison of the companies, they hope to encourage them to compete in exceeding each others efforts in addressing AMR.
1) Framing: The glass is half full
As a consequence of this goal, the AMR Benchmark methodology is to highlight the good examples and the ‘best practices’ among those measured. This “glass half full” approach is an active choice by the Access To Medicines Index Foundation, and is consistent with the approach taken in the broader Access to Medicines Index report that the Foundation also publishes.
Such an approach may (or may not) encourage more poorly performing companies to improve their work. But it should be kept in mind, that even if there are good examples of smaller efforts, these may still not be the most pertinent aspects to highlight, in a situation where the overall performance of the pharmaceutical industry is marked by continued big company withdrawals and decreasing levels of investment in the field.
6 companies removed sales based bonuses – but 16 companies didn’t!
One such example is the highlighting of the six companies, which have removed sales based bonuses to sales staff – a practice which encourage overselling antibiotics and fuels unnecessary use. Given that overuse and misuse of antibiotics is one of the main drivers of resistance development, a more important focus would arguably be on highlighting the 16 companies with antibiotics on the market that still encourage their sales force to oversell by rewarding such bonuses.
This behavior stands in stark contrast to the public statement that companies have made in support of stewardship in the AMR Industry Alliance Declaration from 2017, where they state they “are committed to antibiotics only being used in patients who need them”. The Declarations even call on others to remove financial incentives to reward volume sales (nevermind that these 16 companies are not willing to do this themselves):
“Furthermore, we call for governments, insurers, healthcare providers and other health system stewards to remove financial incentives for individuals (such as doctors, veterinarians and pharmacists) or institutions that reward the prescribing of antibiotics in greater volumes”.
Removing these sales bonuses should be seen as an absolute minimum requirement, and a first step for all companies lauding to take any interest in addressing antimicrobial resistance. It would suit the AMR Benchmark to more clearly point out the dissonance between companies public statements and commitments and their actual actions in order to hold them accountable to these.
By contrast, not removing sales bonuses is not weighed more in the AMR Benchmark scoring, than companies engagement in stewardship educational activities (activities, which by the way, comes with strong conflict of interest problems). We would argue that these two actions are not of equal importance – in fact, the first undermines the latter! However, as the AMR Benchmark works today all actions are counted with equal weight and non-actions aren’t really captured negatively. The Access to Medicines Index has over the years developed a more differentiated weighing of scores over the years – an approach the Benchmark would benefit from adapting.
2) Relative comparison
The AMR Benchmark and the Access to Medicines Index publications both take the approach of relative comparison. This means that there is no objective standard against which companies’ action (or inactions) can be measured for impact or progress. Instead companies are being compared against each other in their respective groups – big pharma, SMEs and generics.
This approach may indicate that company A is doing more than company B within its category. It may also provide examples of best practices among those companies surveyed. It does not however show whether those “best practices” have an actual impact on the ground, or if they even can be considered to be ‘best practices’ in comparison with other industries.
The relative comparison also means that it is not possible to measure whether any progress in overall performance of the industry has happened from the last AMR Benchmark report. The 2020 AMR Benchmark is just a snapshot of how the companies involved in the field today compare to each other.
Unclear what conclusions to draw from scoring
It is therefore somewhat unclear what conclusion readers can safely draw from the Benchmark scoring. When GSK scores 86 out of 100 possible points, does that then indicate that GSK is just 14 points from doing everything that could ever be expected of a company addressing antimicrobial resistance? And does it by extension mean that the full sum of GSKs actions has a net positive impact on resistance?
The answer is likely no. The only thing we can say for sure is that GSK is doing more than the other big companies surveyed. But after fully removing sales bonuses on antibiotics previously, GSK has chosen to re-introduce such bonuses in the last 2 years. Despite being the only company out of those surveyed to actually regress on this damaging practice, GSK is still rated as the best performing of the big companies.
A useful piece of the puzzle on access
The efforts to measure the number of countries in which companies have filed for drug registration for both new and old antibiotics by the AMR Benchmark should however be commended. This data gives an interesting insights into access to and availability of both new and old antibiotic products in a broad set of countries, and the findings are truly concerning.
Just 3 in 13 on-patent antibiotics was filed for registration in more than ten of what the Benchmark defines as “access countries” (defined as a group 102 low- and middle- income countries incl. India, China, South Africa and Brazil). While most companies manufacture one or more so-called ‘forgotten antibiotics’ –ie. old but still effective antibiotics – less than half of these drugs are supplied to those ‘access countries’ where the need is arguably the greatest.
Findings should inform R&D discussions
The AMR Benchmark is right to point out that this is an area where companies can do more. In fact, these numbers show that companies still have a very long way to go before they can credibly say they care about access in low- and middle- income countries.
These finding should inform policy makers, philanthropic funders and others engaged global R&D discussions, where the argument that big industry is an essential part of future solutions because of their expertise and resourcefulness in ensuring market entrance and drug registration globally. Judging by these findings, these claims seem to be wholly unfounded.
The impossible minus score
The lack of qualitative assessments of initiatives that companies engage in should be pointed out. A number of experts on access to medicines from organizations like MSF, have for example noted that tiered pricing is more of a business strategy seeking to maximize prices in different countries, than it is an access strategy. While the AMR Benchmark has added more critical comments on practices such as tiered pricing in the report, such critique is however not reflected in the scores. This means that a company, which through licensing engaged in price-lowering generic competition (which has been proven to lower prices more effectively and sustainably) would not score better on improving affordability than one that simply takes a tiered pricing strategy.
Effects of discharge efforts unknown
Another example is the progress made on environmental standards on discharges, which the Industry themselves have touted in their own recent self-assessment report as an area of big progress. However, the AMR Benchmark notes that companies will not disclose the levels of antibacterials in waste waters discharged from their production sites or the full results of audits conducted at these sites. Results of audits to suppliers’ sites or the suppliers’ identities are also not published. So while the companies might score points for having frameworks in place and claim they require un-named sub-suppliers to follow such frameworks, the actual effect of these efforts remain unknown.
Yet another example is Pfizer, where the AMR Benchmark actually makes a link between the company’s lack of registration of benzylpenicillin (the only drug on the market to prevent mother-to-child transmission of syphilis) to a rising trend of syphilis in these countries. Pfizer, however manages to be ranked as secnd best performer in the big company category. Regardless of how serious the consequences of companies actions seem to be for patients and on global health, it is – so far – impossible to score negatively in the AMR Benchmark.
The question then remains: if it is not possible, based on the AMR Benchmark’s ranking and presentation, to conclude anything about the actual impact of companies actions on AMR development, can we then really use it to assess how they manage ‘risks and opportunities’ of AMR?
Alternative models should urgently be explored
The serious shortcomings and continued disengagement of the big pharmaceutical industry shouldn’t be glossed over. The scale and urgency of the AMR challenge is too serious for this. Even previous proponents of the Industry, such Lord Jim O’neill, who authored the UK AMR Review Report, publicly said last year that he was “shocked by pharmaceutical companies failing to tackle drug-resistant infections” and that the solution may be to “just take it away from them and take it over”.
This is the more important point that policy makers, investors and decision makers should urgently start exploring.
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