Antimicrobial resistance is one of the defining health threats of our time, yet the market for new antibiotics remains broken. A comprehensive new analysis published in The Lancet Regional Health – Europe reveals that while governments across the United Kingdom, Sweden, Germany, France, Italy, the United States, Japan, and the European Union have launched a growing array of “pull incentives” designed to revive antibacterial drug development, these schemes apply strikingly different eligibility and evaluation criteria—a patchwork that researchers warn may be sending confused signals to pharmaceutical developers and fragmenting the global response to drug-resistant infections.

The study, led by Michael Anderson and Elias Mossialos of the London School of Economics and Political Science along with colleagues across European health policy institutions, represents the first systematic effort to compare, side by side, the fine print of the world’s antibacterial pull incentives. Unlike “push” incentives such as grants and direct research funding that reduce the upfront cost of discovery, pull incentives promise rewards—guaranteed revenues, extended market exclusivity, faster regulatory review, or preferential pricing—contingent on success. Because these rewards shape late-stage development decisions and commercial viability, the criteria attached to them effectively define what kind of antibiotic the world’s developers are being asked to build.

The research team searched MEDLINE and Embase for reviews published between 2014 and October 2024, supplemented by grey literature searches and a December 2025 review of the Global AMR R&D Hub dashboard. From an initial haul of 3,584 records, they identified 28 pull incentives: 20 already implemented and 8 proposed or in development in the US, Japan, Canada, Australia, Switzerland, and the EU. Two reviewers independently extracted criteria from official policy documents and technical guidance, categorizing them into six product domains—priority medical need, relative effectiveness, unmet clinical need, innovative characteristics, health-system impact, and other product features—and five company domains covering antibacterial stewardship, patient access, environmental health, economic criteria, and other obligations.

The results expose deep inconsistencies. All nine groups of implemented incentives required products to target high-priority medical need, and seven of nine assessed unmet clinical need. Relative effectiveness appeared in six of nine schemes, and innovative characteristics—such as a new mechanism of action or a novel chemical class—in only four. More striking is the treatment of company-level obligations. Stewardship requirements, patient access commitments, and environmental safeguards were applied narrowly and unevenly across countries. Only two of nine implemented schemes explicitly addressed environmental health, and just four incorporated antibacterial sustainability criteria. The United Kingdom’s subscription model emerged as the most comprehensive, satisfying all eleven criteria domains mapped by the researchers, followed by Sweden’s Annual Revenue Guarantee at eight of eleven.

The UK model, deployed by NHS England and the National Institute for Health and Care Excellence, pays pharmaceutical companies a fixed annual fee—between £5 million and £20 million per product—for access to novel antibiotics, deliberately decoupling company revenue from sales volumes to discourage overprescription. The first contracts, signed in June 2022 for ceftazidime/avibactam and cefiderocol, committed up to £10 million annually per drug over three years, with options to extend to ten. To qualify, products must be authorized by the Medicines and Healthcare products Regulatory Agency and target pathogens the World Health Organization classifies as critical. Companies must also guarantee supply security, restrict promotion to educational activities, submit to independent assessment of manufacturing standards, and demonstrate commitments to social value, including net zero carbon goals.

Sweden’s pilot revenue guarantee, concluded in 2020, committed approximately SEK 4 million (around €400,000) per year for each of five antibiotics, including cefiderocol and meropenem/vaborbactam. Eligibility required European Medicines Agency approval, proven activity against at least one carbapenem-resistant pathogen—Enterobacterales, Pseudomonas aeruginosa, or Acinetobacter baumannii—and a safety profile comparable to beta-lactam antibiotics. Companies were required to maintain warehouse capacity in Sweden, dispatch hospital orders by the next working day, report stock and sales data regularly, and comply with environmental regulations governing pharmaceutical production and disposal.

Other models are leaner. Italy’s Innovative Medicines Fund, operational from 2025, grants the Italian Medicines Agency up to €100 million annually to negotiate higher prices for antibiotics classified as “Reserve” on the WHO AWaRe list or targeting pathogens on the WHO Bacterial Priority Pathogens List. Nine antibacterials had qualified as of January 2026. Germany, meanwhile, exempts designated “reserve” antibiotics from internal reference pricing under its Social Code, using a four-stage, expert-informed national list of multidrug-resistant bacteria to determine eligibility. France ties preferential pricing to its ASMR clinical benefit ratings, while the United States relies primarily on regulatory levers: the 2012 GAIN Act’s Qualified Infectious Disease Product designation grants five extra years of market exclusivity and priority review, the Limited Population pathway accelerates approval for drugs targeting narrow patient groups, and Medicare’s New Technology Add-on Payments reward hospital use of qualifying new agents.

The researchers also compared the pathogens targeted by each scheme against the WHO’s 2024 priority pathogen list and national equivalents maintained by Germany’s Robert Koch Institute, the US FDA, the CDC, and the Public Health Agency of Canada. While most incentives anchor their criteria to established lists, the breadth varies considerably—some countries focus narrowly on carbapenem-resistant critical pathogens such as Acinetobacter baumannii and resistant Enterobacterales, while others adopt broader lists including medium-priority organisms like macrolide-resistant Streptococcus pneumoniae or even fungal threats such as Candida auris.

This heterogeneity matters, the authors argue, because pull incentives work by shaping investment expectations. When developers face divergent, sometimes conflicting criteria across their potential markets, uncertainty about returns rises—a problem the WHO flagged as early as 2022 when it declared the antibacterial pipeline insufficient to combat rising resistance. The study’s modeling reference points suggest the stakes: previous analysis cited in the paper estimates that G7 plus EU27 countries should collectively deliver annual global revenues of US$258 million to US$562 million for antibacterial innovation, yet only the UK and Italy currently meet the mid-range target.

The authors propose a pragmatic middle path: a small set of essential criteria applied universally—targeting priority pathogens and basic stewardship requirements—supplemented by optional criteria that countries adopt as their regulatory and monitoring capacity matures. They point to the stewardship and access standards developed by CARB-X, the well-funded accelerator based at Boston University, as a ready-made foundation for a global standard. Multilateral platforms including the Global AMR R&D Hub, the G7, and the G20 could convene the necessary consensus-building, potentially through structured expert processes such as Delphi panels. The WHO’s recent publication of target product profiles for new antibacterial agents—specifying desired pharmacokinetics, routes of administration, and stability characteristics—offers another anchor for harmonization.

The study’s limitations are acknowledged candidly. Some eligibility criteria embedded in confidential contracts remain inaccessible, and it is too early to evaluate which mechanisms most effectively stimulate research and development, given the decade or more required to move a candidate through preclinical and clinical testing. Nonetheless, the analysis provides the most current global map of antibacterial incentive design and a clear warning: without greater alignment, well-intentioned national schemes risk undermining each other, weakening stewardship, and ultimately failing the patients who desperately need new antibiotics. Getting the criteria right, the researchers conclude, could ensure that public investment drives development of the antibacterials with the greatest public health value—before resistance renders modern medicine’s foundations once again fragile.

Subject of Research: Comparative analysis of eligibility and evaluation criteria for pull incentives designed to stimulate antibacterial innovation and access across high-income countries and the European Union

Subject of Research: Medicine

Article Title: Designing eligibility and evaluation criteria for antibacterial pull incentives: a comparative review of implemented and emerging initiatives

Article References: Anderson, M., O’Neill, E., Ljungqvist, G., Cherla, A., Claessens, Z., Schoefs, E., Crabb, N., Cowell, W., Cohn, J., Patel, D., & Mossialos, E. (2026). Designing eligibility and evaluation criteria for antibacterial pull incentives: a comparative review of implemented and emerging initiatives. The Lancet Regional Health – Europe, 70, Article 101849. https://doi.org/10.1016/j.lanepe.2026.101849

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101849

Keywords: antimicrobial resistance, pull incentives, antibiotic innovation, UK subscription model, Sweden Annual Revenue Guarantee, WHO priority pathogens, stewardship, access and reimbursement policy, antibiotic pipeline, international alignment

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Ophelia Keating. (September 8, 2026). Comparing eligibility and evaluation criteria for antibacterial pull incentive programs. Scienmag. https://scienmag.com/comparing-eligibility-and-evaluation-criteria-for-antibacterial-pull-incentive-programs/

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