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The article from Leonard and the team from the National Institute for Health and Care Excellence, NHS England, and NHS Improvement [1] asks the question whether the UK subscription program can restore the antibacterial pipeline, with an insiders’ description of the process and strategy that led to implementation (briefly, a ‘pull incentive’ of reimbursement for new antibacterials that is delinked from volume of sales with payments based on the added value to the whole health and social care system).

Governments [2,3,4,5,6,7,8,9], academics [10,11,12], civil society [13, 14], think tanks [12, 15,16,17,18], and other key stakeholders [19, 20] have clearly articulated the problems with the pipeline for antibacterials, with an increasing focus on pull incentives that do not depend on the volume of sales, also known as delinked pull incentives. This delinked approach is recognized as the key because it resolves the tensions that create the underlying market failure of antibacterials: via delinked pull incentives, companies are rewarded for innovation while stewardship is simultaneously supported by eliminating any incentive to generate sales through marketing efforts. Although these tensions are also potentially true for any class of antimicrobial therapeutic, they are most acute for antibacterials because of the frequency of use and the presence of prior generations of antibacterials with partial but declining effectiveness.

As described in their article, the UK has now become the first country to implement a delinked pull incentive for novel antibacterials. To appreciate this monumental achievement, three analogies may be helpful.

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