What AMR teaches us about policy innovation

Professor Dame Sally Davies calls for new thinking to mobilise governments, health systems and communities

In 2024, an off-Broadway Scottish musical called The Mould That Changed The World (now renamed Lifeline) was performed on the floor of the United Nations, telling the story of Alexander Fleming, the discovery of penicillin and the consequences of antimicrobial resistance (AMR). This was no ordinary drama put on for the entertainment of the representatives of the UN’s 193 states, but a highly unusual and unconventional piece of global health diplomacy.

As such, it conveyed a message that diplomatic texts and scientific papers struggle to communicate: AMR is not only a scientific challenge, it is one that affects and demands the attention of the whole of society. It requires governments to break out of traditional policy silos and cycles and to mobilise wider coalitions in the cause of preserving one of medicine’s greatest achievements for future generations.

As a doctor, former Chief Medical Officer (CMO) for England and UK Government Envoy, AMR has shaped much of my professional life over the past 15 years. It has also shaped my understanding of what effective policy looks like when confronting so-called ‘wicked’ problems, complex long-term, cross-border and socio-technical challenges like AMR that defy traditional solutions.

Why AMR is not just a health issue 

Drug-resistant infections – or ‘superbugs’ – represent one of the most pressing global health crises of our time. Modern medicine, after all, from routine surgery and caesarean sections to cancer chemotherapy, transplants and neonatal care, depends on effective antimicrobials – as does our entire food chain.

AMR already causes more than 1.1 million deaths globally each year and contributes to nearly five million others. Across Europe, it is estimated to cause 100 deaths every day. Sadly, one of those deaths two years ago was my own goddaughter. As resistance rises, the most vulnerable populations – the very young, the elderly and those with chronic conditions – face increasing risk. 

The financial burden is severe – and growing. AMR leads to longer hospital stays and poorer outcomes, placing pressure on already stretched health systems.

But the consequences of the waning effectiveness of antibiotics and other anti‑infectives go much further, rippling across food systems, denting economic productivity and even threatening national security. The Centre for Global Development (CGD) estimates that, if not mitigated, it could cost the global economy trillions in annual healthcare costs and economic losses.¹ It is because of these systemic impacts that, as CMO, I argued for AMR to be reflected in the UK’s National Risk Register.

Yet AMR rarely generates the urgency of other acute crises. Its impacts are cumulative, long-term and dispersed across sectors. Responsibility for dealing with it spans human and animal health, agriculture, trade, finance and the environment, and cuts across public and private actors. Its reach exposes the limits of traditional policy cycles, institutional and societal incentives and political timeframes. 

For governments, AMR therefore provides a test case for innovative policy and regulatory approaches, the use of evidence and expertise, the advantages of working across silos and the benefits of mobilising broad coalitions of actors. The threat it poses challenges us to be more open, more collaborative and more willing to experiment to find policy solutions. 

Evidence is necessary but not sufficient 

Over the past decade, improved surveillance, economic modelling and scientific analysis have helped AMR onto national and international agendas. The 2016 Review on Antimicrobial Resistance chaired by Jim O’Neill (known as the O’Neill Review) was instrumental in reframing AMR as a threat to global economic prosperity and development. 

UK investment through the Fleming Fund, meanwhile, has strengthened laboratory and surveillance capability across human and animal health and the environment in up to 25 low- and middle-income countries. 

Looking ahead, a key outcome of the 2024 UN High-Level Meeting on AMR was the agreement to establish an Independent Panel for Evidence for Action. If designed well, such a panel could play a role similar to the Intergovernmental Panel on Climate Change – strengthening the link between science and policy and supporting countries to act.

However, my experience at the intersection of clinical practice, government and public policy suggests that data alone does not deliver sustainable change. Evidence does not automatically translate into political momentum, different types of behaviour or delivery at scale. 

What we need is a clearer pathway from evidence to action, including financing for national action plans (NAPs), particularly in high-burden, low-resource settings; the sustaining of surveillance systems we have built; better links between data and policy; improved access to antimicrobials and diagnostics; and the rebuilding of fragile innovation systems. 

AMR cannot be tackled in isolation. It intersects with climate change, pandemic prevention and preparedness, global conflicts and the achievement of the Sustainable Development Goals. Our policy responses must reflect this interconnectedness and involve the whole of society to mitigate the spread of resistance through responsible prescribing, farming, manufacturing and investment.

Innovation beyond technology

When we talk about innovation, we often refer to novel drugs or diagnostic approaches. These are essential – especially as resistance rises and the antimicrobial pipeline remains fragile – but without parallel innovation in policy, regulation and public engagement, scientific and technological advances will not translate into new antimicrobials for the patients who need them.

As things stand, the antibiotic pipeline remains worryingly thin, with too few candidates in development and even fewer targeting the most critical bacterial threats. Investment in novel antimicrobials is widely seen as commercially unattractive, driven by high R&D costs and low expected returns – especially where stewardship measures rightly limit use to preserve effectiveness. Private capital has largely moved away from the sector. 

The UK’s NHS antimicrobial products subscription model is an example of a policy innovation designed to address this market failure. Co-developed by the National Institute for Health and Care Excellence and NHS England, the NHS ‘Netflix’ subscription model delinks revenue from sales, instead paying participating companies a fixed annual fee based on the value of an antimicrobial to the NHS. This ‘pull’ incentive improves revenue predictability and reduces commercial risk, while rewarding innovation and supporting availability and responsible stewardship. After a successful pilot in 2019, the full-scale model was launched in the UK in 2024. 

The UK was at the forefront of this approach and has shaped international discussions in the G7 and the EU. Raising awareness among investors and pharmaceutical companies about the urgency and portfolio-wide impact of AMR is equally important. We need to become better at communicating the systematic and long-term risk AMR poses to societal and economic resilience.

Embracing AI sensibly and proactively

Emerging technologies, including artificial intelligence, offer crucial capabilities to strengthen AMR surveillance, accelerate R&D, optimise chemistry, mitigate toxicity, reduce costs and support clinical decision making. 

These benefits are not limited to high-income countries. Through my work with the Trinity Challenge, I have seen how innovators in high-burden countries are already using big data and AI to support clinical decision-making and to provide farmers with veterinary support even in remote areas, to counter the threat of substandard and falsified drugs and to support early warning and outbreak response. For example, AMRSense provides a One Health, AI-enabled ecosystem that links data capture, analysis and community engagement, bringing high-quality AMR surveillance and stewardship into communities where data and awareness gaps remain acute.

AI is not a silver bullet, but it is a powerful opportunity to use resources beyond drug discovery – whether in early warning systems, outbreak detection, community engagement or operational decision making. 

The policy challenge is not whether to use AI, but to create the conditions for it to be used responsibly, with demonstrable benefit to all communities. Governments need to establish clear but proportionate guardrails. As a doctor, I know there is no such thing as 100% certainty or zero risk. We must not allow the perfect to become the enemy of the good. 

Ways of working across government

As our understanding of AMR deepens – and as we learn from other long‑term challenges such as climate change – we must continue to broaden our coalitions. The UK has led the way in engaging the private sector, including investors, in recognising AMR as a systemic risk across portfolios. 

The UK has also pioneered new forms of public engagement, including transferring Lifeline, the Edinburgh Fringe and off-Broadway production originally performed on the floor of the United Nations, to the Southwark Playhouse in London for a six-week run. The Lifeline volunteer chorus brings together healthcare workers, scientists and others on the frontline of AMR, performing alongside professional actors, in a production that is not only raising awareness but, crucially, is inspiring performers and audience to act. 

Let’s hope this can be a model for many more creative and unconventional approaches to helping solve complex long-term risks. For a challenge like AMR, there really is no such thing as too much creativity. We need to bring in the widest possible mix of people, skills and ideas if we are going to keep making progress.

As public finances tighten and development budgets come under pressure, the UK’s influence will rely less on how much we spend and more on how we use what we have. That means making the most of our science, our regulatory expertise, our diplomacy and our ability to convene others. Partnership matters more than ever.

AMR, meanwhile, has a lot in common with other long-term, cross-border challenges such as climate change, pandemics and biosecurity. None of these can be solved by a single department, country or discipline. All require governments to work across silos, over long timeframes and to accept a degree of uncertainty. 

Let’s face the music 

Policy innovation such as the NHS subscription model discussed earlier addresses a failure of our markets; creative productions like Lifeline address a different failure – the failure to make long-term risks salient to governments and relatable to the communities they affect.

When people understand a problem, they are more likely to care. When they care, they are more likely to act. Whole of society challenges require whole of society approaches. That means being willing to work with unconventional partners, to be bold, to experiment and to create spaces for action at all levels, be they local or international.

As we approach the centenary of Fleming’s discovery of penicillin in 2028, the question is not only how we preserve one of medicine’s greatest achievements, but whether government can adapt its systems to rise to the challenge of wicked problems like AMR. Bold and creative trailblazers have shown me that this is possible, but only if we are prepared to innovate – not just in what we do, but in how we work, who we work with and how we enable action across society.

Dame Sally Davies, former Chief Medical Officer, is the UK Special Envoy on AMR and 40th Master of Trinity College, Cambridge. She acknowledges the contribution to this article of Anna Roessing, private secretary to the UK Special Envoy.