The case for regional pooled procurement of antibiotics

Antibiotic shortages are quietly driving resistance. Buying these drugs regionally, with different rules for different tiers, could fix supply and protect stewardship at the same time.

Antibiotics are now among the five most shortage-prone classes of medicine, with four in five shortages lasting more than six months. Photo: Mikhail Nilov

In September 2024, every UN member state signed up to the same target: by 2030, at least 70% of the antibiotics people take should come from the World Health Organization’s (WHO) Access group—narrow-spectrum, first-line drugs that are least likely to fuel antimicrobial resistance. It was meant to be the cornerstone of the global response to antimicrobial resistance.

But a target is only as good as the drugs available to meet it. When first-line antibiotics run short, clinicians reach for stronger, broader drugs, and lean on last-resort options. Antibiotic resistance climbs with every substitution.

There is a practical way to break this cycle: buying antibiotics regionally across the whole WHO AWaRe spectrum, applying different procurement rules at each tier. AWaRe groups antibiotics by how they should be used: Access drugs are first-line treatments, Watch drugs are broader-spectrum agents requiring closer stewardship, and Reserve drugs are last-resort options for multidrug-resistant infections.

Pooled procurement itself is simple: a group of countries aggregates demand to buy together, so one central buyer negotiates with manufacturers on the group’s behalf and delivers the medicines back to each member.

The Pan American Health Organization (PAHO) has run one such fund for the Americas for over 20 years. It pools demand for essential medicines, antibiotics among them, to forecast need and head off stockouts. When Colombia started buying its hepatitis C medicines through the fund in 2017, prices dropped by more than 90%, and over 1,000 patients were treated in the first year alone. In September 2024, PAHO signed an agreement with Africa CDC to pass that experience on to a new African Pooled Procurement Mechanism.

The model works. The question is whether we are willing to build one specifically for antibiotics.

Why this matters now

The underlying numbers are sobering. Antibiotics are now among the five most shortage-prone classes of medicine, with four in five shortages lasting more than six months. About 70% of the active ingredients in the world’s antibiotics come from just two countries—China and India—so a single disruption in either is felt in clinics worldwide.

In low- and middle-income countries (LMICs), the reality is worse than the official picture suggests. Shortages get buried inside chronic stockouts, patchy surveillance, and substandard products in local markets. Patients never hear the word “shortage”; they just find a clinic without the drug they came for.

All of this is happening just as donor money pulls back. The Institute for Health Metrics and Evaluation (IHME) estimates that sub-Saharan Africa absorbed a 25% fall in development assistance for health between 2024 and 2025. Whatever comes next, the grant-funded model that built Gavi, the Vaccine Alliance will not be what builds an antibiotic mechanism.

How a tiered regional pool works

A well-run regional pool would do three jobs at once. First, it would secure supply across all three tiers, with different rules at each. Access antibiotics like amoxicillin are the foundation; they need bulk, multi-year contracts that take the guesswork out of demand and keep shelves stocked. Watch antibiotics like ceftriaxone should come with strings attached: reliable supply in return for proper stewardship and reporting on use. Reserve antibiotics like cefiderocol, held back for confirmed multidrug-resistant infections, are better handled through subscription contracts and regional stockpiles, released only once a diagnosis confirms they are needed.

Second, it would reshape a broken market rather than chase a lower price. With antibiotics, the real failure is not high prices. It is that demand is unpredictable, margins are thin, and contracts are short, which is why manufacturers walk away and shortages recur. Multi-year commitments tackle that head on, giving suppliers the certainty to keep making low-margin Access drugs nobody else wants to produce.

Third, it only works at a regional scale. Resistance is local: what counts as first-line for sepsis in West Africa is not the same as in South-East Asia, and no global pool could tailor its Watch and Reserve baskets to each local picture. The cost of getting this wrong is already clear. In the WHO African Region, more than 70% of E. coli and K. pneumoniae bloodstream infections no longer respond to third-generation cephalosporins, the Watch drugs clinicians fall back on when the first line fails. Stewardship, too, is something only regional bodies are close enough to enforce.

The economics push the same way. Antibiotics are high-volume, low-margin drugs used every day in primary care, not the kind of product that benefits from global aggregation the way vaccines do. None of this is frictionless: countries are wary of ceding purchasing authority, so these mechanisms will likely start with joint forecasting and shared standards before binding tenders.

The scaffolding is already going up: PAHO and Africa CDC are designing an African mechanism, and SECURE, a joint WHO and Global Antibiotic Research & Development Partnership (GARDP) initiative, is working with the Health Intervention and Technology Assessment Program (HITAP) on a version for the Association of Southeast Asian Nations (ASEAN).

What success looks like

Picture where this could be by 2030: three or four regional pools up and running across Africa, ASEAN, the Eastern Mediterranean, and Latin America, each buying the full AWaRe spectrum of antibiotics on its own tiered rules. Real progress towards the 70% Access target, driven by reliable supply rather than aspiration, with fewer stockouts as manufacturers count on demand, and a model that stands on its own rather than waiting on more donor funding.

Getting there asks three things. Regional bodies like the African Union, ASEAN, and the Gulf Cooperation Council (GCC) need to set up pooled procurement now, with tiered AWaRe rules built in. Development finance institutions such as Afreximbank and the African Development Bank need to provide working capital and offtake guarantees that give the pools commercial weight. The WHO and GARDP, through SECURE, along with whatever donors remain, should line up behind this effort rather than duplicate it.

If we want clinicians to prescribe responsibly, the least we can do is make sure they have reliable antibiotics to prescribe. Bought together today, and, where it makes sense, made closer to home tomorrow.

---

The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.

Rahul Dwivedi is a global health leader with 14 years of experience in market shaping, health equity, and access strategy across low- and middle-income countries. His work focuses on antimicrobial resistance, innovative financing, and sustainable access to medicines. He has held senior roles at GARDP, Roche Pharma India, and Biocon Biologics.