Access to medicines: making market forces serve the poor

In recent years, the need for uninterrupted supplies of medicines has become more urgent.

The importance of preventing stock-outs has been underscored by the advent of antiretroviral therapy for HIV, the long duration of treatment for multidrug-resistant tuberculosis, the ability of artemisinin-combination therapies to prevent malaria deaths if administered quickly, and the need for life-long treatment of chronic conditions such as hepatitis B infection and diabetes. Lack of access to medicines is one of the most complex – and vexing – problems that stand in the way of better health.

The agenda for improving access is exceptionally broad. Gaps in local health systems and infrastructures hamper the delivery of medicines to millions of people.

Access also depends on procurement practices, tax and tariff policies, mark-ups along the supply chain, and the strength of national drug regulatory authorities.

Apart from being affordable and of good quality, medicines must also be safe. International conventions for the control of narcotic drugs can be another barrier to access.

They place a dual obligation on governments: to prevent abuse, diversion and trafficking, but also to ensure the availability of controlled substances for medical and scientific purposes.

Many controlled substances play a critical role in medical care, for the relief of pain, for example, or use in anaesthesia, surgery, and the treatment of mental disorders.

WHO estimates that 80 per cent of the world’s population lives in countries with zero or very little access to controlled medicines for relieving moderate to severe pain.

Efforts to improve access are complicated by a number of economic issues. Affordability matters for households and health budgets.

WHO estimates that up to 90 per cent of the population in low- and middle-income countries purchases medicines through out-of-pocket payments.

If a household is forced to sell an asset, like the family cow, or take its children out of school, this payment can be the final nail in the coffin that buries the family in intergenerational poverty.

This is the pathology of poverty when no forms of social protection, such as those provided by universal health coverage, are available and even low-cost generic products are a heavy financial burden.

When prices are so low they preclude profits, companies leave the market. For health budgets, staff costs usually absorb the biggest share of resources, with the costs of drug procurement following closely behind.

The part of the budget devoted to medicines varies significantly according to a country’s level of economic development.

Medicines account for 20 to 60 per cent of health spending in low- and middle-income countries, compared with 18 per cent in countries belonging to the Organisation for Economic Co-operation and Development.

One of the most daunting economic issues comes from the fact that the research-based pharmaceutical industry is a business, and a big one.

Multinational pharmaceutical companies, concentrated in North America, Europe and Japan, are powerful economic operators. Economic power readily translates into political power.

When ways to improve access are negotiated at WHO, a familiar polarizing tension surfaces. Which side should be given primacy, economic interests or public health concerns?

As many have argued, letting commercial interests override health interests would lead to even greater inequalities in access to medicines, with disastrous life-and-death consequences.

At the same time, the pharmaceutical industry is a business, not a charity. When prices are so low they preclude profits, companies leave the market – and leave a hole in the availability of quality products, as happened with anti-snakebite venom.

Economic factors shape another pressing public health concern.

Many diseases mainly prevalent in poor populations have no medical countermeasures whatsoever, or only old and ineffective ones.

In other cases, access suffers from the lack of products adapted to perform well in resource-constrained settings with a tropical climate.

The patent system, with its market-driven Research and Development (R&D) incentives, has historically failed to invest in new products for poor populations with virtually no purchasing power, resulting in a paucity of R&D driven by the unique health needs of the poor.

Recent shifts in the poverty map introduce another set of problems.

An estimated 70 per cent of the world’s poor now live in middle-income countries which are losing their eligibility for support from mechanisms like the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance.

Will governments step in to make up for the shortfall in access to medicines and vaccines? If not, vast numbers of poor people living in countries that are rapidly getting rich will be left to fend for themselves.