Equitable Access to Essential Medicines: a Framework for Collective Action

Introduction

Essential medicines save lives and improve health when they are available, affordable, of assured quality and properly used. Still, lack of access to essential medicines remains one of the most serious global public health problems. Although considerable progress in terms of access to essential medicines has been made in the last 30 years since the introduction of the essential medicines concept (Figure 1) not all people have benefited equally from improvements in the provision of health care services, nor from low cost, effective treatments with essential medicines. 

Essential medicines are only one element in the continuum of health care provision but they are a vital element. The major access challenges which can be obstacles for health improvement are:

• Inequitable access - about 30% of the world’s population lacks regular access to essential medicines; in the poorest parts of Africa and Asia this figure rises to over 50%.

• Health reforms - in many low- and middleincome countries, health sector reforms have led to insufficient public funding for health.

• Medicine financing - in many high income countries, over 70% of pharmaceuticals are publicly funded through national health insurance schemes whereas in low- and middle income countries 50% to 90% of medicines are paid for by patients themselves

• Treatment costs - high costs of treatments with new essential medicines for tuberculosis, HIV and AIDS, bacterial infections and malaria will be unaffordable for many low- and middle-income countries.

• Globalization - global trade agreements can threaten access to newer essential medicines in low- and middle-income countries. Access to health care and therefore to essential medicines is part of the fulfillment of the fundamental right to health. All countries have to work towards the fulfillment of equitable access to health services and commodities, including essential medicines necessary for the prevention and treatment of prevalent diseases.

WHO Access Framework

Improving access to essential medicines is perhaps the most complex challenge for all actors in the public, private and NGO sectors involved in the field of medicines supply. They must all combine their efforts and expertise, and work jointly towards solutions. Many factors define the level of access, such as financing, prices, distribution systems, appropriate dispensing and use of essential medicines. WHO has formulated a four-part framework to guide and coordinate collective action on access to essential medicines (Figure 2). This framework has also been adopted by WHO’s key partners. The first two components are discussed in more detail below.. 

1. Rational selection and use of essential medicines 

There are global concepts which can be applied in any country, in both public and private sectors and at different levels of the health care system. Careful selection of essential medicines is the first step in ensuring access. Rational selection and use can be pursued through various tools, including:

• National treatment guidelines are defined by WHO as systematically developed evidence-based statements which assist practitioners and patients to make informed decisions about appropriate health interventions.

• National lists of essential medicines should be developed for different levels of care and on the basis of standard treatment guidelines for common diseases and conditions that should be treated at each level. Rational use of essential medicines requires trained and motivated health staff, and the necessary diagnostic equipment, to ensure safe and effective treatments, minimizing the risks and waste linked to irrational prescribing and use of medicines.

2. Affordable prices

With the potential cost of providing a full range of treatments for prevailing common diseases, medicine prices and financing are fundamental factors in access to essential medicines. Affordable prices can be pursued through the following mechanisms:

• Price information is essential to obtain the best price.

• Price competition through tendering of generic products and therapeutic competition are powerful price-reduction tools, as evidenced by experiences from large producing countries such as Brazil and India. Through generic competition, price reductions of over 75% were achieved over the initial brand prices.

• Bulk procurement encompasses that medicine orders are pooled together in order to increase purchasing power. Bulk procurement can be through cooperation of facilities in a country, but positive experience has also been reported from arrangements between countries.

• Generics policies are effective instruments when a patent expires. In the United States of America the average wholesale price falls to 60% of the price of the branded medicine when one generic competitor enters the market, and to 29% with 10 competitors. 

• Equitable pricing is especially important for newer essential medicines that are still protected by patents or other instruments that provide market exclusivity. Equitable pricing is explained as the adaptation of prices which are charged by the manufacturer or seller to countries with different purchasing power.

• Reduction or elimination of duties and taxes for both generic and patented essential medicines contribute to price reduction. In developing countries, the final price of a medicine may be two to five times the producer or importer price. This reflects the effects pharmaceutical import taxes and duties, high distribution costs, and dispensing fees.

• Local production of assured quality when economically feasible and where it follows good manufacturing practices (GMP) can result in lower medicine prices. Generic companies in Brazil, India and Thailand have offered their help to low- and middle income countries to produce antiretrovirals locally through technology transfer. 

“From: WHO Policy Perspectives on Medicines, No.8, March 2004, WHO, Geneva. Prepared by: Marthe Everard, Focal Point Access to Essential Medicines, Department of Medicines Policy and Standards, World Health Organization, Geneva, Switzerland. “ The complete text of the WHO Policy Perspectives paper on Equitable Access to Essential Medicines: a Framework for Collective Action can be found on: http://www.who.int/medicines/public ations/ policyperspectives/en/index.html Please visit the WHO medicines web site: http:// www.who.int/medicines/