Written by Graham Lister, Chair of BoT
Medsin members will be aware that access to medicines is crucial to global health equity. Currently access to vital medicines is limited for people with low incomes by three key factors. First medicines are often unaffordable because prices are set by rich country markets and may even be higher in low income countries. Second the prospect of low affordability deters the development of medicines for neglected tropical diseases resulting in what is known as the 10/90 gap. This means that only 10% of research funding is devoted to conditions that cause 90% of the global disease burden. Third the lack of effective health systems including diagnostic and prescribing skills and logistics for the delivery and control of medicines inhibits the provision of medicines as one aspect of effective healthcare. This blog considers what Medsin members can do to address these issues in the light of the UN Secretary General’s High Level Panel Report on Access to Medicines, which will be debated at this year’s World Health Assembly, here.
The global social contract with pharmaceutical companies embodied in WTO intellectual property agreement (TRIPS), provides global protection for 20 years for patented drugs. While patent protection starts from the filing of the patent application, which can be several years before commercial availability, pharma companies can extend this by introducing minor enhancements to their drugs. The Doha declaration of 2001 provides exception in the case of health crises, allowing the provision of lower cost generic medicines, of which India is the largest producer. Some companies provide medicines at a lower price to low income countries through intermediaries such as the Clinton Foundation. It has been suggested that the main obstacle to setting affordable prices for low income countries (where prices are often higher) is the fear of so called parallel exporting (corruptly selling drugs back to high income markets) and counterfeit medicines (an estimated market of over $75 billion).
More than one billion people suffering from one or more neglected tropical diseases (NTDs) benefited from large-scale treatment programmes of preventive chemotherapy in 2014 as part of perhaps the world’s largest public health intervention led by the WHO. This programme benefited from donations of drugs from pharmaceutical companies worth billions of dollars. It also identified the need for the development of affordable diagnostics, drugs and insecticides targeted at NTDs. It is perhaps unsurprising that this programme has remained largely unknown in the western press because these diseases are not thought of as threats to health in high income countries. Medsin members may wish to see the paper here The WHO convenes a panel of scientists and health experts every year to identify the diseases they consider most likely to cause the next global health emergency. This year the list is headed by three relatively little-known NTDs: MERS (Middle East Respiratory Syndrome, known as Camel Flu), Lassa fever and Nipah virus.
The greatest obstacles to the delivery of medicines in low income countries, noted by the WHO, are the level of insecurity and the weakness of health systems. The problems vary from country to country, but the underlying issue is a lack of funding. My experience in East Africa was that in rural areas, where more than 70% of people live, health services were led by nurses and midwives with support from a medical assistant with two years training to prescribe a limited range of essential medicines, usually dispensed from tins. The situation is improving as “E-health” services are introduced but this is limited by the training of local staff in using such facilities. If the need for a medicine is identified (other than the locally available essential medicines) patients must travel to a pharmacy (formal or informal) to buy what they can afford. This often means that they do not complete a course of medicine, which leads to antimicrobial resistance. The service is likely to be very expensive for patients who bear 30- 60% of the cost (government health services provide 15-30% with a similar level from aid or charitable sector provision).
The key question is what can be done to improve access to medicines for those with greatest need and how can Medsin members advocate for and take action to improve the situation? One step is of course to press for government funding including renewal and extension of its support for the Neglected Tropical Diseases Programme. Medsin branches might like to focus on specific disease based programmes covering fields such as Dengue Fever, Trachoma or the three diseases identified in this year’s WHO report as representing the greatest risk for global health emergency.
Another step might be to call for a more fundamental review of the social contract with global pharmaceutical companies (the TRIPS agreement), to ensure that the risk and rewards of investment in research and development (by universities and pharma companies) are adequately incentivised for contribution to global health priorities. This could include reassessment of the way in which the research and development of medicines is funded and priced in high and low income markets.
It is perhaps too easy to blame pharmaceutical companies for neglecting certain diseases and issues concerning drug delivery in low income countries It might be more constructive to evaluate their performance in supporting access to medicines. The Access to Medicines Index, which is supported by UKAID, the Bill and Melinda Gates Foundation and the Netherlands Ministry of Foreign Affairs reviews the performance of 20 of the world’s largest research-based pharmaceutical companies on how they make medicines, vaccines and diagnostics more accessible in low and middle-income countries. It highlights best and innovative practices, and areas where progress has been made and where action is still required. It has been published every two years since 2008. You may wish to view the index here. This provides a clearer way to target those companies who need to improve their performance, to call for the adoption of best practice and perhaps to celebrate those that act as responsible global corporate citizens. Medsin members could play a role in focussing student attention on those pharmaceutical companies that need to be encouraged to increase their efforts to support global health equity.
Since posting the Coalition for Epidemic Preparedness (CEPI) have announced a $460 million programme to develop potential vaccines for the high priority NTDs noted above. .