Access to Medicines Factsheet

Publication date: 2006

1 Access to medicines Millennium Development Goal 8: A global partnership for development Target 17: In co-operation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries Key messages • Properly used, essential medicines save lives, reduce suffering and improve health. • By improving access to essential medicines and vaccines, up to 10.5 million lives could be saved every year worldwide: 4 million in Africa and South-East Asia alone. • Concerted action is needed to ensure fair and sustainable financing, affordable prices, reliable health and supply systems, and the rational use of medicines.1 Efforts are also needed to develop new vaccines, drugs and other health technologies that meet developing country needs. • This requires partnership between developing country governments and healthcare providers, donors, international agencies, non-governmental organisations, pharmaceutical and biotechnology companies and the broader private sector, as well as consumers and health researchers. Key facts and figures • A third of the world’s people lack access to the medicines they need – rising to 50% in parts of Asia and Africa. • Up to 50% of medicines are inappropriately prescribed, dispensed or sold, leading to wasted resources and potentially resulting in patient harm. • Patients improperly use up to 50% of medicines, resulting in reduced treatment efficacy and potentially leading to resistance. • In developing countries, medicines account for 60% - 90% of household expenditures on health. Inappropriate prescription, high prices, low quality and improper use mean that the poor often receive little health benefit for their spending on drugs. Are we on track to meet the Millennium Development Goal (MDG) target? MDG indicator 46 relates to the proportion of the population with access to affordable essential drugs on a sustainable basis. The MDGs, targets and indicators relating to 1 WHO Policy Perspectives on Medicines – Equitable access to essential medicines: a framework for collective action (March 2004) FactsheetA DFID practice paper JANUARY 06 2 HIV and AIDS, malaria, TB, child and maternal mortality are also relevant to medicines access.2 • Globally, the proportion of people without access to essential medicines fell from less than a half to around a third between 1975 and 1999. However, the total number of people without access remained the same at approximately 1.7bn. In 1999, 16% of countries reported that less than half their populations had access to essential medicines. By 2003, the situation had improved somewhat, with 15% reporting such limited access. Challenges and obstacles • WHO has identified six challenges which must be addressed to improve access to medicines in developing countries: unaffordable medicines, irrational use of medicines, unfair health financing mechanisms, unreliable medicines supply, the quality of medicines, and the need for new medicines.3 • Countries need to develop policies to improve access to medicines. Different ministries must work together. For example, countries’ trade policies and patent laws may not allow the use of public health flexibilities available in World Trade Organisation (WTO) rules governing intellectual property, potentially affecting the ability to import or produce copies of patented medicines – also known as ‘generics’. Equally, finance ministries impose a variety of taxes and tariffs on medicines, which, along with distribution chain mark-ups, can raise prices by up to 50% – 80%, posing serious barriers to access.4 • There is a critical need in many countries to strengthen health and procurement systems, and to improve poor people’s access to health services. Investment is required from governments and others, such as donors. Barriers, such as a lack of skilled healthworkers, must be addressed. • Provider, community and patient awareness raising about medicines is equally important to address poor prescribing, overpricing, quality and use issues. • In many countries, the majority of medicines are accessed through the private or informal sectors. Where access to health services is low, the poor may rely on drug sellers – trained or untrained – for both diagnosis and prescription. Counterfeit drugs pose a particular problem (see WHO factsheet). • Emerging challenges include increased resistance to key drugs, such as those for malaria. The growing trade in substandard and counterfeit medicines is also a major problem, contributing to an increase in drug resistance and resulting in ineffective – and often unsafe – treatment. It is estimated that up to 70% of drugs in some West African countries may be counterfeit, with no guarantee of quality or safety.5 2 See DFID factsheets on Maternal Health, Child Mortality, HIV and AIDS, TB and malaria at http://www.dfid.gov.uk/mdg/ 3 WHO Medicines Strategy: Countries at the Core 2004 – 2007, WHO 2004 4 World Medicines Situation, WHO 2004 pp 29 5 See http://218.111.249.28/ras/default.asp 3 Progress – what the UK is doing to help The UK Government accords high priority to the drive to increase access to medicines in the developing world. In July 2001, the Prime Minister established the high level UK Working Group on Increasing Access to Essential Medicines in the Developing World.6 After extensive cross-Government7 and external stakeholder consultation, Increasing access to essential medicines in the developing world: UK Government policy and plans was published in June 2004 and outlines activities in four key areas; • Strengthening UK efforts to address access to medicines through the UK development assistance programme, including work to increase poor people’s access to health services. • Trade policy, where the UK will support developing countries to understand and make use of the flexibilities within WTO rules governing intellectual property, including through improving the quality and appropriateness of technical assistance.8 • Engagement with the business community, where the UK will work with the pharmaceutical industry to ensure the longer-term supply of affordable medicines to developing countries and to stimulate ‘best practice’ by companies as they engage in developing country markets. A Framework for Good Practice for the Pharmaceutical Industry was launched in March 2005.9 • Efforts, with a wide range of stakeholders, to increase research and development (R&D) into new medicines and other healthcare products needed in developing countries. This includes increased public investment in R&D and developing incentives to increase industry contributions, such a proposals for ‘Advanced Market Commitments’ to create viable markets for future products needed by developing countries. Strengthening access to health services The UK places a high priority on ensuring that drugs, vaccines, commodities and services are accessible through well functioning health systems. Examples of country-level support on medicines include: • The Nigeria Partnership for Transforming Health Systems (PATHS) to which we have committed £39m for the period 2001-2007; • The South African Drug Action Programme (SADAP) which supports the implementation of South Africa’s national drug policy and to which DFID contributed £3.6m from 1996-2003. The programme has reported improvements in a number of areas since its initiation, such as the number of primary health care centres that have and use approved lists of essential drugs and guidelines for treatment; 6 The Working Group was chaired by Clare Short, the then Secretary of State for International Development, and reported to the Prime Minister in November 2002. The report is available at http://www.dfid.gov.uk/aboutdfid/organisation/accessmedicines.asp 7 Including DFID, HM Treasury, the Foreign and Commonwealth Office, Department of Trade and Industry, Patent Office, Inland Revenue and the Department of Health 8 See DFID funded research 9 See http://www.dfid.gov.uk/pubs/files/pharm-framework.pdf 4 • DFID has provided over £1.8m to The Pakistan Network for Consumer Protection (The Network), which aims to assert and protect the rights of poor consumers in relation to goods and services directly affecting health.10 Providing affordable drugs DFID is working with others, including G8 colleagues and the pharmaceutical industry, to secure greater international commitment to affordable pricing of medicines. This is particularly important when medicines are new – such as antiretrovirals (ARVs) for HIV and AIDS, artemisinin-based drugs for malaria and treatments for non-communicable disease – as these tend to be more expensive. The G8 made important commitments in this area at the Evian Summit in 2003. The European Union has also put in place a regulation to encourage affordable pricing of drugs for AIDS, TB and malaria by tackling the diversion of such drugs back to richer markets like the EU. In March 2005, DFID launched Increasing People’s Access to Essential Medicines in Developing Countries: A Framework for Good Practice in the Pharmaceutical Industry. The document sets out a range of actions that pharmaceutical companies can take to support better access to medicines and includes proposals to support affordable pricing. The document also sets out what needs to be done by government to complement these efforts. Supporting global partnerships DFID works with and funds a number of international agencies and initiatives that undertake work that support increased access to medicines. • WHO plays a central role in developing policies, monitoring progress, setting standards and providing technical support to increase access to medicines.11 The UK supports WHO through an annual contribution to its core budget. In 2004 DFID also provided $5m to WHO to support its work on HIV and AIDS, including the commitment to increase the number of people receiving HIV treatment to 3million by 2005. • DFID has been a key donor to the Global Fund to fight AIDS, TB and Malaria, pledging a total of £259m from 2002 – 2007/08. The Global Fund has already approved grants totalling US$3 billion for direct support to programmes in 128 developing countries – approximately 50% of this will go towards commodity purchase. Almost $1.2bn has been disbursed.12 The Global Fund has developed policies to ensure that pharmaceuticals purchased with its funds are safe and of high quality. • The UK committed £35million to GAVI 2001 – 2005, with a further 3 year commitment of £30m in 2005. GAVI estimates that it has supported an additional 6m children to access basic vaccines and 48m to access newer under used vaccines. In Sept 05, the UK, France, Italy, Spain and Sweden launched the International Financing Facility for Immunisation (www.iffim.com) with commitments of $4bn to support GAVI’s work over the next 10 years. It is 10 See http://www.thenetwork.org.pk 11 See http://www.who.int/medicines 12 http://www.theglobalfund.org/en/ accessed 18 May 2005. 5 estimated that this funding will save the lives of 5m children and prevent a further 5m deaths of immunised children in their adult lives. • DFID has provided £48.5million to the Roll Back Malaria partnership since 1999, and £7million to the Stop TB partnership from 2002 to 2008 to support coordinate international responses to these diseases. • DFID supports public-private partnerships to develop a new generation of affordable drugs and other products needed if the health-related MDGs are to be reached and progress sustained beyond 2015. o Between 2001/02 and 2005/06 DFID is contributing £1million annually in support of the Medicines for Malaria Venture (MMV). o The UK was the first government to make a major commitment to HIV vaccine development, with a 5 year commitment of £14million in 1999 to the International AIDS Vaccine Initiative (IAVI) and a further £4million for 2005/06. o The UK is a major contributor to efforts to develop microbicides as a new HIV prevention technology that can be initiated by women. DFID has funded the Microbicides Development Project to a total of £39.8million to support the development and large scale Phase III trials of a promising microbicide candidate. DFID has also provided a grant of £2 million to the International Partnership for Microbicides. Case study – Ghana The Government of Ghana has made important strides in strengthening health systems and improving essential medicines access, supply and logistics. Recent national drug policy revision and intellectual property legislation have provided a sound basis for the protection of public health and the development of a supportive rights and trade environment. With support from DFID, a cross-government advisory group under the Ghana National Drugs Programme, with private sector and development partner participation, has embarked on further actions to enhance Ghana's programme to sustainably increase access to essential medicines. This includes actions to address the affordability, quality, reliable supply and rational use of drugs. The programme is working with policy makers, health workers, those selling drugs and consumers to improve standards, build capacity and increase access to medicines. Ghana is also introducing a social health insurance scheme to support more equitable and sustainable health financing. The scheme will cover a core set of essential medicines and develop an accreditation system for those prescribing and dispensing drugs. Further reading o The World Medicines Situation. WHO 2003 o WHO Medicines Strategy 2004 - 2007: Countries at the Core. WHO 2004 o Increasing access to essential medicines in the developing world: UK Government policy and plans. DFID June 2004 o Increasing people’s access to essential medicines in developing countries: a framework for good practice in the pharmaceutical industry. DFID March 2005 This guidance is part of the Policy Division Info series. Ref no: PD Info 074. © Crown copyright 2006. Any part of this publication may be freely reproduced providing the source is acknowledged. << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveEPSInfo true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile () /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /Unknown /Description << /ENU (Use these settings to create PDF documents with higher image resolution for high quality pre-press printing. The PDF documents can be opened with Acrobat and Reader 5.0 and later. These settings require font embedding.) /JPN <FEFF3053306e8a2d5b9a306f30019ad889e350cf5ea6753b50cf3092542b308030d730ea30d730ec30b9537052377528306e00200050004400460020658766f830924f5c62103059308b3068304d306b4f7f75283057307e305930023053306e8a2d5b9a30674f5c62103057305f00200050004400460020658766f8306f0020004100630072006f0062006100740020304a30883073002000520065006100640065007200200035002e003000204ee5964d30678868793a3067304d307e305930023053306e8a2d5b9a306b306f30d530a930f330c8306e57cb30818fbc307f304c5fc59808306730593002> /FRA <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> /DEU <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> /PTB <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> /DAN <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> /NLD <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> /ESP <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> /SUO <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> /ITA <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> /NOR <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> /SVE <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> >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice

View the publication

You are currently offline. Some pages or content may fail to load.