Access To Medicines (ATM) ‘is defined as having medicines continuously available and affordable at public or private health facilities or medicine outlets that are within one hour’s walk from the homes of the population’.1 A pared down way of defining access if the proportion of the potential beneficiaries of a given treatment who indeed receive the treatment.
The history of access is closely related to the development of the concept of essential medicines. The latter originated in military medicine, particularly during the second world war. Countries first began to adopt their own Essential Medicines Lists (EMLs) in the 1970s, especially LMIC countries like Bangladesh and Sri Lanka.2 In 1977, the WHO issued its first official EML. By the 1980s and 1990s, many different actors were considering the access problems relating to EMLs, rather than simply the creation of such lists.3 Then in the 1990s, the global AIDS epidemic and the related access problems ‘expanded the question of access from one that focused primarily on the availability and affordability of essential drugs to one that confronted broad and comprehensive trade and development concerns’.4 Access was enshrined as Millennium Development Goal 8: ‘ In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries.’5 In 2015, access was also incorporated into Sustainable Development Goal 3: ‘Ensure healthy lives and promote well-being for all at all ages.’ Two of the targets for this goal are:
Access is now a widely used term in global health circles and a current political problem.
Another important context for understanding the term access is that of universal access. This is used synonymously with Universal Health Coverage (UHC),7 and refers to equal access to all forms of healthcare for all peoples. The WHO constitution states that health is ‘one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.’ In 2005, WHO member states adopted UHC as a central goal.8 UHC or universal access is thus a broader concept than access itself, which usually refers specifically to medicines. Access can be seen as a component of UHC, which also includes things like medical training and number of hospitals and doctors.
It is important to recognise that there are varying degrees of access: ‘We think of access not as a single event but as a process involving many activities and actors over time. Access is not a yes-or-no dichotomous condition, but rather a continuous condition of different degrees’.9 Moreover, there is a strong normative element to the definition of access, which hinges upon what medicines are regarded necessary and what level of availability is regarded appropriate. Different normative systems for assessing access include a cost-effectiveness based utilitarian position, a market-based position, an egalitarian position under which those who are worst off are prioritised, and a rule-of-rescue principle under which the sickest are helped first.10
The presence or absence of medicines is determined by a range of factors, and various different schema have been proposed to anatomise access. Peters et al put medicine quality at the heart of their framework, with geographic accessibility, availability, financial accessibility, and acceptability of services as the additional elements of access.11 Frost and Reich state that ‘Our framework is based on four A’s: architecture, the organizational structure and relationships for access; availability, which emphasizes the supply components of access; affordability, the cost issues for various players; and adoption, which includes demand factors and acceptance’.12 Bigdeli et al use a simpler model of equitable access, affordability, appropriate use.13 Wirtz et al enumerated five core challenges to essential medicines policies, including access: financing, affordability, quality, use and ‘missing medicines’, or medicines which are not developed because there is not a sufficient profit incentive to do so.14 It is important to note, as the authors of these models do, that access includes use.15 That is to say that even once a medicine has reached a patient through availability and affordability, without appropriate medical guidance and sufficient social acceptability, the medicine remains worthless. Access is then a complete process including manufacture, sale, distribution, dispensation and use.
There is no universally used definition of affordability. It is common to compare the cost of a medicine with the available resources of a household.16 The WHO/HAI methodology uses the salary of the lowest-paid government worker can be used to estimate how many days’ wages a medicine costs.17 Several authors have used 40% of household income after food expenditure over the course of four weeks as a cut-off for high/catastrophic spending.18
It is important to note both that affordability of medicines is only one component of access, and that monopoly patents are only one component of affordability. In recent times discussion of access has tended to focus on affordability in relation to patents, to the exclusion of other aspects of the access system. Frost and Reich argue that ‘the focus on certain types of access barriers (especially pricing and patents) has tended to obscure other important barriers to access, such as distribution, delivery, and adoption problems.’19 Bigdeli et al also claim that a focus on ‘vertical disease-focused programmes’ targeting problems of affordability has diverted attention from the appropriate use of medicines, and the role of medicines in overall health system strengthening efforts’.20 Access is a part of universal health coverage; affordability is a part of access, and monopoly patents are a contributing factor to affordability.
Measurement of ATM was undertaken in a fairly ad hoc way until the launching of the WHO/Health Action International (HAI) methodology in 2003.21 This methodology uses two core indicators to estimate ATM:
“Access to Medicine Index 2016.” Access to Medicine Foundation, 2016.
Bigdeli, Maryam, Bart Jacobs, Goran Tomson, Richard Laing, Abdul Ghaffar, Bruno Dujardin, and Wim Van Damme. “Access to Medicines from a Health System Perspective.” Health Policy and Planning 28, no. 7 (2012): 692–704.
Bigdeli, Maryam, David H. Peters, Anita K. Wagner, World Health Organization, and others. “Medicines in Health Systems: Advancing Access, Affordability and Appropriate Use,” 2014. http://apps.who.int/iris/bitstream/10665/179197/1/9789241507622_eng.pdf.
Cameron, Alexandra, Margaret Ewen, Dennis Ross-Degnan, Douglas Ball, and Richard Laing. “Medicine Prices, Availability, and Affordability in 36 Developing and Middle-Income Countries: A Secondary Analysis.” The Lancet 373, no. 9659 (2009): 240–249.
“Delivering on the Global Partnership for Achieving the Millennium Development Goals.” United Nations, MDG Gap Task Force, 2008. http://www.who.int/medicines/mdg/MDG08ChapterEMedsEn.pdf.
Frost, Laura J., Michael R. Reich, and others. Access: How Do Good Health Technologies Get to Poor People in Poor Countries? Harvard Center for Population and Development Studies, 2008. https://www.cabdirect.org/cabdirect/abstract/20103004633.
“Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies.” World Health Organisation, 2010. http://www.who.int/healthinfo/systems/monitoring/en/.
Organization, World Health, and others. “Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage,” 2014. http://apps.who.int/iris/bitstream/10665/112671/1/9789241507158_eng.pdf.
Wagner, Anita K., Amy Johnson Graves, Sheila K. Reiss, Robert LeCates, Fang Zhang, and Dennis Ross-Degnan. “Access to Care and Medicines, Burden of Health Care Expenditures, and Risk Protection: Results from the World Health Survey.” Health Policy 100, no. 2 (2011): 151–158.
Xu, Ke, David B. Evans, Guido Carrin, Ana Mylena Aguilar-Rivera, Philip Musgrove, and Timothy Evans. “Protecting Households from Catastrophic Health Spending.” Health Affairs (Project Hope) 26, no. 4 (2007): 972–83. doi:10.1377/hlthaff.26.4.972.
Peters, David H., Anu Garg, Gerry Bloom, Damian G. Walker, William R. Brieger, and M. Hafizur Rahman. “Poverty and Access to Health Care in Developing Countries.” Annals of the New York Academy of Sciences 1136, no. 1 (June 1, 2008): 161–71. doi:10.1196/annals.1425.011.
Quick, Jonathan D., Hans V. Hogerzeil, Germán Velasquez, and Lembit Rago. “Twenty-Five Years of Essential Medicines.” Bulletin of the World Health Organization 80, no. 11 (2002): 913–14.
Wirtz, Veronika J., Hans V. Hogerzeil, Andrew L. Gray, Maryam Bigdeli, Cornelis P. de Joncheere, Margaret A. Ewen, Martha Gyansa-Lutterodt, et al. “Essential Medicines for Universal Health Coverage.” The Lancet 389, no. 10067 (2017): 403–76. doi:10.1016/S0140-6736(16)31599-9.