Affordability, a combination of cost and availability of funds, is a key driver of access to medicines, and as such is included in all theoretical frameworks. Other drivers of access include use, drug quality and availability.
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 There are a number of ways of thinking about what drives access to medicine. Firstly, theoretical models seek to enumerate the drivers of access at a high level. While not based directly on evidence, to the extent that these models agree, we can be fairly confident that the factors raised have some relation to access. Secondly, empirical evidence shows the factors which bore a causal relation to levels of access in particular contexts. Such evidence tends to refer to specific interventions, which are often examples of factors raised in the theoretical literature. While empirical evidence is messy because of the difficulty in proving causation, it is also an essential testing ground for neater theoretical models.
Affordability is a key driver of access, and as such is included in all theoretical frameworks.2 Affordability is a combination of price, cost and availability of funds.3 In other words, it refers to the relationship between a medicine’s financial components and the medicine purchaser. These purchasers are usually either individuals or governments. Affordability is related to the funding mechanisms used to incentivise medical innovation, in that intellectual property rights cover the price of R&D via the sale of products. This means that drug prices are higher than the price of manufacture under this mechanism.
It is important to note that it is also possible that lower prices can decrease access in particular circumstances, or have other negative side effects. For example, low prices could lead to overuse and the development of resistance, as the case of artemisinin-based combination treatments (ACTs) for malaria illustrates.4 Lower prices for medicines reduce the incentives to register, market and promote drugs, as happened in the case of magnesium sulphate for the treatment of pre-eclampsia and eclampsia.5 This evidence suggests that there is an optimal price for a medicine which depends on the wider institutional and economic factors at play. Bearing such contextual variation in mind, affordability remains a key driver of ATM.
However, ATM is not a single-factor issue, and models have tended to focus on affordability at the expense of other key drivers.6 As Frost and Reich point out, ‘most instances of inadequate access are not single-failure problems… Rarely can access problems be solved simply by providing more money’.7 The findings of Chaudhuri, Goldberg and Jia support this idea, and in a study of quinolones in India found availability to be just as important as affordability.8 This is reflected in theoretical frameworks, which all include multiple drivers of access.
Frost and Reich 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’.9
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.10
Bigdeli et al. use a simpler model of equitable access, affordability, appropriate use.11 Wirtz et al. enumerate 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.12 This missing medicines factor indicates the relationship between access and innovation: where no drugs are developed, there can be no access. However, it is more common to treat access and innovation as separate but interlocking problems, than to enumerate innovation as one of the drivers of access.
To summarise the factors which have been considered as drivers of access:
Solutions to the access problem need to address at least these factors. The implementation of solutions would also require testing and empirical work to account for the context specific nature of access.
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.
Chaudhuri, Shubham, Pinelopi K. Goldberg, and Panle Jia. “Estimating the Effects of Global Patent Protection in Pharmaceuticals: A Case Study of Quinolones in India.” American Economic Review 96, no. 5 (2006): 1477–1514. doi:10.1257/aer.96.5.1477.
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:10.119…
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,…
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.
See 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.
“Delivering on the Global Partnership for Achieving the Millennium Development Goals.” United Nations, MDG Gap Task Force, 2008. http://www.who.int/pmnch/knowledge/topics/mdggapreport/en/.
