Access to medicines from a health system perspective

Abstract

Most health system strengthening interventions ignore interconnections between systems components. In particular, complex relationships between medicines and health financing, human resources, health information and service delivery are not given sufficient consideration. As a consequence, populations' access to medicines (ATM) is addressed mainly through fragmented, often vertical approaches usually focusing on supply, unrelated to the wider issue of access to health services and interventions. The objective of this article is to embed ATM in a health system perspective. For this purpose, we perform a structured literature review: we examine existing ATM frameworks, review determinants of ATM and define at which level of the health system they are likely to occur; we analyse to which extent existing ATM frameworks take into account access constraints at different levels of the health system. Our findings suggest that ATM barriers are complex and interconnected as they occur at multiple levels of the health system. Existing ATM frameworks only partially address the full range of ATM barriers. We propose three essential paradigm shifts that take into account complex and dynamic relationships between medicines and other components of the health system. A holistic view of demand-side constraints in tandem with consideration of multiple and dynamic relationships between medicines and other health system resources should be applied; it should be recognized that determinants of ATM are rooted in national, regional and international contexts. These are schematized in a new framework proposing a health system perspective on ATM.

Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration

“…Because medicines are part of the six building blocks of health systems, 30 scaling up of access to medicines cannot be achieved in isolation, 31 but needs a comprehensive health system approach including, for example, pharmaceutical sector governance, appro priate pharmaceutical workforce training, pharmaceutical manage ment information systems, procurement planning, and sustainable fi nancing of medicines. 32 Increase effi ciency in selection, procurement, supply, and use to promote access to medicines within the existing health budget…”

Improving access to medicines via the Health Impact Fund in India: a stakeholder analysis

“…Although the majority were in favour rather than against, it is clear that policies which improve access to medicines, whether to gain support of government or the pharmaceutical sector, will require consideration of more than drug affordability. Any policy aiming to tackle access to medicines should be multi-sectoral and involve consultation of multiple, different stakeholders, in order to maximize support and likelihood of success, as well as using available information regarding affordability, availability and other components of access [4]. Reassuringly, several stakeholders felt that the HIF may not be radical enough, suggesting again that policy reform has to be cross-sectoral and cannot be a ‘stand-alone’ measure.…”

“…Before the HIF can be implemented, policy details such as the exact nature of health impact assessment and reward mechanisms need to be finalized. Moreover, research and modelling of the pharmaceutical market (branded versus generic, pre- and post-trial drugs, common versus rare diseases, well-funded versus poorly funded diseases) are essential to maximize feasibility and ensure credibility [4]. …”

“…We used directed content analysis [37] with principal themes of the HIF and access to medicines. In particular, with respect to access, we considered availability (the supply and demand), affordability (the drug price and patients’ ability to pay), accessibility (physical access) and adaptability (the relationship between patients perceptions and what is being offered) as per previous studies of access to medicines [4]. Initially, text relevant to each theme was highlighted.…”

“…Since the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement was signed by India in 1994 and fully ratified by 2005, the adoption of product-patent law (where intellectual property rests with the product rather than the process of its production) was required and this reverse engineering/generic production model was discarded. The assumption was that the product-patent model would incentivise greater innovation in the pharmaceutical industry and bring about novel medicines at a competitive price [4,13–15]. However, research suggests the contrary [13], and TRIPS may instead reduce access to medicines [16], widening global health inequalities [17,18].…”