Access to Medicines: Common problems, common solutions?

Abstract

This thesis investigates four cross-cutting controversies in access to medicines – aspects of pharmaceutical R&D, equity, generics policy and scale up. Chapter 2 describes the state of pharmaceutical research and development (R&D). It finds that failure rates remain high with the probability of market entry for vaccines being just 1.8%. It is observed that whilst it may be difficult to predict the future productivity of pharmaceutical R&D from the past, it remains true that the escalating costs of R&D may make investments unaffordable for many diseases affecting low and middle income countries. Chapter 3 addresses the question of equity from the perspective of age and gender. An analysis of 3 diseases across 15 middle and low income countries finds that gender differences are age and condition specific. Such complexity also characterises the analysis of the use of antifungals in life limiting illness in a high income country. Associations between the use of such medicines and age, gender, deprivation and ethnicity were found but the directions of that association are not consistent. In contrast, the use of antipsychotics in the people with dementia, associated with a series of adverse events, is on the decline in England but an antipsychotic was nevertheless used to treat a person with dementia in more than one in eight episodes of hospital care. Chapter 4 describes the success and drivers of pro-generics policies in low and middle income countries. It reveals the extent to which branded generics dominate low and middle income markets, and the marked variations between regions. A deeper analysis of the drivers of prescribing in Brazil suggests that the extent of out of pocket payments to be made by the patient affected doctors’ prescribing choices, perhaps heralding in a new phase in generic policy development where patients are encouraged to raise concerns over price with their doctor. Chapter 5 concerns itself not with policy but with how it should be financed and implemented. It finds that the ring fenced Cancer Drug Fund in England may lead to greater inequalities between disease groups than was envisaged. It also echoes the calls from social marketing organisations and donors for a total market approach. In Cote d’Ivoire and Senegal subsidised product may be replacing unsubsidised product. This constrains further private sector investment and is seen as an inefficient use of donor funds. Chapter 6 highlights the methodological and policy implications. It observes that gender and age discrimination may be more complex than assumed. It notes the growing focus of donor organisations on utilising the skills and/or capacity of the private sector and the potential wider role of the patient. In particular it emphasises the importance of contextual information for both policy evaluation and implementation, suggesting that such information may fall into a category of pre-competitive research and, as such, may be more open to initiatives that take advantage of the “wisdom of crowds”. In this light it discusses the potential of such open platforms as Citizendium that give expert authors both a particular role and recognition.