Bill Gates is correct when he says pharmaceutical companies need to get the credit when they do more for neglected diseases.
The 2018 Access to Medicines Index recently released by the Access to Medicines Foundation provides an opportunity to see where the pharmaceutical industry is working to improve access to medicines for the poor people of the world.
The report, conducted every two years, measures how the top 20 global pharmaceutical companies are improving access to medicines in seven areas: management, compliance, R&D, pricing, patents, capacity and donations.
A decade after the release of the first report in 2008, the Index is now increasingly acknowledged by pharmaceutical companies as one tool to measure how they are improving access to medicines in low- and middle-income countries.
It is also increasingly recognised by investment analysts and fund managersas an indicator of the extent to which companies are taking a long-term view of potential business threats and opportunities.
A key question many are asking in global health today is how companies can frame access to medicines in lower income countries as a business proposition.
The Index helps companies, the industry, investors and the broader community better understand and navigate these issues.
The 2018 report
So, it was against this backdrop that this year’s reportcame out with some interesting findings.
The media, predictably, had negative headlines like “Big pharma 'failing to develop urgent drugs for poorest countries'” or “Big pharma leaves big gaps: drugmakers urged to do more for poor”.
Nothing sells newspapers or drives clicks on a website like bad news.
But as the Access to Medicines Foundation’s executive director, Jayasree Iyer, said: “There have been massive improvements in global health in the past decades, with all major pharmaceutical companies taking action. To close the gaps that remain, a greater diversity of companies must get involved and stay engaged for the long haul”.
And she’s right.
The real story is actually more encouraging.
Despite some of the headlines, there are several positive insights from the 2018 report.
The pharmaceutical industry continuesto do more to improve access to medicine, with good practice models in areas such as access planning and licensing.
In this year’s Index, GSK retained top spot, followed by Novartis.
The big movers were Takeda, which moved up 10 places to take 5th place, and Roche, which moved up 9 places to 10th.
Takeda’s performance to reach 5th place this year is particularly striking, given that four years ago in 2014it was ranked lastout of the 20 companies.
The finding that got a lot of media headlines is that almost two-thirds (63%) of the medicine R&D in priority areasfor populations in low- and middle-income countries is being done by just five companies. In addition, 91 of the 139 priority product gaps are not being addressed.
The media criticised the industry for this, but there probably needs to be a sensible conversation informed by business nous about how the industry might be encouraged to do more in this space and protect what work is already being done.
The report found that most of the access initiatives for cancerin low- and middle-income countries tend to focus mostly on pricing and donations. This is not surprising given many of the innovative treatments for cancer are newer, patented medicines that tend to be relatively more expensive and price is something companies can influence.
Importantly, of the 53 patented medicines definedin the Index as critical medicines, 37 of them (70% or almost three-quarters) were covered by company access initiatives, mostly in pricing initiatives which facilitate affordability for low-income populations.
This finding didn’t get much media coverage but should have.
It’s a finding corroborated by a previous studyof the WHO’s Essential Medicines List supported by the World Intellectual Property Organisation, which showed that most patented medicines on the EML have access strategies put in place by companies.
While there may be more that can be done here, this trend suggests that companies are playing a greater role in making new, high cost essential medicines accessible to poor populations.
When it comes to medicine pricing, as well as setting different prices for different countries, companies are also doing more targetingof different prices for different population segments withina country. This targeting is based on factors like differences in income level, disease burden and effectiveness of health systems within a country.
This is an innovation in company business models that should be welcomed and encouraged.
Despite some concerns heard from companies about its methodology, after 10 years of development the Index is becoming embedded in the health policy landscape and the business landscape for the industry.
For example, this year the Foundation organised briefingsfor investment analysts in London, New York and Tokyo and hosted by the likes of Goldman Sachs and UBS. These briefings provide pharmaceutical companies the opportunity to discuss how they are responding to the issues in the Index with investment analysts.
Gaps in the Index
This is not to say that there aren't problems with the Index.
For a start, the methodology of putting together the Index is a Herculean task wrapped in a Gordian knot to say the least.
The methodology and inputs have evolved over the years which could explain some of the variation in company rankings in that time. In any event, such an exercise can sometimes trigger earnest discussions about what is ‘in’ and ‘out’ of the Index.
More fundamentally, a problem with the Index is that it puts the focus squarely on what innovative pharmaceutical companies are doing at a time when the global strategy on access to medicines is shifting more towards collaboration between different stakeholders.
For example, generics companies have not been included in the Index since 2010.
This just seems wrong considering the growth of the international generics industry, the role of generics in global health and the strong promotion of generics by governments, health experts and activists today.
Nor are governments benchmarked for their action and behaviour in improving access to medicines to anything like the degree pharmaceutical companies are scrutinised.
Government investment in their countries’ health systems and infrastructure is critical to ensure people get access to medicines.
As the industry often argues, we know that access to medicine problems in countries often stem from a lack of investment and leadership from governments, but the focus on what companies are doing can distract attention from the role of governments.
Benchmarking the public sector in a similar way to the private sector might be something worth considering.
The road forward
When it comes to engendering change in the private sector, the best public policy programmes tend to be those that have a judicious blend of
- new ‘stretch’ goals, standards or regulations;
- a clear narrative and business case of why things need to change;
- the freedom for companies to use their competitive and innovative strengths to reach these goals; and
- clear commercial incentives and rewards for companies when these goals are achieved.
Sadly, not enough people in the global health community get this.
While not without its shortcomings, the Access to Medicines Index does try to take an evidence-based approach to achieving global public health goals in partnership with the corporate sector.
And that’s something that everyone should be working towards.
Brendan Shaw is Principal at Shawview Consulting