The World Health Organization estimates that at least one-third of the world’s population does not have access to essential medicines, resulting in millions of avoidable deaths each year from infectious diseases including malaria, tuberculosis, and HIV. Barriers to access to these medicines disproportionately affect people in low- and middle-income countries (LMICs) due to unaffordable drug prices, drug shortages, and poor distribution and manufacturing infrastructure. If the world is going to achieve global equity in drug access, and therefore decrease inequities in disease, these countries must be able to not only afford the drugs but deliver them to those who need them the most.

Affording the Drugs

Frequent shortages in drug supply highlight the need for better access to life saving medicines in lower income countries. In the global pharmaceutical market, many low and middle income countries have very little bargaining power with patents and are unable to set their prices for drugs. As a result, many low and middle income countries rely heavily on imported pharmaceuticals. This dependency makes them vulnerable to events including natural disasters and trade restrictions, which can disrupt the global distribution of generic drugs. In the case that there are shortages in generic drugs, this reliance also forces these countries to choose between buying the more expensive non-generics, or not having any drugs at all.

Fortunately, there are ways to decrease that dependence. Drugs that are made within a country’s own borders and with their own materials can play a crucial role in making them more affordable. Most countries start the drug making process with active pharmaceutical ingredients (APIs), or the chemicals that allow the drug to work. In the United States, only 24% of drugs are made with imported APIs while over 50% of drugs produced in the United States use APIs also produced in the United States. Likewise, many lower-income countries including many in sub-Saharan Africa must import over 80% of their drugs and APIs which increases the costs. Organizations like the newly created African Continental Free Trade Area (AfCFTA), however, are working to boost drug manufacturing across the continent. This new initiative works to not only boost the production of APIs and increase the number of manufacturing plants but also improve trading between those countries, decreasing dependence on high-income countries across the entire continent.

Just increasing production within lower and middle income countries, however, is not enough to achieve global drug equity. Many lower income countries are also being drained of their own manufacturing resources to support the drug manufacturing of higher-income countries. While higher-income countries may import APIs from lower-income countries, they also outsource drug manufacturing to those same countries to save on labor and manufacturing costs. Unfortunately, many of the countries that do the work of making drugs for higher-income countries rarely have access to or can afford the finished product.

Distributing the Drugs

Once countries can make drugs more affordable, they must establish a way to distribute them to their citizens. This requires a partnership between governments and policymakers to create a country wide effort to identify those who need the medicine, oversee its distribution; and quickly address issues that may arise. This effort also requires collaboration with local healthcare personnel and public health volunteers who would be doing the distribution groundwork.

Through such an effort, Egypt has been able to eradicate hepatitis C. By lowering the costs of drugs through price negotiating and setting up a well defined and collaborative system of over 60,000 personnel, Egypt was able to cure 1.23 million people in just seven months.

The importance of infrastructure can also be seen when looking at inequitable vaccine distribution during the early COVID-19 pandemic. A majority of low and middle income countries were unable to achieve at least 10% population coverage during initial vaccine rollouts and distribution took as much as 100 days longer than in high-income countries. While a great deal of this shortage was due to the high costs of importing enough vaccines for whole populations, poor infrastructure for the storage, transportation, and distribution of the vaccines led to delays in getting them to remote and rural areas. To address this, global health institutions including the World Health Organization and The World Bank must dedicate funds to help these countries develop the necessary structures.

Although many countries are making important strides in increasing the availability of drugs for their citizens, inequities persist. These inequities arise from high drug costs and a lack of proper infrastructure. Some key strategies for overcoming those barriers are allowing countries to manufacture their drugs within their own borders and increasing funding for these countries to build up public health systems. Finally, higher-income counties must compensate lower and middle-income countries for the role they play in drug development.