1. Increasing Access to Medicines – Taking a multifaceted approach ICIUM 2011 Saul Walker*, Clare Innes** *Senior Health Advisor, **Private Sector Advisor UK Department for International Development

2. Why address access to medicines?  High need  10m avoidable deaths  Health systems issue  Core component  Supports multiple MDG goals (4,5,6 and 8) and NCDs  Improve value for money  3/9 top inefficiencies (WHR 2010)  5% savings in total health spend

3. UK Comparative Advantage DFID Established Govt Working Established Analytical Framework Strong global & country presence Disease & system approaches Rising R&D budget Recognised leadership (e.g Financing) In-house expertise & ext. partners

4. Access challenges  Financing – insufficient and inequitable  Complex state/non-state mix  Weak infrastructure and HR  Weak regulatory environment  Very high information asymmetries  Weak management information systems  Strong external players  Portable, high value goods

5. Discover Develop & Test Approve & Register Scale-up & Manufacture Procure Prescribe & Dispense Distribute Demand & Use Low commercial incentives Limited product development expertise in public sector Limited R&D/trial capacity in developing countries Limited ID and Dev Country expertise in private sector Unclear pathways Limited harmonisation Very limited capacity at country level – approval, quality, pharmacovigilence Affordability/ lack of social financing Limited access Social barriers Poor information Low health literacy Poor adherence Weak logistics, infrastructure and information Poor coverage Leakage Mark-ups Inefficiencies Poor demand data IP challenges Limited capacity for some products Regulatory Low & variable financing Multiple channels Poor quantification Poor use of pricing info Non-transparent EMLs/STGs Limited HR Informal sector Limited regulation Unethical promotion Poor practice Value chain blockages

6. Cumulative losses in efficiency Community effectiveness of healthcare: A study of malaria treatment in adults and children in Burkino Faso Krause & Sauerborn, Ann Trop Paed 2000 Doesn’t include availability of ACTs at int’l level Doesn’t include correct dosing or adherence

7. Innovation Enabling Environment Health Systems Policy Research Discover Develop & Test Approve & Register Scale-up & Manufacture Procure Prescribe & Dispense Distribute Demand & Use Push Investment – e.g. PDPs Pull Mechanisms e.g. AMC Regulatory Paths and Capacity e.g AMRH TRIPS Flexibilities/Patent Pools/IP – Industry Good Practice - e.g. IGFAM Affordable Medicines Facility Malaria Medicines Transparency Alliance Bilateral Country Programmes Global Funds and Market dynamics/engagement - e.g CHAI, GF MDC Southern Africa Regional Programme on Access to Medicines UK value chain interventions

8. Example – Malaria Treatment Discover Develop & Test Approve & Register Scale-up & Manufacture Procure Prescribe & Dispense Distribute Demand & Use MMV - Coartem D ® + pipeline DNDi – ASAQ + ASMQ FDCs Affordable Medicine Facility for Malaria - £40m + funds for M&E CHAI - Subsidy Proof of Concept, research, ACT WHO Global Malaria Programme and RBM e.g. normative guidance (ACTs, RDTs), monitoring, mobilisation, best practice learning 16 bilateral programmes - Rx specific and sector GFATM – long-term funding, board & MDC 92m Coartem D* (15.3m AMFM) *Source: Regina Coghlan, MMV

9. Challenges Measuring results –Long and complex results chain –Measuring the impact of influence Plausibility of top to bottom interventions –Aligning policy, multilateral and bilateral programmes –Few clear lines of sight Spread too thin? Contribution and attribution Strengthen evidence base (AHPSR) International engagement Normative frameworks, multilateral practice (e.g. IHP), bilateral partners DFID strategies (malaria, RMNH) e.g malaria and RMNH Partnerships Cluster interventions (overlap?)

10. Final thoughts Value chain only effective if all links work –International, national, provincial and last-mile Value chain useful analytical tool but processes aren’t linear –Highly-reflexive system (linked to other systems) –Not self-correcting Multi-disciplinary approaches needed to put technical solutions in context –Political, organisational change, anthropological, economic, philosophical (values)

11. Acknowledgments Emma Back Danny Graymore Jane Haycock Dr Michael Borowitz Dr Charles Clift Clare Innes

12. Leading the UK government’s fight against world poverty Tel: +44 (0) 20 7023 0000 Fax: +44 (0) 20 7023 0016 Website: www.dfid.gov.uk E-mail: enquiry@dfid.gov.uk Public Enquiry Point: 0845 300 4100 If calling from abroad: +44 1355 84 3132 LONDON 1 Palace Street London SW1E 5HE EAST KILBRIDE Abercrombie House Eaglesham Road East Kilbride Glasgow G75 8EA