8.13 Proportion of population with access to affordable essential drugs on a sustainable basis

Modified on 2012/11/05 14:20 by MDG Wiki Handbook — Categorized as: Goal 8



Goal 8. Develop a global partnership for development Target 8.E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries


The proportion of population with access to affordable, essential drugs on a sustainable basis is the share of the population that has essential medicines continuously available and affordable at public or private health facilities or medicine outlets that are within one hour’s walk from the homes of the population.

This indicator is expressed as a percentage.

Given its complexity, an overall picture of the degree of access to essential medicines can only be generated using a range of indicators that provide data on medicine availability and price, in both public and private sectors, in combination with key policy indicators. WHO has developed a standard set of nine structural and process indicators that quantify access to essential drugs (see method of computation).

Access to medicines is defined as having essential medicines continuously available and affordable at public or private health facilities or medicine outlets that are within one hour’s walk from the homes of the population. Sustainable access depends on four key factors: first, patients must receive appropriate medicines in the correct dosages and within the required time frames; second, Governments and individuals must be able to afford the medicines essential to maintaining health; third, funds to pay for treatments must continue to be available when needed; and, fourth, health and supply systems that ensure medicines are available when required.

Affordable is generally measured using a benchmark that relates the cost of medicines to income, usually a comparison to a day’s wages. One day’s wages might be considered an affordable monthly cost for medicines that are required on a continuous basis for the remainder of a patient’s life. For income, a readily and widely available benchmark for the country’s poor is the earnings of the lowest-paid government worker, although many people in low- and middle-income countries earn less than the lowest-paid government worker. Possible alternative benchmarks are the national poverty line (see indicator 1.1a) or international poverty lines of $1.25 per day (extreme poverty) or $2 per day at purchasing power parity (see indicator 1.1),

Essential drugs (medicines) are those that satisfy the priority health care needs of the population. They are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford. Essential medicine lists are country-specific, drawn up in line with the WHO model with due regard to disease prevalence, efficacy, safety and comparative cost-effectiveness.

Method of computation
The indicator can be calculated only by using a range of indicators on price and availability and key health policies. The set of nine indicators developed by WHO is:
  1. Average availability of 30 selected essential medicines in public and private health facilities, reported as the percentage of medicine outlets where a medicine was found on the day of the survey.
  2. Median consumer price ratio of 30 selected essential medicines in public and private health facilities. Consumer price ratios are calculated as the ratio between median unit prices (e.g. price per tablet) and Management Sciences for Health (MSH) median international reference prices for the year preceding the survey. MSH international reference prices are used as a comparator as they are widely available, updated frequently, and relatively stable over time. They represent median prices of high quality multi-source medicines offered to developing and middle income countries by different suppliers. Data are unadjusted for differences in MSH reference price year used, exchange rate fluctuations, national inflation rates, variations in purchasing power parities, levels of development or other factors.
  3. Margin or mark-up (as a percentage) between producer and consumer price. Cumulative mark-up percentage is calculated by comparing the final medicine price to the manufacturer's selling price or the import cost, insurance and freight price.
  4. Existence and year of last update of a published national medicines policy. An official updated national medicines policy (NMP) is recorded as existing when the country has an official NMP document that has been updated within the last 5 years.
  5. Existence and year of last update of a published national list of essential medicines. An updated essential medicines list is recorded as existing when the country has a list of essential medicines that has been updated within the last 5 years.
  6. Legal provisions to allow/encourage generic substitution in the private sector expressed as a yes/no indicator.
  7. Public and private per capita expenditure on medicine, available from National Health Accounts
  8. Percentage of population covered by health insurance. This indicator is included in some surveys, but is not routinely collected
  9. Access to essential medicines/technologies as part of the fulfilment of the right to health, recognised in the constitution or national legislation. This indicatior is not routinely collected.


Millions of people die prematurely or suffer unnecessarily each year from diseases or conditions for which effective medicines or vaccines exist. Essential drugs save lives and improve health, but their potential can only be realised if they are accessible, rationally used and of assured quality.

Low and middle income countries spend a larger proportion of their health expenditure on pharmaceuticals than high income countries and the prices patients pay vary widely across countries and are often much higher than international reference prices. Thus it is important to examine the different elements of the access to and cost of essential medicines in order to improve coverage and affordability.

Moreover, non-communicable diseases are the leading cause of death in low and middle income countries. Improving access to essential medicines for these diseases will help to achieve the MDGs. Access to medicines is also an essential component of MDGs 4, 5, and 6.


Indicators 1, 2, 3: Data on medicine availability and prices are obtained from national surveys of medicine price and availability conducted using a standard methodology developed by WHO and Health Action International. In these surveys, data on the availability and price of a specific list of medicines are collected in at least four geographic or administrative areas in a sample of medicine dispensing points. In addition, data on the add-on costs that contribute to the final price of medicines are collected by tracking selected tracer medicines through the supply and distribution chain.

Indicators 4, 5, 6: Data on national medicines policies, essential medicines lists and generic substitution are obtained from answers provided to the WHO Questionnaire on structures and processes of country pharmaceutical situations, which is sent out every four years.. It is a basic assessment tool that provides a rapid means of obtaining information on the existing infrastructure and key processes of each component of the pharmaceutical sector. Governments provide measures of their structures and processes through country questionnaires that are sent to WHO representatives in each member state. A coordinator, who is often an official from the Ministry of Health, is identified to supervise the completion of the questionnaire in each country. The coordinator identifies responsible people, government agencies or groups who can provide responses to the different pharmaceutical sections/areas in the questionnaire.

Indicator 7: Most countries compile regular National Health Accounts, which constitute a systematic, comprehensive, and consistent monitoring of resource flows in a country’s health system for a given period. They are designed to capture the full range of information contained in these resource flows and to reflect the main functions of health care financing: resource mobilization and allocation, pooling and insurance, purchasing of care, and the distribution of benefits.

Indicators 8 and 9: Data on insurance coverage was collected in the World Health Survey conducted in 2004 (www.who.int/healthinfo/survey), but is not routinely collected. Similarly, a review of national constitutions for recognition of access to essential medicines/technologies as part of the fulfilment of the right to health was conducted in 2008, but is not routinely collected.


The indicators on availability and price can be disaggregated in a number of ways. Two major ones are the split between public and private health facilities, and the split between originator brand and generic medicines. Depending on the survey size, it might be possible to report urban and rural areas separately.


The main limitation of this indicator is the difficulty of arriving at a single measure in order to track progress in a comparable way across countries and time. The measure of availability is limited to the health facility included and the day of the survey and so may not provide an accurate measure of the sustainable availability of medicines in that clinic, region or for the whole country. Affordability relies on a benchmark which may not adequately reflect the poorest people. Moreover, regardless of the benchmark used, medicine affordability does not take other treatment costs, such as diagnosis, into account and so underestimates the true cost of health care.

The indicators do not measure the role of the pharmaceutical companies as called for by the target. This is not something that can be measured at country level. At the global level there are a number of initiatives, such as UNITAID founded in 2006, to work with pharmaceutical companies to increase access to affordable medicines. Other initiatives are to form patent pools and advanced market commitments to accelerate the development and supply of affordable medicines.


In many settings, households headed by women tend to have lower incomes thus making it more difficult for them to afford essential medicines for themselves and their families. The low social status of women in some countries limits their access to economic resources and basic education and thus their ability to make decisions related to their health. In some countries cultural rather than economic reasons can reduce the access of women and girls to essential treatments.


The World Health Organisation and Health Action International collect data for global and regional monitoring. Additional data to measure country pharmaceutical situations are collected by WHO in association with Harvard Medical School and Harvard Pilgrim Health.

As of the end 2009, data are still being provided to the MDG database. When they are, the methods for aggregating by region and globally will be described in the online metadata.




HEALTH ACTION INTERNATIONAL (Website). Global. Medicine Prices. Amsterdam. Available from www.haiweb.org/medicineprices.

THE LANCET (2009, 373: 240-49) Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis (by Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R.), London. Available from www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61762-6/abstract.

UNITED NATIONS (2009) MDG Gap Task Force Report: Strengthening the Global Partnership for Development in a Time of Crisis. New York. Available from www.un.org/millenniumgoals/pdf/MDG_Gap_%20Task_Force_%20Report_2009.pdf.

UNITED NATIONS (2008) MDG Gap Task Force Report: Delivering on the Global Partnership for Achieving the Millennium Development Goals. New York. Available from www.un.org/esa/policy/mdggap/.

WORLD HEALTH ORGANIZATION, HEALTH ACTION INTERNATIONAL (2008). Measuring medicine prices, availability, affordability and price components, 2nd edition. Geneva. Available from www.haiweb.org/medicineprices/manual/documents.html.

WORLD HEALTH ORGANIZATION, HARVARD MEDICAL SCHOOL AND HARVARD PILGRIM HEALTH (2006) Using Indicators to Measure Country Pharmaceutical Situations: Fact Book on WHO Level I and Level II Monitoring Indicators. Geneva. Available from http://apps.who.int/medicinedocs/index/assoc/s14101e/s14101e.pdf.

WORLD HEALTH ORGANIZATION (2007). WHO operational package for monitoring and assessing country pharmaceutical situations: Guide for coordinators and data collectors. Geneva. Available from www.who.int/medicines/publications/WHO_TCM_2007.2.pdf.

WORLD HEALTH ORGANIZATION (2009). WHO Model List of Essential Medicines 16th List, Unedited version. Geneva. Available from www.who.int/selection_medicines/committees/expert/17/WEB_unedited_16th_LIST.pdf.

WORLD HEALTH ORGANIZATION (Website). National Health Accounts. Geneva. Available from http://www.who.int/nha/en/.