The Covid-19 epidemic has brought back to the fore recurrent debates on the barriers to access to medicines, diagnostic tests and vaccines. MSF has been involved in these debates since 1996, leading the association to first launch the Campaign for Access to Essential Medicines (initially known as the CAME, now renamed the MSF Access Campaign) in 1999, and then to support the creation of the Drugs for Neglected Diseases initiative (DNDi) in 2003.

For some in the association, global systems, notably rules around intellectual property, are primarily responsible for the inequalities in access to medicines. Over the last decade MSF’s public communications on the subject, led by the Access Campaign, have largely reflected this analysis. However, others question the impact of this approach, and the potential of a predominant focus on campaigning for changes to global systems of patents and drug pricing to effectively address the problems faced by MSF teams and other practitioners in the places where MSF works.

It is in this context that the CRASH organised a two-day online workshop on 3rd and 4th February 2022, aimed principally at the directors and operational managers of MSF Operational Centre Paris, as well as members of the Access Campaign based in the Paris office, to help enlighten our colleagues on current debates, and to determine together which elements of the discussion would be the most relevant to resolve to support the advancement of MSF OCP’s operational projects. Is Access to Medicines the same issue today as it was when MSF first became interested in the mid-1990s? Rather than just concentrating on the obstacles to accessing medicines, should the debate be broadened to encompass what are now called ‘health products’ or even further, towards access to care and thus largely structural problems of human resources, financing, or the absence of national health insurance policies?

We aimed to address these questions via four roundtables that each examined an important issue we want to tackle together, selected from current and future struggles felt to be priorities in our practice and our operational portfolio: vaccines for tuberculosis, malaria and beyond; the approach to tuberculosis and antibiotic resistance; the management of cancer patients; and issues in nutrition, malaria and paediatric health in general. To begin each roundtable we invited a small panel of people with a particular viewpoint of the subject to first provide their perspectives on the landscape, experiences and possibilities upon which MSF could develop, before opening the discussion more widely to the operational managers and other participants via Zoom. Although for reasons of manageability of an online discussion we had to limit the number of participants able to interact directly via their camera and microphone chiefly to OCP’s operational managers, we extended an invitation to colleagues from the MSF OCP medical department, the Access Campaign, Epicentre, and other Operational Centres to observe the workshops via a live stream, and to engage in the debate via the Live Chat function.

During the workshop we suggested to start each round table by defining therapeutic indications: for what purpose do we want to prescribe, and for whom? We then attempted to discuss what prevents us from doing so, illustrated by obstacles encountered in particular situations. To help frame those reflections we established a non-exhaustive typology of possible obstacles, which was circulated to participants in advance of the workshops. Finally, we requested participants to propose or conceptualise some solutions that could be envisaged for these problems, notably via the actions of MSF. The discussions were held in French and English, with simultaneous translation.

Prior to the workshop we organised a series of video interviews to solicit the views of experts external to MSF on the evolution of the pharmaceutical landscape and the circumstances of the development of drugs and health products today. The resulting video, with subjects that range from pre-development to distribution, via patents and quality-related issues, was circulated in advance to all workshop participants. We extend our grateful thanks to those experts for taking the time to describe their work to us; their in-depth knowledge and clear presentations make comprehensible even complex subjects that were previously unfamiliar to many of us. We highly recommend watching the video, which is available on the CRASH website, before reading this cahier: https://msf-crash.org/en/conferences-debates/doing-drugs-video-briefing-access-medicines

We find the workshop discussions extremely rich, in their density and complexity, as well as in the range of experiences and perspectives of the participants. Twenty-five years after MSF first became interested in the subject, a healthy debate continues about how best to address barriers to accessing medicines, tests and vaccines via our medical humanitarian practice. We hope these discussions will inspire and encourage practitioners from MSF and beyond to reflect on their work and the work of the association.

Natalie Roberts

Michaël Neuman

Jean-Hervé Bradol

Different obstacles to accessing medicines encountered by medical humanitarian practitioners

This is an attempt to outline a non-exhaustive typology of the obstacles encountered by practitioners in accessing medicines and vaccines:

1/ Useful, even indispensable, products, whose production has been halted because the market is too small. In the 1990s drugs prescribed against Human African Trypanosomiasis (HAT) and antibiotics for epidemic forms of meningitis saw their production and distribution abandoned - by the pharmaceutical company in one case, and by the manufacturer in the other. A similar contemporary situation is related to raw materials: some pharmaceutical companies have stopped manufacturing drugs for which there are generic versions, because they are not profitable. This means that they may also no longer produce the raw materials used to manufacture those products (China and India produce 80% of the world’s active pharmaceutical ingredients), with the knock-on effect that they may also cease manufacturing other drugs that use the same raw materials, because they are in low demand or have low profit margins, but for which there are no generic versions.

2/ Useful, even indispensable, products whose prices are too high to prescribe them on the scale they are needed. This phenomenon is related to monopolies made possible by the globalization of intellectual property rules applied to the health product industry since the 2000s (an example of this is Sofosbuvir, and the way in which prices were set).

3/ Products that are necessary but non-existent because of a lack of necessary research into the treatment for diseases that affect the poorest people in particular. This category refers either to the absence of products for the treatment of neglected tropical diseases, or to the availability of products whose specifications (e.g. a cold chain of minus 80°) make their use difficult in the often precarious conditions of our work.

4/ Obstacles created by MSF’s partners (usually ministries of health) or by MSF itself. This was the case when MSF rejected prescribing treatment for patients with extra-pulmonary tuberculosis or refused to modify its treatment or care protocols for malaria in Burundi, for trypanosomiasis in Angola, and more recently in the response to Ebola epidemics. The weakness and venality of some ministries of health should not be ignored here.

5/ Problems - complex requirements, slow procedures, lack of competences, influence of pharmaceutical companies - with the regulatory institutions that issue authorizations for the use of products at national or international (e.g. WHO prequalification) levels.

6/ The plethora of generic products, the quality of which is difficult, if not impossible, to determine, and for which prices can remain relatively high.

7/ Access to medicines is not a substitute for access to care. Some within MSF believe that access to medicines is just one of many barriers – and perhaps today far less crucial than others - to access to care, and that the real focus of the organisation should be to prioritise its influence and resources to improve “access” in a broader sense.