Why is the Access to Medicines movement underfunded?

Although I have no way of scientifically confirming, I get the sense from recent conversations that many civil society organisations working on ‘access to medicines’ are running low on funding or funding opportunities.

How strange. We are at a ‘seminal’ moment in access to medicines — the COVID-19 pandemic has brought access to the front pages of every newspaper and news program — and access has become very mainstream (any mention of this topic pre-pandemic would instantly put people to sleep or lead them to run away).

My diagnosis of the funding landscape could be too pessimistic. But if it’s right, it is worth thinking about why there is scarcity at a time that foundations and philanthropies should be investing heavily in the movement.

Here are several reasons I would put forward:

1. We have the wrong foundations ‘investing’ in access to medicines. Whereas in previous years there was generous support from the likes of the Ford Foundation and Rockefeller Foundation (alongside the historic and on-going support of the Open Society Foundation), today the space is mostly dominated by the Gates Foundation and the Wellcome Trust — both of whom have made this issue a priority. This should be a boon — these are two of the world’s largest and well-resourced philanthropies.

Unfortunately, neither of them is really a good fit. Both are more focused on investing in global health agencies, forming partnerships with governments, or investing in companies or research and clinical development. Or, as the New York Times noted about Bill Gates and his foundation, to essentially manage (or control) international health.

Both are also very conservative — you could never imagine either foundation supporting any of the activism that underpins the access to medicines movement. The Gates Foundation does support advocacy, but of the milquetoast type — organisations like ONE, the Centre for Global Development, and the Pandemic Action Network — more focused on cheerleading and win-win solutions than the hard-nosed advocacy that has underpinned most of the progress of the last few decades.

And while it probably merits a separate blog, one could argue that the policies and investments of these two foundations are actively undermining the efforts of organisations who work on access to medicines, something I wrote about with two colleagues as it relates to the Gates Foundation. The Wellcome Trust is not much better, it has an underwhelming access policy and actual or potential conflicts of interest tied to its own investments.

2. Efforts to promote innovation and access to medicines are dominated by ideas that are too technical, too friendly, and therefore too simplistic. The more that access to medicines is equated with ‘complex’ market shaping, innovation partnerships, advanced market commitments, voluntary licensing (though some would disagree on this point), pricing structures, and incentive mechanisms — the more simplistic, counterproductive, and misdirected ‘access to medicines’ becomes. Innovation and access to medicines has always been about power and politics — who has it, who seeks it, and how it is wielded for good (or bad) outcomes. It is messy, chaotic, at times confrontational, and has nothing to do with the endless PowerPoint decks, White Papers, and yes, management consultants, littering the access landscape.

One just needs to look at pharmaceutical companies. They may participate in all the pleasantries of partnerships and intellectual convenings, but they continue to pour millions of dollars into lobbying and influencing and are not afraid to bare their fangs at the first sign of any government stepping out of line. Nevertheless, everyone in global health pretends like this is perfectly fine, and instead look to form partnerships with drug corporations instead of challenging them, while shutting out civil society or just kind of ignoring their efforts.

The point is, the conventional wisdom has shifted so much to these technical interventions that activism now looks unfashionable and irrelevant, consigning those engaged in the political fights to a dark corner of the access universe. This makes it less compelling to foundations and philanthropies which support activism and rights-based approaches. Perhaps they wrongly believe that technical interventions are enough (and therefore the technical investments of Gates and Wellcome are enough), and decide their time and energy is better spent elsewhere.

3. The access to medicines ‘community’ has not evolved with the times. The problem for the access to medicines movement is it tends to be a bit too much of a one-trick pony, focusing on strategies to bring down medicine prices and foster generic competition, or I guess a two-trick pony if you include efforts to encourage development of medicines on behalf of neglected populations and/or ensuring affordability.

The movement’s focus makes sense of course — this is what matters most and what is the core of the industry’s business. Yet organisations working on access to medicines perhaps could have broadened how they work on access — one criticism is that it was too focused on drugs and did not make space for access issues related to diagnostics and vaccines. Diagnostics and vaccines have become central to the COVID-19 response much more than drugs.

Another problem is the disease focus was too narrow — the access movement has not really made the case for heavier investment in other areas of need such as non-communicable diseases, antimicrobial resistance, or rare diseases (or have not broadened their efforts sufficiently to these areas of need). A third problem is that even as the technologies have evolved, our strategies and interventions have not. I still do not think most organisations have credible approaches to deal with access challenges for biologics, much less the onrush of new technologies — e.g., mRNA.

More generally, over the last two decades — pandemic notwithstanding — global health has moved from the centre of development to the periphery — and other critical issues — whether climate change, racial justice, economic inequality, financialization, digital rights etc. have moved to the fore. That is a good thing of course, it was never sustainable to have such a singular focus on health. Yet this should have been a signal for the access to medicines community to reframe its efforts more broadly — whether to look at the carbon footprint and environmental damage of the industry (or to examine how countries will need to adapt to climate change through new investments in R&D for neglected tropical diseases), the intersection of racial justice with access to medicines — which I applaud my colleague Priti Krishtel — for tackling, or the growing (and very disturbing) intersection of the tech and pharmaceutical sectors and the expanding use of artificial intelligence and Big Data by drug companies.

Then again, the drug industry remains singularly focused on issues of intellectual property and pricing — it is where the rubber hits the road (and how they make their money) — and for the access movement to move into other frames — while perhaps necessary to sustain itself — may leave the drug industry, basking in the false glory of its pandemic response — even more powerful and more capable of securing new monopolies and ever-higher drug prices.

Rohit Malpani is a public health consultant and advocate, based in Paris, France.