The Insightful Corner Hub: Why Essential Medicines Remain Unaffordable in Low‑ and Middle‑Income Countries

Introduction

Access to essential medicines is a cornerstone of universal health coverage (UHC) and a fundamental human right. Yet, despite decades of global health investment, essential medicines remain unaffordable and inaccessible for large segments of the world’s population, especially in low‑ and middle‑income countries (LMICs). This article explores the complexity of this challenge, evaluates recent data on pricing and availability, and identifies structural barriers and policy levers that could improve equitable access.

1. Defining Essential Medicines

Essential medicines are drugs that satisfy priority health care needs of the population; they include treatments for major communicable and non‑communicable diseases (NCDs) and are selected based on disease prevalence, evidence on efficacy and safety, and comparative cost‑effectiveness. 

The World Health Organization (WHO) Model List of Essential Medicines is globally accepted and periodically updated to reflect current clinical evidence and public health needs. 

2. Global Availability: A Persistent Challenge

Although essential medicines should be universally accessible, surveys reveal major gaps in real‑world availability:

• WHO facility surveys show that the percentage of health facilities with a core set of essential medicines in selected LMICs ranges from as low as 8% to 41%. 
• In private and public sector surveys across 36 countries, average availability was only 38% in the public sector and 64% in private pharmacies, both below WHO targets. 

The reasons extend beyond shortages: even when medicines are stocked, price can place them effectively out of reach for patients.

3. Price vs Affordability: The Central Paradox

3.1 Price Variations Across Countries

A large 2025 cross‑sectional analysis of 549 essential medicines across 72 markets revealed stark disparities in prices:

• After adjusting for purchasing power parity (PPP):
  • Essential medicine prices were 18.1% of German prices in Lebanon
  • Conversely, they were approximately 3.0 times higher than German prices in the United States
• These adjustments demonstrate that nominal prices do not accurately reflect affordability for consumers globally. 

3.2 The Minimum Wage Burden

Affordability is often measured by the number of days a lowest‑paid worker must work to afford a month’s supply of essential medicines. In many regions:

• Some medicines require multiple days’ wages for a single month of treatment post‑adjustment. 
• In low‑income settings, even widely used generics for chronic conditions (e.g., metformin, insulin) can be beyond affordable thresholds for many households. 

This disparity means that, although list prices might appear lower in LMICs, real affordability after accounting for income and purchasing power is worse than in wealthier countries. 

4. Out‑of‑Pocket Costs: A Major Barrier to Access

In many LMICs:

• Up to 90% of the population pays for medicines out of pocket, as social insurance coverage is limited or nonexistent. 
• Medicines can become the largest household expenditure item after food, particularly when chronic treatment is required. 

This spending pattern forces many families into catastrophic expenditure or treatment rationing, undermining health outcomes.

5. Structural Barriers Beyond Price

5.1 Supply Chain Markups

Even if manufacturers offer reasonably priced drugs, multiple actors add costs that inflate patient prices:

• Wholesaler, distributor, retailer mark‑ups
• Taxes and duties
  These cumulative charges can result in final patient prices that are many times higher than the base cost. 

5.2 Regulatory and Market Failures

• New essential medicines enter LMIC markets slowly due to weak registration systems, leaving patients without access to clinical innovations. 
• Supply chain weaknesses and procurement bottlenecks further restrict availability, especially for chronic disease treatments identified in cross‑national studies. 

6. Case Example: Chronic Conditions in LMICs

One study of chronic respiratory medicines across 60 LMICs shows that preventive treatments are variably available and largely unaffordable, while symptom‑relief drugs are more affordable but do not meet long‑term health needs. 

This evidence underscores the complex relationship between availability, cost, and meaningful access to life‑long care for chronic disease.

7. Policy Solutions: What Works

Achieving affordable access to essential medicines requires multifaceted reforms:

7.1 Price Regulation and Transparency

Governments can adopt systems for price regulation, reference pricing, and transparent negotiation with manufacturers to avoid excessive mark‑ups. 

7.2 Generics and Competitive Markets

Promoting generic competition, where safe and therapeutically equivalent products are used widely, can reduce prices without sacrificing quality.

7.3 Universal Health Coverage (UHC) and Insurance

Expanding health insurance to cover essential medicines reduces out‑of‑pocket expenditures and enhances affordability.

7.4 International Cooperation

Global health actors including WHO, World Bank, and national policymakers need to coordinate pricing data collection and equitable policies to ensure that affordability gaps shrink over time.

8. Conclusion: A Global Imperative

Despite decades of policy efforts, essential medicines remain unaffordable for large populations, particularly in low‑ and middle‑income countries. The combination of limited availability, adverse pricing structures, and high out‑of‑pocket expenditure undermines both health outcomes and economic stability for patients.

Addressing these barriers is not only a matter of market or policy reform it is a human rights imperative central to achieving universal health coverage.

Call to Action for Public Health Stakeholders

• Policymakers: Implement transparent pricing and strengthen procurement systems.
• Healthcare Advocates: Push for expanded insurance coverage for medicines.
• Researchers: Generate timely, comparable pricing and affordability data.
• Civil Society: Hold systems accountable for equitable access to essential medicines.