An access-to-medicine strategy is a business strategy specifically intended to improve access to medicine in low- and middle-income countries. Such strategies should cover all portfolio products and therapeutic areas, including new innovative medicines, and they must be aligned with the companies’ overall corporate strategy.

17 out of 20 companies have a clear access-to-medicine strategy. AbbVie, Astellas and Daiichi Sankyo share general commitments to improve access to medicine, but have no concrete strategy applied across their business model. 11 of those 17 companies apply access strategies to all therapeutic areas and have integrated them into their overall business strategy.

Prioritising access to medicine at the top level and incentivising action
To ensure progress towards access to medicine, the strategy needs to be a priority at the highest level. Top-level accountability is likely to filter into the rest of the company – incentivising a culture whereby access is a priority for senior-level staff and the rest of the organisation — and can help enable teams within the company to deliver on access-to-medicine initiatives. Over half the companies in scope assign responsibility directly with the board, helping to ensure top-level accountability for access, with a long-term horizon.

Financial and non-financial (e.g. awards) incentives at a managerial level, from the CEO to the country-level managers, can help achieve access-related objectives. If a CEO has key performance indicators (KPIs) specifically linked to access-to-medicine objectives, access is more likely to be an important goal of the whole organisation. Over half of the companies have access-related incentives at the top level: Astellas, AstraZeneca, Bayer, Daiichi Sankyo, Eisai, Eli Lilly, Gilead, GSK, Novo Nordisk, Novartis, Pfizer, Sanofi, Takeda.

Novartis’ CEO has management targets for access to medicine tied to its annual performance plan. The CEO’s access to healthcare objective are published in its annual report. The CEOs of some companies such as GSK, Novartis, Pfizer with incentives linked to its Purpose Blueprint strategy and Takeda have incentives based on access targets. Others, such as Sanofi’s CEO, have incentives linked to Corporate Social Responsibility (CSR) targets, which can include improving access to medicine. Gileads CEO has incentives specifically linked to expanding access to hepatitis C products, while Eisai’s CEO has incentives related to non-tropical disease (NTD) elimination as part of its mission. 

Johnson & Johnson has access-related KPIs for regional managers, including the Head of Global Public Health Africa team and senior executives, but not directly for the CEO. However, the CEO oversees the access-related KPIs for the two vice chairmen of the Executive committee. 

Managing financial incentives
If incentives can encourage employees to work towards achieving access-related goals, (e.g. KPIs aiming at promoting the delivery of access set for CEOs), sales volume-based incentives can conversely jeopardise access to medicine. It is common practice that the sales agent bonuses and rewards are linked to sales volume, which in turn is increasing the risk of mis-selling (i.e. the act of selling a product to a person when it is not necessary or adapted for them) or over-selling products. 

Yet, in recent years more and more companies are moving away from rewards pegged primarily against sales targets. Companies can limit the occurrence of misconduct by changing their sales incentive structures and adopting a balanced scorecard approach decoupling such incentives from sales volume targets only. This can result in a balance between the aim to increase access to medicine and the risk of overuse. In 2021, 12 companies are doing so, but there is still room for improvement in the area of sales practices.

How do companies ensure their access strategies are not undermined by non-compliance or corrupt behaviour? 
Pharmaceutical companies operate in a fiercely competitive environment where the pressure on profits along with country-level stakeholder pressures could increase the temptation for employees to engage in inappropriate, unethical behaviour and corrupt activities. 

The World Health Organization recognises that corrupt activities in the health sector present a threat to global health and access to medicine.* This risk maybe be exacerbated in low- and middle-income countries, where governance and health systems might be weaker than in high-income countries.* Compliance controls are key to ensuring that governance actions promoting access to medicine are not negatively affected (e.g. by undermining confidence in the industry, diverting scarce resources from health budgets, impacting prices or limiting drug availability). The 2021 Index finds that all companies have auditing mechanisms in place; however, only eight demonstrate evidence of all controls looked for by the Index.

Stronger strategy, stronger outcomes
The 2021 Index is seeing clear evidence of how an access-to-medicine strategy infiltrates key areas of access. For example, two leading companies in this area of analysis, GSK and Novartis, demonstrate strong performances in multiple technical areas and topics assessed in the Index, including access strategies, capacity building and R&D. An increasing number of companies is operating in low-income countries by, establishing country offices developing targeted approaches. During the COVID-19 pandemic, more companies are applying their access-to-medicine strategies to new treatments and vaccines to help address the increasing risk of disruption in healthcare systems as the pandemic deepens.*** For example, Johnson & Johnson reports that its Global Public Health unit, which focuses on improving health outcomes for vulnerable populations, now includes COVID-19 in its efforts to tackle epidemics and pandemics. In parallel, companies ought to enforce more control mechanisms aiming at preventing non-compliant activities which can cause barriers to access and to encourage responsible business practices across their operations.

Transparency and goal communication are also essential; they inform external stakeholders of the companies’ activities and progress on such access-to-medicine strategies and they allow accountability. Most companies perform well in their public reporting of commitments, measurable targets and objectives of access-related activities, for example through their annual or corporate social responsibility reports or via partner platforms such as the IFPMA Global Health Progress and the Access Observatory. Furthermore, the Index continues to encourage companies to publicly disclose the outcomes of their access activities.

* World Health Organization. Integrating a Focus on Anti-Corruption, Transparency and Accountability in Health Systems Assessments.; 2018. https://apps.who.int/iris/bitstream/handle/10665/310991/9789241515177-eng.pdf. Accessed October 21, 2020.
** U.S. Securities and Exchange Commission. Sanofi Charged With FCPA Violations. https://www.sec.gov/news/press-release/2018-174. Accessed December 22, 2020.
*** Toor J, Adams ER, Aliee M, et al. Predicted Impact of COVID-19 on Neglected Tropical Disease Programs and the Opportunity for Innovation. Clin Infect Dis. September 2020. doi:10.1093/cid/ciaa933