In preparation for the Ninth High-level Meeting of the Small Countries Initiative (SCI) – a platform bringing together 11 Member States in the WHO European Region with populations of 2 million or less – the SCI held its first policy dialogue on 8 March 2023. It set out to better understand countries’ needs for access to medicines and the specific areas where technical assistance will be most needed in the coming year.
SCI members identified the key priorities related to access to medicines in their respective countries, namely how to ensure access to new medicines, how to address shortages of essential medicines, and how to engage the private sector.
A roadmap responding to small countries’ challenges
The Roadmap Towards Better Health in Small Countries in the WHO European Region, 2022¬–2025 was endorsed at the Eighth High-level Meeting of the SCI in June 2022 in Bečići, Montenegro. The Roadmap calls for stronger mechanisms to ensure accessibility, availability and affordability of medicines, vaccines and medical devices in response to challenges shared by small countries. These include issues related to small markets, vaccine procurement, vaccine uptake, communication (including drug labelling) and misinformation.
Multiple barriers to access
Many small countries face shortages of medicines because their market is not large enough for the pharmaceutical industry to enter. Some key examples, including shortages of paediatric antibiotics, were identified as recurring problems for many small countries.
Small countries also often pay significantly more for the same medicines than other countries in the Region because of their limited bargaining power. Prices ranging from 50% higher to 3 times higher were cited as examples.
In addition, the industry often establishes a minimum stock for purchase, which is often too large for small countries. This means that countries either buy more than they need and have wastage (especially if they cannot legally agree with the industry to donate doses to other countries), or they do not buy, resulting in lack of access for patients.
Some countries also cited the problem of not having a reporting system or centralized system to monitor drug stocks and warn of shortages; many have to rely on the reporting system of a larger neighbouring country.
Solutions and good practices
A first key point is to work with neighbouring countries. These collaborations have led to pooled procurement, which allows sufficient quantities of medicines to be purchased collectively by pooling demand. Successful examples come from the Baltic countries and, to varying degrees, from Iceland with the Nordic countries, as well as through Iceland's direct interactions with Denmark and Norway.
A second proposed solution is to increase involvement in the new Access to Novel Medicines Platform established by WHO/Europe, which allows Member States, partners, the private sector and other non-State actors to have honest conversations and negotiations.
The outcome of the policy dialogue was a brief summary of key issues to be discussed by ministers of health at the upcoming Ninth High-level Meeting in Luxembourg on 10–12 May 2023. WHO also agreed to produce a policy brief on access to medicines in small countries to raise awareness of the specificities of small countries and possible solutions.