^39. WHO recommends the adoption of drug policies which include access, quality and rational use. This document emphasizes aspects on drug access.

Many countries are using two principal strategies for implementing national drug policies, as recommended by WHO. The first is fundamental and concerns the promotion of essential drugs as the major focus from the health viewpoint. This is complemented by the use of quality generic pharmaceuticals as an important means of ensuring availability as well as access (Brundtland 2000).

The reforms made to the social security systems in the six countries studied have, to a certain extent improved access to drugs. The studies clearly show that the reforms did not consider drug policy. Where some policy elements have been included, this has not been done in an integrated manner to fully address access, quality and rational use. Furthermore, with regard to access, when health reforms implement drug policies, the success of the latter will depend on the type of system adopted and within this the insurance strategy defined by the health system. It would not be too contentious to state that the ideal context/framework for the implementation of a national drug policy, as recommended by WHO, is a health system based on principles of universality, compulsory solidarity and efficiency (Madrid, Velásquez, Fefer, 1998).

In many developing countries, unlike in industrialized countries, the majority of the population has to pay for the medicines they use from their own pocket, resulting in lack of equity in access to drugs. As the present study shows, the only sustainable long-term solution to guarantee regular access are social security schemes, especially those with public financing based on taxes, such as in Costa Rica. The system in the United States of America, based on private health insurance, gives the whole population access but at too high a cost. As stated in the WHO World Health Report 2000 the US scheme is the dearest in the world but does not achieve the best results. This demonstrates that a private insurance-based health system requires a high degree of State regulation, which many developing countries may not be able to provide.

It is important to define social security systems based on principles of universality, equity and solidarity. Achieving universal coverage should be the goal of any health system in a way that achieves economic levelling - reduces economic inequality - through wealth redistribution. Reducing economic inequality puts everyone on the same footing with regard to access to drugs. Equity does not means everyone receives exactly the same but what is needed by the individual. Equity implies providing for each person according to need, with the possibility of receiving treatment at whatever stage of illness, whatever level of complexity, on an equal basis for all citizens. But besides being independent of ones birth, housing and work status, all sectors of the population should enjoy high health standards measured by the usual indicators such as life expectancy and mortality rates.

Solidarity means that those using the health system contribute in accordance with their resources in a way that each person can receive care when needed. It is important that solidarity is established between the healthy and the infirm, as well as those with similar working conditions and those whose social conditions are different.

So, policy must be centred/focused on access, meaning that everyone has access to the drugs they need within a framework of quality, cost-effectiveness and utility costs.