“Despite the long list of successes in health achieved globally during the 20th century, the balance sheet is indelibly stained by the avoidable burden of disease and malnutrition that the world’s disadvantaged populations continue to bear.”

The World Health Report 1999. ²

The bad news is that not all people have benefited equally from improvements in health care. Worldwide, about 50 million people die every year. Of these, 10 million deaths (20%) are due to a few common communicable diseases - acute respiratory infections, diarrhoeal diseases, tuberculosis and malaria. Another 10 million deaths every year are due to two leading types of noncommunicable disease: ischaemic heart disease and cerebrovascular disease. ⁹ These diseases affect poor populations disproportionately: for them, 60% of deaths are due to the common communicable diseases, and a further 30% to noncommunicable diseases. ¹⁰ So although in absolute numbers access to essential drugs has increased greatly, over one-third of the world's population still lacks such access and pays a heavy price in terms of poor health and elevated mortality.

Figure 1: The number of people with access to essential drugs has doubled in 20 years but one-third of the world’s population still lacks such access

Source: World Health Organization. ¹¹

In the poorest parts of Africa and Asia, the picture is even worse, with over 50% of the population lacking access to even the most basic essential drugs. Poverty, newly emerging diseases, and the high prices of newly developed essential drugs are just some of the factors hampering efforts to improve the situation. ¹¹

Poor drug quality is another major concern. ¹² For although global standards for drug quality are becoming increasingly rigorous, the actual quality of drugs on the market is inadequate in many countries. Surveys from a number of developing countries show that between 10 and 20% of sampled drugs fail quality control tests. ¹³ Part of the reason for this is insufficient drug regulatory capacity. Fewer than one in three developing countries are estimated to have fully functioning drug regulatory authorities. Failure to apply good manufacturing practices is another contributory factor and often results in toxic, sometimes lethal, products. Meanwhile, global trade in pharmaceuticals is bringing global quality assurance challenges.

Quality issues also concern traditional medicine. In developing countries up to 80% of the population relies on traditional medicine to meet its health care needs. Such medicine is not only affordable, but also widely available and trusted. In developed countries, traditional and complementary medicine has always been secondary to the practice of modern Western medicine, but a rapid upsurge is now being observed in its popularity. However, the efficacy of much traditional medicine - no matter where it is practised - is as yet scientifically unproven, and provision of traditional medicine is often unregulated.

Irrational use of drugs also remains widespread, despite progress made in drug selection, therapeutic information and training. For example, up to 75% of antibiotics are prescribed inappropriately, even in teaching hospitals. ¹⁴ This is contributing to growing antimicrobial resistance, particularly in relation to major infectious diseases, including bacterial diarrhoea, gonorrhoea, malaria, pneumonia and tuberculosis. The more potent, new, second-line drugs needed to conquer such resistance are usually 3 - 10 times more expensive than firstline drugs. Sometimes they are 50 - 90 times more expensive, as in the case of multi - drugresistant tuberculosis. In poorer countries, even first-line antibiotic treatments may be out of the financial reach of patients. In fact, 90% of customers in these countries buy only three days' supply of antibiotics or less. ^{15, 16} Other irrational use problems relate to dispensing time - on average a mere 15 to 80 seconds per patient in some settings, with virtually no time for counselling. ¹⁷ Worldwide, only 50% of patients take their medicines correctly. ¹⁸

In brief, this Medicines Strategy must be effectively and rapidly implemented if the unfinished agenda and new challenges of the pharmaceutical sector are to be tackled successfully in the early 21st Century. But by providing an overview of what remains to be done, a framework for action for all partners, and indicators for measuring progress, this strategy aims to make these tasks less daunting.