Intended for healthcare professionals

Letters Universal health coverage and drug quality

Universal health coverage: drug quality and affordability can go together

BMJ 2019; 367 doi: (Published 15 October 2019) Cite this as: BMJ 2019;367:l6004
  1. Raffaella Ravinetto, senior researcher1,
  2. Catherine Dujardin, health officer2
  1. 1Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
  2. 2Belgian Directorate-General Development Cooperation and Humanitarian Aid, Brussels, Belgium
  1. rravinetto{at}

In her thoughtful essay, Elizabeth Pisani warns against some possible unwanted consequences of the efforts to achieve universal health coverage.1 In particular, an unconditional push for the lowest possible prices of essential drugs may lead some manufacturers to apply cuts to quality assurance costs, thus increasing the risk of poor quality drugs or of manufacturers’ withdrawal from the market.1

The prevalence of poor quality drugs is higher in countries where under-resourced national regulatory authorities cannot provide effective oversight.234 Risks are magnified if organisations buy drugs based exclusively on pricing considerations without stringent prerequisites for quality standards. Focusing on minimising the direct cost of drugs neglects to take into account their value—a cheaper, substandard medicine may harm the patient and a failure to cure will eventually impose higher costs on the health system.5

We believe, however, that quality and affordability can go together—as shown by the World Health Organization’s prequalification programme (WHO PQP)6 and the Medicines Patent Pool7—and that incentives to invest in pharmaceutical quality assurance may even descend from the market, as prices are not only linked to manufacturing costs but also to manufacturing volumes and market opportunities.5 In many cases, WHO PQP brought international procurement prices of quality assured drugs down, because manufacturers that invested in WHO PQP were indirectly rewarded through access to markets and, in turn, they had the opportunity for economies of scale.56

To complement the important measures listed by Pisani, we call on all major purchasers, including major funding agencies and their implementers, to create the demand for quality assured essential drugs by setting stringent criteria as a prerequisite for purchase.8 In doing so, they would positively shape the market towards affordable, quality assured products and would contribute to the achievement of universal health coverage.