The COVID-19 pandemic has given investors new fuel to push for institutional changes at the world's top pharmaceutical companies to ensure equitable access to medicines in lower income countries.

Lower income nations tend to wait longer to receive access to lifesaving drugs as they emerge from the research and development pipeline, according to the Access to Medicine Foundation's Access to Medicine Index. The companies on the latest edition of the index released Jan. 26 create plans for their medicines early on in the development stage, sometimes years before the drug is ever approved for use in any country.

The index comes after a year in which the pharmaceutical industry suddenly pivoted to tackle the COVID-19 pandemic, with the disease caused by the novel coronavirus becoming one of the biggest R&D focuses for many companies. Pfizer Inc., along with German partner BioNTech SE, have one of the few authorized vaccines for COVID-19. The U.K.'s AstraZeneca PLC has another that is being administered around the world.

The World Health Organization and others are now pushing for vaccines to be provided to all nations, not just those rich enough to buy the first doses.

"The COVID insight is an interesting snapshot. It's like all the access dilemmas playing out at warp speed, but it's very, very much the same patterns that we see whenever a new product starts to hit the market," said Anna Massey, communications manager for the foundation.

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Expanding access to COVID-19 therapeutics and vaccines is not just up to pharma; governments and international organizations must get involved as well, according to Claudia Martinez, research programme manager for the index.

"COVID has helped to really highlight why access to medicine is a systemic issue and why it is financially material for investors, not just in the pharma sector but across all sectors," said Mara Lilley, investor engagement manager for the foundation.

Meaningful action

Novartis AG was the first company to have a systemic plan in place to ensure equitable access to medicines. But the Swiss pharmaceutical giant is now joined by GlaxoSmithKline PLC, Merck KGaA, Johnson & Johnson, Sanofi, AstraZeneca and Takeda Pharmaceutical Co. Ltd., according to the index.

Pfizer has climbed to the fourth spot out of 20 of the world's leading pharmaceutical companies for developing action plans to improve access to medicines in 106 low- and middle-income nations. The New York-based pharmaceutical giant was in the lower half of the index in prior years but has gained after refreshing its access strategy and bringing on CEO Albert Bourla in January 2019.

"These are the kinds of movements that we want to see … in companies' plans, because obviously intentions and commitments are very important, but they don't necessarily lead to action," said Martinez. "Intention without action is kind of meaningless."

2021 was the year that Pfizer's access strategy changes came to fruition. Originally covering just vaccines, the strategy has now been expanded to all products with planning beginning two years before a product is launched. While many companies focus on product delivery to boost access, Pfizer has shared intellectual property with third-party researchers as well.

Pfizer could improve its rating by providing better access to antibiotics Zavicefta and Zinforo through an equitable pricing strategy and registering the products in more countries such as Nigeria, Niger and Guinea, where lower respiratory tract infections are prominent, the report suggests.

GSK and Novartis are nearly tied for the top slot, followed by J&J and Sanofi in third and fifth place, respectively.

Landing on the lower end of the rankings was AbbVie Inc., which the index report suggested could improve by building access concerns into the company's corporate strategy. The North Chicago, Ill.-based pharmaceutical company could also put in place non-assert clauses on certain key patents for hepatitis C treatment Mavyret and the antiretrovirals Aluvia and Kaletra.

Bristol Myers Squibb Co. landed at number 19 due to weak performances on R&D access planning and on responsible promotion practices.

A corporate strategy

The Access to Medicine Foundation works with over 100 investors holding more than $17 trillion in assets, which Lilley said shows that access to medicines has risen to prominence in the ESG movement.

"What we're looking for is for companies not only to think about access to medicine as a strategic problem but to really embed that into their corporate strategies," Martinez said.

Many companies are locking the access issue into incentive packages for executives. Examples include Novartis CEO Vas Narasimhan, who has management targets for access to medicine tied into the company's annual performance plan. GSK, Takeda and Pfizer also have incentives for their CEOs based on access targets. Gilead Sciences Inc. CEO Daniel O'Day has a similar clause tied to expanding access to the company's hepatitis C products and Eisai Co. Ltd. CEO Haruo Naito has performance incentives linked to non-tropical disease elimination.

While pharmaceutical companies are now embedding access planning into the R&D stage, the Access to Medicine Foundation points out that work is needed to expand the availability of already-approved drugs, too. The report shows that only half of the key products from the top 20 pharmaceutical companies examined have access strategies for low- and middle-income countries. Specifically, insulin products for diabetes, contraceptives, cancer drugs and antibiotics for drug-resistant bacteria lack clear access criteria.