The Hubris of Equal Access in Healthcare

Everybody demands it immediately, but supply is limited because we live in a real world. COVID-19 proves it. So how do we provide healthcare to everyone? Can we?

The Pandemic Reality Check

The COVID-19 vaccine rollout was, in many ways, the most visible stress test of global healthcare equity in modern history. And the results were predictable to anyone who has spent time in the pharmaceutical industry: rich countries got vaccinated first, poor countries waited, and the middle-income countries scrambled.

This was not a failure of intent. COVAX — the global initiative to ensure equitable vaccine access — was well-designed and well-intentioned. The problem was more fundamental: there simply weren’t enough doses for everyone simultaneously, and the countries that had funded vaccine development expected preferential access. This is not villainy; it’s economics.

The AstraZeneca Pricing Lesson

AstraZeneca deserves credit for committing to supply its COVID-19 vaccine at cost to developing countries during the pandemic. But this commitment also revealed an uncomfortable truth about pharmaceutical pricing: the same vaccine was sold at vastly different prices to different countries.

This differential pricing — or “tiered pricing” in industry parlance — is actually the most rational approach to global pharmaceutical access. Charging wealthy countries more and poor countries less allows companies to recoup development costs while expanding access. But it also means that “equal access” is, by definition, not “equal pricing.”

The Structural Reality of Pharma P&L

To understand why equal access is so difficult, you need to understand the pharmaceutical industry’s P&L structure. Drug development is a high-risk, high-reward endeavor. For every successful drug, dozens fail. The successful ones must generate enough revenue to cover their own development costs plus the costs of all the failures.

This means that pharmaceutical companies need markets with the ability to pay premium prices. The US, EU, and Japan collectively account for the vast majority of global pharmaceutical revenue, not because they have the most patients, but because they have the purchasing power and reimbursement systems to pay for innovative therapies.

If you forced truly equal pricing globally, one of two things would happen: prices in wealthy countries would rise to compensate for reduced revenue from LMICs (politically untenable), or development programs for diseases primarily affecting LMICs would be abandoned (morally untenable).

The IVD Market Opportunity

Interestingly, the in vitro diagnostics (IVD) market presents a different dynamic. At approximately $2 USD per capita annual spending in many LMICs, the diagnostics market is vastly underserved compared to the pharmaceutical market. This creates a genuine opportunity for innovation that serves underserved populations profitably.

Simple, affordable diagnostic tests — particularly rapid point-of-care tests — can be manufactured at scale for pennies per unit and sold at prices that are both accessible in LMIC settings and profitable for manufacturers. The COVID-19 rapid antigen test is perhaps the best recent example: a product that was both commercially successful and genuinely expanded access.

Beyond Hubris

The term “hubris” in the title is deliberate. There is a particular form of arrogance in demanding equal access without acknowledging the structural constraints that make it impossible in the near term. This hubris manifests in several ways:

• Politicians who promise universal access without funding the systems to deliver it
• Advocates who demand price reductions without considering the impact on innovation incentives
• International organizations that create frameworks for equity without the enforcement mechanisms to realize them
• Pharmaceutical companies that make access pledges without the manufacturing or distribution capabilities to fulfill them

The honest answer to “can we provide healthcare to everyone?” is: not yet. Not equally. Not simultaneously.

A More Honest Path

What we can do is more pragmatic and less glamorous than universal equal access:

1. Invest in manufacturing infrastructure in LMICs so they can produce essential medicines domestically
2. Develop products specifically designed for low-resource settings — not adapted versions of high-income market products, but ground-up designs
3. Accept tiered pricing as a feature, not a bug — it’s the mechanism that allows the same products to reach different markets
4. Focus on prevention and diagnostics where the cost per intervention is orders of magnitude lower than treatment
5. Build human capital — the most sustainable healthcare investment is in training local clinicians, scientists, and public health professionals

Equal access is not hubris because it’s the wrong goal. It’s hubris because pretending we’re close to achieving it — or that it can be achieved through declarations and goodwill alone — diverts attention and resources from the unglamorous, incremental work that actually moves the needle.

The path to equal access runs through unequal access. We have to build the infrastructure, develop the workforce, and create the economic conditions that make equal access viable. There is no shortcut, and pretending otherwise serves no one — least of all the people we claim to be helping.