Equitable access to essential medicines has been recognized as a key component for achieving universal health care for the past fifty years [
1‐
4]. As a result, the quest to achieve universal access to essential medicines (ATM) has prominently featured in all the major global health discourses from pioneering concepts such as Primary Health Care (PHC) concept to contemporary Universal Health coverage (UHC). The quest to ensure access to essential medicines is not just an aspirational rhetoric, for the discovery of modern medicines has dramatically altered the course of disease control and alleviated human suffering in the past century. Historical precedents loom large, from the breakthrough discovery of penicillin by Alexander Fleming in 1928 which significantly improved the management of sepsis and became part of the World War 11 machinery [
5]. In the 1940s, the discovery and use of effective medicines for malaria and tuberculosis is credited for reversing the devastating effects of these diseases whilst recent memory vividly captures how anti-retroviral medicines transformed HIV/AIDS from a ‘death sentence into a chronic, but treatable disease’ [
6‐
8]. Thus, the discovery of medicines has been a central symbol of ingenuity and dedication to alleviate human suffering and preserve longevity.
Despite their utmost importance in influencing health, access to essential medicines remains one of the most pressing global challenge and WHO estimates that two billion people all over the world do not have sufficient access to essential medicines [
9,
10]. The foregoing account therefore reveals one of the most challenging paradox in global health -the uttermost need for essential medicines and their widespread inaccessibility in reality, particularly in Low and Middle -Income countries (LMICs). This situation has been attributed to various factors amongst them patent systems that favor profits over public health [
8,
11‐
13], weak health systems [
14,
15] and widespread corruption [
16,
17].
Lack of access to essential medicines also reveals pervasive global inequities [
4,
18], albeit with minimal political action to remedy the situation [
19]. Inequitable access to medicines has been attributed to the global politics of pharmaceutical monopoly [
20,
21] which in itself is a reflection of the structural global power asymmetry between industrialized and non-industrialized countries. This global power asymmetry has been a persistent problem since at least the 1970s [
1,
22] and again has been laid bare by the current skewed global distribution of the COVID-19 vaccine [
23,
24]. The framing of inequitable access to essential medicines as something ‘man-made’ to maximize profits at the expense of human suffering has evoked some deep moral, morally inclined convictions over the matter. As a result, actors concerned with access to medicines have advocated for a ‘fairer’ system based on the principles of human rights, social justice and solidarity [
19,
25,
26]. The pursuit of equitable access to essential medicines sits very well with the aspiration of UHC-a principle that asserts that individuals should get access to health care without facing financial hardship [
4]. In this vein, there has been a concerted global effort to elucidate the problem of inadequate access to medicines and propose solutions to address the identified problems.
This process of defining problems-their scope, causes and who is affected-and the subsequent attachment of solutions to address those problems is referred to as issue framing [
27]. Despite the existence of globally articulated problems and proposed solutions to promote access to medicines in developing countries, little attention has been paid to what problems get prioritized at country level; the related solutions and its potential effect on UHC; aspects that are all underpinned by the way an issue is framed. In this study, we sought to understand the applicability and usefulness of framing theory to analyze access to medicines policies through a review of health sector strategic plans from eight countries in the WHO African region. Whilst there is global literature that mainly focuses on the trade related power contestations in relation to access to medicines particularly at agenda setting stage [
23,
26,
28,
29], we decided to focus on the official policy content at country level, which reflects what governments prioritizes for implementation. It is however important to mention upfront that the aim of this analysis is neither to rate the national strategic plans (NSPs) nor to comparatively benchmark them, but to better understand how the issue of ensuring access to essential medicines is framed at the national level across countries and what, if any, impact this seems to have on the solutions proposed.
The remainder of the paper proceeds as follows. First, we present framing theory and apply it to the evolution of essential medicine policies. We then describe the methods followed by the presentation of findings. The findings are then discussed in relation to their implications on UHC in the selected countries and their potential usefulness in other settings before we conclude.
Framing theory
Framing theory focuses on the primacy of ideas in explaining policy dynamics in contrast to other theories that are oriented towards interests and institutions [
30]. Ideas have been known to be powerful in shaping social preferences as described by political scientist Deborah Stone ‘ideas are a medium of exchange and a mode of influence even more powerful than money, votes and guns’. Shared meanings motivate people into collective action whilst divergent ideas are at the center of all political conflict. Thefore, policymaking, is a constant struggle over the criteria for classification; the boundaries of categories, and the definition of ideals that guide the way people behave’’ [
31]. At the core of ideational policy making is the construction of social problems. Frames are therefore powerful because they shape how problems are perceived by excluding or emphasizing particular information. In this context, framing is a meaning-making process that portrays an issue in a particular way which determines what is termed a routine condition that can be tolerated or a social problem that requires policy action [
32]. The process of framing typically has four components namely a defined problem, causal agents of the problem, judgement of the causal agents and their effects and suggested solutions [
33]. Theoretically, framing analysis draws from various disciplines spanning psychology, political science, communication and social movement.
Problem framing also determines who gets involved. Issues can be framed to make them appear technical and only relevant to technical aspects or linked to wider societal values to heighten participation [
27]. As a result, individual actors involved in policy process constantly re-frame problems to influence policy portrayals and increase the number of people mobilized around an issue [
34], a process known as conflict expansion [
35]. Conflict expansion facilitates the shifting of policy venues or ‘the institutional locations where authoritative decisions are made concerning a given issue’ [
36]. Through strategic framing, policy makers constantly engage in ‘venue shopping’ which involves the recruitment of previously uninterested stakeholders [
35]. An example of the effect of conflict expansion and venue shopping is in relation to the global access to anti-retroviral (ARVs). By framing access to HIV/AIDS treatment as a human right [
12], provision of ARVs became an issue of a wider societal concern that mobilized the interest of activists and pressure groups [
37]. Empowered by the discursive framing of human rights and social justice, these interest groups shifted the venue to the political and pharmaceutical industry arena to lobby for radical reforms in patent regimes including the use of compulsory licensing [
38]. It is also important to note that whilst policy frames can increase mobilization around an issue, they can also be designed to de-mobilize interest.
In this paper, we use the Benford and Snow’s conceptualization of frames, which is influenced by the social movement paradigm [
39], for several reasons. First, according to Benford and Snow, framing is concerned with cognitive mechanisms by which grievances are interpreted, given direction and consensus around the goals of reform. We found this characterization to be consistent with the nature of essential medicines. As stated earlier, the history of essential medicines can be viewed as a long-drawn, grievance driven arena around equitable access to medicines under which there has been intellectual and social movement to address those inequities. Second, in line with the social movement lens, there has been an enduring effort to give direction and consensus to the organization of provision of medicines since the emergence of the essential medicines concept in the mid-1970s. Benford and Snow (1988) argued that any social movement actor involved in mobilization and therefore the attempt to move people “from the balcony to the barricades” on a particular issue has to attend to three “core framing tasks”—“diagnostic,” “prognostic,” and “motivational” framing [
40]. These core-framing tasks are followed by specific problem-setting stories. Table
1 below shows Benford and Snow’s concepts of framing.
Table 1
Benford and Snow’s concepts of framing
Framing tasks | Diagnostic framing | What is the problem? How is it defined? |
Prognostic framing | How do we solve the problem? |
Motivational framing | How do we argue for our definitions and solutions – ideology |
Diagnostic framing involves the identification of a problem and the attribution of blame or causality while prognostic framing is concerned with the proposed solution to the identified problem and the related indication of strategies, tactics, and goals. On the other hand, motivational framing justifies the rationale for action. Diagnostic and prognostic framing is geared towards “consensus mobilization”— creating a shared picture of problem and solution—while motivational framing is aimed at “action mobilization,” pushing collective action on the basis of shared perceptions [
40].
Diagnostic framing
In the mid-late 1970s, the dominant diagnostic frame was the proliferation of medicines that did not align with the priority health needs of the population and general lack of access to medicines particularly in developing countries [
43]. Attendant problems included unethical promotion of medicines by manufacturers and high pricing. At the inception of PHC and the essential medicines concept in developing countries, the framing shifted towards more technical aspects such as reliable supply chain systems, financing and rational use of medicines within the framework of national drug policies [
3]. In the 1990s, the framing was dominated by the frame misalignment between trade related aspects and access to HIV/AIDS treatment [
38]. The 2000s coincided with diagnostic frames that rose to the agenda within the UHC discourse. These include unaffordability, reliance on out of pocket expenditure, sub-optimal quality and safety, irrational use of medicines and limited investment in developing medicines for patient populations that do not represent a profitable market [
4]. Under UHC, the other issue that has emerged as a major problem relates to corruption and wastage in the pharmaceutical sector [
42].
Prognostic framing
In line with Benford and Snow’s conceptualization of framing, the prognostic frame has followed the diagnostic frame in relation to ATM. To address the pervasive proliferation of inappropriate medicines, the WHO adopted the essential medicines concept and developed the first model list of essential drugs in 1977 to provide ‘drugs that satisfy the health care needs of the majority of the population’ [
44]. This prognostic shift has been dubbed ‘a peaceful revolution in international public health’ [
18] to reflect its enduring influence on how ATM is conceived globally. In the aftermath of international acceptance, the prognostic frame shifted towards the diffusion of the concept to country level. In 1982 the WHO launched the essential drugs Action Programme to guide the translation of the essential medicines concept into country level policy. In line with the problems encountered at country level, the prognostic frame emphasized technically oriented interventions such as strengthening supply chains, promoting rational medicines use and ensuring sustainable financing. The prognostic frame of the 1990s is dominated with balancing the conflicting interest of trade and public health in light of the HIV/AIDS epidemic. The 2000s is anchored on ensuring access to essential medicines without financial hardship in line with UHC whilst ensuring efficiency. Consequently, the prognostic frame under UHC emphasizes effiency enhancing strategies , including initiatives aimed at curbing corruption in the pharmaceutical sector such as the WHO’s Good Governance for Medicines [
16,
17,
45,
46].