Access to Medicines Will Be Won or Lost on How Markets Are Built

There is a persistent misconception in global health: that expanding access to medicines requires sacrificing commercial viability. That impact and returns sit in opposition to one another.

This framing is outdated, and it continues to slow real progress at the moment it is most needed.

Low- and middle-income countries (LMICs) account for over 85% of the world’s population and nearly 90% of the global disease burden, yet they represent less than 6% of global pharmaceutical revenue. Does this imbalance come from a lack of need or demand? The short answer is no. It comes from systems and business models that were never built for the realities of these markets.

The imbalance is not a mystery. It is the architecture of the market itself. It is the logical outcome of markets designed without LMICs in mind.

Across LMICs, healthcare and pharma suppliers face familiar constraints: fragmented and unpredictable demand, inefficient procurement processes, limited visibility, and regulatory complexity. These dynamics increase cost, slow execution, and make scale difficult to sustain. The result is inefficiency at scale.

Today, we know that markups on essential medicines in LMICs can reach 200–500%, and in some cases far higher. What’s often missed in these debates is a simple truth: inefficiency is not neutral. Every dollar lost to fragmentation is a dollar that does not reach a patient. Every delay compounds human cost.

Over the past year, the system has been shaken to its core. Traditional donor funding has come under pressure. Long-standing assumptions about who pays, how markets function, and what sustainability looks like have been exposed as fragile. When funding slowed or stopped, supply chains stalled, orders froze, and patients paid the price.

The uncomfortable truth is that we don’t have an access problem. We have a market design problem. What has been missing is not demand, nor intent, nor capital. It has been infrastructure; real systems that allow fragmented markets to function efficiently, transparently, and at scale.

In this environment, intent and ambition are not the limiting factors. Execution is.

This is where the conversation must shift. Access cannot rely indefinitely on short-term funding cycles or one-off interventions. It requires business models designed for the economic and operational realities of LMICs. Models that align affordability, reliability, and sustainability rather than forcing trade-offs between them.

Over the past year, we have seen that when procurement is treated as infrastructure rather than as a transactional afterthought, outcomes change. Aggregated demand lowers prices. Predictability improves supplier performance. Transparency builds trust. Every dollar saved through efficiency becomes a dollar that stretches further... reaching more patients, more reliably.

These outcomes are not achieved through charity alone. They are achieved through disciplined execution, data-driven decision-making, and platforms that reduce friction across the value chain.

As a social-impact venture, we have learned that commercial sustainability and impact are not competing objectives. Systems that work better for buyers also work better for suppliers. Markets that function efficiently attract participation. And health systems that can procure reliably are better positioned to withstand future shocks.

Too often, the debate remains stuck on whether impact and commercial logic can coexist. That question is no longer relevant. The real question is whether global health can afford to keep operating without models that do both.

The future of access to medicines will not be unlocked through donations. It will be shaped by business models that treat LMICs as essential markets, and that embed efficiency, transparency, and sustainability into how those markets function.

This moment demands a willingness to rethink how access is delivered. And the courage to build systems that are fit for the world as it is today, not as it once was.