The fundamental importance of ensuring access to medicines, particularly for the poor, is reflected in MDG 8 however remains poor in many low and middle income countries (LMICs). Country specific evidence on access to medicines is weak in LMICs and research has rarely been from an integrated health systems perspective. This study used an evidence based approach to identify key priority concerns and emerging research questions related to access to medicines in Pakistan. WHO’s Access to Medicine Framework was used as the conceptual basis for data collection on rational usage, affordability, financing and health systems. Methods involved a systematic desk review, in-depth stakeholder interviews and a consensus building Roundtable exercise. In Pakistan there has been considerable work in terms of medicines related policy acts and operative guidelines. However considerable gaps exist between policy and practice and between medicine policies and health systems strategies. Average number of medications prescribed is higher than other LMICs and prescription practices frequently do not follow standard recommended therapies from specialists down to general practitioners. There is a widely entrenched private informal sector and shadow pharmacies which remains largely unregulated. Spending on drugs is mainly borne by households, accounts for 63% of total spending on drugs in Pakistan as compared to only 18% in OECD countries and can lead to catastrophic household expenditure. Medicine therapy for chronic care is particularly unaffordable even with use of low cost generics. Within the public sector, availability of essential generics is extremely low at 3.3% as compared to 29-54% in LMICs. Public sector spending on drugs is far below the minimum $2 per capita indicated for LMICs and existing spending faces issues of questionable adherence to EDL, low quality drugs and outdated logistics management systems. Contracting out the management of BHUs has resulted in better medicine availability. There is serious shortage of trained manpower pharmacists across private and public sector with 0.9 pharmacist / 100000 population in Pakistan far below recommended ratio of 1 pharmacist per 2000 population. Drug regulation also requires with registration of excessive number of drugs, wide quality variation in quality and pricing, and frequent instances of spurious drugs and black marketing. Chronic shortage of low prices essential medicines is a long standing issue linked to disincentive to production due to low pricing and flat price control. The above policy concerns raise need for research in key areas. First, there is need for surveys on continuous surveillance of policy impact on availability, price and affordability of medicines; mapping of private informal sector and shadow pharmacies; and consumer health seeking preferences. Second, collation is required of best practice lessons on registration, pricing, market vigilance and enhancement of rational drug use. Third, operation research pilots in key areas such as alternative health financing mechanisms involving commodity voucher, GP contracting, pre-payment schemes, equity funds for increasing drug availability and affordability; scientific improvement of logistics management system in public sector; and introducing community participation in accountability mechanisms. Pharmaceutical policy and research needs to be centrally placed within larger health systems related initiatives. It needs to be accompanied by sustained dialogue and interaction between multiple stakeholders including private sector. Adequate steps also need to be taken to ensure a continuous culture of research feeding into evidence based policies
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