Nigeria, Ethiopia and the Democratic Republic of Congo (DRC), Africa’s three most populous countries, are among the least considered markets in pharmaceutical companies’ plans to make new medicines available in low- and middle-income countries, raising concerns that millions of patients could be left behind as global drug innovation accelerates.
An analysis of 245 pharmaceutical access plans in the 2026 Access to Medicine Index shows that the three countries feature in fewer than 10 plans each, despite their substantial populations and disease burdens. More than half of the access plans analysed do not include any country in sub-Saharan Africa, exposing a significant gap between the development of new treatments and the prospects of making them available to African patients.
The findings highlight an emerging inequality in global pharmaceutical innovation: while drugmakers are increasingly considering access earlier in the development of new medicines, these preparations are not translating into adequate coverage of some of Africa’s largest and most vulnerable markets.
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The 2026 Index, published by the Access to Medicine Foundation on Tuesday, assessed 20 of the world’s largest research-based pharmaceutical companies and their efforts to improve access to medicines for diseases that disproportionately affect low- and middle-income countries.
Although access plans now cover 69 percent of late-stage pharmaceutical pipeline candidates, more than three times the proportion recorded in 2018, the geographical distribution remains uneven, particularly across sub-Saharan Africa.
South Africa and, to a lesser extent, Kenya are more prominently represented in pharmaceutical companies’ access strategies, reflecting their relatively established healthcare infrastructure and research capabilities. However, the limited inclusion of Nigeria, Ethiopia and the DRC raises questions about whether population size and disease burden are sufficiently influencing decisions about where innovative medicines will eventually be supplied.
For Nigeria, the implications are significant. With a large population and substantial burdens of cancer, diabetes, cardiovascular diseases and other non-communicable diseases, exclusion from early access planning could delay the country’s ability to benefit from treatments currently moving through pharmaceutical development pipelines.
The problem extends beyond the decision to register a medicine. Access planning involves determining how products will be supplied, priced and distributed, including whether patients and public health systems can afford them once regulatory approval is secured.
The Index found that 43 percent of access plans for non-communicable disease products focus solely on regulatory registration rather than addressing wider barriers to availability and affordability.
This means that even when pharmaceutical companies intend to introduce products into developing markets, patients may still face prohibitive prices, weak distribution networks and inadequate healthcare infrastructure.
The disparity is particularly pronounced in cancer treatment, where pharmaceutical innovation is growing rapidly but access remains concentrated in wealthier markets.
Cancer accounts for approximately half of all pharmaceutical clinical candidates assessed in the Index. Although access plans now cover 65 percent of oncology pipeline candidates, only 19 percent of assessed cancer products have strategies covering low-income countries.
Of the 25 newer cancer products assessed, 16, representing 64 percent, have no registration in sub-Saharan Africa. More than half of these products also have no registration in Africa as a whole.
The figures suggest that African patients risk being excluded at two critical stages: the initial planning of access during drug development and the subsequent regulatory process required to make new treatments available.
Claudia Martínez, director of research at the Access to Medicine Foundation, said the industry was making progress through new product approvals, licensing agreements and more sustainable models for reaching patients, but these efforts remained concentrated among too few companies, products and diseases.
“The challenge now is to take what works further and faster, and see these approaches adopted much more widely across the industry,” Martínez said.
The foundation also identified weaknesses in the industry’s investment in diseases that disproportionately affect poorer populations.
Only 14 of the 20 companies assessed engaged in research and development for priority diseases in 2026, the lowest number recorded since 2018. These diseases include conditions that disproportionately affect low- and middle-income countries and often lack effective or suitable treatment options.
While pharmaceutical companies continue to invest heavily in commercially attractive areas such as cancer and GLP-1 diabetes treatments, research into diseases with significant burdens in developing countries remains limited.
This presents a longer-term challenge for African health systems, where the ability to access innovative treatments will depend not only on affordability but also on whether companies invest in developing products relevant to local disease patterns.
The continent’s limited pharmaceutical manufacturing capacity compounds the problem.
Africa imports at least 70 percent of its pharmaceutical products, leaving countries vulnerable to international supply disruptions, currency pressures and shortages. Yet only four of the 20 pharmaceutical companies assessed have technology-transfer agreements in sub-Saharan Africa, with three of the five identified agreements concentrated in South Africa.
The limited spread of technology transfer means that much of the continent remains dependent on medicines manufactured elsewhere, weakening its ability to build reliable regional supply chains and reduce exposure to external shocks.
However, the Index identifies opportunities for pharmaceutical companies to expand their engagement with African markets.
Nine of the 20 companies assessed have specific opportunities to improve access in Africa or sub-Saharan Africa over the next two years. These include expanding oncology access, strengthening local manufacturing, broadening registration strategies and improving access to treatments for sickle cell disease.
Companies such as Bristol Myers Squibb and Roche are already working with African healthcare institutions to improve access to cancer medicines. BMS, through its Innovative Medicines Access Programme, has established pathways for its immuno-oncology medicine nivolumab in Uganda, Zambia and Nigeria.
In Uganda, the collaboration with the Uganda Cancer Institute has supported publicly funded procurement of nivolumab, while in Nigeria, the medicine has been supplied to Lakeshore Cancer Center, with efforts underway to expand the programme to a publicly funded hospital network.
Roche has also partnered with healthcare authorities in the Democratic Republic of Congo to strengthen cancer screening, diagnostics and treatment infrastructure, including an agreement targeting the screening of one million women for cervical and breast cancer over five years.
These initiatives demonstrate that pharmaceutical companies can move beyond medicine registration to address wider barriers across the healthcare system.
Novartis, which ranked first in the 2026 Index for the second time, has also expanded its sickle cell disease programme across Ghana, Kenya, Tanzania and Uganda. The programme has trained more than 8,000 healthcare professionals, screened over 200,000 newborns and infants and supported more than 150 treatment centres.
Novartis retained its leading position across all three technical areas assessed: governance of access, research and development, and product delivery. GSK ranked second, followed by AstraZeneca, Sanofi, Bayer, Boehringer Ingelheim, Roche and Pfizer.
The ranking comes as the foundation marks 20 years of tracking pharmaceutical companies’ efforts to improve access to medicines in underserved markets.
Jayasree K. Iyer, chief executive officer of the Access to Medicine Foundation, said two decades of progress had strengthened the industry’s ability to address persistent access gaps, with companies increasingly integrating access considerations into their operations.
“Twenty years of progress have put us in a stronger position than ever to tackle persistent gaps in access. The Index has shown what works, companies have more tools at their disposal and access is increasingly being considered earlier,” Iyer said.
However, she warned that funding constraints, geopolitical instability and rising healthcare needs were putting increasing pressure on the global health ecosystem.
“The opportunity now is to build on that foundation and reach many more people,” she added.
Despite the progress, the foundation argues that successful access approaches remain concentrated among too few companies, products and diseases.
It is urging companies to develop access strategies earlier in drug development, work with local partners to identify country-specific barriers and provide more transparent reporting on the number of patients benefiting from their programmes.
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It also wants companies to establish measurable targets for patient reach, affordability and reliable supply, rather than relying on announcements of partnerships and commitments.
For Nigeria, the challenge is also to create a more predictable operating environment that makes the market commercially viable for pharmaceutical manufacturers. Regulatory efficiency, stronger public procurement systems, sustainable healthcare financing and improved foreign exchange conditions could help reduce the risks associated with supplying medicines.
The findings point to a growing disconnect between pharmaceutical innovation and equitable healthcare delivery. Unless companies extend their access planning to markets with substantial disease burdens, the development of more sophisticated medicines could deepen existing inequalities rather than close them.
