INTRODUCTION

Global inequality impacts global health. The rich can, but the poor cannot, access many of the existing medicines they need. About a third of all deaths, 18 million a year or 50,000 every day, are poverty-related (World Health Organization 2004). There is also a large mismatch between pharmaceutical research and development (R&D) spending and the global burden of disease (GBD) (Lichtenberg 2005: 663-90; Culp and Hassoun forthcoming). Pharmaceutical companies have very little incentive to do new R&D on drugs for the poor (who lack the money to buy them). What should we do to address the consequences of inequality for global health?

One option is to restructure the incentives pharmaceutical companies face so that they can extend access on essential medicines to the poor. Many have argued that this is morally required (Hollis and Pogge 2008: Flory and Kitcher 2004: 36–65). To date, however, very few philosophers have advanced concrete proposals for doing so. Though, many have criticised Thomas Pogge's proposal for a Health Impact Fund that would provide prizes for companies producing new drugs in proportion to their impact on global health (Pogge 2008a). That more philosophical work has not been done on this topic is unfortunate. To begin to fill this lacuna, this chapter considers the case for a new alternative: rating companies’ efforts to extend access on essential medicines on the basis of the disease burden their innovations might alleviate, their effectiveness, and how many people have access to them.