Inequitable access to medicines for neglected tropical diseases in Europe: health system vulnerabilities and a call for coordinated action

Summary

The COVID-19 pandemic has exposed the vulnerability of the European medicine supply systems, but the lack of access to medicines for diseases of poverty, including neglected tropical diseases (NTDs), is unfrequently brought to the attention of the European policy makers. As a result, clinicians in Europe are forced to “bricolage solutions” to treat NTDs: ad hoc donations from companies, product-specific donations via the World Health Organization (WHO) or WHO collaborating centres, case-by-case importation -sometimes from poorly regulated countries-, and possibly the recourse to compounding pharmacies. Noteworthy, NTDs are unlikely to decrease in the next years in Europe, due to increasing global mobility, and climate change expanding the parasites’ habitat. This serious but neglected problem was discussed at the 2025 European Congress in Tropical Medicine and International Health (ECTMIH) in Hamburg, Germany. This viewpoint analyses the availability, affordability and accessibility challenges in some countries in Europe, and their consequences at patient and health system level. It also proposes a set of interconnected recommendations and policy measures to make quality-assured medicines for NTDs sustainably available and affordable across Europe. Restoring access to these essential and sometimes life-saving medicines is critical for restoring the right to health for all in Europe, while protecting continental public health.

Introduction

Traditionally, lack of access to essential medicines hit low- and middle-income countries,1, 2, 3 but nowadays countries in the European Union (EU) are not spared either. The COVID-19 pandemic exposed the vulnerability of supply systems, with numerous shortages that led to the introduction of the Critical Medicine Act.⁴ If the EU upholds the individual right to health, nobody should be left behind.⁵ However, there are unresolved concerns, e.g. regarding access to medicines for tuberculosis,⁶ severe malaria (intravenous artesunate), relapse of P. vivax/P. ovale malaria (primaquine), and for diseases of poverty, including neglected tropical diseases (NTDs).

NTDs comprise 21 conditions,⁷ mainly caused by protozoa or helminths, prevalent in the Global South. Some of them, such as strongyloidiasis, leishmaniasis, echinococcosis, and arbovirus infections, are also present in Europe, especially but not exclusively in the Mediterranean basin. Their prevalence is low but increasing, especially among international travelers, military personnel, refugees, asylum seekers and migrants, but also within local (sedentary) populations.

NTDs often cause significant chronic morbidity, and can be fatal if not timely recognized and treated. The case management is often complex, and not supported by strong evidence.⁸ Particularly in non-endemic settings, it tends to be individualized rather than standardized. In Europe, chronic presentations often lead to first contacts with specialists of various disciplines not trained to diagnose NTDs.⁹ Besides the absence of harmonized guidelines, clinicians face multiple barriers to accessing NTD medicines, including unstable supplies, shortages, volatile prices and inconsistent financing policies. Problems are exacerbated by the regulatory process: market authorizations must be initiated by suppliers, making availability primarily driven by commercial interests, and poorly appealing for private companies.

These issues were discussed at the 2025 European Congress in Tropical Medicine and International Health (ECTMIH) in Hamburg, Germany.¹⁰ Participants highlighted, through a set of concrete cases, the urgent need for advocacy to improve access to NTD medicines in Europe. This viewpoint outlines key-discussion points, and calls for action to address systemic weaknesses affecting availability, affordability and accessibility.

Availability

Praziquantel is a widely-used medicine to treat schistosomiasis and other parasitosis. Although multiple generic manufacturers exist globally, its availability in Europe has been historically inconsistent. In some countries, e.g. Italy and Belgium, praziquantel is not registered because no license holders have submitted applications to national regulators. Pragmatic interim solutions include the importation from the US at high cost (around €600 for six tablets); sourcing it from countries like India and Bangladesh, with weaker pharmaceutical quality assurance systems; and -in Italy-procuring it through a World Health Organization (WHO) Collaborating Centre (CC) that distributes WHO-donated anthelmintics.¹¹ Although helpful in isolated cases, these arrangements are neither secured nor sustainable. They shift responsibilities from National Health Systems (NHS) to prescribers and patients; expose prescribers to legal liability; and imply quality risks, if imports come from markets with weak pharmaceutical regulation.^12,13 Elsewhere, including the Netherlands, France and Germany, praziquantel is only registered as Biltricide® by Bayer AG, whose production was abruptly discontinued in 2024.¹⁴ The manufacturer's decision, and the lack of reaction from national and European health authorities, will create a continental gap¹⁵ which is both ethically debatable and pragmatically short-sighted, given the projected increase of schistosomiasis cases and of local transmission across Europe.

Similar barriers affect other NTD medicines such as diethylcarbamazine (DEC), the first-line therapy of loiasis, which has become de facto unavailable in Europe.^16,17 Alternative treatments are poorly investigated. The use of albendazole is insufficiently supported by evidence, thus clinicians still occasionally try to import DEC for single cases, or ask patients to obtain it from endemic countries via family or relatives.

Affordability

Life-saving medicines for NTDs are often not financed under national health coverage systems, placing financial burden on patients. Besides triclabendazole for fascioliasis (Box 1), and ivermectin for strongyloidiasis, reported examples include miltefosine, a rescue medicine for severe leishmaniasis refractory to first-line therapy with liposomal amphotericin (total cost estimated at 3500 euros, not reimbursed in Belgium). These medicines are primarily registered for veterinary use, or for very restricted human indications. For instance, in Belgium ivermectin is reimbursed only for scabies, while in Italy it is not reimbursed at all. A four-tablets pack costs between €28 and €38.50, which may result in prohibitive expenses for socioeconomically vulnerable individuals.¹⁸

Box 1. Triclabendazole in Belgium.

Belgium, 2018: a man in his 50's attended an outpatient travel clinic, upon return from South Sudan, with low-grade fever, moderate epigastric pain and a 10 kg weight loss over approximately 2 months. Clinical examination was unremarkable. Laboratory analyses showed high eosinophil cell count (2646/μl; normal <500/μl). Imaging revealed a heterogenous mass of 10 cm in the liver. A diagnosis of subacute fascioliasis (infection due to liver flukes) was made, based on strongly positive serology (1:1280). Triclabendazole, the first-line therapy for this condition, was imported ad hoc, at a price of 700 euros for a 2-day regimen, at full patient's cost. Clinical recovery was complete within a month.

Accessibility

Spain is home to one of the largest populations with Chagas disease outside Latin America: at least 55,000 persons are infected, with underdiagnosis at 70% and undertreatment at 82.5%.¹⁹ The medicines for treatment, nifurtimox and benznidazole, are not commercially available, even if nifurtimox was registered in 2025, and the registration process for benznidazole is ongoing. At global level, access depends on agreements between suppliers and the WHO, which guarantee availability and fair pricing, but the mechanism is burdensome for non-endemic countries. In Spain, importation involves an application to the “Foreign Medicines Office”, and the provision of mandatory individual medical reports, reports to the territorial pharmacy, and special forms including those for WHO.²⁰ Moreover, procedures vary across Spanish regions, with different reimbursement measures (from gratuity to a 20–65 € user-fee) and prescription-to-dispensing timelines (one-to-four weeks, or longer). Overall, this remains a fragile, non-integrated supply system. In-country availability of registered products could reduce bureaucracy, speed up procurement and secure supply.

Similar scenarios are found elsewhere in Europe: the ability of countries to access the donation from the WHO varies significantly, also depending on national regulations. Italy, for instance, ranks second in Europe for Latin American immigration, but treatment could be available only in very few infectious diseases reference centres.²¹

‘Bricolage’ or structural solutions?

Being based on some cases presented at a scientific session, this Viewpoint is not offering an exhaustive overview of all medicines for NTDs for which there are access problems across Europe, nor are the specific cases systematically generalizable to other European settings. Nonetheless, it is concerning that, beginning of 2026, clinicians in Europe are forced to “bricolage solutions” to treat NTD. These include reliance in ad hoc donations from companies, product-specific donations via the WHO or WHO CCs, sourcing from foreign markets, patients purchasing medicines in endemic countries through relatives, and possibly the recourse to compounding pharmacies. Yet all these bricolage solutions carry inherent risks.

Donations via the WHO come free-of-cost, with quality-assured products, but they are not structurally available everywhere, and cannot ensure either sustainability or full coverage of needs. Moreover, for WHO CCs, reporting to donors is complex, and there are unresolved issues concerning national regulatory authorizations and packaging requirements. Donations from licence holders do not present quality concerns, but are neither structured nor sustainable, with minimal coverage of needs–the sustainability of donations has already proven insufficient in endemic countries.²² Imports from non-EU countries can result in very high prices, from high-income countries, or in the risk of substandard or falsified products, from poorly-regulated markets. Moreover, the liability for any product defects remains with prescribers. Purchase outside Europe by patients or relatives is risky in terms of quality, and somehow morally unfair. Pharmaceutical compounding should be reserved for specific medical needs that cannot be met by industrial production; and be conducted only locally, under strict regulatory control, using quality-assured active ingredients.²³

Recommendations and conclusion

By discussing real-life challenges, we showcased that NTDs adequate and timely management is particularly compromised in Europe due to availability, affordability and accessibility challenges. Access to medicines does not play in a vacuum: other policy measures are needed to maximise quality of care, e.g. the integration of NTDs in medical curricula, the (re)training of healthcare workers from varied disciplines, the harmonisation of diagnostic and treatment guidelines, and adequate screening policies including outreach to populations with difficulties accessing health systems. However, lack of access to medicine remains a major obstacle.

We need, now, policy measures that make quality-assured NTDs medicines sustainably available and affordable across Europe. For this, we propose a set of interconnected recommendations for action, which are listed in Panel 1.

Panel 1. Recommendations for action.

• 1.Focused research on the availability, affordability and accessibility of medicine for NTDs in Europe is urgently needed, in order to accurately quantify and monitor the European demand and local offer of NTDs medicines. National and European professional societies like the Federation of European Societies for Tropical Medicine and International Health (FESTMIH), perhaps supported by the WHO, could lead in (a) determining the list of medicines necessary for NTDs, in adequate formulations and convenient packaging, and (b) collecting and collating patient and medicine data across countries.²⁴
• 2.
  Collated demand data, and if possible, projections, should be used by scientific societies and advocates for advocacy vis-à-vis manufacturers, to create a business case for registration and distribution; and vis-à-vis national regulators, the European Medicine Agency (EMA) and national Ministries of Health, to promote and endorse adequate policies. In particular:

  • 2a
    National regulators and EMA could find regulatory and access pathways for medicines whose registration cannot be left alone to commercial interests.
  • 2b
    The EMA could design critical, flexible procedures and incentives based on other initiatives -such as the Critical Medicines Act- in order to respond to the NTDs challenges.
  • 2c
    EU countries could create a coordinated system to procure and maintain strategic stocks of essential NTDs medicines. Linked with WHO, suppliers, FESTMIH, and key-stakeholders, this would enable rapid access, redistribution, and replenishment of scarce treatments, improving equity across Europe.
  • 2d
    National health insurances should fully reimburse essential NTDs medicines, to uphold the human right to health, and to protect public health.

With increasing global mobility and climate change expanding the parasites' habitat, NTDs are unlikely to decrease in next years in Europe. The consequences of poor access to medicines will be multiple: vulnerable people are not cured; health systems must manage advanced diseases at higher cost; and local transmission may increase. The problem is compounded by poor awareness and knowledge, sporadic cases, non-completely known burden, unfavourable market dynamics, short-sightedness of stakeholders, patients’ vulnerability, and lack of advocacy –while caregivers strive for emergency solutions.

Health is a right of the person and a collective interest. It is time to break the silence, and take action for restoring access to quality NTDs medicines for all in Europe,²⁵ while protecting continental public health. A European health issue can only be addressed collectively at European level.

Contributors

RR, MA, EB, DF, ILG, GC and RM conceptualised this manuscript. RR wrote the initial draft. MA, EB, DF, ILG, GC, RM, SVDB, MBTS and LR contributed to developing the final version, which is approved by all the authors.

Declaration of interests

The Authors declare no competing interests.