Territorial inequities in access to essential medicines for neglected tropical diseases in a decentralised European health system: a nationwide assessment in Spain

BACKGROUND: Neglected tropical diseases (NTDs) represent an increasing but often overlooked challenge for European health systems owing to international mobility, migration, travel, and climate-related changes in disease ecology. Although effective treatments exist for most NTDs and many are included in the World Health Organization (WHO) Model List of Essential Medicines, their availability in decentralised high-income health systems remains poorly characterised. This study assessed the availability, accessibility, and territorial variability of essential medicines for NTDs across the autonomous communities of Spain and identified the main barriers to equitable access. METHODS: A nationwide, cross-sectional study was conducted across the 17 autonomous communities of Spain. Data were collected between January and December 2025 through a structured survey of Hospital Pharmacy Services in centres with expertise in tropical medicine and infectious diseases and were complemented by expert clinical validation. Medicines were classified according to commercial status, access pathways, dispensing circuits, and regional availability. Descriptive analyses summarised inter-regional variability from a health systems and policy perspective. RESULTS: Data were obtained for 63 medicines and vaccines, generating 1134 records from all 17 autonomous communities. Twenty-two medicines were commercially available in Spain, whereas 39 required exceptional access mechanisms. Routine stock availability across all centres was reported in only 31.1% of valid records, while 52.8% reported no routine stock and 16.1% restricted availability to reference centres. Joint management by prescribing physicians and hospital pharmacy services was required in 72.1% of access procedures. Marked territorial variability was also observed in dispensing circuits and financing mechanisms, with 47.9% of valid records requiring full out-of-pocket payment and 47.1% involving co-payment. CONCLUSIONS: Access to essential medicines for NTDs in Spain remains structurally fragmented and territorially unequal. Strengthening coordinated national pharmaceutical policies is necessary to reduce reliance on exceptional access mechanisms and ensure equitable, timely, and sustainable access to essential medicines in Spain and other decentralised European health systems.