The Foundation publishes the Index every two years. It picks twenty companies based on market capitalisation and how relevant their portfolios are to diseases of poverty - mostly the household names of pharma, with one notable inclusion, the unlisted German firm Boehringer Ingelheim, that meets the criteria. Researchers measure each company across three Technical Areas: Governance of Access, Research and Development, and Product Delivery. The framework uses self-reported company data, but cross-checked against public sources, and the analysis is weighted: a company gets credit for what actually reaches patients, not just for what it promises in a corporate-responsibility report. The 2024 edition tracked 81 priority diseases across 113 low- and middle-income countries. Funders included the Dutch foreign ministry, the British Foreign, Commonwealth and Development Office, the Gates Foundation, the Wellcome Trust, the Helmsley Trust, Axa Investment Managers, and Stewart Investors - an unusual coalition of governments, philanthropies and investors who share the view that the data matters.

The Index landed in 2008 with one early endorsement that mattered: Bill Gates mentioned it in Time that July, calling it the kind of incentive that gives businesses credit for what they're already doing. Two years later Paul Hunt, the former UN special rapporteur on the right to health, described it as a way to measure pharma against its human-rights obligations. A 2010 UBS report told institutional investors that the Index was a usable tool for assessing access-to-medicine performance on its own terms, separate from broader corporate-responsibility frameworks. That last point opened a door. Asset managers in Japan, the UK, Sweden, Australia and beyond began citing Index rankings in their engagement with pharmaceutical boards. A spreadsheet from a small Amsterdam foundation had become part of how the world's drug companies are valued.

The Index focuses on low- and middle-income countries defined by the World Bank, the UN's Least Developed Countries list, the Human Development Index, and the Inequality-Adjusted Human Development Index. That last classification matters: it pulls in countries that look prosperous on paper but contain enormous internal inequality - places where a drug being theoretically available in a capital city tells you nothing about whether a child in a rural province can actually get it. The 2024 disease list covered 81 conditions and pathogens, from HIV and tuberculosis to neglected tropical diseases and antibiotic-resistant infections. In 2023 the Foundation also launched a separate Generic and Biosimilar Medicines Programme, recognising that the original Index - which excludes pure generics manufacturers - was missing a huge part of how affordable medicine actually moves through the world.

Self-reported data carries an obvious risk: companies grade themselves. The Foundation answers that by checking against external sources where possible, and by publishing the rankings every two years so that gaps between what companies promise and what they deliver become visible over time. A company that promised expanded access in one cycle has to explain a missing programme in the next. There are honest limits. Drug access is one dimension of pharmaceutical responsibility; an Index ranking is not a verdict on whether a company is good or bad. What it does instead is something subtler - it makes a previously invisible comparison legible. The result, twenty years in, is that boardrooms in New York, Basel, Tokyo and Mumbai pay attention to a small Dutch nonprofit they probably wish did not exist.