Making medicine access governable: Payment and procurement architectures for sustainable pharmaceutical access
Bowen ShengBackground
Medicine-access commitments can remain fragile when affordability objectives are not supported by durable purchasing, payment and supply arrangements.
Purpose
This study examines why access-oriented pharmaceutical strategies become institutionally difficult to sustain and identifies architectures that make them more governable.
Methods
A theory-building qualitative design combines longitudinal public-document process tracing of GSK’s access and restructuring trajectory with mechanism-focused comparisons of England’s antimicrobial subscription model and Australia’s hepatitis C lump-sum arrangement.
Results
Commitments are most vulnerable when their value is delayed, weakly contractualized or concentrated as an open-ended balance-sheet burden. Durability improves when access is embedded in multi-year procurement, funded offtake, subscription payments, aggregate purchasing or technology transfer. The NHS model delinks revenue from volume to support stewardship, while Australia’s arrangement reduces the payer’s marginal budget exposure to enable treatment scale-up. The analysis further shows that business viability and public-health value can be aligned without relying on indefinite unilateral corporate concessions. These mechanisms also illuminate how generic-medicine markets can align affordability with procurement predictability and reliable supply.
Conclusions
Sustainable access depends less on one-off concessions than on institutional architecture that specifies payment, duration, supply responsibilities and accountability. The framework offers practical guidance for pharmaceutical and generic-medicine firms, purchasers and health-system managers.