Equitable access to essential medicines, which the World Health Organization (WHO) defines as those that meet the priority needs of the population,1 is key to achieving universal health care coverage.(2) However, it is estimated that essential medicines are unaffordable or unavailable to 1 in 4 people worldwide.(3) As governments strive to achieve universal access to essential medicines, it is important to understand how the prices and affordability of these medicines vary between countries. High drug prices strain both personal and government budgets, especially in low- and middle-income countries, where patients often face high out-of-pocket costs.

Although many national surveys of medicine prices and affordability have been conducted, fewer analyses have compared these variables internationally, with most research dating back to 2011 or earlier.(4-20) Many of these studies have focused on high-income countries. Of the studies that also included low- and middle-income nations, most compared the prices of 15 or fewer medicines or included a small number of countries, limiting the generalizability of those findings. Therefore, little is known about the relationship between national income and drug prices. The question remains whether some poor countries routinely pay more than rich countries for the same prescription drugs, possibly owing to weaker pharmaceutical pricing policies.

This cross-sectional study used global data on pharmaceutical sales to compare the list prices of 549 essential medicines in 72 high-, middle-, and low-income markets (covering 87 countries) in 2022, both in nominal and purchasing power–adjusted terms. We also evaluated the affordability of 8 essential medicines used to treat major causes of death and disability globally.

On May 12, 2025, the Trump administration issued an executive order to lower prescription drug costs by mandating that the US pay no more than prices in peer countries. The legality of implementing this so-called most favored nation (MFN) pricing through executive action is unclear. However, the idea of benchmarking US drug prices to prices in other countries is not new. The Trump administration unsuccessfully attempted a more limited MFN policy during its first term, and a 2019 bill passed by House Democrats used international prices as upper limits for Medicare price negotiations. Although lowering drug prices is a priority, achieving this by linking prices in the US to those in other countries is a misguided approach built on a misdiagnosis of the reason prices are higher in the US than in other countries.

The responses to our study on wealth and mortality in the United States and Europe raise important questions about causal inference, potential confounding, and the interpretation of cross-national differences. As noted by the correspondents, our findings reflect associations, not causal relationships. Although the patterns we observed were consistent across settings, more work is needed to disentangle the complex relationship between wealth and health.

Uncertainties about the benefits and harms of new drugs are common at the time of drugs’ approval. It is unclear to what extent the Food and Drug Administration (FDA) communicates these uncertainties in the FDA-approved prescribing information (the drug label), which is the primary channel of communication between the FDA and physicians. Although physicians might not regularly consult the drug label for prescribing decisions, other information sources used by physicians either index or incorporate information from the label. We searched FDA review documents for uncertainties identified by FDA reviewers with new cancer drugs. We considered the subset of uncertainties highlighted in the FDA’s Benefit-Risk Framework as important to the FDA’s approval decision. During the period 2019–22, the FDA approved fifty-two new cancer drugs. In review documents, FDA reviewers identified a total of 213 clinical trial uncertainties with new cancer drugs, 50 percent of which were considered to be important uncertainties to the FDA’s approval decision. Labels for physicians reported information on 26 percent of all uncertainties and 48 percent of uncertainties that were important to the FDA’s approval decision. Communicating uncertainties about the evidence of drugs in the label is essential for informing physicians about drugs’ safe and effective use.

Scholars express concern that general practitioner shortages and specialist surpluses induce overspecialization, with overuse of costly specialist services and underuse of cost-effective primary care services. Yet few studies directly assess the relationship between physician supply and patient utilization. Given this gap, this paper examines the associations between physician supply, care utilization, and patient need and whether patients use more specialists in areas with lower primary care supply.

We appreciate the responses to our Article, which suggest that the health cost of paying for new pharmaceuticals in the National Health Service (NHS), estimated at £1·25 million quality-adjusted life-years (QALYs) lost between 2000 and 2020, might be justified by the benefits of incentivising future innovation, attracting industry funding, or prioritising certain populations—we disagree.

Outcomes after a hip repair in the older adult population are highly dependent on patients’ characteristics. However, contextual factors such as the hospital of treatment may have an impact not sufficiently studied. We aimed to elicit the effect of hospital providers on all-cause-adjusted mortality rates after hip fracture repair. Observational study on virtually all potentially eligible hip fracture patients treated in 2240 hospitals from Ontario (Canada), Aragon (Spain), Finland, Sweden, and the USA (40 states). The primary endpoint was the risk-adjusted all-cause mortality after hip repair measured 30 days and 180 days after surgery. Following a federated approach, GAMM-logit models were run for each region. Median odds ratio (MOR) were estimated to elicit the variation at hospital level. The study included 535 519 hip repairs. The overall predicted 30-day adjusted mortality rate was 40.5 per 1000 hip repair episodes; 136.3 per 1000 hip repair episodes in the 180-day adjusted mortality rate. 30- and 180-day adjusted mortality rates were larger within the regions than across regions. Variance in patients’ mortality at the hospital provider accounted for MOR: 1.43 in 30-day mortality and MOR: 1.35 in 180-day mortality. Beyond differences in the individual risk of death, our study found wide systemic variations in mortality rates in older adult patients exposed to hip fracture repair attributable to the hospital of treatment. Our results call for a reorientation of care pathways after hip repair in frail patients, both in the short- and the long-term.

The English National Health Service (NHS) is a publicly funded system, however significant disparities in provision exist. Whereas the national picture of the distribution of Intensive Care Unit (ICU) beds has increased over time, less is understood about the regional variation in the rate of growth in ICU services and whether this is related to population growth. The aim of this study was to describe the national variation in the supply of ICU beds in England and evaluate whether there has been a narrowing of the regional disparities in providing ICU beds over time.

In the most recent National Health Expenditure (NHE) Projections, for 2024-33, Sean Keehan and colleagues at the Centers for Medicare and Medicaid Services (CMS) predict strong growth in health care expenditures in 2024, and average annual growth over the entire projection period that exceeds growth in GDP. According to their projections, health care is set to comprise 20.3 percent of GDP by 2033. This increase in health spending is expected despite declines in coverage, prompted by the continued unwinding of Medicaid pandemic policies and lower enrollment in private insurance stemming from the expiration of the IRA’s temporarily enhanced premium tax subsidies for Marketplace plans.

The Publication-of-the-Year Award recognizes the best and most relevant peer-reviewed, scientific work that the fields of health services research and health policy have produced and published in the prior calendar year.

Publication-of-the-Year Award
Differential Legal Protections for Biologics Vs Small-Molecule Drugs in the U.S.
Olivier J. Wouters, Ph.D.

The past two decades have seen a surge in available patient safety metrics. However, the variability in how healthcare organizations choose and monitor these metrics remains unknown. We cataloged the metrics organizations chose and how actively they monitored them. We investigated factors influencing the monitoring of patient safety metrics using surveys and in-depth interviews with patient safety experts from 11 Harvard-affiliated organizations.

In this piece we examine three forms of coercive or otherwise involuntary care that can occur with patient consent. To do so, we examine: (1) uninformed consent, (2) contingency-based consent and (3) constrained-market consent, amongst female sterilization patients. While there is broad recognition that “coercion” in sterilization care can manifest beyond instances of overt force and clarity on what constitutes coercion within clinical care, this has not translated to accountability. The current practice of identifying coercion through discrete civil cases may facilitate a narrow understanding of its contemporary prevalence; one that does not align with definitions of coercion supported by international human rights entities. We use three acute, and widely recognized, examples—hysterectomies in ICE detention facilities, India’s sterilization camp deaths and birth control quotas for Uyghur women—as an entry point to highlight less overt contemporary forms of coercive sterilization care, pairing each example with data that explores prevalence at a broader population level. These data suggest less visible forms of coercion may persist relatively unchallenged—raising the ethical case for a functional approach to the measurement of coercion. In turn, we argue the relevant question may not be “when is coercion ethically justified in public health,” but rather, why is coercion already the status quo?

Worse health outcomes have been described for patients with sepsis from more deprived neighborhoods, but it is unclear if this disparity gap has narrowed. Moreover, the mechanisms by which neighborhood disadvantage influences sepsis outcomes are not fully understood. This study aims to understand the trajectory of mortality among patients with sepsis in England across varying levels of neighborhood deprivation, and to what extent do patterns of ICU admission and treatment explain the observed differences.

Since 1999, the National Institute for Health and Care Excellence has weighed costs against benefits to help the NHS decide what it should buy. The institute’s boss, Sam Roberts, calls it a mindful “health-care innovation shopper”. Within a fixed budget, every new drug it buys risks squeezing essentials like GPs or ambulances among existing health-care services.

Fever is associated with brain injury after cardiac arrest. It is unknown whether fever management with a feedback-controlled device impacts patient-centered outcomes in cardiac arrest patients. This trial aims to investigate fever management with or without a temperature control device after out-of-hospital cardiac arrest. The TEMP-CARE trial will investigate if post-cardiac arrest management of fever with or without a temperature control device affects patient-important outcomes after cardiac arrest.

We performed a longitudinal, retrospective cohort study involving adults 50 to 85 years of age who were included in the Health and Retirement Study and the Survey of Health, Ageing, and Retirement in Europe between 2010 and 2022. Wealth quartiles were defined according to age group and country, with quartile 1 comprising the poorest participants and quartile 4 the wealthiest. Mortality and Kaplan–Meier curves were estimated for each wealth quartile across the United States and 16 countries in northern and western, southern, and eastern Europe. We used Cox proportional-hazards models that included adjustment for baseline covariates (age group, sex, marital status [ever or never married], educational level [any or no college education], residence [rural or nonrural], current smoking status [smoking or nonsmoking], and absence or presence of a previously diagnosed long-term condition) to quantify the association between wealth quartile and all-cause mortality from 2010 through 2022 (the primary outcome).

The volume-outcome relationship has been a commonly invoked policy initiative aimed at improving the quality of healthcare. This inverse relationship between the caseload volume of patients treated and patient mortality has been described across many health settings and in many countries. Despite the large body of literature demonstrating this favourable relationship, most studies have focused on differentiating the effects of selective referral and the true effects of volume. In comparison, there are few studies evaluating the underlying mechanism of the volume-outcome relationship, namely dynamic learning-by-doing or the static effect of economics of scale. Resolving this tension between policies that allow providers to accrue experience over time and policies that promote centralisation of services would make a more compelling argument for policies such as minimum volume standards to be firmly established.

In recent months, a new kind of partnership between telehealth companies and pharmaceutical manufacturers has come under scrutiny over concerns that such arrangements could lead to inappropriate prescriptions and poor care. Eli Lilly and Pfizer, along with five telehealth companies accessible through the pharma companies’ websites, have recently received letters from four senators echoing those concerns, asking questions about care, prescription volume, and the flow of data and money between the firms. The lawmakers want to determine whether pharma-telehealth deals may be violating the federal anti-kickback statute. That question has also piqued the interest of three health policy researchers at Brown University.

In this retrospective study, between 2009 and 2021, avoidable mortality increased in all US states, primarily due to increases in preventable deaths, while it decreased in comparable high-income countries. Health spending was significantly negatively associated with avoidable mortality for other high-income countries but not across US states.

Americans have grown accustomed to direct-to-consumer pharmaceutical advertisements and the refrain, “If you think [this drug] is right for you, talk to your doctor.” But some recent online ads feature a new twist — a link to a clinician offering telehealth services. Several pharmaceutical companies have also launched online platforms that direct users to websites run by telehealth companies, where clinicians are available to prescribe medications after a virtual consultation.

Repeated Supreme Court cases suggest uninformed sterilization care is a persistent and contemporary issue in India. This article examines patient satisfaction ratings as a potential accountability mechanism to assess normalized forms of coercion. With a sample of over 180,000 sterilized women in India, it identifies a statistically significant relationship between exposure to coercive care and odds of reporting low quality. However, over 95 percent of women who underwent a tubal ligation procedure rated their care highly even when provided with inadequate information (a recognized form of coercion), with more pronounced discordance when a patient belonged to a historically marginalized caste. System-modifiable factors, such as conditional cash transfers (CCT) to the patient and postpartum procedure timing increased reporting discordance. Using a reproductive justice lens and building on Amartya Sen’s capabilities approach, this work examines how to identify human rights violations in the routine delivery of care.

Repeated Supreme Court cases suggest uninformed sterilization care is a persistent and contemporary issue in India. This article examines patient satisfaction ratings as a potential accountability mechanism to assess normalized forms of coercion. With a sample of over 180,000 sterilized women in India, it identifies a statistically significant relationship between exposure to coercive care and odds of reporting low quality. However, over 95 percent of women who underwent a tubal ligation procedure rated their care highly even when provided with inadequate information (a recognized form of coercion), with more pronounced discordance when a patient belonged to a historically marginalized caste. System-modifiable factors, such as conditional cash transfers (CCT) to the patient and postpartum procedure timing increased reporting discordance. Using a reproductive justice lens and building on Amartya Sen’s capabilities approach, this work examines how to identify human rights violations in the routine delivery of care.

The aim of this report from the Expert Group (see Box 1) on Health Systems Performance Assessment (HSPA) is to establish a comprehensive definition of low-value care in line with the concept of valuebased healthcare and from a health system perspective, and to identify low-value care indicators and measures to facilitate the reduction of low-value care for national HSPA practices. To achieve this aim, a “value-based healthcare” working group was established as a subgroup of the Expert Group with country representatives from Belgium, Czechia, Estonia, France, Germany, Hungary, Italy, Poland, Portugal, Romania and Slovenia as well as the European Observatory on Health Systems and Policies, the Organisation for Economic Co-operation and Development (OECD) and the DirectorateGeneral for Health and Food Safety (DG SANTE)