Drug Rationing in the post-Covid Era: The Regulatory Healthcare State in an Age of Politicisation and Geopolitical Tensions

Over the last few decades, governments across the industrialised world have faced oft-contradictory pressures over funding drugs through the public health care systems, including ensuring citizens’ access, containing costs, and promoting the industry producing health technologies. Recent trends have put these cross-cutting pressures into a new light: on the one hand, the arrival of new, expensive treatments has made drug pricing a salient political issue; on the other hand, the shortage of drugs – an issue that was not only felt acutely during the Covid-19 pandemic but has also become increasingly pressing over the last decade – has drawn public and political attention. Yet, despite the centrality of the provision of, and population access to, health technologies in modern, public health care systems, we have only limited understanding of to what extent and how governments have responded to these emerging challenges. This paper presents an analytical framework for understanding political struggles over drug rationing in rich democracies. Drawing on the historical institutionalist literature on policy feedback and policy development, the framework considers how different regulatory decision-making structures over drug funding/rationing emerged in the 1990s and 2000s – notably around the creation of health technology assessment bodies and concomitant regulatory institutional reforms in drug funding that were designed to augment the role of the “regulatory healthcare state” – have shaped the subsequent government strategies in the face of new challenges. The paper illustrates the framework through a comparative-historical analysis of the trajectories of drug rationing policies in England, France, the EU, and Japan, major advanced economies with different regulatory decision-making structures around drug funding. Drawing on extensive documentary evidence, newspaper coverage data to measure politicisation in the public arena, and interviews with different actors in the policy process, it traces how the different regulatory decision-making structures have shaped varying political struggles and policy development. It also evaluates the impact of major events since the late 2000s, such as Brexit, Covid-19, and rising geopolitical tensions triggered by the US-China trade wars and Russia’s invasion of Ukraine, on the subsequent developments. Overall, the paper thus demonstrates how studying health politics comparatively and historically can contribute to more general theory development in political science – the interactions of regulatory state and democratic politics facing adaptive challenges and pressures