Presentation (CTI)

OBJECTIVES: Equitable pharmaceutical pricing is fundamental to Pharmacoequity and Universal Health Coverage (UHC), yet in Nepal it is dictated less by policy than by power. Market dominance, federal fragmentation, and geopolitical dependence now shape price formation in the absence of a coherent national pricing policy. This policy vacuum has institutionalized regulatory loopholes and enabled political-commercial interference, eroding state control over medicine access. This study analyzes how actor power, administrative asymmetries, and geopolitical market dependence drive price variation and constrain Nepal’s UHC goals.
METHODS: A mixed-methods design was applied, comprising: (1) a systematic review of peer-reviewed and grey literature (2000-2025; n = 56); (2) secondary analysis of medicine price data from public hospitals, private pharmacies, and national procurement records across all seven provinces of Nepal (n = 348 observations); and (3) semi-structured stakeholder interviews with regulators, providers, pharmaceutical industry actors, insurers, and patient advocates (n = 24). Affordability was assessed using WHO/HAI methodology as the number of days’ wages required by the lowest-paid unskilled worker. A comparative policy benchmarking framework was applied with five lower-middle-income countries.
RESULTS: Substantial price variation was observed across essential medicines, with minimum-maximum price ratios exceeding five-fold within the same therapeutic categories. Non-revision of discretionary price ceilings and weak enforcement of retail mark-up limits were strongly associated with wide intra-market dispersion. Stakeholders reported persistent political and commercial interference through regulatory delays and selective enforcement, while pharmacies operated predominantly as profit-maximizing commercial entities. Comparator countries with centralized price oversight and formal reference pricing frameworks demonstrated consistently narrower price bands.
CONCLUSIONS: Nepal’s pharmaceutical pricing crisis reflects a governance and political economy failure rather than a technical policy gap. Advancing UHC requires establishment of an independent pricing authority, statutory reference pricing and mark-up regulation, mandatory periodic price revision, and integration of pricing governance with national health insurance and procurement systems.