National Responses to Sanctions and Economic Recession in the Pharmaceutical Sector: A Realist Review

Aim Ensuring equitable access to essential medicines remains a persistent global health challenge, particularly under conditions of economic and political instability. This realist review aimed to identify how countries maintain pharmaceutical access during economic recessions and sanctions, and to explain what mechanisms make policies successful in different contexts. Methods RAMESES guidelines were followed to analyze how countries maintain pharmaceutical access during economic crises. We systematically searched four databases (2000–2025), identifying 25 eligible studies across 24 countries. Using the WHO access to medicines framework, we extracted data on national interventions and their impacts, focusing on context-mechanism-outcome configurations. Through iterative analysis, we developed and refined program theories explaining how different strategies succeed or fail in various crisis settings. Results Our analysis demonstrates that successful pharmaceutical access during crises requires coherent strategies across rational medicine use, affordable pricing, sustainable financing, and reliable supply systems. Austerity measures like price cuts and patient co-payments achieved immediate fiscal savings but consistently led to drug shortages and access barriers. Sustainable outcomes emerged from combining institutional flexibility with equity focused governance, particularly safety nets for vulnerable groups, alongside strategic supply chain investments in domestic production and proactive monitoring systems. Conclusion Protecting medicine access during economic crises demands integrated system wide approaches rather than isolated cost containment measures. Policymakers should balance fiscal responsibility with equitable access through adaptable governance structures and strategic investments in supply chain resilience.