From Revolving Drug Funds to Sustainable Medicine Access: A Systematic Review of Implementation Cycles and Failure Pathways in Low and Middle Income Countries

Background The Revolving Drug Fund (RDF) model has been widely implemented across low- and middle-income countries (LMICs) since the 1980s as a market-based mechanism to address chronic medicine shortages. Despite early successes in improving drug availability, many RDFs have experienced significant challenges leading to failure or substantial modification. This systematic review examines the full lifecycle of RDF implementation in LMICs, analysing systematic patterns of decline and transition. Methods Following PRISMA 2020 guidelines, we conducted comprehensive searches across PubMed, Scopus, Embase, and Web of Science (2000–2023). Sixty-seven studies met the inclusion criteria, representing diverse LMIC contexts. Thematic analysis identified failure patterns across financial, governance, and operational dimensions, with critical appraisal based on Joanna Briggs Institute protocols. Results Our analysis delineates three distinct RDF lifecycle phases: (1) Initiation (years 0–3), characterized by 40–70% reductions in stock-outs and 70–90% cost recovery; (2) Consolidation (years 4–7), marked by emerging governance challenges and inflationary pressures; and (3) Decline/Demise (years 8+), wherein only 31% of programs retained their original structure. Primary failure pathways included financial unsustainability (85% of studies), weak governance structures (78%), macroeconomic shocks (71%), equity violations (66%), and supply chain inefficiencies (59%). The Sudanese transition from RDF to the National Medical Supplies Fund (NMSF) exemplifies strategic adaptation to these systemic limitations. Conclusion RDFs exhibit predictable lifecycle patterns with inherent structural vulnerabilities in LMIC settings. Sustainable pharmaceutical financing requires integrated approaches that combine efficient procurement with robust equity protections. Future models must navigate the tension between cost recovery and universal access through hybrid financing mechanisms and stronger integration within health systems.