Abstract:
Medicine affordability in Sri Lanka and other low- and middle-income countries
(LMICs), as classified by the World Bank, has long been pursued through price
ceilings and procurement reforms. However, evidence on how governance conditions
influence the success or failure of these measures remains fragmented. This
study addresses that gap by synthesizing global practices in price-ceiling regulation
and analyzing seven decades of pharmaceutical policy in Sri Lanka. The
objective is to develop an adaptive multi-level governance framework that links
political economy, institutional accountability, and actor behavior. A scoping review
was conducted using JBI and PRISMA-ScR guidance. Searches across MEDLINE,
Scopus, Web of Science, and major grey literature sources covering 2009
to 2025 identified 66 documents from 13 countries. Findings show that transparent
pricing methodologies, predictable revision cycles, and structured stakeholder
engagement are the strongest drivers of both affordability and supply sustainability.
These governance conditions are more influential than the formulas used.
Weak enforcement and opaque processes align with shortages and policy reversals.
Sri Lanka’s experience from 1949 to 2025 demonstrates this pattern, with shifts
often propelled by leadership discretion and symbolic actions that generate shortterm
legitimacy while weakening institutional capacity. The framework highlights
coherence across macro-level political legitimacy, meso-level accountability mechanisms
built on transparency, answerability, and enforceability, and micro-level
actor reasoning. Price ceilings should be understood as governance instruments
rather than technical measures. Integrating them into adaptive systems that publish
methodologies, institutionalize reviews, use health technology assessment and
procurement data, and enable participatory oversight can reduce oscillation and
support sustained access. Limitations include variability in reporting across countries.
Future research could apply the framework in live regulatory environments
to assess its practical value. Overall, this study shows that governance rather
than pricing formulas underpins resilient pharmaceutical regulation and provides
principles that can guide LMIC regulators seeking durable and transparent systems
for medicine pricing.
