Pharmaceutical Pricing and Governance in Sri Lanka and LMICs: From Price Ceilings to Adaptive Accountability.

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.