Jay Iyer, CEO of the Access to Medicine Foundation, warns that rising nationalism and “onshoring” risk dismantling decades of progress in global health. As geopolitical tensions reshape how drugs are made and priced, Iyer argues that fragmented supply chains and profit-driven R&D often leave low-income nations – and the world’s most vulnerable patients – behind.
In the last two decades, increased access to medicine has saved countless lives. International partnerships have helped resource-constrained countries strengthen health systems, while governments have increasingly treated health as a political priority. Collaboration with the pharmaceutical industry has expanded the availability of numerous life-saving treatments and improved control of infectious diseases.
These hard-won gains are now at risk. A more nationalistic approach in geopolitics is reshaping how medicines are developed, manufactured and delivered, with potentially damaging consequences for global access.
Companies today face mounting political pressure over manufacturing locations and investment allocation. This is driven in part by legitimate concerns over supply-chain resilience and national security. Yet the shift is altering the global health landscape in ways that could reverse progress in access, particularly in low- and middle-income countries (LMICs).
The effects will not be confined to poorer regions but will also affect the resilience of health systems in wealthy nations, including the United States.
A clear example is the renewed emphasis on “onshoring” of the production of medicines and key ingredients via industrial policies. Faced with the threat of new tariffs from the Trump administration, at least 15 of the largest pharmaceutical companies have recently invested billions to shift their manufacturing to the US
This reorientation risks exacerbating fragility in emerging economies and lower-income markets. In Africa, several multinationals have already scaled back local commercial in favour of distributor-led models, citing competitive pressures and rising operating costs. This is concerning for a continent with only around 375 drugmakers, mostly concentrated in North Africa, while India and China have approximately 10,000 and 5,000 manufacturers, respectively.
US pricing reforms add another layer of strain. Policymakers have prioritised lowering drug costs, most notably through the Inflation Reduction Act, which grants Medicare new authority to negotiate prices and limits annual price increases to inflation. The first set of negotiated prices took effect in 2025, and this year’s reforms are expected to save Medicare enrollees an estimated USD 1.5 billion in out-of-pocket costs. A further 15 medicines are scheduled for price negotiations in 2027, with discounts averaging around 36 percent below net prices. At the same time, President Trump’s most-favoured-nation (MFN) initiative, designed to peg US drug prices to those paid in other developed countries, is adding to the pressure, leading to delayed introductions of new drugs to Europe and other countries.
The implications for access are concerning. When profitability is squeezed, companies become more risk averse and investment flows into narrow therapeutic areas serving wealthier populations with predictable returns. That leaves diseases that disproportionately affect lower-income countries, including many infectious diseases, struggling for funding. The ramifications are already evident in the fight against drug-resistant bugs, where the pipeline of new antibiotics is now dangerously thin. The 2026 Antimicrobial Resistance (AMR) Benchmark shows a 35 percent decline in the R&D pipeline among large pharmaceutical companies over the past five years. This is what happens when innovation and production are overly concentrated in the most commercially attractive segments and geographies.
Manufacturing and innovation are closely linked. As global production becomes more concentrated, supply chains become more vulnerable. Infectious diseases, climate‑driven health threats and AMR do not respect borders. Weakening innovation and access in one part of the world undermines health security everywhere.
Recent drug shortages underscore this fragility. The first half of 2025 saw over 214 active medication shortages in the US and 135 in the UK, including essential cancer drugs, antibiotics for children and treatments for heart disease. These shortages reflect a system overly reliant on a limited number of production sites. The situation is only aggravated by supply chain disruptions due to ongoing global conflicts and deteriorating trust between the US and China, a major source of pharmaceutical ingredients.
Against this backdrop, companies need portfolios that serve all needs, so that businesses investing in cancer also develop drugs to fight off infections in those same patients. Voluntary licensing is one way to lower the cost of goods and expand access, as demonstrated by the success of deals for HIV and hepatitis C across LMICs that have unlocked increased regional manufacturing.
Unfortunately, such approaches remain underutilised. The 2024 Access to Medicine Index shows that they remain largely restricted to a handful of the main infectious diseases, with priority medicines for non-communicable diseases, including cancer and diabetes, largely excluded.
Predictable approval pathways are key to investment. Today’s global innovation landscape is multipolar, with China now rivalling the US in global drug approvals. While such diversification can be healthy, regulatory fragmentation driven by geopolitical tensions would be highly damaging. LMICs are likely to be the first to lose out, but wealthier countries will ultimately pay a price through higher costs and increased shortages.
Regional initiatives could help rebalance this system. In Africa, the African Medicines Agency (AMA) is now moving toward implementation, which gives the continent a chance to harmonise regulatory standards and bolster local capacity. If implemented effectively, the AMA could improve both access and innovation while combating Africa’s long-standing problem of counterfeit and substandard medicines.
Ensuring that geopolitics do not undermine access is a matter of life or death. For over 20 years, my foundation has studied the pharmaceutical industry’s actions and guided it to do more to bring life-saving treatments to those who need them the most. The lesson is clear: companies that invest in global health, rather than retreat from it, are better positioned to navigate an increasingly uncertain world.
This is not only a moral imperative but a commercial one. Emerging markets already account for 20-30 percent of revenues for some pharmaceutical companies, so failing to invest in their development will increase earnings volatility and weaken growth prospects. Working with generic manufacturers to expand access through licensing deals can be a win-win, since it cuts costs and enables rapid scale-up while generating royalty streams for the originators.
In a world of interconnected health threats, resilience depends on distributed manufacturing, shared innovation and a commitment to serving patients everywhere. The alternative is a fragmented system that leaves every country vulnerable.
