Intended for healthcare professionals


Healing an ailing pharmaceutical system: prescription for reform for United States and Canada

BMJ 2018; 361 doi: (Published 17 May 2018) Cite this as: BMJ 2018;361:k1039
  1. Adam Gaffney, instructor in medicine1,
  2. Joel Lexchin, professor emeritus2,
  3. US,
  4. Canadian Pharmaceutical Policy Reform Working Group
  1. 1Department of Medicine, Cambridge Hospital/Harvard Medical School, Cambridge, MA 02139, USA
  2. 2School of Health Policy and Management, York University, Toronto, Ontario, Canada
  1. Correspondence to: A Gaffney agaffney{at}

Our pharmaceutical systems are broken, and only fundamental reform can ensure universal access to safer, more innovative, and more affordable drugs

Key messages

  • The US and Canadian pharmaceutical systems are dysfunctional

  • Costs are exorbitant, commercial goals distort drug development, misleading promotion fosters misuse, and medications are too often unaffordable for patients

  • We propose reforms that would provide universal drug coverage without fees at the point of use while reducing prices through negotiations with drug firms and, when needed, compulsory generic manufacture

  • Innovation would be enhanced through patent reform and by establishing new public agencies to fund drug development and clinical trials

  • Drug safety, efficacy, and prescribing quality would be improved by raising standards for approval and safety monitoring

  • While the proposals face formidable political obstacles, a popular mandate exists for pharmaceutical reform in both nations

Drugs are among medicine’s most powerful tools. Yet the pharmaceutical systems of the United States and Canada are mired in dysfunction. The industry’s pricing practices—charging whatever the market will bear, especially in the US—strain budgets and put vital medicines out of reach for many patients.1234 Despite some notable advances, the industry’s overall rate of real innovation remains incommensurate with our vast drug spending; many new drugs are marketed each year but few represent substantial clinical improvements.567 And commercial imperatives distort drug trials,8 research priorities, and drug regulation.910

While many recognize the need for change, proposed remedies vary3111213 and would fall short of achieving the fundamental reform that these deficiencies call for. The advocacy organization Physicians for a National Health Program therefore encouraged a working group of US and Canadian doctors, scholars, and advocates (the US/Canadian Pharmaceutical Policy Reform Working Group) to come together to craft a wide ranging reform proposal for both nations. …

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