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

From Revolving Drug Funds to Sustainable Medicine Access: A Systematic Review of Implementation Cycles and Failure Pathways in Low and Middle Income Countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review From Revolving Drug Funds to Sustainable Medicine Access: A Systematic Review of Implementation Cycles and Failure Pathways in Low and Middle Income Countries Hamad A. Albagir This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8776349/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. Health Economics and Outcomes Research drug financing essential medicines health systems sustainability pharmaceutical policy developing countries Full Text Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8776349","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":585073481,"identity":"4f64cb97-1a43-418a-bcfd-b538f280f50d","order_by":0,"name":"Hamad A. 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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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFollowing PRISMA 2020 guidelines, we conducted comprehensive searches across PubMed, Scopus, Embase, and Web of Science (2000\u0026ndash;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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur analysis delineates three distinct RDF lifecycle phases: (1) \u003cb\u003eInitiation\u003c/b\u003e (years 0\u0026ndash;3), characterized by 40\u0026ndash;70% reductions in stock-outs and 70\u0026ndash;90% cost recovery; (2) \u003cb\u003eConsolidation\u003c/b\u003e (years 4\u0026ndash;7), marked by emerging governance challenges and inflationary pressures; and (3) \u003cb\u003eDecline/Demise\u003c/b\u003e (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.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRDFs 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.\u003c/p\u003e","manuscriptTitle":"From Revolving Drug Funds to Sustainable Medicine Access: A Systematic Review of Implementation Cycles and Failure Pathways in Low and Middle Income Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-04 19:42:38","doi":"10.21203/rs.3.rs-8776349/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"938d514e-8f44-49c4-bdb3-852a30259096","owner":[],"postedDate":"February 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62242357,"name":"Health Economics and Outcomes Research"}],"tags":[],"updatedAt":"2026-02-04T19:42:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-04 19:42:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8776349","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8776349","identity":"rs-8776349","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}