pharma-punk

Price is not a property of the molecule.

Wed, 28 Oct 2026 12:00:00 +0000

A molecule has a structure. Its price comes later, produced by rules, expectations and relations of power. Yet in public debate, the price of a medicine often comes to seem like one of its natural characteristics, as if it were its molecular weight.

The WHO describes high prices as a barrier to access to medicines and calls for the policies governing them to be assessed and reviewed. That alone shifts the problem: from the isolated product to the conditions under which it circulates.

Research costs money. So does failure. These facts alone do not establish what price is justified for a particular product. That discussion requires information about additional benefit, alternatives, risk and who bore it. The word innovation cannot do all that work for us.

When a price is presented as inevitable, negotiation disappears from view. What remains looks like a compulsory choice: find more money or go without. This is a convenient frame for anyone able to set the initial terms.

A critical pharmacoeconomics begins before the calculation. It asks how that price was reached, which alternatives were excluded and who had a voice in the discussion. The numbers come afterwards. Then they can finally answer a less domesticated question.

Sources: WHO · Guideline on country pharmaceutical pricing policies (2020)

Sustainable for whom?

Wed, 28 Oct 2026 12:00:00 +0000

Sustainable for whom? For the annual budget, for those working in services, for those waiting for treatment? Without a subject, sustainability is a word that closes the discussion just when it ought to begin.

Resources are limited. Opportunity cost takes that limit seriously: funding one intervention can divert resources from other health benefits. The NICE manual makes this relationship explicit. Ignoring it would leave unrepresented the people who lose something without appearing in the case under discussion.

The next step, however, requires a political choice. Which resources do we consider available? Over what period? Which costs fall on families and which remain within the public budget? Changing the boundaries of the account changes what appears cost-effective.

Imagine a service reducing its expenditure by transferring an activity to family members. Its budget may record a saving. The time of those providing care is still being used up. This is a hypothetical example, but it makes a concrete problem of perspective clear.

Scarcity deserves analysis. So does the way it is distributed. Calling an arrangement sustainable without saying who supports it leaves someone carrying the weight outside the frame.

Sources: NICE · Incorporating economic evaluation

The patient the model does not see.

Wed, 28 Oct 2026 12:00:00 +0000

The QALY combines length of life and health-related quality of life in a common measure. It allows comparison between outcomes that would otherwise be difficult to place on the same scale. This is a valuable analytical possibility.

The problem begins when a useful measure is asked to exhaust our judgement. An aggregate result, on its own, says little about the distribution of benefits, people’s starting conditions or the barriers they face in accessing a service.

In NICE’s methodological reference for guidelines, a QALY carries equal weight across groups. This makes a convention explicit. It does not settle every question of equity: it places them alongside the calculation, where they can be discussed.

A spreadsheet does not necessarily hide people. It can make their needs visible, especially those pushed to the margins by the story of an individual case. But doing so requires us to know which differences we have chosen to represent and which we have compressed into an average.

The criticism we need enters the model, reads its assumptions and comes out with more precise questions. Who gains health? Who remains excluded? Which difference disappears when we present only the total?

Sources: NICE · Measuring and valuing health effects

The promise before the evidence.

Wed, 28 Oct 2026 12:00:00 +0000

An indicator improves. A curve shifts. The presentation is already speaking the language of a breakthrough. Between that signal and what changes in people’s lives, though, there may be a distance still to be measured.

The FDA distinguishes direct clinical outcomes from surrogate endpoints used to predict a benefit. It also distinguishes levels of surrogate validation. Confusing them turns evidence of differing strength into a single, undifferentiated promise.

There can be serious reasons for making a decision early. Waiting has a cost, particularly when alternatives are few. Uncertainty, however, does not evaporate at the moment of purchase. Someone continues to bear it: the service that pays, the person receiving treatment, those awaiting confirmation of the result.

This raises a concrete economic question: how does the agreement change if the expected benefit fails to materialise? Answering it requires the ability to track outcomes, read the terms and understand how the consequences of error are distributed.

The future is already in the price. The question is whether, when it arrives, we can still hold it to account for the promises made.

Sources: FDA · Surrogate Endpoint Resources for Drug and Biologic Development

The future outside the budget.

Wed, 28 Oct 2026 12:00:00 +0000

We grow used to discussing which treatments we can afford. We less often discuss the conditions that determine the answer. Debate takes today’s rules as a permanent frame, then calls any proposal that fits inside it realistic.

Meanwhile, we ask technology to invent the future. We ask politics to administer the present. This division of labour leaves untouched the very mechanisms that determine who will be able to use what gets invented.

A different price, another form of funding, a differently organised service: each possibility requires evidence, resources and debate. None is good simply because it is an alternative. But excluding them before the analysis makes the result predictable, and predictability comes to look like necessity.

Pharmacoeconomics can do something more interesting than certify compatibility with existing arrangements. It can compare scenarios, make trade-offs explicit and test new rules. To do so, it also needs to be able to choose the question.

This notebook begins at that point. Where a conclusion presented as inevitable becomes open to discussion again. And therefore, perhaps, to change.