The Foreign Inspection Gap: FDA GMP Oversight of U.S. Drug Imports, 2014–2024

With the globalization of the pharmaceutical industry, the majority of active pharmaceutical ingredients and finished drug products entering the U.S. market originate from overseas manufacturing sites. From 2014 to 2024, FDA-conducted foreign Good Manufacturing Practice (GMP) inspections have fallen sharply. This divergence underpins the FDA’s recent shift toward unannounced foreign facility inspections and underscores the need to modernize global oversight. This study examines how trends in FDA inspection quality relate to increasing import volumes of drugs into the United States by analyzing FDA-issued observations since 2014 and assessing the impact of escalating imports on inspection practices and enforcement. U.S. FDA inspections and import volumes of drugs and drug products to the United States were assessed. Ratios of import quantities and inspections were used to evaluate the FDA’s effectiveness in enforcing inspections abroad, as drug imports increased from 2014 to 2024. Increasing import volumes corresponded with declining inspection frequencies from 2014 to 2019. For every additional billion dollars of drug imports to the United States, there were 23 fewer inspections conducted during 2014–2019. Additionally, while import volumes increased in leading import nations, inspections declined over the same period in most cases. The documented decline in inspection intensity (China: 101.8 to 18.3 inspections per billion USD of imports, 2014–2024), stable inspection outcome rates with observations (VAI + OAI) despite varying inspection volumes, and persistent disparities between MRA and non-MRA countries provide empirical support for the FDA’s May 6, 2025, shift toward unannounced foreign inspections. Foreign facilities exhibited inspection outcome rates with observations 1.3–1.8 times higher than the U.S. baseline (49.3%), with China (69.0%) and India (62.3%) showing particularly elevated rates. These findings underscore the need for continued modernization of the foreign inspection framework and development of metrics to ensure oversight scales proportionally with the globalization of pharmaceutical manufacturing