Balancing policy ambition and systems reality in expanding access to NCD medicines: lessons from Ghana and Georgia

Abstract Ensuring sustained access to affordable, high-quality medicines is central to achieving universal health coverage (UHC) in low- and middle-income countries (LMICs). This is particularly true for chronic non-communicable diseases (NCDs), which require long-term, uninterrupted treatment. Although global guidance recommends expanding pharmaceutical benefits, regulating prices, promoting generics, and strengthening procurement and supply chains, many LMICs continue to face inequities in medicine availability and high out-of-pocket costs. The experiences of Ghana and Georgia, two countries that have invested heavily in UHC reforms, pharmaceutical benefits, centralized procurement, and pricing policies, illustrate gaps between policy ambitions and implementation realities in expanding access to NCD medicines. This paper examines four health-system factors influencing access to NCD medicines: system capacity, provider behaviour, digital enablers, and public trust. In both countries, centralized procurement faces forecasting inaccuracies, procurement delays, supply chain weaknesses, and distribution challenges, leading to stockouts and inconsistent availability. Provider behaviours further influenced access, with reimbursement delays, low payment rates, and administrative burdens contributing to informal fees, off-list prescribing, and suboptimal use of generics. Investments in digital systems such as logistics management information systems and electronic prescribing showed promise but were limited by uneven adoption, data quality issues, and insufficient integration into decision-making processes. Public awareness and trust emerged as critical yet neglected determinants. Limited communication and perceptions of low-quality of state-purchased medicines reduced uptake of benefits in Georgia, while gaps between National Health Insurance Scheme (NHIS) intentions and patient experiences constrained equitable access in Ghana. Strengthening access to NCD medicines requires system-wide readiness, aligned provider-patient incentives, effective digital integration, and sustained community engagement to build trust and support uptake.