Pharma in 2026 will be defined by unpredictability. Executives are already being pushed by shifting policy, commercial, and scientific forces into making fast and tough strategic choices, with more to come throughout the year, as regular contributor Brendan Shaw lays out in his annual look-ahead.
Senior executives in the pharma industry starting the new year reading about narco‑terrorist states, invasions of Greenland, and ‘6-7’ must be scratching their heads and wondering ‘What just happened?’
Here, today, one-quarter of the way through the 21st century, it is a cliché to say that the world is awash with disruption in geopolitics, society, economics, business, technology, and the environment. With all the uncertainty and change going on, who would bother trying to pick five things to watch at the beginning of the year?
But, after last year’s surprisingly correct predictions for 2025, this year I again try my hand at picking five things for pharma company executives to watch in 2026 – and, yes, we again finish with a provocative and unexpected ‘6th thing’ to reflect on as well.
MFN
Few acronyms have shaken the pharmaceutical industry as much as MFN. Once a technical concept rooted in trade policy, “most favoured nation” pricing now threatens to upend global pharmaceutical economics more profoundly than any policy shift since the emergence of universal health coverage and the modern drug industry. Since the Second World War, pharma and health systems have co-evolved: high-income countries built publicly and privately funded models early on, while lower- and middle-income countries have been catching up more recently.
However, as in other areas of economic and foreign policy, in the last 12 months the United States has flagged that it no longer wants to lead in funding the development of medicines. The pressure on other countries to do more may transcend political divides within the US. Those in other countries hoping that a possible Democrat win in the mid-term Congressional elections in November might remove the pressure for change are likely to be sorely disappointed. If there’s one thing that has united Republicans and Democrats over the years, it has been a desire to get US drug prices down one way or another.
Pharmaceutical companies will have to use all their skills to operate, invest and grow in this changing policy environment. Meanwhile, governments, insurers and other funders may want to navigate this changing landscape carefully. It might be that the rudimentary post-war consensus on how medicines get funded for the world is starting to unravel. The recent announcements of changes to the United Kingdom’s NICE cost-effectiveness threshold as a result of last year’s US-UK trade agreement could be a portent of things to come.
The pressures and problems in medicine funding confronting governments around the world have been building for some time. Trump has merely been the catalyst for reforms that needed to happen. Whether it’s outdated health technology assessment systems, the use of pharmaceutical company rebates to help co-fund public health systems, or declining R&D levels, Trump has tapped into these long-running issues to progress his policy agenda. This will all continue to dominate 2026 for the industry.
Government affairs and global health become key to commercial strategy
For years, the government affairs and global health functions in many pharmaceutical companies were important, but seen as somewhat secondary to the hard-nosed commercial parts of the business. 2026 may be the year where policy, access to medicines, market access and sustainability become central to company business strategy. With the US actively negotiating trade and pricing policy one-on-one with individual pharmaceutical companies, various other countries under pressure to recalibrate their own medicines evaluation and funding systems, and the rest of the world trying to catch up, the companies that will perform best are those that get comfortable integrating and leading in both the policy and business environments.
In trade negotiations, it is usually governments that negotiate amongst themselves on these issues. However, today we’re seeing individual companies effectively negotiating international trade policy and agreements one-on-one with the White House. This is consistent with the Administration’s practice of negotiating deals with individual companies in areas like tech and AI chips.
Last year we saw the likes of Pfizer, AstraZeneca, Eli Lilly, EMD Serono, Novo Nordisk, Novartis, Roche and Sanofi all negotiate deals with the White House on pricing issues, tariffs and investment commitments in the United States. With these negotiations spilling over to affect other major markets this year – as evidenced by the United Kingdom – companies are going to have to sharpen their policy and government engagement skills and bring them into the centre of their commercial strategies in 2026.
Will pharma go ‘multipolar’?
Foreign policy experts and historians talk about how the world is becoming ‘multipolar’, effectively saying that the previous ideas of globalisation and one global economy are giving way to a world where there are multiple poles of economic, strategic, political and industrial power. The challenge for global businesses is trying to work out how to navigate through this.
At the same time, the pharmaceutical industry is itself becoming ‘multipolar’. While the Trump Administration is trying to reassert the US’s position in the global industry, the locus of investment activity in the industry is heading East. Europe is having to reassess its attractiveness as an investment location, while countries like India have plans to grow their innovative output. China is becoming a major player in drug development, partnerships, investment and as a market. Moreover, the demand side of the pharmaceuticals market is changing, with market-based private health systems coming under more government control, publicly funded HTA-based systems experiencing more private market moves and investment pressures, and emerging countries’ health systems still evolving.
Donald Trump has been President of the United States for 12 months, and pharmaceutical companies and industry associations around the world have been scrambling to adjust to this in real time. Companies and associations will increasingly need to balance rapid policy changes in some countries that put direct pressure on them in other countries where there has been almost no reform or change.
The key question is: how will the pharma industry handle this? Does it go ‘multipolar’ and say and do different things in different countries? Does it go ‘global’ and set the agenda on global level issues to help humanity? Or does it stay quiet and say nothing? 2026 might be the year where more companies must face this conundrum head-on.
Disruption will be across the business model
These days disruption in the pharma industry happens all the time, but 2026 particularly will see a lot of change. M&A activity will continue and move in new directions, driven by technological and economic developments. The explosion in GLP-1s in the obesity space is an example of this, where current market leaders are likely to be rapidly followed by other companies coming into the market. Pfizer’s recent acquisition of Metsera and licensing deal with China-based YaoPharma is a case in point. But disruption also comes from the growth in direct-to-consumer sales spurred on by TrumpRx.gov and negotiations between companies and the US administration. It will be interesting to see if this growth in DTC sales in the US spills over into other markets.
The industry is facing major patent expiries in the future and 2026 will be the year this starts to hit home. Companies are responding by restructuring, downsizing and acquiring new technologies. Expect to see more shake-outs. Poster child for the obesity market, semaglutide, sees its molecule patent start to expire in 2026, which will trigger the next ‘revolution’ in the anti‑obesity market. Other major molecules that might see the start of patent expiries this year include MSD’s Januvia® and Janumet® in diabetes, Pfizer’s Xeljanz® in immunology, and several anticoagulants to prevent stroke such as Boehringher Ingelheim’s Pradaxa® and BMS/Pfizer’s Eliquis®.
Other disruptions are likely to continue. For my mind, one of the major technologies to watch is 3D printing of drugs. Six months ago, researchers announced that they had successfully manufactured insulin-producing human pancreas cells using 3D printing technology. The manufactured cells survived in test tubes for 3 weeks and produced insulin in response to glucose, opening up opportunities for new treatments. Also keep an eye on the embedding of environmental conditions in decisions on funding medicines, which countries like the UK, France and the Nordic countries are adopting to reduce carbon emissions and environmental pollution. This could become the norm elsewhere too.
Sticking up for science
Let’s face it, someone has to do it. 2026 may be the year that the pharma industry helps in reweighting the debate about the role of science and evidence in decision-making. For all the criticisms made about the pharma industry, one thing critical to its success is getting the science and evidence right. I may be a heretic here, but I think the industry can help explain to people how important science and evidence is to humanity if done properly.
The debate about vaccination is a case in point. The resurgence of the anti-vax movement and vaccine hesitancy is a real concern for human health. Vaccination rates have stalled and are even falling in some parts of the world and people, including children, are at greater risk of dying from preventable diseases as a result. Pfizer CEO Albert Bourla has made a commendable early intervention saying that vaccination should be guided by the science. The industry could do more in this space.
Meanwhile, there are concerns being raised by others about the US Food and Drug Administration losing its credibility as a science-based agency with some of the changes being implemented. I’m a supporter of reforming public sector agencies to improve performance. I even support periodic reviews of the scientific evidence to test and validate the best and latest information. But what’s happening at the FDA seems to be something else. There are memes on social media now showing the FDA organisation chart looking more like a game of noughts and crosses with the number of experienced scientists and executives who have left the organisation in the last 12 months. What these changes mean for the world generally, and the industry’s role in defending science, data and evidence may be tested in 2026.
The ‘unexpected’ 6th trend – Will the health sector have a ‘Challenger’ moment?
This month will mark the 40th anniversary of the Challenger Space Shuttle disaster. Forty years ago, in the United States on 28 January 1986, a shuttle imploded soon after launch, scattering debris over a wide area and taking the lives of seven astronauts. The subsequent Presidential Commission on the Space Shuttle, the Rogers Commission, investigated the causes of the incident. The Commission found that while the immediate technical cause of the disaster was a faulty O-ring seal in one of the Challenger’s booster rockets, the underlying causes were a range of organisational, management and communication problems in NASA, the US government agency responsible for space missions. NASA was an organisation that was under pressure in the lead-up to the tragedy. Not listening to experts, not adopting calm evidence-based decision making, and senior leadership under external pressure ignoring the evidence in front of them all contributed to the disaster.
With all the uncertainties and pressures both public and private sector healthcare organisations will be facing in 2026, senior executives may want to flick through the pages of the Challenger case study and review its lessons as this year kicks off.
Wishing you all the best for 2026.
Brendan Shaw is the Principal of Shawview Consulting and an Adjunct Professor at the Sydney Pharmacy School, Faculty of Medicine and Health, at the University of Sydney.
