Global Use of Medicine - 2023 by IQVIA

Global Use of
Medicines 2023
OUTLOOK TO 2027
JANUARY
2 0 2 3

Introduction
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express written consent of IQVIA and the IQVIA Institute.
Reaching a post-pandemic era is an alluring prospect for almost everyone
around the world after the disruptions of the past three years. The outlook for
global spending on medicines has become clearer as the traumas recede and
uncertainties give way to more predictable challenges. Policymakers across
developed and emerging economies are shifting from crisis to rebuilding modes
with a focus on longer-term issues of sustainability. Complex trade-offs remain,
and improved efficiency and quality of healthcare informed by evidence-based
decision-making will inform the critical decisions in the coming decade.
The largest driver of medicine spending through the
next five years is still expected to be global COVID-19
vaccinations, but leaving aside the pandemic, global
spending on medicines continues to be driven by
innovation and offset by losses of exclusivity and the
lower costs of generics and biosimilars.
In this report, we quantify the impact of these dynamics
and examine the spending and usage of medicines in
2022 and the outlook to 2027, globally and for specific
therapy areas and countries. We intend for this report
to provide a foundation for meaningful discussion about
the value, cost, and role of medicines over the next five
years in the context of overall healthcare spending.
The study was produced independently by the
IQVIA Institute for Human Data Science as a public
service, without industry or government funding. The
contributions to this report by Mohit Agarwal, Aurelio
Arias, Urvashi Porwal, Jamie Pritchett, Sarah Rickwood,
Priya Srivastava, Durgesh Soni, Alan Thomas, and dozens
of others at IQVIA are gratefully acknowledged.
Find Out More
If you wish to receive future reports from the IQVIA
Institute for Human Data Science or join our mailing list,
visit iqviainstitute.org
MURRAY AITKEN
Executive Director
IQVIA Institute for Human Data Science
The Global Use of Medicines 2023: Outlook to 2027

Table of Contents
Overview 2
Impact of COVID-19 on the use of medicines 4
Outlook for the use of medicines and historic drivers 13
Spending and growth by regions and key countries 19
Key therapy areas 37
Notes on sources 50
Definitions and methodology 51
About the authors 53
About the Institute 55
Table of Contents

As the COVID-19 pandemic enters its fourth year, it has
been the most impactful global public health crisis in
decades, and yet it has illustrated the resilience of global
health systems as they have readily adapted to peaks in
demand and developed novel vaccines and therapeutics
with significant efficacy, safety, and unusual speed. The
global vaccination program that countries and industry
have implemented is unprecedented in its speed and
reach to lower-income countries previously thought to
be inaccessible. While challenges remain in managing
the pandemic into an endemic phase, other health
concerns are also coming back into focus. Overall, global
use and spending on medicines is expected to return
to pre-pandemic growth rates by 2024, though the
next two years are not without important uncertainties
related to viral variants, vaccination rollout for COVID-19,
and under-usage of booster shots, as well as economic
uncertainties related to global inflation, geopolitical
conflicts, and climate change.
IMPACT OF COVID-19 ON THE USE OF MEDICINES
Global spending on medicines from 2020 to 2027 is
expected to exceed the pre-pandemic outlook by $497Bn
in aggregate, largely due to new spending on COVID-19
vaccines and novel therapeutics, as well as the impact on
other therapeutic areas. Global market growth will return
to pre-pandemic projected rates by 2024 despite year-to-
year fluctuations and geographical variations.
All regions around the world have exceeded previously
projected first wave COVID-19 vaccination rates,
resulting in 530 million more vaccinated people by the
end of 2023 than initially modeled. The largest areas
of over-achievement in this area have been in upper-
middle and lower-middle-income countries as defined
by the World Bank, with 4.4 billion people vaccinated,
490 million more than earlier estimates. Immunity
achieved from COVID-19 infection or vaccines appears
to wane after a year, and annual boosters are being
recommended, including new versions for emerging viral
variants; adoption, however, generally includes less than
half of the population who had received the first-wave
shots and is lagging in lower-income countries. Ongoing
booster usage will likely increase, especially if there are
impactful surges with new variants, and these patterns
characterize the expected nature of the endemic phase.
COVID-19 therapeutics will continue to be widely used
and will result in a cumulative spend over eight years of
$120Bn through 2027. Other medicine use was disrupted
during the pandemic across a range of therapy areas,
some related to the symptom profile of the pandemic,
others related to disrupted management of chronic
diseases. Sustained complications of COVID-19 infection
across almost all organ systems, known as ‘long-COVID’, is
now better understood, with 10–20% of infected patients
suffering with persistent symptoms requiring ongoing
demand for treatments, often with older generic drugs.
OUTLOOK FOR THE USE OF MEDICINES AND
HISTORIC DRIVERS
The use of medicines globally plateaued in 2022
following a significant rebound in 2021 as markets
recovered from the pandemic. Overall volume is
projected to grow 1.6% CAGR in days of therapy through
2027, driven by Asia-Pacific, India, Latin America,
Africa and the Middle East, and China, all of which are
expected to exceed global volume growth. Higher
income countries in Western Europe and North America
as well as Japan and Eastern Europe are expected to
grow more slowly at 0.1 to 0.4% through 2027, partly due
to their already higher per capita use. Eastern Europe
volume growth is also hampered by disruptions from the
ongoing Ukraine conflict.
Per capita use of medicines varies by GDP, with use in
higher-income countries typically higher than in lower-
income countries. Countries such as Japan and those in
Western Europe have more than double the use of most
other regions measured in WHO defined daily doses.
Countries vary considerably in the therapy areas which
drive most of their volume use of medicines, linked to the
burden of disease they experience as well as factors which
influence the structure and functioning of health systems.
While overall volume has increased by 2% CAGR over the
past decade, oncology has increased at 15% per year,
driven by the significant advances in novel treatments
and improved access to cancer care around the world.
2 | The Global Use of Medicines 2023: Outlook to 2027
Overview

iqviainstitute.org | 3
SPENDING AND GROWTH BY REGIONS AND
KEY COUNTRIES
The global medicine market — using invoice price levels
— is expected to grow at 3–6% CAGR through 2027,
reaching about $1.9Tn in total market size. Spending and
volume growth will follow diverging trends by region
with larger established markets growing more slowly,
and growth markets in Eastern Europe, Asia and Latin
America growing in both volume and spending.
The U.S. market, on a net price basis, is forecast to grow
-1 to 2% CAGR over the next five years, down from 4%
CAGR for the past five years. Prior editions estimated
0–3% CAGR on a net basis. The new forecast, including
projected effects of the Inflation Reduction Act, reflects
an outlook that has a 1% lower range. Provisions of
the new legislation are expected to drive incremental
volume by reducing cost exposure for patients and by
driving lower prices through inflation penalties and
price negotiations. Other aspects of the law will impact
the interactions of stakeholders and the responsibility
for cost shifts between government, payers, and
pharmaceutical manufacturers, especially in the
Medicare program.
Spending in Europe is expected to increase by $59Bn
through 2027, with a focus on generics and biosimilars,
and escalating pressures on the value and negotiated
prices of novel medicines. The pandemic’s impact on
Asia-Pacific countries varies considerably, but a return
to steady growth is projected after 2021. Japan medicine
spending growth is projected at -1 to 2% through 2027 as
robust brand growth is offset by a shift in annual price
cuts and ongoing moves to generics. Spending growth
in China is expected to slow, with positives driven by
greater uptake and use of new original medicines and
offset by pressures on off patent and generic pricing.
Growth in developed economies continues at relatively
steady rates, with new products offset by patent
expiries. Latin America, Eastern Europe and parts of
Asia are expected to grow strongly from volume and
adoption of novel medicines.
KEY THERAPY AREAS
The key growth area for medicines in the next five years
is biotech, which will represent 35% of global spending
and will include many of the areas of greatest activity
for novel medicines. In addition, global savings from
biosimilars will exceed $290Bn in cumulative spending
through 2027, which is below estimates without new
biosimilars, representing a significant mechanism to
generate wider usage of these medicines as well as ease
payer budget pressures on overall spending. Specialty
medicines will represent 43% of global spending in
2027 and more than 55% of total spending in developed
markets, continuing the shift from more traditional
medicines underway for over a decade.
The two leading global therapy areas — oncology and
immunology — are forecast to grow 13–16% and 3–6%
CAGR, respectively, through 2027, reflecting diverging
trends with one still driven by novel medicines and the
other facing biosimilar competition. Oncology is projected
to add 100 new treatments over five years, contributing
to an increase in spending of $184Bn to a total of more
than $370Bn in 2027 and facing limiting new losses of
exclusivity. Treatments for auto-immune disorders are
forecast to reach $177Bn globally by 2027, driven by
steadily increasing numbers of treated patients and new
products, and offset after 2023 due to biosimilars.
Diabetes spending growth is slowing to low single digits
in most developed markets and declining in some,
especially net of rebates. New therapies contribute to
growth of neurology markets, including greater use of
novel migraine therapies, potential treatments for rare
diseases, and the potential for therapies for Alzheimer’s
and Parkinson’s.
The outlook for next generation biotherapeutics includes
significantly uncertain clinical and commercial prospects
for cell, gene, and RNA therapies, which will grow from
current $8Bn spending in 2022 to $27Bn by 2027.

• Global spending, including COVID-19 vaccines and
therapeutics, is expected to exceed pre-pandemic
outlook by $497Bn to 2027.
• Global market growth will return to pre-pandemic
projected growth rates by 2024 despite year-to-year
fluctuations.
• All regions around the world have exceeded previously
projected first wave vaccination rates while booster
utilization is lagging.
• Global spending on COVID-19 vaccines is expected to
exceed previous estimates, primarily from
higher volume.
• Medicine use in pharmerging countries has varied
greatly since early 2020 and has been more stable in
developed countries.
• Medicine use was disrupted in some therapies
throughout the pandemic, with most countries
returning to pre-pandemic levels.
• Research has been able to identify sustained
complications of COVID-19 infection across almost
all organ systems and the degree of impact is
becoming clearer.
Impact of COVID-19 on the use of medicines
The COVID-19 pandemic has transitioned to a new phase with vaccines
and therapeutics available but inconsistently used and resulting periodic
emergence of infection and hospitalization surges leaving significant
uncertainty in the years ahead.

• The outlook for global medicine spending has shifted
considerably during the COVID-19 pandemic but
is expected to be largely similar to the pre-COVID
outlook, excluding the spending for COVID-19 vaccines
and therapeutics.
• For non-COVID spending, lower trends in the near-
term are expected to be largely offset and by 2027, the
cumulative reduction from the pre-pandemic outlooks
is expected to be only $4Bn.
• The most important drivers of lower spending will
be those, often asymptomatic, conditions that have
disrupted patient engagement and fail to make up the
backlog of previously expected usage and spending.
• The phased rollout of vaccines and booster shots in the
base case estimate will result in $380Bn in incremental
spending globally.
• Expected use of novel therapeutics for COVID-19 are
expected to result in a total of $120Bn over seven
years, resulting in a total impact of vaccines and
therapeutics of $497Bn, or about 3% of cumulative
global spend during that period.
• A rapid first wave of vaccinations exceeded previous
expectations but has been followed by lower rates of
booster utilization.
• Lower-income countries generally vaccinated fewer
people than higher-income countries, and 2022 has
been characterized by recurrent outbreaks with new
viral variants, a pattern which is largely expected
to continue, though severity and impact on health
systems’ capacity appear to be more moderate than
earlier in the pandemic.
Exhibit 1: Changes in the historical and projected global medicine spending model due to COVID-19, 2019–2027, US$Bn
Notes: Estimates of pre-pandemic outlook are based on US$ at variable exchange rates under the same ex-rate assumptions as the current non-COVID
outlook. Neither outlook were modeled including COVID-19 vaccines and the estimates of vaccine spending are entirely incremental spending. Vaccine costs
reflect medicine costs only and do not include costs from provider administration or government contributions to manufacturing or distribution costs.
COVID-19 therapeutics are novel therapeutics including antivirals and antibody treatments new to the market but excluding existing medicines ‘repurposed’
for COVID-19. No confidential or proprietary information is included in these estimates.
Global spending, including COVID-19 vaccines and therapeutics,
to exceed pre-pandemic outlook by $497Bn to 2027
Source: IQVIA Market Prognosis, Sep 2022; IQVIA Institute, Nov 2022.
1,278 1,312
1,450 1,482 1,557 1,651 1,742 1,828 1,917
3
117
92
75
60
53
51
50
Incremental spend for COVID-19 vaccines & therapeutics
Current outlook excluding COVID-19 vaccines
Pre-COVID-19 outlook
Cumulative difference in non-COVID-19 spending from pre-COVID-19 levels
Cumulative COVID-19 therapeutics Total cumulative difference from pre-COVID-19 levels
Cumulative COVID-19 vaccine spending
2019 2020 2021 2022 2023 2024 2025 2027
2026
2019 2020 2021 2022 2023 2024 2025 2027
2026
Cumulative difference, US$ billion
=
+
+
Spending outlook change
due to COVID-19: $497Bn,
2020–2027
COVID-19 vaccine spending:
$380Bn ($315–$425Bn)
COVID-19 therapeutics:
$120Bn ($105–135Bn)
COVID-19 disruption
impact: -$4Bn
2020–2027
-19
-75 -62 -87 -106 -99 -76 -43 -4
104
158
211 256 297 338 380
3
-19
-72
57
124
181
247
323
407
497
0
16 53 76 91 103 112 120

• The near-term impact of the COVID-19 pandemic on
medicine spending has been the notable short-term
disruptions in 2020 and rebound in 2021 with a return
to pre-pandemic growth rates by 2024.
• Including estimates of higher spending growth from
COVID-19 vaccines and lower spending from existing
treatments due to disruptions from the pandemic,
the five-year CAGR to 2027 is expected to be 4.6%,
compared to 4.5% if the pandemic had not taken place.
• Perhaps the largest uncertainty in the next five
years will be the potential impact of economic
factors on countries’ budgeting and whether there
will be shifts in policies regarding healthcare and
medicine spending.
• It is expected that the pricing and value of medicines
will be under increased scrutiny during this period,
especially considering concurrent events related to
economic inflation, and geopolitical disruptions such
as the Ukraine conflict.
• While the pandemic has dominated much of the past
three years, the wider trends on the use of medicines
continue to evolve relatively unchanged, which offers
some hope to the millions living in lower-income
markets, with their improved health situation largely a
result of increased access to medicines.
Exhibit 2: Comparison of current outlook to pre-COVID-19 outlook
Notes: Pre-COVID outlook based on IQVIA Market Prognosis, Sep. 2019 edition which included projections to 2024 and which has been extended to include
the periods to 2027 with a linear projection. Current outlook based on IQVIA Market Prognosis Sep 2022 edition. Incremental COVID vaccine and therapeutic
scenario based on current outlook combined with incremental spending for vaccines and novel COVID-19 therapeutics.
Global market growth will return to pre-pandemic projected
growth rates by 2024 despite year-to-year fluctuations
Pre-COVID-19 outlook
Current outlook including incremental spend on COVID-19 vaccines
Current outlook excluding COVID-19 vaccines
1 2020: Growth -2.0% slower than pre-pandemic
projection (~$26Bn)
2 2021: +3.4% above pre-COVID-19 growth;
+5.1% above 2020 growth excluding vaccine
and therapeutics
3 2021: +10.6% higher growth including
vaccines and therapeutics compared to
spending without them
4 2022: Significant decline in required spending
for COVID-19 vaccines as much of the world is
inoculated to some degree
5 Expected budget pressures will emerge from
longer-term pressures of sustained pandemic
Key events in the outlook
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
-2%
2019 2020 2021 2022 2023 2024 2025 2027
2026
Constant dollar growth forecast (invoice)
1
5
3
4
Post-pandemic
volume rebound
Incremental COVID-related usage
for treatments and vaccines
Post-pandemic
economic/budget
pressures
Vaccine spending declines
with shift to boosters
2
Demand
impact
during
pandemic

• Most countries around the world achieved higher
rates of vaccination than previously modeled, with
upper-middle, lower-middle, and low-income countries
exceeding projections the most.
• The WHO had identified disparities in access as of late
2021, reflecting concerns of a two-track pandemic if
left unaddressed, and while generally vaccinations
have taken place at higher rates, lower-income
countries continue to lag far behind.
• Low-income countries are expected to continue to
lag behind higher income countries until achieving
higher rates near the end of 2023, when globally more
than six billion people will have received at least one
COVID-19 vaccination.
• Across geographies, the rates of booster shot usage
has been below expectations, and even in the
wealthiest countries, fewer than half of those people
initially vaccinated are receiving boosters.
• It remains possible and even likely that relaunched
vaccine drives will result in significant acceleration
in these rates across a wide range of low and lower-
middle-income countries, especially considering
periodic surges from newly emerging viral variants.
Exhibit 3: Percentage of total population vaccinated by month and comparison to prior forecast
Notes: Estimates of vaccination rates based on reported vaccination data through October 2022. Countries within the four World Bank income bands have
been projected to achieve a maximum vaccination rate by the end of 2023. The high-income and upper-lower-income countries average over 60% and will
have a slowing rate of new vaccinations until they reach the projected peak. The lower-middle-income and low-income countries currently have much lower
vaccination rates and widely diverging trends in the most recent months. The differences across countries are expected to narrow by the end of 2023 as
global initiatives to encourage vaccination partly achieve their goals. The percentage of the population vaccinated with at least one dose is compared from
the current estimates to that published by the IQVIA Institute in the prior edition of this report. The vaccinated population are relevant to the estimations of
the population eligible for booster shots at a point in time used in overall volume projections. Estimates of fully vaccinated population with boosters are an
estimate of the population with a current booster in the prior 12 months in addition to initial vaccination.
All regions around the world have exceeded previously projected
first wave vaccination rates while booster utilization is lagging
Source: IQVIA Institute, Nov 2022; Vaccination trends to date from Ourworldindata.org,accessed October 2022.
Population vaccinated with at least one dose Population fully vaccinated with boosters
High-income countries
Lower-middle-income countries
100%
80%
60%
40%
20%
0%
>60-70%, 2.3 billion people (+240Mn)
>80%, 1.1 billion people (+5Mn)
Range of vaccination, # of people vaccinated in the region in the prior model, (incremental vaccinated people in the updated model).
100%
80%
60%
40%
20%
0%
.
Previous edition
D
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Upper-middle-income countries
Low-income countries
>50-60%, 400 million people (+35Mn)
>70-80%, 2.1 billion people (+250Mn)
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3

• Global COVID-19 spending is expected to exceed
$50Bn in 2022 and $380Bn in total over seven years
to 2027, higher than earlier projections of $251Bn
through 2026.
• Previous modeling phased the initial vaccination wave
more slowly and included half-sized booster shots
every other year; the revised assumptions include
expected faster achievement of initial vaccination rates
in higher-income countries, slower in lower-income
countries, and more frequent boosters of the same
size as initial shots.
• Cost per dose assumptions in the current model reflect
a slight upward trend in cost per dose in later years
as manufacturers pressure for higher prices, and
preference for higher-cost mRNA vaccines impacts
average costs.
• In this model, vaccinations to-date and segmentation
of initial and booster types have been considered to
create a base case estimate for the number of people
who will be vaccinated in an initial wave and then
receive booster shots later.
• The number of doses consumed per patient is
expected to continue to increase as immunity appears
to wane over time and annual boosters, potentially
including protection from multiple variants, will be
necessary, but will be used by a smaller proportion of
patients than in the first wave.
Exhibit 4: COVID-19 vaccination spending and volume forecasts
Notes: Scenario modeling was conducted by the IQVIA institute based on public information as of October 2022. Estimates of future vaccination trends
include input from the public statements of responsible agencies and manufacturers, as well as modeling by the IQVIA Institute. Estimates of cost per patient
are based on assumptions of the number and mix of doses of available vaccines, the published prices, and IQVIA Institute estimates of the prevailing prices
that will exist across geographies through 2027. As costs are based on public statements, they may overstate the true costs after negotiated discounts. Doses
are based on the expected dosing including booster shots.
Global spending on COVID-19 vaccines is expected to exceed
previous estimates primarily from higher volume
Source: IQVIA Institute, Nov 2022; Pricing information from public disclosures as of October 2022; Vaccination trends to date from Ourworldindata.org.
• Higher income countries achieved higher than
expected vaccination rates earlier in the
pandemic while the slower early pace in the
developing world has been significantly improved
to date, though the overall vaccination rate is still
far below wealthier countries
• Previous modeling had expected half-size booster
doses taken by more of the initially vaccinated.
Information to date suggests that booster doses
will be the same size as an initial dose but will be
taken by fewer people
• Although increased competition will drive down
cost per standardized dose later in the period,
the preference in developed markets for mRNA
vaccines resulted in higher-than-expected cost
per dose through 2024, and slower booster
uptake is a factor in some companies stated
plans for future pricing
Updated base case scenario
Previous scenarios range
120
100
80
60
40
20
0
2021 2022 2023 2024 2025 2027
Constant
US$,
billion
COVID-19 vaccine
global spending scenarios
$0
$5
$10
$15
$20 Cost per dose scenarios, US$
2021 2022 2023 2024 2025 2027
2021 2022 2023 2024 2025 2027
2026 2026
2026
Standard doses scenarios, billions
Updated 7-year total of
base case =$380Bn
(315–425)
Previous 6-year total of
base case =$251Bn (185-295)
.
Base case key assumptions
0
2
4
6
8
10
Previous base case scenario

• The impact of the pandemic on medicine use has
been highly varied, including both surges in usage
of chronic medicines, referred to as stockpiling, and
then returning to a more normal trend, with the
average for developed markets at baseline volumes
by the end of 2020.
• Countries with the least impact from the pandemic,
largely due to early and effective containment,
including Australia and Canada, have then seen drops
in volume in more recent periods.
• Pharmerging markets have had a much more varied
pandemic experience, with significant variations in
volume through Q3 2020 but generally returning
to higher than pre-pandemic levels for the seven
quarters since then.
• As the pandemic has continued, developed markets
have demonstrated resilience to various logistical
disruptions, offering financial assistance to the public
and shifting healthcare interactions to remote or
virtual settings.
• Lower-income countries in the pharmerging group of
countries have recovered to an average of 110% of
pre-pandemic volume, higher than the average 106%
in the 10 developed countries.
Exhibit 5: Trends in Defined Daily Doses (DDD) in 10 developed and pharmerging markets indexed to Q3 2019
values (Q3 2019 value = 100)
Notes: Defined Daily Doses (DDD) are based on WHO definitions where each medicine is assigned a volume of medicine per day (see definitions &
methodology). All charted values are indexed to Q3 2019 values, such that the Q3 2019 value is set equal to 100%. The 10 developed countries are the 10
largest high-income countries (U.S., Japan, Germany, France, Italy, Spain, UK, Canada, Australia, South Korea). Pharmerging includes countries with per capita
GDP <$30,000 in 2021 and forecasted 5-year aggregate pharma sales growth >$1Bn (absolute or rounded) in at least two forecasts.
Medicine use in pharmerging countries varied greatly since early
2020 and has been more stable in developed countries
Source: IQVIA MIDAS, Jun 2022; IQVIA Institute, Dec 2022.
10 developed Pharmerging
60
40
100
120
80
140
160
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Spain, 112.8
Japan, 110.8
U.S., 107.0
Germany, 106.8
Italy, 106.4
Korea, 106.4
France, 106.3
UK, 105.8
Average, 105.9
Australia, 100.4
Canada, 96.4
Chile, 140.1
Indonesia, 132.4
Colombia, 111.1
Average, 110.1
South Africa, 89.5
Ukraine, 54.3

• Early in the pandemic, with few treatments appearing
to offer benefits for patients, there was an increased
use of rescue inhalers normally intended for asthma
in patients in ICUs, driving a significant shift in usage
in the respiratory market overall and then falling as
hospitalization rates fell.
• Mental health therapies have seen a gradual rise
in usage, though more modest than some had
expected, potentially due to barriers to beginning
new treatments for mental health disorders, including
social stigma.
• Pharmerging markets have seen generally less
disruption to these therapies, as many countries were
later impacted by COVID-19 and experienced less of
the early wave of uncertainty-driven behavior changes.
• Higher use of vitamins and minerals in pharmerging
markets is, as a result of reports in the media in some
of those countries, generally not supported with
clinical evidence that certain treatments would either
be beneficial or protective relative to COVID-19.
Exhibit 6: Trends in medicine use in 10 developed and pharmerging markets, standard units indexed to Q3 2019
values (Q3 2019 value = 100)
Notes: Indexed values are based on standard units. Common ICU medications are those indicated by the American Society of Health-System Pharmacists:
Atracurium Besilate, Cisatracurium Besilate, Dexamethasone, Dexmedetomidine, Epinephrine, Etomidate, Fentanyl, Hydromorphone, Ketamine, Midazolam,
Norepinephrine, Phenylephrine, Propofol, Rocuronium Bromide, Vasopressin, and Vecuronium Bromide. Chronic and acute definitions are based on therapy
classes predominantly used for maintenance therapy or not. Vitamins and minerals includes OTC when captured.
Medicine use was disrupted in some therapies throughout the
pandemic with most countries returning to pre-pandemic levels
Pharmerging 10 developed
80
100
120
120
Antidiabetics
80
100
120
120
Common ICU
medications
Acute therapies Chronic therapies Mental health
Vitamins and minerals Respiratory Hypertensives
2
0
1
9
Q
3
2
0
1
9
Q
4
2
0
2
0
Q
1
2
0
2
0
Q
2
2
0
2
0
Q
3
2
0
2
0
Q
4
2
0
2
1
Q
1
2
0
2
1
Q
2
2
0
2
1
Q
3
2
0
2
1
Q
4
2
0
2
2
Q
1
2
0
2
2
Q
2
2
0
1
9
Q
3
2
0
1
9
Q
4
2
0
2
0
Q
1
2
0
2
0
Q
2
2
0
2
0
Q
3
2
0
2
0
Q
4
2
0
2
1
Q
1
2
0
2
1
Q
2
2
0
2
1
Q
3
2
0
2
1
Q
4
2
0
2
2
Q
1
2
0
2
2
Q
2
2
0
1
9
Q
3
2
0
1
9
Q
4
2
0
2
0
Q
1
2
0
2
0
Q
2
2
0
2
0
Q
3
2
0
2
0
Q
4
2
0
2
1
Q
1
2
0
2
1
Q
2
2
0
2
1
Q
3
2
0
2
1
Q
4
2
0
2
2
Q
1
2
0
2
2
Q
2
2
0
1
9
Q
3
2
0
1
9
Q
4
2
0
2
0
Q
1
2
0
2
0
Q
2
2
0
2
0
Q
3
2
0
2
0
Q
4
2
0
2
1
Q
1
2
0
2
1
Q
2
2
0
2
1
Q
3
2
0
2
1
Q
4
2
0
2
2
Q
1
2
0
2
2
Q
2

• The ongoing COVID-19 pandemic is reported to have
increased levels of depression, anxiety and stress in
the population at large as well as creating challenges
for those with substance abuse disorders or drug
dependency, which are often stigmatized.
• While quarantines and shutdowns have become less
common across many geographies, many patients
have remained less engaged with healthcare, likely
resulting in continuing numbers of disrupted or
delayed diagnoses and treatments especially for those
with asymptomatic conditions.
• For many asymptomatic and lifestyle-influenced
conditions such as obesity, diabetes, and heart disease,
the ongoing disruptions to what was normal life before
the pandemic are expected to result in greater rates of
these chronic diseases, especially as people are more
sedentary for sustained periods of time.
• The pandemic is also impacting other infectious
diseases by limiting patient’s exposure due to
pandemic precautions, which may be contributing to
elevated rates and severity of respiratory infections in
the 2022/2023 seasons for seasonal flu, common cold,
RSV, and other respiratory infections.
• Disrupted seasonal patterns for these infections may
also be a factor contributing to desynced supply and
demand issues for antibiotics resulting in shortages.
• Vaccine hesitancy for COVID-19 may result in an
expansion of these attitudes to other vaccines,
generating risk in previously well-controlled infections
such as measles, mumps, and rubella, among others.
• Clarity is slowly emerging around post-acute
sequelae of COVID-19 (PASC), with 10-20% of
previously infected people reporting long-term
symptoms, largely confirming early concerns about
this feature of the virus.
Exhibit 7: Summary of expected impacts of the COVID-19 pandemic on patients and therapeutics
Increased uncertainty about demand and use of medicines linked
to pandemic impact
Source: IQVIA Institute for Human Data Science, Nov 2022.
Disrupted or delayed diagnoses of conditions
Post-COVID-19 conditions
Population level mental health
Impact on infectious diseases
• Vaccine hesitancy spreads to others and results in
outbreaks of previously controlled viruses such as
measles, mumps, rubella
• Other respiratory infections such as RSV (respiratory
syncytial virus) and the common cold may be similarly
affected by seasonal disruptions
• Depression/anxiety, stress disorders
• Substance abuse/dependency
• Lack of clear understanding of causes and
consequences of “long-COVID” conditions
• Estimated over 100 million newly diagnosed conditions
in COVID-19 patients, particularly in CNS and respiratory
• Treatment modalities still being investigated
• Interruption of typical healthcare seeking behaviors
due to quarantines / shutdowns could have had lasting
effects or result in more severe disease when
diagnosed, especially cancer
• Greater rates of chronic diseases such as obesity,
type 2 diabetes and heart disease due to disrupted
patterns of daily life
• Seasonal flu season disruption could result in more
virulent strains in future seasons, especially if
vaccination rates drop

• COVID-19 infection results not only in debilitating
symptoms and sometimes death, but for an important
percentage of patients, long-term complications.
• Post-COVID conditions are now understood as a
multi-organ disorder or syndrome that consist of a
constellation of different conditions, which are acute
or chronic or both, and vary in terms of severity;
estimates of how many people may be affected have
varied considerably as multiple organizations have
developed widely varying criteria for assessing the
presence of post-acute sequelae of COVID (PASC).
• Early estimates ranged from 10-30% of COVID-19
patients having PASC, but incompatible definitions
relating to the nature of symptoms and duration
of persistence had made comparisons across
studies unreliable.
• For mild or asymptomatic COVID-19 cases, a
complication could be thought to be the result of
some other pre-existing condition, unless a COVID-19
antibody test were used to verify a previously
unknown infection.
• Research is ongoing to improve understanding
of the prevalence of PASC, as well as to develop
specific therapies to address these symptoms where
existing medicines are ineffective or have suboptimal
outcomes, and while the pandemic continues, the
ultimate size of this population remains uncertain
but growing.
Exhibit 8: Longer-term complications of COVID-19 infection on patients
Research has been able to identify sustained complications of
COVID-19 infection across almost all organ systems
Source: IQVIA Institute: Assessing the Global Burden of Post-COVID-19 Conditions, Dec 2021.
Neurological
Brain fog, fatigue, headache, strokes, seizures,
encephalopathies, nerve disorders, disturbance in
smell and/taste, POTS, Parkinson's disease,
dementia, dry eyes, pink eye.
Endocrine
New onset diabetes mellitus.
Respiratory
Chronic cough, bronchiectasis, pulmonary
fibrosis, pulmonary vascular disease, worsening
of pre-existing respiratory conditions
(asthma/COPD), shortness of breath.
Cardiac
Dysrhythmias/arrhythmias, hypertension,
dyslipidemia, myocardial injury, myocarditis,
heart failure, acute coronary syndrome,
cardiomyopathy, hypercoagulation, DIC,
VTE, cardiogenic shock, cardiac arrest,
low blood pressure.
Gastrointestinal disorders
Post infectious dysmotility, abdominal pain, nausea,
diarrhea, anorexia, GI vascular diseases, gastroesophageal reflux.
Psychiatric
Depression, anxiety, psychotic disorders,
mood disorders, sleep disorders, substance misuse,
post-traumatic stress disorder, delirium, suicidality.
Ear, Nose and Throat (ENT)
Tinnitus, sore throat, earache,
hearing loss, inner ear disorder.
Renal
Renal damage, acute renal injury,
chronic kidney disease, accentuation of post
hypertension/diabetes mellitus renal disorders.
Musculoskeletal
Myositis, chest pain rhabdomyolysis, muscle
pain, joint pain, muscle disorders including
increase severity of pre-existing diseases.
Dermatological
Vasculitis rash, urticaria, chilblains, vesicular
purpura, irritant dermatitis, hair loss.

• The use of medicines plateaued in 2022 following a
significant rebound in 2021 as markets recovered from
the pandemic.
• Overall volume is projected to grow 1.6% in days of
therapy through 2027, driven by Asia-Pacific, India,
Latin America, Africa/Middle East, and China, all of
which are expected to exceed global volume growth.
• Higher-income countries in Western Europe, North
America as well as Japan and Eastern Europe are
expected to grow more slowly at 0.1 to 0.4% through
2027 partly due to their already higher per capita use.
• Per capita use of medicines varies by GDP, with use
in higher-income countries typically higher than
lower-income.
• Per capita medicine use varies by region, with Japan
and Western Europe having more than double the use
of most other regions.
• Countries vary considerably in the therapy areas that
drive most of their volume use of medicines, and while
overall volume has increased by 2% over the past
decade, oncology has increased at 15.3% per year.
Outlook for the use of medicines and historic drivers
Medicine use grew by 36% over the past decade, driven by increased access to
medicines in regions around the world, but is projected to slow through 2027.
Meanwhile the lowest income countries continue to see declines in access to
medicines, potentially putting health improvements at risk.

• The global use of medicines — based on modeling
medicine volumes shipped according to defined daily
dose assumptions — has been growing for the past
decade; however, this growth is expected to slow
across all markets over the next five years.
• As a lagged effect of the pandemic, the use of
medicines grew sharply in 2021 and then slowed in
2022 as some of the usage was related to temporary
shifts in demand, referred to as ‘stockpiling.’
• The highest volume growth over the next five years
is expected in Asia-Pacific, Latin America, India and
Africa/Middle East, largely driven by population
growth.
• Lower volume growth in higher income regions such
as North America, Western Europe and Japan are
linked to more established health systems and existing
access to medicine.
• Eastern Europe is expected to slow partly as a result of
the regional impacts of the Ukraine conflict.
• Lower-income countries have dramatically lower
access to medicine; access has been declining for the
past five years and is expected to remain steady over
the next five years, potentially counteracting other
policy initiatives to improve health in those countries.
• It is important to interpret these trends with caution,
as chronic diseases drive many days of therapy, and
treatments for them are often much less common in
lower-income countries.
Exhibit 9: Historical and projected use of medicine by region, 2012–2027, Defined Daily Doses (DDD) in Billions
Notes: Chart represents IQVIA Institute estimates of global defined daily doses (DDD). These estimates are based on IQVIA audited data and application of
WHO-DDD factors in IQVIA MIDAS as well as additional DDD calculation assumptions developed by the IQVIA Institute (see Methodology). Asia-Pacific does
not include China, India, and Japan which are reported separately.
OUTLOOK FOR THE USE OF MEDICINES AND HISTORIC DRIVERS
The use of medicines plateaued in 2022 following a significant
rebound in 2021 as markets recovered from the pandemic
Source: IQVIA Market Prognosis, Sep 2022; IQVIA Institute, Dec 2022.
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
CAGR %
2023–2027
2,318
2,476
2,598 2,659
2,741 2,802
2,876
2,946
3,018
3,160 3,158
3,242
3,335
3,425 3,426 3,422
Global
Japan
North America
China
Africa & Middle East
Eastern Europe
Western Europe
Latin America
India
Asia-Pacific
1.6
0.4
0.1
1.7
2.3
0.5
0.4
2.4
2.4
2.5
Forecast
314 330 351 369 394 433 472 487 510 542 553 577 601 624 625 626
293 305 325 343 351 355 383 393 399 434 443 463 481 499 500 499
175 201 239 263 259 269
281 292 355
368 376 390 407 426 424 424
369 374
379 385 390 392
396 401
402
409 403 407 410 414 414 412
292
322
325 316 330
363
373 382
383
400 369 369
374
379 380 378
317
360
377 372 392
353
332 323
312
311 319
331
342
353 355 357
200
214
232 244
259 270
273 298
286
313 318
328
339
348 348 346
237
250
252 251
249 249
247
248
249
256 253
254
255
256 255 255
121
121
118 118
117 118
120
121
122
126 123
124
125
126 126 125

• Broadly there is a correlation to gross domestic
product per capita, with higher medicine use in higher
income countries.
• As countries vary in the cost burden patients directly
bear, there is some correlation in the way patients
use medicine.
• The U.S. has the lowest per capita DDD volumes of
developed markets, which may be the result of high
patient out-of-pocket cost exposure.
• Other factors include the disease burden patients face
and the aspects of the health system they can readily
access to begin using medicines for a specific disease.
• Eastern Europe has nearly four times higher use of
medicines per capita than China, despite GDP per
capita being roughly 50% higher.
• Countries in Africa and the Middle East lag the furthest
in terms of per capita use, even as some countries in
the region are significant outliers with robust GDP
and usage.
Exhibit 10: Defined Daily Doses (DDD) per capita by region compared to per capita gross domestic product PPP,
current international dollars
Per capita use of medicines varies by GDP with use in higher
income countries typically higher than lower-income
Source: IQVIA MIDAS, Jun 2022; IQVIA Institute, Dec 2022; The World Bank, Jul 2022; International Monetary Fund, Oct 2022.
1,200
1,000
800
600
400
200
0
0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000
GDP PPP per capita 2022 (current international dollars)
DDD
per
capita
2022
500Bn
250Bn
100Bn
Size of
Bubble:
Total 2022
DDDs
Asia-Pacific
India
Western Europe
Eastern Europe
Latin America
China
North America
Japan

• When medicine use is adjusted for population, global
medicine use is projected to remain flat over the next
five years, indicating growth in medicine use will follow
population growth.
• After peaking in 2021, medicine use per capita declined
in 2022 in some regions due to the increased use of a
variety of medicines during the pandemic.
• Eastern Europe declined in 2022 related to the Ukraine
conflict but is expected to recover slowly through the
forecast period.
• Most regions have steadily rising usage on a per capita
basis, slower than in the past 10 years, and notably
declining in North America.
Exhibit 11: Historical and projected per capita use of medicine by region, 2012–2027
Per capita medicine use varies by region with Japan and Western
Europe having more than double the use of most other regions
Source: IQVIA Market Prognosis, Sep 2022; IQVIA Institute, Dec 2022; The World Bank, Jul 2022.
5-Year
CAGRs
5-Year
CAGRs
5-Year
CAGRs
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
India
Asia-Pacific
Forecast
Western Europe Africa & Middle East
Eastern Europe
China
Latin America North America Global
Japan
1,200
1,000
800
600
400
200
0
DDD
per
capita
0.3%
0.7%
7.9%
4.0%
-0.4%
2.7%
5.3%
2.8%
-0.3%
5.5%
0.3%
0.4%
5.9%
0.2%
1.1%
1.4%
3.8%
3.5%
-4.2%
3.0%
-0.5%
0.4%
1.6%
0.4%
0.9%
0.7%
1.5%
1.5%
0.0%
1.6%

• Per capita use of medicines is projected to grow in
most regions except Africa and the Middle East, where
all volume increases are driven by population growth.
• Wealthier countries in Western Europe, Japan and
North America have higher levels of per capita use and
are expected to grow less through 2027.
• Regions with more middle- and lower-income countries
are expected to resume historic volume growth trends
as access to medicines contributes to volume growth
above population growth trends.
Exhibit 12: Defined Daily Doses (DDD) per capita by region 2022 and growth to 2027
When adjusted for population, per capita use will fall in
North America and be flat in Africa and Middle East
Source: IQVIA MIDAS, Jun 2022; IQVIA Institute, Dec 2022; The World Bank, Jul 2022; International Monetary Fund, Oct 2022.
120
100
80
60
40
20
0
-20
-40
0% 200 400 600 800 1,000 1,200
DDD per capita 2022
Absolute
change
in
DDD
per
capita
2023-2027
500Bn
250Bn
100Bn
Size of
bubble:
Total 2027
DDDs
Asia-Pacific
China
India Japan
Western Europe
North America
Eastern Europe
Latin America

• As health systems and disease burdens vary around
the world, regions demonstrate important variations
in the use of different therapies.
• Regions with higher average GDP such as North
America, Western Europe and Japan have notably
higher use of cardiovascular, diabetes, respiratory and
neurology treatments than other regions.
• While most major therapy areas have seen growth in
medicine use in the last decade, oncology usage has
far exceeded the others with a 10-year CAGR through
the last full year (2021) of 15.3%.
Exhibit 13: Share of Defined Daily Doses (DDD) by therapy area in 9 regions and globally, 2021
not include China, India, and Japan which are reported separately. Oncology includes supportive care. Hematologics are non-oncology.
The distribution of medicine usage across therapy areas varies
by region
Asia-Pacific India Western
Europe
Eastern
Europe
Latin
America
China Africa &
Middle East
North
America
Japan Global
All others
Respiratory
Genitourinary/
Women's health
Oncology
Infectious disease
Endocrinology
Immunology
Gastrointestinal
Neurology
Eye & ear
Dermatologics
Hematologics
Vitamins & minerals
Cardiovascular
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Global DDD CAGRs %
2012–2021
5.6
3.9
3.0
15.3
0.0
5.6
6.0
2.1
2.7
1.9
5.1
3.3
4.4
4.2

• The global medicine market — using invoice price
levels — is expected to grow at 3-6% CAGR through
2027, reaching about $1.9Tn in total market size.
• Spending and volume growth will follow diverging
trends by region with larger established markets
growing more slowly, and growth markets in Eastern
Europe, Asia and Latin America growing in both
volume and spending.
• The U.S. market, on a net price basis, is forecast to
grow -1 to 2% CAGR over the next five years, down
from 4% CAGR for the past five years including
projected effects of the Inflation Reduction Act.
• Spending in Europe is expected to increase by $59Bn
through 2027, with a focus on generics and biosimilars,
and escalating pressures on the value and negotiated
prices of novel medicines.
• The pandemic’s impact on Asia-Pacific countries
varies considerably, but a return to steady growth is
projected after 2021.
• Japan medicine spending growth is projected at
-1 to 2% through 2027 as robust brand growth is
offset by a shift in annual price cuts and ongoing shifts
to generics.
• Spending growth in China is expected to slow, with
positives driven by greater uptake and use of new
original medicines and offset by pressures placed on
off-patent and generic pricing.
Spending and growth by regions and key countries
Growth in developed economies continues at relatively steady rates,
with new products offset by patent expiries; Latin America, Eastern
Europe and parts of Asia are expected to grow strongly from volume
and adoption of novel medicines.

• Global medicine spending — the amount spent
purchasing medicines from manufacturers before off-
invoice discounts and rebates — is expected to reach
$1.9Tn by 2027, increasing at a rate of 3–6% per year.
• This outlook is excluding the separate impact of
spending on COVID-19 vaccines and therapeutics
modeled separately (see Exhibits 1–4).
• Overall growth trends are expected to moderate
after the disruptions from the pandemic in 2020
through 2022.
• The differing impact of the COVID-19 pandemic across
countries is expected to impact growth through 2023
before returning to historic patterns in 2024.
• Key drivers of growth through the forecast period
include the contribution of new products, the impact
of patent expiries and the growing impact
of biosimilars.
• Payers in developed markets are expected to face
budget pressures and act to curb drug spending
growth, in part motivated by the costs of managing
the pandemic.
Exhibit 14: Global medicine market size and growth 2013–2027
Notes: Does not include estimates for COVID-19 vaccines and therapeutics.
SPENDING AND GROWTH BY REGIONS AND KEY COUNTRIES
The global medicine market — using invoice price levels —
is expected to grow at 3–6% CAGR through 2027 to about $1.9Tn
Global spending US$Bn % Growth constant US$
2,000
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
12%
10%
8%
6%
4%
2%
0%
Spending
US$Bn
%
Growth
constant
US$
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Forecast

• Regions around the world are growing following
diverging trends, with some more volume driven
while others have a greater contribution from
adoption of innovation.
• Countries in Latin America, Asia-Pacific, and Africa and
the Middle East are expected to grow more than 10%
by volume over the five years to 2027, while spending
growth will increase by over 30%, indicating both
population-driven volume growth and a shift in the
mix of products to more expensive products.
• China as the world’s second largest country by
pharmaceutical spending, will increase volume by 8% in
aggregate over five years, while spending will increase
19%, a more modest rate than in the prior years and
still embedding a focus on expanding access to novel
drugs via the National Reimbursement Drug List (NRDL).
• Eastern Europe spending is expected to increase 45%
over the next five years while volume will increase only
1%, hampered by the regional disruptions from the
Ukraine conflict, and at the same time reflecting the
expected adoption of novel drugs, albeit later than in
Western Europe and other developed markets.
• North America and Western Europe are expected
to show flat to very low overall volume growth over
five years, while spending will increase more than
20%, excluding the impact of off-invoice discounts
and rebates.
• Japan spending growth is expected to be flat over
the forecast as price controls evolve to encourage
innovation while offsetting with savings on older and
off-patent medicines.
Exhibit 15: Spending and volume growth by region
Notes: Does not include estimates for COVID-19 vaccines and therapeutics. Asia-Pacific does not include China, India, and Japan which are reported separately.
Spending and volume growth follow diverging trends by region
60%
50%
40%
30%
20%
10%
0%
-10%
2023–2027
Percent
spending
growth
constant
US$
2023–2027 percent volume growth standard units
-5% 0% 5% 10% 15%
Spending growth through 2027 expected to
be high, driven by 'mix' (wider use of novel
drugs at higher average prices)
Above average volume and
spending growth through 2027
Below average volume and
spending growth through 2027
Below average spending growth, with expanded access to
novel drugs driving spending growth faster than volume
Asia-Pacific
China
Eastern Europe
Western Europe
India
Japan
Latin America
North America

• Global medicine spending is expected to slow to 3–6%
through 2027, reaching $1.9Tn, with the ongoing
impacts of the pandemic impacting medicine spending
and usage patterns through 2023 and returning to
pre-pandemic trends afterward.
• North America medicine spending is expected to slow
dramatically in 2023 from the combined effects of
a relatively smaller contribution from new products
and the impact of significant patent expiries and
biosimilars including adalimumab (Humira) in 2023.
• Latin America spending growth has been especially
high in the first two years of the pandemic, including
patients use of established and generic medicines as
symptom management for COVID-19. Starting in 2023,
growth will average 7-10% CAGR led by Brazil, Mexico,
Argentina and Colombia.
• The Asia-Pacific region (excluding China, India and
Japan) has some of the highest spending growth
sustained through the forecast driven by population
growth and an expected contribution from
economic growth.
• Japan’s spending growth is expected to average
-2 to 1% with relatively flat trends, a result of a shift
to annual price cuts in place of the historic biennial
price cut policy.
• China’s spending has swung wildly during the
pandemic, partly influenced by zero tolerance
pandemic policies but expected to return to more
moderate 2–5% growth through 2027.
Exhibit 16: Spending growth globally and in 9 regions, total market, const US$ 2019–2027
Notes: 2019 is included to show the impacts of the pandemic on spending growth. Asia-Pacific does not include China, India, and Japan which are reported
separately.
The COVID-19 impact varies by region with a return to a
more stable trend by 2024 and higher growth in key regions
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
3–6%
$1,900–1,930Bn
2.5–5.5%
$790–820Bn
3.5–6.5%
$355–385Bn
5.5–8.5%
$108–138Bn
-2–1%
$71–91Bn
4.5–7.5%
$54–74Bn
7–10%
$115–135Bn
6–9%
$100–120Bn
7.5–10.5%
$35–39Bn
2–5%
$180–210Bn
2027 Spending
2023–27 CAGRs
Spending growth
20%
15%
10%
5%
0%
-5%
20%
15%
10%
5%
0%
-5%
Global Western Europe
North America Asia-Pacific
Japan
Latin America Eastern Europe India China

• Spending at net levels in the U.S. is projected to grow
at -1 to 2% as rising off-invoice discounts and rebates
are expected to be amplified by the provisions of the
Inflation Reduction Act (IRA).
• In total, off-invoice discounts and rebates result in
spending that is estimated at 36% lower than invoice
level in 2022 and projected to be 45% lower than
invoice level in 2027.
• Projections prior to the passage of the IRA showed
this gross to net difference reaching 39% in 2026, with
growth averaging 0–3% on a net basis, 1% higher than
the revised outlook.
• In addition to discounts and rebates, ongoing market
dynamics around the use of medicines, the adoption
of newer treatments, the impact of patent expiries,
and new generic or biosimilar competition will all
contribute to historically slow market growth in the
U.S. for the next five years.
Exhibit 17: U.S. medicine spending and growth at invoice-level and estimated net 2013–2027
Notes: Estimates of net manufacturer sales are based on analysis by the IQVIA institute from public sources combined with IQVIA’s audited invoice-level data
(see Methodology).
The U.S. market, on a net price basis, is forecast to grow -1–2% CAGR
over the next 5 years, down from 4% CAGR for the past 5 years
Source: IQVIA Institute, Nov 2022.
259 291 318 331 331 344 363 363 385 402 412 420 416 415 420
337
390
437 456 465
493
521
545
588
629
657
680
705
734
763
5-Year
CAGRs
5-Year
CAGRs
Invoice
CAGR
7.6%
Net 29%
below
invoice
Net
CAGR
5.2%
Invoice
CAGR
6.2%
Net 36%
below
invoice
Net
CAGR
4.0%
Invoice
CAGR
2.5-5.5%
Net 45%
below
invoice
Net
CAGR
-1 to 2%
5-Year
CAGRs
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Net sales Invoice to net difference
Forecast

• Spending on medicines in the U.S. at invoice prices is
expected to increase by $134Bn through 2027, slower
than the $164Bn increase over the past five years.
• The largest driver of growth will be increased usage
of existing protected branded products which are
expected to add $154Bn in spending over five years,
much higher than the $122Bn increase from 2017 to
2022 for products more than two years after their
launch up until their loss of exclusivity (LOE).
• The contribution from new brands is expected to
increase to $110Bn over five years as more than 250
new active substances (NASs) are expected to launch
in the period.
• The impact of losses of exclusivity is expected to
increase dramatically to $141B from $49Bn in the prior
five years as both small molecule and biologic product
exposure to LOE has increased substantially.
• Generics, including biosimilars, have had an only
modest impact on growth as price deflation has largely
offset growth from the related patent expiry events.
• Overall medicine spending at invoice prices is expected
to reach $763Bn by 2027 even as off-invoice discounts
and rebates are expected to reach 45% and net
spending increases by only $18Bn over five years.
Exhibit 18: Spending and growth drivers in US 2017–2027 const US$Bn
Notes: New brands growth contribution defined as the growth during periods when products had been marketed for less than two years. Growth from
products defined as new in each year of the five-year period are aggregated together. Existing brands are those which are no longer new and not yet off-
patent. Off-patent brands have faced Loss of Exclusivity (LOE). Generics includes non-original branded products or ‘branded generics’ as well as biosimilars.
Other includes OTC/other products.
Spending in the U.S. is expected to increase by $134Bn through
2027 driven by new and existing brands
465
86
-49
122 5 0 629
110
-141
154 12
-1
763
Forecast
New
brands
LOE Existing
brands
Generics Others New
brands
LOE Existing
brands
Generics Others
2022
spending
2027
spending
2017
spending

• Losses of exclusivity in the U.S. are expected to be
$141Bn through 2027, with significant impact on
spending for both small molecules and biologics.
• Small molecule expiries are expected to reduce brand
spending by $98Bn through 2027, more than double
the impact of the last five years, including the impact
of high-profile products in the anticoagulants therapy
area, including rivaroxaban (Xarelto).
• Biologics are expected to result in $42Bn in lower
brand spending over five years as biosimilar
market dynamics mature and major products face
competition, including the continuing impact on
ranibizumab (Lucentis) in 2022, as well as adalimumab
(Humira) and ustekinumab (Stelara) in 2023.
• The approval of interchangeable biosimilars for
insulins in the second half of 2021 and for adalimumab
pending launch in 2023 suggests more dramatic
volume uptake is possible, contributing to the $14Bn
impact of biologics overall in 2024.
• Questions remain around the relationship of
interchangeability, alternative originator formulations,
and the commercial and negotiating strategies of
stakeholders which could dramatically increase or
reduce the impact of these biosimilar events.
Exhibit 19: U.S. impact of brand losses of exclusivity 2018–2027, US$Bn
Notes: Does not reflect offsetting spending increases from generic or biosimilar competitors. Losses in future periods are modeled based on expected pre-
expiry growth for the brand and subsequent post-expiry loss of sales for the brands. The rates of loss are based on historic averages in each country and
inclusive of adjustments for products with expiries in progress from historic periods where losses extend into the forecast periods. Historic period analyses
are based on audited data. Expected loss of exclusivity dates are highly variable and can change due to outcomes of litigation, granting of new patents or
changes in the expectation of launch of biosimilars. Information is current as of September 2022.
The impact of exclusivity losses will increase to $140.8Bn over
5 years including significant biosimilars in 2023 and 2024
-1.2 -1.8 -4.4 -2.2 -0.8
-7.6
-14.2
-8.3
-5.1 -7.1
-7.1 -9.5
-8.8
-5.7 -7.2
-13.6
-14.8
-21.8
-23.2
-24.9
-8.4
-11.3
-13.2
-7.9 -8.0
-21.2
-29.1 -30.1
-28.4
-32.0
Biologic Small
$10.4Bn $38.4Bn
$48.8Bn
$42.3Bn $98.4Bn
$140.8Bn
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Forecast
$ Total brand loss due to LOE

• There were dramatically fewer new active substance
(NAS) launches in the U.S. in 2022 following the record
year in 2021, reflecting both fewer approvals and some
approved but not yet launched medicines.
• Four of the last five years have had more than
50 NAS launches and the next five years are expected
to average at least 50 per year, with an aggregate total
of more than $22Bn in new brand spending per year.
• Over the next five years, more than 250 NASs are
expected to launch in the U.S. and new products
in aggregate are expected to contribute $110Bn
in spending.
• New launches in the next five years are expected to
include 100 new cancer drugs globally, with most of
those available in the U.S. at launch.
• Other clusters of innovative drugs include as many as
60 next generation biotherapeutics, which include cell
and gene therapies and RNA therapeutics, and which
partly overlap with oncology treatments.
Exhibit 20: U.S. new brand spending
Notes: New brands spending defined as products marketed for less than two years in each year. Number of New Active Substances (NAS) per year reflect
launches rather than approvals as there can be a lag between approval and launch. *NAS launches in 2022 Estimated based on information confirmed as of
Dec 14, 2022.
New brand spending in the U.S. is projected to be higher than the
last 5 years but a smaller share of spending
8 25 35 34 22 18 22 15 18 12 15 22 24 24 25
12%
10%
8%
6%
4%
2%
0%
40
35
30
25
20
15
10
5
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
New
brands
%
of
total
brand
spending
New
brand
spending
US$Bn
US NAS
Launches 41 46 49 30 42 57 51 54 69 41
(39–43)
Average launches projected at 50–55/year
(250–275 launches within 5-years)
New brand spending New brands share of brand spending
Forecast
Total 2013−17 = $124Bn
Total 2018−22 = $86Bn
Total 2023−27 = $110Bn

• Overall, the Inflation Reduction Act is expected to result
in a net reduction of manufacturer revenue through
price negotiation, inflation penalties and a shift in
cost-subsidy responsibility in the Medicare program.
• Patient costs are also expected to be reduced
substantially in the Medicare program through a
combination of lower price inflation, a $2,000 per year
out-of-pocket cap, insulin price caps, and provisions
that limit patient exposure to premium increases.
• There is an expected increase in medicine use for
some patients who are thought to have been non-
adherent to planned treatment under the current cost-
sharing model but who would be more able to afford
their medicines under new provisions and ultimately
fill their prescriptions.
• The changes to the Medicare Part D benefit and cost-
sharing model are expected to influence insurance
plans, who will absorb responsibility for costs
previously paid by the government and will seek to
offset those costs through changes in formulary
management, negotiation with manufacturers or
through premium increases to the extent allowed.
• Perhaps the most discussed provision of the law is the
phased in price negotiation which initially affects a
limited number of drugs but introduces government
negotiated prices to the U.S. market for the first time.
• Some of the provisions of the law take effect in early
2023 while others will progress through executive branch
rulemaking and comment periods through the next few
years, with important changes likely to emerge.
• Most patients already face extremely low costs and
only those with the most extreme cost exposures are
likely to experience significant savings.
Exhibit 21: Selected components of the Inflation Reduction Act
Key elements of the Inflation Reduction Act (IRA) are expected to
impact medicine pricing and cost sharing among stakeholders
Source: IQVIA Market Access Strategy Consulting, Nov 2022.
Prescription drug inflation rebates
• New policy for manufacturers to pay rebates if prices
increase faster than general inflation, took effect
beginning October 2022
Maximum patient out-of-pocket caps
• Beginning in 2024, Medicare part D cost sharing
maximum $2,000 per year, and eliminates the previously
uncapped ‘catastrophic’ phase
• Beginning in 2023, insulins capped at $35 per month
Part D benefit redesign
• Cost-sharing changes take effect beginning in 2024
• Patient cost-sharing in ‘catastrophic’ phase ends in 2024,
while manufacturer cost sharing shifts in 2025, with reduced
responsibility in the former donut hole phase and increased
responsibility in the higher-cost ‘catastrophic’ phase
• Costs shift from CMS to Part D plans in former
catastrophic phase of cost sharing model
• Consumers’ premiums will be capped at 6% in the first
few years of the reform
Lowering prices through “negotiation”
• Phased in implementation of drugs subject to Medicare
negotiation starting in 2026
• High-expenditure, single-source medicines not otherwise
subject to generic or biosimilar competition
• Marketed for 9+ years for small molecules and 13+ years
for biologics
• Mechanism and basis for negotiation is pending

• Medicine spending in the top five European markets is
expected to increase by $59Bn over the next five years,
up from $53Bn in the past five years but with large
shifts in the drivers of growth.
• New brands were the largest driver of growth from
2017 to 2022 and are expected to continue in the next
five years but be hampered by lingering effects of
the pandemic on marketing operations early in the
period and reimbursement decisions later as budget
pressures increase.
• Generics, including biosimilars, are expected to add
$12Bn in growth over the next five years, about the
same as in the past five years despite a larger impact
of losses of exclusivity as volume gains will be offset by
price deflation.
• Payer actions will be shaped by the pace of economic
and COVID-19 recovery, including broader inflation
concerns and the impact on fuel commodity costs in
the region related to the Ukraine conflict.
• Innovation is expected to be significantly strong in
the next five years despite expected greater scrutiny
of the value of new medicines in the form of health
technology assessments.
• It is possible that new brand growth will be lower while
older established brands may grow more after they
have demonstrated value in the market and negotiated
market access, and these dynamics represent an area
of significant uncertainty.
Exhibit 22: Spending and growth drivers in France, Germany, Italy, Spain, and UK 2017–2027 const US$Bn
Notes: Spending in US$ with constant Q2 2022 exchange rates. New brands growth contribution defined as the growth during periods when products had
been marketed for less than two years. Growth from products defined as new in each year of the five-year period are aggregated together. Existing brands
are those which are no longer new and not yet off-patent. Off-patent brands have faced Loss of Exclusivity (LOE). Generics includes non-original branded
products or ‘branded generics’ as well as biosimilars. Other includes OTC/other products.
Spending in Europe is expected to increase by $59Bn through 2027,
driven by new brands
151
38
-9
7
14 2 204
45
-31
31
12 2 263
Forecast
New
brands
LOE Existing
brands
Generics Others New
brands
LOE Existing
brands
Generics Others
2022
spending
2027
spending
2017
spending

• The impact of losses of exclusivity (LOE) in the five
largest European markets (Germany, France, Italy,
Spain and the UK) are expected to more than triple
over the next five years, and more than half of the
impact is expected to be biologics, with $17.5Bn of
the $31Bn total impact.
• The major impact is seen in 2023 and 2024 with
patent expiry of ranibizumab (Lucentis) in 2022 and
ustekinumab (Stelara) in 2024.
• Europe’s biosimilar market is largest in the world,
with the first biosimilar launched in 2006. The biologic
molecules facing biosimilar competition increased
from 2013 to 2018 in the European Union, with the EMA
approvals increasing in 2017 and 2018.
• The approval of biosimilars is based on solid and
robust legal pathways introduced in 2004 and since
then has led to the highest number of biosimilar
approvals in the world.
• Small molecule LOE is expected to double in terms of
impact on brands in the next five years even as they
have been a smaller share of overall impact.
Exhibit 23: EU4+UK impact of brand losses of exclusivity 2018–2027, US$Bn
Notes: Does not reflect offsetting spending increases from generic or biosimilar competitors. Losses in future periods are modeled based on expected pre-
expiry growth for the brand and subsequent post-expiry loss of sales for the brands. The rates of loss are based on historic averages in each country and
inclusive of adjustments for products with expiries in progress from historic periods where losses extend into the forecast periods. Historic period analyses
are based on audited data. Expected loss of exclusivity dates are highly variable and can change due to outcomes of litigation, granting of new patents or
changes in the expectation of launch of biosimilars. Information is current as of September 2022.
The impact of exclusivity losses will reach $31Bn over 5 years, with
more than half due to the availability of biosimilars
-0.2 -0.3 -0.6 -0.5
-1.3
-2.3 -2.2
-5.7
-4.9
-2.3
-1.5 -0.9 -0.6 -0.7
-2.4
-3.5
-2.0
-2.7
-2.7
-2.5
-1.7
-1.2 -1.3 -1.2
-3.6
-5.9
-4.2
-8.5
-7.7
-4.8
Biologic Small
$2.9Bn $6.0Bn
$8.9Bn
$17.5Bn $13.5Bn
$31.0Bn
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Forecast
$ Total brand loss due to LOE

• Over the next five years, more than 200 new
active substances (NASs) are expected to launch
in the leading European countries and new products in
aggregate are expected to contribute $45Bn
in spending.
• Three of the last five years have had 40 or more NAS
launches and the next five years are expected to
average at least 40–45 per year, with an aggregate
total of over $9Bn in new brand spending per year.
• New launches in the next five years are expected to
include one-third from cancer drugs, and important
clusters in neurology including rare diseases.
• Other clusters of innovative drugs include next
generation biotherapeutics, which include cell and
gene therapies and RNA therapeutics, and which
partly overlap with oncology treatments, though
reimbursement decisions may be complex due to the
budget impact for relatively few benefitting patients.
Exhibit 24: EU4+UK new brand spending
Notes: New brands spending defined as products marketed for less than two years in each year. Number of New Active Substances (NAS) per year reflect
launches rather than approvals as there can be a lag between approval and launch. *NAS launches in 2022 Estimated based on YTD Dec 14 2022.
New brand spending in EU4+UK is projected to be higher than the
last 5 years but a smaller share of spending
3 6 12 12 10 11 8 6 6 7 8 9 9 9 10
0%
5%
10%
15%
0
5
10
15
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
New
brands
%
of
total
brand
spending
New
brand
spending
US$Bn
EU4+UK
NAS
Launches
24 42 37 29 42 36 29 40 50 40
(38–42)
Average launches projected at 40–45/year
(200–225 launches within 5 years)
New brand spending New brands share of brand spending
Forecast
Total 2013−17 = $42Bn
Total 2018−22 = $38Bn Total 2023−27 = $45Bn

• Latin America and Eastern Europe represent two of
the fastest growing regions in terms of medicine
spending globally.
• Latin America’s growth is led by Brazil and Mexico
at 9–12% and 7.5–10.5%, respectively, and together
representing two-thirds of the spending in the
region overall.
• Argentina has been impacted by inflation significantly
in recent years, and these issues are at least partly
driving the 25% and 37% growth in 2021 and 2022;
growth is expected to slow to 3.5–6.5% through the
forecast period.
• Colombia is the highest growth country of the rest
of the region and represents an important stabilization
of the market after many years of political and
economic instability.
• In Eastern Europe, growth is led by Russia, which is
projected to grow 6–9% CAGR through 2027.
• Turkey’s high growth in the forecast may be a result of
ongoing inflation issues and bears careful attention.
• Poland and Romania are expected to return to
pre-pandemic growth rates from 2023 through 2027.
• The largest uncertainty in the region is the Ukraine
conflict, which is having direct and demonstrable
impacts on that country’s medicine use and spending.
• The conflict is also likely impacting neighboring
countries with the medical needs of displaced persons,
as well as the ongoing effects on economic activity,
fuel costs and regional business activity.
Exhibit 25: Spending growth in select pharmerging countries 2019–2027, total market, const US$
Notes: 2019 is included to show the impacts of the pandemic on spending growth. Argentina growth in 2021 (25.4%), 2022 (37.2%) and Turkey 2022 (-6%)
not plotted.
Latin America and Eastern Europe are expected to return to steady
growth outpacing the global market
2
0
2
6
2
0
2
7
Eastern Europe Russia Turkey Poland Romania
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
Others
Latin America Brazil Mexico Argentina Colombia Others
25%
20%
15%
10%
5%
0%
-5%
25%
20%
15%
10%
5%
0%
-5%
2027 Spending
2023–27 CAGRs
Spending growth
7–10%
$115–135Bn
9–12%
$57–77Bn
6–9%
$100–120Bn
6–9%
$25–29Bn
7.5–10.5%
$15–19Bn
3.5–6.5%
$15–19Bn
15–19%
$14–20Bn
5.5–8.5%
$12–16Bn
6–9%
$6–8Bn
3–6%
$15–19Bn
7–10%
$7–9Bn
3.5–6.5%
$41–45Bn

• The ongoing conflict in Ukraine has reduced medicine
spending by 10.3% in the first half of 2022 and an
expected 22% through the full year.
• As the duration of intensity of the conflict represents
unknowns, scenarios may be helpful to quantify the
impacts; in the most pessimistic scenario, the conflict
would continue similar to the 2011 conflict in Syria
and result in a three-year decline of 20-30% per year
followed by a decade-long disruption at 70% below the
pre-war level.
• A more optimistic view could see the conflict resolved
in 2023 with rebuilding and health system reforms
hampering spending growth initially, with growth
returning to pre-war rates by 2025.
• The base case scenario embeds a stabilization of the
conflict in 2023, lingering economic disruption and
challenges in funding rebuilding that last longer into
the forecast period.
• Domestic impacts in Ukraine are only part of the
impact of the conflict, which has region-wide and
global implications.
• Ukraine and Russia each have played important
roles in regional supply chains for active ingredients
and finished pharmaceuticals as well as clinical trial
operations for drug development, all of which have
been and will continue to be disrupted as the
conflict continues.
• A Europe-wide winter fuel crisis and inflation are also
linked to the events in Ukraine.
• In addition to these effects, persons displaced to
neighboring Eastern European countries are
expected to impact medicine needs in Poland, which
has taken in more than 1 million refugees, as well as
other countries.
Exhibit 26: Ukraine medicine spending scenarios 2012–2027, constant US$Bn
Notes: Ukraine estimates based on historic data through June 2022 and IQVIA Institute scenario modeling.
Ukraine medicine spending has been disrupted by the ongoing war,
with substantial sustained impact through the forecast
Modeling with Syria-war growth rates Base case
Return to pre-pandemic growth rates in 2025
2017
2016
2015
2014
2013
2012 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Constant
US$Bn
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0
Earlier end to conflict but lingering
healthcare reform issues, rebuilding
and funding dependent on GDP
recovery, growth returns to 2019
rates by 2025
Base case embeds a stabilization of the
conflict in 2023, lingering economic
disruption and challenges in funding
rebuilding that last longer into the
forecast period
Modeled on historic growth rates in
Syria at the beginning of the civil war
in 2011 (20-30% declines for 3 years,
steady -70% of prewar level after that)

• The impact of the pandemic on medicine spending
growth has been significant in some markets across
the Asia-Pacific region, but these are expected to
moderate and return to 5.5–8.5% growth through 2027.
• Key countries in the region include two higher
income developed markets — South Korea with
growth 4.5–7.5% and Australia growing at 2–5% before
discounts and rebates.
• China’s growth has swung wildly in recent years, but is
expected to stabilize at 2–5% through 2027.
• India continues to grow through volume while costs
remain low and medicines focus on generics; spending
will increase 7.5–10.5% through 2027, reaching $35–39Bn.
• Japan, with growth of -2 to 1% through 2027, is expected
to drop from third to become the fourth largest global
market by 2027, as policies to control spending growth
remain the key focus of the health ministry.
Exhibit 27: Spending growth in select Asia-Pacific countries 2019–2027, total market, const US$
Notes: 2019 is included to show the impacts of the pandemic on spending growth. Asia-Pacific excludes China, India and Japan which are shown separately.
The pandemic’s impact on Asia-Pacific countries varies
considerably but a return to steady growth is projected after 2021
Source: IQVIA Market Prognosis, Sep 2022; IQVIA Institute, Nov 2022
2027 Spending
2023–27 CAGRs
Spending growth
25%
20%
15%
10%
5%
0%
-5%
25%
20%
15%
10%
5%
0%
-5%
Asia-Pacific Japan
5.5–8.5%
$108–138Bn
2–5%
$180–210Bn
4.5–7.5%
$21–25Bn
2–5%
$16–20Bn
-2–1%
$71-91Bn
7.5–10.5%
$35–39Bn
3.5–6.5%
$9–13Bn
7–10%
$61–81Bn
China India
South Korea Australia Indonesia Other Asia-Pacific
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7
2
0
1
9
2
0
2
0
2
0
2
1
2
0
2
2
2
0
2
3
2
0
2
4
2
0
2
5
2
0
2
6
2
0
2
7

• Spending growth in Japan is expected to maintain a
consistent -2 to 1% growth rate over the next five years
as COVID-19 recovery continues and long-term trends
affecting long-listed brands continue.
• While 2020 had the impact of being a price-cut year on
top of the pandemic, the more muted rebound in 2021
included an off-cycle price-cut as well as the lingering
effects of the pandemic on the market.
• Annual frequency of pricing revisions is expected
through the full forecast period, though the annual
off-year impacts may be lower than the established
biennial price cut years.
• Over the past decade, protected brands share of
spending has risen from 48% to 54%, reversing a long
historical trend where share would decline over time,
and reflecting a shift in investment by manufacturers
launching earlier in Japan and government focus on
enabling earlier access to novel medicines.
• Long-listed products have declined from 25% of
spending in 2013 to 13% in 2022 and are expected to
drop to 9% by 2027.
• Generic share of spending is also expected to rise,
supported by policies that have been largely effective
over this entire 15-year period, encouraging doctors
to substitute available generics with a combination of
incentives and penalties.
• Pharmaceutical spend associated with long-COVID
is expected to represent up to an additional 3-5% of
spend over the forecast period, declining over time
and likely focused in generic and long-listed segments,
though the uncertainty in this area will continue.
Exhibit 28: Japan medicine spending by product type 2013–2027, constant US$Bn
Notes: Medicine spending at ex-manufacturer level, segmented according to Japan-specific product types which differ from segmentations used elsewhere in
this report. Price revisions historically have taken effect in April, every other year.
Japan medicine spending is forecast nearly unchanged over 5 years
as innovation is offset by shift to annual price cuts
Source: IQVIA Market Prognosis, Sep 2022; IQVIA Japan, Sep 2021; IQVIA Institute, Nov 2022.
68 69
73 74 73 72 74 72 73 73 74 74 74 74 75
420
5-Year
CAGRs
5-Year
CAGRs
2.0%
3.9%
16.4%
10.3%
-5.2%
0.2%
1.1%
2.8%
1.1%
-5.4%
0.3%
1.5%
-0.1%
-8.5% 2.1% 4.3%
1.4% 0.6% 3.5%
-1.3%
-6.6%
5-Year
CAGRs
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Long-listed products Generics NHI others Non-NHI products OTC/others
Protected brands
Forecast

• Medicine spending in China has risen from $93Bn in
2013 to $166Bn in 2022.
• Over the past five years spending growth was driven
by original branded products, most often from
multinational companies, which grew at an average of
10.1% per year to reach 28% of spending in 2022, up
from 22% five years earlier.
• Over the next five years, the government policies to
update the National Reimbursement Drug List (NRDL)
annually is contributing to a greater share of new
original medicines being reimbursed, resulting in
higher levels of spending, though these are generally
subject to lower negotiated net prices.
• Over the next five years original brands will grow by
more than 5% per year, while other types of products
will grow at 4% or less, contributing to the overall
growth rate slowing to 2–5%.
• Non-original brands, including versions of
medicines originated by multi-nationals, are the
second largest segment of spending in China but are
expected to grow by less than 1% per year, partly as
a result of a government focus on curbing spending
growth in hospitals.
• By 2027, China is projected to exceed $194Bn, an
increase of almost $30Bn in the next five years.
Exhibit 29: China medicine spending by product type 2013–2027
Notes: Original brands are those marketed by their originator (or licensed partner) and includes vaccine products by all manufacturers.
Analysis does not include COVID-19 vaccines.
Spending growth in China is expected to slowly recover
post-COVID, driven almost entirely by new original medicines
93
105
113
123
131
137
155 157
163 166 169
175
182
187
194
420
5-Year
CAGRs
5-Year
CAGRs
9.6%
12.2%
9.1%
7.8%
11.2%
5.0%
10.1%
1.5%
2.8%
8.5%
3.1%
5.7%
0.7%
2.3%
4.3%
5-Year
CAGRs
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
Non-original brands
OTC & others
Unbranded products Original branded products
Forecast
200
150
100
50
0
Medicine
spending
const
US$Bn

Exhibit 30: Global medicine spending and growth by product type
Notes: Developed markets is a term related to World Bank Income bands and includes high-income and upper-middle-income countries. The 10 developed
countries are the 10 largest high-income countries (U.S., Japan, Germany, France, Italy, Spain, UK, Canada, Australia, South Korea). Pharmerging includes
countries with per capita GDP <$30,000 in 2021 and forecasted 5-year aggregate pharma sales growth >$1Bn (absolute or rounded) in at least two forecasts.
Medicine spending and growth by product type varies by region
ORIGINAL
BRANDS
NON-ORIGINAL
BRANDS
UNBRANDED
GENERICS
OTHER TOTAL
Spending
2022 US$
Global 902.1 244.5 150.2 185.5 1,482.3
Developed 788.8 109.3 101.0 89.3 1,088.3
10 Developed 722.4 83.9 90.8 71.9 968.9
Other developed 66.4 25.4 10.2 17.4 119.4
Pharmerging 105.7 124.4 47.8 93.0 370.8
Lower-income countries 7.7 10.8 1.5 3.2 23.2
Constant
dollar CAGR
2018–2022
Global 6.8% 6.1% 3.0% 5.2% 6.1%
Developed 6.6% 7.6% 0.4% 3.6% 5.7%
10 Developed 6.6% 7.7% -0.1% 3.1% 5.7%
Other developed 6.2% 7.2% 6.2% 5.8% 6.4%
Pharmerging 9.2% 5.0% 10.0% 6.8% 7.2%
Lower-income countries 4.4% 5.8% 9.7% 9.2% 6.0%
Spending
2027 US$
Global $1,155–1,185 $325–355 $160–190 $215–245 $1,900–1,930
Developed $1,000–1,030 $150–165 $105–115 $98–108 $1,370–1,400
10 Developed $910–940 $117–127 $92–102 $75–85 $1,207–1,237
Other developed $83–103 $34–38 $12–16 $21–25 $156–176
Pharmerging $133–153 $157–177 $62–64 $114–134 $487–518
Lower-income countries $9–11 $12–16 $2-3 $2.5–5.5 $29–33
Constant
dollar CAGR
2023–2027
Global 3–6% 5–8% 1–4% 3–6% 3–6%
Developed 3–6% 5–8% -1–2% 0.5–3.5% 2.5–5.5%
10 Developed 3–6% 5–8% -1–2% -0.5–2.5% 2.5–5.5%
Other developed 4–7% 5–8% 3.5–6.5% 3.5–6.5% 4–7%
Pharmerging 5–8% 5–8% 4.5–7.5% 5–8% 5–8%
Lower-income countries 4–7% 4–7% 6.5–9.5% 6–9% 4.5–7.5%
• The types of medicines driving spending and growth vary
considerably across countries broadly correlated with a
degree of economic development.
• Generally wealthier countries have higher levels of
spending on original branded products, especially earlier
in the patented periods of these products.
• Lower-income countries have a greater reliance on
generic drugs, and sometimes prefer non-original
branded versions, sometimes called branded generics,
and when patent enforcement is less stringent these are
referred to as ‘copy products.’
• Developed countries typically have higher shares from
original branded products but vary to the degree they
shift usage to generics or non-original products after
patent expiry, contributing to differences in spending
share for originators including those that are off-patent.
• Pharmerging and lower-income countries have much
lower shares of spending from originator products, with a
greater focus on either generics or non-original branded
products, and all products typically have lower prices.

• Global savings from biosimilars will exceed $290Bn in
cumulative spending through 2027 — below estimates
without new biosimilars.
• Specialty medicines will represent 43% of global
spending in 2027 and over 55% of total spending in
developed markets.
• The two leading global therapy areas — oncology and
immunology — are forecast to grow 13–16% and 3–6%
CAGR, respectively, through 2027.
• Oncology is projected to add 100 new treatments over
five years, contributing to an increase in spending of
$184Bn to a total of more than $370Bn in 2027 and
facing limited new losses of exclusivity.
• Treatments for autoimmune disorders are forecast
to reach $177Bn globally by 2027, driven by steadily
increasing numbers of treated patients and new
products, and offset after 2023 due to biosimilars.
• Diabetes spending growth is slowing to low single
digits in most developed markets and declining in
some, especially net of rebates.
• New therapies contribute to growth of neurology
markets, including greater use of novel migraine
therapies, potential treatments for rare diseases,
and the potential for therapies for Alzheimer’s
and Parkinson’s.
• The outlook for next generation biotherapeutics
includes significantly uncertain clinical and commercial
prospects for cell, gene and RNA therapies, which will
grow to $27Bn in spending by 2027.
Key therapy areas
Biotech will represent 35% of spending globally and include both
breakthrough cell and gene therapies as well as a maturing biosimilar
segment. Major advances are expected to continue, especially in oncology,
and immunology. Notable small molecule innovations are also expected in
these diseases as well as neurology.

• Global spending on biotech drugs — those created
through recombinant DNA technology — are expected
to reach $666Bn by 2027, about 35% of global medicine
spending.
• Biotech includes a range of therapies — traditional
therapies such as insulin analogues and more complex
specialty medicines.
• Spending for biotech drugs will include $14–17Bn by
2027 from cell and gene therapies, which currently
represent approximately $4Bn and are expected to
grow from wider use, especially in developed markets.
• Overall biotech growth will occur despite brand losses
of $65Bn due to biosimilars in the five years to 2027.
• Spending growth is expected to slow significantly in
the next five years from the impact of key biosimilars
especially in developed markets but remain robust
through the continued flow of new medicines.
• Biotech drugs will see a 54% aggregate increase over
five years with a 7.5–10.5% CAGR through 2027, adding
$235Bn over the period globally.
Exhibit 31: Global biotech spending and growth
Notes: Biotech medicines defined as those produced through recombinant DNA technology.
KEY THERAPY AREAS
Global biotech spending to exceed $660Bn by 2027, with growth
slowing to 7.5–10.5% from biosimilar savings
119 130
152
174
198
223
257
299
331
381
431
474
522
569
617
666
Spending
Forecast
Growth
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
0
100
200
300
400
500
600
700
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027
%
Spending
growth
constant
US$
Spending
constant
US$Bn
2023–2027 Key metrics
+54% total
spending growth
(7.5–10.5% CAGR)
$65Bn impact
on brands from
biosimilars
+$235Bn

Exhibit 32: Global savings from biosimilars 2023–2027
Notes: Savings estimated by calculating spending in a scenario where historic trends continue and compared to modeled impact of brand losses of
exclusivity and biosimilar uptake. Range reflects uncertainty of the level of uptake, price deflation, and incremental volume after LOE. Modeling includes the
impact in the 5-year period of savings from earlier biosimilar introductions.
KEY THERAPY AREAS
Global savings from biosimilars will have a significant impact on
country medicine spending through 2027
Savings high-low range
Savings
250
200
150
100
50
0
2023 2024 2025
5-year savings scenarios
$383Bn base case ($290–476Bn range)
2026 2027
• Incremental savings from biosimilars are expected to
be a cumulative $383Bn globally from 2023 to 2027.
• Annual savings could exceed $100Bn in 2026 and 2027
as some of the largest spending biologic molecules will
have well developed biosimilar competition for several
years by this time.
• This level of savings will also likely mean the opening
of access to relevant biologic medicines to more
people globally, as costs of treating patients for cancer
or autoimmune disorders are reduced to affordable
levels for patients or governments across all countries.
• Incremental usage of biologic therapies has been
observed in periods after biosimilar entry, and this is
expected to be particularly important in lower-income
countries, but the largest savings will still be focused
on developed markets, which already have very
high levels of usage and spending on the originator
versions of these medicines.
• Key upcoming biosimilars are expected to reach
patients throughout the next five years, but particularly
notable are autoimmune therapy adalimumab, currently
the world’s leading medicine by spending, with the first
biosimilar launching in the U.S
in January 2023.

• Specialty medicines have been increasing as a share of
spending in higher-income countries, such as the
10 largest developed countries and other high and
upper-middle-income countries, where they have
reached 49% and 39%, respectively, in 2022, up from
28% and 27% 10 years earlier.
• Pharmerging countries have lagged behind largely due
to cost, and had 16% of spending in 2022 on specialty
medicines, expected to be unchanged as a share of
spending in 2027.
• Globally specialty medicines will be 43% of global
spending by 2027, with more than half of spending on
these products in major developed markets.
• Specialty medicines are those which treat chronic,
complex and rare diseases, and while they have a
range of characteristics — including the complexity
of disease management or distribution — the most
commonly noted attribute is that they are more
expensive than other more traditional medicines.
• As specialty medicine share of spending increases,
it is notable that they treat only 2–3% of patients;
and while the unmet needs of these few patients are
being addressed, by contrast other patients getting
traditional therapies are seeing their costs decline.
Exhibit 33: Specialty medicines share of spending
Notes: For details on specialty medicine definition, see the methodology and definitions section.
KEY THERAPY AREAS
Specialty medicines will represent about 43% of global spending in
2027 and 56% of total spending in developed markets
Global
Pharmerging
Other developed
10 developed
Forecast
2012 2017 2022 2027
28%
40%
49%
56%
27%
36%
43%
47%
10%
12%
16% 16%
24%
32%
39%
43%

Global Use of Medicine - 2023 by IQVIA

Global Use of Medicine - 2023 by IQVIA

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