The list that grows because the system is working
Patient advocate Malcolm Mulholland of Patient Voice Aotearoa has warned that Pharmac’s Options for Investment list, the medicines the agency would fund if its budget allowed, could balloon from around 100 drugs today to as many as 400 within one to two years. “Whilst today we might be talking about 100 drugs that Pharmac want to fund, it’s very realistic that in the space of a year to two, we could be talking about 400 drugs,” he told RNZ.
This is not scaremongering. Pharmac’s own chief medical officer, Dr David Hughes, confirmed the direction of travel: “As we work through the current backlog of historic applications, we expect the Options for Investment list to grow, helping ensure that more medicines can be considered for future funding,” he said. Associate Health Minister David Seymour agreed with the analysis, noting “record funding increases” and pledging to campaign for more.
When the advocate, the agency and the minister all agree on the scale of a looming problem, it stops being a health-sector detail. It becomes a fiscal one.
The reform paradox
Here is the uncomfortable mechanics. The government’s Pharmac reforms were designed to speed up assessment, moving medicines through evaluation faster and onto the visible priority list sooner. That is the right policy direction. But faster assessment without proportionally faster funding produces one predictable outcome: the unfunded list grows.
Medicines that once sat invisibly in an opaque assessment queue now surface as approved-but-unfunded. The gap between what is clinically available and what is publicly paid for becomes legible, and legible gaps are politically combustible. Pharmac has recruited additional health economists and expert advisers and is trialling more efficient processes. The better it gets at its job, the larger the wishlist it publishes.
The arithmetic problem
As of 15 March 2026 there were 139 applications on the Options for Investment list. Behind that sits a pipeline of around 190 funding applications awaiting assessment.
Against that queue, Pharmac has a medicines budget of $1.760 billion for 2025/26, rising to $1.794 billion by 2027/28. The headline commitment of $6.294 billion over four years, with a $604 million uplift, was the largest in Pharmac’s history. Genuine progress: in 2024/25 Pharmac made 64 investment decisions, benefiting an estimated 79,131 patients.
But that uplift was sized against a queue of roughly 100 to 140 medicines. If the list reaches 400, the funding gap scales with it. And the backlog is already stretching: the same Q3 report shows the average time to rank proposals has climbed to 43.8 months, up from a five-year average of 31.1 months. Sixty-four decisions a year against 190 applications awaiting assessment is not a queue that clears itself.
Where the bill lands on business
This is where a health story becomes an employer’s problem. A longer unfunded list pushes more patients toward private cover for medicines the public system will not pay for. Insurers either fund them, feeding premium inflation, or exclude them, hollowing out the value of cover. Employers who offer health insurance as a staff benefit sit at the end of that chain, absorbing the cost either way.
Delayed access to standard-of-care treatment also carries a productivity price. Longer illness means more absence and earlier workforce exit. New Zealand already lags on access, historically spending about 4.9% of health expenditure on pharmaceuticals against an OECD average of 13.3%, with earlier analysis finding medicines can take 7 to 10 years from Medsafe approval to Pharmac funding versus 6 to 18 months in Australia. A widening gap only accelerates the drift toward a self-pay tier and offshore treatment.
The Budget question no one can dodge
Treasury saw this coming. Its December 2023 risk memo flagged the Combined Pharmaceutical Budget as a significant fiscal risk, citing price increases, ageing demographics and a shift toward more expensive treatments.
A queue of 100 is a health story that flares up each Budget and subsides. A queue of 400, every drug assessed, ranked and publicly documented, is a standing fiscal negotiation that only grows louder. The government has done the genuinely hard part. It built a faster machine that surfaces need instead of hiding it. The choice ahead is whether it funds what that machine now exposes, or lives with an ever-lengthening list of medicines the state has approved but declines to buy.
Sources
- Pharmac’s wishlist of drugs could increase four-fold in next two years – advocate (2026-07-22)
- Updated information about Pharmac’s priority lists (2026-03-15)
- Pharmac Statement of Performance Expectations 2025-26 (2025)
- Pharmac Budget Information Memorandum to Minister Brown 2025 (2025)
- Pharmac Quarter Three Report 2024-2025 (2025-02-28)
- Treasury Report T2023/2029: Pharmac Combined Pharmaceutical Budget Funding (2023-12-20)
- Pharmac needs more staff and money to speed-up drug funding decision – advocates
- NZ ‘significantly behind’ other OECD countries in new-medicine access
- Pharmac wants to trim its controversial medicines waiting list