Exploring Strategy, Logistical Processes, and Access to Medicines in Malta’s Public Sector Pharmaceutical Distribution: A Grounded Theory Study

Introduction

Access to medicines is a foundation of the right to health, yet small island states face distinct challenges in ensuring equitable and sustainable pharmaceutical delivery and access to medicines. In Malta, a small island nation reliant on imports, the pharmaceutical supply chain is shaped by logistical limitations, regulatory frameworks, entitlement and procurement policies. Despite extensive studies in larger countries, little research explores how small states manage medicine access and system resilience within limited resource environments. This study addresses this gap by examining Malta’s public sector pharmaceutical supply chain through a constructivist grounded theory approach, providing context-specific insights for small-state health systems.

Goals and Methods

The study aims to develop a grounded theoretical model explaining how policy, procurement, pricing, and governance interact to influence access to medicines. Data was collected through eight semi-structured interviews with procurement and policy stakeholders, supported by documentary analysis. Using MAXQDA, over 1,700 data segments were coded and analysed through constant comparative analysis to identify conceptual categories and higher-order themes.

Results

Six core categories emerged: formulary governance, pharmaceutical pricing, procurement systems, treatment availability, regulatory frameworks, and cross-organisational collaboration. Preliminary results reveal inefficiencies in formulary management, outdated pricing policies misaligned with post-pandemic realities, and a rigid procurement system highly dependent on UK-sourced medicines. These factors contribute to inequities in treatment availability and systemic strain on resources and budgets.

Conclusions

The emerging grounded theory highlights how governance, pricing, and procurement interconnect to shape access to medicines in small-island contexts. Findings offer actionable insights for integrated reforms to strengthen Malta’s public pharmaceutical system, enhancing resilience, equity, and sustainability.