Australia's public medicines system is sclerotic. The Pharmaceutical Benefits Scheme labours under chronic under-investment, dressed up as 'evidence-based' decision-making, while patients wait around two years for reimbursed access to new medicines. Some wait longer. Many suffer or even die waiting.
Nothing better symbolises the PBS’s institutional sclerosis than the Health Technology Assessment Review. Announced in September 2021, more than five years ago, it is still labouring towards technical adjustments and additional processes for a decision-making framework already tripping over itself.
The chronology is an indictment. It took until March 2023 to publish terms of reference. The final report, 50 recommendations, arrived in September 2024. An Implementation Advisory Group followed, with a roadmap due in January 2026.
None of that is to criticise the individuals who each participated in different stages with a genuine belief in the process.
The institution is the problem. Its instinct for self-protection, and reticence to even acknowledge the need for change, is the generational obstacle to meaningful reform.
The review has, in reality, just become another process for preserving the institution. Alternatives that expose its failure become threats to be controlled and managed away.
Surely, nobody has any belief left in a process that is approaching its end like a drunk stumbling home from a big night out.
Fortunately, the review may ultimately serve an important purpose, but not the one intended. It may stand as the clearest evidence of chronic failings. The process makes the case for fundamentally upending an institution that is plainly incapable of reforming itself.
While the review labours from one absurd process to another, a dynamic, people-focused private market has emerged for GLP-1 medicines for weight loss.
When the review was launched, monthly spending on GLP-1 medicines was around $25 million, primarily directed towards PBS reimbursement for diabetes. It is now ten times that and dominated by private market use for weight loss.
The Australian unsubsidised and private medicine markets are not new.
Australians are dispensed over 100 million PBS prescriptions each year that attract no subsidy. For the around 20 million Australians without a concession card, the vast majority of medicines they receive are unsubsidised. For these people, the PBS is a high-cost medicines subsidy scheme.
Yet there is also a burgeoning private market, where millions of Australians access unsubsidised medicines outside any PBS framework, including women's and men's health products, medicinal cannabis, and GLP-1s for weight loss.
As BioPharmaDispatch reports today, intelligence firm Nostradata, which collects data from over 90 per cent of Australian community pharmacies, shows that approximately 1.6 million individuals have accessed a GLP-1 via the private market in the past 12 months, boosting it to around $2.3 billion annually.
This private market is expected to continue growing rapidly.
Meanwhile, the PBS decision-making framework has stumbled over GLP-1 medicines.
In November 2025, the PBAC recommended Novo Nordisk's WEGOVY (semaglutide) for a comparatively small cohort of patients with severe, established cardiovascular disease and obesity, contingent, as ever, on a price. Almost a year later, the listing has still not occurred. Eli Lilly, meanwhile, decided not to proceed with the recommendation for its MOUNJARO (tirzepatide).
Why would either company bother with the PBS? It's probably more trouble than it's worth.
The companies could keep dealing with the PBS and its moribund HTA processes and parsimonious pricing policies. Or they could opt for distribution through an efficient, dynamic, large, patient-focused private market.
Walking away also serves a critical public service as a rebuke this institution needs. A system accustomed to dictating terms must learn that companies, in some circumstances, can reject them, and patients can bypass it.
The institution would benefit from some competition.
The inevitable and understandable objection will be inequality. People on low incomes cannot afford to access the medicines privately. Fair enough. It is undoubtedly terrible for these people in need. Yet that is not the private market's fault. Nor do the companies have any particular obligation given the Australian Government administers the PBS and its decision-making frameworks.
Australia's health system is a 'Faustian bargain'. Government dominance, with a command-and-control mindset, comes with delay and denial.
Nothing new in Australians responding by seeking alternatives.
The private GLP-1 market has not created a two-tier health system. It has further exposed the one we already have.
Australians who can afford private care have always bought their way out of queues for specialists, medicines, vaccines, diagnostics, and surgery.
If our public institutions deny patients reimbursed access to treatment, they can't complain when people opt to pay for it themselves through a responsive, patient-focused market that provides choice.
Some will instinctively want to rein in the private GLP-1 market, perhaps even shut it down. Why? Because its success implicitly rebukes the institution. For some, it's better to close the escape route than discuss the realities of why so many need one.
This private market will keep evolving, as markets always do, and as it should.
More weight-loss medicines are advancing through late-stage development, including oral and long-acting formulations. Competition will drive prices down and widen access. The private market is doing what an ossified public institution cannot. It will make these innovations more affordable and accessible. Government should stay out of its way, particularly if it continues to obfuscate on funding outcomes. It might even learn some lessons.
The HTA review will eventually stagger to an end, producing more processes, adjustments to technical inputs, and most likely, more reasons for patients to wait. Sadly, some patients have no option but to wait in hope. Others are acting. The private GLP-1 market is partly a verdict on the institution's performance. Australians have shown that when the public system cannot or will not deliver, they will find another way. The question for government is why an institution trusted with ensuring access to medicines has made a huge private market a logical response.
