Furthermore, medicines prices are usually high, particularly in the private sector and up to 80 times the price in high-income countries; availability can be low, particularly in the public sector; treatments are often unaffordable, requiring 15 days of wage to buy a 30 days treatment; government procurement can be inefficient by buying expensive original medication as well as cheaper generics; and numerous taxes and duties are being applied to medicines, including essential ones. These issues were observed in China, an upper-middle-income economy, with its bribery scandals involving GlaxoSmithKline and Sanofi. However, inspired by the use of ERP by high-income countries and the lesser technical and analytical requirements to implement ERP compared to other price control mechanisms such as cost-plus or pharmacoeconomic analysis, LMICs are increasingly following suit, by using ERP in combination with other methods of cost control (cost plus, internal reference pricing, profit controls, economic evaluation, direct fixation). Similarly to high-income countries, there is only limited evidence as to the impact of ERP in LMICs. However, some countries such as Turkey and Indonesia saw a decrease in drug prices following the implementation of ERP, although there is no objectively direct evidence this decrease was caused by the introduction of ERP.  , a systematic review found that markup regulation and ERP are the most commonly implemented drug pricing policies in LMICs, followed by cost-plus and the use of generics. Another review found limited evidence that implementing ERP had the effect of narrowing down the prices, by lowering drug prices in high-price countries and raising them in low-price countries. Hence, it is suggested that optimal ERP implementations are dependent on a clear set of requirements and calculation in full transparency, and that ERP should not be used as the sole pricing mechanism but rather as one benchmark for pricing decisions. ERP differs from internal reference pricing, or therapeutic reference pricing, where the price of a medication is compared against other domestic drugs that are its therapeutic equivalents, based on a given ATC level. This sets a reference price for a class of equivalent or similar therapeutic agents, the rest being paid out-of-pocket by the patient. Hence, a prerequisite of internal reference pricing is the availability of comparable medicines, which usually implies this can be implemented only after patents expiry and when generic or biosimilar medicines enter the market. Internal reference pricing may reduce expenditures in the short term by incentivizing people to use the reference drugs at the reference price, but the effect on drugs with a higher price than reference and on health is uncertain.