From Value Imperative to Operating Reality: Rethinking Trust in Pharma

Trust remains one of the central paradoxes in the pharma industry. Few sectors contribute more directly to human health and societal progress, yet few operate under such persistent skepticism. Trust in pharma goes far beyond being merely an abstract ideal or a communications challenge; it shapes access to patients and health care professionals, influences credibility with regulators and policy makers, and underpins the industry's broader license to operate. At its core, trust functions as both a social contract and a business enabler, reinforcing resilience, legitimacy and long‑term value creation in an environment where confidence is constantly tested rather than presumed.

The nature of trust itself, however, is shifting. What once appeared episodic and largely reputational now functions as something systemic, continuous and increasingly measurable. Expectations that previously differentiated leading companies have become the baseline requirements for participation in the health care ecosystem. Trust is built not through stated intentions or sporadic initiatives, but through consistent performance over time, expressed in leadership decisions, behaviors and outcomes that key constituents can observe, evaluate and compare.

This perspective builds on “Trust: A Value Imperative,”¹ a 2023 article that positioned trust as both a social obligation and a strategic asset for pharma companies. Since then, the operating environment has fundamentally changed. Regulatory volatility, artificial intelligence (AI) acceleration and access pressures have created conditions in which trust must be demonstrated continuously, not declared periodically. Trust no longer functions primarily as a source of competitive advantage; it now operates as a prerequisite for sustained engagement, continuity and, ultimately, the ability to create impact at scale.

The pharma trust landscape in 2026

Since 2023, the environment in which pharma companies earn — and lose — trust has shifted in ways that fundamentally alter both expectations and exposure. What distinguishes the current landscape is not a single inflection point but the convergence of regulatory, technological, societal and operational forces that collectively raise the bar for credibility while compressing response time.

Regulatory and policy conditions are now simultaneously more fluid and more exacting. In the United States, leadership turnover across federal health agencies and evolving vaccine and advisory processes have introduced greater uncertainty into regulatory engagement. Globally, reforms such as the EU Pharma Package build expectations around clinical trial transparency and accelerated approvals, whereas the implementation of the Inflation Reduction Act embeds Medicare price negotiation and pricing policies directly into the commercial life cycle. As a result, decision‑making is scrutinized not only for compliance but also for perceived fairness, scientific integrity and societal intent, often in real time.

AI and digital technologies are moving trust from the realm of reputation into the core operating model. AI‑enabled drug discovery, trial design and regulatory submissions promise efficiency and speed, but they come with new expectations: explainability, bias mitigation, data governance and accountability. As algorithmic outputs increasingly inform scientific and regulatory judgment, trust in innovation now depends on demonstrable governance — clear processes for assessing risk, transparent decision-making and visible lines of accountability. Failures in transparency or oversight reverberate quickly across regulators, patients and clinical partners.

These pressures converge most visibly around access, affordability and value. The glucagon-like peptide‑1 experience illustrates how therapeutic breakthroughs can evolve into trust stress tests, exposing tensions among innovation, supply constraints, pricing, coverage and health equity. Similarly, the slow uptake of biosimilars, despite patent expirations and cost‑containment logic, reveals enduring trust gaps among clinicians, patients and payers. In both cases, trust deficits translate directly into adoption friction, reputational vulnerability and policy intervention.

Expectations for inclusive practices and equity are intensifying. Organizations are moving beyond programmatic commitments toward sustained focus on inclusive culture, where representation, equity and belonging are assessed through measurable outcomes rather than intent alone. A shifting political environment challenges companies to remain authentic to these principles while navigating heightened scrutiny, particularly in workforce policies, clinical trial diversity and patient engagement.

Patient and public activism, alongside transparency norms, persist at a much higher intensity level. Post‑COVID-19 collaboration models raised the bar for transparent partnerships and shared, pre‑competitive initiatives on public health challenges. At the same time, social‑media‑driven patient activism shapes expectations for clinical trial design, end point relevance and access programs. These dynamics are amplified by the spread of health misinformation and intensified scrutiny of pharmacy benefit managers, rebate practices and formulary decisions. The expansion of direct‑to‑consumer pathways, including telehealth prescribing and online pharmacies, further introduces new trust intermediaries and risk vectors.

Finally, supply chains, once largely invisible to the public, are moving from operational concerns to board-level trust issues. Recurring drug shortages, geopolitical dependencies in active pharmaceutical ingredient manufacturing, tariff uncertainty, counterfeit pharmaceuticals and climate‑related disruptions expose fragility that patients, regulators and investors increasingly expect companies to acknowledge and address transparently. Supply continuity, resilience and disclosure now form part of the trust calculus.

Taken together, these changes both tighten and extend the original Hierarchy of Trust (see Figure 1 below). First introduced as a framework for understanding how trust builds — from the benefits of medicines, to integrity, to the broader social contract — the hierarchy still follows a fundamentally vertical logic. What has changed is that elements once implicit — digital trust, scientific integrity under accelerated development and supply resilience — are now explicit trust determinants requiring intentional oversight.

Accountability, too, shifts position within the hierarchy. Rather than appearing primarily as an outcome of strong governance and leadership, accountability now cuts across every layer, shaping how decisions are made, how trade‑offs are explained and how commitments are upheld.

The result is a more tightly coupled system. Trust still builds through consistent performance and transparency, but the speed and interconnectedness of breakdown have accelerated. Failures now cascade horizontally across regulatory relationships, patient confidence, employee engagement and investor perception, often faster than organizations can respond. Trust fragility has become amplified and systemic.

Trust as an operating reality: Lessons from the Pharma 50

To assess how trust is being operationalized across the pharma industry, we examined the Pharma 50 companies referenced in Pharm Exec’s latest annual listing using observable, structural indicators rather than stated values or reputational measures. This analysis focuses on how trust is embedded in everyday decision‑making through governance, organizational structure, leadership and culture — the four operational mechanisms that determine whether trust holds under pressure (see Figure 2).

Building on our initial assessment in 2023, we expanded the underlying metrics to reflect how expectations for trust have evolved, including greater emphasis on accountability, transparency and emerging risk domains. Together, these indicators provide a practical view of whether trust is embedded in how organizations operate or remains largely aspirational.

1. Governance: Broad adoption, uneven depth

By 2026, trust‑related governance structures are well established within the Pharma 50. Two‑thirds of these companies maintain at least one board‑level committee with explicit oversight of trust‑adjacent areas spanning sustainability; ethics; compliance; patient access; culture; or environmental, social, and governance (ESG). This signals that trust considerations have moved firmly into formal governance mechanisms.

Depth of governance, however, remains uneven. Among the Pharma 50 companies, most rely on one or two committees — most commonly, corporate governance or audit — to oversee trust‑related topics. A smaller subset (24%) has established a dedicated committee focused specifically on trust‑related oversight. Only a small minority of companies (10%) have expanded board mandates to explicitly address newer trust domains, notably technology governance (including cybersecurity, AI ethics and data stewardship) or supply‑chain resilience, despite these areas representing some of the fastest‑growing sources of trust risk.

Beyond formal committee structures, active cross‑ecosystem engagement at the board level is now the norm. Eighty‑six percent of companies include directors who also serve on the boards of health systems, hospitals, academic medical centers, health‑related nonprofits or technology companies, with an average of four such directors per board. This pattern suggests a deliberate effort to embed external health care and digital innovation perspectives into governance, bringing researcher, patient, provider, technology and system‑level realities closer to strategic oversight and reinforcing pharma's role within the broader health ecosystem.

2. Structure: Elevation without full integration

Structural commitment to trust has become increasingly visible across the Pharma 50, though it continues to take different forms. The vast majority of companies (72%) now manage compliance at the highest enterprise level, either through a dedicated chief compliance officer or as part of the general counsel’s remit. This reflects a clear recognition that ethical and regulatory integrity represent enterprise‑level considerations, with accountability embedded among core leadership rather than delegated to purely technical functions.

Beyond compliance, trust‑related responsibilities are frequently embedded within shared or hybrid executive roles. More than half of companies (54%) have elevated information technology and digital capabilities to the executive level, sometimes as part of broader mandates spanning shared services or operations. This structure reflects the growing interconnectedness of digital capabilities with risk, data stewardship and trust‑critical functions.

A similar pattern emerges across other trust‑relevant domains. Three-quarters of companies (76%) have assigned trust-related responsibilities to one or more executive roles, most commonly structured as shared mandates across strategy, sustainability, human resources, public policy or corporate affairs. Thirty percent of Pharma 50 companies have established dedicated C‑suite roles focused on patient experience, patient advocacy, equity and access, or public policy.

These patterns suggest that many organizations are distributing trust responsibilities across existing leadership roles rather than creating dedicated ownership. Although this approach embeds trust considerations broadly, it also requires deliberate coordination to ensure accountability remains clear, particularly in areas such as patient advocacy, where only a small minority have established clear, dedicated leadership separate from commercial or corporate affairs functions, such as a chief patient officer role.

As trust considerations continue to expand across technology, access, culture and external engagement, the ongoing question is not whether trust has a place at the leadership table, but how shared responsibilities can be coordinated effectively as complexity and expectations continue to rise.

3. Leadership: Transparency outpaces incentives

Leadership transparency has expanded notably through disclosure. Nearly all Pharma 50 companies (96%) use transparency as a primary trust mechanism, publishing regular, multi‑topic reports covering ESG, ethics, patient access and sustainability. Most companies (78%) publish one or two such reports regularly, whereas a smaller subset issues three or four separate reports, reflecting increased detail to address rising expectations for openness.

The link between trust and executive accountability, however, shows adoption but uneven depth. Half of companies now tie leadership evaluation and incentives to trust-related priorities such as ESG, sustainability or inclusive culture. However, the scope and rigor of these commitments vary considerably: from symbolic inclusion in scorecards to substantive weighting in compensation formulas, from corporate-level targets to individual accountability and from annual bonuses to long-term incentive structures. What is becoming more common is the practice itself; what remains inconsistent is how meaningfully it shapes executive behavior and decision-making. At this stage, disclosure is advancing faster than incentive alignment, expanding visibility without always establishing consequence.

4. Culture: Strong signals, limited outcome measurement

Cultural commitment is widely articulated across the Pharma 50. Nearly one‑fourth of companies (24%) highlight formal culture or values initiatives tied to purpose, integrity or patient focus. External validation reinforces this emphasis: Over half (56%) appear on major employer reputation rankings such as Forbes, Fortune, Glassdoor or Great Place to Work, suggesting relatively strong employee trust and engagement.

Yet culture remains the least operationalized dimension of trust. Although initiatives and recognition are increasingly common, consistent disclosure of outcome‑based measures, ranging from pay equity to inclusion metrics to employee well‑being indicators that would enable external verification of whether cultural commitments translate into tangible results, remains rare. As expectations continue to shift toward measurable accountability, this gap increasingly distinguishes organizations that manage trust systematically from those that rely primarily on narrative and signaling.

2023 vs. 2026: From emergence to structural risk

Compared with 2023, the most significant shift is one of normalization. What was still emerging or differentiating three years ago has now become expected baseline practice. Board‑level oversight of ESG, ethics and culture has expanded, transparency has deepened and trust‑related language is now embedded in standard governance and reporting across much of the industry.

What has changed less, however, is how deliberately trust is governed as an enterprise‑wide system. In 2023, the principal risk was absence: missing structures, limited oversight and insufficient visibility. In 2026, the risk has evolved. Today's vulnerability lies not in neglect, but in fragmentation.

Many companies now carry multiple trust‑related mandates across governance, leadership roles, reporting mechanisms and cultural initiatives. The next evolution requires moving from distributed activities to coordinated accountability: establishing clear ownership for trust outcomes, defining shared metrics that connect AI governance, patient access, organizational culture, and supply resilience, and ensuring executive-level mechanisms that surface trade-offs and dependencies across these domains rather than managing them as separate functional priorities.

Leadership implications

Trust is shaped less by stated values than by leadership behavior under pressure. In an environment marked by regulatory fluidity, scientific acceleration and heightened scrutiny, trust strengthens or erodes through cumulative patterns: how consistently leaders apply principles, whether difficult issues surface early, and how visibly accountability is shared across the executive team. Organizations that sustain trust demonstrate coherence between what leaders say and how they decide, especially when outcomes are imperfect or contested.

The central leadership question is no longer one of intent. It is whether leaders can convert intent into accountable action when regulatory frameworks evolve, supply chains fracture, algorithmic outputs demand explanation or political environments increase the cost of authenticity. In this context, accountability and humility function not as soft attributes but as strategic capabilities that determine whether trust holds under strain.

Unclear ownership of trust-critical decisions, incentives that privilege near-term performance over long-term credibility and executive forums that reward acquiescence over constructive challenge all raise trust risk. This places particular weight on collective leadership, not just individual capability. Where executive teams operate with clear norms for escalation, open debate and shared accountability, risks surface earlier, and responses tend to be more credible.

Several leadership imperatives now distinguish organizations able to operate with trust at scale:

Navigate regulatory complexity with scientific integrity and agility. Leaders must balance rigor with responsiveness, maintaining strong regulatory relationships as policy environments shift. This requires investment in regulatory intelligence, tight cross-functional alignment and a willingness to let scientific evidence and judgment anchor decisions when timelines compress.

Institutionalize AI and data governance as core infrastructure. Leaders must establish clear ownership for AI ethics, embed review mechanisms for bias and explainability, and elevate data stewardship from technical function to strategic discipline accountable at the highest levels.

Demonstrate purpose through actions, not declarations. Leaders must ensure that commitments to inclusion, equity and patient advocacy are reflected in hiring practices, trial design and access strategies, even when trade-offs invite criticism. Silence or ambiguity under pressure erodes trust faster than imperfect action.

Build resilience into supply chains and communicate it transparently. Leaders must anticipate vulnerabilities, invest in diversification and redundancy and activate stakeholder communications before disruptions escalate. Transparency about constraints builds credibility; delayed disclosure undermines it.

Engage key constituencies as partners, not audiences. This means involving patients in protocol design, employees in strategic choices and cross-sector partners in innovation-driven collaboration, backed by mechanisms for shared accountability and visible follow-through.

Foster a culture of psychological safety and accountability. Building trust at scale requires creating environments where employees can surface concerns early, challenge assumptions constructively and hold one another accountable without fear of retaliation. This begins with executive team norms that model transparency, humility and shared ownership of outcomes.

These imperatives begin with the executive team itself. Trust-centered leadership requires not only functional expertise but collective behaviors such as courage, humility, active listening and sound judgment. Team norms must surface risk early and reward constructive challenge before trust is compromised.

Trust is no longer something leaders inspire. It is something they operationalize — day by day, action by action.

Future fabric

In the years ahead, the most consequential shift for pharma leaders is not whether trust matters but how it functions within the enterprise. Trust has moved from an asset that organizations cultivate to an operating condition that they must continuously meet. It now governs how innovations are evaluated, how decisions are interpreted and how quickly legitimacy compounds or erodes. Leaders who treat trust as foundational infrastructure rather than reputational overlay are better positioned to sustain innovation, navigate scrutiny and create durable impact.

Morten Nielsen is senior partner, life sciences; Saule Serikova is chief commercial insights officer; and Susan M. Snyder is executive partner, leadership advisory, all with WittKieffer.

Reference

1. Foster L, Nielsen M, Serikova S. Measuring pharma’s trust performance. Pharmaceutical Executive. June 9, 2023. https://www.pharmexec.com/view/measuring-pharma-s-trust-performance