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This exploratory paper gives a cross-sectional account of how established health care systems have responded to the novel challenge of drug shortages (DS). In line with previous research, our analysis confirms the existence of strong path dependence in the adoption of policy responses. This path dependence is manifested in a pronounced typology of response patterns where jurisdictional approaches to DS management differ along two core dimensions. These are the salience attributed to the problem, and the level to which state organisations engage with the problem. These patterns are mirrored in the conceptual framing and strategic orientation of the respective DS policies, with Spanish and Irish DS policies focusing on the individual product level and being largely reactive; US policies focusing on the therapeutic level with a focus on mitigation; and German and Austrian policies seeking to address the active ingredient level with a proactive focus on shortage prevention. Despite the importance of legacies, we find evidence of innovation and path creation particularly in relation to the US and German approaches, which we explain by the simultaneous occurrence of internal crisis with pressures from local stakeholders.