Presentation (CTI)

OBJECTIVES: Most-favored-nation (MFN) pricing policies, increasingly adopted in high-income markets, are typically evaluated for their domestic cost-saving effects alone. This analysis examines how MFN provisions interact with external reference pricing (ERP) networks to affect differential pricing sustainability and vaccine access in low- and middle-income countries (LMICs).
METHODS: A conceptual framework was developed incorporating three dimensions: health system financing structure, institutional procurement architecture (Gavi, PAHO, and Global Fund versus commercial channels), and the strategic pricing flexibility, a calibration window, that ERP systems have historically preserved. The framework was applied to three vaccine markets, pneumococcal conjugate (PCV), human papillomavirus (HPV), and malaria, using documented list- and procurement-price data.
RESULTS: MFN provisions eliminate the calibration window manufacturers use to sustain differential pricing, producing upward price cascades through ERP chains. Middle-income countries face compounded exposure: ineligible for donor-subsidized prices, yet losing the flexibility ERP previously preserved. PCV pricing shows a roughly six-fold gap between Gavi and PAHO middle-income prices (US$2 vs. US$12.83 to 14.50 per dose); HPV shows the steepest gradient (US$4.50 to 96.32 per dose) with a post-graduation cost cliff exceeding US$10 million annually; malaria vaccine pricing reveals an analogous donor-financed cascade (US$0.20 to 9.30 per dose across tiers), with inter-donor competitive benchmarking documented in a 2025 manufacturer price reduction.
CONCLUSIONS: PPP-based analyses of MFN effects are insufficient: differential pricing sustainability instead depends on health system financing structure, institutional procurement architecture, and the strategic pricing flexibility that MFN provisions eliminate. Middle-income countries, caught between donor and commercial pricing tiers, bear the greatest equity burden. MFN policy design should incorporate explicit income-level carve-outs protecting Gavi, PAHO, and Global Fund procurement from comparator baskets. LMIC health ministries should engage proactively in international pricing governance to safeguard the differential pricing architectures on which equitable access depends.