Presentation (CTI)

OBJECTIVES: The United States most-favored-nation (MFN) policy ties US prices to the lowest among high-income countries and explicitly seeks to raise those ex-US prices to end foreign free riding. Many Middle East and North Africa (MENA) systems set prices by external reference pricing (ERP) on overlapping baskets. We assessed how MFN pressure propagates to MENA access, with Morocco as the worked case, payer perspective.
METHODS: We mapped ERP rules for eight MENA markets from primary decrees and ERP literature, classifying each by rule and the MFN status of the price-binding member, defined against the US MFN target set (OECD countries with GDP per capita at least 60% of the US). Morocco's decree rule was traced to the binding reference and a floor-country withdrawal. Manufacturer responses were modeled as anticipated scenarios.
RESULTS: Lowest-of-several rules dominate the region, so basket size and MFN-target count do not govern exposure; the binding floor does. Pure-lowest markets over a non-target floor (Egypt, Kuwait, Bahrain) and lowest-of-several markets (Jordan, UAE) stay insulated; Saudi Arabia, a price-maker, is moderately exposed; pure-average Qatar scales with targets. Morocco is the exception, referencing the lowest of six countries (France, Belgium, Spain, Portugal, Turkey, Saudi Arabia); three are MFN targets, yet the binding floor is non-target Turkey, a low-price market manufacturers may raise or exit. A withdrawal recomputes the minimum over costlier members, raising the price and delaying access. Minimum-rule pricing is associated with markedly later launch (hazard ratio 0.19, 95% confidence interval 0.10 to 0.36).
CONCLUSIONS: MENA vulnerability to MFN is structural rather than proportional to target-market count. The minimum rule, meant to secure low prices, becomes the main source of fragility when the floor market is under MFN pressure. Morocco's method transfers to other reference-pricing systems exposed to upstream price shocks.