OBJECTIVES: This research aims to characterize the extent to which health technology assessment (HTA) is currently being used to determine pharmaceutical coverage in the Middle East and North Africa (MENA) region. The objectives are to understand which decision-makers are currently undertaking this activity, the extent of its formalization, and in which parts of the healthcare system in each country there is greatest appetite for its implementation.  METHODS: In-depth, qualitative interviews were conducted with a total of 11 payer decision-makers and 20 industry stakeholders in Egypt, Saudi Arabia, Turkey and the United Arab Emirates (UAE). Published literature and government websites were also reviewed. Primary and secondary research focused on current and evolving reimbursement decision-making procedures in these countries in addition to potential policy reforms. RESULTS: Of the countries considered, HTA focused on evaluation of specific pharmaceuticals appears to have gained the most traction in Saudi Arabia, where one of the public-sector payers has begun undertaking in-depth pharmacoeconomic (PE) analysis. In Egypt, while a PE unit has been established, its present role is to support the country’s Drug Pricing Committee on a case-by-case basis. In Turkey, while PE data is required for reimbursement submission, budget impact is reported to remain the primary driver of national-level decision-making. Meanwhile, in the UAE, there is little evidence that the insurers increasingly responsible for coverage under the country’s healthcare reforms are using formal HTA.   CONCLUSIONS: The extent of HTA formalization and the specific areas of the healthcare system in which HTA operates vary across the MENA region, in line with the broader policy framework. Champions of further HTA development come from diverse stakeholder groups in each country. With time, it is expected that HTA will gain increasing traction across MENA, alongside arrangements such as risk-sharing schemes, with significant consequences for pharmaceutical access.