Balancing Innovation, Access, and Equity in Drug Pricing: Comparative Institutional Lessons for Advancing Universal Health Coverage

Context: Global efforts to reform prescription drug pricing must navigate the trade-offs between four core objectives: cost containment, innovation incentives, equitable access, and administrative feasibility. In the United States, the Most Favored Nation (MFN) pricing rule and emerging value-based care (VBC) models reflect divergent strategies for aligning prices with therapeutic value. However, comparative analyses across different health systems are limited. Methods: A structured trade-off matrix was employed to compare pharmaceutical pricing strategies in the U.S., Canada, and the UK across four dimensions: cost containment, innovation incentives, equity in access, and implementation feasibility. The comparison is drawn from peer-reviewed scholarly literature, policy studies, and regulatory publications spanning the period 2007 to 2025. Findings: The MFN model offers short-term savings but can hinder innovation and outcome-based reimbursement in fragmented systems such as the U.S. The UK achieves significant value and pricing alignment through centralized institutions, such as NICE and the VPAG scheme. Canada, via the PMPRB, enforces price controls and international referencing, yet lacks integration of value-based principles and risk-sharing mechanisms. These findings have implications for the pursuit of Universal Health Coverage, illustrating how institutional design influences equity in access to essential medicines. Conclusions: Global models offer guiding principles, whereas sustainable pricing reforms must be designed to fit local political, institutional, and market conditions. Value-based incentives combined with cross-country yardsticks in hybrid models, though flexible and transparent, can create a more feasible reform approach for the U.S. Achieving Universal Health Coverage will require institutional designs that balance equity, innovation, and feasibility in pharmaceutical pricing.