Abstract
OBJECTIVE: In many emerging economies, simple cost-plus markups push medicine prices far above reference benchmarks, undermining affordability and access. Iran exemplifies this problem, with a public sector median price ratio (MPR) of 6.70 - nearly seven times the reference price - and an out-of-pocket (OOP) burden exceeding 50%. This study aims to benchmark Iran's cost-plus pricing framework against international alternatives, quantify the independent effects of cost-plus dominance and inflation on relative prices, and model policy scenarios to reduce household spending. METHODS: We compared eleven countries (high-income: Germany, France, UK; upper-middle-income: South Korea, China, Brazil, Turkey, South Africa, Thailand; lower-middle-income: Iran, India) using WHO/HAI surveys (2023) to derive public/private MPRs, OOP percentages, and availability metrics. An ordinary-least-squares regression of ln (MPR) on cost-plus dominance (binary), log GDP per capita, and consumer-price-index (CPI) inflation quantified key drivers. Scenario modeling for Iran estimated OOP impacts under (i) a 30% CPI-adjusted cap (MPR = 4.69) and (ii) an health-technology assessment (HTA)-linked value-based regime (MPR = 2.00). FINDINGS: Iran's cost-plus system predicts a 178% higher MPR (β = 1.02; P < 0.001); each 1% inflation adds 2% to ln (MPR) (β = 0.02; P < 0.001). Under a CPI cap, OOP falls from 52% to 35%; HTA-based pricing could halve OOP to 20%. CONCLUSION: Static cost-plus pricing perpetuates catastrophic patient costs. Phased reforms - beginning with CPI-indexed ceilings and advancing to HTA-driven value pricing - can transform unaffordable systems into sustainable, equitable models for emerging markets.