Study Scores Essential Medicines List Processes in 143 Countries

An international research team has scored how well national essential medicines list selection processes are designed across 143 countries, and the results reveal wide variation, with total effectiveness scores ranging from just 2 percent in Mauritius to 88 percent in Brazil. The descriptive study, published in the journal Globalization and Health, used a previously developed 16-item instrument to measure the design effectiveness of the processes countries use to select which medicines make it onto their national essential medicines lists.

National essential medicines lists are a foundational component of essential medicines-based policy, and the list itself serves as a key policy tool for governments. The World Health Organization provides guidance for policy development that aligns with the Accountability for Reasonableness framework, along with a model essential medicines list intended to support countries as they develop their own selection processes. An effective selection process, the researchers note, is one that aligns with these international guidelines and leads to a national list that addresses a nation’s priority healthcare needs.

To carry out the assessment, the authors identified the selection process design for every country with publicly available information through a document review. They then applied the 16-item instrument to score the effectiveness of each process design, and additionally calculated sub scores for the conditions of the Accountability for Reasonableness framework by aggregating the item scores mapped to each condition.

The scope of the analysis was defined by data availability. Of the 159 WHO member countries that have a national essential medicines list, 143 countries, or 90 percent, had publicly available process information and were included in the study by the authors. The remaining countries could not be assessed because the relevant documents were not publicly accessible, a limitation that shapes how the findings should be read.

The headline numbers show a field with considerable room for improvement. Total effectiveness scores across the 143 countries had a mean of 47 percent, with a standard deviation of 18.7 percent, a median of 49 percent and a mode of 41 percent. Only six countries, about 4 percent of those assessed, scored above 80 percent, while the lowest performer, Mauritius, managed just 2 percent. Even the strongest performer, Brazil at 88 percent, leaves a gap against a theoretical maximum.

Breaking the scores down by the conditions of the Accountability for Reasonableness framework exposed a consistent weak point. Mean sub scores were highest for relevance at 61 percent, followed by publicity at 40.4 percent and enforcement at 35 percent. The lowest scores came in revisions and appeals, with a mean of just 29.1 percent, suggesting that across most countries the mechanisms for revising lists and handling appeals are the least well developed part of the selection process design.

Regional patterns also emerged. Mean total scores were highest in the WHO South-East Asia region at 57.7 percent, followed by Europe at 54 percent and the Americas at 53.3 percent, and lowest in the Eastern Mediterranean region at 17.8 percent. When countries were aggregated by World Bank income classification, mean total effectiveness scores were greatest for lower-middle-income countries at 50 percent, followed by upper-middle-income countries at 49 percent and high-income countries at 47 percent, with low-income countries lowest at 38 percent. Notably, the income gradient does not run in the direction many observers might expect, with wealthier countries not automatically posting the strongest process designs.

The authors conclude that the effectiveness of national essential medicines list selection process design varies widely across countries and regions, with consistently low scores for revisions and appeals. They argue that assessing these processes with standardized tools can highlight specific areas for improvement and support alignment with WHO guidelines and the conditions of the Accountability for Reasonableness framework. Strengthening the processes, they suggest, may improve policy design, responsiveness to national health priorities, and equitable access to essential medicines.

As a descriptive study based on publicly available documents, the work captures how selection processes are designed rather than how they perform in practice, and it covers only the 90 percent of WHO member states with a list for which process information could be found. Even with those constraints, the standardized scoring offers governments a comparable benchmark, and the identification of revisions and appeals as the weakest condition gives policymakers a concrete starting point for bringing their selection processes closer to international guidance.

Subject of Research: A descriptive study scoring the design effectiveness of national essential medicines list selection processes across 143 countries.

Article Title: Quantitative assessment of national essential medicines lists processes: a descriptive study of 143 countries

Article References: Saxena, E., Kohler, J. C., Thorpe, K. E., & Persaud, N. (2026). Quantitative assessment of national essential medicines lists processes: a descriptive study of 143 countries. Globalization and Health. https://doi.org/10.1186/s12992-026-01237-5

Image Credits: AI Generated

DOI: 10.1186/s12992-026-01237-5

Keywords: essential medicines, WHO, national essential medicines lists, Accountability for Reasonableness, health policy, drug selection, global health, medicine access, health systems, descriptive study, low- and middle-income countries, pharmaceutical policy