Global norms, local institutions: a controlled comparative case study of WHO essential medicines policy adoption in Eastern Europe

BACKGROUND: To improve equitable access to medicines and avoid inefficient pharmaceutical spending, the World Health Organization (WHO) has long promoted five core principles regarding the selection of medicines for reimbursement: 1) the establishment of a national essential medicines list (NEML); 2) a diverse, independent selection committee; 3) an evidence-based methodology for selecting medicines; 4) integration with clinical guidelines; and 5) monitoring of use and expenditure. While many countries have formally adopted these principles, their integration into financing and procurement systems varies widely. Using Kingdon's Multiple Streams Approach (MSA) and the policy transfer framework, this study compares how WHO selection principles were adopted in two Eastern European countries: Ukraine (higher adopter) and Moldova (lower adopter). RESULTS: Both countries established NEMLs aligned with WHO guidance, but only Ukraine more fully embedded these principles into pharmaceutical governance. Higer adoption in Ukraine is associated with sustained donor engagement, reform momentum, and domestic leadership. In Moldova, adoption remained largely absent, associated with weak institutional capacity and episodic donor support limiting integration. CONCLUSIONS: This study illustrates how international guidance interacts with political windows, domestic will, and patterns of donor engagement to shape reform trajectories. The findings suggest that global health guidance is most influential when coupled with long-term technical support, local champions, and mechanisms for institutional continuity, helping to move reforms towards meaningful system change.