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

The National Essential Medicines List (NEML) selection process is a foundational component of an essential medicines based policy, and the NEML itself is a key policy tool. The World Health Organization (WHO) provides guidance for policy development that aligns with the Accountability for Reasonableness (AFR) framework, along with a model Essential Medicines List (EML) to support NEML selection process development. An effective selection process is one that aligns with international guidelines and leads to the selection of a NEML that addresses the priority healthcare needs of a nation. This study uses a previously developed 16-item instrument to measure NEML selection process design effectiveness for all countries with publicly available information and examines AFR condition sub scores. NEML selection process design for countries with publicly available information was identified through a document review. A 16-item instrument was used to score the NEML selection process design effectiveness. AFR conditions sub scores were also determined by aggregating item scores mapped to each condition. Of 159 WHO member countries with a NEML, 143 (90%) with publicly available process information were identified and included by the author. NEML selection process design total effectiveness scores (TES) ranged from 2% (Mauritius) to 88% (Brazil), with a mean of 47% (SD 18.7%), a median of 49%, and mode 41%; 6 countries (4%) scored above 80%. Mean AFR sub scores were highest for relevance (61%), followed by publicity (40.4%), enforcement (35%), and revisions and appeals (29.1%). By WHO region, mean total scores were highest in South-East Asia (57.7%), followed by Europe (54%) and the Americas (53.3%), and lowest in the Eastern Mediterranean (17.8%). When aggregated by World Bank Income Classification (WBIC), mean TES was greatest for Lower-Middle-Income Countries (LMICs) (50%), followed by, Upper-Middle-Income Countries (UMICs) (49%), High-Income Countries (HICs) (47%), and finally Low-Income Countries (LICs) (38%). National Essential Medicines List selection process design effectiveness varies widely across countries and regions, with consistently low scores for revisions and appeals. Assessing processes using standardized tools can highlight areas for improvement and support alignment with WHO guidelines and AFR conditions. Strengthening these processes may improve policy design, responsiveness to national health priorities, and equitable access to essential medicines.