Global status of essential medicine selection: a systematic comparison of national essential medicine lists with recommendations by WHO

Abstract

Objectives: Examining the availability of essential medicines is a necessary step to monitor country-level progress towards universal health coverage. We compared the 2017 essential medicine lists (EML) of 137 countries to the WHO Model List to assess differences by drug class and country setting.

Methods: We extracted all medicines prioritised at country level from most recently available national EMLs and compared each national EML with the 2017 WHO Model List of Essential Medicines (MLEM) as the reference standard. We assess EMLs by WHO region and for different types of medicine subgroups (eg, cancer, anti-infectives, cardiac, psychiatric and anaesthesia medicines) using within second-level anatomical therapeutic class (ATC) drug classes of the ATC Index.

Results: We included 406 medicines from WHO's 2017 MLEM to compare to 137 concurrent national EMLs. We found a median of 315 (range from 44 to 983) medicines listed on national EMLs. The global median F1 score was 0.59 (IQR 0.47-0.70, maximum possible score indicating alignment with MLEM is 1). The F1 score was the highest (ie, most similar to MLEM) in the South-East Asia region and the lowest in the European region (ie, most dissimilar to MLEM). The F1 score was highest for stomatological preparations (median: 1.00), gynaecological-anti-infectives and antiseptics (median: 1.00), and medicated dressings (median: 1.00), and lowest for 9 anatomical or pharmacological groups (median: 0.00, eg, treatments for bone diseases, digestive enzymes).

Conclusions: Most countries are expected to improve their national health coverage by 2030 offering access to essential medicines, but our results revealed substantial gaps in selection of medicines at the national level compared with those recommended by WHO. It is crucial that governments consider investing in those effective medicines that are now neglected and continue monitoring progress towards essential medicine access as part of universal health coverage.

Keywords: health economics; health policy; public health.

Figure 1

Defining sensitivity and precision in the context of the medicines on national EMLs, visual diagram adapted from Wikipedia. EMLs, essential medicine lists.

Figure 2

Essential medicine list receiver operator curve (sensitivity vs 1 – specificity). In this figure, we present the sensitivity (true positive rate) plotted against 1 – specificity (false positive rate). Circles represent each national EML and circle size represents the total number of medicines listed. Circle colour represents who region. National EMLs in the top left of the plot have the highest true positive rate and lowest false positive rate. Many outliers exist, however, this plot demonstrates a general trend to increasing false positive rate with increasing true positive rate. EMLs, essential medicine lists.

Figure 3

Box and whisker plot of true positive rate for core and complementary EML by WHO region. This figure demonstrates the median, min, max, and IQR, in a box-and-whisker plot for the true positive rates of core and complementary essential medicines by WHO region. True positive rates are higher for the core essential medicines in every WHO region. While eastern Mediterranean, Europe and the Americas have a smaller difference between the true positive rates of core and complementary essential medicines, Africa, South East Asia and Western Pacific have large differences indicating that many complementary essential medicines are not being listed in these regions.

Figure 4

Box and whisker plot of F1 statistic by who region. This figure demonstrates the median, min, max, and IQR, in a box-and-whisker plot for F1 statistic for each who region. This figure demonstrates the lowest median F1 statistic for Europe (0.49) and the highest for south-east Asia (0.64). As a marker of within region variability, Europe has the largest IQR (0.16), and the Americas demonstrates the lowest (0.05).

Figure 5

Box and whisker plot of F1 statistic for all national Essential Medicine Lists by ATC level two drug class. This figure demonstrates the median, min, max and IQR, in a box-and-whisker plot for the F1 statistic by ATC level two drug class. The colours present level 1 groupings of drug class. For certain drug classes, including A11—vitamins and B03—antianemic preparations, there is a high median F1 and low IQR. For other classes, including D04—antipruritics, D11—other dermatological preparations, H04—pancreatic hormones, the IQR of the F1 statistic ranges from 0 to 1. ATC, anatomical therapeutic class.

Figure 6

Heat map of F1 statistic by National EML list and ATC drug class (alternative presentations provided). This figure demonstrates a heat map of the F1 statistic by drug class for each national EML, grouped by WHO region. As is demonstrated, there is substantial variation in the F1 statistic by National EML and by drug class. ATC, anatomical therapeutic class; EML, essential medicine lists.