Research Comparison of essential medicines lists in 137 countries Nav Persaud,a Maggie Jiang,a Roha Shaikh,a Anjli Bali,a Efosa Oronsaye,a Hannah Woods,a Gregory Drozdzal,a Yathavan Rajakulasingam,a Darshanand Maraj,a Sapna Wadhawan,a Norman Umali,a Ri Wang,a Marcy McCall,b Jeffrey K Aronson,b Annette Plüddemann,b Lorenzo Moja,c Nicola Magrinic & Carl Heneghanb Objective To compare the medicines included in national essential medicines lists with the World Health Organization’s (WHO’s) Model list of essential medicines, and assess the extent to which countries’ characteristics, such as WHO region, size and health care expenditure, account for the differences. Methods We searched the WHO’s Essential Medicines and Health Products Information Portal for national essential medicines lists. We compared each national list of essential medicines with both the 2017 WHO model list and other national lists. We used linear regression to determine whether differences were dependent on WHO Region, population size, life expectancy, infant mortality, gross domestic product and health-care expenditure. Findings We identified 137 national lists of essential medicines that collectively included 2068 unique medicines. Each national list contained between 44 and 983 medicines (median 310: interquartile range, IQR: 269 to 422). The number of differences between each country’s essential medicines list and WHO’s model list ranged from 93 to 815 (median: 296; IQR: 265 to 381). Linear regression showed that only WHO region and health-care expenditure were significantly associated with the number of differences (adjusted R2: 0.33; P < 0.05). Most medicines (1248; 60%) were listed by no more than 10% (14) of countries. Conclusion The substantial differences between national lists of essential medicines are only partly explained by differences in country characteristics and thus may not be related to different priority needs. This information helps to identify opportunities to improve essential medicines lists. Introduction Methods More than 5 billion people live in countries that use essen- We prespecified the main analysis for this observational study tial medicines lists. These lists typically contain hundreds of before data collection (NCT03218189) and report the results medicines intended to meet the priority health-care needs of using the STROBE reporting guidelines.6,7 a population.1–3 Since the World Health Organization (WHO) In June 2017, we searched the WHO essential medicines published the first Model list of essential medicines in 1977, the and health products information portal. This online repository list has been revised every two years and adapted to circum- contains hundreds of publications on medicines and health stances in more than one hundred countries. Governments products related to WHO priorities and has a full section and health-care institutions use essential medicines lists to dedicated to national lists of essential medicines.2,3 A WHO determine which medicines to fund, stock, prescribe and information specialist actively searched for updated versions dispense.4 As essential medicines lists influence the medicines of national lists, including national formularies, reimburse- that people have access to, contents of these lists constitute ment lists and lists based on standard treatment guidelines. important determinants of health worldwide. We included all national lists of essential medicines that were Countries must select medicines for their essential posted on the repository irrespective of publication date and lists appropriately to facilitate sustainable, equitable access language. When we found more than one national list from to medicines and promote their appropriate use.4 Since a the same country, we used the most recent list. country’s list is intended to meet the needs of its population, We excluded documents that were not essential medicines countries that are geographically close or similar to each other lists, such as prescribing guidelines. We also excluded diag- in population size, health-care expenditure and health status nostic agents, antiseptics, disinfectants and saline solutions. might be expected to have similar essential medicines lists. Data collection processes Differences between such lists that are not explained by differ- ences in country-specific needs may represent opportunities We developed a data extraction method for medicines in na- for improving the lists. tional lists, which we pilot-tested on lists from five countries. Here we aimed to compare the medicines included in One of six reviewers extracted information from each country national essential medicines lists with the 2017 WHO’s Model and another reviewer verified the information before inclusion list of essential medicines,5 and to determine whether character- in an electronic database. istics, such as WHO Region, population size, and health-care For identified countries with essential medicines lists, expenditure account for the differences. we collected eight country characteristics that might explain a Centre for Urban Health Solution, St. Michael’s Hospital, 80 Bond Street, Toronto, Ontario, M5B 1X2, Canada. b Centre for Evidence-Based Medicine, University of Oxford, Oxford, England. c Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland. Correspondence to Nav Persaud (email: [email protected]). (Submitted: 5 September 2018 – Revised version received: 7 March 2019 – Accepted: 8 March 2019 – Published online: 4 April 2019 ) 394 Bull World Health Organ 2019;97:394–404C | doi: http://dx.doi.org/10.2471/BLT.18.222448 Research Nav Persaud et al. Essential medicines lists differences in the lists and that are of several medicines that should be con- and subtracting the number of uncom- widely available and commonly used sidered therapeutically equivalent.5 We monly listed medicines. This calculation in international comparisons: WHO assumed that the medicines in the same provides a similarity integer score for region; population size; life expec- chemical subgroup as the exemplar were each country; positive scores indicate tancy; infant mortality; gross domestic equivalent (e.g. enalapril is equivalent that most medicines in the country’s list product (GDP) per capita; health care- to all other in the chemical subgroup are commonly listed in other countries’ expenditure per capita; GINI index as a C09A: captopril, lisinopril, perindopril, lists, and negative scores indicate that measure of income inequality; and the ramipril, quinapril, benazepril, cilaza- most medicines are uncommonly listed corruption perception index. In June pril, fosinopril, trandolapril, spirapril, in other countries’ lists. 2017, we extracted data on WHO Region delapril, moexipril, temocapril, zofeno- Data sharing and per capita health-care expenditure pril and imidapril), except when WHO’s from the WHO Global Health Obser- list specified particular equivalent The underlying data used in this study vatory, the most recent information medicines (e.g. bisoprolol is specified as are publicly available and, separately, available at the time.8 We extracted data equivalent to atenolol, metoprolol, and a database with updated information on population, life expectancy, infant carvedilol). As a result of uncertainty about national essential medicines lists mortality and GDP per capita from the whether these medicines are truly equiv- will be maintained online.17,18 Central Intelligence Agency’s World alent, and because we do not know how Factbook.9 We obtained the GINI index countries interpreted the indications of Results from the most recent data available from equivalence, or if they used them at all, the World Bank in the United Nations we also report results disregarding the We identified essential medicines lists Human Development Report 2016.10 equivalence to exemplars. posted on the WHO repository for We retrieved the corruption perception Data analysis 137 countries (70% of 195 countries). score from Transparency International’s The total number of medicines on each 2016 corruption perceptions index.11 For descriptive data, we calculated me- country’s list ranged from 44 to 983 Data extraction dians with interquartile ranges (IQRs). (median: 310; IQR: 269 to 422). In total Comparison with WHO’s model list we identified 2068 unique medicines. From each country’s list we abstracted Table 1 (available at: http://www.who. medicines using International Nonpro- To determine whether countries’ char- int/bulletin/volumes/97/6/18-222448) prietary Names (INNs).12 For medicines acteristics accounted for differences presents the characteristics of the in- whose names were not in English, between each country’s list and the 2017 cluded countries. we used the Anatomical Therapeutic WHO model list, we created a linear Fig. 1 shows the relationship be- Chemical classification system,13 if regression model with the total number tween the number of essential medicines available, or translated the names using of differences from the WHO’s model listed by each country and GDP. Most Google Translate.14 We listed each medi- list as the dependent variable and the countries with a lower GDP had shorter cine individually, whether it was part following characteristics as independent national lists of essential medicines, but of a combination product or not. We variables: WHO region, population size, there were many exceptions. Sweden treated medicine bases and their salts life expectancy, infant mortality, GDP per has a high