Adequacy of national essential medicines lists of Sahel States Alliance countries (Burkina Faso, Mali, Niger) with WHO Guidelines and local epidemiological needs: a cross-sectional study

¹World Health Organization, N'Djamena, Chad, ²Health Ministry, Ouagadougou, Burkina Faso, ³World Health Organization, Bangui, Central African Republic

^&Corresponding author
Ragomzingba Frank Edgard Zongo, World Health Organization, N'Djamena, Chad

Introduction    

The countries of the Alliance of Sahel States (AES)-Mali, Burkina Faso, and Niger-operate in a context characterized by a convergence of security, political, economic, and health crises that have persistently weakened their health systems. These structural vulnerabilities are further compounded by harsh climatic conditions and recurrent humanitarian crises, undermining equitable access to healthcare services and essential health products. The recent withdrawal of these countries from the Economic Community of West African States (ECOWAS) has further exacerbated these challenges by restricting access to regional mechanisms for financing, health coordination, and medicine distribution, which have historically been supported through West African community frameworks [1].

In this context, access to essential medicines aligned with local epidemiological needs represents a major public health challenge. AES countries face a high burden of morbidity and mortality dominated by infectious diseases such as malaria, tuberculosis, HIV/AIDS, diarrhoeal diseases, and recurrent epidemics of cholera, meningitis, and viral haemorrhagic fevers, all of which exert sustained pressure on already fragile health systems. At the same time, the region is experiencing a growing burden of non-communicable diseases (NCDs), particularly hypertension and diabetes, driven by increasing urbanization and lifestyle changes, thereby making therapeutic needs more complex and diversified [2-4].

The World Health Organization (WHO) developed the Model List of Essential Medicines (EML) to guide countries in the selection of safe, effective, and cost-effective medicines that address priority public health needs. This list serves as an international reference for the development of national essential medicines lists (NEMLs), which are used as a central tool for planning, procurement, and the rational use of medicines [5,6]. However, to be fully operational, national EMLs must not only align with WHO recommendations but also accurately reflect country-specific epidemiological, logistical, and economic realities. For example, malaria case management requires the continuous availability of artemisinin-based combination therapies or quinine, while the management of viral outbreaks depends on access to specific medicines and appropriate symptomatic treatments [7].

Several studies have shown that although more than 150 countries use the WHO EML as a reference, significant gaps persist between national lists and WHO recommendations, both in terms of content and updating processes, with substantial delays in the integration of new therapeutic priorities. These gaps are often exacerbated by economic constraints, supply chain disruptions, and suboptimal availability of essential medicines in health facilities, particularly in conflict-affected and unstable settings [8,9].

Against this background, the present study aims to assess the adequacy and compliance of the national essential medicines lists of Burkina Faso, Mali, and Niger with WHO guidelines and local epidemiological needs. The specific objectives were to: (i) Identify the main diseases present in each country; (ii) verify the suitability of essential medicines listed on national lists for these diseases; (iii) verify the WHO recommendations incorporated into the national lists; (iv) analyze the discrepancies between medicines on national lists and those recommended by the WHO; and (v) analyze the main differences between the lists of the three countries.

Methods     

Study design: this was a cross-sectional study conducted between January and April 2025, aiming to explore and compare NEMLs against WHO model lists and epidemiological needs.

Study setting: the study focused on the three founding countries of the AES: Burkina Faso, Mali, and Niger. These countries share comparable health system characteristics, including limited resources, a high burden of disease, and structural dependence on technical and financial partners. The analysis was based on official documents obtained from ministries of health and national medicines regulatory authorities, as well as the most recent national health statistical yearbooks available for each country: 2021 for Burkina Faso, 2022 for Mali, and 2016 for Niger. Data were collected through a systematic documentary review.

Participants: it was a study based on documentation. The study population consists of all medicines listed in the National Essential Medicines Lists (NEMLs) of the three member countries of the Alliance of Sahel States (AES)-Burkina Faso, Mali, and Niger-in the versions in force during the study period (January-April 2025).

Variables: a structured documentary analysis grid was developed based on the WHO methodological guidelines for the selection of essential medicines [10]. This grid was used to standardize the comparison of national lists across several variables grouped into three main categories: 1) Descriptive variables: year of last update; structure of the NEML (therapeutic classification, existence of a paediatric list, differentiation by levels of care); and total number of medicines listed; 2) compliance variables: inclusion of medicines listed in the WHO Model Lists (2021-2023); application of the WHO access, watch, reserve (AWaRe) classification for antibiotics; and consideration of demonstrated efficacy and safety criteria; 3) epidemiological adequacy variables: correspondence between the most prevalent diseases identified in national statistical yearbooks and the therapeutic classes covered by the NEMLs.

Data sources/measurement: the main documentary sources used in this study included: 1) the most recent National Essential Medicines Lists (NEMLs) available (Burkina Faso, 2023; Mali, 2024; Niger, 2018); 2) the World Health Organization (WHO) model lists of essential medicines, 2021 and 2023 editions; 3) national health statistical yearbooks reporting the leading causes of morbidity and mortality; 4) national health development plans: plan national de développement sanitaire (PNDS) 2021-2030 for Burkina Faso, plan décennal de développement sanitaire et social (PDDSS) 2014-2023 for Mali, and plan de développement sanitaire et social (PDSS) 2022-2026 for Niger; 5) scientific publications and technical reports related to the selection and updating of essential medicines.

Bias: the main limitations of this study relate to its documentary nature and the temporal gaps between NEML editions, which may affect direct comparability.

Study size: for each country of AES, the last version of NEML and the national health statistical yearbook were collected. Each medicine and pathology listed was included in the analysis.

Quantitative variables: to determine the inclusion of medicines listed in the WHO model lists (2021-2023), each medicine listed in the NEMLs was matched against its corresponding entry in the WHO model list of essential medicines in order to establish three levels of correspondence: medicines included in both lists (full compliance); medicines included in the NEML but not in the WHO model list (national additions); medicines included in the WHO model list but absent from the NEML (gaps). Concerning the correspondence between the most prevalent diseases identified in national statistical yearbooks and the therapeutic classes covered by the NEMLs, each pathology was matched against its corresponding therapeutic class in the national health statistical yearbooks.

Statistical methods: comparative analysis across the three countries made it possible to calculate concordance rates (defined as the ratio between the number of medicines common to both lists and the total number of medicines in the corresponding WHO model list), to identify country-specific medicines, and to document thematic discrepancies across therapeutic categories (e.g. anti-infectives, cardiovascular medicines, antineoplastic agents). A qualitative interpretation complemented the quantitative analysis in order to contextualize the observed differences in light of local health system realities.

Results     

Participants: all the essential medicines and therapeutic classes listed on the three national and WHO essential medicines lists were included in our study.

Descriptive data: the study focused on the most recent versions of the National Essential Medicines Lists (NEMLs) of the three member countries of the Alliance of Sahel States (AES): Burkina Faso (2023 edition): published by the ministry of health and aligned with the WHO Model list of essential medicines (2021); Mali (2024 edition): developed following the update of the ten-year health and social development plan (PDDSS 2014-2023); Niger (2018 edition): based on the WHO model list of essential medicines (2017) and under revision at the time of data collection (April 2025).

These three national documents were compared with the WHO Model list of essential medicines (23^rd edition, 2023) and with the most recent national health statistical yearbooks available: 2021 for Burkina Faso, 2022 for Mali, and 2016 for Niger.

All three NEMLs comply with several key WHO recommendations: 1) Differentiation by levels of care (hospital, health centre, community): implemented in all three countries; 2) separate paediatric list: present only in Burkina Faso list; 3) application of selection principles based on efficacy, safety, and cost-effectiveness: partially observed in all countries; 4) regular revision (every 2-4 years): adhered to in Mali and Burkina Faso, but not in Niger. However, the application of the WHO AWaRe classification for antibiotics was not effective for all national lists: documented in the NEMLs of Burkina Faso and Mali, but not in that of Niger.

Outcome data: the outcomes of the study were summarized using descriptive and comparative indicators. These included: (i) The proportion of medicines that were aligned with the WHO model list of essential medicines in terms of international nonproprietary name (INN), pharmaceutical form, and dosage; (ii) the proportion of medicines covering main pathologies; (iii) the number of medicines included in NEMLs but absent from the WHO model list; and (iv) the number of WHO-recommended medicines absent from national NEMLs. Results were presented as counts and percentages, allowing cross-country comparisons and identification of convergence and divergence patterns across the three national lists.

Main results

Comparative epidemiological profiles: the three countries share a broadly similar burden of disease, dominated by infectious diseases, which account for more than 60% of consultations in public health facilities. The most frequently reported conditions include: 1) Malaria (accounting for approximately 30-40% of outpatient visits and hospital admissions); 2) acute respiratory infections (ARIs) and infectious diarrhoeal diseases in children; 3) tuberculosis and cerebrospinal meningitis; 4) hypertension and diabetes mellitus, which are rapidly increasing in urban areas; and 5) anaemia, sickle cell disease, and metabolic disorders. However, some country-specific epidemiological patterns were observed. Niger is characterized by a higher prevalence of parasitic diseases, including onchocerciasis, leishmaniasis, and filariasis. Mali reports a growing burden of cardiovascular and mental health disorders. Burkina Faso shows a more pronounced diversification of metabolic and digestive diseases.

The concordance rate between priority disease profiles across the three countries was estimated at 63.6%, indicating substantial regional epidemiological homogeneity alongside distinct nationally specific disease patterns.

Adequacy of NEMLs in relation to priority diseases: cross-analysis of major disease burdens and the therapeutic classes included in the NEMLs shows that: 1) All three countries adequately cover the main infectious diseases, with the availability of antimalarial medicines (artemether/lumefantrine, artesunate, quinine), first-line antibiotics (amoxicillin, ceftriaxone, ciprofloxacin), and essential anti-tuberculosis medicines (isoniazid, rifampicin, pyrazinamide, ethambutol); 2) non-communicable diseases (NCDs), although recognized as an emerging public health challenge, remain unevenly addressed. Mali and Burkina Faso provide comprehensive treatment options for hypertension (amlodipine, hydrochlorothiazide, enalapril) and diabetes (insulin, metformin, glibenclamide), whereas Niger shows partial coverage, with the absence of several modern antihypertensive agents; 3) mental and neurological disorders are covered in all three countries through the inclusion of antipsychotics (haloperidol, chlorpromazine, risperidone) and antiepileptic medicines (phenobarbital, carbamazepine). However, newer-generation antipsychotics (olanzapine, clozapine) are included only in the lists of Burkina Faso and Mali; and 4) in maternal and neonatal health, the availability of key medicines such as oxytocin, misoprostol, and magnesium sulfate is consistent across the three countries.

Overall adequacy between identified priority diseases and available medicines was estimated at 82% for Burkina Faso, 79% for Mali, and 74% for Niger, indicating generally satisfactory but incomplete therapeutic coverage.

Compliance with the WHO model list: the concordance rates between national NEMLs and the WHO model list of essential medicines were: 75% for Burkina Faso; 75% for Mali; 73.7% for Niger. These rates reflect a strong commitment to alignment with international standards. However, detailed comparison revealed several discrepancies: medicines included in NEMLs but absent from the WHO model list: 42 in Burkina Faso, 37 in Mali, and 34 in Niger. These largely consisted of improved traditional medicines, nutritional supplements, and locally formulated products; WHO-recommended medicines were absent from national NEMLs: 28 in Burkina Faso, 31 in Mali, and 39 in Niger, particularly antineoplastic agents, second-generation antivirals, and certain paediatric emergency medicines.

Country-specific medicines and structural differences: the analysis highlights national specificities reflecting policy choices and public health priorities: 1) Burkina Faso stands out for the inclusion of several improved traditional medicines (Tisane Saye, Sirop Douba, Faca) and innovative cardiology and oncology medicines (trastuzumab, imatinib), indicating openness to integrative medicine and advanced therapies; 2) Mali includes recently introduced vaccines (rotavirus, R21/Matrix-M, and RTS, S) as well as neonatal medicines such as surfactant and caffeine citrate, reflecting a strong focus on maternal and child health and prevention; 3) Niger’s list, which is older, remains largely focused on primary healthcare needs with limited specialised medicines; however, it includes rare antidotes (flumazenil, dimercaprol) and detoxification agents, suggesting a pragmatic approach to emergency management.

Qualitative analysis suggests that observed gaps are more strongly associated with update timelines and financial constraints than with a lack of strategic orientation.

Discussion     

Key results: this study aimed to assess the alignment of the NEMLs of Burkina Faso, Mali, and Niger with the WHO model list of essential medicines and to examine their consistency with national epidemiological priorities. Overall, the three countries exhibited substantial epidemiological similarity, with infectious diseases accounting for the majority of the disease burden, reflected by a 63.6% concordance in priority disease profiles across the Alliance of Sahel States. This regional homogeneity was largely mirrored in the structure of the NEMLs.

In relation to the first objective, the NEMLs demonstrated generally adequate coverage of major priority diseases, particularly infectious diseases and maternal and neonatal conditions. Estimated adequacy levels ranged from 74% in Niger to 82% in Burkina Faso, indicating broadly satisfactory but incomplete alignment between disease burden and available essential medicines. Regarding the second objective, alignment with international standards was moderate to high, with concordance rates of 75% for Burkina Faso and Mali and 73.7% for Niger when compared with the WHO model list. However, important gaps persisted, notably the absence of several WHO-recommended medicines, especially in oncology, advanced antivirals, and paediatric emergency care.

Finally, these findings underscore the need for regular updating of NEMLs, strengthened regional harmonization, and improved integration of epidemiological evidence into national pharmaceutical policy-making within the AES.

Limitations: this study has several limitations that should be considered when interpreting the findings. First, the analysis relied exclusively on documentary sources, including NEMLs, the WHO model list of essential medicines, and published epidemiological reports. Consequently, the results reflect policy intent rather than the actual availability, accessibility, or use of medicines at the health-facility level. This reliance on normative documents is likely to overestimate effective therapeutic coverage, as medicines included in NEMLs are not always consistently procured or available in practice. The resulting bias is expected to be moderate, particularly in contexts affected by supply-chain and financing constraints. Second, differences in NEML update timelines across the three countries introduce a source of temporal bias. Some national lists had been revised more recently than others, leading to systematic variation in the inclusion of newer medicines and vaccines. This may have underestimated alignment for countries with older NEMLs-most notably Niger-while potentially exaggerating inter-country differences. The overall effect of this bias is a tendency toward lower concordance estimates for less frequently updated lists, with a moderate influence on comparative findings. Finally, as an exploratory and comparative policy analysis, this study was not designed to establish causal relationships between epidemiological profiles and medicines selection. The findings should therefore be interpreted as descriptive and explanatory rather than predictive. Despite these limitations, the use of standardized documentary sources, transparent analytical criteria, and cross-country comparison enhances the internal consistency of the analysis and supports the relevance of the findings for informing regional pharmaceutical policy discussions within the Alliance of Sahel States.

Interpretation

Overall alignment with the WHO model list: all three countries demonstrated relatively high concordance rates with the WHO model list of essential medicines (EML)-75% for Burkina Faso and Mali, and 73.7% for Niger. However, as noted by Persaud et al. [11] and Wirtz et al. [12], a high level of concordance does not necessarily translate into functional adequacy. Several medicines included in national lists remain unavailable at the point of care due to supply chain disruptions, logistical weaknesses, or financial constraints. This persistent gap between policy formulation (listing) and implementation (effective availability) remains one of the major challenges facing pharmaceutical policy implementation in Sahelian countries.

Adequacy of medicines in relation to epidemiological profiles: the results indicate that the NEMLs largely cover priority disease conditions, particularly infectious diseases such as malaria, tuberculosis, and acute respiratory infections, which remain the leading causes of morbidity in the region. This reflects a strong alignment between pharmaceutical planning and epidemiological realities, in accordance with WHO guidance advocating for medicine selection based on local disease burden. However, non-communicable diseases (NCDs) remain insufficiently represented despite their rapid increase across Sahelian countries. This finding is consistent with observations by Peacocke et al. [8], who reported that many African NEMLs have yet to fully account for the epidemiological transition, continuing to prioritize historically dominant infectious diseases at the expense of emerging chronic conditions. The incomplete coverage of NCDs can be attributed to economic constraints (notably the high cost of cardiovascular and antidiabetic medicines), limited availability of innovative products, and slow revision processes. Niger’s case is illustrative, with a NEML dating back to 2018.

Consideration of the WHO technical recommendations: key WHO technical recommendations-such as differentiation by levels of care and the application of the AWaRe antibiotic classification-are well integrated into the NEMLs of Burkina Faso and Mali but only partially implemented in Niger. This finding aligns with Hogerzeil et al. analysis [13], which underscores that full implementation of WHO guidelines is highly dependent on the institutional capacity of national medicines committees and the availability of local data on antimicrobial resistance.

The study also highlights increasing consideration of paediatric medicines and age-appropriate formulations, particularly in Burkina Faso, in line with the WHO’s 2020 recommendations on the development of separate paediatric essential medicines lists. Nevertheless, the application of evidence-based selection criteria remains partial, as several listed products-especially traditional syrups and herbal preparations-lack comprehensive clinical evaluation.

Integration of traditional medicine and innovative products: a particularly innovative feature of the NEMLs of Burkina Faso and Mali is the inclusion of improved traditional medicines, such as ‘tisane saye’ and ‘sirop douba’. This approach aligns with the WHO traditional medicine strategy 2014-2023, which encourages member states to integrate locally derived medicinal products provided their safety and efficacy are scientifically validated. This orientation is especially relevant in the Sahelian and broader African context, where more than 80% of the population reportedly relies on traditional medicine as a first line of care [14]. However, such integration necessitates rigorous scientific oversight, particularly with regard to quality control, regulatory approval, and post-marketing surveillance.

Structural differences among the three countries: the comparative analysis reveals marked differences in the structure and revision dynamics of the NEMLs. Mali stands out for its recent update, incorporating neonatal medicines and next-generation vaccines (R21/Matrix-M, RTS, S). Burkina Faso demonstrates a more inclusive pharmaceutical policy, integrating both modern medicines and products derived from local pharmacopoeia. In contrast, Niger’s older list reflects a primary healthcare-focused approach, with limited integration of therapeutic innovations, suggesting a stronger reliance on vertical programmes.

These disparities reflect variations in institutional capacity and the availability of technical resources required to conduct regular NEML revisions. As highlighted by Bigdeli et al. [15], pharmaceutical governance plays a critical role in determining the quality, coherence, and responsiveness of national essential medicines policies.

Policy implications: the comparative methodology employed allowed for the identification of trends consistent with findings from previous evaluations of essential medicines lists [16]. The results underscore the need to establish a regional pharmaceutical coordination mechanism among AES countries, aimed at harmonizing the processes of selection, revision, and monitoring of essential medicines. Such a mechanism, supported by WHO, could facilitate pooled expertise, enable joint procurement strategies, and strengthen pharmaceutical system resilience in the face of recurrent crises [17].

Generalizability: this study explored how well the NEMLs of Burkina Faso, Mali, and Niger align with national epidemiological priorities and the WHO model list of essential medicines. Conducted between January and April 2025, the analysis used a documentary and comparative approach to assess policy-level coherence between disease burden and medicines selection in the three member states of the Alliance of Sahel States.

The findings show that the three countries share broadly similar epidemiological profiles. Infectious diseases remain the dominant cause of morbidity, accounting for more than 60% of health facility consultations. Malaria, acute respiratory infections, diarrhoeal diseases, tuberculosis, and meningitis continue to represent the main health challenges. At the same time, non-communicable diseases-particularly hypertension and diabetes-are increasing rapidly, reflecting an ongoing epidemiological transition. A 63.6% concordance in priority disease profiles indicates substantial regional homogeneity, although some country-specific differences persist.

Overall, the alignment between priority diseases and medicines included in national lists was relatively high but not complete. Adequacy was estimated at 82% in Burkina Faso, 79% in Mali, and 74% in Niger. Medicines for infectious diseases and for maternal and neonatal health were consistently well covered across the three countries. However, important gaps were identified in several areas, notably non-communicable diseases, mental health, oncology, and paediatric emergency care. These gaps were most pronounced in Niger. Alignment with the WHO model list was moderate to high, with concordance rates ranging from 73.7% to 75%. Differences reflected both the inclusion of medicines responding to local needs and the absence of some WHO-recommended treatments, particularly those that are costly or require specialized health system capacity.

While the study is limited by its reliance on documentary data, differences in NEML update timelines, and the use of aggregated epidemiological information, the findings are relevant beyond the Sahel context. Overall, the study underscores the importance of regular updates to essential medicines lists, stronger regional harmonization, and closer integration of epidemiological evidence into pharmaceutical policy-making in resource-constrained settings.

Conclusion     

Our study confirms that the national essential medicines lists of Burkina Faso, Mali, and Niger are broadly aligned with WHO standards but require regular revision based on updated epidemiological data and recent therapeutic advances. The gradual integration of traditional medicine, while innovative, must be accompanied by rigorous scientific validation. Strengthening pharmaceutical governance, epidemiological surveillance, capacity building of key stakeholders, and regional coordination are critical levers to ensure better alignment between the health needs of Sahelian populations and the medicines made available to them.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Ragomzingba Frank Edgard Zongo conceived the study, collected and validated the data, and drafted the manuscript; Ghislain Gnimbar Poda provided scientific supervision. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors thank the Higher Institute of Public Health (ISSP), the Ministries of Health of Burkina Faso, Mali, and Niger, as well as all technical partners who facilitated access to the data.

References