For Croatia, the burden of non-communicable, chronic diseases, including cancer, definitely influences the composition of both the mandatory and supplementary national medicines list. This explains why the greatest fraction of medicines unique to the CIHI Basic List was from the classes of neoplastic, cardiovascular and nervous system diseases. The increase of non-communicable diseases in the developing world is a pertinent public health problem and it can be expected that the WHO EML will also include more medicines for these disease groups. Cost does not seem to be the driving factor for inclusion in the CIHI Basic List, which guarantees reimbursement for all persons with national health insurance coverage. For example, the CIHI Basic List had 2605 entries from more than 160 different providers for 509 medicines in 9 analyzed ATC groups. We could not obtain the full dataset for the spending and expenditures for individual medicines of 9 ATC classes included in the analysis. Pragmatically, the process of pricing is rather complex, so that the price listed in the CIHI Basic List may differ from the actual price paid but the CIHI because of Compound Library inhibitor complex rebate and bundling arrangements with the pharmaceutical companies. We could obtained expenditure data only for medicines on the CIHI list which were deleted from the WHO EML, for which Croatia spent about 40 million Euros over the time when the CIHI Basic List from this study was in effect. Just like the WHO EML, CIHI considers comparative effectiveness for medicines on the list, so that EML-deleted or rejected medicines should probably not have been included on the Croatian national medicines list. Expenditure for such medicines is a significant problem for the system of health care that is burdened by over-utilization of and over-expenditures for medicines and subjected to constant reforms to achieve financial sustainability and efficiency with limited resources. Evidence for the efficacy may also not be a primary motivator for decisions about the Croatian national medicines list, despite proclaimed principles of evidence-informed decision-making. Our study demonstrated that for at least some of the medicines on the basic national list there was evidence that the harms outweigh the benefits versus their comparators for specific indications. The recommendations of the CIHI Committee should be officially based on 1) importance of the medicine from a public health point of view, 2) therapeutic importance, 3) relative therapeutic value, and 4) ethical aspects. However, there is little transparency in the decision making process for the recommendations of the CIHI Committee about the new or existing medicines on the list. The process is further burdened by possible conflict of interest introduced by the requirement that any application for inclusion on CIHI lists should be accompanied by a paid opinion of a professional expert. In conclusion, our study demonstrated the value of WHO EML and the recommendations of its Expert Committee in evaluating a national medicines list, which is also the national insurance mandatory reimbursement list in Croatia. We identified a number of cases where medicines were included in the national mandatory list against the evidence from an international standard such as the WHO EML. There is also insufficient transparency of the decision-making for inclusion or deletion of medicines from the list. There are examples from both developed and developing country settings for successful implementation of essential medicines principle in practice. In the current situation of growing demands and reducing financial resources for national health care coverage, greater reliance on a well-established and evidence-based.