Improving Rational Use through Efficient Procurement: review of the existing evidence base to guide

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Improving Rational Use through Efficient
Procurement review of the existing evidence base
to guide procurement

• Levison L, Laing RL, Waning B, Kaplan W

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• Title Improving Rational Use through Efficient
  Procurement review of the existing evidence base
  to guide procurement
• Authors Levison L, Laing RL, Waning B, Kaplan W
• Institution Boston University School of Public
  Health and Center for International Health and
  Development
• Problem Statement The efficiency of Essential
  Medicine procurement systems has a direct impact
  on drug availability and total health costs,
  which in turn affects access and rational use.
  However little evidence exists to assist health
  systems to evaluate the performance of their
  procurement departments nor to select "best"
  procurement practices.
• Objectives To review current literature on
  Essential Medicine procurement to summarize
  current knowledge of procurement methods to
  identify the factors which impact procurement
  performance to identify health programs which
  have implemented "best methods" of procurement
  and to identify future research priorities to
  improve access related to rational use.
• Design Literature review.
• Setting and Population Study subjects included
  procurement offices described in available
  literature including public, commercial, mission
  and non-governmental health systems.
  Methodologies used by procurement agents and
  non-profit suppliers were also studied.
• Outcome Measures An understanding of the
  relationship between procurement choices made and
  the success of the procurement program for those
  factors that are described in the literature. An
  understanding of how to measure the success of
  procurement systems.
• Results The study summarizes the available
  evidence in best procurement methods. The
  evidence shows that recent changes in supplier
  pre-qualification, the use of Essential Medicines
  lists as a basis for procurement, quality
  assurance, and restricted competitive tendering
  have a positive impact on the procurement
  process. The evidence also identifies numerous
  phases of procurement where an evidence-base is
  lacking, and proposes over 50 studies aimed at
  gathering this missing evidence.
• Conclusions Currently the evidence base for best
  methods of pharmaceutical procurement is very
  weak. A research agenda that focuses on the many
  understudied factors of procurement is needed.
  This research summarizes current knowledge and
  proposes the required research agenda.

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Background

• Research paper commissioned by RPM-Plus
• Identify evidence supporting efficient and
  effective Essential Medicine procurement systems
• Identify current gaps in knowledge
• Methods
• Searched, 1994-2004
• MEDLINE, IPA, EMBASE
• Online discussions E-Drug, IP-Health
• General procurement literature

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Study questions

• Review literature on pharmaceutical procurement
• Summarize evidence on procurement methods
• Identify factors that impact procurement
  performance
• Identify health systems which are best method
  examples
• Identify future research priorities

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Procurement participants and system structure

• Participants
• Minimal literature/evidence on public, private
  for-profit, non-profit sectors
• Recent reviews of public-private partnerships
• System structure
• Decentralization well reviewed
• Pooled procurement adequate literature more
  implementation details needed

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Procurement process

• No literature found
• 1 or 2 citations
• 3-5 citations
• gt5 citations
• Selection
• Quantification
• Tender format
• Pre-qualification ()
• Tender quantities
• Market intelligence

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Procurement process, cont.

• Analyzing costs
• Payment
• Contract specification ()
• Adjudication
• Reception quality control
• Monitoring procurement
• Continued quality monitoring
• For contracts no evidence, but very good
  reference documentation

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Example study Van der Veen Fransen, 1998

• Studied final cost variations for different
  tendering methods of STD drugs
• Prices of generics 3-6 times higher for
  ministries doing national tendering than for
  international procurement agencies

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Planning and resources

• Procurement planning
• Human resources
• Access to adequate resources
• Almost no evidence available on impact of human
  resources on pharmaceutical procurement

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Lessons learned

• Scarcity of published evidence
• Little evidence for well-established procedures
• Need for easily accessible case studies
• Need metric to assess and compare procurement
  systems

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Improving rational use

• Decentralization sub-optimal for procurement
• Base selection on EML
• Reduce work and prices with
• pre-qualification and restricted tender
• Implement QC at reception
• 0.39-0.53 of procurement cost
• Access to market data lowers costs
• Strengthen Purchaser terms in contracts
• Improve communication in system
• Provide training, resources to procurement

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Future studies

• Over 60 study outlines listed in paper
• Focus on gathering evidence to inform
  implementation choices
• Each proposed study contains
• Problem description
• Previous studies
• Required knowledge
• Outline of study with suggested variables
• Examples Does tendering format impact base
  price? What tax policies are in place on
  medicines? What percentage of cost should be
  spent on quality assurance?

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Best case studies

• Huff-Rousselle Burnett Cost containment
  through pharmaceutical procurement a Caribbean
  case study
• Chaudhury Delhi Society for the Promotion of
  Rational Use of Drugs
• Van der Veen Fransen Drugs for STD management
  in developing countries choice, procurement,
  cost and financing
• Kawasaki Patton Drug supply systems of
  missionary organizations
• Stapleton Bhutan Essential Drugs Programme
• WHO/HAI The Medicines Prices project
• de Goeje 25 years of essential drugs the
  quality issue Ideals, attainments and failures