1. Levison L, Laing RL, Waning B, Kaplan W
Improving Rational Use through Efficient Procurement: review of the existing evidence base to guide procurement
Levison L, Laing RL, Waning B, Kaplan W

2. 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.

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

4. 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

5. Procurement participants and system structure
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

6. Procurement process “ ” No literature found + 1 or 2 citations
Selection
Quantification
Tender format
Pre-qualification (+)+
Tender quantities
Market intelligence

7. 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

8. 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

9. Planning and resources
Procurement planning
Human resources
Access to adequate resources +
Almost no evidence available on impact of human resources on pharmaceutical procurement

10. 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

11. 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:
% of procurement cost
Access to market data lowers costs
Strengthen Purchaser terms in contracts
Improve communication in system
Provide training, resources to procurement

12. 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?

13. 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