Drugs, medical equipment and supplies can be acquired through a variety of channels. Governments in some countries have established procurement agencies to acquire and import medicines and health-related commodities. Where this is the case, as with CAMERWA in Rwanda, it is important to work closely with the national procurement agency in order to obtain supplies through authorized channels, while retaining flexibility and approval to procure through other channels if it becomes necessary to avoid stockouts or delays.

Working with the government ensures that you conform with national regulations and are aware of the national procurement mechanisms that are already in place. The government may have resources available to augment your stock of needed supplies. For example, several African countries, including Rwanda, have AIDS initiatives that offer free ARV treatment to Ministry of Health facilities on a national scale. If the government is unable to meet your needs, your project should be prepared to purchase from other sources to augment your supply. It is also possible to help strengthen their systems by providing projections of patients' needs over a six to twelve month period, or beyond.

Additionally, many Ministries of Health have a required essential drug list and shelf life minimums. It is important to maintain relationships within the MOH to assist with negotiations to import short-dated or off-list products in special circumstances or emergencies.

Non-profit organizations working in developing countries are often able to obtain material donations of medicines and medical supplies, either through medical recycling organizations or directly from manufacturers. More information is available in the “Donation” section below.

Purchases can also be made either directly from manufacturers or through procurement agents that specialize in supplying high-quality, low-cost medicines and supplies for health systems and projects in developing countries. Some of these procurement agencies include the IDA Foundation, Médecins Sans Frontières, UNICEF, and the United Nations Development Program (UNDP).

Donations

Donations can come in the form of cash or as material donations of medical supplies. Material donations provide hospitals with essential medical supplies and allow financial resources to be directed toward other priorities: acquiring new laboratory equipment, restocking the pharmacy, or purchasing hospital beds. Financial donations can be used in a number of ways to support a project, but sometimes donors place restrictions on how they can be used.

PIH has established three basic guidelines for handling material donations:

1) Require that donations meet certain standards

2) Manage your donations appropriately

3) Work with medical supply recovery organizations both to procure medical supplies and to redistribute unwanted material donations

1. Donations should meet certain standards

It is imperative that donated medicines and supplies meet high and clearly defined standards for quality. The notion that beggars can’t be choosers, that people living in abject poverty can benefit from anything that is donated, simply does not hold, especially when dealing with medical supplies. We recommend establishing a clearly stated policy of high standards from the beginning to avoid unnecessary confusion with donors. PIH summarizes our donation policy on our website and in other publications to avoid receiving donations that do not conform to our needs and standards:

“Please note that Partners In Health is unable to accept expired or short-dated pharmaceuticals, hazardous materials or used prosthetics of any kind. All donated medical equipment must be in excellent condition, fully operational and electrically compatible.”

2. Manage donations appropriately

It is important for all organizations to manage their donations appropriately. Evidence of donations getting “dumped” can be very damaging to NGOs, corporate donors, and governments. If you are going to receive donations, make sure that the staff at the project site are equipped with detailed lists of expected and needed donations.

Resource-poor settings often do not have efficient modes of trash disposal. So beyond the financial waste of paying to ship unneeded goods, it is important to avoid having to dispose of unnecessary donations once they arrive in country. Good management of donations is important both in building fruitful partnerships with other organizations and in preventing the environmental degradation or harm to the patients that may result from poor practices.

3. Medical recycling organizations

A number of medical recycling organizations can be helpful both in procuring affordable medical consumables and equipment and in redirecting unwanted donations. These organizations specialize in redistributing the tons of excess medical supplies that become available in the United States everyday and redistributing them to organizations that can put them to use.

An important criterion in choosing which one of these organizations to work with is how detailed they are in categorizing their donations. To a clinician or a patient, for example, a Chromic Gut 4-0 suture and a Vicryl braided 1-0 suture are far from interchangeable. So taking donations from a medical recycling organization that chooses to lump them together under 'sutures' can mean a lot more work at your already busy sites.

Other considerations are the costs involved with each organization. Many organizations rely on services fees charged to recipients as a source of income. These fees are normally a percentage of the value of the goods being donated. Some organizations have a flat fee for the contents of a container and the shipping costs. In selecting a medical recycling organization, ask about fees and expected shipping rates to determine the actual cost of receiving donated goods.

Here are some examples of medical recycling organizations. You may find other organizations that are located closer to your project sites through online research or by asking at nearby hospitals.

Purchasing

Partners In Health is fortunate to have unrestricted funding for the purchase of medicines and medical supplies. This gives us flexibility in selecting the sources for our drug purchases. We are able to buy high-quality generic drugs at low prices, and in some cases we work directly with manufacturers to ensure the best prices.

PIH understands that other projects may face restrictions from funders and therefore may be limited in their procurement choices. The information provided below is intended to give a broad range of sourcing options. PIH trusts that projects will use this information in accordance with the rules and guidelines imposed by their governments, funders or funding agencies.

The majority of our essential drugs are purchased from the International Dispensary Association (IDA) in the Netherlands. The IDA Foundation is the world's largest non-profit supplier of high-quality, low-cost generic drugs and medical supplies. They offer a wide range of products, specializing in the pharmaceuticals included in the World Health Organization's Essential Drug List (EDL).The IDA Foundation also provides HIV drugs and testing supplies, and first- and second-line tuberculosis drugs. More on those specific product lines can be found below.

A catalog and product information can be found at http://www.idafoundation.org and initial inquiries can also be directed to IDA through their website. Clients are assigned to a sales and service representative based on the geographic location of the client. Please note, however, that IDA is not able to ship medicines or medical supplies to United States addresses. US-based NGOs can purchase from them but will need to provide IDA with a foreign address for delivery.

Other suppliers provide similar services to IDA, either on a for-profit or not-for-profit basis. These include MissionPharma in Denmark, UNICEF, and MSF Supply (a branch of Médecins Sans Frontières).

If your country or project has unrestricted funds available, you can also purchase directly from the manufacturer. It is often easier, however, to use a procurement agent, like the IDA Foundation or UNICEF for your HIV purchasing. This is especially true if you are purchasing products from multiple manufacturers. Procurement agents can survey the manufacturers and secure the most competitive price. They can also assist in preparing customs documents for importation and making transport arrangements for delivery to international sites.

It is sometimes possible to negotiate reduced prices with vendors by educating them about the charitable aspects of your work, providing quantitative information about your expected spending, and soliciting multiple quotations to allow for competition between vendors. It is important to balance the urgency of your procurement efforts with the need not to be wasteful. Be sure to look into local options before purchasing medical supplies in the United States. When comparing prices from local suppliers it is important to consider the additional cost of shipping abroad and the long-term benefits of strengthening local capacity to meet local needs.

Over time, purchasing can be expected to grow exponentially, along with the number of patients in your catchment area, the range of services provided by your project and the level of available funding. Check with local suppliers, seek meaningful donations (see donation guidelines) and choose generic brands and buy in bulk to save money.

Procurement plans for funding organizations

Global Fund to Fight AIDS, TB and Malaria (GFATM)

Many developing countries have benefited from the HIV-related funding provided by the GFTM. Valuable information can be found on the GFATM website.

The GFATM maintains a policy that regulates how GFATM-funded projects may procure single- or limited-source products, such as some HIV and tuberculosis medications. If your country or project is GFATM-funded, you may already be aware of the procurement policy. This policy was amended in April 2005. Information specific to the procurement policy can be found on the Global Fund website.

Because of our longstanding relationship with the IDA Foundation, PIH has opted to use IDA as the procurement agent for our GFATM-funded work in Haiti and Peru. Another advantage to procuring medicines through IDA or another procurement agent is that such agents are aware of the GFATM rules and will provide quotations with detailed information about the supplier and how the supplier complies with the GFATM policy.

The President's Emergency Plan For AIDS Relief (PEPFAR)

The President's Emergency Plan for AIDS Relief, known as PEPFAR, was launched in 2003 as a five-year, $15 billion global initiative to combat the HIV/AIDS epidemic. Reauthorization of PEPFAR for another five years with an expanded budget of $50 billion appears likely in 2008. During the first five years of the program, funds were targeted to 15 of the most affected countries in the world: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, Zambia.

Funding from the U.S. government normally involves strict and specific guidelines for procurement of drugs, medical supplies and laboratory supplies. If your country or project has received PEPFAR funding, work with your in-country representatives (likely from USAID or the Centers for Disease Control) to learn about the purchasing policies and restrictions.

Projects or countries purchasing HIV drugs with PEPFAR monies or other funds from the United States will find they now have access to a broad range of approved products. The Food and Drug Administration created a “fast-track” application for manufacturers of generic HIV drugs, and as a result many low-cost Indian products are approved for purchase with U.S. grant funds.

Clinton Foundation

The work of the William J. Clinton Foundation has resulted in lower-cost ARV drugs and diagnostic tests for specific sub-Saharan and Caribbean countries. Over 40 countries have taken advantage of these prices, which the Foundation negotiated directly with Indian generic manufacturers.

If the country in which you work is covered by the Clinton HIV/AIDS Initiative, you can access these products through a procurement agent such as UNICEF, UNDP, or the IDA Foundation. A list of the current partner countries can be found here.

Tuberculosis drugs: First-line drugs

First-line tuberculosis drugs are available from a variety of sources, including the WHO Global Drug Facility. Founded in 2001 under the Stop TB Partnership and housed by the WHO, the Global Drug Facility (GDF) originally was mandated to oversee procurement of drug-susceptible TB medications. On May 29, 2007, GDF announced that it had provided "anti-TB drug treatments for 10 million people to 78 countries (over) the past six years”. Other suppliers of first-line medication include the IDA Foundation, and Médecins Sans Frontières. In addition, many national drug systems and Ministries of Health (MOH) supply first-line drugs to tuberculosis-treatment programs within the country. This is yet another reason why it is important to establish links and relationships with the MOH and national and local health providers.

Tuberculosis drugs: Second-line drugs

Although it is possible to purchase second-line TB drugs on the open market, the WHO's Green Light Committee, or GLC, makes reduced-price second-line drugs available to projects that demonstrate proven efficacy in the treatment of multi drug-resistant tuberculosis. Projects make application to the GLC and, once approved, have access to lower cost drugs. The IDA Foundation is currently the contracted procurement agent serving GLC-approved projects. The GLC application process is long; PIH suggests that interested projects contact the GLC Secretariat for information on application deadlines and additional information.

The Stop TB Partnership Coordinating Board, the Stop TB Department of WHO, and the Working Group on DOTS-Plus for MDR-TB agreed to bring together the duties of GDF and GLC in 2006, with full transference of procurement responsibilities to GDF for second-line drugs taking place throughout 2007. As such, the GDF currently negotiates contracts with the procurement agent and monitors its activities, and compiles second-line drug projections for GLC-approved projects. The terms of the new contract with the procurement agent, signed in 2007, allow closer monitoring by GDF of the procurement agent in terms of ordering and procedures.

As of November 2007, funding for a buffer stock of second-line drugs for 800 patients was provided. The drug stockpile is still being established in early 2008. Once created, it will ensure that a ready supply of MDR-TB drugs is always available. The drugs from this stockpile are to be used to avoid stock-outs with existing projects and expedite the launch of new sites.

Medical supplies

A large number of medical supply companies exist in the marketplace today. It is important to narrow this list down by soliciting multiple quotations and comparing pricing and delivery time. Partners In Health has used the following suppliers with varying frequency:

• Moore Medical
• Owens and Minor
• McKesson Medical
• Fisher Scientific

These companies provide us with the majority of medical and surgical consumables needed for our project in Haiti, which includes nine hospitals and four operating rooms. There is a large range of sizes, brands and styles for each product, so it is important to involve staff at the project site with purchasing to ensure that the correct products are selected. It is a misuse of both funds and staff time to purchase and ship supplies that go unused because there is no need for them or they don't work in the setting. When purchasing surgical and laboratory equipment, it is also important to budget and plan for training of on-site staff as an essential complement to the procurement process.

Surgical, laboratory and radiology supplies

The costs of constructing and outfitting surgical suites can be very high. Medical recycling and donor organizations, such as Remedy, International Aid and Direct Relief International can be of help in locating and securing operating equipment, as operating room furniture and supplies are often disposed of unused.

There has been an upsurge in the availability of donated dental and regular x-rays as hospitals and private clinics upgrade to the newly introduced digital x-ray machines. In addition to the x-ray machines themselves, it is also possible to secure donations of related equipment (cassettes, hangers, film, developers etc.) The transport of donated machines requires crating which can add around $2000 to any anticipated shipment costs. However, it has been our experience that even with the associated shipping costs money is still saved over purchasing a new x-ray machine.

The consumables needed for x-rays include film, developer and fixer for processing, and envelopes and tape for storage. Protective clothing for patients and x-ray technicians (gloves, aprons, shields) should also be factored into a radiology budget. Casettes, hangers for drying or a film dryer and a tank for developing are also needed. Paragon Medical and 3endt are two possible suppliers for most of these materials. Replacement parts are occasionally needed, so it is recommended that projects keep as much information as possible for each machine (make, model, serial number) so that parts can be ordered quickly.