Effect of clinical engagement on value, standardisation, decision-making and savings in NHS product procurement

BACKGROUND

UK healthcare expenditure is now £193.8 billion a year. The procurement function is seen as central to driving efficiencies within the NHS. This comes with an increasing onus on clinicians, including nurses and allied health professionals, to accept procurement outcomes to realise efficiency savings, with or without prior engagement.

AIMS

This empirical study seeks to examine whether clinical engagement in the procurement of healthcare products in the NHS is necessary to achieve value, savings and standardisation; it will thereby address a gap in the research.

METHODS

A multi-method qualitative case study design was used, which included a survey and eight semi-structured interviews.

FINDINGS

Results identified three factors that influence the achievement of value, savings and standardisation around clinical engagement: micro-level processes for clinical engagement; clinical stakeholders and clinical procurement professionals as experts at the centre of procurement activity; and clinical value in standardisation. A shift away from standardisation to resilience was identified, resulting from current market supply pressures.

CONCLUSION

This research brings empirically derived findings to address gaps in research, supports the benefit of clinical engagement through specific forums for collaboration at a trust level and provides a clinical/expert impact/preference matrix as a resource for procurement professionals to facilitate clinical engagement.

The Importance of Multiorgan Procurement in the Improvement of Residents' Open Surgical Skills

INTRODUCTION

The multiorgan procurement (MOP) represents a chance for the general surgery resident to learn the fundamental steps of open abdominal surgery. The objective of this study was to evaluate the impact of MOP on the residents' open surgical skills.

METHODS

Residents' surgical skills were assessed during a 6-month transplant rotation (October 2020-March 2021) using a modified Objective Structured Assessment of Technical Skills with the global rating scale. The surgeries were self-assessed by residents and tutors based on 9 specific steps (SS) and 4 general skills (GS). Each item was rated from 1 (poor) to 5 (excellent) with a maximum score of 45 points for SS and 20 for GS. A crossed-effects linear regression analysis was performed both to evaluate any associations between GS/SS scores and some prespecified covariates, and to study differences in the assessments performed by residents and tutors.

RESULTS

Residents actively participated in a total of 59 procurements. In general, there were no significant differences in SS/GS mean scorings between residents (n = 15) and tutors (n = 5). There was a significantly positive association between mean GS/SS scorings and the number of donor surgeries performed (at least 5). Comparing the evaluations of the tutors with the residents, this significance was retained only when scorings were assigned by the tutors.

CONCLUSIONS

MOP was shown to improve basic open surgical skills among residents. Awareness of the utility of a clinical rotation in transplant surgery should be raised also on an institutional level.

Integrated procurement and reprocessing planning for reusable medical devices with a limited shelf life

We present a new model formulation for a multiproduct dynamic order quantity problem with product returns and a reprocessing option. The optimization considers the limited shelf life of sterile medical devices as well as the capacity constraints of reprocessing and sterilization resources. The time-varying demand is known in advance and must be satisfied by purchasing new medical devices or by reprocessing used and expired devices. The objective is to determine a feasible procurement and reprocessing plan that minimizes the incurred costs. The problem is solved in a heuristic manner in two steps. First, we use a Dantzig-Wolfe reformulation of the underlying problem, and a column generation approach is applied to tighten the lower bound. In the next step, the obtained lower bound is transformed into a feasible solution using CPLEX. Our numerical results illustrate the high solution quality of this approach. The comparison with a simulation based on the first-come-first-served principle shows the advantage of integrated planning.

Prices of paediatric vaccines in European vaccination programmes

Objective

To compare the vaccine prices per vaccinated child under 18 and vaccine funding and procurement systems in the national vaccination programmes (NVPs) in Europe.

Methods

The on-line survey targeted to NVP managers collected data referred to the information available on 31 December 2016. The prices of vaccines were categorised into three groups. The price per child 1) fully vaccinated comprised all vaccines and doses offered in the NVP; 2) vaccinated with standard vaccines comprised the vaccines included in the NVP in all countries; 3) vaccinated with recent vaccines comprised the pneumococcal conjugate, human papillomavirus and rotavirus vaccines.

Results

In the 23 out of 32 countries that answered the survey, 17 funded the vaccines by taxes and six by social insurance. 18 countries procured the vaccines through public tenders or negotiations. Five countries purchased the vaccines by healthcare providers and reimbursed from the health insurance system.In the countries with vaccine procurement through public tenders the price per child vaccinated with standard vaccines ranged from €59 to €117 when using pentavalent and from €98 to €220 when using hexavalent vaccines. The mean price per child vaccinated with recent vaccines was €130 for the countries that offered pneumococcal conjugate and human papillomavirus vaccines and €142 for the countries that in addition included rotavirus vaccine.In the countries that purchased the vaccines by healthcare providers and reimbursed from the health insurance system the price per child vaccinated with standard vaccines ranged from €136 to €427.

Conclusions

The vaccine prices differ notably in Europe. Prices were lower in countries where vaccines in the NVP were tax-funded and nationally or regionally procured. Improved procurement systems could lead to substantial savings or possibilities to introduce more vaccines into the NVP.

A machine learning-based Biding price optimization algorithm approach

Trading companies of used product market are struggling to gain customers attentaion and to sell the products. The aim of this research is to develop a mechanism that can maximize the sale of products while considering profit implications. The literature review classifies the procurement mechanism. Given the limited-supply nature, that also includes unpredictable quality levels and a procurement mechanism that perceives the company offering prices to suppliers on a single-item basis. The academic literature has not covered such a mechanism. Techniques like those that improve the required bidding strategy are reviewed and considered fit to be included in the support tool as the procedures intention to maximize an objective function depending on the bidding price and contain the probability of winning the auction and the profit made from the proceeding, the motivation laid on the approach that predicts the probability. It is determined that this assembles a Response to Reverse Request for Quotation that meets the assumptions of a First-Price Sealed-Bid(FPSD) auction that potentially includes a hidden reservation price.

Use of evidence-based approaches in procurement and implementation of health and welfare technologies - a survey among Swedish municipalities

BACKGROUND

Health and welfare technologies (HWT) are increasingly procured and implemented by public providers in Swedish municipalities, but it remains unclear if and how evidence for these technologies' effectiveness is used in both processes. The aim of this study was to investigate the use of evidence in Swedish municipal public sector procurement and implementation of HWT.

METHODS

A telephone survey of 197 municipalities was conducted with questions regarding the use of evidence in both processes, as well as eventual support needs regarding its use. Standard definitions of HWT and evidence were provided prior to the survey. Response frequencies and percentage proportions were calculated per question. Lambda (Λ) values with corresponding significance values were calculated for associations between responses to selected questions and the size and type of municipality, with values of 0.01 to 0.19 designated as weak associations, 0.20 to 0.39 as moderate, and 0.40 and above as strong.

RESULTS

Sixty-four municipalities completed the entire survey. Consistent use of evidence for effectiveness of HWT occurred in less than half of respondents' municipal public procurement processes. Two-thirds of municipalities did not have an established model or process for implementation of HWT that used evidence in any manner. More than three quarters of municipalities lacked a systematic plan for follow-up and evaluation of effectiveness of implemented HWT, and of those that did less than half followed their plan consistently. Most municipalities expressed the need for support in using evidence in HWT-related processes but did not consider evidence and systematic evaluation to be prioritized.

CONCLUSIONS

Weaknesses and gaps in using evidence in procurement and implementation processes may create a legacy of sub-optimal implementation of HWT in Swedish municipal health- and social care services, and lost opportunities for real-world evidence generation. There was a clear indication of the need for unified national guidance for using and generating evidence in key HWT-related municipal processes and implementation. Such guidance needs to be developed and effectively communicated.

Two-stage stochastic formulation for relief operations with multiple agencies in simultaneous disasters

The increasing damage caused by disasters is a major challenge for disaster management authorities, especially in instances where simultaneous disasters affect different geographical areas. The uncertainty and chaotic conditions caused by these situations combined with the inherent complexity of collaboration between multiple stakeholders complicates delivering support for disaster victims. Decisions related to facility location, procurement, stock prepositioning and relief distribution are essential to ensure the provision of relief for these victims. There is a need to provide analytical models that can support integrated decision-making in settings with uncertainty caused by simultaneous disasters. However, there are no formulations tackling these decisions combining multiple suppliers, multiple agencies, and simultaneous disasters. This article introduces a novel bi-objective two-stage stochastic formulation for disaster preparedness and immediate response considering the interaction of multiple stakeholders in uncertain environments caused by the occurrence of simultaneous disasters. At the first stage, decisions related to the selection of suppliers, critical facilities, agencies involved, and pre-disaster procurement are defined. Resource allocation, relief distribution and procurement of extra resources after the events are decided at the second stage. The model was tested on data from the situation caused by simultaneous hurricanes and storms in Mexico during September of 2013. The case is contrasted with instances planning for disasters independently. The results show how planning for multiple disasters can help understand the real boundaries of the disaster response system, the benefits of integrated decision-making, the impact of deploying only the agencies required, and the criticality of considering human resources in disaster planning.

Is the near coming xenotransplantation era relieving us from needing to look for more non-living organ donors?

Despite organ transplantation being the most successful treatment for end-stage organ dysfunction, the number of annual solid organ transplantations is much lower than that required to satisfy the demand of patients on waiting lists. The explanation for this phenomenon is the relative scarcity of non-living organ donors due to several factors, such as: (1) Late arrival of patients with a neurocritical condition to an emergency service; (2) lack of detection of those patients as possible organ donors by health professionals dedicated to procurement or by clinicians at emergency and intensive care units, for instance; (3) late transfer of the patient to an intensive care unit to try to recover their health and to provide hemodynamic, ventilatory, and metabolic support; (4) lack of confirmation of the physiological status of the possible donor; (5) late or incorrect positive diagnosis of the subject’s death, either due to brain or cardiac death; (6) difficulty in obtaining legal authorization, either by direct relatives or by the authority, for the extraction of organs; and (7) deficient retrieval surgery of the organs actually donated. The recent reports of relatively successful xenotransplants from genetically modified pigs open the possibility to fix this mismatch between supply and demand, but some technical (organ rejection and opportunistic infections), and economic issues, still remain before accepting a progressive replacement of the organ sources for transplantation. An approximate economic cost analysis suggests that the hypothetical acquisition cost of any genetically modified pig derived organ is high and would not even satisfy the solid organ demand of the wealthiest countries.

Was EU's COVID-19 vaccine procurement strategy irrational? A re-analysis based on cost-effectiveness considerations

AIM

The European Union (EU) has received criticism for being slow to secure coronavirus disease (COVID-19) vaccine contracts in 2020 before the approval of the first COVID-19 vaccine. This study aimed to retrospectively analyze the EU's COVID-19 vaccine procurement strategy. To this end, the study retrospectively determined the minimum vaccine efficacy that made vaccination cost-effective from a societal perspective in Germany before clinical trial announcements in late 2020. The results were compared with the expected vaccine efficacy before the announcements.

METHODS

Two strategies were analyzed: vaccination followed by the complete lifting of mitigation measures and a long-term mitigation strategy. A decision model was constructed using, for example, information on age-specific fatality rates, intensive care unit costs and outcomes, and herd protection thresholds. The base-case time horizon was 5 years. Cost-effectiveness of vaccination was determined in terms of the costs per life-year gained. The value of an additional life-year was borrowed from new, innovative oncological drugs, as cancer is a condition with a perceived threat similar to that of COVID-19.

RESULTS

A vaccine with 50% efficacy against death due to COVID-19 was not clearly cost-effective compared with a long-term mitigation strategy if mitigation measures were planned to be lifted after vaccine rollout. The minimum vaccine efficacy required to achieve cost-effectiveness was 40% in the base case. The sensitivity analysis showed considerable variation around the minimum vaccine efficacy, extending above 50% for some of the input variables.

CONCLUSIONS

This study showed that vaccine efficacy levels expected before clinical trial announcements did not clearly justify lifting mitigation measures from a cost-effectiveness standpoint. Hence, the EU's sluggish procurement strategy still appeared to be rational at the time of decision making.

Outsourcing and children's social care: A longitudinal analysis of inspection outcomes among English children's homes and local authorities

Most residential children's social care services in England, including children's homes, are operated by for-profit companies, but the implications of this development are not well understood. This paper aims to address this gap by undertaking the first longitudinal and comprehensive evaluation of the associations between for-profit outsourcing and quality of service provision among English local authorities and children's homes. To enable investigation of the implications of outsourcing children's residential social care services, we create and analyse a novel and longitudinal dataset covering more than 13,000 children's home inspections by Ofsted (the independent regulator of children's social care in England) over a period of 7 years (2014-2021). We also investigate the association between Ofsted local authority (LA) ratings and the reliance of LAs on for-profit and third sector outsourcing of children in care placements. Our analysis shows that for-profit providers are statistically significantly more likely to be rated of lower quality than both public and third sector services. For-profit children's homes also violate a greater number of requirements and receive more recommendations compared to other ownership types. These findings are robust to model specification and consistent over the full analysed period. At LA level, we find provisional evidence that LA Ofsted ratings are negatively correlated with the percentage of for-profit outsourcing, suggesting that LAs which outsource a greater amount of their children in care placements perform less well than those which do not. These findings are of significant concern given the focus of these services on society's most vulnerable service users. However, caution is needed in terms of regulating the sector going forward, as the role of for-profit provision cannot be replaced without substantial coordination and long-term planning.

The connection between COVID-19 vaccine abundance, vaccination coverage, and public trust in government across the globe

This study investigates that how the number of COVID-19 vaccines secured correlates with the vaccination coverage (full and booster) depending on whether there is trust in national government or not across 47 countries. The data are based on global figures as of Nov. 2021 and Feb. 2022 while measures for confidence in government is according to Gallup World Poll, Oct. 2021. The model includes an interaction term of the two key variables, also controls for a range of socio-economic factors and country specific variables. The results indicate a non-linear and mixed relationship between the numbers secured, the public trust, and the vaccination rate. In Feb. 2022, with confidence in government, securing number of vaccines to cover 200% of the population (or more) increased the full vaccination rate by 12.26% (95% CI: 11.70 - 12.81); where number secured was 300% (or more), the coverage increased by 7.46% (95% CI: 6.95 - 7.97). Under similar scenarios, rate of booster shots increased by 13.16% (95% CI: 12.62 - 13.70; p < 0.01) and 14.36% (95% CI: 13.86 - 14.85; p < 0.01), respectively. Where the number secured fell below 200%, confidence in government had a revers relationship with the rate of full vaccination (-2.65; 95% CI: -3.32 - -1.99), yet positive with the rate of booster shots (1.65; 95% CI: 1.18 - 2.12). These results indicate that better success can be achieved by a combination of factors including securing sufficient number of vaccines and also ensuring the public trust. Vaccine abundance, however, cannot be translated into greater success in vaccination coverage. This study highlights the importance of efficiency in acquiring vaccine resources and need for improvement in public belief in immunization programmes rather than stock piling.

Factors Influencing Procurement of Digital Healthcare: A Case Study in Dutch District Nursing

BACKGROUND

Digital health is considered a promising solution in keeping health care accessible and affordable. However, implementation is often complex and sustainable funding schemes are lacking. Despite supporting policy, scaling up innovative forms of health care progresses much slower than intended in Dutch national framework agreements. The aim of this study is to identify factors that influence the procurement of digital health particular in district nursing.

METHODS

A case study approach was used, in which multiple stakeholder perspectives are compared using thematic framework analysis. The case studied was the procurement of digital health in Dutch district nursing. Literature on implementation of digital health, public procurement and payment models was used to build the analytic framework. We analysed fourteen interviews (secondary data), two focus groups organised by the national task force procurement and eight governmental and third-party reports.

RESULTS

Five themes emerged from the analysis: 1) rationale 2) provider-payer relationship, 3) resources, 4) evidence, and 5) the payment model. Per theme a number of factors were identified, mostly related to the design and functioning of the Dutch health system and to the implementation process at providers' side.

CONCLUSION

This study identified factors influencing the procurement of digital health in Dutch district nursing. The findings, however, are not unique for digital health, district nursing or the Dutch health system. The results presented will support policy makers, and decision makers to improve procurement of digital health. Investing in better relationships between payer and care provider organisations and professionals is an important next step towards scaling digital health.

The application and deployment of welfare technology in Swedish municipal care: a qualitative study of procurement practices among municipal actors

Background

Welfare technology has been launched as a concept to accelerate digital transformation in care services, but the deployment of these technologies is still hindered by organisational resistance, lack of infrastructure, and juridical and ethical issues. This paper investigates decision-making among municipal actors in the application and deployment of welfare technology from a procurement process perspective. The study explores the perceptions and negotiations involved in purchasing welfare technology at each stage of the procurement model, revealing the impact of technical, economic, juridical and ethical competence on the mapping, planning, procurement, implementation and management of welfare technology.

Methods

The study presents empirical findings from qualitative interviews conducted among municipal actors in Sweden. Semi-structured interviews were gathered in 2020 among procurement managers, IT managers, and managers in social administration in three different municipalities (n = 8). Content analysis and systematic categorisation were applied resulting in the division of procurement practices into sub-categories, generic categories and main categories.

Results

Challenges in the application and deployment of welfare technology occur at all stages of the procurement model. In mapping and planning, barriers are identified in the need analysis, requirement specification and market analysis. In the procurement stage, economic resources, standardisation and interoperability hinder the procurement process. Implementation and management are complicated by supplier assessment, legislation, cross-organisational collaboration and political strategy. Building on these findings, this study defines ‘procurement competence’ as consisting of technical, economic, juridical and ethical expertise in order to assess and evaluate welfare technology. Technical and ethical competence is needed in early stages of procurement, whereas juridical and economic competence relates to later stages of the model.

Conclusions

Procurement competence is associated with the application and deployment of welfare technology in (1) assessment of the end-user’s needs, (2) estimation of the costs and benefits of welfare technology and (3) management of juridical and legislative issues in data management. Economic and juridical decisions to purchase welfare technology are not value-neutral, but rather associated with socially shared understandings of technological possibilities in care provision. Optimisation of procurement processes requires a combination of capabilities to introduce, apply and deploy welfare technology that meets the demands and needs of end-users.

Military Working Dogs: An Overview of Veterinary Care of These Formidable Assets

For the clinician treating military working dogs, an understanding of how they are sourced, preventive medicine policies, and common disease conditions is paramount in optimizing the delivery of health care. Military personnel rely heavily on the availability of these K-9s, which bring a diverse array of capabilities to myriad operational settings. Anticipating and mitigating common diseases will ensure these dogs continue to serve the needs of US military and allied forces.

Use of liver grafts from cadaveric donors: Implementation impact of a local evaluation and procurement team in Mexico

INTRODUCTION AND AIMS

Cadaveric donor liver graft retrieval is complex in Mexico. The aim of the present article was to present the experience in liver graft use during the first year of work of a local evaluation and procurement team.

MATERIALS AND METHODS

We reviewed the organ donation report forms and allocation offer records covering the time frame of December 15, 2017 to December 15, 2018, and registered the donor characteristics, causes of organ discard, causes of declined offers, transport time, and graft and recipient survival at 30 days.

RESULTS

There were 17 donations and we completed the evaluation of 14. Two donors were considered ideal (14.2%) and 12 were expanded criteria donors (ECDs) (85.7%). Two grafts with steatosis were not offered (14.2%). Twelve liver grafts were offered 88 times (mean 7.6 offers per graft). The acceptance rate was 6% for public hospitals and 23.6% for private hospitals (p = 0.016). One graft was discarded during the procurement process due to steatosis. The rate of use after evaluation was 78.5% (11/14). All the grafts were procured by the local team and 9 (81.8%) were transported by commercial airline (median 240 min, range 85 min). Graft and recipient survival at 30 days was 100%.

CONCLUSIONS

The participation of a local evaluation and procurement team notably increased liver graft use with excellent results. Commercial airline transportation of the grafts to all active transplantation centers of the country resulted in cold ischemia times <6 h.

Assessing competition in the hip implant industry in the light of recent policy guidance

NHS procurement is a highly topical area, attracting a great deal of recent policy focus. The pivotal report by Lord Carter of Coles (2016) highlighted unwarranted variation, estimating it to be worth approximately £5bn in efficiency savings. In relation to hip replacement surgery, recent procurement policy guidance has recommended the use of cemented hip implants for all patients aged 68 years and over in England and Wales. Previous work established that the hip implant supplying market was very concentrated, with only a few large suppliers, especially for cemented implants. The advocated major shift towards cemented implants would almost certainly increase further the market share of the dominant manufacturer of cemented sector thus raising potential competition and welfare issues. We carry out a market study to establish whether there might be a potential competition concern, using data from the National Joint Registry (2005-2018, 37 suppliers, nearly 700 models). We first establish the structure of the industry with a specific focus on seller concentration. Secondly we evaluate the dynamics underlying concentration in the market, assessing the innovative performance of the sector using a novel statistical analysis of the dynamics of market shares. We then look to three comparable but alternative markets for similarities or differences to the THR implant industry. We find a high and increasingly concentrated oligopolistic and static market structure, largely devoid of dynamics and with no real sign of innovation. These findings are further emphasized when compared with the three close alternative markets. Although this stability could just be a mature market where technical advances have already taken place, our findings highlight the potential welfare and policy implications of concentrating on cemented fixation. Given the current emphasis on efficiency in procurement, it is essential that there should also be scrutiny of the firms dealing with public procurement.

Procurement, commissioning and QA of AI based solutions: An MPE's perspective on introducing AI in clinical practice

PURPOSE

In this study, we propose a framework to help the MPE take up a unique and important role at the introduction of AI solutions in clinical practice, and more in particular at procurement, acceptance, commissioning and QA.

MATERIAL AND METHODS

The steps for the introduction of Medical Radiological Equipment in a hospital setting were extrapolated to AI tools. Literature review and in-house experience was added to prepare similar, yet dedicated test methods.

RESULTS

Procurement starts from the clinical cases to be solved and is usually a complex process with many stakeholders and possibly many candidate AI solutions. Specific KPIs and metrics need to be defined. Acceptance testing follows, to verify the installation and test for critical exams. Commissioning should test the suitability of the AI tool for the intended use in the local institution. Results may be predicted from peer reviewed papers that treat representative populations. If not available, local data sets can be prepared to assess the KPIs, or 'virtual clinical trials' could be used to create large, simulated test data sets. Quality assurance must be performed periodically to verify if KPIs are stable, especially if the software is upscaled or upgraded, and as soon as self-learning AI tools would enter the medical practice.

DISCUSSION

MPEs are well placed to bridge between manufacturer and medical team and help from procurement up to reporting to the management board. More work is needed to establish consolidated test protocols.

Essential medicine shortages, procurement process and supplier response: A normative study across Indian states

Efficient public-procurement systems are critical for ensuring Access to Medicines (ATM) and enabling universal healthcare delivery. This is especially true of India where public healthcare caters to the underprivileged population who have limited access to medicines. However, essential medicine shortage in the Indian public-healthcare system is significant and is exacerbated by inefficiencies in the procurement system. Healthcare policy makers have to constantly contend with delays and non-fulfillment of medicine orders leading to shortages. Pharmaceutical companies supplying orders argue that the current system is not business-viable or fair. To explore these issues in-depth, we distill insights from structured interviews with a Policy Maker and interactions with the pharmaceutical industry to identify supply side issues which lead to medicine shortages. We build a normative model and utilize public medicine procurement data to study how pharmaceutical supplier response and order fulfillment is impacted by orders from multiple Indian states with different procurement conditions. We then employ standard supply chain theory to propose solutions to mitigate some of these issues. We find that the current system can be significantly improved by increased capacity allocation at suppliers for state orders, staggered ordering at the state level, stricter but gradual implementation of penalties and blacklisting and sourcing from suppliers located closer to the state.

Establishing a national HTA program for medical devices in Italy: Overhauling a fragmented system to ensure value and equal access to new medical technologies

Differing contexts have greatly influenced HTA development in various countries, with considerable effort recently made by international HTA networks (e.g., EUnetHTA) and the European Union (EU) to make HTA a more coherent, equal, and efficient process. Medical devices (MDs) present particular challenges for HTA because of frequent, rapid innovation, outcomes influenced by end-user competence, dynamic pricing and often low-quality scientific evidence. Our objective is to describe the development, structure and governance of a National HTA Program for MDs (PNHTADM) in Italy, a highly participatory, stakeholder-engaged, evidence-based process to reform a fragmented system of appraisal and approval. Based largely on EUnetHTA methods, the resulting process delineates a standardized system for proposing MDs by any stakeholders, accrediting HTA producers, setting criteria for prioritization and appraisals, and innovatively linking recommendations with coverage, reimbursement and procurement of MDs. Expected benefits include reduced disparities in pricing and reimbursement policies and improved access to new technologies across 21 regional healthcare systems in Italy's decentralized, universal system, complete with provisions to require additional evidence collection and centrally monitor diffusion. Though devised for Italy, the design, resources and underlying analysis provide a framework for other nations seeking to consolidate HTA initiatives, particularly in light of new EU regulation.

Arterial Intimal Fibrosis in Reperfusion Biopsy Correlates with Graft Function after Kidney Transplant

INTRODUCTION

Alterations to the procurement biopsy are one of the main reasons that kidneys are not suitable for transplant and are discarded. The literature on procurement and reperfusion biopsy is inconsistent and heterogeneous. The objective of this study is to describe the correlation of the different histological characteristics detected by the procurement and reperfusion biopsies in relation to graft function.

METHODS

This is a retrospective cohort study of deceased donor kidney transplants performed from 2013 to 2017. All of the different histological components of procurement and reperfusion biopsies were analyzed with nonparametric tests and multivariate regressions. Graft function was expressed as glomerular filtration rate (GFR) at 1, 3, 6, and 12 months after transplant. All tests were based on a level of significance of α = 0.05.

RESULTS

A comparison of procurement and reperfusion biopsies revealed that 60.4% of the grafts exhibited more arterial intimal fibrosis and 55.6% more arteriolar hyalinosis in the reperfusion biopsy than in the procurement biopsy. Arterial intimal fibrosis in reperfusion biopsy correlated with GFR at all time points, and it was the only histological characteristic of the reperfusion biopsy that remained significant in multivariate analysis. Glomerulosclerosis in the procurement biopsy correlated with graft function and remained significant in multivariate analysis, but only at 6 months. Arterial intimal fibrosis in the reperfusion biopsy is significantly associated with graft function independently of clinical characteristics.

CONCLUSION

Our study highlights the importance of arterial intimal fibrosis in predicting kidney function after transplant. Because arterial intimal fibrosis is a chronic change not related to ischemia-reperfusion injury, the differences between the 2 biopsies may be due to the biopsy technique. In order to increase the prognostic accuracy of the procurement biopsy, the technique should be improved to better evaluate the vasculature.

Modes of coordination for health technology adoption: Health Technology Assessment agencies and Group Procurement Organizations in a polycentric regulatory regime

The challenge of novel and high cost health technologies has encouraged the growth of regulatory agencies such as Health Technology Assessment (HTA) organizations and Group Procurement Organizations (GPO). Yet the existence of several agencies in the same polycentric regulatory regime raises questions about whether and how their work can be coordinated. Drawing on a case study of GPOs and HTA agencies across four provinces in Canada, involving document review and key informant interviews (n = 44) conducted between 2013 and 2016, we explore the separate evolution of these agencies, emerging connections between them for non-drug technologies, and the organizational processes and evaluative judgments that underpin coordination efforts. HTA agencies and GPOs developed separately; connections emerged recently in three provinces and suggest four modes of coordination. One mode aligns most closely with that recommended by health economists and HTA practitioners, whereby HTA precedes procurement, with coverage decisions informing technology acquisition. The second mode is a version of the first, where procurement refers cases to HTA for coverage or technology management support; unlike the first, it recognizes procurement's evaluative strengths. Yet both the first and second modes focus on exceptional cases and will be infrequent. The third mode is more systemic, reflecting a generalized complementary of purpose as public agencies. HTA could support GPOs in contested technology acquisition efforts through timely and responsive input, while procurement could expand HTA's impact and inform HTA's growing interest in responsible innovation and environmental sustainability. The final mode is non-coordination, reflecting the potential for agencies to occupy quite distinct regulatory niches within the same regime. We conclude that consistency and convergence around a single model of resource allocation is not inevitable; nor is it necessary for coordinated effort. Thus, where differences in regulatory practice and epistemology persist, mutual accommodation and shared learning may prove most productive.

Benchmarking the Vendor Qualification Process

The vendor qualification assessment (VQA) process is regarded as expensive and time consuming but there is no quantitative data characterizing and benchmarking this process. The Tufts Center for the Study of Drug Development (Tufts CSDD)-in collaboration with the Avoca Group and 13 pharmaceutical, biotechnology and contract research organizations-conducted a survey of 120 unique companies to gather baseline data. The study results confirm that companies are investing substantial time and resources to support a high and growing volume of vendor qualifications and re-qualifications each year. The average total time to perform a vendor qualification is almost 5 months for single service providers and nearly 7 months for multi-service providers with wide variation within and between companies observed. Re-qualification cycle times are only marginally faster although, in theory, experience and familiarity with a given vendor should replace some assessment requirements. Significant differences were observed by company size and type. A high percentage of assessments-most notably those conducted by large companies-involve customized assessment areas. CROs are able to perform the VQA process significantly faster with fewer personnel. Based on the data provided, Tufts CSDD estimates that global drug developers spent about $375 million to perform approximately 25,000 new vendor qualifications and re-qualifications in 2018.

Purchasing medical devices: The role of buyer competence and discretion

This paper investigates the price variability of standardized medical devices purchased by Italian Public Buyers (PBs). A semiparametric approach is used to recover the marginal cost of each device. Average prices vary substantially between PBs; we show that most of the difference between the purchase prices and estimated costs is associated with a PB fixed effect, which, in turn, is related to the institutional characteristics and size of the PB. Repeating the main estimation using device fixed effects yields similar results. Finally, an exogenous policy change, i.e. the termination of the mandatory reference price regime, is used to assess how discretion affects medical device procurement given the skills of each PB. Our results show that less PB discretion - i.e. when mandatory reference prices apply - determines efficiency gains and losses for low- and high-skilled PBs, respectively.

Exploring the need for and application of human factors and ergonomics in ambulance design: Overcoming the barriers with technical standards

Ergonomic risk factors, such as excessive physical effort, awkward postures or repetitive movements, were the leading causes of injuries amongst EMS workers in the United States, of which 90% were attributed to lifting, carrying, or transferring a patient and/or equipment. Although the essential tasks of patient handling, transport, and care cannot be eliminated, the design of ambulances and associated equipment is modifiable. Our aims were to identify the extent of Human Factors and Ergonomic (HFE) considerations in existing ambulance design standards/regulations, and describe how HFE and the standards/regulations were applied in the EMS system. Through an extensive environmental scan of jurisdictionally relevant standards/regulations and key informant interviews, our findings demonstrated that existing standards/regulations had limited considerations for HFE. As a result, HFE principles continue to be considered reactively through retrofit rather than proactively in upstream design. We recommend that performance-based HFE requirements be integrated directly into ambulance design standards.

The Urgent Need for Transparent and Accountable Procurement of Medicine and Medical Supplies in Times of COVID-19 Pandemic

The COVID-19 pandemic has unleashed unprecedented and complex public policy issues. One that has emerged as a challenge for many countries globally is how to ensure the efficient and effective procurement of quality medical supplies. Existing corruption pressures on procurement-everything from undue influence to the outright bribery of public officials-has been amplified by the pandemic, and thus demands commensurate policy responses. We argue that transparency and accountability in procurement are essential to preventing the corruption risks that threaten the health and well-being of populations.

Biobanking for necrotizing enterocolitis: Needs and standards

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease that primarily affects premature infants. Despite medical advances, mortality and morbidity from NEC are still unacceptably high. This is partly because of the lack of specific biomarkers and therapies for this disease. Availability of high-quality biological samples and the associated data from premature infants are key to advance our understanding of NEC, and for biomarker discovery and drug development. To that end, the NEC Society Biorepository was established with the goal of promoting studies in human infants through sharing specialized biospecimen and data procurement for NEC research.

OBJECTIVE

In this review, we will discuss the required infrastructure for biobanks, discuss the importance of informatics management, and emphasize the logistical requirements for sharing specimens. Finally, we will discuss the mechanism for how tissues and material will be shared between the institutions.

CONCLUSION

We have developed a state-of-the-art biobank for human infants to advance the field of NEC research. With the NEC Society Biorepository, we seek to facilitate and accelerate the basic and translational studies on NEC to provide hope to the infants afflicted with NEC and their families.

STUDY TYPE

Review article, level V.

Digital pathology for second opinion consultation and donor assessment during organ procurement: Review of the literature and guidance for deployment in transplant practice

Telepathology has been an important application for second opinion consultation ever since the introduction of digital pathology. However, little is known regarding teleconsultation for second opinion in transplantation. There is also limited literature on telepathology during organ donor procurement, typically utilized when general pathologists on-call request back-up to help assess donor biopsies for organ suitability or to diagnose newly discovered tumors with urgent time constraints. In this review, we searched Pubmed/Embase and websites of transplant organizations to collect and analyze published evidence on teleconsultation for donor evaluation and organ procurement. Of 2725 records retrieved using the key terms 'telepathology', 'second opinion' and 'transplantation', 26 suitable studies were included. Most records were from North America and included validation studies of telepathology being used for remote frozen section interpretation of donor biopsies with whole slide imaging. The data from these published studies supports the transition towards digital teleconsultation in transplant settings where consultations among pathologists are still handled by pathologists being called on site, via telephone and/or email.

Logistics and procurement outsourcing in the healthcare sector: A comparative analysis

As outsourcing ventures become more complex, opportunities for synergies and efficiencies increase, but also create longer and more fragmented supply chains which could have disastrous consequences, particularly in a healthcare context. This study investigates the implications of outsourcing on healthcare supply chains by comparing two alternatives: outsourcing from public-to-private and outsourcing from public-to-public. A conceptual framework, adapted from previous literature, has been employed to provide a comprehensive overview of the phenomenon and consider the implications of logistics and procurement outsourcing on the healthcare supply chain structure and performance. The study presents a European cross-country comparison, analysing both the National Health Service (NHS) outsourcing in England (public-to-private outsourcing) and the Regional Health Service (RHS) outsourcing in the Tuscany region (Italy) (public-to-public outsourcing). Specificities and commonalities of the two outsourcing experiences provide suggestions for managers and policy-makers and enhance the current knowledge of outsourcing in the public healthcare sector.

Medicine shortages and challenges with the procurement process among public sector hospitals in South Africa; findings and implications

BACKGROUND

Medicine shortages are a complex global challenge affecting all countries. This includes South Africa where ongoing medicine shortages are a concern among public sector hospitals as South Africa strives for universal access to healthcare. The objectives of this research were to highlight challenges in the current pharmaceutical procurement process for public sector hospitals. Subsequently, suggest potential ways forward based on the findings as the authorities in South Africa seek to improve the procurement process.

METHOD

Qualitative in-depth interviews were conducted with 10 pharmacy managers in public sector hospitals in the Gauteng Province, South Africa. A thematic content analysis was performed, with transcripts coded by two of the authors. Coding was discussed until consensus was reached. Categories were developed and grouped into themes.

RESULTS

The 'Procurement process' emerged from the data as the overarching theme, rooted in three main themes: (i) The buy-out process that was used to procure medicines from suppliers other than the contracted ones; (ii) Suppliers not performing thereby contributing to medicine shortages in the hospitals; and (iii) Challenges such as the inaccuracy of the electronic inventory management system used in the hospitals.

CONCLUSIONS

Effective management of contracts of suppliers by the Provincial Department of Health is crucial to ensure accessibility and availability of essential medicines to all citizens of South Africa. Ongoing monitoring and support for the future use of computerised inventory management systems is important to reduce medicine shortages, and this is being followed up.

Stakeholder perspectives on the challenges surrounding management and supply of essential medicines

Background Shortages of essential medicines impact patient safety and raise the costs of medicines to consumers and governments. Ongoing medicine shortages have become a critical issue that threaten global access to medicines. Objective The aim of this study was to explore key stakeholders' perspectives on the challenges surrounding management and supply of essential medicines. Setting Western Pacific, Asia, Europe, North America, and Africa. Methods In-depth, semi-structured interviews with 47 participants were conducted across seven stakeholder groups globally. Stakeholders included government, academics, consumer groups, non-profit organisations, hospital healthcare providers, manufacturers, and wholesaler/distributors. A grounded theory approach was applied to qualitative analysis. Main outcome measure Stakeholders' perspectives on the challenges surrounding management and supply of essential medicines. Results This study showed that supporting consumer demand for a wide range of therapeutic products required increased resources and coordination. Four main themes were identified: (1) consumer demand for a wide range of individual therapeutic needs cannot be sustained by the supply chain; (2) there lacked a coordinated approach to manage medicine shortages throughout the supply chain; (3) there were gaps in communication throughout the continuum of the supply chain; and (4) both international and local disruptions contributed to vulnerabilities in the supply chain. Conclusion Prioritisation of supply, logistics, and budget decisions around essential medicines need to be clearly coordinated between stakeholders to mitigate medicine shortages. Financial structures should include resilience planning to support fair and equitable access to medicines that meet consumer needs.

Tools for Transparency in Central Government Spending

Trust in government, policy effectiveness and the governance agenda has rarely been more important than in the opening decades of the twenty first century. For that reason, we herein present centgovspend, an open source software library which provides functionality to automatically scrape and parse central government spending at the micro level. While the design ideals are internationally applicable to any future data origination pipelines, we specifically tailor it to the United Kingdom, a country which is unique not only in terms of its transparency in procurement, but also one which was subject to a parliamentary expenses scandal, years of austerity, and then a volatile political process regarding a referendum to leave the European Union. The library optionally reconciles suppliers and subsequently analyzes payments made to private entities. Our implementation results in scraping over 4.9m payments worth over £3.5tn in value. As a way of showcasing what such a dataset makes possible, we outline three prototype applications in the fields of public administration (procurement across Standard Industry Classifier), sociology (stratification across those who supply government) and network science (board interlock across suppliers) before presenting suggestions for the future direction of public procurement data origination and analysis.

Opportunities for improving access to vaccines in emerging countries through efficient and aligned registration procedures: An industry perspective

Vaccines play an essential role in preventing infectious diseases. Their registration in importing countries is often cumbersome and unpredictably lengthy, leading to delays in vaccine access for populations that need them most. This report builds on a previous publication identifying challenges for registration of vaccines in emerging countries. As a matter of social responsibility, it was judged necessary to address the challenges and offer a set of solutions for open dialogue. Based on regular exchange of information and experiences, a group of regulatory experts from the vaccine industry developed three sets of proposals for consideration by vaccine stakeholders, with a view to improving the situation, by fostering regulatory convergence, with viable options for streamlining registration procedures through reliance on other experienced regulators or international agencies. Further, it offers options for alignment of structure and contents of Common Technical Document modules and presents a harmonized template application form that could potentially be used by all countries.

We Need to Talk About Corruption in Health Systems

The health sector consistently appears prominently in surveys of perceived corruption, with considerable evidence that this has serious adverse consequences for patients. Yet this issue is far from prominent in the international health policy discourse. We identify five reasons why the health policy community has been reluctant to talk about it. These are the problem of defining corruption, the fact that some corrupt practices are actually ways of making dysfunctional systems work, the serious challenges to researching corruption, concerns that a focus on corruption is a form of victim blaming that ignores larger issues, and a lack of evidence about what works to tackle it. We propose three things that can be done to address this situation. First, seek consensus on the scale and nature of corruption. Second, decide on priorities, taking account the importance of the particular problem and the feasibility of doing something about it. Third, take a holistic view, drawing on a wide range of disciplines.

Pricing of HPV vaccines in European tender-based settings

BACKGROUND

Vaccine price is one of the most influential parameters in economic evaluations of HPV vaccination programmes. Vaccine tendering is a cost-containment method widely used by national or regional health authorities, but information on tender-based HPV vaccine prices is scarce.

METHODS

Procurement notices and awards for the HPV vaccines, published from January 2007 until January 2018, were systematically retrieved from the online platform for public procurement in Europe. Information was collected from national or regional tenders organized for publicly funded preadolescent vaccination programmes against HPV. The influence of variables on the vaccine price was estimated by means of a mixed-effects model.

FINDINGS

Prices were collected from 178 procurements announced in 15 European countries. The average price per dose for the first-generation HPV vaccines decreased from €101.8 (95% CI 91.3-114) in 2007 to €28.4 (22.6-33.5) in 2017, whereas the average dose price of the 9-valent vaccine in 2016-2017 was €49.1 (38.0-66.8). Unit prices were, respectively, €7.5 (4.4-10.6) and €34.4 (27.4-41.4) higher for the 4-valent and 9-valent vaccines than for the 2-valent vaccine. Contract volume and duration, level of procurement (region or country), per capita GDP and number of offers received had a significant effect on vaccine price.

INTERPRETATION

HPV vaccine procurement is widely used across Europe. The fourfold decrease in the average tender-based prices compared to list prices confirms the potential of tendering as an efficient cost-containment strategy, thereby expanding the indications for cost-effective HPV vaccination to previously ineligible target groups.

Hip hemiarthroplasty for fractured neck of femur; a freedom of information study to assess national variation in implant selection and procurement

INTRODUCTION

During 2016, according to the National Hip Fracture Database (NHFD), over 65,000 patients suffered a hip fracture of which approximately half underwent hemiarthroplasty. Clear guidelines exist on the usage of proven cemented implants. The Getting It Right First Time (GIRFT) Report highlighted the financial implications of 'unwarranted variation' and stressed the importance of rationalising and standardising service provision, in particular implant usage. The primary aims of this study were to investigate the variation in hip hemiarthroplasty implant usage and associated costs. We hypothesised there to be large variation in implants used and procurement costs.

METHODS

Freedom of Information Requests (FOI) were sent to all 177 hospitals listed in the 2017 NHFD Report as treating hip fracture patients. All hospitals were asked for their most commonly used hemiarthroplasty implant and the cost of this, per patient.

RESULTS

One hundred sixty six (94%) responses were received. Eighty four (51%) provided implant name and cost, 78 (47%) provided implant name but refused costs and 4 (3%) refused to provide any details. Nineteen different prostheses were used nationally with 20 hospitals using a non-ODEP (Orthopaedic Data Evaluation Panel) 10A implant. Average total cost was £725.00 (range £71-£1378). Significant cost variation was demonstrated for the same implants; one implant was £978.19 at it's most costly and £285.59 at it's cheapest.

DISCUSSION

The aims of this study have been met. We have demonstrated huge variation in the implants used for hip hemiarthroplasty and their costs. Notwithstanding the nuances of departmental procurement processes, the financial implications for this variation are significant.

CONCLUSIONS

This article demonstrates a requirement for rationalisation of implant usage and procurement in order to potentially improve patient outcomes and provide opportunities for significant cost saving in an already overstretched health service.

Procurement and Storage of Surgical Biospecimens

A biobank is an important nexus between clinical and research aspects of pathology. The collection and storage of high quality surgical samples is essential for diagnosis post-surgery, and can also be used to create vaccines, identify therapeutic targets or establish eligibility of cancer patients in a clinical trial. Therefore, personnel handling surgical tissues should follow standard operating procedures (SOP) to maximize efficiency and preserve tissue quality. This chapter is intended to familiarize novice biobank personnel with the issues associated with different steps of surgical tissue collection including patient consent, sample collection, tissue storage, quality control, and distribution.

Procurement, Storage, and Use of Blood in Biobanks

Blood is a widely used biospecimen in the field of biobanking, secondary to the ease with which it is collected along with the wide variety of analytes obtained from it for analysis. It carries the potential to further the search for biomarkers in countless diseases; therefore, the standardization and optimization of blood collection procedures is of importance in assuring reproducibility of results. Here, we briefly review procedures for the procurement, storage, and use of blood and its fractions for biobanking purposes. Select commonly used methods for collecting blood with various vacutainer blood collection tubes are described, along with optimal storage conditions of various samples in short- and long-term situations.

Vaccines, inspiring innovation in health

This report covers the topics of pandemics, epidemics and partnerships, including regulatory convergence initiatives, new technologies and novel vaccines, discussed by leading public and private sector stakeholders at the 18th Annual General Meeting (AGM) of the Developing Countries Vaccine Manufacturers' Network (DCVMN). Contributions of Gavi and the vaccine industry from emerging countries to the growing global vaccine market, by improving the supply base from manufacturers in developing countries and contributing to 58% of doses, were highlighted. The Coalition for Epidemic Preparedness Innovations (CEPI), the International Vaccine Institute (IVI) and others reported on new strategies to ensure speedy progress in preclinical and clinical development of innovative vaccines for future MERS, Zika or other outbreak response. Priorities for vaccine stockpiling, to assure readiness during emergencies and to prevent outbreaks due to re-emerging diseases such as yellow fever, cholera and poliomyelitis, were outlined. The role of partnerships in improving global vaccine access, procurement and immunization coverage, and shared concerns were reviewed. The World Health Organization (WHO) and other international collaborating partners provided updates on the Product, Price and Procurement database, the prequalification of vaccines, the control of neglected tropical diseases, particularly the new rabies elimination initiative, and regulatory convergence proposals to accelerate vaccine registration in developing countries. Updates on supply chain innovations and novel vaccine platforms were presented. The discussions enabled members and partners to reflect on efficiency of research & development, supply chain tools and trends in packaging technologies improving delivery of existing vaccines, and allowing a deeper understanding of the current public-health objectives, industry financing, and global policies, required to ensure optimal investments, alignment and stability of vaccine supply in developing countries.

The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania

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Prompt post-exposure vaccination is extremely effective in preventing human rabies.

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Intradermal post-exposure vaccination is easily adopted by health workers in Tanzania.

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High costs of PEP to government affect the supply chain and limit its availability.

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Limited PEP supply results in higher out-of-pocket payments and increased risks.

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Investment to facilitate free PEP provision would reduce rabies deaths.

Background

Rabies is preventable through prompt administration of post-exposure prophylaxis (PEP) to exposed persons, but PEP access is limited in many rabies-endemic countries. We investigated how access to PEP can be improved to better prevent human rabies.

Methods

Using data from different settings in Tanzania, including contact tracing (2,367 probable rabies exposures identified) and large-scale mobile phone-based surveillance (24,999 patient records), we estimated the incidence of rabies exposures and bite-injuries, and examined health seeking and health outcomes in relation to PEP access. We used surveys and qualitative interviews with stakeholders within the health system to further characterise PEP supply and triangulate these findings.

Results

Incidence of bite-injury patients was related to dog population sizes, with higher incidence in districts with lower human:dog ratios and urban centres. A substantial percentage (25%) of probable rabies exposures did not seek care due to costs and limited appreciation of risk. Upon seeking care a further 15% of probable rabies exposed persons did not obtain PEP due to shortages, cost barriers or misadvice. Of those that initiated PEP, 46% did not complete the course. If no PEP was administered, the risk of developing rabies following a probable rabies exposure was high (0.165), with bites to the head carrying most risk. Decentralized and free PEP increased the probability that patients received PEP and reduced delays in initiating PEP. No major difficulties were encountered by health workers whilst switching to dose-sparing ID administration of PEP. Health infrastructure also includes sufficient cold chain capacity to support improved PEP provision. However, high costs to governments and patients currently limits the supply chain and PEP access. The cost barrier was exacerbated by decentralization of budgets, with priority given to purchase of cheaper medicines for other conditions. Reactive procurement resulted in limited and unresponsive PEP supply, increasing costs and risks to bite victims.

Conclusion

PEP access could be improved and rabies deaths reduced through ring-fenced procurement, switching to dose-sparing ID regimens and free provision of PEP.

Replacement costs of cold storage equipment for medical products of public healthcare establishments of European Union countries

This study presents a quantification of the financial needs to maintain the stock of cold equipment for the preservation of medical products in public health care establishments of European Union (EU) countries. The conditions that must be guaranteed, the types of equipment used, the installed capacity, the total annual financial needs and the estimate of its evolution in the near future are addressed. A field survey involving Portuguese establishments of various types and dimensions was performed in order to assess the currently installed volume by type of equipment. Through an analysis based on possible scenarios and using a methodology considered adequate, the financial needs to maintain such equipment in operation was estimated for Portugal, for each EU country and for the EU as a whole. The economic value of these amounts in 2017 and following years was obtained assuming the average price of each type of equipment and considering an expected evolution of its value.

The rise of inventory management in operating theatre departments

The procurement and inventory management challenges within our healthcare sector have been the subject of debate for some time, but with new government initiatives recently introduced, procurement and inventory management have become the new areas of focus behind muchneeded change within the NHS back-office.

Using process net-map to analyse governance challenges: A case study of livestock vaccination campaigns in Zambia

The outbreak of livestock diseases in Sub-Saharan African countries is the most critical challenge affecting the development potential of the livestock sector. Vaccination campaigns are one of the most important strategies to deal with this challenge. However, such campaigns are difficult to implement due to major governance challenges, such as delays in the procurement of vaccines and the disbursement of funds. This paper presents an in-depth analysis of these governance challenges, based on a case study of a Livestock Development Animal Health Project in Zambia. The goal was to examine in detail why these problems occur and how they are linked to the implementation procedure. A novel qualitative research tool called Process Net-Map, which is a visual participatory mapping technique was applied. The tool made it possible to develop an understanding of the exact implementation mechanism and to identify the different actors involved, including government officials, private sector companies, and farmers. The study revealed that the complex design of the procurement procedure, the limited capacity of the procuring entity, and a lack of urgency among the actors involved, resulted in the procurement delays. The findings also indicate that the delay in the release of funds arises because of a diversion of funds. Some strategies to improve the efficiency of the procurement process were identified, such as increasing the sense of urgency, building staff capacity, using e-procurement and entering into framework contracts with suppliers. Building sustainable financial capacity in the overall management of public funds seems essential to deal with the challenge of fund diversion. Use of Citizen Report Cards and lobbying political decision markers are some of the mechanisms that farmers can employ to increase their capacity to hold the animal health service providers accountable and demand better services. The problems identified are not only relevant for vaccination programs but are general implementation challenges encountered in developmental programs that involve the distribution of publicly procured inputs.

Acquisition and Reception of Primary Tissues, Cells, or Other Biological Specimens

The use and banking of biological material for research or clinical application is a well-established practice. The material can be of human or non-human origin. The processes involved in this type of activity, from the sourcing to receipt of materials, require adherence to a set of best practice principles that assure the ethical and legal procurement, traceability, and quality of materials.

Rethinking health sector procurement as developmental linkages in East Africa

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012-15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa.

Structure-Based Virtual Screening of Commercially Available Compound Libraries

Virtual screening (VS) is an efficient hit-finding tool. Its distinctive strength is that it allows one to screen compound libraries that are not available in the lab. Moreover, structure-based (SB) VS also enables an understanding of how the hit compounds bind the protein target, thus laying ground work for the rational hit-to-lead progression. SBVS requires a very limited experimental effort and is particularly well suited for academic labs and small biotech companies that, unlike pharmaceutical companies, do not have physical access to quality small-molecule libraries. Here, we describe SBVS of commercial compound libraries for Mer kinase inhibitors. The screening protocol relies on the docking algorithm Glide complemented by a post-docking filter based on structural protein-ligand interaction fingerprints (SPLIF).

All that Glitters is not Gold: Six Steps Before Selecting and Prioritizing e-Health Services

Since the market for e-health applications is constantly growing, it is getting an ever more complex endeavor to select and prioritize the right service offering given a particular situation. In examining the extant literature, it was revealed that little emphasis is actually placed on how to analyze contextual or environmental factors prior to the selection and prioritization of e-health services. With this paper, we therefore propose a formative framework consisting of six fundamental yet very pragmatic steps that may support decision makers in identifying the most important contextual pre-requisites that e-health services need to fulfill in order to be considered as effective for their environment to be implemented.

Fresh osteochondral allografts-procurement and tissue donation in Europe

Fresh osteochondral allografts are a well-established treatment for large, full-thickness cartilage defects. The clinical outcome for carefully selected patients is very favorable, especially for the young and active and graft survival up to 25 years has been described in the literature. Furthermore, a high patient satisfaction rate has been reported, but the biggest obstacle to overcome is the availability of tissue for transplantation. Large fresh bone allografts for cartilage damage repair only can be harvested from organ donors following organ removal or cadaveric donors, preferably in the setting of an operation room to minimize possible contamination of the tissue. Apart from the logistic challenges this entails, an experienced recovery team is needed. Furthermore, the public as well as medical staff is much less aware of the possibility and requirements of tissue donation than organ donation and families of deceased are rarely approached for bone and cartilage donation. This review aims to highlight the current situation of organ and tissue donation in Europe with special focus on the processing of bones and possible safety and quality concerns. We analyze what may prevent consent and what might be done to improve the situation of tissue donation.

Allografts: Osteochondral, Shell, and Paste

There is an increasing need for articular cartilage restoration procedures. Hyaline cartilage lacks intrinsic healing capacity. Persistent osteochondral defects can lead to early and rapid degenerative changes. Microfracture and autologous chondrocyte implantation provide reasonable outcomes for smaller defects without bone loss. However, these techniques have limited effectiveness for lesions greater than 4 cm² or with significant bony involvement. Ostochondral allografts provide an option for these lesions. This article reviews osteochondral allografts for articular defects. Emerging options provide different approaches to difficult cartilage defects. We discuss current screening, procurement, and storage methods, surgical techniques, outcomes, and bacterial/viral transmission.