How well does Malaysia achieve value for money in public sector purchasing of medicines? Evidence from medicines procurement prices from 2010 to 2014.

BACKGROUND: Malaysia's public healthcare sector provides a greater volume of medicines at lower overall cost compared to the private sector, indicating its importance in providing access to medicines for Malaysians. However, the Ministry of Health (MOH) has concerns about the continuous increase in the public sector medicines budget, and achieving efficiencies in medicines procurement is an important goal. The objectives of this study were to assess the overall trend in public sector pharmaceutical procurement efficiency from 2010 to 2014, and determine if the three different ways in which MOH procures medicines influence efficiency. METHODS: We matched medicines from the public sector procurement report by medicine formulation to medicines with a Management Sciences for Health (MSH) International Reference Price (IRP) for each year. Price ratios were calculated, and utilizing the information on quantity and expenditure for each product, summary measures of procurement efficiency were reported as quantity- and expenditure-weighted average price ratios (WAPRs) for each year. Utilizing MOH procurement data to obtain information on procurement type, a multiple regression analysis, controlling for factors that can influence prices, assessed whether procured efficiency (relative to IRPs) differed by MOH procurement type. RESULTS: Malaysia's public sector purchased medicines at two to three times the IRP throughout the study period. However, procurement prices were relatively stable in terms of WAPRs each year (2.2 and 3.2 in 2010 to 1.9 and 2.9 in 2014 for quantity and expenditure WAPRs, respectively). Procurement efficiency did not vary between the three different methods of MOH procurement. Procurement efficiency of both imported originators and imported generics were significantly lower (P < 0.001 and P < 0.01) than local generic products, and medicine source and category influenced the procurement efficiency of each MOH procurement mechanism. CONCLUSION: The design of different medicines procurement mechanisms, along with the balance between ensuring competitive procurement prices and adhering to national industry and procurement policies, have not been able to achieve lower public sector medicines procurement prices (relative to IRP). Introducing pooled procurement options along with continuous monitoring of procurement efficiency and exploring ways to improve price competition among local and foreign suppliers is recommended.

Trends and determinants of childhood stunting and underweight in Sri Lanka.

INTRODUCTION: Child undernutrition is a major risk factor for child mortality and adult ill-health. Despite substantial progress in most health indicators, undernutrition remains high in Sri Lanka, with recent trends being unclear, owing to methodological differences in national surveys. METHODS: This study uses data from the 1987, 1993, 2000 and 2006-07 Demographic and Health Surveys (DHS) and the 2009 Nutrition and Food Security Survey (NFSS) to investigate trends and determinants of child undernutrition in Sri Lanka. The prevalence rates of stunting, underweight and wasting were re-estimated using the 2006 WHO growth standards to ensure consistency. Multivariate regression analysis was then undertaken to analyse the determinants of height-forage in children aged 9-23 months, and 24-59 months, and the relative impact of key factors was assessed using prediction models. RESULTS: Stunting and wasting substantially improved from 1987 to 2000, but rates stagnated from 2000 to 2006/07. Whilst economic inequalities in under nutrition were greater than in most other countries, the multivariate analysis found that maternal height, household wealth, length of breast-feeding and altitude are significant determinants of stunting, but differences in child feeding practices and other factors were not. Of these, maternal height and household wealth had the most influence. CONCLUSION: The results are consistent with the finding that food insecurity is the main driver of undernutrition, but more research is required to validate this. The strong relationship of child height with maternal height suggests that epigenetic factors, proxied by short maternal height, constrain the applicability of the WHO growth standards in Sri Lanka.

Trends, inequalities and determinants of low birth weight in Sri Lanka.

INTRODUCTION: This study analyses the DHS 1993, 2000 and 2006-07 and NFSS 2009 survey data to investigate trends, inequalities and determinants of low birth weight (LBW) in Sri Lanka. METHODS: We re-evaluated recent trends in LBW incidence, adjusting for changes in the coverage of DHS surveys to ensure comparability, and used multivariate logistic regression to investigate determinants. We quantified the degree of economic inequality using wealth and concentration indices, and assessed the contribution of determinants to inequality by decomposition. RESULTS: There was a continuing, but slowing decline in LBW incidence, reaching 17% during 2001/02-2006/07, whilst very low birth weight incidence declined from 0.9% to 0.6%. Concentration indices reveal persistent, large economic inequalities in LBW incidence. Maternal body mass index (BMI), height and education, altitude and Indian Tamil ethnicity were the major determinants of LBW, with supply of 'Thriposha' having no significant impact. Accounting for maternal BMI and height largely eliminates the impact of economic status, and reduces the impact of ethnicity. Decomposition analysis reveals the major contributors to the inequalities are maternal BMI (21%), height (12%) and education (14%), ethnicity (9%) and altitude (7%). CONCLUSIONS: The results imply that food insecurity mediates the association of LBW with poverty, and is the major amenable risk factor. The impact of maternal height and Indian Tamil ethnicity suggests that epigenetic mechanisms play a role, and that reductions in LBW incidence will take considerable time. There is a need to substantially improve the effectiveness of interventions to reduce LBW in coming generations.