Jordan Health Sector Reform Project
Deliverable 8
ANALYSIS OF DRUG UTILISATION IN JORDAN
AND PREDICTIONS FOR THE FUTURE
September 2004
Jordan – Health Sector Reform Project
ACKNOWLEDGEMENT
The author wishes to thank all the people who gave up their valuable time to meet with the
Consultant‟s team, Dr Salah Mawajdeh, Director General, Jordanian Food and Drug
Administration (JFDA) for his support and Dr Rania Bader (JFDA consultant) for her expert
assistance provided throughout this project.
We would also like to thank the Kinh Hussein Cancer Centre and our local expert consultants
for their support during this period.
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CONTENTS
EXECUTIVE SUMMARY 4
1. BACKGROUND 6
1.1 Introduction 6
1.2 National Drug Expenditures 7
1.3 Current Methods of Deciding on Tender Quantities 8
1.4 Joint Procurement Administration (JPA) Agencies 8
1.5 King Hussein Cancer Center (KHCC) 10
2. IMPROVING EFFECTIVENESS OF DRUG NEED FORECASTING 11
2.1 Purchasing according to an essential drugs list 11
2.2 ABC/VEN Applications 11
2.3 Estimating Need 12
3. DATA ISSUES 14
3.1 Data Weaknesses 14
3.2 Mortality and Morbidity Data 16
4. ANALYSIS OF AVAILABLE DATA 17
4.1 Drug Import Statistics 18
4.2 JUH Tender Data 18
4.3 Drug Quantity Estimate Prediction 19
5. REGISTRATION AND PRICING TO CONTROL DRUG EXPENDITURES 26
5.1 Registration 26
5.2 Procurement 26
5.3 Pricing 28
6. NEW METHOD OF GOVERNMENT DRUGS FUNDING 30
APPENDIX 33
JUH TENDER QUANTITIES FOR 2002 AND 2003 33
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Executive Summary
The aim of this report which addresses forecasting issues related to the procurement of
public sector funded drugs, is to identify the key issues which, when addressed
appropriately, will yield a more accurate prediction of public sector drug utilization. Improved
forecasting of public sector drug needs will most importantly provide the basis for improved
drug supply to public patients so that the right drugs are available in the various government
clinics and dispensaries when needed. It should be noted however, that any analysis of the
utilization of drugs in Jordan is complicated by the lack of appropriately classified national
level data that details the expenditure and the use of drugs in the country.
It has been stated elsewhere in the Project that main strategic objectives of a national
pharmaceutical procurement should be to:
1. Procure the most cost-effective drugs in the right quantities.
2. Select reliable suppliers of high-quality products.
3. Ensure timely delivery.
4. Achieve the lowest possible total cost.
The discussion of the issues concerning drug procurement practices, the forecasting of
utilization and the ensuing recommendations are aimed at achieving these basic objectives.
A review of the broad national drug expenditure statistics reveals that the national per capita
expenditure on drugs has been very stable and although the government is likely to be
funding reducing quantities of drugs and the burden for the funding of drugs is shifting to
private consumers.
It is observed that the current government drug procurement processes are protracted and
consume a level of administrative resources that is not in keeping with the outcomes that are
delivered. The system tends to promote the continuance and sometimes exacerbate the
shortcomings. The advent of the Joint Procurement Agency (JPA) however offers
opportunities for reviewing the present system and provide a new framework for effectively
evaluating actual drug requirements of the population.
An important approach that should be used to improve the drugs procurement and
forecasting model is to utilise the Essential Drugs List (EDL) which should be the basis for
the selection of drugs for government procurement. It is recommended that steps are taken
to update the existing EDL which should be configured so that drugs are listed generically to.
An EDL which is based on generic names and which is used to select drugs for procurement
will provide benefits by limiting the numbers of brands purchased. The decrease in brands
purchased will serve to increase volumes of orders of the cheapest drugs in individual
therapeutic classes. The larger volumes purchased will improve competition and the
effectiveness of the supply processes.
When there is a need to impose budget discipline, procurement rationing decisions should be
based on established and agreed to criteria which involves clinicians. Rationing decision
making should be based on techniques such as VEN and ABC analyses is to establish drug
procurement priorities. The role of the clinicians is to make appropriate judgments in the
context of maximizing the effectiveness of limited health sector resources which can be
reinforced by them being given responsibility to manage their own finite drug budgets.
Accurate forecasting and effective procurement decision making require good data which is
currently not available in Jordan. To develop the data holding for drug procurement decision
making, improvements should be made to the quality and breadth of the historical and
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epidemiological data. If historical data is to be used for procurement decision making it
should: be corrected for stock-outs when they occur – prescribing not dispensing information
should be collected; take account of remaining stocks in regional stores and care provider
facilities; and adjusted to improved prescribing practices that take account of rational drug
use.
Methodologies for forecasting drug utilization should make use epidemiological data to
analyse the burden of disease in Jordan. Improved data collection systems should gather
demographic and epidemiological data which will identify major diseases, assist in identifying
health sector priorities and consequently provide guidance for drug utilization forecasts. The
design of better health data collection systems should begin with a health information
strategy which should chart both short term and long term measures to improve the quality
and quantity of data collected. Strategic initiatives should comprise the design of operational
level electronic data collection systems in both the care provider-prescriber environment and
the pharmacy dispensing environment.
The Consultant designed a simple methodology for the estimation of the drug procurement
needs using historical data and can be used once there is confidence that the data is
reliable. The methodology forecast the requirements for the following year and comprises
the following six basic steps:
i) Take quantity actually used in 2003 (considered as the base year).
ii) Determine monthly use by dividing by the number of months that the item was in
stock.
iii) Multiply by 6 to determine estimated usage for remainder of 2004 (if the
estimation is being done in mid year six months will be left).
iv) Subtract iii) from current stock level to determine stock remaining at end of 2004.
v) Multiply ii) by 14 to obtain an annual estimate (this factor includes a two month
“safety or buffer stock”).
vi) Subtract iv) from v) and this quantity is the estimated order quantity for 2005.
The use of the following approach should be used only if there is a good understanding of
data quality issues. For example;
the figures must be adjusted for drug stocks which may be in the supply “pipeline”
and stock outs when there is no record kept of unmet demand in government
pharmacies;
quantities in stock should be adjusted for possible short-dating;
full data sets are required for all strengths; and
data should be adjusted periodically for demographic changes and changes in the
burden of disease.
It would appear that problems with drug registration can occasionally impact on the drug
procurement processes. It is noted that on some occasions drugs are procured before they
are registered for use by the MOH and special dispensation is required for that to happen. It
is important that all drugs that are included on the EDL and are proposed to be used in the
public setting should be registered in order that procurement can be effectively facilitated.
The drug registration processes should be able to provide a fast track arrangement for those
drugs:
that offer substantial savings to the Government;
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for which there is a recognised clinical need and where there is no reasonable
alternative available; and
that are registered in countries recognised for their high standards of GMP and
registration process.
Simplifying procurement processes will also have a positive impact on the system‟s ability to
more successfully forecast future drug requirements. The points below describe the key
areas where efficiencies can be achieved and include:
A revision to the drug committee structure to require a more evidence-based
approach to drug selection for procurement;
A rationalisation of the drug requirements – that is, reduce the chemical entities in
each therapeutic group – e.g. two ACE inhibitors, two proton pump inhibitors;
More frequent deliveries of drugs - rather than annual deliveries; and
Improvements in stock control and documenting utilisation.
Improved approaches to pricing are required to obtain better value for money from the tender
process. There are a number of areas where savings could be achieved by negotiating
cheaper drug prices. The main opportunities in savings are as follows:
select strengths that provide the best value for money and seek prices for other
strengths in relation to these;
tender on the basis of therapeutic sub-groups with the lowest price being selected
where products are clinically similar;
use prices negotiated by the JFDA as the ceiling price for products, especially those
where there are no alternative brands; and
tender internationally to obtain offers from international manufacturers and suppliers
to improve competition.
A number of the problems experienced in Jordan in supplying the entitled population with
government subsidized drugs stems for the nature of the system where the national drug
needs are procured and distributed by the public sector. As these issues are largely
systemic, consideration should be given to changing the method through which government
funded outpatient drugs are supplied to the eligible population. The alternative approach
would replace the current government driven procurement processes by a system in which
drugs are supplied by community pharmacies and their cost is reimbursed by the
Government according to predetermined schedules.
1. BACKGROUND
1.1 Introduction
The aim of this report which addresses forecasting issues related to the procurement of
public sector funded drugs is to identify the key issues which, when dealt with, will yield a
more accurate prediction of public sector drug utilization. Improved forecasting of public
sector drug needs will most importantly provide the basis for enhanced drug supply to public
patients so that the right drugs are available in the various government clinics and
dispensaries when needed. Secondly, drug utilization forecasting is fundamental if informed
decisions are to be made about the size of the government drugs budget and how the budget
is to be allocated.
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The contents of this report which reflects the work undertaken as part of the other project
deliverables related to utilization, procurement and data. It covers these issues in the context
of improving the drug supply system efficiency and effectiveness. It should be noted
however, that as stated in other project reports, the estimation of the utilization of drugs in
Jordan is complicated by the lack of appropriately classified national level data that details
the expenditure and the use of drugs in the country.
1.2 National Drug Expenditures
The Jordan National Health Accounts Study (2000) reported that in 1998 the total
expenditure on drugs was some JD159 million. Drug expenditure comprised some one-third
of total public and private health expenditure of JD454 million which is a relatively high 9.12%
of GDP. According to MOH data, the government expenditure on drugs as a proportion of
total drug expenditure in Jordan is relatively small, ranging from between 19% in 1996 and
17% in 2003. Another way of putting is that over 80% of the cost of drugs purchased in
Jordan by the public are funded through out of pocket payments.
Table 1: Jordan drug expenditure statistics
1996 1997 1998 1999 2000 2001 2002 2003
Jordan Population 4,440,000 4,600,000 4,756,000 4,900,000 5,039,000 5,182,000 5,300,000 5,480,000
MOH 14,070,000 NA 21,102,000 NA NA 23,232,303 20,696,776 21,588,457
KAH 0 0 0 0 0 1,207,162 1,191,770 1,261,491
RMS 6,862,294 6,840,270 7,086,000 8,013,270 8,366,300 8,360,150 12,130,287 10,096,693
JUH 3,460,706 5,536,501 373,450 4,162,607 4,356,905 2,831,975 3,239,039 2,537,706
Total public sector
24,393,000 NA 28,561,450 NA NA 35,631,590 37,257,872 35,484,347
expenditure on drugs
Per capita public sector drug
5.49 NA 6.01 NA NA 6.88 7.03 6.48
expenditure
Total MOH budget NA NA 91,093,000 101,393,000 110,000,000 114,270,000 117,760,000 NA
MOH drug expenditure as a
NA NA 23.17% NA NA 20.33% 17.58% NA
% of total MOH budget
Total public and private
128,345,136 138,239,786 157,365,302 165,126,703 160,175,934 184,630,938 191,483,382 211,007,592
expenditure on drugs
Per capita total drug
28.17 30.34 33.1 33.7 31.8 35.63 35.63 38.51
expenditure
Government drug
expenditure as % of total drug 19.01% NA 18.15% NA NA 19.30% 19.46% 16.82%
expenditure
Sources: Data from MOH Drugs Directorate Annual Report, Jordan National Health Accounts and Health
Utilisation and Expenditure Survey 2000
According to the data available to the Consultant, there appears to have been relatively low
growth in per capita government expenditure on drugs over the recent eight year period. As
documented in Table 1 below, the per capita expenditure on drugs (in current JDs) increased
from JD5.49 in 1996 to JD6.48 in 2003 which is a controlled 18% increase in current JDs
over the eight year period (growth of 2% per annum). Since little data is available on the
quantities of drugs purchased during the period however, it is difficult to ascertain whether
the budget control measures have impacted on the government‟s ability to satisfactory meet
the drug therapy needs of the eligible population.
Another point of interest which arises from Table 1 is that MOH drug expenditure as a
percentage of the total MOH budget actually decreased, from 23.2% in 1998 to 17.6% in
2002. This behaviour is against world trends which see drugs budgets being an increasing
proportion of health expenditure.
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Although it is difficult to draw conclusions from the above figures with any confidence,
indications are that, if the above data are correct, the government may be funding reducing
quantities of drugs on a per capita population basis, and that the burden for the purchasing of
drugs is shifting to private consumers through out-of-pocket payments.
1.3 Current Methods of Deciding on Tender Quantities
The main drug procurement agencies, namely the Ministry of Health (MoH), the Royal
Military Service (RMS) and the Jordan University Hospital (JUH) have developed similar
approaches in attempting to determine the drug requirements for future tenders. In general,
they start out with the quantities ordered in the most recent year and then increase the
amount by a percentage according to an inflator which is decided independently by the
various agencies.
Some agencies monitor drug utilization trends better than others and their estimates of
tender quantities therefore, are based on a more accurate methodology which factors in
anticipated changes in drug use. Generally, it would appear that hospitals have better
systems for monitoring drug use than outpatient clinics. In JUH for example, the drugs needs
estimates include the consideration of the new clinical procedures being introduced in the
hospital. Physician input is also sought regarding changes in treatment protocols or best
practice guidelines that may impact on pharmaceutical requirement for the following year.
Once the agencies determine their prospective drugs needs for both inpatient and outpatient
care, the estimates are costed and submissions for tender budgets are made to the Ministry
of Finance. In all likelihood the response from the MOF will be to trim the requested amounts
and negotiation then takes place between the parties to identify how the savings can be
made.
Once the total budgets are approved by the MOF, consultations take place on how the funds
are apportioned among the providers. Whilst the discussions are essentially based on clinical
merit, inevitably, the negotiating ability and standing of the negotiators can influence the
outcome of the allocation.
1.4 Joint Procurement Administration (JPA) Agencies
Publicly insured patients and many uninsured patients obtain their medical supplies through
Government clinics and hospitals. The majority of drugs provided to public patients are
acquired through tenders. Currently each of the main agencies, the Ministry of Health
(MoH), the Royal Military Service (RMS) and the Jordan University Hospital (JUH) raise their
own tenders although this is due to change due to the recent advent of the Joint
Procurement Agency (JPA).
The fragmented procurement system exhibited inefficiencies and duplication in
pharmaceutical procurement and supply management. The processes were fairly complex
and time consuming and are described below as applied by the various agencies.
1.4.1 Jordan University Hospital
At the JUH the characteristics of the process used for its annual tenders is as follows:
The total time period commencing with the estimation of the drug needs until the
tendered drugs are received, is almost 12 months.
The process commences by listing all the drugs and quantities used over the past 12
months.
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The next step is assessing stock on hand in storage and at each pharmacy – there are
16 pharmacies at the hospital. The expected deliveries for the remainder of the current
tender period are added to the stock take.
Past utilisation (all drug categories) is studied to estimate average monthly usage, how
long the existing stock will last and how much to order for the next year.
The initial tender estimation amount will be based on the monthly usage adjusted by a
factor of about 10%.
The Drug Committee is asked to review this and provide their requirements for additional
products - new products need to be justified on the basis of clinical need and on average,
20 to 30 new drugs (chemical entities) are added to the tender list every year.
The tendency is to purchase special requirements (one off requirements or rare
diseases) on a case by case basis rather than through tender.
The central tender committee that must approve all the requirements works to a budget
which is normally based on the previous year‟s cost and usage.
If the initial tender plan works out to be higher than the amount provided for in the budget,
then the quantity for each drug is reduced proportionately.
Tenders are issued by therapeutic group and in many cases hospital pack sizes are
sought.
Even though the tenders are by therapeutic group, the doctor‟s requirements are catered
for – for example there may be a tender for PPIs but the order will be for particular
quantities of omeprazole, pantoprazole, lansoprazole etc. All these drugs do a similar job
but the tender is spread over the different chemical entities to satisfy the requirements of
individual doctors.
After the tenders are approved (a period of about 4 months is taken to get this far),
invitations are sent out and a period of 30 days is given for responses.
A technical committee studies the offers and choice is made on quantity and price – the
committee needs to justify decisions that are not based on the lowest price – for example
some members may consider certain brands to be inferior.
After the tender offers are received, the quantity requirements are reviewed to ensure
that there has been no significant shift since the initial estimate of drug needs.
Between 30% and 40% of the drugs chemical entities required by the hospital have only
one supplier because they are either in patent, small quantities are involved or tender not
sought from abroad. This implies that there is no effective competition which leads to
relatively high prices.
The assessment of tenders takes about 2 months.
Tenders need to be authorised before agreements can be made with suppliers. The
authorisation takes time depending on the level of the tender. For tenders with the value
of JD 1 million or more, approval is required from higher authorities which could take a
further 2 months.
Agreement with the suppliers is undertaken after the tenders are authorised.
1.4.2 Other JPA Agencies
A similar process to that used by the JUH is used by the MoH and the RMS. The RMS
recently went to a 2 year tender and the tender conditions provide for a variation of the
quantity by up to plus or minus 30% with the same tender price.
Both the JUH and the MoH restrict tenders to the local market – that is local companies and
the agents for the multinational companies. The RMS on the other hand, makes use of
international tenders and uses VEN analysis (discussed later) in ascertaining drug
procurement priorities.
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Large stocks of drugs are generally held by each of the agencies. Suppliers tend to make
deliveries every three to four months or in some cases, supply the annual requirements in
one delivery. Suppliers, especially importers, prefer one delivery due to the fact that each
batch of imported product needs to be inspected and for this there is a charge of JD 50.
The three agencies have an agreement in respect of exchange of stock. Where one is out of
stock of a particular item, it will seek to obtain interim supplies from one of the other agencies
until a purchase order can be filled. Where stocks are approaching time expiry, agencies will
advise each other to minimise wastage. This coordination process will be further improved by
the newly established JPA.
There is a general requirement by the agencies that the products accepted for tender are
registered in Jordan. However, both the JUH and the RMS are able to obtain approval from
the MoH to import drugs that are considered to be essential and have no reasonable
alternatives registered in the country.
Recommendation: Generally, the drug procurement systems used by the three agencies
are extended and resource consuming, and do not produce the hoped for outcomes of
accuracy and appropriateness. The systems tend to promote the continuance of any
shortcomings in drug utilization and do not offer opportunities for evaluating actual needs and
procuring according to these needs. It is recommended that with the advent of the JPA the
procurement system aims are reviewed and strategies put in place to satisfy the agreed to
objectives. Drug procurement processes should then be reviewed in relation to these
strategies and redesigned to bring about a more efficient and effective system of drug
utilization forecasting and procurement.
1.5 King Hussein Cancer Center (KHCC)
A different approach to the procurement of drugs has been adopted the King Hussein Cancer
Center (KHCC). Once a patient has been diagnosed with cancer, this centre provides all the
patient‟s medical and pharmaceutical needs (except for specialised services).
Rather than tender for its drug supplies, it has adopted the following approach:
Purchases are mainly direct from the drug stores (wholesalers) and the price paid is
generally the JFDA negotiated price at pharmacy level (includes the 19.6% wholesaler
mark-up).
Drug requirements are delivered on an as needs basis – generally monthly.
There are some partnership deals with the industry where a nominated company supplies
a particular product – especially where there is only one product selected, to meet the
hospital‟s requirements in a particular therapeutic area.
The wholesale price is set by regulation and wholesalers are not allowed to discount the
price but can provide bonuses. The procurement deals generally provide for value adding
by the supplier such as educational support to the KHCC.
KHCC has a policy that the originator brand must be purchased unless there has been
bio-equivalence established with KHCC. This rarely happens due to the expense
involved. (It would appear that, the KHCC does not trust the bio-equivalence approval
process of the JFDA). The outcome of this policy is that generics are only used if bio-
equivalence has been established by the KHCC which is something that is both time
consuming and costly for both parties.
Generally the KHCC tries to obtain products that are registered but if a drug is not
registered and it is required by the KHCC, an approval to import is sought from the MoH
(there are some 200 products in the current list in this category).
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There is an arrangement between both the MoH and the RMS about drug stocks. Stocks
can be sourced from each other and at the end of the year, a reconciliation is undertaken
for payment.
The KHCC believes it has saved a great deal in drug costs through direct procurement,
having stocks replenished as required, and rationalising the product range provided to the
hospital. An example of rationalizing the product range is reducing the number of proton
pump inhibitors procured from four to one. Savings are made as better prices can be
obtained for higher volumes of a single product and tendering with manufacturers and there
is less cost in administration and storage.
2. IMPROVING EFFECTIVENESS OF DRUG NEED FORECASTING
2.1 Purchasing according to an essential drugs list
As alluded to above, the fewer drugs that are listed for procurement and the higher the
volumes the easier it is to forecast utilization for the procurement processes.
A limited list of drugs for procurement, based on an essential drugs list or drug formulary,
defines which drugs will be regularly purchased and is one of the most effective ways to
control drug expenditure.
Procurement according to the essential drugs list (EDL) would concentrate scarce health
sector resources on the most cost-effective and affordable drugs to treat prevailing health
problems. The selection of drugs based on an EDL allows for concentrating on a limited
number of essential products.
Jordan has a National Drug Formulary and an EDL which was developed some time ago to
provide recommended therapy for the major groups of diseases encountered in Jordan, and
it would appear that it needs some updating.
Although the EDL should be the basis for the selection of drugs for government procurement,
there is little evidence that the EDL is used in the purchasing process The EDL should be
regularly updated and should list drugs generically. The generic list should be adopted in
purchasing to improve competition and simplify the current challenges faced in forecasting of
utilization for the tender process.
The EDL should be as inclusive as possible and it can be designed to cover some 95% of
the therapeutic needs in Jordan. The remaining 5% would comprise of special needs which
can be catered for by a separate procurement process. Routine procurement therefore
should then be restricted to the EDL, and monitoring processes be put in place to ensure that
doctors prescribe according to the EDL. Linked to this policy would be a system for the rapid
approval to prescribe special need non-EDL drugs for medical conditions that are out of the
ordinary.
2.2 ABC/VEN Applications
The Pareto Principle, or 80/20 rule, suggests that a relatively few contributors account for
most of the effect. In terms of pharmaceutical procurement for example, it can be used to
assist managers in identifying which areas to focus on in order to achieve the maximum
impact.
The ABC analysis uses this principle and uses three levels for analysis:
Level A items are the highest cost/highest volume items and typically account for
75% of the total value of drugs purchased or consumed.
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Level B items comprise the next group of 15%.
Level C items include the lowest 10% - low cost or low volume items.
The relative percentages in each Class can be varied at the discretion of the analyst.
ABC analyses can be used in many ways. In pharmaceutical management they can be used
to assist in purchasing decisions so that lower cost alternatives for Level A drugs can be
explored. The outcomes of the analytical work can be used for selecting alternative drugs
within a class of drug, as well as identifying where the use of a high cost items appears in
excess of the probable needs resulting from morbidity in the country.
The basis of a VEN analysis in drug management is the categorization of each drug
treatment into one of three priority statuses for example:
V - Vital, life saving drugs
E - Essential drugs that are important drugs, but not necessarily life saving
N - Non-essential drugs that are desirable on a formulary but not essential.
VEN and/or ABC analyses can be utilized in the procurement processes to identify priorities,
particularly where the available budget is not adequate for all the desired drugs to be
purchased. In such a situation priority setting would be used to ensure that the total needs of
the „V‟ drugs are purchased, together with majority of the „E‟ drugs. This would be done at
the expense of the „N‟ nominated drugs.
2.3 Estimating Need
2.3.1 Current Issues
The current processes for estimating tender drug needs are essentially ineffective. There
appears to be poor communication between the MOH procurement function and MOH
providers with respect to drug quantities that are needed. Tender quantity calculations
appear to be based on store stock levels without reference to the stocks which may remain
in the hospitals. It also appears that the government care providers order drugs largely
according to quota, even when these drugs are not needed. The result of this rather flawed
process is that necessary drugs are out of stock in some locations whilst there are excess
stocks in others.
To address this shortcoming, the MOH has designed a data collection instrument which asks
the operational levels to identify their drug requirements on a monthly basis. This is an
excellent move forward to the improved quantification of drug procurement needs based on
data received from prescribers and once these data have been accurately collected, the
challenge will be to ensure that the budget process recognizes the identified need.
In cases where budget discipline is being imposed and cuts are made to the drug quantities
requested by the care providers, there appears to be no process (except for the RMS) for
identifying the priority drugs needed for treatment. Rather, the method that is used is that
10% (if the cut is 10%) is removed from every tender item. This means that there is no
professional input into determining the choices which must be made in the rationing of
therapy.
In order to provide for professional decision making in the budgetary control process in drug
procurement, consideration should be given to the use of departmental cost centres within
care provider organizations. In this way specialist areas are provided with their own budgets
and clinicians are able to make appropriate rationing decisions in evaluating drug needs. If a
budget cut becomes necessary, the cost-centre would be responsible for deciding on its drug
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therapy need priorities. Such a procedure, which involves decision making at the operational
level, would facilitate collaboration between central administrations and prescribers in drug
procurement decision making. This collaboration would lead to the supply of drugs which is
more appropriate to the clinical needs of patients, while still satisfying budgetary constraints.
Recommendation: In applying budget discipline, procurement decisions be based on
prioritisation of needs. Rationing decision making should be based on techniques such as
VEN Analysis to establish drug procurement priorities. Also, clinicians should be involved in
the process and where appropriate, be given responsibility to manage their drug budgets.
2.3.2 Forecasting based on Historical Data
Past consumption is an acceptable way to predict and quantify future demand, providing that
the supply pipeline has been consistently full and that consumption records are reasonably
accurate. Such historical data must be adjusted in the light of known or expected changes in
morbidity patterns, seasonal factors, service levels, prescribing patterns and patient
attendance. Also, it should be appreciated that a drawback of forecasting drug consumption
based on historical data is that any existing patterns of irrational drug use will be
perpetuated.
As in many countries, Jordan has incomplete historic drug consumption data and it does not
reflect real demand because as mentioned above, the supply pipeline is not always full and
drug use has not always been rational. When historic data is inaccurate and there is a need
to improve forecasting methodology, morbidity-based consumption estimation techniques
can be used to determine likely procurement requirements. Even if historic data is more
reliable, the morbidity-based method should be used periodically to check on the rationality
of past consumption. This is done by comparing actual consumption with the estimated need
to treat common diseases based on standard treatment protocols and epidemiological data.
When funds are not available to purchase all drugs in the quantities which were estimated to
be needed, it is necessary to prioritise the procurement list to match available financial
resources. As discussed above, various techniques such as VEN (vital, essential and non
essential) Analysis, Therapeutic Category Analysis and ABC Analysis can be used to select
priorities and reduce the quantities of less cost-effective drugs. A VEN priority list should be
defined in advance of any decision related to reducing procurement.
It should be noted that a VEN analysis is used by the RMS to prioritise the procurement list in
line with the available financial resources. It is suggested that the use of the VEN analysis be
extended to the other agencies and used in the newly established Joint Procurement
Agency.
Recommendation: In quantifying tender quantities using historical data, the calculations
should be corrected for stock-outs, and adjusted for altered prescribing habits due to the
improved focus on EDL medicines. The calculation should also take account of remaining
stocks in regional stores and at care provider facilities.
2.3.3 Forecasting Based on Epidemilogical Data
Jordan is in a stage of epidemiological transition with increasing prevalence of chronic non-
communicable diseases as the population ages. This is altering patterns of drug use and
cost. The Government needs to be able to project future drug requirements for such
conditions and to predict other changes before they happen.
An alternative to the historical based method of calculating estimated drug requirements for
tender therefore, is to have accurate measures of morbidity and mortality in the country, then
to apply established treatment guidelines to these figures, which are subsequently corrected
for population growth. It is considered that this process can not be undertaken in Jordan at
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present as collection of epidemiological data is not fully developed and comprehensive
treatment guidelines are not yet available.
In order to be able to develop morbidity based projections therefore, it will be necessary to
gather demographic and epidemiological data to reach an understanding of incidence of
disease and priority health risk areas. The epidemiological needs can be mapped according
treatment guidelines in order to determine the likely pharmaceutical demand if best practice
were adopted. These projections should be moderated by results of surveys to determine
likely patient compliance and by an assessment of physician compliance with therapeutic
guidelines in order to determine the realistic pharmaceutical demand. The success of
interventions aimed at improving rational prescribing and compliance will also need to be
factored in. By closely monitoring the impact of various interventions and other variables it is
then possible to predict future pharmaceutical demand.
These issues and relationships are presented diagrammatically in Figure 1 below.
Figure 1 - Forecasting pharmaceutical need based on epidemiological data
Intervention
Baseline
Data
Pharmacy
Practice
Current
Mortality
and Prescribing
Mobidity Therapeutic Projected Practice
Actual Pricing
Guidelinbes Optimum Drug
Drug and
for Drug Patient Expenditure
Usage Procurement
Key Diseases Usage Compliance
Projected
Mortality EDL
and
Mobidity
Pharmacy
Practice
Recommendation: Steps should be taken to collect and analyse demographic and
epidemiological data with the intention of understanding the burden of disease in Jordan,
identify priority disease risk areas and apply this data to among other things, the forecasting
of drug treatment needs factoring in the expected level of RDU and compliance.
3. DATA ISSUES
3.1 Data Weaknesses
To develop a basic historically based forecast of drug utilisation three major elements
required:
list of products by chemical entity;
volume required for the products; and
cost of the products.
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There are major deficiencies is each of these areas and the required data does not appear to
be available. The major data related problem areas are described below.
There is no data on the actual usage of drugs under the tenders. The MoH data records
expenditure only and this may not relate to actual usage. Further, the MoH data records
value but not the quantities of products procured.
There appears to be no data on usage of individual products. For community use, the
only data is from IMS statistics which relate to drugs used through community pharmacy
only. The data are not publicly available and would not be provided to the Consultant by
either drug companies or IMS.
Individual Government clinics and hospitals record what drugs have been issued which
may not be what the clinicians had prescribed. For example if the doctor prescribed
penicillin but this was not available, the clinic may dispense amoxycillin if that is available
and record amoxicillin rather than penicillin If a clinic or hospital is out of stock, there is
no record made of how many requests there were for particular drugs. Where a patient
needs to get the product from a community pharmacy due to stock outs, no records are
made of the details of these referrals.
Where a clinic or hospital is out of stock of a particular product and doctors are made
aware of this, they may prescribe another product (which may or may not be appropriate)
and thus utilisation predictions will be incorrect. As an example, if the doctor is aware
that amoxicillin is out of stock but there is stock of amoxicillin with clavulanic acid (a more
potent drug) then he/she may prescribe amoxycillin with clavulanic acid when in most
instances amoxicillin would have done the job. In some cases the change in drug may be
inappropriate but doctors and pharmacists in hospitals and clinics are under pressure
from patients to prescribe something to avoid the need to go to community pharmacies.
Many consumers obtain their pharmaceutical needs direct from community pharmacies
without a prescription and no records are kept of this method of acquiring medication.
If the breadth and quality of data is to be improved systems must be introduced that gather
data from care provider institutions. The systems should permit delegated staff to accurately
record the drugs that are prescribed by doctors.
As an example of the issue, it was observed during a visit to one of the major clinics that
prescriptions that were dispensed were recorded and used for predictions for future use.
The clinic dispensed about 500 to 600 prescriptions per day (the total for 2003 being
135,000), but there were between 150 and 200 prescriptions per day (some 25% of total)
that could not be filled, and there was no recording made of these.
Also, the Consultant found that the MOH Health Insurance Department does not keep
records of the drugs that it reimburses to community pharmacies as a result of stock outs in
public facilities.
It can be concluded from the above therefore, that due data collection deficiencies, it is likely
that there is no record of what doctors are prescribing for some 25% of the instance and this
has significant consequences on the quantities being nominated for procurement by tender.
The issue of accurately collecting and storing drug utilisation data is addressed in detail in
Study 7. In summary though, it requires the introduction of a comprehensive and integrated
data entry tool which records drug utilization at the operational level and in addition to drug
import data, the system should gather information relating to the volumes of domestic sales
by local drug manufacturers.
Another approach which can be a parallel method of data collection would be to collect
pharmacists dispensing data. Not only would this information be useful for procurement
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purposes, but it would also be used for assessing drug utilization, monitoring the dispensing
of prescription drugs and providing a record to the MOH Health Insurance Directorate on the
drugs that it is funding through community pharmacy dispensing. The system would record
the prescription information and if possible collect information on the patient and prescriber
identity, the diagnosis, the drug being prescribed, and the method of payment – including any
copayment. If introduced, the system would provide the opportunity for the adoption of a
community pharmacy based, outpatient drug reimbursement system discussed in Section 6
of this report.
If an electronic pharmacy dispensing system were introduced, its roll out could be a phased
process in which participating pharmacists could be provided with incentives to adopt the
system. Even with partial adoption, the data provided by the participating sentinel
pharmacies would provide information that would improve that accuracy of forecasting
quantities for drug procurement requirements. The program currently planned in Jordan that
could be extended into a comprehensive pharmacy dispensing system is the pharmacy bar-
coding project.
3.2 Mortality and Morbidity Data
There is currently very little in the way of national mortality and morbidity data collected
within Jordan. The MOH Information Studies and Research Directorate (ISRD) has taken the
initiative to improve the process and has printed standardized Cause of Death forms and
guidelines for physicians in completing the forms. The ISRD records the information in a
database according to ICD10. This system has been operating since June 2003 and so far
3400 records have been entered.
The main source of disease information (other than reportable diseases) is from various
studies that have been undertaken and diseases where there is a patient register such as
Cancer, Tuberculosis and Thalassemia.
There has been no routine collection of encounter or disease information and this is a
particular problem at outpatient level where, unlike inpatient treatment where patient records
are kept, there appears to be little recording of patient visits.
The nature of the financing system for MOH hospitals is such that hospitals do not have
financial reasons to analyse service utilization. The motivation for collecting, coding and
analysing admission and discharge data appears to be driven by individuals within hospitals
who see the benefit of evaluating service utilization for planning purposes and comparing
their hospital‟s performance. The process is just developing and at this stage little reliable
information is available.
An example of such individual initiatives is the Al Bashir Hospital which collects ICD10
patient data is collected on discharge. The Consultant understands that the Al Bashir data
collection system is obtaining sector support and it is planned to extend this initiative to a
further 25 hospitals over the next 5 years.
The collection and analysis of health system wide diagnosis and procedures data coded to
ICD10 would require significant investments in information technology which is not planned
at this juncture. If a program were to be put in place, it would be possible to start to achieve
meaningful health planning information, by selecting sentinel hospitals and clinics.
Recommendation: A data collection strategy should be developed to improve the quality
and quantity of information available for the monitoring of drug utilization. The strategy
should comprise both short term and long term initiatives and begin with improving the
current historic drug utilization data being gathered at the operational level. Longer term
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strategic initiatives should include the improvement of epidemiological information related to
the burden of disease, the establishment of a pharmacy dispensing system and a system
which records hospitals admission and discharge data. Such systems would provide
extensive health sector MIS capability and provide important information for national health
planning and policy decision making.
4. ANALYSIS OF AVAILABLE DATA
The Consultant collected all available data that may contribute to obtaining a better
understanding of the future drug needs and assist in improving the current procurement
forecasting processes. Utilisation data that was available and which is discussed below
comprises drug import statistics for 2001, 2002 and 2003, JUH tender data for 2002 and
2003 and utilisation data for 2003 of a selected basket of 26 drugs.
Table 2: Pharmaceutical Imports for Use in Community Pharmacies
Therapeutic Class Public Price Public Price Increase Public Price Increase
2001 JD 2002 JD 2003 JD
A Alimentary Tract and Metabolism 11,895,067 14,364,513 20.76% 14,106,824 -1.79%
B Blood and Blood Forming Organs 3,056,613 3,650,956 19.44% 4,277,718 17.17%
C Cardiovascular System 9,649,613 13,573,941 40.67% 14,667,719 8.06%
D Dermatologicals 5,401,168 5,787,296 7.15% 5,461,970 -5.62%
G Genito Urinary System Sex 10,004,163 10,789,378 7.85% 10,546,663 -2.25%
Hormones
H Systemic Hormonal Preparations 1,667,926 2,465,089 47.79% 2,550,433 3.46%
J General Anti-Infectives Systemic 18,392,620 19,103,816 3.87% 22,328,624 16.88%
K Hospital Solutions 1,194,597 1,598,766 33.83% 1,365,727 -14.58%
L Cytostatics 3,621,625 7,907,796 118.35% 14,336,763 81.30%
M Musculo-Skeletal System 6,587,579 8,911,790 35.28% 8,902,818 -0.10%
N Central Nervous System 10,345,427 12,203,808 17.96% 15,227,964 24.78%
P Parasitology 432,470 264,582 -38.82% 384,918 45.48%
R Respiratory System 6,964,736 9,339,006 34.09% 10,320,197 10.51%
S Sensory Organs 3,054,486 3,422,588 12.05% 3,601,500 5.23%
T Diagnostic Agents 276,431 325,680 17.82% 518,591 59.23%
V Various 7,412,103 8,882,578 19.84% 7,547,609 -15.03%
TOTAL 99,956,624 122,591,583 22.64% 136,146,038 11.06%
Table 3: Pharmaceutical Imports for Use in Ministry of Health Tenders
Therapeutic Class Public Price Public Price Increase Public Price Increase
2001 JD 2002 JD 2003 JD
A Alimentary Tract and Metabolism 881,871 1,543,536 75.03% 1,829,329 18.52%
B Blood and Blood Forming Organs 846,297 935,241 10.51% 1,358,232 45.23%
C Cardiovascular System 675,432 940,867 39.30% 519,620 -44.77%
D Dermatologicals 478,265 312,319 -34.70% 400,138 28.12%
G Genito Urinary System Sex 485,538 145,423 -70.05% 409,351 181.49%
Hormones
H Systemic Hormonal Preparations 547,662 174,070 -68.22% 241,336 38.64%
J General Anti-Infectives Systemic 3,682,738 2,875,061 -21.93% 4,857,623 68.96%
K Hospital Solutions 514,300 288,335 -43.94% 96,486 -66.54%
L Cytostatics 1,334,703 998,579 -25.18% 2,698,034 170.19%
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M Musculo-Skeletal System 95,118 818,617 760.63% 760,770 -7.07%
N Central Nervous System 1,376,430 1,382,369 0.43% 780,795 -43.52%
P Parasitology 33,015 41,961 27.10% 0 -100.00%
R Respiratory System 686,860 494,805 -27.96% 1,006,003 103.31%
S Sensory Organs 432,509 310,573 -28.19% 302,169 -2.71%
T Diagnostic Agents 25,606 26,510 3.53% 0 -100.00%
V Various 988,678 1,010,205 2.18% 815,718 -19.25%
TOTAL 13,085,022 12,298,471 -6.01% 16,075,604 30.71%
Table 4: Pharmaceutical Imports for Use in Jordan University Hospital Tenders
Therapeutic Class Public Price Public Price Increase Public Price Increase
2001 JD 2002 JD 2003 JD
A Alimentary Tract and Metabolism 123,305 241,131 95.56% 23,770 -90.14%
B Blood and Blood Forming Organs 118,952 89,541 -24.73% 96,271 7.52%
C Cardiovascular System 300,492 211,824 -29.51% 191,444 -9.62%
D Dermatologicals 97,617 14,791 -84.85% 0 -100.00%
G Genito Urinary System Sex 35,106 43,479 23.85% 3,433 -92.10%
Hormones
H Systemic Hormonal Preparations 47,435 34,035 -28.25% 13,977 -58.93%
J General Anti-Infectives Systemic 474,011 265,041 -44.09% 183,591 -30.73%
K Hospital Solutions 91,095 91,890 0.87% 0 -100.00%
L Cytostatics 370,882 793,147 113.85% 486,794 -38.62%
M Musculo-Skeletal System 23,458 127,207 442.28% 104,280 -18.02%
N Central Nervous System 78,845 221,355 180.75% 23,185 -89.53%
P Parasitology 0 0 0
R Respiratory System 24,191 86,343 256.92% 0 -100.00%
S Sensory Organs 17,995 10,557 -41.33% 18 -99.83%
T Diagnostic Agents 17,256 16,406 -4.93% 0 -100.00%
V Various 200,148 68,795 -65.63% 23,845 -65.34%
TOTAL 2,020,788 2,315,542 14.59% 1,150,608 -50.31%
4.1 Drug Import Statistics
The tables above provide data on drug import expenditures classified according to
Therapeutic Class. Information was not available on RMS drug import costs, on the actual
quantities of the different class of drugs imported, nor the costs or quantities of locally
produced drugs consumed by the market.
As there is no data available on quantities of drugs imported, no worthwhile conclusion can
be drawn from the figures contained in the tables. Looking at the information in isolation
therefore, is not likely to provide insights into consumption trends, as the variations could
reflect factors such as price changes, the clearing of stocks, and switching to and from local
manufacturers.
4.2 JUH Tender Data
The JUH provided data on their tender quantities for 2002 and 2003 (details of the tender is
in the Appendix) and an analysis of cardiovascular drugs, anti-infective drugs and drugs used
for peptic ulcers was undertaken.
In the case of cardiovascular drugs, the main usage was in the capsules and tablets. The
following observations are made:
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The quantity for 2003 is more than double that of 2002;
There were increases in all areas but the largest was in the area of calcium channel
blockers and ACE Inhibitors; and
In 2003, two sub-groups of products were grouped together – Angiotensin II Receptor
Blockers (Candesartan and Valsartan) and Statins (Atorvastatin, Fluvastatin,
Pravastatin and Simvastatin) rather than the individual drugs – which may indicate
that it is recognised that the products are interchangeable.
For the anti-infective drugs, the main usage was in tablets and capsules, but injections made
a sizeable contribution. The data shows:
Overall quantities for 2003 were 91% higher than for 2002;
The major increase was in Amoxycillin capsules which appears to be against the
trend in the private market where most of the usage is with Amoxycillin with
Clavulanic acid (see Deliverables 3 and 4 where it indicates that the two products that
have a large contribution to total drug expenditure are Amoclan and Augmentin, both
of which are brands of Amoxycillin with Clavulanic Acid) ; and
In 2003, quantities for 1st and 2nd generation cephalosporins were sought as a group
rather than individual products – indicating that the individual products were
considered to be similar.
For the drugs used for peptic ulcerations, the data shows:
The great majority of the usage is in the capsules and tablets;
Quantities for 2003 are more than three times the quantities for 2002;
The main area of increase with the H2 Receptor Antagonists, closely followed by the
Proton Pump Inhibitors; and
In 2002, all Proton Pump Inhibitors were listed together but in 2003, Omeprazole was
separated from Lansoprazole and Rabeprozole - indicating that Omeprazole was considered
to be different, which is not supported by clinical evidence.
Generally, it proved to be very difficult to make any constructive comments on this data,
comparing only two years. While the 2003 quantities represent significant increases over the
2002 quantities, details of the number of patients treated and stock holdings at the beginning
and end of the periods are not known. It is noted however, that the MoH data which provided
information on imports, indicates a significant reduction in imports for the JUH for 2003.
Considering the JUH data therefore indicates that there must have been a substantial
increase in the utilisation of domestic products for 2003.
4.3 Drug Quantity Estimate Prediction
The analysis below is for a selected basket of drugs and is based on data supplied by each
of the four procurement agencies. The analysis estimates the annual requirement for each
agency which is presented in the last column of the respective table. A summary table was
then formulated (Table 9) to give total quantity estimate of the basket of drugs for the public
sector.
It should be noted that in this exercise it is the process rather than the final figure which is
important.
This process is summarised as:
vii) Take quantity actually used in 2003.
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viii) Determine monthly use by dividing by the number of months that the item was in
stock.
ix) Multiply by 6 to determine estimated usage for remainder of 2004 (six months
left).
x) Subtract iii) from current stock level to determine stock remaining at end of 2004.
xi) Multiply ii) by 14 to obtain an annual estimate (this factor includes a two month
“safety or buffer stock”).
xii) Subtract iv) from v) and this quantity is the estimated order quantity for 2005.
Again, the tables below are indicative only and the following assumptions should be noted if
there is the need to use the quantities for any other than illustrative purpose:
The relevant figures have not been adjusted for drug stocks which may be in the
“pipeline” as such information could not be determined with any accuracy by the
Consultant in the time available. The MOH is in the process of determining these
figures and will be in a position to undertake improved quantity prediction for 2005.
The calculations are only as accurate as the baseline information which has been
presented by the purchasing agencies.
Quantities in stock have not been adjusted for possible short-dating (and therefore
removal from calculations) as agencies stated that their contracts allow for
replacement of short-dated stock, if the dating was insufficient on receipt.
Information provided by the purchasing agencies contained some omissions. These
gaps were due to use of alternative strengths (amoxycillin 125mg/5ml susp,
hydrochlorthiazide 25mg tabs, haloperidol 2mg tabs, beclomethasone inhaler 50mcg,
metformin 500mg tabs) item not used (timolol eye drops 0.5%), item purchased
/distributed through an alternative process (zidovudine 100mg caps, vincristine 1mg
inj).
No allowance was made for population or demand increase in the calculations,
however a factor of 10% could be applied if desired.
Some drugs will be out of stock before the end of this year, and there may already be
orders outstanding. If this is the case, then this order quantity should be deducted
from the estimated quantity result.
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Table 5 MOH Basket of Drugs Quantity Data
Category Generic Name Form & Quantity Time o/s In stock Brands Est.
Strength Used 2003 2003 Quantity
Analgesic Paracetamol Tab 500mg 44,001,600 2months 39,718,900 1 48,284,300
Ibuprofen Tab 400mg 13,398,300 1month 9,056,300 1 15,304,241
Opioid Analgesic Morphine Inj 10mg/ml 4,200 - 790 1 6,210
Anaphylaxis Dexamethasone Inj 4mg/ml 118,000 3months 81,100 2 181,120
Antiepileptics Phenytoin Sodium Cap or Tab 100mg 861,900 2months - 1 1,723,800
Valproate Sodium Susp 30mg/5ml 21,000 - 10,618 2 24,382
Antibacterials Amoxycillin Susp 125mg/5ml - - - - -
Gentamicin Inj 80mg/2ml 97,800 - 11,000 1 152,000
Rifampicin Cap 300mg 104,700 2months - 1 209,400
Zidovudine (AZT) Cap 100mg - - - - -
Immunosuppressant Azathioprine Tab 50mg 301,000 3months 308,000 1 360,888
Cytotoxic Vincristine Inj 1mg - - - - -
Hormones Prednisolone Tab 5mg 2,062,700 - 3,044,500 393,332
Antiparkinsonian Levodopa/Carbidopa Tab 100mg/10mg 408,000 - - 1 680,000
Anticoagulant Warfarin Tab 1mg 5mg 472,900 6months 360,300 1 ?
Cardiovascular Atenolol Tab 50mg 3,000,000 2months 38,400 1 5,961,600
Hydrochlorthiazide Tab 25mg - - - - -
Enalapril Tab 10mg 5,295,500 3months 2,024,320 1 9,743,457
Simvastatin Tab 10mg 278,100 7months - 1 1,112,400
Scabicides Benzyl Benzoate Lotion 25% 10,000 7.5months 13,336 1 31,114
Gastrointestinal Omeprazole Cap 10mg 487,760 6months 442,996 1 1,182,870
Antidiabetic Metformin Tab 500mg (or ? 2,072,000 5months 1,372,500 1 4,547,500
850mg)
Eye Timolol Drops 0.25% - - - - -
Psychotherapeutic Haloperidol Tab 2mg - - - - -
Antiasthmatic Beclomethasone Inhaler 50mcg - - - - -
Parenteral Sodium Chloride Infusion 0.9% 500ml 163,142 7.5months 0 1 725,074
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Table 6 RMS Basket of Drugs Quantity Data
Category Generic Name Form & Quantity Time In stock Brands Est. Quantity *
Strength Used 2003 o/s
2003
Analgesic Paracetamol Tab 500mg 28,711,296 - 355,334 1 47,496,826
Ibuprofen Tab 400mg 5,857,600 - 4,937,775 1 4,824,889
Opioid Analgesic Morphine Inj 10mg/ml 15,842 - 144,84 1 11,918
Anaphylaxis Dexamethasone Inj 4mg/ml 62,790 - 35,250 1 69,397
Antiepileptics Phenytoin Sodium Cap or Tab 100mg 808,350 - 64,100 1 1,283,150
Valproate Sodium Susp 30mg/5ml 21,887 2months 8,428 1 35,341
Antibacterials Amoxycillin Susp 125mg/5ml 58,922 - 2,387 1 95,815
Gentamicin Inj 80mg/2ml 57,971 - 119,959 1 0
Rifampicin Cap 300mg 24,060 - 26,160 1 13,940
Zidovudine (AZT) Cap 100mg - - - - -
Immunosuppressant Azathioprine Tab 50mg 245,940 - 5,310 1 404,590
Cytotoxic Vincristine Inj 1mg 930 6months 745 1 2,355
Hormones Prednisolone Tab 5mg 2,089,060 - 142,910 1 3,338,855
Antiparkinsonian Levodopa/Carbidopa Tab 100mg/10mg 389,000 - 173,300 1 475,032
Anticoagulant Warfarin Tab 1mg - - - - -
Cardiovascular Atenolol Tab 50mg 2,070,154 - 118,861 1 3,231,394
Hydrochlorthiazide Tab 25mg 106,950 2months 62,170 1 151,730
Enalapril Tab 10mg - - - - -
Simvastatin Tab 10mg 2,122,510 - 1,299,297 1 2,238,207
Scabicides Benzyl Benzoate Lotion 25% 782,500 - 239,995 1 1,064,170
Gastrointestinal Omeprazole Cap 10mg 287,378 - 126,512 1 352,450
Antidiabetic Metformin Tab 500mg - - - - -
Eye Timolol Drops 0.25% 7,345 1month 1,825 1 11,528
Psychotherapeutic Haloperidol Tab 2mg - - - - -
Antiasthmatic Beclomethasone Inhaler 50mcg 22,756 - 14,059 1 29,230
Parenteral Sodium Chloride Infusion 0.9% 500ml 218,539 - 261,044 1 103,179
* Because the RMS receives two split deliveries nine months apart, this estimate would require further adjustment following receipt of the
second half of the existing contract order.
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Table 7 JUH Basket of Drugs Quantity Data
Category Generic Name Form & Quantity Time o/s In Brands Est. Quantity *
Strength Used 2003 2003 stock
Analgesic Paracetamol Tab 500mg 895200 - Y 4 1,044,400
Ibuprofen Tab 400mg 292500 3months Y 2 455,000
Opioid Analgesic Morphine Inj 10mg/ml 5930 - Y 1 41,509
Anaphylaxis Dexamethasone Inj 4mg/ml 19300 1month Y 1 24,563
Antiepileptics Phenytoin Sodium Cap or Tab 100mg 98800 3months Y 1 153,688
Valproate Sodium Susp 30mg/5ml 2300 6months Y 1 5,366
Antibacterials Amoxycillin Susp 125mg/5ml - - - - -
Gentamicin Inj 80mg/2ml 5160 1month Y 2 6,567
Rifampicin Cap 300mg 600 6months Y 1 1,400
Zidovudine (AZT) Cap 100mg - - - - -
Immunosuppressant Azathioprine Tab 50mg 91000 3months Y 1 141,555
Cytotoxic Vincristine Inj 1mg 1000 - Y 1 1,166
Hormones Prednisolone Tab 5mg 479000 - Y 2 558,833
Antiparkinsonian Levodopa/Carbidopa Tab 100mg/10mg 10600 4months Y 1 18,550
Anticoagulant Warfarin Tab 1mg 3mg 35000 2months Y 1 49,300
Cardiovascular Atenolol Tab 50mg 416000 - Y 3 485,333
Hydrochlorthiazide Tab 25mg 49000 - Y 2 57,166
Enalapril Tab 10mg 261000 7months N 2 730,800
Simvastatin Tab 10mg 631000 - Y 3 736,166
Scabicides Benzyl Benzoate Lotion 25% 127 - Y 1 148
Gastrointestinal Omeprazole Cap 10mg 290000 7months N 3 812,000
Antidiabetic Metformin Tab 500mg 1200000 3months Y 3 1,866,666
Eye Timolol Drops 0.25% 0.5% 1500 6months N 2 3,500
Psychotherapeutic Haloperidol Tab 2mg - - - - -
Antiasthmatic Beclomethasone Inhaler 50mcg - - Y 1 -
Parenteral Sodium Chloride Infusion 0.9% 93000 - Y 3 108,500
500ml
* this figure has not been corrected for amount currently in stock, as that figure was not quoted by JUH
Deliverable 8: Drug Utilisation and Predicting Need Page 23
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Table 8 JUST Basket of Drugs Quantity Data
Category Generic Name Form & Quantity Time o/s In stock Brands Est.
Strength Used 2003 2003 Quantity
Analgesic Paracetamol Tab 500mg 178,530 - 0 2 297,550
Ibuprofen Tab 400mg 40,522 - 4,872 1 62,713
Opioid Analgesic Morphine Inj 10mg/ml 1,090 - 2,030 1 0
Anaphylaxis Dexamethasone Inj 4mg/ml 2,985 - 5 2 4,969
Antiepileptics Phenytoin Sodium Cap or Tab 100mg 12,100 - 0 2 20,165
Valproate Sodium Susp 30mg/5ml - - - - -
Antibacterials Amoxycillin Susp 125mg/5ml 180 - 42 108 258
Gentamicin Inj 80mg/2ml 5,804 - 2,386 2 7,286
Rifampicin Cap 300mg 2,020 - 1,740 1 1,605
Zidovudine (AZT) Cap 100mg - - - - -
Immunosuppressant Azathioprine Tab 50mg 10,700 - 0 1 17,832
Cytotoxic Vincristine Inj 1mg 450 - 123 2 627
Hormones Prednisolone Tab 5mg 107,200 - 0 1 178,665
Antiparkinsonian Levodopa/Carbidopa Tab 100mg/10mg - - - - -
Anticoagulant Warfarin Tab 1mg - - - - -
Cardiovascular Atenolol Tab 50mg 15,400 - 0 1 25,665
Hydrochlorthiazide Tab 25mg 5,900 - 0 1 9,832
Enalapril Tab 10mg 13,275 - 0 2 22,125
Simvastatin Tab 10mg - - - - -
Scabicides Benzyl Benzoate Lotion 25% 30 - 176 1 0
Gastrointestinal Omeprazole Cap 10mg - - - - -
Antidiabetic Metformin Tab 500mg 28,600 - 1,550 1 46,115
Eye Timolol Drops 0.25% 55 - 9 1 82
Psychotherapeutic Haloperidol Tab 2mg - - - - -
Antiasthmatic Beclomethasone Inhaler 50mcg - - - - -
Parenteral Sodium Chloride Infusion 0.9% 500ml 43,679 - 795 3 72,002
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Table 9 Four Agency Basket of Drugs Total Quantity Data
Category Generic Name Form & MOH RMS JUH JUST Total Public
Strength Quantity Quantity Quantity Quantity Sector
Estimate Estimate Estimate Estimate Quantity
Estimate
Analgesic Paracetamol Tab 500mg 48,284,300 47,496,826 1,044,400 297,550 97,123,076
Ibuprofen Tab 400mg 15,304,241 4,824,889 455,000 62,713 20,646,843
Opioid Analgesic Morphine Inj 10mg/ml 6,210 11,918 41,509 0 59,637
Anaphylaxis Dexamethasone Inj 4mg/ml 181,120 69,397 24,563 4,969 280,049
Antiepileptics Phenytoin Sodium Cap or Tab 100mg 1,723,800 1,283,150 153,688 20,165 3,180,803
Valproate Sodium Susp 30mg/5ml 24,382 35,341 5,366 - 65,089
Antibacterials Amoxycillin Susp 125mg/5ml - 95,815 - 258 96,073
Gentamicin Inj 80mg/2ml 152,000 0 6,567 7,286 165,853
Rifampicin Cap 300mg 209,400 13,940 1,400 1,605 226,345
Zidovudine (AZT) Cap 100mg - - - - -
Immunosuppressant Azathioprine Tab 50mg 360,888 404,590 141,555 17,832 924,865
Cytotoxic Vincristine Inj 1mg - 2,355 1,166 627 4,148
Hormones Prednisolone Tab 5mg 393,332 3,338,855 558,833 178,665 4,469,685
Antiparkinsonian Levodopa/Carbidopa Tab 100mg/10mg 680,000 475,032 18,550 - 1,173,582
Anticoagulant Warfarin Tab 1mg ? - 49,300 - 0
Cardiovascular Atenolol Tab 50mg 5,961,600 3,231,394 485,333 25,665 9,703,992
Hydrochlorthiazide Tab 25mg - 151,730 57,166 9,832 218,728
Enalapril Tab 10mg 9,743,457 - 730,800 22,125 10,496,382
Simvastatin Tab 10mg 1,112,400 2,238,207 736,166 - 4,086,773
Scabicides Benzyl Benzoate Lotion 25% 31,114 1,064,170 148 0 1,095,432
Gastrointestinal Omeprazole Cap 10mg 1,182,870 352,450 812,000 - 2,347,320
Antidiabetic Metformin Tab 500mg 4,547,500 - 1,866,666 46,115 6,460,281
Eye Timolol Drops 0.25% - 11,528 3,500 82 15,110
Psychotherapeutic Haloperidol Tab 2mg - - - - -
Antiasthmatic Beclomethasone Inhaler 50mcg - 29,230 - - 29,230
PARENTERAL Sodium Chloride Infusion 0.9% 725,074 103,179 108,500 72,002
500ml
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The corrected total quantities for the four agencies for the basket of drugs are provided in the
final column in Table 9. For central tender estimation, the figures should be corrected to the
nearest thousand and then further corrected for population increase.
In addition to the assumptions noted above, it should be remembered that KAH is a relatively
new hospital and that patient numbers are increasing. In these circumstances therefore,
using historic data to forecast future needs will not be appropriate.
As previously stated, the tabulated quantities should be corrected for drugs which are in the
“pipeline” and for orders which may still be outstanding. This is particularly important in
relation to the RMS which receives a split contract order nine months apart.
5. REGISTRATION AND PRICING TO CONTROL DRUG EXPENDITURES
Consultant‟s research has identified a number of inefficiencies in the current system and it is
believed that significant savings can be made through some relativity simple measures.
Below is a discussion of some of these issues.
5.1 Registration
The drug registration processes are covered in other project reports. For the purpose of this
document we note that all drugs that are used either in the public setting or the private
setting should be registered so that procurement can be effectively facilitated. It is
considered important that the drug registration processes is able to provide a fast track
arrangement for those drugs that:
offer substantial savings to the tendering agency;
products for which there is a recognised clinical need and where there is no
reasonable alternative available; and
products that are registered in countries recognised for their high standards of GMP
and registration process.
The other major issue for the registration process is that it needs to be rigorous and the
results highly acceptable to the stakeholders. For this to occur, there may need to be more
resources applied to the registration functions and this, if necessary could come from higher
charges to the industry. It is most likely that the pharmaceutical industry will accept higher
charges in return for drug registration assessments that provide the required confidence to
prescribers. For example, improving the reliability of bio-equivalence studies would
advantage the local drug companies as they will be able to market their products more
effectively within Jordan.
5.2 Procurement
The procurement issues are covered in detail in Report 6. The summary below discusses the
key areas where efficiencies can be achieved. The improvements include:
A revision to the committee structure to require a more evidence-based approach to
selection;
A rationalisation of the drug requirements – that is, reduce the chemical entities in
each therapeutic group – eg two ACE inhibitors, two proton pump inhibitors;
More frequent deliveries of drugs - rather than annual deliveries; and
Improvements in the assessment of needs and stock-holding.
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For the system to work more efficiently, it is important the agencies work together under the
JPA to develop and apply a common drug tendering list and this should be based on the
essential drug list. Committees that have been established to determine what drugs should
be placed on tenders should use selection criteria that are based on the evidence available.
For this to occur, committee membership should be adjusted to include more
pharmacologists and pharmacists who would provide greater insights into drugs and the
clinical relationship.
As an example of the approach, the King Hussein Cancer Center (KHCC) has established a
strong Pharmacy and Therapeutics Committee. This Committee is comprised mainly of
clinicians and every medical department of the hospital is represented including the nursing
and pharmacy areas. In addition, the Committee is provided with support from pharmacists
to advise on drug therapies and relationships between individual drugs.
The KHCC Pharmacy and Therapeutics Committee has developed its own drug formulary
and doctors are required to restrict their prescribing to that formulary. Drug requirements for
the hospital are based on this formulary and, as a result drug tenders call for:
A reduced number of antihistamines with the number reduced from twenty to two –
one sedating and one non-sedating;
only one H2 receptor antagonist;
only one proton pump inhibitor (PPI); and
only two non-steroidal anti-inflammatory drugs.
The rationalisation of the drugs on the formulary can itself achieve considerable savings.
Limiting the range to only one or perhaps two drugs in a therapeutic sub-groups will lead to
greater competition between suppliers which can provide products at lower prices. Further,
the greater volume will make it more acceptable for suppliers to make deliveries on a more
frequent basis.
Tenders should be awarded to the lowest priced, bio-equivalent brand of a chemical entity,
or, is the case of a therapeutic sub-group, should be awarded to the lowest priced chemical
entity. The practice of splitting tenders between different brands and different chemical
entities in the same therapeutic sub-group should be discontinued if cost efficiencies are to
be maximised.
Another area where significant savings can be made is in better assessing the monthly drug
requirements and maintaining stocks of the required drugs. As discussed in Section 3.1
above, it was observed in one of the major Government clinics (and there was nothing to
indicate that this clinic was not typical) was not able to dispense about 25% of the drugs
prescribed, and had no equivalent alternatives to offer.
In cases where the drugs are not available, and patients must obtain their products through
prescriptions to community pharmacies, the cost to the Government is significantly greater.
This is because it is common for the tender price to be lower than the ex-manufacturer price,
and the community pharmacy price includes a 52% profit over and above the ex-
manufacturer price. An example of the calculation is below.
Price ex-manufacturer 100.00
Add wholesaler profit mark-up (14%) 114.00
Add wholesaler expense mark-up (4%) 119.60
Add pharmacy profit mark-up (20%) 143.52
Add pharmacy expense mark-up (6%) 152.13
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As discussed in other Project reports, the current drug procurement forecasting is caught in a
cycle which produces increasingly flawed estimates of drug needs as the ordered quantities
only take into account the drugs which were prescribed and supplied, and omit those that
were prescribed but could not be supplied.
Recommendation: The current procurement methods can be improved to achieve better
effectiveness from the drug budget in the following ways: using an evidence-based approach
to the selection of drugs for the tender list; rationalizing the drug requirements by reducing
the chemical entities purchased in each therapeutic group; increasing the frequency of drug
deliveries; and Improvements in the assessment of needs and stock-holding by improved
data collection of prescribed drugs.
5.3 Pricing
As discussed in Project Report 3, there are a number of areas where savings could be
achieved by negotiating cheaper drug prices. The main opportunities in savings are as
follows:
select strengths that provide the best value for money and seek prices for other
strengths in relation to these;
tender on the basis of therapeutic sub-groups with the lowest price being selected
where products are clinically similar;
use prices negotiated by the JFDA as the ceiling price for products, especially those
where there are no alternative brands; and
tender internationally to obtain offers from international manufacturers and suppliers
to improve competition.
Where a range of strengths of individual products are called for, the price for each strength
should be critically examined before the tender is accepted. There are a number of
instances where the price between strengths varies considerably and the purchases are not
cost effective. The following products provide examples of the differing price for unit (tablet
or capsule):
Ranitidine 150mg – 0.02098 300mg – 0.1165
Lopressor 100mg – 0.996 200mg – 0.023998
Renitec 5mg – 0.07 20mg – 0.029621
When reviewing prices, the strength that represent the most cost efficient purchase should
be used as the base for setting prices of other strengths. As a general rule, the price of a
double strength tablet should be about 150% of the price of the single strength. There will be
variations but one should not pay more than double the price.
Significant savings can also be achieved by tendering on the basis of therapeutic sub-groups
and pricing on the basis of the lowest cost supplier. Table 10 provides examples to indicate
the level of savings that could be achieved. Clinical evidence on the comparator drugs in the
table below indicates that there are of similar safety and efficacy.
The price of products supplied through tender should, as a general rule, not be greater than
the ex-manufacturer price for the same products sold through community pharmacy.
However, an examination of the tender prices revealed that this was not the case in many
instances as the tender process for some drugs may be compromised as doctors require
specific brands to be included on the procurement list. Table 11 provides examples of
products where the ex-manufacturer price is higher that the tender price
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Table 10 Comparison of Therapeutic Sub-Group Drugs
Product Group Comparator Drugs Current Tender Price Potential Savings
(30 Pack) JD per pack JD
H2 receptor Famotidine 40mg 0.4569 0
Antagonist Ranitidine 300mg 3.495 3.0381
Proton Pump Lanzor 30mg 2.250 0.57858
Inhibitors Omeprazole 20mg 1.67142 0
Losec Mups 20mg 36.75858 35.08716
ACE Inhibitors Renitec 20mg 0.88863 0
Zestrel 20mg 14.49978 13.61115
Acuitel 20mg 9.35001 8.46138
Starila 20mg 21.88929 21.000666
Psychoaneleptics Prozac 20mg 10.5 0
Cipram 20mg 19.82142 9.32142
Remeron 30mg 25.95999 15.45999
Table 11 Comparison of Ex-manufacturer Prices and Tender Prices
Product Ex-manufacturer Price JD Tender Price JD
(calculated from community
pharmacy prices)
Alprazolam tab 0.5mg x 30 1.79 2.41
Ambroxil cap 75mg x 10 2.55 2.87
Amlodipine cap 5mg x 28 6.95 15.52
Atorvastatin tab 10mg x 30 19.76 21.41
Bisoprolol Fumarate
Tab 5mg x 30 4.23 5.26
Tab 10mg x 30 7.03 9.01
Candesartan tab 8mg x 16 8.18 9.16
Carbemazepam Syruo 2% 250ml 3.84 5.02
Cefixime Suspension 100mg x 60ml 5.45 6.00
Clarithromycin tab 500mg x 14 9.38 11.93
Diclofenac Sodium amp 75mg x 5 2.28 3.53
Dydrogesterone tab 10mg x 20 3.14 5.00
Fluvastatin tab 40mg x 28 14.95 17.72
Gabapentin cap 400mg x 100 55.77 63.36
Lamotrigine tab
25mg x 30 9.95 13.17
100mg x 30 29.00 38.13
Loperamide tab 2mg x 10 0.66 0.78
Metformin tab 850mg x 30 1.76 2.17
Norethisterone tab 5mg x 20 2.07 2.32
Risperidone tab
1mg x 60 24.60 30.15
2mg x 60 46.89 56.64
Simvastatin tab 10mg x 30 9.39 17.16
Valsartin tab 80mg x 28 15.09 18.19
In order to get effective procurement prices, especially for newer products where there is no
brand competition, the prices negotiated by the JFDA should be used as a guide for the
tender prices. The JFDA Pricing Section should be able to provide a list of prices at ex-
manufacturer level to assist with this examination.
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As referred to in Report No.3, the calling of international tenders could generate additional
savings. It is understood that the Royal Medical Service follows this arrangement to some
extent. If international tenders are adopted by the new JPA, a guide as to the prices that
can be obtained are available in the International Drug Price Indicator Guide
(http://erc.msh.org/) which is published annually by Management Sciences for Health (MSH).
The MSH guide documents a range of prices from non-profit drug suppliers and
procurement agencies. The therapeutic categories used in this Guide are based on the WHO
Model List of Essential Drugs (EDL). Care needs to be taken however, when using the
prices contained in this Guide and they will have to be adjusted for the Jordan context and
the following issues need to be considered:
In the majority of cases, the prices are for large pack sizes (1,000 tablets or more);
In a number of instances the prices only apply within the countries stated, that is, the
agencies only supply the local market;
Most prices do not include insurance or freight costs;
Many newer products are not listed; and
Products would require local labeling and packaging.
Recommendation: The procurement process should take advantage of savings that can be
delivered through improved pricing approaches which would include: pricing negotiations on
the basis of strengths that provide the best value; tender on the basis of therapeutic sub-
groups with the lowest price being selected where products are clinically similar; use prices
negotiated by the JFDA as the ceiling price for products, especially those where there are no
alternative brands; and tendering internationally.
6. NEW METHOD OF GOVERNMENT DRUGS FUNDING
As described in Report 6, there are alternatives to the current system of government funding
and the method of supplying drugs to the population of Jordan. As an alternative to the
government having to plan for the bulk procurement of drugs and distributing these drugs
through the public system, government funded outpatient drugs can be supplied through
community pharmacies.
In terms of this report which addresses issues related to forecasting of utilisation for
procurement purposes, it is suggested that the private distribution of outpatient drugs can
reduces public sector administrative costs, provide improved access to the drugs by the
eligible population, minimise wastage, minimise problems with stock outs and the
consequent costly referrals to private pharmacies to have the prescriptions filled, and if
implemented effectively, could be more cost-efficient way of distributing drugs as the
Government no longer bears the supply risks which include exchange rate fluctuations.
The system where the private sector supplies government funded drugs through community
pharmacies would have the following characteristics:
Community pharmacies supply drugs under a prescription from licensed providers
and the government reimburses the pharmacist for this activity.
The drugs that are reimbursed accord with a government approved list of drugs that
fulfill the necessary cost/benefit criteria for public subsidy. The government listing
criteria should include affordability and be based on the principles of rational drug
use.
The prices of the drugs are regulated by the government. The price is set at the time
of listing for public subsidy and the evaluation of cost/benefit.
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A reliable pharmacy invoicing and payment system is instituted to ensure that the
pharmacies are paid promptly.
The reimbursement system is automated so that data can be collected on which
patient receives which drug from which pharmacy, according to a prescription from an
identified licensed provider who notes the indication for which the prescription is
given. It should be noted that such a system would generate valuable health data
which can be used for the health sector as a whole.
The data is analysed and systems are put in place to maximise professional
compliance and minimise fraud.
A co-payment system can be accommodated whereby the pharmacies collect part an
agreed co-payment from the patient and the remainder is reimbursed by the
government.
The system described above has been demonstrated to work well in other countries and
would be supported by the community pharmacies as long as they are confident of a reliable
government reimbursement regime through which they expect timely payments. The current
distributors of government funded outpatient drugs, the MOH and RMS would no longer have
the need to purchase, store and distribute large stocks of outpatient drugs and the
elimination of those functions would result in considerable administrative cost savings.
Institutionally and administratively the community pharmacy distribution system would
replace current tendering although it would require tougher negotiations with suppliers with
respect to the pricing of the drugs to be listed for reimbursement. In implementing such a
system the drug listing and pharmacy payment processes can be administered by the MOH,
possibly through the Health Insurance Directorate which role is in essence to purchase
health care efficiently.
It should be noted that at the time of drug stock-outs in government clinics, which appears to
be quite frequent, the system described above is currently being used to supply drugs.
Patients whose drug needs cannot be met by the government clinic are given prescriptions
which are filled, at some considerable additional expense, in private pharmacies. It has been
estimated that some 10% of outpatient drugs are already supplied through this method.
If the community pharmacy drug distribution system is to be adopted, measures should be
taken to ensure that patients in outlaying areas which are not serviced by private pharmacies
have access to drugs. In such cases where there are no private pharmacies, outpatient
drugs can remain to be supplied through government clinics although the administrative
process and payment systems used can be the same as those used for the private sector.
The only proposed continuing drug procurement responsibility of the government sector
therefore would be inpatient drugs and outpatient drugs, in regional areas that are not
serviced by community pharmacies.
As discussed elsewhere in this Project the four strategic objectives of a national
pharmaceutical procurement should be as follows:
1. Procure the most cost-effective drugs in the right quantities
2. Select reliable suppliers of high-quality products
3. Ensure timely delivery
4. Achieve the lowest possible total cost
It is suggested that if implemented appropriately, the community pharmacy drug distribution
system for outpatient drugs discussed above would satisfy all of the above objectives more
Deliverable 8: Drug Utilisation and Predicting Need Page 31
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efficiently than the current arrangements which are limited by their lack of responsiveness
and flexibility.
Recommendation: Consideration should be given to changing the method through which
government funded outpatient drugs are supplied to the eligible population. The current
government procurement processes can be replaced by a system by which drugs are
supplied by community pharmacies and their cost is reimbursed by the Government.
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Appendix
JUH Tender Quantities for 2002 and 2003
CARDIOVASCULAR DRUGS
Capsules/Tablets
Drug Strength Form Quantity Quantity Percentage
2002 2003 Increase
Alfuzocin SR 5mg Tab. 10,000 50,000 400.00%
Amiloride 10mg Tab. 500
Amiloride + hydrochlorothiazide --- Tab. 90,000 300,000 233.33%
Amiodarone 200mg Tab. 14,000 65,000 364.29%
Amlodipine 5mg Tab. 100,000 600,000 500.00%
Angiotensin II Receptor Blockers all Tab. 60,000
concentrations
Atenolol 100mg Tab. 240,000 500,000 108.33%
Atenolol 50mg Tab. 160,000 500,000 212.50%
Atorvastatin 10mg Tab. 60,000
Atorvastatin 20mg Tab. 60,000
Benazepril + Hydrochlorothiazide 20mg + 25mg Tab. 5,000 6,000 20.00%
Betaxolol 10mg Tab. 5,000
Betaxolol 20mg Tab. 5,000
Bisoprolol 5mg Tab. 10,000 90,000 800.00%
Bisoprolol 10mg Tab. 10,000 30,000 200.00%
Bumetanide 1mg Tab. 1,000 4,000 300.00%
Candesartan 8mg Tab. 5,000
Captopril 50mg Tab. 50,000 75,000 50.00%
Captopril 25mg Tab. 100,000 165,000 65.00%
Carvedilol 25mg Tab. 40,000 125,000 212.50%
Cinnarizine 25mg Tab. 10,000 32,000 220.00%
Cinnarizine 75mg Tab. 15,000 80,000 433.33%
Clonidine 0.15mg Tab. 1,000
Clopidogrel 75mg Tab. 3,000
Digoxin 0.25mg Tab. 30,000 120,000 300.00%
Digoxin 0.125mg Tab. 20,000 42,000 110.00%
Diltiazem 60mg Tab. 90,000 112,000 24.44%
Diltiazem L.A 90mg Tab. 90,000 145,000 61.11%
Diltiazem L.A 120mg Tab 30,000 100,000 233.33%
Doxazosin mesylate 1mg Tab. 10,000 30,000 200.00%
Doxazosin Mesylate 4mg Tab. 55,000 70,000 27.27%
Enalapril 5mg Tab. 60,000 100,000 66.67%
Enalapril 10mg Tab. 150,000 500,000 233.33%
Enalapril 20mg Tab. 180,000 500,000 177.78%
Enalapril + Hydrochlorothiazide 20mg + Tab. 180,000 5,000 -97.22%
12.5mg
Felopipine 10mg Tab. 5,000
Fluvastatin 40mg Tab. 20,000
Fosinopril 10mg Tab. 40,000 50,000 25.00%
Fosinopril 20mg Tab. 50,000 40,000 -20.00%
Frusemide 40mg Tab. 20,000 450,000 2150.00%
Frusemide 80mg Tab. 100,000
Gemfibrosil 600mg Tab. 70,000 90,000 28.57%
Hydralazine 10mg Tab. 10,000
Hydralazine 25mg Tab. 7,000 40,000 471.43%
Hydralazine 50mg Tab. 17,000
Hydrochlorothiazide 25mg Tab. 25,000 95,000 280.00%
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Drug Strength Form Quantity Quantity Percentage
2002 2003 Increase
Indapamide SR 1.5mg Tab. 85,000 200,000 135.29%
Isosorbide Dinitrate Sublingual Tab. 30,000 85,000 183.33%
5mg
Isosorbide Dinitrate 20mg Rcap. 120,000 500,000 316.67%
Isosorbide Dinitrate 10mg Tab. 40,000 40,000 0.00%
Isosorbide dinitrate 40mg Tab. 50,000 350,000 600.00%
Isosorbide mononitrate 20mg Tab. 70,000
Lisinopril 5mg Tab. 65,000 35,000 -46.15%
Lisinopril 10mg Tab. 50,000 100,000 100.00%
Lisinopril 20mg Tab. 25,000 100,000 300.00%
Methyldopa 250mg Tab. 130,000 200,000 53.85%
Metoprolol 100mg Tab. 2,000
Moexipril 7.5mg Tab. 4,000 10,000 150.00%
Moexipril 15mg Tab. 4,000 10,000 150.00%
Nadolol 80mg Tab. 10,000 15,000 50.00%
Nebivolole 5mg Tab. 10,000 3,000 -70.00%
Nifidipine 20mg R tab. 150,000 320,000 113.33%
Nifidipine 10mg Cap. 20,000
Nimodipine 30mg Tab. 3,000
Nitroglycerin 10mg Skin patch 1,000 2,000 100.00%
Nitroglycerin 5mg Skin patch 7,000
Pentoxyfillin 400mg Tab. 10,000 80,000 700.00%
Perindopril 2mg Tab. 1,000 5,000 400.00%
Perindopril 4mg Tabs. 6,000 10,000 66.67%
Pravastatin 20mg Tab. 50,000
Propranolol 10mg Tab. 15,000 90,000 500.00%
Propranolol 40mg Tab. 25,000 90,000 260.00%
Purified micronized flavonic --- Tab. 5,000 5,000 0.00%
fraction
Quinapril 5mg Tab. 55,000 10,000 -81.82%
Quinapril 20mg Tab. 55,000 90,000 63.64%
Reserpine + Clopamide 0.1mg +5mg Tab. 40,000 30,000 -25.00%
+Dehydroergocristine +0.5mg
Simvastatin 10mg Tab. 260,000
Simvastatin 20mg Tab. 100,000
Sotalol 40mg Tab. 500
Sotalol 80mg Tab. 500
Spironolactone 25mg Tab. 50,000 80,000 60.00%
Spironolactone 50mg Tab. 10,000 30,000 200.00%
Spironolactone 100mg Tab. 8,000 8,000 0.00%
Statin Group All Tab. 1,000,000
concentrations
Tamsulosin 0.4mg Tab. 70,000
Terazocine 2mg Tab. 10,000 5,000 -50.00%
Terazocine 5mg Tab. 25,000 3,000 -88.00%
Ticlipidine 250mg Tab. 30,000 65,000 116.67%
Trimetazidine HCL 20mg Tab. 28,000 55,000 96.43%
Valsartan 80mg Tab. 5,000
Valsartan + Hydrochlorothiazide Tab. 5,000
Verapamil 240mg S.R Tab. 30,000 95,000 216.67%
Verapamil 40mg Tab. 1,000 8,000 700.00%
Verapamil 80mg Tab. 1,000 20,000 1900.00%
3,897,500 9,048,000 132.15%
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Injections
Drug Strength Form Quantity Quantity Percentage
2002 2003 Increase
Adenosine triphosphate 6mg Inj. 250 320 28.00%
Adrenaline 1mg/ml I.V, S.C & 6,000 16,500 175.00%
I.M
Amiodarone 50mg/ml Inj. 100 1,300 1200.00%
Atropine sulphate 0.6mg/ml Inj. 5,000 18,000 260.00%
Atropine sulphate 1mg Inj. 15,000
Bretylium Tosylate 50mg Inj. 50 20 -60.00%
Digoxin 0.5mg Inj. 200 50 -75.00%
Diltiazem 25mg Inj. 300 450 50.00%
Dobutamine 250mg Inj. 500 100 -80.00%
Dopamine HCL 200mg Inj. 10,000 9,000 -10.00%
Enalapril 2.5mg Inj. 500
Ethanolamine oleate or Sodium -- Inj. 50 150 200.00%
Tetra decyl sulphate 3%
Frusemide 20mg Inj. 15,000 60,000 300.00%
Frusemide 250mg Vial 300
Hydralazine 20mg Inj. 1,000 1,300 30.00%
Isosorbide dinitrate 0.10% I.V Inj. 1,000 600 -40.00%
Isuprenaline --- Inj. 500 120 -76.00%
Metoprolol 5mg Inj. 50 100 100.00%
Nimodipine 30mg Inj. 50
Nitroglycerine 1mg/ml 10ml inj. 6,000 5,500 -8.33%
Nitroprusside 50mg Inj. 50 95 90.00%
Nor-adrenaline BP or USP Inj. 50 50 0.00%
Procainamide 100mg/ml Inj. 20 50 150.00%
Propranolol 1mg Inj. 2,200 500 -77.27%
ProstaglandinE1 Alprostadil 500mcg/ml Inj. 500 50 -90.00%
Tirofiban ---- Inj. 150 100 -33.33%
Tolazoline -- Inj. 50 30 -40.00%
Tranxamin acid or aminocaproic acid Amp. 500 800 60.00%
Verapamil 5mg Inj. 100 100 0.00%
65,420 115,335 76.30%
Suspension/Syrup
Drug Strength Form Quantity Quantity Percentage
2002 2003 Increase
Cholestyramine 4GM Sachets 1,500 1,000 -33.33%
Digoxin Syrup 5mcg/ml Bottle 50 150 200.00%
Propranolol 5mg/ml Syrup 200 50 -75.00%
1,750 1,200 -31.43%
GENERAL ANTI-INFECTIVES
Capsules/Tablets
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Amoxycillin 250mg Caps 16,000 25,000 56.25%
Amoxycillin 500mg Caps 150,000 450,000 200.00%
Amoxycillin 250mg + Clavulanic --- Tab 66,000 200,000 203.03%
acid 125mg
Azithromycin 250mg Cap. 6,000 12,000 100.00%
Cefaclor 250mg Caps. 2,000
Cefaclor 500mg & Caps. 29,000
750mg
Deliverable 8: Drug Utilisation and Predicting Need Page 35
Jordan – Health Sector Reform Project
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Cefixim 200mg Caps 6,000 25,000 316.67%
Cefprozil 250mg Tab 15,000
Cefprozil 500mg Tab 15,000
Cefuroxime axetil 250mg Tab. 30,000
Cephalexin 500mg Cap. 70,000
Cephalexin 250mg Caps 5,000
Cephalosporin (1st Generation) All Cap 167,000
Concentratio
ns
Cephalosporin (2nd Generation) All Cap 250,000
Concentratio
ns
Ciprofloxacin 500 mg Tab 60,000 128,000 113.33%
Clarithromycin 500mg Tab. 43,000 40,000 -6.98%
Clarithromycin 250mg Tab. 30,000 100,000 233.33%
Clindamycin 150mg Cap. 5,000 27,000 440.00%
Cloxacillin 250mg Caps 55,000 75,000 36.36%
Cotrimoxazole 480mg Tab 45,000 64,000 42.22%
Dapsone 50mg Tab 1,000 500 -50.00%
Diloxanide Furoate + 250 mg + Tab 10,000 5,000 -50.00%
Metronidazole 200mg
Doxycyclin 100mg Caps 60,000 64,000 6.67%
Erythromycin 250mg Tab. 20,000
Fluconazole 150 mg Caps 3,000 6,600 120.00%
Fluconazole 50 mg Caps 2,000 4,000 100.00%
Grisofulvin 125mg Tab. 1,000
Itraconazole 100 mg Caps 1,000 5,000 400.00%
Ketoconazole 200 mg Tab 3,000 1,600 -46.67%
Lamivudine 150mg Tab. 15,000
Lincomycin 500mg Cap 16,000
Mebendazole 100 mg Tab 35,000 1,000 -97.14%
Metacrezol sulphonic acid + Formaldehyde Ovule 1,300
Metronidazole 250 mg Tab 90,000 145,000 61.11%
Miconazole 400 mg Ovules 3,000 7,200 140.00%
Minocylcin 50 mg Cap 2,000 8,000 300.00%
Neomycin Sulphate 500mg Tab 1,000 500 -50.00%
Nitrofurantoin 100 mg Tabs 40,000 30,000 -25.00%
Nitrofurantoin 200mg Tab. 30,000
Norfloxacin 400 mg Tab 20,000 40,000 100.00%
Paromomycin Sulphate 250mg Tab. 5,000
Pefloxacin 400mg Tab 4,000
Penicillin V 312mg Tab 2,000 2,500 25.00%
Roxithromycin 150mg Tab. 10,000 48,000 380.00%
Spiramycin 250 mg + --- Tab 8,000 15,000 87.50%
Metronidazole 125 mg
Terbinafine 100mg Tab. 2,000 4,000 100.00%
Tetracycline 250mg Caps. 10,000 10,000 0.00%
Tinidazole 500mg Tab. 10,000
Valacyclovir 500 mg Tabs. 8,000 7,000 -12.50%
989,300 2,039,900 106.20%
Deliverable 8: Drug Utilisation and Predicting Need Page 36
Jordan – Health Sector Reform Project
Injections
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Acyclovir 250 mg Inj 4,500 2,000 -55.56%
Amikacin 500 mg /2ml Inj. 3,000 6,000 100.00%
Amikacin pead. 50 mg / ml 2ml Amp 500 500 0.00%
Amoxycillin 500mg+Clavulanic --- Inj. 1,000 1,000 0.00%
acid 100mg
Amoxycillin Igm + Clavulanic acid 200mg Inj. 1,000 1,000 0.00%
Amphotericin B 50 mg Inj 50 200 300.00%
Ampicillin + Cloxaxillin 250 mg + Inj 2,000 2,000 0.00%
250mg
Ampicillin Inj 500mg Inj 5,000 17,000 240.00%
Azithromycin IV Inj 500
Aztreonam 1Gm Inj 500 1,000 100.00%
Aztreonam 0.5Gm Inj 100 1,000 900.00%
Benzathine Penicillin 0.6mega Inj. 100
Benzathine Penicillin 1.2mega Inj. 1,000 2,000 100.00%
Benzyl Penicillin 2mega Inj 1,000 10,000 900.00%
Benzylpenicillin 1 mega Inj 1,000
Caspofungin 50mg Inj. 100
Cefepime 1Gm Inj 7,500 12,000 60.00%
Cefoperazone 1Gm Inj. 1,000 1,000 0.00%
Cefotaxime 1Gm I.V. Inj. 3,500 3,000 -14.29%
Cefoxitin 1Gm Inj. 12,000 15,000 25.00%
Ceftazidime 1Gm Inj. 22,000 2,000 -90.91%
Ceftizoxime 1Gm I.V 12,000 12,000 0.00%
Ceftriaxone 1Gm I.V. Inj. 20,000 27,000 35.00%
Ceftriaxone 500mg I.V. Inj. 10,000 6,500 -35.00%
Cefuroxime 750mg I.V. Inj. 24,000 39,500 64.58%
Cephalosporin (1st generation)Inj 1 Gm Inj. 5,000 24,000 380.00%
Chloramphenicol 1Gm Inj. 4,000 4,000 0.00%
Ciprofloxacin 200 mg Inj. 500
Claxacillin Inj. 500mg Inj 15,000
Clindamycin 150mg Inj. 500 4,000 700.00%
Cloxacillin 250mg Inj. 30,000 32,000 6.67%
Cloxacillin 500mg Inj. 13,000
Cotrimoxazole 480mg Inj 1,000 1,500 50.00%
Cotrimoxazole 960mg Inj 50
Fluconazole 2mg/2ml I.V inf. 1,300 1,400 7.69%
Ganciclovir 500mg Inj 100
Gentamycin 20mg/2mls Inj. 1,000 4,800 380.00%
Gentamycin 80mg/2mls Inj. 4,000 6,200 55.00%
Imipenam+Cilastin --- Inj 15,000 20,000 33.33%
Lincomycin 600 mg/2 ml Inj 1,000 1,000 0.00%
Metronidozole 500 mg Inj 12,000 32,000 166.67%
Miconazole 200mg/5ml Inj. 50
Pefloxacin 400mg Inj. 200
Pipracillin + Tazobactam 4mg + 0.5gm Inj. 3,000
Procain Penicillin 400,000u Inj. 1,000 1,000 0.00%
Streptomycin 1Gm Inj 100 100 0.00%
Teicoplanin 200m Vials 1,600
Tetracyclin vial 500mg 500 mg 1,000
Tetracyclin vial 250 mg 250mg 2,000
Deliverable 8: Drug Utilisation and Predicting Need Page 37
Jordan – Health Sector Reform Project
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Vancomycin 500mg or 1gm Inj 18,000 14,000 -22.22%
245,400 326,050 32.86%
Suspesion/Syrup
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Acyclovir Suspension 200 mg/5ml Bottle 20 20 0.00%
Amoxycillin 125mg /5ml Bot. 100ml 100 1,000 900.00%
Amoxycillin 250mg /5ml Bot. 100ml 5,000 7,000 40.00%
Amoxycillin 125mg + clavulanic acid 31 Bot. 100 1,000 900.00%
Amoxycillin 250mg + Clavulanic --- Bot. 6,000 10,000 66.67%
acid 62mg
Azithromycin Pead. 200mg/5ml Bottle 800 2,000 150.00%
Cefaclor 125mg/5ml Bot. 100
Cefixim 100mg/5ml Bot of 60ml 100 500 400.00%
Cefixim 100mg/5ml 30ml Bottle 100 500 400.00%
Cefprozil 125 mg/5ml Bot 400
Cefprozil 250 mg/5ml Bot 400
Cefuroxime axetil 125mg/5ml Bottle 1,500
Cephalexin 125mg/5ml Bot. 400
Cephalexin 250mg/5ml Bot. 100
Cephalosporin (2nd Generation) All Bot. 7,500
Suspension Concentrations
Clarithromycin 125mg/5ml Bottle 500 1,200 140.00%
Cloxacillin 125mg/5ml Bot. 200 100 -50.00%
Cotrimoxazole 240mg /5ml Bottle 500 1,600 220.00%
Erythromycin + Sulfisoxazole 200mg + Bottle 100
600mg
Erythromycin 200mg/5ml Bottle 500
Mebendazole 100 mg/5ml bot 500 120 -76.00%
Metronidazole 125 mg/5 ml bot 500 1,600 220.00%
Miconazole Oral Gel 2% Tube 1,500 1,600 6.67%
Miconazole Vaginal Cream 2% Tube 400 800 100.00%
Nalidixic acid 125 mg/5 ml Bottle 200 480 140.00%
Nitrofurantoin 25 mg/5ml Bottle 300 200 -33.33%
Nystatin Oral Drops 100000U/ml Bottle 2,000 2,000 0.00%
Paromomycin Sulphate Bot. 200
Penicillin V 125mg /5ml Bot. 150 320 113.33%
Rifampicin 100mg/5ml Bottle 200
22,070 40,340 82.78%
DRUGS USED FOR PEPTIC ULCERATION
Capsules/Tablets
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Bismuth sub citrate 120mg Tab. 6,000 15,000 150.00%
Famotidine 20mg Tab. 50,000 175,000 250.00%
Famotidine 40mg Tab. 90,000 320,000 255.56%
Lansoprazole & Rabeprazole 30mg & Caps. 30,000
10mg
Nizatidine 150mg Tab. 45,000 30,000 -33.33%
Nizatidne 300mg Tab. 20,000 20,000 0.00%
Deliverable 8: Drug Utilisation and Predicting Need Page 38
Jordan – Health Sector Reform Project
Omeprazol, Lanzoprazol or --- Tab. 150,000
Pantaprazole
Omeprazole 20mg Tab. 500,000
Omeprazole 20mg Mups 4,000
Ranitidine 300mg Tab. 40,000 100,000 150.00%
Ranitidine 150mg Tab. 150,000 720,000 380.00%
Ranitidine + Bismuth 400mg Tab. 20,000 40,000 100.00%
Sucralfate 1Gm Tab. 4,000 10,000 150.00%
Teprenone 50mg Caps. 5,000
580,000 1,964,000 238.62%
Injections
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Omeprazole 40mg Inj. 6,000
Ranitidine 50mg/2ml Amp. 20,000 40,000 100.00%
20,000 48,003 140.02%
Syrup
Drug Strength Form Quantity Quantity Percentage
2,002 2,003 Increase
Ranitidine 75mg/5ml Bottle 50
Deliverable 8: Drug Utilisation and Predicting Need Page 39