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Enhancing effectiveness, efficiency and social sustainability Maximizing health program budgets April 20, 2012 Presenter: Peter Smith Technical: Jason Williams

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Enhancing effectiveness, efficiency and social sustainability

Maximizing health program budgets

April 20, 2012Presenter: Peter SmithTechnical: Jason Williams

PEPFARImplementing Partner

Procurement optimization to reduce costs

• Optimizing laboratory procurement Selecting and procuring the right product within the national tiered laboratory system, with an appropriate throughput and complexity, that is sustainable within it’s regional and local setting.

• Strategy• Define the diagnostic coverage• Compare actual demand to capacity• Determine level of harmonization• Increase utilization to reduce costs

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PEPFARImplementing Partner

Maputo Declaration, 2008

The Maputo Declaration on Strengthening Laboratory Systems called for:

• The standardization of tests, reagents, consumables and equipment needed at each level of a tiered laboratory system within a country

• The harmonization and standardization of these laboratory commodities to improve the laboratory supply chain system and equipment maintenance

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PEPFARImplementing Partner

HARMONIZATION

EQUIPMENTMAINTENANCEPROCUREMENT

QUANTIFICATION

Understanding the landscape

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PEPFARImplementing Partner

PEPFAR procurement

ARV55%

Reagents10%

Test kits9%

Lab 5%

Clinical Supplies2%

Gloves1%

Other14%

Non ARV Drugs4%

PEPFAR spend

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PEPFARImplementing Partner

PEPFAR procurement: Reagents

Flow Cytometry62%

Hematology19%

Biochemistry16%

Molecular2%

Immunoassay1%

Microbiology0%

PEPFAR spend:  Reagents

PEPFARImplementing Partner

PEPFAR spend: Reagents

Flow Cytometry

Hematology

Biochemistry

 $‐

 $5

 $10

 $15

 $20

 $25

2008 2009 2010 2011

Millions

PEPFARImplementing Partner

Country X: Instrument diversity CD4 Testing Chemistry Testing Hematology Testing

Model # of Machines % Model # of Machines % Model # of Machines %FACScount 147 85.5 SCREEN MASTER 3000 89 38.5 ABX MICROS 60 98 42.1FACSCALIBUR 20 11.6 FULLY 39 16.9 SYSMEX KX-21N 47 20.2Cyflow Partec 3 1.7 VISUAL SECOMAM 20 8.7 ABX PENTRA 80 25 10.7GUAVA Easy 2 1.2 Star dust MC15 15 6.5 SYSMEX pochi 100i 18 7.7PIMA ??? ??? HUMASTAR 80 9 3.9 HEMOCUE Hb 201+ 12 5.2

HUMALIZER 3000 9 3.9 CELL DYNE 1800 8 3.4BTS 330 SEMI 7 3.0 H18 LIGHT 8 3.4Biosystem A15 7 3.0 CELL DYNE 1700 5 2.1COBAS 400 INTERGRA 6 2.6 Coulter ACT 5 Diff CP 4 1.7BSA 3000 6 2.6 MINDRAY BC 3200 3 1.3ERBA Chem-6 5 2.2 SYSMEX 5 DIFF 2 0.9ERBA CHEM 5 4 1.7 HUMACOUNT 1 0.4MINDRAY BS 200 3 1.3 BECKMAN COULTER 1 0.4Star dust MC16 2 0.9 Cell-Dyne 3500 1 0.4MICROLAB 2 0.9Bisystem MC15 2 0.9Star dust MC17 1 0.4Human 300 1 0.4Human 2000 1 0.4Humalyser 3500 1 0.4ERBA CHEM 27 1 0.4Cobas C III 1 0.4

Approved Utilization 97.1 58.0 57.9

Total Machines 172 4 231 22 233 14

PEPFARImplementing Partner

 $‐

 $2

 $4

 $6

 $8

 $10

 $12

 $14

 $16

 $18

2008 2009 2010 2011

Millions

CellCheckCOBAS ‐ ElecsysHycelCLIMA9180MAXMCellyAMSMedonicAvantCOBASEQA Panal (ET)KenzaKonelabHumastarElxxHitachi 902COBAS ‐ C111ElitechDiaSysMGITHumalyserCOBAS ‐ AmplicorHemoCueBTPimaVitros DTHumaCountCOBAS ‐ TaqmanGuavaAU400Generic or MiscVitros 350PointcareReflotronArchitectCOBAS ‐ IntegraAcTDiffHumanFullyBeckmanCelltacCyflowABXCell‐DynSysmex

PEPFARImplementing Partner

Take away

Focus on reducing instrument diversity and push to harmonize to nationally approved instruments

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PEPFARImplementing Partner

Driving up utilization: Current situation

• Forecasts are based on demographic/morbidity data, little regard to actual service delivery or capacity

• Instrument procurement requests are not aligned with nationally approved instrument plans

• Limited data use to direct overall laboratory optimization

• Need to get more value from a declining fundingenvironment (do more with less) 11

PEPFARImplementing Partner

CD4 Lab distribution based on demographics

Plan to 300% of capacity

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PEPFARImplementing Partner

Country A: Service data

Country A Machines % Distribution Lab Level % Utilization Dx Contribution

All Instruments 138 33% 100%

FACSCount 51 37% Level I   ‐ Primary outpatient 55% 40%

FACSCount 55 40% Level II  ‐ District labs  44% 35%

FACSCount 12 9% Level III ‐ Regional/Provincial Lab 22% 4%

FACSCount 5 4% Level IV ‐ National Reference Lab 53% 4%

FACSCount Total 123 89% 47% 82%

FACSCaliber 0 0% Level I   ‐ Primary outpatient 0% 0%

FACSCaliber 3 2% Level II  ‐ District labs  7% 2%

FACSCaliber 7 5% Level III ‐ Regional/Provincial Lab 8% 5%

FACSCaliber 5 4% Level IV ‐ National Reference Lab 26% 11%

FACSCaliber Total 15 11% 14% 18%

PEPFARImplementing Partner

Country B: Service data

Country B Machine #s % Distribution Lab Level % Utilization DXcontribution

All Instruments 105 11% 100%

Guava 30 29% 12% 29%

Cyflow 2 2% 0% 1%

FACSCount Level I   ‐ Primary outpatient 0%

FACSCount 11 10% Level II  ‐ District labs  7% 7%

FACSCount 51 49% Level III ‐ Regional/Provincial Lab 9% 30%

FACSCount 2 2% Level IV ‐ National Reference Lab 33% 1%FACSCount Total 64 61% 10% 38%

FACSCaliber Level I   ‐ Primary outpatient 0%

FACSCaliber Level II  ‐ District labs  0%

FACSCaliber 2 2% Level III ‐ Regional/Provincial Lab 5% 7%

FACSCaliber 7 7% Level IV ‐ National Reference Lab 15% 25%FACSCaliber Total 9 9% 13% 32%

PEPFARImplementing Partner

Country X: Finding the best cost / utilization

Point of Diminishing Returns

PEPFARImplementing Partner

Case study: Ethiopia

• SCMS partnered with USAID and the CDC in a lab harmonization initiative to help the Ethiopian government maximize donor funding for lab equipment procurement and distribution

• Analyzed CD4 testing needs by researching the number of patients served at each site, ART and pre-ART patient targets and testing trends

• Moved from FACSCalibur machines for lab ART monitoring sites to less costly FACSCount machines for lower-volume sites

• Saved over $600,000 in the cost of equipment and reagents within the first year and an additional $100K every year after 16

PEPFARImplementing Partner

Eight questions as guide for harmonization

1. Is the diagnostic instrument on the nationally approved instrument list?

2. Is the request to replace existing old instruments? If yes, is there an instrument replacement strategy?

3. If these instruments are for new locations, is there an instrument deployment plan for the proposed instruments?

4. What is the current estimated diagnostic capacity for this particular instrument type in country?

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PEPFARImplementing Partner

Eight questions as guide for harmonization

5. What is the diagnostic burden at the proposed sites? Is the instrument selected appropriate, based on instrument capacity vs. diagnostic demand?

6. Is there suitable infrastructure at the proposed sites -any additional peripheral needs?

7. Is there expected service delivery expansion at the proposed sites? (scale up)

8. Have the additional costs of reagents, staff training, maintenance been considered - what are the funding sources and estimated costs?

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PEPFARImplementing Partner

Take aways

• Focus on reducing instrument diversity and pushing to harmonize in accordance with nationally approved instruments

• Base forecasts on service data vsdemographic morbidity and monitor utilization

• Monitor the gap between service statistics and service capacity – plan against utilization

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PEPFARImplementing Partner

• Asante-Safari njema

• Thank you – Good travels!

Mr. Peter J SMITHProcurement Operations Manager, Global Supply ChainPartnership for Supply Chain Management (PFSCM)1616 North Fort Myer Drive12th FloorArlington, VA 22209, USAOffice Direct Telephone: +1.571.227.8740Email: [email protected]: www.pfscm.org

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