Living with HIV: when life depends on public procurement
Of the 2.1 million people diagnosed as HIV-positive in Latin America, only 1.3 million (61%) are able to access treatment. Their health depends on efficient and transparent public procurement. For HIV patients, any delay in public procurement of medicines can mean that their treatment becomes ineffective, putting their lives at risk and forcing governments to buy new drugs at higher costs.
When Latin American activist groups and people living with HIV as well as journalists and transparency organizations met at an event a few years ago, conversations and shared experience focused on the problems and challenges in medicine procurement. It was clear from these discussions that process inefficiencies were directly affecting people’s right to health.
In 2018, working in conjunction with the International Treatment Preparedness Coalition (ITPC) and Red Legal, PODER created the first investigative journalism prototype to analyze data on the procurement of antiretroviral (ARV) drugs in Guatemala. Two years later, with the pandemic making life a whole lot harder for HIV patients, PODER teamed up with Salud con Lupa to investigate what was happening behind the procurement systems of a wider group of countries. The organizations re-adopted the methodology used in the pilot and promoted a second version of «Vivir con VIH» (Living with HIV). This initiative examined almost 10,000 purchases of antiretroviral drugs between 2017 and 2019 in 6 Latin American countries: Bolivia, Costa Rica, Ecuador, Guatemala, Mexico and Peru. In addition to looking at the data, the research team were keen to speak to those who were experiencing first-hand the problems with the procurement processes.
Among the main regional findings, the team noted that health policy changes brought about by COVID-19 along with inefficiencies in ARV procurement processes had caused shortages in countries such as Mexico. Patients were receiving fewer medicines than they needed, leading to more frequent visits to doctors. Analyzing the procurement processes in the six countries, they also found that buying from local suppliers and from pharmaceutical companies directly was more costly for governments.
The first challenge: getting information and standardizing data
How governments allow citizens to access and consult data varies from country to country. While some have platforms for examining procurement contracts, others work on the basis of information access requests and, in some cases, a combination of both is required in order to fully reconstruct the procedures.
So the team’s first challenge was to search for ARV procurement data between 2017 and 2019. Using a list of drugs to be analyzed, they lodged public information requests in Mexico and Guatemala whereas procurement in Bolivia, Peru, Costa Rica and Ecuador was researched using the government procurement platform. PODER’s Eduard Martín-Borregón recalls that the team followed a two-stage process: they firstly needed to understand how the systems worked in each country but then the pandemic brought their work to a standstill, forcing them to rethink the way they collected data because of the barriers to access they were encountering. In total, the work took around 3 months.
The team used web scraping to download information from websites although in some cases it was impossible to gain a full picture. In Ecuador and Guatemala, the team was unable to access information about ARV procurement via the UN-supported program, because they received no reply to their enquiries and because the country’s procurement laws do not require information to be published.
In total, the team managed to compile information about 9,958 procurement processes in the 6 countries in the region. PODER and Salud con Lupa now had the vital information required for the next stage in the process: preparing the data for analysis.
Methodology: leveraging past experience was key to the project
Thanks to the regional experience of Vivir con VIH, it was not necessary to reinvent the wheel. In 2017, with support from Hivos, Daniel de León from the International Treatment Preparedness Coalition began to design a methodology for auditing ARV procurement in Guatemala. The first stage was to draw up a list of medicines to be investigated. Data was then organized in a database where more detail could be added to the information by looking at documents obtained from the procurement systems. For example, the data could include the unit cost per tablet or bottle purchased, weighted according to any logistical costs. This aspect is vitally important because medicine prices can vary depending on whether the procurement specifications include transport or insurance costs, for example. This stage also involved converting prices into dollars based on the exchange rate applied for that year by each country’s central bank. The team looked up the reference prices for these drugs according to information provided by the Pan American Health Organization (PAHO) and also analyzed any patents for these drugs and their expiry dates. Finally, the team compared the purchases made with the reference prices so that they could determine which purchases had been efficient and which had not.
For Ana Gabriel Zuñiga, manager of Hivos Latin America, the opportunity to roll out the Guatemala prototype across the region was a «very powerful way of showing the good practices that one country can take from another». But she also explains that one of the advantages of scaling up the work was that it built up capacity to use this for data and procurement in civil society.
The method designed by ITPC went beyond simply giving a «snapshot» of what was happening in procurement processes. By analyzing such a vast number of databases, price lists and procurement mechanisms, the team was able to:
- Determine which country has the most efficient procurement processes.
- Identify potential savings in medicine procurement.
- Name one pharmaceutical company that snapped up 84% of the contracts despite accusations of faking auction bids for its own profit.
- Compare local and international procurement models.
- Determine the effectiveness of procurement mechanisms such as reverse auctions to achieve better prices.
De León highlights the importance of thinking about «the appropriate structure for the information to be published, for example, defining what standard will be used for naming a medicine or active substance, and what their identifier will be.» He also emphasizes the importance of considering aspects such as standardization of units of measurement and currency convertibility in order to be able to make valid comparisons.
There are numerous challenges but one that appears time and time again throughout the project is the need to generate more data and have greater transparency about procurement through international mechanisms. None of the international agencies contacted for the project provided any information. Where access was available, it was provided by the countries themselves. So without being able to map all of the data, drawing general conclusions becomes difficult.
The importance of planning. Applying the same methodology to data from the six countries in the region revealed some interesting patterns and differences. Mexico was the country where most purchases had been made in the period and it also paid the least for each contract (US$ 28,345 on average). But these seemingly positive facts were not quite so positive when a closer light was shone on the country’s procurement processes. During the years analyzed, Mexico’s procurement system did not allow medicines to be purchased through PAHO or UN mechanisms.
Moreover, Martín-Borregón explains that medicines were purchased by the bottle, «which gave the impression that they were able to meet needs when in fact they needed to keep rebuying because they were running out of supplies». This is confirmed by the data, which shows that 2,400 contracts involved the purchase of fewer than 10 bottles of ARVs in each process. As a result, many purchases were made directly from the manufacturer in order to avoid interruptions to treatment and to ensure that patients received the drugs they needed. This was not the case in other countries such as Peru, where there were only five cases of purchases for fewer than 1,000 products, besides the fact that the country had a large number of open contracting processes which was an indication of better process planning.
Where data was accessible, it was seen that procuring supplies through international mechanisms was cheaper. The team found that making purchases through international mechanisms such as PAHO was less expensive than procuring medicines via suppliers based in each country. This is most evident with Atazanavir. Whereas Mexico paid an average of US$140 for the drug, Peru paid $40 and Bolivia, which channeled its purchases via PAHO, ended up paying just $16 per bottle.
Bolivia: the most efficient country. The data analysis also looked into «the percentage variation between the cost at which countries purchased ARVs and the reference prices established for each one by PAHO. The countries which had less variation according to this method were deemed to have bought more efficiently. Bolivia was found to be the most efficient (3.5%) followed by Costa Rica (27.5%) and Guatemala (33.1%) whereas Mexico (73.2%) and Peru (45.2%) were the least efficient.
Patients: the victims of inefficiencies
For Borregón, the regional version of Vivir con VIH «connected demand (need) with patients, science and purchases (procurement)». In other words, it sought to bring together two strands: the importance of achieving greater government efficiency and the need to show the faces of those whose right to health had been violated. This was possible through working with Salud con Lupa and platforms such as La Voz de Guanacaste, Rindecuentas, La Data Cuenta and Plaza Pública. In this way, the team and organizations that came together for the initiative offered a 360o panorama of the problem.
The reports showed that in Guatemala for example, the indigenous population is particularly badly affected because of the lack of solutions available in their indigenous languages despite the fact that they make up the majority of the population. In Mexico, while the healthcare system and the supply of ARVs was collapsing, the black market for drug traffickers was growing by the day. And in Peru, people are not accessing the necessary treatment because of problems in delivery, delays and expired medicines.
So in addition to learning about the issues affecting people living with HIV, the team also looked at public policy, procurement mechanisms, market supply and many other factors that can affect the prices, distribution, quality or supply of these medicines that keep so many people alive.
Zuñiga explains that one of the most important lessons learned from Vivir con VIH is the realization that governments have a very important role to play in guaranteeing the right to health. For that reason, she emphasizes that it is very important «to work with but not for governments, to identify opportunities for cooperation and to form key partnerships. We cannot talk about health without understanding the role that the government needs to play as guarantor. We’re talking about people’s lives, their rights, and about how procurement can change their life.»
Illustration: Rocío Urtecho (aka Jugo Gástrico)