Medicine Procurement Prices and Processesin the United Nations Relief

medicine procurement prices and processes in the united nations relief and works agency for palestine refugees in the near east (UNRWA)

december 2011

"© United Nations Relief and Works Agency for Palestine Refugees in the Near East, 2012. All rights reserved. The views expressed in this report are those of the author(s) and do not necessarily reflect the views of UNRWA. UNRWA does not endorse or recommend specific medicines, companies or products of manufacturers, whether or not mentioned in this report. UNRWA does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use."

Table of Contents

Abbreviations ...... 5 Foreword ...... 6 Executive Summary ...... 7 1. Introduction ...... 8 2. Objectives ...... 10 3. Methodology ...... 11 3.1 Data collection ...... 11 3.2 Medicine selection ...... 11 3.3 Price comparators ...... 12 3.4 Analysis ...... 13 4. Findings ...... 15 4.1 International price comparisons for centrally procured medicines ...... 15 4.2 Potential savings when purchasing at IDA, JPD or GCC prices ...... 17 4.3 Price and quantity by supplier ...... 23 4.4 Comparison of prices from local and central procurements ...... 25 4.5 Medicine procurement process ...... 26 4.5.1 Responsibilities ...... 26 4.5.2 Key Issues ...... 27 5. Study Limitations ...... 33 6. Conclusions and Recommendations ...... 34 6.1 Medicine Prices ...... 34 6.2 Procurement process ...... 34 6.3 PLD recommendations ...... 36

Annexes

Annex 1 Medicines selected for price comparisons (in descending order by expenditure ...... 37 Annex II UNRWA procurement prices as a ratio to MSH, IDA, JPD, and GCC prices...... 39 Annex III Procurement prices (in US$) for UNRWA’s purchasing units ...... 41 Annex IV Annual savings by purchasing medicines from IDA ...... 44 Annex V Annual savings by purchasing medicines at JPD prices ...... 46 Annex VI Annual savings by purchasing medicines at GCC prices ...... 49 Annex VII Suppliers of medicines to UNRWA, JPD and GCC for medicines where there are matches...... 52 Annex VIII Ratios of prices and quantities of UNRWA local procurements to central procurements ...... 58 Annex IX Pre-qualified suppliers in 2007 and 2011 for the four medicine tender groups ...... 60

List of Tables

1. Top 10 medicines purchased in 2010 by expenditure (central and local procurements) ...... 12 2. Summary of ratios of UNRWA prices to MSH, IDA, JPD and GCC prices ...... 15 3. Five highest and lowest priced medicines compared to MSH ...... 15 4. Five highest and lowest priced medicines compared to IDA (bulk packs) ...... 16 5. Five highest and lowest priced medicines compared to JPD ...... 16 6. Five highest and lowest priced medicines compared to GCC ...... 17 7. Annual savings if medicines procured at IDA, JPD or GCC prices ...... 17 8. Annual savings over US$ 100,000 for individual medicines procured at IDA (bulk), JPD, GCC prices ...... 18 9. UNRWA and comparator prices for top 10 medicines by expenditure, for UNRWA purchasing units ...... 19 10. Potential savings of UNRWA top 10 medicines at lowest comparator price ...... 20 11. Potential savings for antidiabetic medicines at GCC prices ...... 21 12. Current suppliers of medicines where savings show potential greatest ...... 22 13. Recommended medicines that offer greatest potential for savings ...... 22 14. Prices and quantities of medicines supplied to UNRWA, JPD and GCC by the same pharmaceutical company ...... 24 15. Summary of ratios of prices for locally procured versus centrally procured medicines ...... 25

List of Figures

1. Price ratios, UNRWA prices to comparator prices, for UNRWA top 10 medicines by expenditure ...... 19 2. Number of prequalified suppliers in 2007 and 2011 by medicine tender group ...... 29 3. Number of prequalified suppliers in 2007 and 2011 by origin of company ...... 29

Abbreviations

CFR Cost and Freight to the named port of destination CPT Carriage Paid to the named place of destination CPLD Chief, Procurement and Logistics Department DDP Delivered Duty Paid to the named place of destination DDU Delivered Duty Unpaid to the named place of destination FPLO Field Procurement and Logistics Officer (Head of Procurement at field level) GCC Gulf Cooperation Council HAI Health Action International HD Health Department JFDA Jordan Food and Drug Administration JPD Joint Procurement Department in Jordan LMIC Low and Middle Income Countries ml Milliliter MSH Management Sciences for Health NCDs Non-communicable Diseases PIMS UNRWAs Procurement Inventory Management System PHC Primary Health Care Centers PLD Procurement and Logistics Division (HQ) RDL Rational Drug List UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East WHO World Health Organization

!"#$%"#&' ! ! It is our great pleasure to present this report on the extensive analysis on how UNRWA procures medicines for approximately 5.1 million Palestine refugees dispersed in Gaza, Jordan, Syria, Lebanon, and the West Bank. With the growing number of refugees and the increasing demand for quality health care services, UNRWA faces immense challenges under the current financial constraints.

This report is a fruitful result of extensive analysis condcuted by two distinguished international experts in the area of medicine procurement. We wish to extend sincere gratitude to Ms Margaret Ewen from HAI Global, and Dr Maisa Al Sakit ex-Director Joint Procurement Department in Jordan for their tireless effort to realizing the comprehensive analysis and providing UNRWA with recommendations for further efficiency.

This report is of value for many reasons.

Firstly, the report confirmed that UNRWA purchases medicines efficiently. In 2010, UNRWA spent almost US$18 million for medicine procurement, and the expenditure has been increasing. The international recognition on UNRWA’s efficiency on medicine procurement, therefore, is a great support and it motivates the Agency to consider better ways for improvements.

Secondly, the report indicated possible room for further efficiency gain, or savings, that UNRWA could explore. This requires regular price monitoring in market, price negotiation with suppliers, and seeking different procurement options for certain medicines and so forth. The recommendations are certainly the guiding tools to strengthen the overall procurement system.

Thirdly, and most importantly,this report is an outcome of the partnerships within and outside UNRWA. It started with inspiring discussions between departments of health and procurement of UNRWA, which extended to WHO and then to HAI. Later, it engaged Jordan, the host country. The results were so extensive that they were presented in a number of international conferences including one specific meeting in WHO Headquarters.

In this regard, we would like to reiterate our sincere thanks to those engaged in this joint work particularly UNRWA staff at health, procurement and logitics, and finance departments at field and headquarters offices, and also the Joint procurement department of Jordan.

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Executive Summary

In 2010, UNRWA spent about US$ 18.31 million on medicines. Of this, US$ 15.4 million came from their General Fund .With budget constraints and increasing demand (primarily medicines to treat diabetes and cardiovascular disease), there was a need to assess the efficiency of the medicine procurement process, in particular the procurement price of medicines.

Of the 143 medicines that UNRWA procured in 2010 from the General Fund, 80 were initially selected for price comparisons (equating approximately to the top 80 medicines by expenditure). Of these, 77 were purchased centrally (by tender). Their prices were compared with median supplier prices in Management Sciences for Health’s (MSH) International Drug Price Indicator Guide, prices offered by IDA Foundation, and 2010 tender prices for Jordan’s Joint Procurement Department (JPD) and the Gulf Cooperation Council (GCC).

Overall, UNRWA prices were equal to or less than MSH, JPD, GCC and IDA (blister packs), and 12% more than IDA prices (bulk packs). Based on the quantities purchased and price of each medicine, overall expenditure would increase if UNRWA purchased at IDA, JPD or GCC prices. However, if a limited list of 9 medicines could be purchased at comparator prices, savings of about US$ 1.6 million might be achieved (about 10% of General Fund medicine expenditure). There are a few cases where companies are charging UNRWA a higher price despite larger quantities procured than they charge JPD or GCC.

Across all medicines procured locally and centrally, Jordan field and Syria field are paying 7% and 20% less respectively when procuring locally. Overall Lebanon, West Bank and Gaza are paying 83% to 128% more than the central tender price when procuring locally. However, in all cases except Syria few medicines were purchased locally, and some fields, in particular Gaza and West Bank fields are limited in the number of suppliers they can purchase from.

Two major issues were identified when reviewing the procurement process. The first is the lack of clear criteria when prequalifying suppliers and limited product quality testing which pose a potential risk that UNRWA could purchase and distribute substandard products. That said, quality tests on products supplied to Jordan field have not detected problems for many years. The second is that while the number of pre-qualified suppliers of medicines has increased over the last few years, currently numbering 100 companies, expansion would be beneficial especially from outside the region where prices may be more competitive.

Other procurement issues include fields wanting to procure locally due to the tardiness of the tender process, quantification based on consumption rather than need, and a lack of transparency on awarded tenders. The current IT system is not efficient. Not all health centers are computerized and where they do operate, there is no integration with the Central Pharmacy and headquarters. It appears that demand side issues are not given as much focus as supply issues. UNRWA pharmacists appear to focus predominantly on inventory management. There is a need for pharmacists to work more with patients and health care providers to improve the use of medicines.

Key recommendations include exploring options to reduce the prices for a limited list of medicines, and annual monitoring of the prices of the top 20 medicines by expenditure. A priority should be the development of minimum regulatory standards for prequalifying suppliers and product quality assurance. Consideration should be given to identifying suppliers particularly from outside the region who are supplying products registered with competent regulatory authorities and are likely to have competitive prices. Efficiencies could be gained with a more user-friendly and integrated computer system, and pharmacists involved in medicine use issues.

1. Introduction

The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides assistance, protection and advocacy for approximately 5 million Palestine refugees in Jordan, Lebanon, Syria and the occupied Palestinian territory (Gaza Strip and the West Bank). Services and support provided by UNRWA include health, education, relief and social services, at an annual cost of about US$ 500 million.

Health is considered a critical component of the social and economic development of Palestine refugees, leading to improved educational outcomes, labor force capacity and overall well-being.1 For more than 60 years UNRWA has been the main primary health care provider for Palestine refugees in the Middle East, which has resulted in significant improvements in their health status, in particular in the reduction of maternal and child mortality. This has been achieved despite the poor living conditions and high levels of unemployment of refugees, and political instability and conflict in the region.

In accordance with the UN criteria for human development, the goal of UNRWA’s Health Department is to enable refugees to live long and healthy lives by:

• ensuring universal access to quality comprehensive services • preventing and controlling disease • protecting and promoting family health

This is achieved primarily by providing services in 137 primary health care (PHC) centers across the 5 areas of operation (‘fields’) and 1 hospital located in the West Bank. In 2010, 3 million refugees accessed care which resulted in over 11 million medical consultations. In addition, UNRWA provided laboratory, physiotherapy, radiology, dental, mental health, and other health services, preventative programmes, and provided and/or funded some secondary and tertiary care services. Access to these services is vital, especially where refugees are unable to access any government health services in host countries such as Lebanon.

Medicines are supplied free-of-charge to refugees. In 2010, US$ 18.31 million was spent on medicines, of which about US$ 15.4 million was from the General Fund and about US$ 3 million was emergency medicine supplies and donations.

A number of factors are likely to be contributing to increased demand for services including:

• an increase in the refugee population: from a total of US$ 4.8 million in 2009 to US$ 5 million in 2010 • an increase in the elderly population: the number of people 60+ years has doubled since 1972 • an epidemiological transition from communicable to non-communicable diseases (NCDs): unlike communicable diseases, NCDs require access to diagnostic services, medicines and other services for the life-time of the patient. Over the last decade, the number of patients with hypertension and/or diabetes has increased by 134%. NCDs currently account for 70- 80% of deaths among refugees.

1 UNRWA. Annual Report of the Department of Health, 2010.

Coupled with increasing demand, UNRWA is facing a funding deficit – estimated to be US$ 63 million in 2011 (out of a total budget of US$ 500 million).

Faced with the challenge of providing health services in an environment of growing need and resource constraints, UNRWA initiated a health reform process in 2009. This includes a comprehensive review of three areas of health expenditure which collectively account for about 85% of total health expenditure, namely, staff salaries, hospital payments, and medicines. The objective is to assess where efficiency gains could be made.

UNRWA used the rational use of medicines concept and the logistics cycle to frame the medicines review, as both underpin improved access to medicines. As a first step, in 2010 the Health Department (HD) and the Procurement and Logistics Division (PLD) reviewed the medicines on the Rational Drug List (“Product Selection” in the logistics cycle). Following the review the number of medicines and vaccines on the list decreased to 109 (the list includes 136 items when medical supplies, alcohol and disinfectants are included). In 2011 the HD and PLD commenced a review of the remainder of the logistics cycle, namely, quantification and procurement (the procurement process, prices, financing etc.), inventory management (including storage and distribution) and use of medicines in PHCs.

A preliminary comparison of UNRWA’s procurement prices by the Senior Pharmacist and Director of Health indicated that prices were generally reasonable but opportunities existed for savings on some medicines. It was decided that a more extensive assessment of UNRWA’s procurement prices was needed, including an assessment of related procurement issues. This report is the outcome of this assessment.

2. Objectives

Project title: Joint Assessment on Rational Use of Medicines by the Health Department and Procurement & Logistics Division of the UNRWA.

Part I: Joint Assessment of Medicine Selection and Procurement

The overall objective was to assess if efficiency gains are possible in the procurement of medicines.

To achieve this, the following activities were required to be undertaken by the consultants:

• A comparison of UNRWA’s procurement prices with other reliable international, regional and national suppliers, and if relevant, to recommend possible ways to identify other suppliers with less-costly quality medicines. This could include possible procurement of medicines from Syria where the medicine prices are under strict government regulation and thus reasonably less expensive.

• A review of the status of UNRWA’s selection and procurement of essential medicines and their suppliers, and to identify possible areas of improvement and efficiency gain.

3. Methodology

3.1 Data Collection

In July 2011, the consultants spent two weeks at UNRWA headquarters in Amman collecting procurement price data and discussing the procurement process, issues and challenges with staff in the health, procurement and finance departments. In addition, the consultants met with the pharmacist and senior staff at the Central Pharmacy in the Jordan field and visited a primary health care centre in Amman. Data was also collected at Jordan’s Joint Procurement Department. Due to the conflict, it was not possible to visit the Central Pharmacy in Syria.

3.2 Medicine selection

In 2010 UNRWA purchased 143 medicines and vaccines, strength and dose form specific, at a total cost of US$ 15,443,906.2 These included medicines purchased centrally (through the tender process by the Procurement Department) and those purchased locally by field procurement staff.

To make the analysis manageable the number of medicines needed to be reduced (while ensuring the final selection provided enough data points for a robust analysis). Medicines more specific to UNRWA (e.g. metacresolsulphonic acid-formaldehyde pessaries, co-magaldrox tablets) were excluded, as were medicines where comparators were less likely to have products with identical active ingredients and strengths (e.g. compound haemorroidal preparations, multivitamin preparations). Hep B vaccine, the only vaccine UNRWA purchased in 2010, was also excluded. In total 80 medicines were selected for price comparisons, roughly equating to UNRWAs top 80 medicines by expenditure, as it was felt these should provide enough data points for a reliable analysis. The 80 medicines had a combined expenditure, from central and local procurements, of US$ 14,462,304 (about 93% of total General Fund medicine and vaccine expenditure).

Note: Most vaccines, some contraceptives and some medicines (e.g. tuberculosis medicines, iron tablets) plus some medical supplies are donated free-of-charge by UNICEF, UNFPA, host governments or NGOs to fields (36% of donated medical supplies are earmarked for Gaza). These medicines were not included in the analysis, nor were medicines purchased in emergency situations.

Annex I lists the 80 medicines in the analysis, tender quantities and expenditures (from central and local purchases).

Table 1 lists the top 10 medicines purchased, by expenditure, in 2010. The total expenditure for these medicines was US$ 6,753,853 (about 45% of General Fund medicine expenditure). Of note is the expenditure on premixed 30/70 insulin, which alone accounts for about 10% of General Fund medicine expenditure.

2 Data supplied by the Procurement Department UNRWA from the PIMS database; from the General Fund and excluding medical, dental and laboratory supplies and medicines used in surgical procedures (local anesthetics, skin disinfectants etc).

Table 1. Top 10 medicines purchased in 2010 by expenditure (central and local procurements) UNRWA Strength and Therapeutic Quantity Expenditure Medicine Purchasing Dose Form Group purchased US$ Unit Premixed 30/70 Antidiabetic 100IU/ml vial 10ml vial 476,650 1,478,122 Human Insulin medicine Co-Amoxiclav 500+125mg tablet Antimicrobial 100 tabs 54,653 973,521 250mg/5ml 100ml Amoxycillin Antimicrobial 999,566 716,602 suspension bottle Enalapril Maleate 10mg tablet Antihypertensive 100 tabs 667,500 661,834 Amoxycillin 500 mg capsule Antimicrobial 100 caps 158,655 606,882 250+62mg/5ml 100ml Co-Amoxiclav Antimicrobial 219,110 567,409 suspension bottle Cephalexin 500mg capsule Antimicrobial 100 caps 86,955 473,402 Antidiabetic Metformin HCL 500mg tablet 100 tabs 470,370 446,482 medicine Antidiabetic Gliclazide 80mg tablet 100 tabs 159,725 418,102 medicine 250mg/5ml Antipyretic, 100ml Paracetamol 1,161,843 411,496 suspension Analgesic bottle total 6,753,853

3.3 Price comparators

To assess the efficiency of UNRWA prices, procurement prices were collected from the following sources:

• Management Sciences for Health’s (MSH) International Drug Price Indicator Guide MSH was chosen as they list prices for a large range of good quality multi-source medicines offered to low and middle-income countries (LMIC) by different suppliers. These prices are publicly available on the internet (http://erc.msh.org), updated annually, and often used as international reference prices.

• IDA Foundation IDA is a not-for-profit supplier of a wide range of good quality medicines to LMIC. While IDA prices are included in the MSH suppliers list, they were analyzed separately to see if they differ from the MSH price and potentially offer savings for UNRWA if purchased. Most IDA prices for tablets and capsules on the MSH website are for bulk packs. As UNRWA has limited ability to repack medicines, a separate analysis of prices for overall prices with blister packs was undertaken; however, this analysis used 2011 prices (2010 prices could not be accessed).

• Joint Procurement Department (JPD) in Jordan JPD was chosen as Jordan is a host country and they procure only products that have been approved for marketing, and passed quality testing, by the Jordan Food and Drug Administration (JFDA). JPD procures for the Ministry of Health, Royal Medical Services, Jordan University Hospital, King Abdullah University Hospital, King Hussein Cancer Centre and the Prince Hamza Hospital. Most medicines, but not all, were in unit packs. JPD publishes their prices on the internet (www.jpd.gov)

• Gulf Cooperation Council (GCC)3 GCC pools the procurement of medicines across six countries in the Arab Gulf region (United Arab Emirates, Bahrain, Kingdom of Saudi Arabia, Oman, Qatar and Kuwait). Tender quantities can be very large. While the quantity of each medicine was available, for tablets and capsules the pack size and whether loose tablets or in blisters was largely known.

Efforts to collect procurement prices from the Ministries of Health in Lebanon, Syria and Egypt were unsuccessful.

3.4 Analysis

UNRWA procurement prices for 2010 were available in US$ for central and local purchases. The price included freight to either the port or place of destination.4 Any discounts had been deducted. The median price for the purchasing unit was used (not the average although a comparison of the two showed very similar results).

Only central (tender) prices were included in the international price comparison, thereby reducing the number of medicines in this analysis from 80 to 77.5 A separate analysis was undertaken comparing central and local purchases for each field (which was intended to all medicines procured both locally and centrally to provide a greater dataset).

MSH 2010 median supplier prices (in US$) were used in the price comparison (or median buyer prices where no supplier prices were available). As MSH is EX-WORKS prices, 15% was added to cover insurance and freight charges.6

IDA prices were accessed from the MSH website. IDA’s standard handling fee of 1.5% (applied to orders over 5000 euro) was added plus 15% to cover insurance and freight (IDA prices are EX- Amsterdam).

JPD prices, from the 2010 tender, were converted to US$ using the exchange rate of 1 Jordanian Dinar = US$ 1.41 (official fixed rate). No freight charges were added as JPD prices are to the central warehouse.

GCC prices for the 2010 tender were provided in US$. They include freight charges to the central warehouse in each of the six countries in the GCC.

Unit prices (tablet, dose, milliliter etc.) were converted to UNRWAs standard purchase packs (known as ‘units’). For tablets or capsules the unit is 100. Most units for liquid preparations are 100 milliliters.

For some liquid preparations, GCC permits supply within a usually narrow pack size e.g. chlorphenamine 2mg/5ml oral solution could be supplied in bottles of 100 - 120ml, ferrous sulphate as 20-30ml and nystatin suspension in 30-60ml. As the actual pack size supplied was unknown, the analysis was based on the UNRWA purchase unit of 100ml for chlorphenamine, 30ml for nystatin and 30ml for ferrous sulphate.

3 Data provided by a company supplying medicines to GCC 4 Delivery terms were either CFR, CPT, DDU or DDP 5 Warfarin 5mg tablets, biperiden 2mg tablets and benzyl benzoate application were only purchased locally 6 As advised by MSH

Medicines and/or prices were not included in the analysis where pack sizes were significantly different e.g. silver sulphadiazine cream procured in 500g jars when the UNRWA pack was 30g tubes, the price of 1 ml premixed insulin in determining the MSH price (UNRWA only procures 10ml vials).

Across the analysis the only differences in medicine strengths were:

• benzylpencillin benzathine - the GCC price was for 1MIU/vial whereas UNRWA and IDA prices were for 1.2MIU/vial • miconazole oral gel - the MSH price was for 25mg/ml whereas UNRWA, JPD and GCC prices were for 24mg/ml • paracetamol infant suppositories – the IDA price was for 120mg whereas UNRWA, JPD and GCC price was for 125mg • iron and folic acid tablets - the GCC price was for 45-105mg+350-500mcg whereas UNRWA was 100-105mg+325-400mcg

Note: The government of Israel imposes various restrictions on the supply of medicines to Gaza and West Bank. This can result in higher freight charges and greater documentation requirements compared to Syria, Jordan and Lebanon fields. Some of these extra costs are difficult to quantify so were not included in the analysis, however, it must be remembered that they do impact on medicine prices and expenditure.

4. Findings

4.1 International price comparisons for centrally procured medicines

As shown in Table 2, there was little difference between UNRWA prices and comparator prices across the medicines where there were matches.

Overall UNRWA procurement prices were:

• 1% less than MSH prices (across 68 medicines) with half the medicines between 34% below the MSH price to 49% above. • 12% higher than IDA prices (across 52 medicines, bulk packs for tablets/capsules), with half between 24% below to 57% above IDA prices. Using IDA prices for blister packs, UNRWA prices were 10% less than IDA prices (44 medicines). Note: prices for IDA blister packs were only available for 2011 while UNRWA prices were for 2010. • The same as the prices paid by JPD (across 56 medicines) with half between 27% below JPD prices to 47% above. • 2% less than GCC prices (across 62 medicines). Half the medicines were 41% below to 39% above the prices paid by GCC.

Annex II gives the ratios of UNRWA prices to MSH, IDA, JPD and GCC prices for individual medicines.

Table 2. Summary of ratios of UNRWA prices to MSH, IDA, JPD and GCC prices IDA IDA MSH JPD GCC (bulk) (blister 2011) Median Ratio of UNRWA price to comparator price 0.99 1.12 0.90 1.00 0.98 25th percentile Ratio 0.66 0.76 0.56 0.73 0.59 75th percentile Ratio 1.49 1.57 1.31 1.47 1.39 Maximum Ratio 20.93 9.94 4.00 2.96 7.55 Minimum Ratio 0.08 0.23 0.16 0.23 0.14 Number of medicines 68 52 44 56 62

The widest variation was seen when comparing with MSH prices. As shown in Table 3, UNRWA prices were more than three times MSH prices for five medicines, two of which were acetylsalicylic acid tablets, with benzylpenicillin benzathine about 20 times the MSH price. UNRWA procured five medicines at 30% or less of the MSH price, two of which were paracetamol paediatric suppositories.

Table 3. Five highest and lowest priced medicines compared to MSH Medicine Strength & Dose Form Price Ratio Benzylpenicillin benzathine 1.2MIU vial 20.93 Acetylsalicylic acid 500mg tablet 9.55 Highest Ratios Chlorphenamine 4mg tablet 5.23 Acetylsalicylic acid 100mg tablet 4.80 Digoxin 0.25mg tablet 3.39 Paracetamol Children 250mg suppository 0.29 Paracetamol Infant 125mg suppository 0.25 Lowest Indomethacin 100mg suppository 0.25 Ratios Salbutamol 0.5% resp. solution 0.10 Miconazole 2% oral gel 0.08

When compared to IDA (bulk prices), UNRWA prices varied from about 10 times the price for acetylsalicyclic acid 500mg tabs to 23% of the IDA price for paracetamol infant suppositories (as shown in Table 4). Whereas UNRWA was paying over three times the MSH price for digoxin tablets, they were only paying 24% of the IDA price. This indicates how variable an individual supplier price can be compared to MSH’s median supplier price.

Table 4. Five highest and lowest priced medicines compared to IDA (bulk packs) Medicine Strength & Dose Form Price Ratio Acetylsalicylic acid 500mg tablet 9.94 Acetylsalicylic acid 100mg tablet 4.74 Highest Ratios Chlorphenamine 4mg tablet 4.55 Benzylpenicillin benzathine 1.2MIU vial 4.00 Metronidazole 250mg tablet 2.37 Erythromycin Ethylsuccinate 125mg/5ml susp. 0.40 Azithromycin 250mg tablet 0.37 Lowest Salbutamol 0.5% resp solution 0.31 Ratios Digoxin 0.25mg tablet 0.24 Paracetamol Infant 125mg suppository 0.23

As shown in Table 5, UNRWA paid at least twice the JPD price for four medicines (azithromycin suspension, chlorphenamine tablets, gliclazide and salbutamol inhaler). Conversely, UNRWA prices for five medicines were up to 44% of JPD prices.

Table 5. Five highest and lowest priced medicines compared to JPD Medicine Strength & Dose Price Ratio Form Azithromycin 200mg/5ml susp. 2.96 Chlorphenamine 4mg tablet 2.91 Highest Ratios Gliclazide 80mg tablet 2.02 Salbutamol 100mcg/dose inhaler 2.00 Cefuroxime 750mg vial 1.95 Acetylsalicylic acid 100mg tablet 0.44 Sodium Valproate 200mg tablet 0.41 Lowest Frusemide 40mg tablet 0.32 Ratios Hydrochlorothiazide 25mg tablet 0.25 Mebendazole 100mg/5ml susp. 0.23

The comparison of UNRWA prices to GCC prices showed the least variation across the medicines in the analysis. UNRWA was paying over twice the GCC price for three medicines (benzylpenicillin benzathine7, chlorphenamine tablets and cefuroxime). UNRWA was paying 20% or less of the GCC price for four medicines as shown in Table 6 (hydrochlorothiazide, indomethacin suppos, carbamazepine, and nifedipine).

7 Note: the GCC price is for the 1MIU/vial strength while the UNRWA price is for 1.2MIU/vial

Table 6. Five highest and lowest priced medicines compared to GCC Medicine Strength & Dose Form Price Ratio Benzylpenicillin benzathine 1.2MIU vial 7.55 Chlorphenamine 4mg tablet 3.34 Highest Ratios Cefuroxime 750mg vial 2.99 Nystatin 100000U/ml susp. 1.78 Co-Amoxiclav 500+125mg tablet 1.78 Hydrochlorothiazide 25mg tablet 0.20 Lowest Indomethacin 100mg suppository 0.15 Ratios Carbamazepine 200mg tablet 0.15 Nifedipine 20mg SR tablet 0.14

4.2 Potential savings when purchasing at IDA, JPD or GCC prices

Expenditure is based on the unit price and quantity procured so it is important to focus not only on price ratios but also on actual prices and tender quantities. Annex III lists UNRWA and comparator prices in US$, by UNRWA purchasing unit, and UNRWA’s tender quantities. This data enables assessments of potential savings if UNRWA purchased at IDA, JPD or GCC prices.

Annexes IV-VI show expenditure for each medicine, based on the UNRWA tender quantity, if procured at IDA, JPD or GCC prices. The key finding is summarized in Table 7, that is, there is no net savings if all medicines where there were matches were procured at IDA, JPD or GCC prices.

Table 7. Annual savings if medicines procured at IDA, JPD or GCC prices Source Number of Annual Net Savings $ Medicines IDA 52 - 125,558 JPD 56 - 360,580 GCC 62 - 1,884,408

Savings may be possible if some individual medicines could be procured at IDA, JPD or GCC prices. Apart from sourcing from IDA, achieving savings will require negotiating with companies to provide medicines at the JPD or GCC price or joining their tenders. For competitive negotiation, a limited list of medicines would be desirable. Three approaches were used to identify a limited number of medicines which offered the greatest savings potential:

• Medicines where potential annual savings exceed US$ 100,000 • UNRWA’s Top 10 medicines by expenditure • Antidiabetic medicines

Medicines where potential annual savings exceed US$ 100,000 Table 8 lists medicines where annual savings exceeding US$ 100,000 may be possible. For two medicines, benzylpenicillin benzathine and co-amoxiclav tablets, savings would be greatest if procured at GCC prices, whereas savings are greatest if gliclazide tablets were procured at the JPD price (rather than the GCC price). Savings of about US$ 73,000 may be possible if acetylsalicyclic acid was purchased at GCC prices. Paracetamol is available from IDA in blister packs. Even buying this medicine in blister packs, savings may be possible (based on the 2011 blister pack price savings of about US$ 79,000 would be possible)

Table 8. Annual savings over US$ 100,000 for individual medicines procured at IDA (bulk), JPD, GCC prices Strength & Annual Savings $ Medicine Quantity Dose Form IDA JPD GCC Acetylsalicylic acid 100mg tab 293,790 x100 228,351 73,039

Acetylsalicylic acid 500mg tab 44,000 x100 169,734

Benzylpenicillin 1.2MIU vial 100,685 vials 210,690 243,822 benzathine Paracetamol 500mg tab 272,690 x100 100,648 ($79,297 blister 2011 price) Co-Amoxiclav 500+125mg tab 50,480 x100 389,696 393,109

Co-Amoxiclav 250+62mg/5ml 209,110 235,070 susp. x100ml Gliclazide 80mg tab 159,725 x100 210,907 119,416

Azithromycin 200mg/5ml susp. 88,940 x100ml 144,489

Enalapril Maleate 10mg tab 603,500 x100 109,222

Insulin 30/70 Premixed 100IU/ml vial 476,650 x10ml 467,624 vials

UNRWAs Top 10 medicines by expenditure Figure 1 shows price ratios of the top 10 medicines by total expenditure procured by UNRWA, and Table 9 gives actual prices for UNRWA purchasing units. Premixed insulin is being procured by UNRWA at a lower price than MSH and JPD, but is 46% higher priced than the GCC price (US$ 2.12 a vial). While the UNRWA price for co-amoxiclav tablets is lower than the MSH and IDA price, it was considerably higher (at about US$ 8 for 100 tablets) than the JPD and GCC price. For enalapril, only JPD was paying a lower price than UNRWA (about US$ 0.83 for 100 tablets compared to about US$ 1.01 paid by UNRWA). For amoxycillin 500mg capsules, UNRWA was paying 10-15% more than MSH, IDA and JPD. JPD was also paying lower prices for co-amoxiclav 250+62mg/5ml suspension (about US $1.47 a bottle compared to US$ 2.66 paid by UNRWA) and cephalexin capsules (US$ 4.91 versus US$ 5.44). For metformin, amoxicillin suspension and paracetamol suspension, UNRWA was paying similar or lower prices than the comparators. But for gliclazide, UNRWA paid twice the JPD price and 40% more than the GCC price.

Figure 1. Price ratios (UNRWA prices to comparator prices) for UNRWA top 10 medicines by expenditure 2.5 MSH IDA JPD GCC

2 UNRWA higher than 1.5 comparator

UNRWA 0.5 lower than comparator

Tab/cap unless stated

Table 9. UNRWA and comparator prices for top 10 medicines by expenditure, for UNRWA purchasing units Strength, Dose Medicine Form, Purchasing UNRWA $ MSH $ IDA $ JPD $ GCC $ Units Premixed 30/70 100IU/ml 3.1023 5.6776 n/a 3.1735 2.1200 insulin 10ml vial 500+125mg tablet Co-Amoxiclav 18.2052 21.4360 19.4905 10.2676 10.2000 x100 250mg/5ml Amoxycillin 0.7097 0.6900 0.7340 0.6603 0.8300 susp. 100ml 10mg tablet Enalapril 1.0109 1.7250 n/a 0.8319 1.6100 x100 500 mg capsule Amoxycillin 3.8275 3.3350 3.3785 3.4827 3.9600 x100 250+62mg/5ml Co-Amoxiclav 2.6566 3.5075 n/a 1.4664 n/a susp. 100ml 500mg capsule Cephalexin 5.4400 7.7280 7.4910 4.9124 n/a x100 500mg tablet Metformin 0.9665 1.2075 0.9786 1.0857 1.0200 x100 80mg tablet Gliclazide 2.6169 7.5900 n/a 1.2972 1.8700 X100 250mg/5ml Paracetamol 0.3504 n/a n/a 0.5866 n/a susp. 100ml n/a – no data available

Table 10 shows potential savings if UNRWA procured at the lowest price for these top 10 medicines, except for amoxicillin 500mg caps where the JPD price is used as the IDA price is for a bulk pack. If UNRWA paid the JPD tender price for 6 medicines (amoxicillin suspension and tablets, enalapril, co-

19 amoxiclav suspension, cephalexin tablets and gliclazide) and the GCC tender price for 2 medicines (premixed 30/70 insulin and co-amoxiclav tablets), the combined savings across the 8 medicines would be about US$ 1.5 million. This equate to approximately 10% of UNRWA’s General Fund expenditure on medicines.

Table 10. Potential savings of UNRWA top 10 medicines at lowest comparator price Annual Strength, Dose Annual Medicine Source Price $ Quantity Expenditure Form, Quantity Savings $ $ UNRWA Premixed 100IU/ml 3.1023 1,478,122 476,650 30/70 insulin 10ml vial GCC 2.1200 1,010,498 467,624 UNRWA 500+125mg 18.2052 908,005 Co-Amoxiclav 50,480 tablet x100 GCC 10.2000 514,896 393,109 UNRWA 250mg/5ml 0.7097 679,603 Amoxycillin 963,990 susp. 100ml JPD 0.6603 636,523 43,080 UNRWA 1.0109 611,274 Enalapril 10mg tablet 603,500 x100 JPD 0.8319 502,052 109,222 UNRWA 500 mg capsule 3.8275 606,882 Amoxycillin 158,655 x100 JPD 3.4827 552,548 54,334 UNRWA 2.6566 541,709 Co-Amoxiclav 250+62mg/5ml 209,110 susp. 100ml JPD 1.4664 306,639 235,070 UNRWA 5.4400 451,402 Cephalexin 500mg capsule 82,955 x100 JPD 4.9124 407,511 43,891 UNRWA 80mg tablet 2.6169 418,102 Gliclazide 159,725 x100 JPD 1.2972 207,195 210,907 Total potential annual savings 1,557,240

Antidiabetic medicines UNRWA currently purchases six medicines to treat diabetes:

• Insulin - premixed 30/70, isophane and neutral • Oral hypoglycaemics – glibenclamide 5mg tablets, metformin 500mg tablets and gliclazide 80mg tablets

Expenditure on these six medicines totals US$ 2,592,607 for central and local procurements (17% of General Fund medicine expenditure) excluding syringes and needles. This is likely to increase in coming years as the prevalence of diabetes increases.

As shown in Table 11, if all six medicines were purchased at GCC prices there would be a net annual savings of US$ 596,217 (based on central procurement figures). If the three insulins only were procured at GCC prices the savings would still be significant at US$ 513,357. If gliclazide was added, the savings would increase to US$ 632,773. However, as shown in Table 10, greater savings are possible if gliclazide was procured at the JPD price.

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Table 12. Current suppliers of medicines where savings show potential greatest Strength & UNRWA supplier JPD GCC Medicine Dose Form Supplier supplier Acetylsalicic acid 100mg tab Gulf UAE Gulf UAE Azithromycin 200mg/5ml susp. Gulf UAE Hayat Jordan Benzylpenicillin 1.2MIU vial Atral Portugal Sandoz Austria benzathine Co-Amoxiclav 500+125mg tab Gulf UAE SPIMACO KSA Co-Amoxiclav 250+62mg/5ml susp. Atral Portugal Ram Jordan Enalapril 10mg tab Remedica Cyprus Ram Jordan Gliclazide 80mg tab Medochemie Cyprus MedPharma Jordan Insulin30/70 100IU/ml vial NovoNordisk NovoNordisk Premixed Insulin isophane 100IU/ml vial NovoNordisk NovoNordisk Insulin neutral 100IU/ml vial NovoNordisk NovoNordisk Salbutamol 100mcg/dose inhaler Durbin UK Drogsan Turkey

Taking into account supplier performance, the need for blister packs (ideally unit packs) etc. it is recommended that UNRWA review the procurement of a limited list of 9 medicines that have the greatest savings potential. If the comparator price could be achieved for these medicines the total annual savings could be US$ 1,665,433 (about 10% of General Fund medicine expenditure).

Table 13. Recommended medicines that offer greatest potential for savings Strength & Annual Savings $ Medicine Dose Form IDA JPD GCC Azithromycin 200mg/5ml susp. 144,489

Benzylpenicillin benzathine 1.2MIU vial 243,822

Co-Amoxiclav 500+125mg tab 393,109

Gliclazide 80mg tab 210,907

Insulin 30/70 Premixed 100IU/ml vial 467,624

Insulin isophane 100IU/ml vial 38,816

Insulin neutral 100IU/ml vial 6,916

Paracetamol 500mg tab 79,297

Salbutamol 100mcg/dose inhaler 80,453

Note: paracetamol savings based on 2011 IDA price

4.3 Price and quantity by supplier

In the JPD and GCC tenders some medicines are being supplied by the same pharmaceutical company as was awarded in the UNRWA tender (see Table 14 and Annex VII). This enables an analysis of price versus quantity to see if there is a correlation.

For some companies, such as API in Jordan, lower unit prices are given for larger quantities e.g. UNRWA tendered for 239,600 bottles of gentamicin eye drops and paid less than JPD who tendered for 166,550 bottles. Gulf Pharmaceuticals supplied to all three tenders - in some cases the price was lower for higher quantities but in a number of cases larger quantities, particularly seen with the GCC tender, did not result in lower prices. For example, for mebendazole susp. GCC was purchasing twice the quantity of UNRWA but paying twice the price. While this favored UNRWA, in the case of ferrous sulphate solution UNRWA was purchasing more than GCC but paying a higher unit price (about US$ 0.062 a bottle for 529,000 versus the GCC price of US$ 0.051 for 432,250 bottles).

Nifedipine SR tablets are supplied by United Pharmaceuticals to UNRWA and JPD. UNRWA is purchasing about 50% more tablets than JPD but paying a higher price (about 23% higher). However, JPD was buying in bulk packs hence the lower unit cost compared to UNRWA.

Questions should be asked of suppliers where UNRWA is paying higher prices for larger quantities i.e. acetylsalicylic acid 500mg tab and ferrous sulphate solution from Gulf Pharmaceuticals (note: it was assumed GCC was buying in the same pack size as UNRWA but this could not be confirmed) and digoxin tablets from GlaxoSmithKline.

It was noted that most medicines in the analysis procured by UNRWA were branded generics. In the few cases where originator brands are being procured it is predominantly because of the limited number of suppliers (e.g. insulin and thyroxine tablets).

Table 14. Prices and quantities of medicines supplied to UNRWA, JPD and GCC by the same pharmaceutical company UNRWA JPD GCC Medicine Price $ quantity Price $ quantity price quantity Amman Pharmaceutical Industries Company (API), Jordan Gentamicin eye drops 5ml 0.2591 239,600 0.3173 166,550 Prednisolone eye drops 5ml 1.2653 21,400 0.8249 31,700

Gulf Pharmaceuticals Industries (Julphar), UAE Acetylsalicylic acid 100mg 1.0936 247,790 0.7500 1,928,013 100 Acetylsalicylic acid 500mg 4.1500 12,382 100 4.2833 44,000 Co-trimoxazole susp. 100ml 0.5781 255,300 0.6227 72,460 Ferrous Sulphate soln. 30ml 0.5100 432,250 0.6195 529,000 Mebendazole susp.30ml 0.8900 384,270 0.4311 176,600 Paracetamol Infant suppos 2.3829 24,750 3.5500 185,191 100 2.4050 12,700 Paracetamol Children suppos 2.7055 28,350 5.1000 21,798 100 3.0685 10,090 Ranitidine 150mg tabx100 0.7900 1,294,274 1.2465 18,800 Salbutamol oral liq. 0.4892 134,250 0.2585 225,700 100/120ml GlaxoSmithKline, UAE/Germany Digoxin 0.25mg tab 100 2.8041 20,570 2.3462 20,000 6.5300 54,225 Salbutamol resp soln 20ml 2.0275 2,050 2.0900 685,066

Merck, Germany Thyroxine 100mcg tab 100 3.8000 5,000 3.0000 146,165 NovoNordisk Denmark/Jordan Insulin Premixed 10ml vial 3.1023 476,650 3.1735 502,000 2.1200 1,958,500 Insulin Isophane 10ml vial 3.1459 37,370 3.1759 800 2.1200 893,010 Insulin Neutral 10ml vial 3.1647 6,590 3.1738 11,400 2.1200 718,660 Remedica, Cyprus Enalapril 10mg tab 100 1.0109 603,500 1.6100 149,875 United Pharmaceutical Manufacturing Company, Jordan Nifedipine 20mg SR 100 1.4419 56,800 1.1703 37,100

4.4 Comparison of prices from local and central procurements

While Jordan, Lebanon and Gaza generally procure medicines centrally, Syria and West Bank buy both centrally and locally.

Table 15 compares the price of locally procured versus centrally procured medicines. Prices are expressed as ratios of local price to central price. Overall Jordan and Syria are paying 7% (ratio 0.93) and 20% (ratio 0.80) less respectively when procuring locally, however, the Jordan data is based on only 5 medicines. Overall Lebanon, West Bank and Gaza are paying 83%, 128% and 92% more respectively when procuring locally, although the data for Gaza is based on a comparison of prices for only 7 medicines.

Not surprisingly the quantity of each medicine procured locally is small compared to the central tender quantity. For example, across the 30 medicines that are procured locally by the Syria field and centrally by UNRWA HQ, the Syrians buy in general only 8% of what is procured centrally but pay 20% less. Overall Lebanon, West Bank and Gaza are only buying 3%, 5% and 16% respectively of what UNRWA HQ is buying centrally, but they pay on average about twice the price.

Table 15. Summary of ratios of prices for locally procured versus centrally procured medicines Median th th Number of Field 25 %ile 75 %ile Max. Min. Price Ratio medicines Jordan 0.93 0.85 2.26 3.01 0.40 5 Syria 0.80 0.50 0.95 2.93 0.12 30 Lebanon 1.83 0.83 2.24 3.17 0.35 11 West Bank 2.28 1.48 3.12 9.00 0.82 18 Gaza 1.92 1.61 3.37 7.30 1.14 7

Annex VIII lists the ratios of price and quantity for individual medicines by field. The pharmaceutical companies supplying the medicines are not listed in the annex as they tend to be specific to the field. There was only one example where a company (Birzeit Pharm.) was supplying ranitidine tablets via the central tender and locally in the West Bank. The central tender price was US$ 1.1750 a unit (purchasing 49,800 units), whereas the West Bank procured substantially less (10,000 units) and not unexpectedly paid more (US$ 2.2000 a unit). Interestingly, Jordan field procured 5,400 units of miconazole 2% oral gel from Dar Al Dawa at US$ 0.6992 a unit, whereas GCC procured nearly 7 times the quantity of the identical product but paid a higher price of US$ 0.7500 a unit. This example illustrates that buying large quantities does not necessarily result in lower prices. Many other factors can influence pricing.

4.5 Medicine procurement process

4.5.1 Responsibilities

Finance Department HQ The Finance Department determines the overall field budget (but not the pharmaceutical budget which is done by the field – see below) and makes payment to suppliers.

Procurement Department (PLD/CPLD) HQ Broad responsibilities of PLD staff (mainly accountants, supply officers and others) include:

- Managing the procurement system (maintaining the list of prequalified suppliers, tender document preparation, announcing tenders, evaluating bids, preparing contract award documents etc.) - Revising the Procurement Manual as needed - Managing the procurement information system - Reviewing supplier performance - Approving local procurements (required for purchase orders over US$ 10,000)

Health Department HQ Medicine issues have been delegated by the Director of Health to the Senior Pharmacist, Medical Care Service Division (under the supervision of the Deputy Director). Responsibilities of the Senior Pharmacist include:

- Reviewing the Rational Drug List every two years in collaboration with field pharmacists, field disease prevention and control officers, and field family health officers. - Evaluating dossiers as part of the prequalification of suppliers - Evaluating any discrepancies between samples/packaging of awarded products and those received by the field (if problems reported) - Annual field inspections of storage conditions and the availability of medicines at PHCs, and local procurement specification at the Central Pharmacy. - Recommending specific conditions for contracts with suppliers - Coordinating the redistribution of surplus stock - Training e.g. WHO guidelines on storage management, use of a formulary etc.

Note: it is expected that the terms of reference of this position will soon refocus to more clinical issues including undertaking rational drug use studies, review of prescribing practices, drafting new and revising existing standard treatment guidelines, and consulting with drug and therapeutic committee members at HQ and field level.

Field Office / Central Pharmacy The Field Director sets the pharmaceutical budget, and the field finance officer authorizes local procurements below US$ 10,000 per purchase order.

In each field, the responsibilities of the Field Pharmacist include:

- Quantification after collation of consumption from PHCs - Recommending the budget allocation for medicines - Inspecting products received, ensuring appropriate storage and distribution etc.

- Prequalifying suppliers for local purchasing and undertaking local purchases - Reporting medicine quality concerns and surpluses to the Health Department, and stock ruptures to PLD - Ensuring the testing of products by JFDA - Inspecting PHCs for storage, availability issues including a physical stock-take against stock records.

Jordan field has a Deputy Pharmacist (as in other fields) who assists the Field Pharmacist. From August 2011 the Deputy Pharmacist is part of the PLD and not the Health Department (as was formerly the case). The roles and responsibilities of the Health and Procurement Department need to be segregated as there is a conflict of interest if Procurement Department staff is responsible for quantification, receipt of goods and product testing, and issuing stock to PHC.

In other fields, there is no deputy pharmacist and the field pharmacist alone is responsible for quantification, local procurements, receipt of goods and product testing, and issuing stock to PHC. Because of the recent change in Jordan field, and the need for segregation of responsibilities, different systems will operate across fields. This is not ideal.

Primary Health Centers (PHCs) In addition to dispensing medicines and providing other services, pharmacy assistants in PHCs are responsible for:

- Quantification - Receiving medicines and ensuring appropriate storage - Undertaking daily stock takes for the most dispensed medicines (usually about 50) and monthly stock-takes for all other medicines - Reporting expired stock, surpluses, stock ruptures and storage condition problems to the Central Pharmacy - Monitoring the cold chain

4.5.2 Key issues

Budget The pharmaceutical budget is set at the field level and rarely includes a budget for emergency purchases. There is no opportunity for the Health Department or PLD to undertake inter-field transfers to balance any budget deficit or surplus. Because of budget inequalities some fields are able to treat hypercholesterolaemia with statins whereas others have no means to purchase any medicines to treat this condition.

Medicine selection A Rational Drug List (RDL), updated in 2010, is used to procure medicines centrally. Some non-RDL medicines are procured locally at the field level if funds are available. A review of medicine procurements in 2010 shows strong adherence to the list. The current list includes medical supplies.

Drug and Therapeutic Committees (DTC) have been established in each field but rarely meet in some fields. Updating the RDL is predominantly undertaken by a limited number of people and does not always include input from the field. It may be useful to invite external experts, such as a clinical pharmacologist etc. As a member of the DTC (or other relevant committees).

Quantification Quantification, undertaken by the Central Pharmacy in each field, is based primarily on consumption in the previous year rather than on patient need. Annual increases are about 10%. There is no evaluation to ensure the adequacy of the quantification process.

It was felt by field staff that quantifying based on need should be possible. Capacity building will be needed, an effective and efficient system established, and monitoring to ensure needed medicines are available. An integrated computer system between PHCs and the Central Pharmacy will improve efficiency. Currently all PHCs in Syria, and some in Jordan, are computerized (although this does not generally include inventory management and the computers are not linked to the field office/central pharmacy nor to the Health Department and PLD at HQ).

Pre-qualification of suppliers Medicines in the tender process are split into four therapeutic groups: mental health medicines, topical preparations, antibiotics, and all other medicines (gastrointestinal, cardiovascular, respiratory, endocrine etc). For each group, PLD has a list of pre-qualified suppliers.

PLD undertakes market research, primarily through scanning the internet, to identify potential new suppliers whom they feel may be interested in participating in the tender. These suppliers, and others who have expressed interest, are invited to submit dossiers. On receipt they are commercially evaluated by PLD and if approved, technically evaluated by the Senior Pharmacist in the Health Department. If they meet requirements they are included in the list of pre-qualified suppliers. For local procurements, either the field pharmacist or the Senior Pharmacist at HQ evaluates the dossier. There are no clear criteria for this technical evaluation.

The current list of pre-qualified suppliers for medicines includes 100 local and international companies (see Annex VIX). In 2007 there were a total of 80 pre-qualified suppliers (excluding those in the process where it was not clear if they were finally approved or not). Figure 2 shows the number of pre-qualified suppliers for each of the four groups of medicine tenders. While the number of pre-qualified suppliers has halved since 2007 for antibiotics and medicines for mental health conditions, the number in Group 19 (gastrointestinal, cardiovascular, endocrine, respiratory, nutritional, blood, vaccines etc) has increased by 28%. As shown in Figure 3 the greatest increase in pre-qualified suppliers has been in Syria, increasing from 3 in 2007 to 14 in 2011.

Figure 2. Number of prequalified suppliers in 2007 and 2011 by medicine tender group

As tenders are now open (which commenced in 2011) it is hoped that an increased number of companies will submit bids however, they may or may not be commercially or technically acceptable.

There is consensus that increasing the list of prequalified suppliers is desirable. It may be beneficial for PLD to collaborate with field pharmacists to obtain lists of registered products/suppliers in each field from the Medicines Regulatory Authority/Ministry of Health in the country for comparison. For example, the Jordan FDA lists more than 500 registered suppliers, although it must be remembered that the Jordan pharmaceutical market is not limited as it is in UNRWA. Greater savings may result if companies from further field were to be added to the list. While negotiations between PLD and Cipla were unsuccessful, other Indian pharmaceutical companies should be considered especially those whose products are known to be registered with competent regulatory authorities.

Figure 3. Number of prequalified suppliers in 2007 and 2011 by origin of company

Jordan Syria Lebanon Palestine 2011 Egypt UAE/Oman/KSA 2007 Turkey Europe Americas Asia

0 5 10 15 20 25 30 35 40

Tenders The tender process for each group, from preparation of letters of request to fields to the issuing of purchase orders, takes 36-37 weeks (about 8 months). This is longer than the JPD tender process which is generally 4-6 months. It was reported that fields find the tender process slow hence wish to procure locally, so accelerating the process may be beneficial where local procurements are more costly than central procurements.

Tenders are advertised on the UNRWA, UNDP and UNGM websites for amounts over US$ 100,000 (which usually cover all four medicine tenders), and invitations to bid are sent to pre-qualified suppliers.

A study by the Syrian field pharmacist showed that Syrian prices can be lower than prices obtained through the central tender, and in this analysis medicines procured locally in Syria were generally lower priced than the central tender price. PLD recognizes the value of increasing the number of Syrian companies in the prequalified list (provided the products meet quality standards) and have indeed done so in the last few years. However, PLD reported that Syrian companies rarely responded to requests to tender. This warrants investigation.

At least three quotations are usually received for each medicine on the tender. This is less than JPD who reported about six quotes per medicine. Prices are not negotiated but UNRWA has the right to terminate a contract if they can get a lower price for a medicine. This rarely occurs (although a contract for insulin was once terminated for this reason).

To reduce expenditure, about 85% of awarded contracts are long term (three years), others are for one year. It was reported that 90% of suppliers increase prices from one long term contract to another (usually by 5-15%). Prices can change in a long term agreement, for example in response to a change in volume, but not in response to a company request (such as higher production costs).

Awarded prices are not published on the UNRWA website nor are any bidders told about the awarded tender price and company. Publishing such information on the UNRWA website would improve transparency which the UN promotes. Companies generally know the market so it is unlikely that the publishing of tender prices would result in clustering around that price in future tenders.

The supplier awarded the central tender either distributes directly to the port in each field (UNRWA staff transport from the port to the store) or through the Central Pharmacy in Amman which distributes to the Central Pharmacy in each field. It was reported that field staff often ask PLD for information on delivery requests. In response, PLD very recently established a system to share procurement, vendor and logistics information across HQ and the field pharmacies. Field staff input into the system when stock is received etc.

It was reported that in West Bank PHCs have insufficient and poor quality storage areas for medicines. They receive deliveries every three months and are unable to adequately store the supplies.

Quality assurance There is no requirement that the medicines awarded the tender or procured locally are registered in any of the host countries although host country governments require specific documentation before medicines are supplied.

There is also limited testing of the quality of the medicines. Product testing is only undertaken in Jordan, where the JFDA requires each batch to be tested in their laboratories before it leaves the

Central Pharmacy, and in the West Bank where products supplied by local companies are tested at Birzeit University. It was reported that JFDA has not rejected any batch for the last 7-8 years.

UNRWA has a field reporting system for quality issues. A few queries are received, and over the last 5 years there have only been two cases where the product was proven to be sub-standard and the stock recalled.

The lack of clear criteria when prequalifying suppliers, and limited quality testing, poses a potential risk to UNRWA which needs addressing.

Information technology The Central Pharmacy reported that its computer system is not user-friendly. Currently physical stock-takes are undertaken every three months. This could be reduced to annually or even eliminated if appropriate software was used, that included flagging when stock levels are low. Use of bar-coding could also improve efficiency.

Stock ruptures Stock ruptures were reported due primarily to an inadequate budget and delivery problems. They can pose a serious problem to accessing medicines, especially in Lebanon where Palestine refugees are not permitted to use government health centers and are unable to afford medicines in private pharmacies. In the past patients have stockpiled medicines, so computer software is now used to monitor medicine supply in Lebanon, Syria and Jordan.

To minimize stock ruptures, PHCs undertake daily stock-takes using tally sheets. While this did not appear onerous in the PHC the consultants visited in Amman (although not necessarily effective as salbutamol inhaler was out-of-stock at the time of the visit); it may well be a burden in others. Use of computers for inventory management, which is being piloted in six PHCs in Jordan field, should improve efficiency.

Stock ruptures appear to be rare but when they do happen, the result is a lack of stock for many months and even a year. It seems there is some confusion about responding to stock ruptures. Issues raised in discussions with UNRWA staff include: • low stock levels are not flagged early enough to purchase from alternate suppliers and ensure continuous availability of the product • Local purchases are not always made (with the increased cost met by the tender awarded supplier). There seems to be a number of reasons for this including a lack of funds for such purchases, PLD staff not knowing what field staff wants them to do, and/or field staff not knowing they can purchase locally without PLD involvement and with the increased cost met by the awarded supplier.

An integrated IT approach that links PHCs, the Central Pharmacy, Health Department and PLD should result in a more equitable distribution of stock (reduce ruptures) and a lower inventory burden. Such a system needs to be able to produce reports in a timely and efficient manner.

Training While there is training by HQ staff on various issues, it appears to be on an ad hoc basis and there is no training for new staff. This is not unusual in organizations of UNRWA’s size. It would be advantageous if a training module was developed for new staff. Because UNRWA’s procurement process was relatively recently decentralized and no training was given at that time, consideration should be given to establishing a systematic approach to ongoing training, especially for field staff on procurement-related issues.

Communication While there are frequent telephone calls etc between the field and HQ, it was reported that there is little knowledge sharing on practices, operational issues etc. between field staff and HQ staff. Field staff only meets once every two years which is insufficient. Again this is not surprising especially when working in a decentralized system spread over multiple countries. Consideration should be given to establishing regular meetings (face-to-face, skype or similar) between the field, Health Department, Procurement Department and PHC that foster open discussions and promote feedback from the field on how processes could be made more efficient etc.

It was reported that there is also poor communication when new protocols are set. A contributing factor is that protocol development appears to be undertaken without input from key doctors and other PHC staff, and field pharmacists. Stock levels are not considered when protocols change and phase-in periods are not given.

Rational use While the objective of this review is to see if efficiency gains are possible in pricing and procurement, efficiencies can also result through the improved use of medicines (demand driven). It was reported that patients have an expectation that they will receive a medicine when they visit a health clinic which indicates that a greater focus on rational medicine use is needed. Pharmacists are trained in medicine management so are best placed to work with doctors and other health centre staff on medicine use issues. It should be possible for UNRWA field pharmacists to take a greater role in this, rather than focusing predominantly on inventory management as is the current practice (although it is crucial that a pharmacist be involved in procurement). However, the number of patients is great so to really make a difference UNRWA should look to employ more pharmacists to work on clinical issues. It would be hoped that this would result in better use of medicines and hence improved health outcomes for refugees.

5. Study Limitations

Limitations in undertaking this study included: • The limited number of comparators for the international price comparisons. • For some liquid medicines there were slightly variable strengths and pack sizes across comparators. • For tablets and capsules, IDA prices were for bulk packs and the pack sizes used in the GCC tender were unknown. • No adjustments were made for higher freight charges and greater documentation requirements for medicines to Gaza and West Bank fields. • Any savings are only potential. Competitive negotiation may not result in the prices of comparators, and joining the JPD and/or GCC tender may not be possible or feasible. • The consultants only visited HQ and Jordan field, although they did discuss the findings of the study with Field Pharmacists from Syria, West Bank and Gaza. No contact was possible with the Field Pharmacist from Lebanon.

6. Conclusions and Recommendations

6.1 Medicine Prices

• Overall UNRWA is procuring medicines efficiently

Overall centrally procured medicines were procured at efficient prices when compared with MSH, IDA, JPD and GCC. Total expenditure would increase if all medicines in the analysis were purchased at IDA, JPD or GCC prices.

• Explore procurement options for a limited list of medicines

Savings are possible if some individual medicines were purchased at IDA, JPD or GCC prices. UNRWA could explore options to procure a limited number of medicines at IDA, JPD or GCC prices. Such options include competitive negotiation with suppliers or joining the JPD and/or GCC tenders. Where a low price is obtained, an extended agreement is likely to be beneficial. In addition, IDA should be actively encouraged to submit bids to UNRWA tenders.

• Investigate companies where UNRWA pays more despite larger quantities procured

A few companies are supplying UNRWA at higher prices despite larger quantities procured than JPD and/or GCC. Such situations warrant investigation to ascertain the reasons for this.

• Monitor the prices of the top 20 medicines annually

With budget restraints and a dynamic market, there is a need to regularly monitor prices in order to make informed decisions on the optimum procurement process, bids, contract termination etc. However, price monitoring can be time-consuming hence limiting the review to the top 20 medicines by expenditure is recommended. Consideration of useful comparators is needed; they should be a mix of regional and international sources. For sources whose prices are not publicly accessible, relationships would need to be forged (such as with the medicine procurement department in Syria, Lebanon etc) so that price data can be easily obtained.

• Request WHO to establish a regional procurement price database

A longer term option is to request WHO EMRO to establish a regional procurement price database that UNRWA could both contribute to and access prices paid in countries in the region.

6.2 Procurement process

• Develop minimum regulatory standards for prequalifying suppliers and product quality assurance

The lack of clear criteria when prequalifying suppliers and limited product quality testing poses a potential risk that UNRWA could purchase and distribute substandard products. It is recommended that UNRWA, in collaboration with WHO EMRO and experts, develop

minimum regulatory standards for prequalifying suppliers and product quality assurance based on WHO’s Model Quality Assurance System for Procurement Agencies. The development of regulatory standards and exploration of procurement options could be assisted by reviewing pooled procurement mechanisms such as the Eastern Caribbean Pharmaceutical Procurement Service. HAI has contacts with PAHO so could facilitate the sharing of lessons learnt with UNRWA.

Defining and establishing regulatory standards should be a high priority as the current system exposes UNRWA to risk.

• Improve inequalities in the pharmaceutical budget

To improve inequalities in pharmaceutical budgets across fields, budget setting should be re- centralized to HQ with an emergency budget allocation in each field for local purchases. This should be considered a high priority.

• Assess IT needs

Efficiency gains are expected if the current IT system was more user-friendly. It has been agreed that a new, integrated system will be introduced over the next few years for inventory management (flagging of low stock levels, tracking deliveries etc) as well as quantification, standard reporting etc. This should be considered a high priority.

• Expand the search for potential suppliers particularly from outside the Middle East

Expanding the list of prequalified suppliers is also recommended. This should start with reviewing registered suppliers in the region. Consideration should particularly be given to identifying suppliers from outside the region who are supplying products registered with competent regulatory authorities and are likely to have competitive prices (such as some suppliers from India including Dr Reddy’s).

• Base quantification on need rather than consumption

To improve access to needed medicines, it is recommended that quantification be based on need rather than consumption. Capacity building will be essential, and it is recommended that a pilot be undertaken using one therapeutic group. Monitoring and evaluation will be needed to ensure medicines are available.

• Identify options to hasten the tender process

Some fields find the tender process slow hence wish to procure locally, which will likely increase expenditure in most fields. It is recommended that PLD review the JPD process, which is two months faster, to identify options to hasten the tender process.

• SOP on responding to late deliveries

Standard Operating Procedures (SOPs) need to be developed by PLD, in collaboration with the Health Department and field staff, on how fields should respond to stock shortages due to late deliveries and other causes.

• Consider field pharmacists in medicine management

Medicine demand side issues should not be overlooked. Consideration should be given for field pharmacists to work with patients, doctors and other PHC staff in medicine management (supporting doctors and patients to make best choices and use of medicines, providing drug information and education programmes etc) rather than the current practice of focusing predominantly on inventory management. That said, we are not recommending that pharmacists be excluded from the procurement process. Employing more pharmacists may be needed.

It is essential that roles and responsibilities of field pharmacists and deputy pharmacists be clarified. Quantification, receipt of goods, product testing, and issuing stock to PHCs should be segregated from procurement activities, and there should be consistency in the process across fields.

• Regular meetings between HQ and field staff

Knowledge sharing and feedback, especially from the field, will likely benefit PLD, Health Department and field staff. While face-to-face discussions are preferable, budget and time constraints are such that skype and other options should be explored.

• Improve transparency by publishing tender awards

Just as UNRWA would benefit from price transparency across procurement agencies in the region and beyond, so should UNRWA look to improve its own transparency and publish tender awards on its website.

• Rational Drug List (RDL) reviewed every two years

Separate medical supplies from the RDL. The RDL should be reviewed every two years with input from Drug and Therapeutic Committees at the field level. Consideration should be given to including needed experts as members of DTCs.

6.3 PLD recommendations

At a joint meeting with PLD, Health Department and consultants to discuss the survey findings, PLD recommended: • discussing publishing awarded tenders on UNRWAs website with other UN agencies • re-centralizing field budget allocations, with emergency budgets at the field level, to improve inequalities across fields

Annex 1 Medicines selected for price comparisons (in descending order by expenditure)

Note: data relates to General Fund only Total UNRWA Quantity Annual Medicine Strength Dose Form Purchasing (central & Expenditure Unit local proc.) in US$ Insulin Human 30/70 Premixed 100IU/ml vial 10ml vial 476,650 1,478,122 Co-Amoxiclav 500+125mg tablet 100 tabs 54,653 973,521 Amoxycillin 250mg/5ml suspension 100ml bottle 999,566 716,602 Enalapril Maleate 10mg tablet 100 tabs 667,500 661,834 Amoxycillin 500 mg capsule 100 caps 158,655 606,882 Co-Amoxiclav 250+62mg/5ml suspension 100ml bottle 219,110 567,409 Cephalexin 500mg capsule 100 caps 86,955 473,402 Metformin HCL 500mg tablet 100 tabs 470,370 446,482 Gliclazide 80mg tablet 100 tabs 159,725 418,102 Paracetamol 250mg/5ml suspension 100ml bottle 1,161,843 411,496 Atenolol 50mg tablet 100 tabs 419,080 332,531 Ferrous Sulphate 125mg/ml oral drops 30ml bottle 529,000 329,007 100-105mg+ Iron + Folic Acid 325-400mcg SR tablet 100 tabs 223,560 327,285 Chlorphenamine 2-2.5mg/5ml oral solution 100ml bottle 867,000 308,498 Isosorbide Dinitrate 20mg SR tablet 100 tabs 79,454 301,435 Acetylsalicylic acid 100mg tablet 100 tabs 293,790 293,381 Benzylpenicillin benzathine 1.2MIU vial 1 vial 108,485 283,628 Paracetamol 500mg tablet 100 tabs 294,911 280,299 Cephalexin 250mg/5ml suspension 100ml bottle 281,250 261,589 Azithromycin 200mg/5ml suspension 22.5ml bottle 100,915 232,126 1x 200 dose Salbutamol 100mcg/dose inhaler inhaler 116,700 199,222 Acetylsalicylic acid 500mg tablet 100 tabs 44,000 188,700 Erythromycin Ethylsuccinate 125mg/5ml oral solution 100ml bottle 220,100 162,648 Phenoxymethylpenicillin 125mg/5ml oral solution 100ml bottle 166,550 159,977 Carbamazepine 200mg tablet 100 tabs 68,495 139,642 1x 200 dose Beclomethasone 50mcg/dose inhaler inhaler 55,400 132,312 Hydrochlorothiazide 25mg tablet 100 tabs 119,053 131,696 100 vag Miconazole Nitrate 200mg vag suppos suppos 15,713 123,433 Metronidazole 250mg tablet 100 tabs 81,028 122,953 Betamethasone Valerate 0.1% cream 15g tube 395,000 122,818 Insulin Human Isophane 100IU/ml vial 10ml vial 37,370 118,041 Methyldopa 250mg tablet 100 tabs 39,700 117,536 Nystatin 100000U/ml suspension 30ml bottle 159,700 113,465 Glibenclamide 5mg tablet 100 tabs 219,370 110,973 Nifedipine 20mg SR tablet 100 tabs 83,690 110,131 Ranitidine HCL 150mg tablet 100 tabs 78,600 104,004 Levonorgesterol + Ethinlyoestradiol 0.15mg+0.03mg tablet cycle (28 tab) 111,400 103,578 Co-Trimoxazole Paed 40+200mg/5ml suspension 100ml bottle 131,930 100,535

Total UNRWA Quantity Annual Medicine Strength Dose Form Purchasing (central & Expenditure Unit local proc.) in US$ Ibuprofen 400mg tablet 100 tabs 61,910 100,230 Neomycin Sulphate + 5mg/g+500u/g cream/ointment 20g tube 154,000 98,610 Bacitracin Sodium Valproate 200mg tablet 100 tabs 19,639 93,915 Miconazole 2% (24mg/ml) oral gel 40g tube 123,430 93,436 Diethylamine Salicylate 10-12% cream 40g tube 283,000 89,500 Chlorphenamine 4mg tablet 100 tabs 99,300 87,575 Thyroxine 100mcg tablet 100 tabs 26,828 87,563 Latex Condom Lubricated with Spermicide per condom 1275000 86843 Biperiden HCL 2mg tablet 100 tabs 9,313 85,470 Aminophylline 200mg tablet 100 tabs 19,740 85,248 Sodium Valproate 200mg/5ml oral solution 100ml bottle 18,397 83,819 Mebendazole 100mg/5ml suspension 30ml bottle 188,800 80,537 Gentamicin 0.3% eye drops 5ml bottle 251,550 72,592 Ciprofloxacin 250mg tablet 100 tabs 28,452 70,821 Salbutamol Sulphate 2mg/5ml oral liquid 100 bottle 134,250 69,094 Metronidazole 125mg/5ml suspension 100ml bottle 154,160 65,459 Miconazole Nitrate 2% cream 15g tube 219,020 64,881 topical Benzyl Benzoate 25% 100ml bottle 73,900 62,282 application Digoxin 0.25mg tablet 100 tabs 22,770 61,230 Erythromycin Stearate 250mg tablet 100 tabs 15,530 56,120 Azithromycin 250mg tablet / capsule 100 tabs 7,714 56,054 Frusemide 40mg tablet 100 tabs 64,060 50,181 Amoxycillin 250mg capsule 100 caps 19,790 50,063 Diclofenac Sodium 50mg tablet 100 tabs 72,560 49,138 Hyoscine Butylbromide 10mg tablet 100 tabs 20,110 49,084 Chloramphenicol 1% eye ointment 5g tube 78,400 43,316 Warfarin 5mg tablet 100 tabs 8,742 40,510 Indomethacin 100mg suppository 100 suppos 8,330 39,063 Folic Acid 5mg tablet 100 tabs 45,670 37,878 Sulphacetamide Sodium 20% eye drops 10ml bottle 59,500 34,830 Silver Sulphadiazine 1% cream 30g tube 44,200 33,575 Ethynodiol 0.5mg tablet cycle (28 day) 52,100 33,413 Paracetamol Children 250mg suppository 100 suppos 11,090 33,226 Paracetamol Infant 125mg suppository 100 suppos 13,150 31,535 Betamethasone 0.1% eye/ear drops 5ml bottle 62,650 31,414 Cefuroxime 750mg vial 1 vial 18,745 29,831 Fluconazole 50mg tablet / capsule 100 tabs 4,204 28,517 Tetracyline HCL 1% eye ointment 5g tube 66,850 27,978 Diltiazem HCL 60mg tablet 100 tabs 24,960 27,398 Salbutamol 0.5% respiratory soln 20ml bottle 20,650 27,183 Prednisolone Acetate 1% eye drops 5ml bottle 21,400 26,714 Insulin Human Neutral 100IU/ml vial 10ml vial 6,590 20,887 total 14,462,304

Annex II UNRWA procurement prices as a ratio to MSH, IDA, JPD, and GCC prices

Note in the calculation of the price ratios: UNRWA price is the median landed price including freight for central (tender) procurements. MSH, IDA, JPD and GCC prices also include freight. IDA prices also include a handling fee, and are predominantly bulk packs for tablets/capsules. Medicine Strength Dose Form MSH IDA JPD GCC Acetylsalicylic acid 100mg tablet 4.80 4.74 0.44 1.40 Acetylsalicylic acid 500mg tablet 9.55 9.94 1.03 Aminophylline 200mg tablet 1.52 Amoxycillin 250mg/5ml suspension 1.03 0.97 1.07 0.86 Amoxycillin 500 mg capsule 1.15 1.13 1.10 0.97 Amoxycillin 250mg capsule 1.28 1.40 1.19 Atenolol 50mg tablet 0.74 1.14 0.93 1.40 Azithromycin 200mg/5ml suspension 1.65 1.53 2.96 1.41 Azithromycin 250mg tablet / capsule 0.33 0.37 0.73 0.85 Beclomethasone 50mcg/dose inhaler (200d) 0.92 0.89 1.49 1.11 Benzylpenicillin benzathine 1.2MIU vial 20.93 4.00 7.55 Betamethasone Val. 0.1% cream 0.83 0.82 1.07 1.37 Betamethasone 0.1% eye/ear drops 0.47 Carbamazepine 200mg tablet 1.01 1.17 0.94 0.15 Cefuroxime 750mg vial 1.18 1.95 2.99 Cephalexin 500mg capsule 0.70 0.73 1.11 Cephalexin 250mg/5ml suspension 0.87 0.90 Chloramphenicol 1% eye ointment 2.03 1.57 0.59 0.40 Chlorphenamine 4mg tablet 5.23 4.45 2.91 3.34 Chlorphenamine 2-2.5mg/5ml oral solution 0.69 1.10 0.92 Ciprofloxacin 250mg tablet 1.30 1.28 1.34 1.24 Co-Amoxiclav 500+125mg tablet 0.85 0.93 1.77 1.78 Co-Amoxiclav 250+62mg/5ml suspension 0.76 1.81 Co-Trimoxazole Paed 40+200mg/5ml suspension 1.75 1.48 1.46 0.59 Diclofenac Sodium 50mg tablet 1.39 1.34 1.01 1.32 Digoxin 0.25mg tablet 3.39 0.24 1.20 0.43 Diltiazem HCL 60mg tablet 0.45 0.60 0.26 Enalapril Maleate 10mg tablet 0.59 1.22 0.63 Erythromycin Ethylsucc 125mg/5ml oral solution 0.54 0.40 Erythromycin Stearate 250mg tablet 0.96 0.98 1.06 Ferrous Sulphate 125mg/ml oral drops 1.21 Fluconazole 50mg tab / cap 1.14 1.10 1.27 0.37 Folic Acid 5mg tablet 2.14 2.11 0.45 0.54 Frusemide 40mg tablet 1.57 1.59 0.32 0.54 Gentamicin 0.3% eye drops 1.24 0.55 0.82 0.86 Glibenclamide 5mg tablet 1.31 1.29 0.96 1.00 Gliclazide 80mg tablet 0.34 2.02 1.40 Hydrochlorothiazide 25mg tablet 1.93 1.90 0.25 0.20 Hyoscine Butylbromide 10mg tablet 0.78 0.77 0.86 1.14 Ibuprofen 400mg tablet 1.39 1.33 0.73 1.55 Indomethacin 100mg suppository 0.25 0.86 0.15 Insulin Human 30/70 Premixed 100IU/ml 10 ml vial 0.55 0.98 1.46 Insulin Human Isophane 100IU/ml 10ml vial 0.34 0.99 1.48 Insulin Human Neutral 100IU/ml 10 ml vial 0.37 1.00 1.49

Medicine Strength Dose Form MSH IDA JPD GCC 100- 105mg+325- Iron + Folic Acid 400mcg tablet 0.37 Isosorbide Dinitrate 20mg SR tablet 0.51 0.89 Latex Condom Lubricated with Spermicide each 2.21 1.80 Levonorgesterol + Ethinlyoestradiol 0.15mg+0.03mg cycle (28 tab) 2.58 1.84 Mebendazole 100mg/5ml suspension 1.42 1.69 0.23 0.47 Metformin HCL 500mg Tablet 0.80 0.99 0.89 0.95 Methyldopa 250mg Tablet 1.06 1.05 0.88 0.53 Metronidazole 250mg Tablet 2.40 2.37 0.96 Metronidazole 125mg/5ml suspension 0.78 0.64 0.64 1.11 Miconazole 2% (24mg/ml) oral gel 0.08 1.57 1.00 Miconazole Nitrate 200mg vaginal suppos 0.75 Miconazole Nitrate 2% Cream 1.34 1.55 1.60 Neomycin Sulphate + Bacitracin 5mg/g+500u/g cream/ointment 0.87 0.86 Nifedipine 20mg SR tablet 0.52 0.47 1.08 0.14 Nystatin 100000U/ml suspension 0.71 0.85 1.78 Paracetamol 250mg/5ml suspension 0.60 Paracetamol 500mg Tablet 1.85 1.58 1.36 1.10 Paracetamol Infant 125mg suppository 0.25 0.23 0.97 0.65 Paracetamol Children 250mg suppository 0.29 1.09 0.58 Phenoxymethylpenicillin 125mg/5ml oral solution 1.25 0.90 Prednisolone Acetate 1% eye drops 2.29 1.53 1.62 Ranitidine HCL 150mg Tablet 0.51 0.56 0.49 1.49 Salbutamol 100mcg/dose inhaler (200d) 0.92 0.94 2.00 1.12 Salbutamol 0.5% resp solution 0.10 0.31 1.58 0.59 Salbutamol Sulphate 2mg/5ml oral liquid 0.73 0.42 1.89 0.91 Silver Sulphadiazine 1% Cream 1.46 1.57 1.55 0.84 Sodium Valproate 200mg Tablet 0.50 0.49 0.41 0.36 Sodium Valproate 200mg/5ml suspension 0.59 Tetracyline HCL 1% eye ointment 1.48 1.42 0.74 Thyroxine 100mcg Tablet 0.77 0.44 1.54 1.27 MEDIAN 0.99 1.12 1.00 0.98

Annex III Procurement prices (in US$) for UNRWA’s purchasing units

Note: UNRWA price is the median landed price including freight for central (tender) procurements. MSH, IDA, JPD and GCC prices also include freight. IDA also includes a handling fee. Dose Form & UNRWA MSH Price Medicine Strength IDA Price $ JPD Price $ GCC Price $ Purchasing Unit Price $ Quantity $ Acetylsalicylic acid 100mg 100 tablet 1.0489 293,790 0.2185 0.2214 2.3970 0.7500 Acetylsalicylic acid 500mg 100 tablet 4.2833 44,000 0.4485 0.4311 4.1500

Aminophylline 200mg 100 tablet 5.1011 19,740 3.3465

Amoxycillin 250mg/5ml 100ml susp. 0.7097 963,990 0.6900 0.7340 0.6603 0.8300 Amoxycillin 500 mg 100 capsule 3.8275 158,655 3.3350 3.3785 3.4827 3.9600 Amoxycillin 250mg 100 capsule 2.5265 19,790 1.9665 1.8058 2.1200

Atenolol 50mg 100 tablet 0.8117 419,080 1.0925 0.7107 0.8742 0.5800 Azithromycin 200mg/5ml 22.5ml susp. 2.4265 88,940 1.4671 1.5911 0.8185 1.7250 Azithromycin 250mg 100 tab / cap 7.1478 7,714 21.5280 19.4322 9.8390 8.4000 Beclomethasone 50mcg/dose 1 inhaler (200d) 2.5291 51,400 2.7600 2.8426 1.6951 2.2800 Benzylpenicillin 1.2MIU 1 vial 2.7919 0.1334 0.6988 0.3697 benzathine 100,685 Betamethasone 0.1% 15g cream 0.3145 0.3778 0.3827 0.2933 0.2300 Valerate 395,000 Betamethasone 0.1% 5ml eye/ear drops 0.4500 54,700 0.9534

Carbamazepine 200mg 100 tablet 1.7169 62,250 1.7020 1.4679 1.8330 11.6300 Cefuroxime 750mg 1 vial 1.6119 12,650 1.3629 0.8249 0.5400

Cephalexin 500mg 100 capsule 5.4400 82,995 7.7280 7.4910 4.9124

Cephalexin 250mg/5ml 100ml susp. 0.9218 248,600 1.0580 1.0265

Chloramphenicol 1% 5g eye ointment 0.5640 78,400 0.2783 0.3582 0.9594 1.4000 Chlorphenamine 4mg 100 tablet 0.9019 99,300 0.1725 0.1981 0.3102 0.2700 Chlorphenamine 2-2.5mg/5ml 100ml oral soln. 0.3570 867,000 0.5175 0.3231 0.3900

Ciprofloxacin 250mg 100 tablet 2.4792 28,452 1.9090 1.9339 1.8539 2.0000 Co-Amoxiclav 500+125mg 100 tablet 18.2052 50,480 21.4360 19.4905 10.2676 10.2000 Co-Amoxiclav 250+62mg/5ml 100ml susp. 2.6566 209,110 3.5075 1.4664

Co-Trimoxazole Paed. 40+200mg/5ml 100ml susp. 0.8462 120,930 0.4830 0.5709 0.5781 1.4400 Diclofenac Sodium 50mg 100 tablet 0.6849 72,560 0.4945 0.5126 0.6768 0.5200 Digoxin 0.25mg 100 tablet 2.8041 20,570 0.8280 11.6034 2.3462 6.5300

Dose Form & UNRWA MSH Price Medicine Strength IDA Price $ JPD Price $ GCC Price $ Purchasing Unit Price $ Quantity $ Diltiazem HCL 60mg 100 tablet 1.0958 24,960 2.4150 1.8330 4.1800 Enalapril Maleate 10mg 100 tablet 1.0109 603,500 1.7250 0.8319 1.6100 Erythromycin Ethylsucc 125mg/5ml 100ml oral soln. 0.7403 220,100 1.3800 1.8291 Erythromycin Stearate 250mg 100 tablet 3.4351 14,880 3.5650 3.5183 3.2500 Ferrous Sulphate 125mg/ml 30ml oral drops 0.6195 529,000 0.5100 Fluconazole 50mg 100 tab / cap 6.6750 3,484 5.8765 6.0813 5.2371 18.0000 Folic Acid 5mg 100 tablet 0.5663 35,620 0.2645 0.2680 1.2690 1.0400 Frusemide 40mg 100 tablet 0.7778 64,060 0.4945 0.4893 2.4171 1.4500 Gentamicin 0.3% 5 ml eye drops 0.2591 239,600 0.2093 0.4707 0.3173 0.3000 Glibenclamide 5mg 100 tablet 0.5114 219,370 0.3910 0.3961 0.5352 0.5100 Gliclazide 80mg 100 tablet 2.6169 159,725 7.5900 1.2972 1.8700 Hydrochlorothiazide 25mg 100 tablet 0.8198 105,632 0.4255 0.4311 3.2853 4.0000 Hyoscine Butylbromide 10mg 100 tablet 2.4322 20,110 3.1280 3.1688 2.8200 2.1300 Ibuprofen 400mg 100 tablet 1.5046 57,560 1.0810 1.1301 2.0530 0.9700 Indomethacin 100mg 100 suppository 4.8200 8,330 19.0095 5.6259 33.2000 Insulin Human 30/70 3.1023 5.6776 3.1735 2.1200 Premixed 100IU/ml 10ml vial 476,650 Insulin Human Isophane 100IU/ml 10ml vial 3.1459 37,370 9.2207 3.1759 2.1200

Insulin Human Neutral 100IU/ml 10 ml vial 3.1647 6,590 8.5503 3.1738 2.1200 100- 105mg+325- 100 tablet 1.4626 223,560 4.0000

Iron + Folic Acid 400mcg Isosorbide Dinitrate 20mg 100 SR tablet 3.4668 51,040 6.8385 3.8800 Latex Condom Lubricated with Spermicide each 0.0730 975000 975,000 0.0405

Levonorgesterol + 0.15mg+0.03mg cycle (28 tab) 0.9268 0.3594 0.5043 Ethinlyoestradiol 111,400 Mebendazole 100mg/5ml 30ml susp. 0.4205 188,800 0.2967 0.2481 1.7965 0.8900 Metformin HCL 500mg 100 tablet 0.9665 437,370 1.2075 0.9786 1.0857 1.0200 Methyldopa 250mg 100 tablet 2.9875 37,000 2.8060 2.8426 3.4122 5.6400 Metronidazole 250mg 100 tablet 1.4328 79,088 0.5980 0.6058 1.5000 Metronidazole 125mg/5ml 100ml susp. 0.4225 154,160 0.5405 0.6641 0.6599 0.3800 Miconazole 2% (24mg/ml) 40g oral gel 0.7513 116,030 9.9682 0.4794 0.7500

Dose Form & UNRWA MSH Price Medicine Strength IDA Price $ JPD Price $ GCC Price $ Purchasing Unit Price $ Quantity $ Miconazole Nitrate 200mg 100 vag.suppos. 8.0399 15,713 10.7100

Miconazole Nitrate 2% 15g cream 0.3038 219,020 0.2260 0.1957 0.1900 Neomycin Sulphate + 0.6400 154,000 0.7337 0.7433 Bacitracin 5mg/g+500u/g 20g cream/oint. Nifedipine 20mg 100 SR tablet 1.2625 83,690 2.4495 2.6679 1.1703 8.9000 Nystatin 100000U/ml 30ml susp. 0.7035 159,700 0.9867 0.8318 0.3950 Paracetamol 250mg/5ml 100ml susp. 0.3504 1,088,400 0.5866

Paracetamol 500mg 100 tablet 0.9586 272,690 0.5175 0.6058 0.7050 0.8700 Paracetamol Infant 125mg 100 suppos. 2.3096 13,150 9.3150 10.2404 2.3829 3.5500 Paracetamol Children 250mg 100 suppos. 2.9503 11,090 10.1200 2.7055 5.1000 Phenoxymethylpenicillin 125mg/5ml 100ml oral sol. 0.9594 166,550 0.7705 1.0602 Prednisolone Acetate 1% 5ml eye drops 1.2653 21,400 0.5514 0.8249 0.7800 Ranitidine HCL 150mg 100 tablet 1.1750 68,600 2.3000 2.0854 2.4111 0.7900 Salbutamol 100mcg/dose 1 inhaler (200d) 1.7987 100,700 1.9550 1.9106 0.8982 1.6100 Salbutamol 0.5% 20ml resp soln. 1.2380 20,650 11.8611 3.9424 0.7826 2.0900 Salbutamol Sulphate 2mg/5ml 100ml oral liquid 0.4892 134,250 0.6670 1.1534 0.2585 0.5350 Silver Sulphadiazine 1% 30g cream 0.7647 44,200 0.5244 0.4858 0.4935 0.9120 Sodium Valproate 200mg 100 tablet 3.3943 15,880 6.8540 6.9085 8.2189 9.4000 Sodium Valproate 200mg/5ml 100ml oral soln. 4.5289 18,397 7.6760

Tetracyline HCL 1% 5g eye ointment 0.4080 58,900 0.2760 0.2866 0.5500

Thyroxine 100mcg 100 tablet 3.8000 5,000 4.9450 8.6210 2.4675 3.0000

Annex IV Annual savings by purchasing medicines from IDA

Note: UNRWA expenditure and quantities are for central procurements. IDA prices for tablets/capsules are bulk packs.

UNRWA IDA Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Acetylsalicylic acid 100mg 100 tablet 293,381 0.2214 293,790 65,030 228,351 Acetylsalicylic acid 500mg 100 tablet 188,700 0.4311 44,000 18,966 169,734 Amoxycillin 250mg/5ml 100ml susp. 679,603 0.7340 963,990 707,520 -27,917 Amoxycillin 500 mg 100 capsule 606,882 3.3785 158,655 536,016 70,866 Amoxycillin 250mg 100 capsule 50,063 1.8058 19,790 35,736 14,327 Atenolol 50mg 100 tablet 332,531 0.7107 419,080 297,819 34,712 Azithromycin 200mg/5ml 22.5ml susp. 217,287 1.5911 88,940 141,512 75,775 Azithromycin 250mg 100 tab / cap 56,054 19.4322 7,714 149,900 -93,846 Beclomethasone 50mcg/dose 1 inhaler (200d) 122,792 2.8426 51,400 146,110 -23,318 Benzylpenicillin benz. 1.2MIU 1 vial 281,045 0.6988 100,685 70,355 210,690 Betamethasone val. 0.1% 15g cream 122,818 0.3827 395,000 151,167 -28,349 Carbamazepine 200mg 100 tablet 106,670 1.4679 62,250 91,377 15,293 Cephalexin 500mg 100 capsule 451,402 7.4910 82,995 621,711 -170,309 Chloramphenicol 1% 5g eye ointment 43,316 0.3582 78,400 28,086 15,230 Chlorphenamine 4mg 100 tablet 87,575 0.1981 99,300 19,666 67,909 Ciprofloxacin 250mg 100 tablet 70,821 1.9339 28,452 55,023 15,798 Co-Amoxiclav 500+125mg 100 tablet 908,005 19.4905 50,480 983,878 -75,873 Co-Trimoxazole Paed. 40+200mg/5ml 100ml susp. 95,952 0.5709 120,930 69,033 26,919 Diclofenac Sodium 50mg 100 tablet 49,138 0.5126 72,560 37,194 11,944 Digoxin 0.25mg 100 tablet 57,856 11.6034 20,570 238,682 -180,826 Erythromycin Ethylsucc 125mg/5ml 100ml oral soln. 162,648 1.8291 220,100 402,574 -239,926 Erythromycin Stearate 250mg 100 tablet 51,050 3.5183 14,880 52,352 -1,302 Fluconazole 50mg 100 tab / cap 24,220 6.0813 3,484 21,187 3,033 Folic Acid 5mg 100 tablet 19,869 0.2680 35,620 9,544 10,325 Frusemide 40mg 100 tablet 50,181 0.4893 64,060 31,345 18,836 Gentamicin 0.3% 5 ml eye drops 63,510 0.4707 239,600 112,770 -49,260

UNRWA IDA Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Glibenclamide 5mg 100 tablet 110,973 0.3961 219,370 86,892 24,081 Hydrochlorothiazide 25mg 100 tablet 85,458 0.4311 105,632 45,533 39,925 Hyoscine Butylbromide 10mg 100 tablet 49,084 3.1688 20,110 63,725 -14,641 Ibuprofen 400mg 100 tablet 88,366 1.1301 57,560 65,046 23,320 Latex Condom with Spermicide each 70,343 70,343 975000 975,000 39,528 Levonorgesterol + 0.15mg+0.03mg cycle (28 tab) 103,578 0.5043 111,400 56,182 47,396 Ethinlyoestradiol Mebendazole 100mg/5ml 30ml susp. 80,537 0.2481 188,800 46,850 33,687 Metformin HCL 500mg 100 tablet 410,512 0.9786 437,370 428,010 -17,498 Methyldopa 250mg 100 tablet 111,029 2.8426 37,000 105,176 5,853 Metronidazole 250mg 100 tablet 115,969 0.6058 79,088 47,912 68,057 Metronidazole 125mg/5ml 100ml susp. 65,459 0.6641 154,160 102,370 -36,911 Miconazole Nitrate 2% 15g cream 64,881 0.1957 219,020 42,867 22,014 Neomycin Sulphate + 5mg/g+500u/g 20g cream/oint. 98,610 0.7433 154,000 114,464 -15,854 Bacitracin Nifedipine 20mg 100 SR tablet 110,131 2.6679 83,690 223,272 -113,141 Nystatin 100000U/ml 30ml susp. 113,465 0.8318 159,700 132,840 -19,375 Paracetamol 500mg 100 tablet 265,844 0.6058 272,690 165,196 100,648 Paracetamol Infant 125mg 100 suppos. 31,535 10.2404 13,150 134,661 -103,126 Phenoxymethylpenicillin 125mg/5ml 100ml oral sol. 159,977 1.0602 166,550 176,568 -16,591 Ranitidine HCL 150mg 100 tablet 82,004 2.0854 68,600 143,055 -61,051 Salbutamol 100mcg/dose 1 inhaler (200d) 170,902 1.9106 100,700 192,397 -21,495 Salbutamol 0.5% 20ml resp soln. 27,183 3.9424 20,650 81,410 -54,227 Salbutamol Sulphate 2mg/5ml 100ml oral liquid 69,094 1.1534 134,250 154,837 -85,743 Silver Sulphadiazine 1% 30g cream 33,575 0.4858 44,200 21,473 12,102 Sodium Valproate 200mg 100 tablet 53,434 6.9085 15,880 109,706 -56,272 Tetracyline HCL 1% 5g eye ointment 24,639 0.2866 58,900 16,880 7,759 Thyroxine 100mcg 100 tablet 19,000 8.6210 5,000 43,105 -24,105 Net annual savings -125,558

Annex V Annual savings by purchasing medicines at JPD prices

Note: UNRWA expenditure and quantities are for central procurements

UNRWA JPD Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Acetylsalicylic acid 100mg 100 tablet 293,381 2.3970 293,790 704,215 -410,834 Amoxycillin 250mg/5ml 100ml susp. 679,603 0.6603 963,990 636,523 43,080 Amoxycillin 500 mg 100 capsule 606,882 3.4827 158,655 552,548 54,334 Atenolol 50mg 100 tablet 332,531 0.8742 419,080 366,360 -33,829 Azithromycin 200mg/5ml 22.5ml susp. 217,287 0.8185 88,940 72,798 144,489 Azithromycin 250mg 100 tab / cap 56,054 9.8390 7,714 75,898 -19,844 Beclomethasone 50mcg/dose 1 inhaler (200d) 122,792 1.6951 51,400 87,128 35,664 Betamethasone val. 0.1% 15g cream 122,818 0.2933 395,000 115,846 6,972 Carbamazepine 200mg 100 tablet 106,670 1.8330 62,250 114,104 -7,434 Cefuroxime 750mg vial 21,100 0.8249 12,650 10,435 10,665 Cephalexin 500mg 100 capsule 451,402 4.9124 82,995 407,511 43,891 Cephalexin 250mg/5ml 100ml susp. 229,006 1.0265 248,600 255,188 -26,182 Chloramphenicol 1% 5g eye ointment 43,316 0.9594 78,400 75,217 -31,901 Chlorphenamine 4mg 100 tablet 87,575 0.3102 99,300 30,803 56,772 Chlorphenamine 2-2.5mg/ml 100ml oral soln. 308,497 0.3231 867,000 280,149 28,348 Ciprofloxacin 250mg 100 tablet 70,821 1.8539 28,452 52,746 18,075 Co-Amoxiclav 500+125mg 100 tablet 908,005 10.2676 50,480 518,309 389,696 Co-Amoxiclav 250+62mg/5ml 100ml susp. 541,709 1.4664 209,110 306,639 235,070 Co-Trimoxazole Paed. 40+200mg/5ml 100ml susp. 95,952 0.5781 120,930 69,910 26,042 Diclofenac Sodium 50mg 100 tablet 49,138 0.6768 72,560 49,109 29 Digoxin 0.25mg 100 tablet 57,856 2.3462 20,570 48,261 9,595 Diltiazem HCL 60mg 100 tablet 27,398 1.8330 24,960 45,752 -18,354 Enalapril Maleate 10ng 100 tablet 611,274 0.8319 603,500 502,052 109,222 Fluconazole 50mg 100 tab / cap 24,220 5.2371 3,484 18,246 5,974 Folic Acid 5mg 100 tablet 19,869 1.2690 35,620 45,202 -25,333

UNRWA JPD Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Frusemide 40mg 100 tablet 50,181 2.4171 64,060 154,843 -104,662 Gentamicin 0.3% 5 ml eye drops 63,510 0.3173 239,600 76,025 -12,515 Glibenclamide 5mg 100 tablet 110,973 0.5352 219,370 117,415 -6,442 Glicazide 80mg 100 tablet 418,102 1.2972 159,725 207,195 210,907 Hydrochlorothiazide 25mg 100 tablet 85,458 3.2853 105,632 347,033 -261,575 Hyoscine Butylbromide 10mg 100 tablet 49,084 2.8200 20,110 56,710 -7,626 Ibuprofen 400mg 100 tablet 88,366 2.0530 57,560 118,171 -29,805 Indomethacin 100mg 100 suppos. 39,063 5.6259 8,330 46,864 -7,801 Insulin Human 30/70 100IU/ml 10ml vial 1,478,122 3.1735 476,650 1,512,649 -34,527 Premixed Insulin Human Isophane 100IU/ml 10ml vial 118,041 3.1759 37,370 118,683 -642 Insulin Human Neutral 100IU/ml 10 ml vial 20,887 3.1738 6,590 20,915 -28 Isosorbide Dinitrate 20mg 100 SR tablet 178,782 6.8385 51,040 349,037 -170,255 Mebendazole 100mg/5ml 30ml susp. 80,537 1.7965 188,800 339,179 -258,642 Metformin HCL 500mg 100 tablet 410,512 1.0857 437,370 474,853 -64,341 Methyldopa 250mg 100 tablet 111,029 3.4122 37,000 126,251 -15,222 Metronidazole 125mg/5ml 100ml susp. 65,459 0.6599 154,160 101,730 -36,271 Miconazole 2% 40g oral gel 88,861 0.4794 116,030 55,625 33,236 Nifedipine 20mg 100 SR tablet 110,131 1.1703 83,690 97,942 12,189 Paracetamol 250mg/5ml 100ml susp. 375,195 0.5866 1,088,400 638,455 -263,260 Paracetamol 500mg 100 tablet 265,844 0.7050 272,690 192,246 73,598 Paracetamol Infant 125mg 100 suppos. 31,535 2.3829 13,150 31,335 200 Paracetamol Child 125mg 100 suppos. 33,226 2.7055 11,090 30,004 3,222 Prednisolone Acetate 1% 5ml eye drops 26,714 0.8249 21,400 17,653 9,061 Ranitidine HCL 150mg 100 tablet 82,004 2.4111 68,600 165,401 -83,397 Salbutamol 100mcg/dose 1 inhaler (200d) 170,902 0.8982 100,700 90,449 80,453 Salbutamol 0.5% 20ml resp soln. 27,183 0.7826 20,650 16,161 11,022 Salbutamol Sulphate 2mg/5ml 100ml oral liquid 69,094 0.2585 134,250 34,704 34,390 Silver Sulphadiazine 1% 30g cream 33,575 0.4935 44,200 21,813 11,762

UNRWA JPD Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Sodium Valproate 200mg 100 tablet 53,434 8.2189 15,880 130,516 -77,082 Sodium Valproate 200mg/5ml 100ml oral soln. 83,819 7.6760 18,397 141,216 -57,397 Thyroxine 100mcg 100 tablet 19,000 2.4675 5,000 12,338 6,663 Net annual savings -360,580

Annex VI Annual savings by purchasing medicines at GCC prices

Note: UNRWA expenditure and quantities are for central procurements

UNRWA GCC Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Acetylsalicylic acid 100mg 100 tablet 293,381 0.7500 293,790 220,343 73,039 Acetylsalicylic acid 500mg 100 tablet 188,700 4.1500 44,000 182,600 6,100 Amoxycillin 250mg/5ml 100ml susp. 679,603 0.8300 963,990 800,112 -120,509 Amoxycillin 500 mg 100 capsule 606,882 3.9600 158,655 628,274 -21,392 Amoxycillin 250mg 100 capsule 50,063 2.1200 19,790 41,955 8,108 Atenolol 50mg 100 tablet 332,531 0.5800 419,080 243,066 89,465 Azithromycin 200mg/5ml 22.5ml susp 217,287 1.7250 88,940 153,422 63,866 Azithromycin 250mg 100 tab / cap 56,054 8.4000 7,714 64,798 -8,744 Beclomethasone 50mcg/dose 1 inhaler (200d) 122,792 2.2800 51,400 117,192 5,600 Benzylpenicillin benz. 1.2MIU 1 vial 281,045 0.3697 100,685 37,223 243,822 Betamethasone val. 0.1% 15g cream 122,818 0.2300 395,000 90,850 31,968 Carbamazepine 200mg 100 tablet 106,670 11.6300 62,250 723,968 -617,298 Cefuroxime 750mg vial 21,100 0.5400 12,650 6,831 14,269 Chloramphenicol 1% 5g eye ointment 43,316 1.4000 78,400 109,760 -66,444 Chlorphenamine 4mg 100 tablet 87,575 0.2700 99,300 26,811 60,764 Chlorphenamine 2-2.5mg/ml 100ml oral soln. 308,497 0.3900 867,000 338,130 -29,633 Ciprofloxacin 250mg 100 tablet 70,821 2.0000 28,452 56,904 13,917 Co-Amoxiclav 500+125mg 100 tablet 908,005 10.2000 50,480 514,896 393,109 Co-Trimoxazole paed 40+200mg/5ml 100 ml susp. 95,952 1.4400 120,930 174,139 -78,187 Diclofenac Sodium 50mg 100 tablet 49,138 0.5200 72,560 37,731 11,407 Digoxin 0.25mg 100 tablet 57,856 6.5300 20,570 134,322 -76,466 Diltiazem HCL 60mg 100 tablet 27,390 4.1800 24,960 104,333 -76,935 Enalapril Maleate 10ng 100 tablet 611,274 1.6100 603,500 971,635 -360,361

UNRWA GCC Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Erythromycin Stearate 250mg 100 tablet 51,050 3.2500 14,880 48,360 2,690 Ferrous Sulphate 125mg/ml 30ml oral drops 329,007 0.5100 529,000 269,790 59,217 Fluconazole 50mg 100 tab / cap 24,220 18.0000 3,484 62,712 -38,492 Folic Acid 5mg 100 tablet 19,869 1.0400 35,620 37,045 -17,176 Frusemide 40mg 100 tablet 50,181 1.4500 64,060 92,887 -42,706 Gentamicin 0.3% 5 ml eye drops 63,510 0.3000 239,600 71,880 -8,370 Glibenclamide 5mg 100 tablet 110,973 0.5100 219,370 111,879 -906 Glicazide 80mg 100 tablet 418,102 1.8700 159,725 298,686 119,416 Hydrochlorothiazide 25mg 100 tablet 85,458 4.0000 105,632 422,528 -337,070 Hyoscine Butylbromide 10mg 100 tablet 49,084 2.1300 20,110 42,834 6,250 Ibuprofen 400mg 100 tablet 88,366 0.9700 57,560 55,833 32,533 Indomethacin 100mg 100 suppos. 39,063 33.2000 8,330 276,556 -237,493 Insulin Human 30/70 100IU/ml 10ml vial 1,478,122 2.1200 476,650 1,010,498 467,624 Premixed Insulin Human Isophane 100IU/ml 10ml vial 118,041 2.1200 37,370 79,224 38,817 Insulin Human Neutral 100IU/ml 10 ml vial 20,887 2.1200 6,590 13,971 6,916 100- Iron + Folic Acid 105mg+325- 100 tablet 327,285 4.0000 223,560 894,240 -566,955 400mcg Isosorbide Dinitrate 20mg 100 SR tablet 178,782 3.8800 51,040 198,035 -19,253 Mebendazole 100mg/5ml 30ml susp. 80,537 0.8900 188,800 168,032 -87,495 Metformin HCL 500mg 100 tablet 410,512 1.0200 437,370 446,117 -35,605 Methyldopa 250mg 100 tablet 111,029 5.6400 37,000 208,680 -97,651 Metronidazole 250mg 100 tablet 115,969 1.5000 79,088 118,632 -2,663 Metronidazole 125mg/5ml 100ml susp. 65,459 0.3800 154,160 58,581 6,878 Miconazole 2% 40g oral gel 88,861 0.7500 116,030 87,023 1,839 Miconazole Nitrate 200mg 100 vag.suppos. 123,433 10.7100 15,713 168,286 -44,853 Miconazole Nitrate 2% 15g cream 64,881 0.1900 219,020 41,614 23,267 Nifedipine 20mg 100 SR tablet 110,131 8.9000 83,690 744,841 -634,710

UNRWA GCC Annual Dose Form & (central) Medicine Strength Savings Purchasing Unit Quantity Expenditure Price Expenditure $ procured by $ $ $ UNRWA Nystatin 100000U/ml 30ml susp. 113,465 0.3950 159,700 63,082 50,384 Paracetamol 500mg 100 tablet 265,844 0.8700 272,690 237,240 28,604 Paracetamol Infant 125mg 100 suppos. 31,535 3.5500 13,150 46,683 -15,148 Paracetamol Child 125mg 100 suppos. 33,226 5.1000 11,090 56,559 -23,333 Prednisolone Acetate 1% 5ml eye drops 26,714 0.7800 21,400 16,692 10,022 Ranitidine HCL 150mg 100 tablet 82,004 0.7900 68,600 54,194 27,810 Salbutamol 100mcg/dose 1 inhaler (200d) 170,902 1.6100 100,700 162,127 8,775 Salbutamol 0.5% 20ml resp soln. 27,183 2.0900 20,650 43,159 -15,976 Salbutamol Sulphate 2mg/5ml 100ml oral liquid 69,094 0.5350 134,250 71,824 -2,730 Silver Sulphadiazine 1% 30g cream 33,575 0.9120 44,200 40,310 -6,735 Sodium Valproate 200mg 100 tablet 53,434 9.4000 15,880 149,272 -95,838 Tetracyline HCL 1% 5g eye ointment 24,639 0.5500 58,900 32,395 -7,756 Thyroxine 100mcg 100 tablet 19,000 3.0000 5,000 15,000 4,000 Net annual savings $ -1884408

Annex VII Suppliers of medicines to UNRWA, JPD and GCC for medicines where there are matches

Note: UNRWA prices are the median landed price for central (tender) procurements including freight. JPD and GCC prices also include freight See below the table for the full names of the suppliers Strength, Dose UNRWA JPD GCC Medicine Form & Purchasing Unit Price $ Quantity Supplier Price $ Quantity Supplier Price $ Quantity Supplier 0.8000 46,000 Barakat Syria Acetylsalicylic acid 100mg tabx100 2.3970 161,000 Bayer Germany 0.7500 1,928,013 Gulf UAE 1.0936 247,790 Gulf UAE Acetylsalicylic acid 500mg tabx100 4.2833 44,000 Gulf UAE 4.1500 12,382 Gulf UAE

250mg/5ml susp 0.6300 78,000 Barakat Syria Amoxycillin 0.6603 1,022,300 Ram Jordan 0.8300 6,617,976 SPIMACO KSA x100ml 0.7103 885,990 Riva Egypt Remedica Dar Al Dawa Dar Al Dawa Amoxycillin 500mg capx100 3.8275 158,655 3.4827 304,100 3.9600 964,636 Cyprus Jordan Jordan Remedica Dar Al Dawa Amoxycillin 250mg capx100 2.5265 19,790 2.1200 1,538,389 Cyprus Jordan United Pharm National Pharm Atenolol 50mg tabx100 0.8117 419,080 0.8742 135,600 Ram Jordan 0.5800 39,077 Jordan Oman 200mg/5ml Azithromycin 2.4265 88,940 Gulf UAE 0.8185 238,100 Hayat Jordan 1.7250 470,102 8 Gulf UAE suspx22.5ml 250mg tab/cap Advanced Pharm Azithromycin 7.1478 7,714 Riva Egypt 9.8390 7,500 Hayat Jordan 8.4000 44,739 x100 Jordan 50mcg/dose Shandong Beclomethasone 2.5291 51,400 Durbin UK 1.6951 23,300 2.2800 49,550 Gulf UAE inhaler (200d) Pharm China Benzylpenicillin 1.2MIU vial 2.7919 100,685 Atral Portugal 0.3697 n/a Sandoz Austria benzathine Oman Pharm Betamethasone Val 0.1% cream x15g 0.3145 395,000 API Jordan 0.2933 228,500 APM Jordan 0.2300 121,761 Product Remedica Dar Al Dawa Novartis Carbamazepine 200mg tabx100 1.7169 62,250 1.8330 3,000 11.6300 n/a Cyprus Jordan Switzerland Cefuroxime 750mg vial 1.6119 12,650 Gulf UAE 0.8249 340,000 Hikma Jordan 0.5400 1,746,935 Hikma Jordan Remedica Cephalexin 500mg capx100 5.4400 52,955 4.9124 251,600 RAM Jordan Cyprus 250mg/5ml susp Pharma Intl Cephalexin 0.9218 248,600 Riva Egypt 1.0265 9,600 x100ml Jordan

8 The price is calculated for 22.5ml bottles but 470102 bottles of 15ml size were procured

Strength, Dose UNRWA JPD GCC Medicine Form & Purchasing Unit Price $ Quantity Supplier Price $ Quantity Supplier Price $ Quantity Supplier API Cusi Labs Chloramphenicol 1% eye oint x5g 0.5640 78,400 API Jordan 0.9594 138,300 1.4000 432,735 Jordan Spain National Pharm Chlorphenamine 4mg tabx100 0.9019 99,300 Gulf UAE 0.3102 105,500 n/a 0.2700 723,240 Oman 2-2.5mg/5ml oral Chlorphenamine 0.3570 867,000 Gulf UAE 0.3231 1,711,500 APM Jordan 0.3900 5,767,380 SPIMACO KSA soln x100ml Remedica National Pharm Ciprofloxacin 250mg tabx100 2.4792 28,452 1.8539 30,350 Hayat Jordan 2.0000 2,874 Cyprus Oman 500+125mg 14.4000 3,000 Barakat Syria Sandoz Co-Amoxiclav 10.2676 30,700 10.2000 31,275 SPIMACO KSA tabx100 18.2293 47,480 Gulf UAE Switzerland 250+62mg/5ml 2.6590 199,110 Atral Portugal Co-Amoxiclav 1.4664 230,600 Ram Jordan suspx100ml 1.5000 10,000 Barakat Syria Dar Al Dawa Co-Trimoxazole 40+200mg/5ml 1.0500 48,470 Jordan 0.5781 255,300 Gulf UAE 1.4400 692,6989 Gulf UAE Paed. susp x100ml 0.6227 72,460 Gulf UAE United Pharm Dar Al Dawa Jazeera Pharm Diclofenac Sodium 50mg tabx100 0.6849 72,560 0.6768 99,700 0.5200 1,196,286 Jordan Jordan KSA Digoxin 0.25mg tabx100 2.8041 20,570 GSK UAE 2.3462 20,000 GSK Germany 6.5300 54,225 GSK Germany Remedica Dar Al Dawa Medical & Diltiazem HCL 60mg tabx100 1.0958 24,960 1.8330 3,450 4.1800 25,293 Cyprus Jordan Cosmetic KSA Remedica Enalapril Maleate 10mg tabx100 1.0109 603,500 0.8319 203,400 Ram Jordan 1.6100 149,875 Remedica Cyprus Cyprus Erythromycin National Pharm 250mg tabx100 3.4351 14,880 Gulf UAE 3.2500 241,108 Stearate Oman 125mg/ml oral Ferrous Sulphate 0.6195 529,000 Gulf UAE 0.5100 432,250 Gulf UAE drops x30ml Middle East 7.2564 1,994 MedPharma Advanced Pharm Fluconazole 50mg capx100 Pharm Jordan 5.2371 4,500 18.0000 3,370 Jordan Jordan 6.3500 1,490 Birzeit PNA Remedica Joswee Kuwait Saudi Co Folic Acid 5mg tabx100 0.5663 35,620 1.2690 55,000 1.0400 53,053 Cyprus Jordan Kuwait Frusemide 40mg tabx100 0.7778 64,060 Remedica 2.4171 126,000 APM Jordan 1.4500 229,110 Gulf UAE

9 Price and quantity is for 100ml, however, GCC tender was for 1385896 x 50ml bottles

Strength, Dose UNRWA JPD GCC Medicine Form & Purchasing Unit Price $ Quantity Supplier Price $ Quantity Supplier Price $ Quantity Supplier Cyprus 0.3% eye drops Medical & Gentamicin 0.2591 239,600 API Jordan 0.3173 166,550 API Jordan 0.3000 1,298,170 x5ml Cosmetic KSA Glibenclamide 5mg tabx100 0.5114 219,370 United Jordan 0.5352 248,500 Hikma Jordan 0.5100 1,605,210 Gulf UAE Medochemie MedPharma Gliclazide 80mg tabx100 2.6169 159,725 1.2972 5,900 1.8700 432,565 Tabuk KSA Cyprus Jordan Hydrochlorothiazide 25mg tabx100 0.8198 105,632 United Jordan 3.2853 7,840 JPM Jordan 4.0000 184,700 JPM Jordan Hyoscine Remedica 10mg tabx100 2.4322 20,110 2.8200 100,600 APM Jordan 2.1300 653,023 Tabuk KSA Butylbromide Cyprus Medical & Ibuprofen 400mg tabx100 1.5046 57,560 Gulf UAE 2.0530 118,600 APM Jordan 0.9700 1,334,275 Cosmetic KSA Middle East 0.7000 900 100mg suppos Pharm Jordan MedPharma Indomethacin 5.6259 1,630 33.2000 14,496 Gulf UAE x100 1.7700 1,000 Barakat Syria Jordan 4.8200 6,430 Birzeit PNA Insulin Human 30/70 NovoNordisk NovoNordisk 100IU/ml vial 3.1023 476,650 3.1735 502,000 NovoNordisk 2.1200 1,958,500 Premixed Jordan Denmark Insulin Human NovoNordisk NovoNordisk 100IU/ml vial 3.1459 37,370 3.1759 800 NovoNordisk 2.1200 893,010 Isophane Jordan Denmark Insulin Human NovoNordisk NovoNordisk 100IU/ml vial 3.1647 6,590 3.1738 11,400 NovoNordisk 2.1200 718,660 Neutral Jordan Denmark 100-105mg Remedica Iron + Folic Acid +325-400mcg 1.4626 223,560 4.0000 364,550 Gulf UAE Cyprus tabx100 20mg SR tab Schwarz Schwarz Isosorbide Dinitrate 3.4668 51,040 GSK Germany 6.8385 37,200 3.8800 186,297 x100 Germany Germany 100mg/5ml 0.3400 12,200 Domina Syria Janssen Mebendazole 1.7965 80,450 0.8900 384,270 Gulf Jordan suspx100ml 0.4311 176,600 Gulf Jordan Belgium Metformin HCL 500mg tabx100 0.9665 437,370 Gulf Jordan 1.0857 43,600 Ram Jordan 1.0200 2,162,326 Gulf Jordan Remedica Algorithm Sal. Methyldopa 250mg tabx100 2.9875 37,000 3.4122 24,140 Ram Jordan 5.6400 76,396 Cyprus Lebanon Metronidazole 250mg tabx100 1.3500 2,400 Barakat Syria 1.5000 84,784 Medical &

Strength, Dose UNRWA JPD GCC Medicine Form & Purchasing Unit Price $ Quantity Supplier Price $ Quantity Supplier Price $ Quantity Supplier 1.4480 76,688 Gulf Jordan Cosmetic KSA 125mg/5ml susp 0.4000 28,000 Barakat Syria Medical & Metronidazole 0.6599 253,700 APM Jordan 0.3800 1,610,415 x100ml 0.4236 151,360 Gulf UAE Cosmetic KSA 2% (24mg/ml) Middle East Dar Al Dawa Miconazole 0.7513 116,030 0.4794 182,900 APM Jordan 0.7500 35,865 oral gelx40g Pharm Jordan Jordan 200mg vag 4.0000 1,050 Barakat Syria Dar Al Dawa Miconazole Nitrate 10.7100 18,750 suppos x100 8.1485 14,663 Gulf UAE Jordan Miconazole Nitrate 2% cream x15g 0.3038 219,020 API Jordan 0.1900 1,300,100 Oman Pharm

1.1250 26,890 Birzeit PNA Nifedipine 20mg SR tabx100 1.1703 37,100 United Jordan 8.9000 154,300 Bayer Germany 1.4419 56,800 United Jordan 100000U/ml 0.6200 3,000 Barakat Syria Medical & Nystatin 0.3950 910,350 susp x 30ml 0.7050 156,700 Gulf UAE Cosmetic KSA 250mg/5ml susp Paracetamol 0.3504 1,088,400 Gulf UAE 0.5866 399,000 APM Jordan x100ml Kuwait Saudi Co Paracetamol 500mg tabx100 0.9586 272,690 Gulf UAE 0.7050 1,145,200 Ram Jordan 0.8700 3,039,910 Kuwait 125mg suppos 2.0000 450 Barakat Syria Paracetamol Infant 2.3829 24,750 Gulf UAE 3.5500 185,191 Gulf UAE x100 2.4050 12,700 Gulf UAE 250mg suppos 2.0000 1,000 Barakat Syria Paracetamol Children 2.7055 28,350 Gulf UAE 5.1000 21,798 Gulf UAE x100 3.0685 10,090 Gulf UAE Prednisolone 1% eye drops 1.2653 21,400 API Jordan 0.8249 31,700 API Jordan 0.7800 n/a Jamjoom KSA Acetate x5ml 1.1750 49,800 Birzeit PNA Ranitidine HCL 150mg tabx100 2.4111 3,000 APM Jordan 0.7900 1,294,274 Gulf UAE 1.2465 18,800 Gulf UAE 100mcg/dose Drogsan Salbutamol 1.7987 100,700 Durbin UK 0.8982 252,700 1.6100 3,148,475 Gulf UAE inhaler (200d) Turkey 0.5% resp soln 1.2380 18,600 Birzeit PNA Salbutamol 0.7826 37,500 Gulf UAE 2.0900 685,066 Glaxo KSA x20ml 2.0275 2,050 GSK UAE 2mg/5ml oral liq Kuwait Saudi Co Salbutamol Sulphate 0.4892 134,250 Gulf UAE 0.2585 225,700 Gulf UAE 0.5350 1,049,040 x100ml Kuwait Philadelphia MedPharma Medical & Silver Sulphadiazine 1% creamx30g 0.7647 44,200 0.4935 5,200 0.9120 1,643,080 Jordan Jordan Cosmetic KSA

Strength, Dose UNRWA JPD GCC Medicine Form & Purchasing Unit Price $ Quantity Supplier Price $ Quantity Supplier Price $ Quantity Supplier Remedica Sodium Valproate 200mg tabx100 3.3943 15,880 8.2189 216 Sanofi France 9.4000 139,677 Sanofi France Cyprus 200mg/5ml oral Sodium Valproate 4.5289 18,397 Sanofi Jordan 7.6760 2,200 n/a soln x100ml Kuwait Saudi Co Tetracyline HCL 1% eye ointx5g 0.4080 58,900 API Jordan 0.5500 1,086,805 Kuwait Merck Thyroxine 100mcg tab x100 3.8000 5,000 2.4675 33,800 Activa UK 3.0000 146,165 Merck Germany Germany n/a not available

Supplier names Advanced Pharm - Advanced Pharmaceutical Industries Co. Ltd. Algorithm - Algorithm Pharmaceutical Manufacturers APM – Arab Pharmaceutical Manufacturing Company API – Amman Pharmaceutical Industries Company Atral – Atral Cipan Barakat – Barakat Pharmaceutical Industries Birzeit – Birzeit Pharmaceutical Company Cusi Labs – Alcon Cusi SA Dar Al Dawa - Dar Al DawaPharmaceutical Company Domina – Domina Pharmaceuticals Durbin - Durbin PLC Gulf - Gulf Pharmaceuticals Industries (Julphar) Hikma - Hikma Pharmaceuticals PLC Jamjoom – Jamjoom Pharma Jazeera Pharm - Jazeera Pharmaceutical Industries JPM – Jordanian Pharmaceutical Manufacturing Company Kuwait Saudi Co - Kuwait Saudi Pharmaceuticals Industries Company Medical & Cosmetic - Riyad Pharma Medical & Cosmetic Products Company MedPharma - Medpharma Pharmaceutical and Chemical Industry

Middle East Pharm - Middle East Pharmaceutical & Chemical Industry National Pharm - National Pharmaceutical Industries Co. Oman Pharm – Oman Pharmaceutical Products Company Philadelphia - Philadelphia Pharmaceuticals Company Riva – Riva Pharm Company Schwarz – Schwarz Pharma AG SPIMACO - Saudi Pharmaceutical Industry & Medical Appliances Corporation Tabuk - Tabuk Pharmaceutical Manufacturing Company United - United Pharmaceutical Manufacturing Company

Annex VIII Ratios of prices and quantities of UNRWA local procurements to central procurements

Jordan Field Syria Field Lebanon Field West Bank Field Gaza Field Medicine Ratios: Ratios: Ratios: Ratios: Ratios: Price Quantity Price Quantity Price Quantity Price Quantity Price Quantity Allopurinol 100mg tab 3.72 0.03 Aminophylline 25mg/ml inj 0.91 0.01 Amoxycillin 250mg/5ml susp. 1.47 0.04 Azithromycin 200mg/5ml susp 0.45 0.11 0.82 0.02 Beclomethasone50mcg/dose inhaler (200d) 0.94 0.08 Benzylpenicillin benzathine 1.2MIU vial 0.12 0.08 Betamethasone 0.1% eye/ear drops 1.84 0.15 Carbamazepine 200mg tab 2.75 0.04 3.10 0.06 Cefuroxime750mg vial 0.89 0.48 Cephalexin 500mg cap 1.01 0.05 Cephalexin 250mg/5ml susp 0.95 0.04 1.14 0.09 Co-Amoxiclav 250+62mg/5ml susp Co-Amoxiclav 500+125mg tab 0.86 0.08 Co-Magaldrox tab 0.79 0.22 Co-Trimoxazole 40+200mg/5ml susp 0.49 0.09 Dexamethasone 0.5mg tab 0.83 0.06 Dexamethasone inj 0.75 0.02 2.50 0.01 Digoxin 0.25mg tab 0.55 0.11 Enalapril 10mg tab 0.78 0.11 Erythromycin Stearate 250mg tab 2.27 0.04 Fluconazole 50mg cap 0.85 0.12 0.98 0.08 Folic Acid 5mg tab 0.97 0.07 3.97 0.21 Frusemide 20mg/ml inj 0.64 0.05 Gentamicin 0.3% eye drops 2.93 0.05 Gentamicin 80mg/2ml inj 0.41 2.37 Hydrochlorothiazide 25mg tab 0.95 0.08 9.00 0.05 Hydrocortisone sod succ vial 1.83 <0.01 Hyoscine Butylbromide inj 0.42 0.18

Jordan Field Syria Field Lebanon Field West Bank Field Gaza Field Medicine Ratios: Ratios: Ratios: Ratios: Ratios: Price Quantity Price Quantity Price Quantity Price Quantity Price Quantity Ibuprofen 400mg tablet 1.81 0.08 Isosorbide Dinitrate20mg tab 0.45 0.25 1.92 0.30 Isosorbide Dinitrate 5mg S/L 0.86 0.49 Latex condoms 0.75 0.31 Medroxyprogesterone 150mg inj 3.17 0.03 Metformin 500mg tab 1.13 0.08 Methyldopa 250mg tab 0.81 0.07 Metronidazole 250mg tab 2.51 0.02 Miconazole 2% oral gel 0.93 0.05 0.53 0.02 Nonoyxnol-9 5% pessaries 0.36 0.65 0.36 0.02 Norethisterone 5mg tab 1.10 0.13 Paracetamol 250mg/5ml susp 0.93 0.05 2.43 0.02 Paracetamol 500mg tab 2.26 <0.01 0.66 0.08 Parasiticidal shampoo 1.98 0.03 Prednisolone 1% eye drops 3.25 0.03 Propranolol 40mg tab 0.82 0.48 Ranitidine 150mg tab 1.87 0.15 Salbutamol 2mg tab 1.42 0.08 Salbutamol100mcg/dose Inhaler (200d) 0.98 0.16 Sodium Valproate 200mg tab 2.28 0.08 3.64 0.15 Sodium Valproate 200mg/5ml susp 1.66 0.16 Tetracyline 1% eye oint 1.03 0.13 Thyroxine 100mcg tab 0.40 1.06 0.40 0.80 0.35 0.86 1.54 0.29 1.57 1.36 Water for inj 10ml 3.01 0.88 2.64 0.15 3.82 0.29 7.30 3.43 MEDIAN RATIO 0.93 0.12 0.80 0.08 1.83 0.03 2.28 0.05 1.92 0.16 Number of medicines 5 30 11 18 7

Annex IX Pre-qualified suppliers in 2007 and 2011 for the four medicine tender groups

Note: in the documentation for 2007 a few suppliers were listed as in process. These have not been included in this list 28 28 18 18 19 19 20 20 Mental health Mental health Supplier Country Antibiotics Antibiotics Other meds Other meds Topical preps Topical preps med med 2007 2011 2007 2011 2007 2011 2007 2011 Abbott Laboratories USA X

Abu Shareef Drug Store Jordan X X

ADAllen Pharma Ltd USA X

Advance Pharma Jordan X

Aegis Ltd. Cyprus X X X X

Alcon Cusi Spain X

Aleppo Pharm Industries Syria X X X X X

Alfa Laboratories Lebanon X X

Alkaloid AD Macedonia X X X X X X Al-Hikma Pharm Company Jordan X X X X Al-Kindi Pharmaceutical Jordan X X

Al-Razi Lab Syria X

Amdipharm Sales & Market. UK X

Amman Drugs & Trading Co. Jordan X X X X X X (ADATCO) Amman Pharmaceuticals Jordan X X X

Amrit Medica Syria X

Amstelfarma B.V Netherlands X X X X X X X Apotex Inc. Canada X X X X X Asia Pharm Indust. Syria X

Aspen UAE X

AstraZeneca UK X X

Atral Portugal X X X X X X

Avenzor Syria X

Beit Jala Pharmaceuticals Palestine X X

Benta SAL Lebanon X

Bilim Pharmaceuticals Turkey X X X

28 28 18 18 19 19 20 20 Mental health Mental health Supplier Country Antibiotics Antibiotics Other meds Other meds Topical preps Topical preps med med 2007 2011 2007 2011 2007 2011 2007 2011 Bioton Poland X

Birzeit Pharmaceuticals West Bank X X X X X X

Britannia Medical Ltd UK X X

Chiesi Group Italy X X

Claris Lifesciences Ltd India X X

Dajani Jordan X

Dar Al Dawa Jordan X X X X X X X Dawn Technologies Jordan X X

Demo Greece X X X

Den Norske Eterfabrikk Norway X X

Domina Pharmaceutical Syria X X X X X Durbin UK X X X X X X EGIS Pharmaceuticals Hungary X X

El Saad Pharma Syria X

Eli Lilly Export Switzerland X X

Farabi Medica Syria X

Finishing Enterprises (FEI) USA X

Gerot Pharmaceuticals Austria X X X

GlaxoSmithKline Jordan X X X X

Gulf Pharmaceuticals UAE X X X X X X

Hadylena For Advanced Egypt X Medical Industries Hayat Pharm Jordan X

Help Pharmaceuticals Greece X X X

Hovid Malaysia X X X X X HTSPE Ltd UK X X

Ibn Al Hayyam Pharm. Syria X X

Imres Netherlands X X X X X X

IDA Netherlands X X X

Janssen Cilag Lebanon X X

Jerusalem Pharmaceuticals West Bank X X X X X

Jordan Sweden (JOSWE) Jordan X X X

Jordanian Pharmaceuticals Jordan X X X

Khraim Drug Store Jordan X

Khoury Dental Jordan X

Lundbeck Sweden X

Medical Export Group Netherlands X

Medico Pharmaceuticals Syria X

Mediotic Labs ? X X

Mediterian Pharm Ind. Syria X

Medochemie Cyprus X X X X X X X Menarini Industries Italy X

Mepha Ltd UAE/Switz X X X X

Merck Germany X

Middle East Pharmaceutical Lebanon X X X X X & Ind. Middle East Pharm. & Chem. Jordan X X X X X X Indust. Mina Drug Store Jordan X X

Munir Sukhtian Jordan X X X

Nabih Nabulsi Drug Store Jordan X

National Pharma Industries Oman X X X X X

Nawahil Drug Store Jordan X

Neuraxpharm Arzneimittel Germany X

Ninos Drug Store Jordan X X

Novartis Vaccines and Diag Italy X X

NovoNordisk Jordan X X

N.V.Organon Netherlands X X

Omnitrade Establishment Jordan X

Optimum UK X

Orient Drug Store Jordan X X X

Petra Drug Store Jordan X X

Pfizer UAE/Bel/Egyp X X X X X

Pharma International Jordan X X

PharmaCare West Bank X X X X X X

Pharmadex Lebanon X

Pharmaline Lebanon X X X X X Philadelphia Jordan X X X Pharmaceuticals Purna Belgium X X

RAM Pharmaceuticals Jordan X X X

Remedica Cyprus X X X X X X

Riemser Arzeimittel AG Germany X X

Riva Pharma Egypt X X X

Sami-Dandan - Sadco Lebanon X

Sanofi-Aventis France X X X X X

Saudi Pharmaceuticals Saudi Arabia X X X X (SPIMACO) Schering Germany X

Schwarz Pharma AG Germany X X

Tabuk Pharm Mfg. Co. Saudi Arabia X X X X

The Holding Co. for Pharma Egypt X X X X (Holdipharma) Ulfa Pharm. Jordan X X

Ultra Medica Syria X

UNICEF Supply Division Denmark X X X X

United Pharm. Mfg. Jordan X X X X X X X Umedica Laboratories India X

Universal Pharm Syria X

UNICEF Syria X

Vitabiotics UK X

Weimer Pharma Germany X

Wyeth Ayrest International Germany X X

Total 39 16 66 84 34 35 24 11

This review is a comprehensive analysis of medicine procurement prices and process in UNRWA. UNRWA has long been providing primary health care to 5 million Palestine refugees in Gaza, the West Bank, Jordan, Lebanon, and Syria, including provision of essential medicines. In 2010, UNRWA spent USD 15.4 million on medicines. In order to make the best use of the available resources, particularly under budget constraints, UNRWA assessed the e ciency of the medicine procurement process, particularly procurement prices. The analysis was conducted in collaboration with HAI.

The analysis revealed that, overall, UNRWA is procuring medicines e ciently. UNRWA prices are equal to or less than MSH, IDA, JPD or GCC prices. Still, there is a room for potential savings if more eorts are made to: explore options to reduce the prices for the nine key medicines: develop regulatory standards for prequalifying suppliers with product quality assurance: identify suppliers particularly from outside the region: develop user friendly system should be of top priority, and involve pharmacists more in medicine use issues.