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According to the OECD, 29 percent of all government spending is for public procurement, with public health contracts the second largest spending area (more than 9 percent of GDP).
In addition, since 2009, 11 out of 35 OECD member countries have seen a decline in per capita expenditure to cover healthcare needs. Given the high share of spending on procurement in the health sector and taking into account the downward trend in spending on health care per capita, it is understandable that governments are striving to generate savings and provide the highest quality and more efficient goods and services at a competitive price.
Of course, Slovenia is no exception. For example, in 2015, more than three quarters of current expenditure on health care (75.7 percent) was spent on financing curative treatment services and the purchase of medicines and medical equipment, with the share of expenditure for both purposes increasing in the same year (for services of curative treatment by 5.8 percent, and for medicines and other medical goods by 2.2 percent).
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Public procurement is certainly one of the important factors that influence the level of public health expenditure. Therefore, the debate on public procurement in health care, taking into account the nature of accumulated problems in this field, is not only welcome, but also necessary. Nevertheless, it seems that discussions on healthcare contracts, especially in the last year, are more or less focused solely on reducing the prices of medicines and other medical supplies in order to save them in the health check-box. The red thread of virtually all public debates (p) remains the thesis that, by reducing prices, it can not only save health money, but also regulate the market for medicines and medical devices, prevent bad market practices and stop the allegedly frequent corrupt practices. But,
The development of the law of public procurement, together with new procurement practices, constantly brings new approaches to the implementation of public procurement procedures. The 2014 Public Procurement Directives introduced a series of innovations (the criterion of the most economically advantageous tender, the partnership process for innovation, etc.), which should eliminate the dominance of the "lowest price" criterion and enable public procurement on the basis of a wider reflection on quality, cost-effectiveness, the integration of social and environmental aspects and the possibilities of introducing innovative products and / or services. Therefore, in the selection of the most favorable bid, the public procurement directives put the economic efficiency of the subject of procurement in the forefront and not (more) its price only.
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The economic efficiency in terms of finding the optimal balance between the best possible effect that should be achieved by purchasing the object of the order and minimizing the cost of its acquisition (ownership / use) is (or should at least be) of particular importance in healthcare procurement, the effects of which they exceed (or at least need to be exceeded) merely monetary considerations. Therefore, it would be useful, therefore, to approach the discussion about the design of (otherwise urgent) new approaches to public procurement in health care more cautiously, more deliberately and with a wider view, which should be directed rather early than in the past (opening new and new scandals and finding the culprits for them) to the future.
In order to become increasingly aware of the importance of value-based procurement in the health sector worldwide, it shows a number of initiatives that can be found on the World Wide Web.
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The red thread of this kind of effort is that public procurement in health care is not treated as a one-off and isolated act, but as a system tool that can generate significant shifts and bring benefits to everyone - both for those who buy (hospitals, clinics and other health institutions), as well as for those who use their services. In this context, it is possible (through the use of public procurement) to contribute to the provision of more economically viable solutions in healthcare, and to increase the quality and efficiency of patient treatment, the functioning of health professionals and health systems as a whole. The authors of the initiatives for a holistic approach to public procurement in health care often refer to the definition of "value" in the health care of Porter and Olmsted-Teisberg, which is expressed as "health outcomes relevant to patients,
This simple approach can be an effective tool for measuring the value of healthcare outcomes in a way that aligns all stakeholders to a general starting point. The concept of value-based health care and associated value-based public procurement is thus increasingly becoming one of the ways to build more effective and more sustainable health systems. The approach, which not only depends on the level of purchase prices, but also takes into account wider patient and social needs (taking into account the actual cycle of patient health care costs), is more comprehensive and focuses on controlling the real costs of patient care, not just reducing the costs of an individual order.
In relation to the above, the authors point out that a purchase based solely on the lowest price can lead to higher total costs. It is an illustrative example of the purchase of low-cost IV-catheters that are easily broken, user-friendly, require a lot of time to be properly used and pose a security risk for clinical staff. Additional costs that can be triggered by such purchases do not directly affect the volume of financial resources earmarked for public procurement (as a result, such low-cost purchases may consequently be even shown as "saving" in the budget) and are difficult to identify and quantify. However, it is not wise to overlook them. Overall, savings in health care can only be achieved by considering (other) factors other than price. Study
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, which was carried out in Sweden on the economic impact of a longer battery life in cardiac resynchronization defibrillators, for example, has shown that at the time of the purchase of a device with a longer battery life, it is possible to avoid up to 603 device swaps and related problems in six years for patients and health care institutions) and costs, which can lead to significant financial savings, more effective use of health money resources and a better quality of life for patients with heart failure.
Public procurement in healthcare is, as a rule, extensive and complex, and therefore requires appropriate (economic, technical, medical and other) knowledge. The problem may already be the creation of purchasing services. By carrying out the public procurement procedure and consequently by selecting a particular procurement subject, the public procurement service has a significant impact on the work of healthcare personnel and on the level of patient care. In view of this significant impact of purchasing services, their staffing should be subject to particular attention. If it is, it is right to require professionalization and specialization when designing purchasing services in health care. People who are entrusted with the implementation of public procurement in the health sector are (and will probably be even more in the future) one of the key players in the healthcare system,
Needless to say, the risk of corruption in public procurement in the field of health is realistic. However, such a danger should not completely prevent contacts with potential providers, which, last but not least, are the best known for the situation in the relevant market segment. The valid procurement rules at the stage of public procurement preparation (market review) permit such contacts to be made conditional on not preventing or restricting competition and do not constitute a violation of the principles of equal treatment of tenderers and the transparency of public procurement.
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The set of information thus collected can help the purchasing departments to better understand which technologies are on the market or in the development, and a good understanding of the market situation facilitates the purchasing department to properly plan the execution of a particular procurement procedure.
In recurring orders, it may be worthwhile to even set up a prior market consultation as a continuous process. Draft Guidelines for Public Procurement of Innovation,
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which has been developed by the European Commission in support of wider acceptance of EU public procurement contracts, is encouraging such behavior. In these guidelines, we find, among other things, an example of the purchase of innovative sewing material for surgeons. Sewing yarns used by surgeons can now be impregnated with antibiotics that reduce inflammation after surgery, they can be equipped with labels for ease of sewing or even special nets that allow the patient to withdraw from the seams themselves, without having to to return to the hospital (which on the one hand increases the patients comfort, and on the other hand reduces the cost of medical intervention).
Hence, every six months, hospitals in the Belgian province of Wallonia organize preliminary market consultations with providers that are dedicated to the ongoing upgrading of purchases. On the basis of electronic notification, all providers have the opportunity to present novelties, their characteristics and added value in terms of effectiveness of treatment, side effects, ergonomic effects and / or patient comfort. The samples collected during prior market consultation are then given by surgeons for testing. Surgeons complete a questionnaire in which they assess the characteristics of the solutions available on the market and their usability for a specific purpose of use, as well as any other comments that can be subsequently taken into account in the preparation of the technical specifications. The integration of actual future users into the pre-clarification phase also eliminates potential conflicts between the purchasing department,
There are many other ways in which public procurement in the health sector can be optimized, without concentrating only on (lowering) the purchase price. One such option is offered by cross-border public procurement, involving public contractors from different EU Member States, including the cross-border use of central purchasing bodies and / or the possibility of setting up joint purchasing services.
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Such cooperation does not only lead to a reduction in procurement costs, but also offers a broader insight into the market situation, the exchange of experiences and the formulation (or at least taking) of good practices. As can be seen from the public media, some forms of such cooperation are already being built by the purchasing department in SB Maribor, which is a welcome novelty and an important step to be welcomed.
To conclude: the desire to reduce prices for public procurement in healthcare is certainly commendable, but the current approach is that it does not deal with either the quality or needs of the patient, and in fact blurred the picture of the actual total costs of health care. Public procurement, which is based only on the lowest purchase price, is a short-sighted approach in the field of health, driven by a rigorous focus on short-term savings, while it can have the opposite effect in the long run. Taking into account the entire patient care cycle, which logically relies on the quality of medical equipment and services, with which individual healthcare delivery systems are equipped, it may well be that todays "savings" will become an additional financial burden on the healthcare fund tomorrow.
Vida Kostanjevec is a former member of the State Audit Commission. This article has already been published on the TaxFinLex portal.
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