European collaborations on medicine and vaccine procurement

Abstract To ensure equitable access to medicines and vaccines, organizational efforts and purchase volumes have been pooled in joint procurements and negotiations for decades in some regions of the world, as well as globally through supranational procurement mechanisms. In Europe, countries started to collaborate on procurement and negotiations recently when it became increasingly difficult to ensure access to high-priced medicines, even in high-income countries. Two European country collaborations (the Nordic Pharmaceutical Forum and the Baltic Procurement Initiative) have successfully concluded at least one joint tender process for medicines and vaccines and the Beneluxa Initiative has concluded its first successful joint price negotiation. This article describes the experiences of these country collaborations. Challenges observed included: legal barriers; institutional and organizational differences between health-care systems in member countries; and the risk that suppliers will be reluctant to cooperate with country collaborations. Although these collaborations helped improve access to medicines and vaccines for the countries involved, in situations such as a global health crisis, larger-scale, more-inclusive initiatives are needed. In the current coronavirus disease 2019 (COVID-19) pandemic, COVID-19 Vaccines Global Access (COVAX) initiative established a global procurement mechanism to ensure the equitable distribution of COVID-19 vaccines globally. Despite differences in organization and scale, the European country collaborations and COVAX have some similarities: (i) their success depends on the increased purchasing power associated with pooled order volumes; (ii) expert knowledge and previous procurement experience is pooled; (iii) they perform other collaborative activities that go beyond procurement alone; and (iv) they actively involve external partners and stakeholders.


Introduction
Access to essential medicines has become a major challenge globally. Even high-income countries with health-care systems based on social solidarity are increasingly struggling to afford the high price of medicines. 1 In response, governments have been optimizing their policies on pricing and have piloted and implemented new policies. 2 New initiatives include efforts to improve transparency on pricing and to strengthen collaboration, for example, through pooled procurement and joint price negotiations. 3 Although marketing authorization has been harmonized among countries of the European Union, the pricing and reimbursement of medicines remain national competences. In Europe, national decision-making on pharmaceutical pricing and reimbursement is supported by sharing information and experience with pricing policy through, for example, the Pharmaceutical Pricing and Reimbursement Information network or the Piperska group, 4,5 which are informal collaborations of public authorities and health-care funders that have been in place for more than a decade. Furthermore, European Union Member States and other stakeholders have cooperated on health technology assessment (mainly to improve methods), for instance, through the European Network for Health Technology Assessment (EUnetHTA), which is coordinated by the European Commission. 6 However, compared with other regions of the world, Europe has had limited experience with cross-country collaborations on procurement. In contrast, for decades countries in the Americas have been using the Pan American Health Organization's (PAHO) Revolving Fund for vaccines, syringes and related supplies and PAHO's Strategic Fund for other es-sential medicines. 7,8 Moreover, since the late 1970s, Persian Gulf states have collaborated through the Gulf Cooperation Council to procure medicines jointly. 8,9 In some regions, government-led procurement initiatives are supplemented by global procurement mechanisms for medicines and vaccines coordinated by supranational institutions. Some examples are the Global Drug Facility for tuberculosis drugs, the supply division of the United Nations International Children's Emergency Fund (UNICEF) and the recently established procurement mechanism by COVID-19 Vaccines Global Access (COVAX) initiative for coronavirus disease 2019 (COVID- 19) vaccines. 10,11 Whether country-led or coordinated by supranational institutions, pooled procurement has provided benefits; for example: (i) lower purchase prices and thus improved access to medicines and vaccines; (ii) reduced operational costs and administrative burden; (iii) improved quality assurance; (iv) better governance; and (v) greater equity. 12,13 In 2014, the European Commission approved the Joint Procurement Agreement for medical countermeasures, 14 which established a joint procurement procedure for items such as vaccines, antivirals and other emergency supplies. However, the agreement was not intended to be used to procure high-priced medicines, such as orphan drugs for rare conditions and oncology medicines. 15 In recent years, two main strategies for ensuring access to medicines have become prominent in Europe. First, procurement in general has risen up the political agenda and is increasingly considered an important topic, as confirmed by the European Union's adoption of a pharmaceutical strategy for Europe. 16 The strategic relevance of procurement was also highlighted by discussions on strategic procurement initiated by the World Health Organization's (WHO) Regional Office Abstract To ensure equitable access to medicines and vaccines, organizational efforts and purchase volumes have been pooled in joint procurements and negotiations for decades in some regions of the world, as well as globally through supranational procurement mechanisms. In Europe, countries started to collaborate on procurement and negotiations recently when it became increasingly difficult to ensure access to high-priced medicines, even in high-income countries. Two European country collaborations (the Nordic Pharmaceutical Forum and the Baltic Procurement Initiative) have successfully concluded at least one joint tender process for medicines and vaccines and the Beneluxa Initiative has concluded its first successful joint price negotiation. This article describes the experiences of these country collaborations. Challenges observed included: legal barriers; institutional and organizational differences between health-care systems in member countries; and the risk that suppliers will be reluctant to cooperate with country collaborations. Although these collaborations helped improve access to medicines and vaccines for the countries involved, in situations such as a global health crisis, larger-scale, more-inclusive initiatives are needed. In the current coronavirus disease 2019 (COVID-19) pandemic, COVID-19 Vaccines Global Access (COVAX) initiative established a global procurement mechanism to ensure the equitable distribution of COVID-19 vaccines globally. Despite differences in organization and scale, the European country collaborations and COVAX have some similarities: (i) their success depends on the increased purchasing power associated with pooled order volumes; (ii) expert knowledge and previous procurement experience is pooled; (iii) they perform other collaborative activities that go beyond procurement alone; and (iv) they actively involve external partners and stakeholders.
Policy & practice Joint medicine and vaccine procurement Sabine Vogler et al.
for Europe in 2016. 17,18 Second, some countries of a similar size and income level have joined forces to establish so-called voluntary collaborations. 19 These collaborations are coordinated by national governments that wish to increase the affordability of medicines by aligning their national pricing and procurement procedures -they do not involve regional or supranational organizations. Examples of such voluntary collaborations are the Baltic Procurement Initiative (involving Estonia, Latvia and Lithuania), the Beneluxa Initiative on Pharmaceutical Policy (involving Austria, Belgium, Ireland, Luxembourg and the Netherlands), the Fair and Affordable Pricing initiative (involving mainly countries in Central and Eastern Europe), the Nordic Pharmaceutical Forum (involving Denmark, Iceland, Norway and Sweden, with Finland as an observer) and the Valletta Declaration (involving mainly Mediterranean countries). 20 Apart from the 2012 Baltic Procurement Initiative, all were founded in 2015 or later. Most of these collaborations aim to cooperate in areas such as information sharing, horizon scanning (i.e. identifying potential future medicines in the research and development pipeline) and health technology assessment. The Beneluxa Initiative does not perform pooled procurement but does conduct joint pricing negotiations; 21 initially these were for orphan medicines but now include medicines with a large budgetary impact.
Three collaborations (i.e. the Baltic Procurement Initiative, the Beneluxa Initiative and the Nordic Pharmaceutical Forum) have successfully concluded at least one joint cross-country tender process or price negotiation. The aim of this paper was to describe the experience of these three European country collaborations as the lessons learnt may be of interest to other countries that wish to carry out joint procurement or price negotiations and may be applicable to procurement mechanisms coordinated by supranational organizations. Their experience may also be relevant for WHO's European Programme of Work, which designates pooled procurement initiatives as a key priority. 22 In addition, we compare the experiences of these three collaborations with those of the new global COVAX mechanism for procuring and distributing COVID-19 vaccines.

European experience
The three European country collaborations we studied conducted either a joint procurement process or joint price negotiations, in addition to other activities. The Beneluxa Initiative adopted a value-chain perspective, which involved monitoring medicines during: (i) pre-launch research and development; (ii) the peri-launch period after marketing authorization and before launch onto the market (when pricing and reimbursement decisions are made); and (iii) the post-launch period, when measures to promote appropriate prescribing, dispensing and use of medicines can be implemented. 23 In addition to joint price negotiations, the Beneluxa Initiative collaborated on horizon scanning and health technology assessment, which resulted in the alignment of timelines and health technology assessment methodologies within the collaboration. Further, a joint template was prepared to help manufacturers submit dossiers for joint assessments. 24,25 Countries in the Nordic Pharmaceutical Forum also collaborated on horizon scanning, and members of the Baltic Procurement Initiative established a lending agreement to help each other when there were shortages by lending medicines or medical devices without charge. However, the following discussion focuses on joint procurement and joint price negotiations. The main characteristics of, and the key lessons learnt in, these three collaborations are summarized in Box 1.

Nordic Pharmaceutical Forum
On 1 February 2020, the Nordic Pharmaceutical Forum entered into its first joint tender agreement after the successful conclusion of a technical procurement process lasting over a year. Preparations for the tender call dated back to the summer of 2017 when the Forum explored options for a pilot joint procurement exercise. In September 2018, the collaboration conducted a market survey to collect potential suppliers' views on a preliminary list of suitable products. The first joint tender process focused on ensuring the availability of older medicines whose patent had expired (e.g. antibiotics such as ciprofloxacin, ceftriaxone and metronidazole) and for which it was difficult to find suppliers for Nordic countries because of their relatively small markets.
Details of the procurement were based on an extensive dialogue with potential suppliers. Before tenders were invited, 6 weeks of hearings were held with potential bidders and their comments were considered during preparation of the tender call documents. Denmark was the lead country and the tender call was based on Danish legislation. Norway and Iceland participated in this first Nordic tender process, whereas Sweden (which has a fragmented hospital sector) did not join in. There were several challenges, particularly for Iceland, because potential suppliers did not consider its market to be sufficiently attractive to apply for marketing authorization. Consequently, the Nordic Pharmaceutical Forum let the suppliers decide whether to include Iceland in their offers, with the result that Iceland received an offer from only one company. Overall, a sufficient number of bids was received for most tender calls to ensure adequate competition. In total, nine contracts were signed for medicines such as ondansetron, gentamicin, paracetamol, meropenem, anagrelide and methotrexate. 26,27 Members of the Nordic Pharmaceutical Forum were reportedly satisfied with this first tender process. However, major challenges had to be addressed: (i) legal barriers had to be overcome; (ii) sufficient resources were required; and (iii) adequate time for planning was needed (Box 1).
In June 2021, the Nordic Pharmaceutical Forum issued another joint tender call, which this time included environmental criteria such as: (i) following good practice to ensure zero carbon emissions and clean wastewater at the bidder's and their subsuppliers' production sites; and (ii) making an effort to reduce greenhouse gas emissions from transport. 28 Reportedly, Iceland has started to change its legislation to enable participation in future Nordic tenders. 20

Baltic Procurement Initiative
To date, the Baltic Procurement Initiative has focused on procuring vaccines and has successfully concluded three tender processes. In 2019, the collaboration exited the pilot phase and progressed towards a more strategic collaboration by developing the Baltic countries' first joint procurement plan. However, the first joint tender call in 2015 was unsuccessful because no bids were received. Since then, the collaboration has paid greater attention Joint medicine and vaccine procurement Sabine Vogler et al.
to market analysis and increased its consultations with stakeholders before inviting tenders.
For each joint procurement process, a lead country is identified and other countries legally consent to it procuring products on their behalf. The lead country's legislation is applied. For the first tender process, documents were prepared simultaneously in the national languages of the two participating countries. From the second joint procurement process onwards, all documents (with a few exceptions for legal reasons) were prepared solely in English, a for-eign language in all Baltic countries. The Initiative aims to keep the procurement procedure as simple as possible and is committed to preparing simple, short documents. For each procurement, the three collaborating countries decide which will participate and which will be the lead country. Participation is voluntary and usually involves only those countries that have the particular vaccine in their immunization schedules. 20

Beneluxa Initiative
Using the value-chain approach, members of the Beneluxa Initiative on Pharmaceutical Policy first identify medicines of interest for collaborative action through horizon scanning, then they perform a joint health technology assessment and, finally, they conduct joint price negotiations. Collaborating countries do not all have to be involved in all steps of the process. Moreover, a successful joint negotiation does not necessarily mean that prices and reimbursement conditions are the same for all countries as the final decisions on pricing and reimbursement are taken nationally.

Box 1. Characteristics of, and lessons learnt from, three European country collaborations on procuring medicines and vaccines, 2010-2021
Note: Information was obtained during interviews conducted between July and November 2018 with government officials involved in collaborations and from follow-up correspondence that took place in October 2019 and in January and June 2021.

Nordic Pharmaceutical Forum
Established: 2015 Countries involved: Denmark, Iceland, Norway and Sweden Activity studied: Joint procurement of medicines Activity history: • One successful joint procurement (concluded 2020) • Second tender call in preparation (2021) In July 2018, two countries (Belgium and the Netherlands) were involved in the first successful joint negotiations (for nusinersen, a medicine for spinal muscular atrophy) -a joint health technology assessment had been carried out to inform the negotiations. Reimbursement conditions differed slightly between the two countries and the negotiated price (i.e. the price agreed by payers but kept confidential) may also have differed. The Beneluxa Initiative aims to involve additional member countries in future negotiations. 29 The Initiative has had limited experience with joint negotiations. To date, there have been only two: (i) the nusinersen negotiations; and (ii) earlier, unsuccessful negotiations on the combination of lumacaftor and ivacaftor, which are used for treatment of cystic fibrosis. The Beneluxa Initiative reported that motivating the pharmaceutical industry was difficult, particularly large multinational companies, to enter into negotiations with the collaboration. Additional problems were differences between countries in national pricing and reimbursement processes. Moreover, as Beneluxa joint procedures do not overrule national legislation and national procedures remain in force, 30 member countries must come into legislative and procedural alignment with each other.

European collaborations
In general, the procurement process for medicines and vaccines is prone to failure. Indeed, two of the three collaborations we analysed had unsuccessful negotiations and tender calls. There is a risk that suppliers may have limited interest in tender calls, or may lack the ability to respond to them, and that winning bidders may not meet their contractual obligations. These risks can be mitigated by having in-depth knowledge of the market (e.g. through consultation and dialogue with possible suppliers and by market research) but they can never be eliminated. Good planning is key for procurers but is resource-intensive.
All three European collaborations were confronted with challenges resulting from legal, institutional and organizational differences between healthcare systems in member countries and sometimes a change in legislation was required. For instance, Belgium had to alter its legislation to permit dossiers submitted by manufacturers to be written in English, which is the working language of the Beneluxa Initiative. 20 The Nordic Pharmaceutical Forum and the Baltic Procurement Initiative opted to designate a lead country whose national legislation would be applied during joint procurements. In general, extensive efforts were required to align national procedures with the newly established processes of the country collaboration, especially in the starting phase.
All three collaborations followed the principle of voluntary participation, which meant that, for each collaborative action, member countries could choose whether or not to be involved. If a country decided to join an activity, it had to take on specific responsibilities.

COVAX procurement mechanism
At the time of writing in 2021, the world is fighting one of the most serious health crises in history. Research and development into vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that are effective against viral mutations of concern is essential and global administration of these vaccines is urgently needed. Ensuring their supply to all eligible individuals requires actions that go far beyond what can currently be achieved by the government-led country collaborations described here.
In Europe, the European Commission has been coordinating the pooled procurement of COVID-19 vaccines for all European Union Member States because some states have relatively small markets or relatively low national income levels. This pooled effort, which is supported by investments such as advance purchase commitments, 31 was able to secure vaccines for the European population. 32 The COVID-19 pandemic highlights the vital need for further large-scale collaborations at the global level. In April 2020, the Access to COVID-19 Tools (ACT) Accelerator partnership was launched by the European Commission, WHO and other global health organizations with the aims of: (i) accelerating the development of vaccines, diagnostic tests and treatments for COVID-19; (ii) ensuring equitable global access to vaccines, tests and treatment; and (iii) strengthening health systems. 33 Its vaccine pillar is COVAX, which is led by Gavi, the Vac-cine Alliance, WHO and the Coalition for Epidemic Preparedness Innovations foundation. The COVAX Facility, which is the global procurement mechanism of the partnership, makes investments across the portfolio of promising vaccine candidates and negotiates contracts using the pooled purchasing power of participating countries. Through COVAX Facility mechanisms, vaccines will be distributed equitably as soon as they are available, for example, by richer countries donating excess doses. 34 In addition, UNICEF, the world's largest single vaccine buyer, has partnered with Gavi in the COVAX Facility to manage the procurement of COVID-19 vaccine doses, as well as their transport, distribution and storage. This partnership has led to the procurement and delivery of vaccine to 92 low-income and lower-middle-income countries and has supported procurement for 97 upper-middle-income and high-income countries. 35 In terms of the number of countries and stakeholders involved and its institutional set-up, COVAX is not strictly comparable with cross-country, joint, procurement and negotiation collaborations involving only a few countries. Instead, COVAX enables countries without well-developed health systems to streamline their processes and provides technical support. In addition, it is a risk-pooling mechanism: participating countries do not know in advance which vaccines will eventually be successful. Importantly, COVAX member countries are not involved in negotiations or in the procurement process, as they are in the European collaborations we studied.
Nonetheless, country-led collaborations and COVAX have some common characteristics. First, all joint procurements benefit from the stronger purchasing power associated with pooled order volumes, which helps address problems with access to medicines. Second, joint procurement and negotiations can take advantage of existing knowledge and the experience gained during previous procurement processes: this is reflected by the prominent role played by expert organizations in procurement initiatives (e.g. by central procurement agencies in Denmark and Norway in the Nordic Pharmaceutical Forum and by UNICEF, which partnered with the PAHO Revolving Fund in some cases, in COVAX). Third, procurement and price negotiations constitute only one of several instruments in an end-to-end approach to improving Joint medicine and vaccine procurement Sabine Vogler et al.
access that is influenced by other, equally relevant policies. For example, the CO-VAX Facility is embedded in the ACT Accelerator, which additionally aims to encourage the development of effective vaccines, tests and treatments. Investment incentives, therefore, also play a major role. In country collaborations, joint procurement processes and negotiations form part of a larger portfolio of collaborative action, as reflected by the pharmaceutical value-chain approach chosen by the Beneluxa Initiative. Lastly, success depends on interactions with stakeholders (e.g. developers and suppliers), thereby achieving a beneficial situation for all.

Conclusions
Country collaboration on procurement is important for improving access to medicines and vaccines. In certain circumstances, as exemplified by the high global demand for vaccines and the need for their equitable worldwide distribu-tion during the COVID-19 crisis, there appears to be no alternative to global procurement organized by a coalition of governments and supranational organizations. Further large-scale global procurement and price negotiations could help advance public health goals, particularly in low-and middle-income countries. However, it is unclear whether governments would be interested in extending mechanisms such as COVAX to other medicines and vaccines.
Regardless of whether or not countries collaborate, good practice is essential for public procurement. It is important to be prepared by achieving a good understanding of the needs of users and of the characteristics of products and the market. In addition, joint procurement processes face the challenges of legal barriers and of differences in organizational and financial structures between countries. In government-led collaborations, self-organization is also needed: a working structure must be established first and sufficient resources must be made available for the technical experts involved.
Given the need for up-front and continued investment in collaborations, it is important that outcomes are regularly monitored and evaluated so that operating structures and future investment can be adjusted if defined objectives are not fully met. The examples we studied show that collaborations on procurement and negotiations can produce positive results, although the time needed between the original conception and the establishment of a working structure may be substantial. Although further lessons can be expected from these European collaborations, today they can already serve as models for similar collaborations in other regions of the world. ■