Understanding Public Procurement of Paracetamol and Iron tablets in Nepal’s Health System

Understanding Public Procurement of Paracetamol and Iron tablets in Nepal’s Health System | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding Public Procurement of Paracetamol and Iron tablets in Nepal’s Health System Heem Sunder Shakya, Gurpreet Kaur, Karan Shakya, Roshan Man Bajracharya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9329540/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim The procurement function provides critical opportunities to achieve supply chain cost effectiveness especially in public health logistics system where skill and capacity of the health staff are limited. The public health supply chain continues to face challenges, relating to consistent supply of these two essential drugs due to the inefficient forecasting and procurement processes. These gaps result in frequent stock-outs or overstock and expiry. This study aims to analyze existing procurement processes identify systemic gaps and propose practical, evidence-based solutions to improve procurement efficiency. Method The research employed a mixed-methods approach, using quantitative surveys and qualitative interviews to gather data from various public health institutions. A sample size of 325 health institutions were selected across geographical settings. Data analysis involved both quantitative statistical and qualitative thematic analysis. Result Procurement practices, 40% of health institutions indicated that they procure from exporter, followed by stockist, local manufacturer, and pharmacy. Budget to procure paracetamol and iron tablets, 64% said ‘not enough’ from the health institutions. Method of procurement, 48% of the health institution said they use standard bidding, followed by quotation, and direct purchase. Capacity, 3 among 4 health institution’s staff did not have formal training on public procurement. Conclusions Public procurement practice of health products in Nepal has lot of rooms for improvement. The practice of procurement of health products from the local pharmacy shop should be minimized. The three tiers of the government should allocate adequate and flexible budget for procurement of health products and evidence based quantification/forecasting. Drug Delivery Procurement LMIS Forecasting Quantification Supply Chain System Figures Figure 1 Introduction Operational and effective supply chains provide critical medicines, vaccines, and essential medicines to support communicable disease prevention, control, and response activities. They are critical inputs to national and regional health security 14 . Essential medicines which includes paracetamol and iron tablets are those medicines that cater the primary health care needs of the people 12 . The present Nepal’s budget allocations to the sub-national level result in a loss of efficiency of an estimated NRS 46.6 million due to additional transport costs and NRS 139.8 million due to economies of scale, compared to centrally managed procurement 16 . The procurement function provides critical opportunities to achieve supply chain cost effectiveness. For example, it is estimated that the government of Cambodia could have saved up to $ 50 million annually by more efficiency in purchasing health products, equipment, and medical supplies. The country was paying on average up to six times the international reference price of essential medicines 7 . Better coordination, increased procurement and distribution efficiencies, and rigorous needs assessment is needed. 1 Manufacturer are needed to improve their compliance with WHO prequalification standards. 3 There are clear bottlenecks in supply chain such as forecasting, procurement, inventory management, and distribution. 4 It was revealed that stock-outs were primarily caused by the inadequate quantification of supply needs and delays in distribution due to the international procurement. 30 There is bureaucratic and lengthy procurement with only small number of private prequalified suppliers receiving orders from public health institutions. 19 Quality deviated drugs have increased in Nepal since past decade indicating more strict inspection from regulatory bodies during the public procurement. 22 There are research which validated the hypotheses for the strategic public procurement regulatory compliance model with mediation effect of ethical behavior. 26 Several systemic challenges includes: poor coordination between the tiers of government, delayed release of funds, maldistribution of staff, problems over procurement, and limited monitoring and supervision of the quality of service delivery and data reporting. 29 Procurement reforms and process improvements can minimize the risk of procurement errors, improve transparency, and reduce sourcing lead times. These improve supply chain performance and yield significant cost savings 14 . Our aim is to address these gaps through this research to analyze existing procurement processes and systems, identify major gaps and propose practical, evidence-based solutions to improve pubic procurement efficiency, ensure timely delivery and availability of these two essential medicines. We hope that with the recommendations from the research will help support enhancing the overall public health supply chain system's responsiveness and increase timely availability of health products in health institutions. Methodology We employed a mixed-methods approach, combining quantitative surveys with qualitative interviews. We collected data from a wide range of health institutions and stakeholders at sub-national levels, including provincial health offices, district health offices, municipalities, hospitals, primary healthcare centers, and health posts. We selected a sample size of 325 health institutions across all 7 provinces, covering diverse geographical settings. We used the formula n = Z 2 x p x (1 - p) / E 2 and adjusted using n adjusted = n/1 + n − 1/N. To ensure representative sampling, we applied stratification by dividing the total population into seven provincial subgroups. We then applied random sampling from each province. This blended approach ensured adequate representation of institutional type and geographic diversity, thus increasing the reliability of data and results. Three hundred and twenty five samples were collected from 7 provinces and 44 districts (Fig. 1 .) in following public health institutions (Table 1 .). Table 1 Types of Public Health Institutions and Number for Data Collection. SN. Type Public Health Institution Name Number 1. AI Academic Institution 4 2. BHCC Basic Healthcare Center 20 3. CHCC City Healthcare Center 4 4. DHO District Health Office 8 5. GP Gaon Palika (Rural Municipality) 70 6. Hospital Hospital of all levels 41 7 HP Health Post 110 8. NP Nagar Palika (Urban Municipality) 51 9. PHCC Primary Healthcare Cente 17 Total : 325 Results Sources/suppliers of Procurement : On the question, “What types of suppliers do you procure/source these medicines from? (multiple answers)”, 40% of health institutions indicated that they procure from exporter, followed by stockist, local manufacturer, and pharmacy (shop) ( Graph 1. Table 2. ). Table 2. HF Type Local Mnf Exporter Stockist Pharmacy (shop) AI 3 1 0 0 BHCC 11 7 7 9 CHCC 1 2 2 1 DHO 0 5 4 0 GP 9 53 25 5 Hospital 12 22 9 15 HP 39 61 36 34 NP 9 32 24 6 PHCC 7 4 5 6 Grand Total 91 187 112 76 Budget for procurement: Regarding the question, “Do you have budget as per the quantified/forecast quantity for procurement?”, 64% constitutes the answer of ‘No’ plus ‘Not Enough’ from the health institutions only 36% of health facilities said the budget they have to procure paracetamol and iron tablets are adequate as per the forecast. ( Graph 2. ). The chi-square test of independence showed the significant association between type of health facility and response category (X 2 (16) = 72.36, p < 0.001). The strength of association was found moderate (Cramer’s V = 0.33) which indicates the meaningful differences in the response pattern from the type of health facility. Frequency of Procurement: When asked, “How many times do you procure Paracetamol and Iron tablets?”, There was no systematic procurement pattern among the health institutions. 43% said they procure bi-annually followed by annually (28%), quarterly 19%, and monthly (10%) ( Graph 3. Table 3. ). Table 3. HF Type Monthly Qtrly Bi-Annual Annual AI 1 0 0 3 BHCC 3 7 8 2 CHCC 1 1 1 1 DHO 1 2 2 3 GP 1 5 36 28 Hospital 9 6 16 10 HP 11 33 53 13 NP 0 7 18 26 PHCC 4 3 5 5 Grand Total 31 64 139 91 A chi-square test of independence showed the statistically significant association between type of health institution and procurement frequency. t there was no association between health facility types and perceived reliability of the process, X 2 = 75.23, p < 0.001, indicating that the procurement frequency vary significantly among the type of health facilities. Table 4. HF Type Bidding Quotation Direct Purchae Other AI 3 1 0 0 BHCC 9 7 16 1 CHCC 4 1 1 0 DHO 5 4 2 0 GP 58 24 16 0 Hospital 28 11 20 0 HP 67 44 62 0 NP 44 15 11 0 PHCC 12 6 9 0 Grand Total 230 113 137 1 Methods of Procurement: Regarding the inquiry, “What is the primary method of procurement of Paracetamol and Iron tablets? (multiple answers)”, 48% of the health institution said they use standard bidding for the procurement, followed by quotation (24%), direct purchase (28%), almost none for other method. ( Graph 4. Table 4. ). The chi-square test revealed that there is a statistically significant association between types of health facility and method of procurement ( X 2 = 34.85, df = 16, p = 0.0042). This indicates the way the procurement methods are used via. bidding, quotation, and direct purchase - varies meaningfully across different types of health institutions. Revision of Procurement Budget: On the query, “Can you alter/change your budget to procure based on the quantification/forecast of health products?”, the majority 59% of the health institution said they can not change or alter the allocated budget for the procurement of drugs and medicines, only 19% said they can revise it, and 22% of the health institution said they can but the process is very difficult ( Graph 5. ). Skill or capacity on public procurement: When asked, “Are you formally trained on how to do procurement of health product?”, the massive 73% of the health institution staff said they did not have formal training on public procurement ( Graph 6. ). The chi-square test of independence revealed a statistically significant association between types of health institution and outcome variable (Yes/No), (χ² (8, N = 325) = 25.87, p = 0.001). The distribution of Yes and No responses varied significantly across the types of the health institution. Discussion Delays in the procurement procedure 2 , mostly at the local level, were the main obstacles to the efficient management of essential drugs. Storage issues 5 can provide difficulties, mostly because of a lack of available storage capacity and the requirement to manage extra emergency related comorbidity 27 . Efficient supply chain management require trained 3 and competent staff to execute operations and meet health system demands. The skills needed to manage a supply chain include product quantification/forecasting, inventory management and analysis, and procurement/contract management and monitoring 14 . Poorly coordinated supply chain system lead to high stock-out rate of health products. 8 Pre and in-service training with good record keeping practice is needed for health workers. 9 Stock assessment, streamlined procurement, supervision are needed to mitigate supply disruption. 10 For the sources or suppliers of procurement of health products there was no clear indication of the one major supplier as all the health institution buys from each of these suppliers. The logistics regression results: Outcome Odds Ratio (OR) 95% CI p-value Interpretation Local Manufacturer 0.93 0.64 – 1.35 0.71 Not significant Exporter 0.92 0.64 – 1.31 0.63 Not significant Stockist 0.79 0.53 – 1.18 0.24 Not significant Pharmacy (shop) 1.17 0.81 – 1.69 0.40 Not significant This explained that the health facility type was not statistically significant predictor of using local manufacturer, exporter, stockist, or pharmacies (shops) ( Graph 7. ). The practice of every health institution procuring medicines from pharmacy or shop is concerning because cost-wise it is higher and can not ensure the quality of product you are getting from the shop. On the health product procurement budget among 5 health facilities 3 did not have a adequate/dedicated budget 3 for the procurement as per their need or forecast budget. The difficult task of budget revision especially for the procurement of drugs and medicines in the health institution is a challenge for health staff to sufficiently supply the drugs and medicines for the people. Ideally the procurement frequency should be carried out once a year (annually) so that there is a economy of scale of the product, better price negotiations, and ensuring the quality of the drugs and medicines during the bulk procurement. The Public Procurement Act (2063) and Public Procurement Rules and Regulation (2064) 23 require a public entity to prepare procurement master plan and annual procurement plan for goods (drugs and medicines), services, and works that they plan to procure in the fiscal year. This means the drugs and medicines should be included in the annual procurement plan with details like quantity and budget. Procurement method is not randomly distributed among the type of health institutions, certain health institution prefers certain methods of procurement more than other ( Graph 8. ). For example HP, Hospital, and BHCC favors more direct purchase where and NP and GP prefers more bidding process. The preference of direct purchase method of procurement of drugs and medicines across all the health institutions poses a issue of cost, quality, and transparency of the procurement of drugs and medicines in the health facility. There was a serious gap on the skill set of health staff on the public procurement. Among the 4 health institutions, almost 3 of their staff did not receive the training on public procurement. Conclusion Public procurement practice of health products in Nepal has a lot of rooms for improvement. The practice of all types of health facilities indulging procurement of health products from the local pharmacy shop should be minimized. The three tiers of the government with must allocate adequate and flexible budget for procurement of health products and evidence based quantification/forecasting and health administration 6 , 11 should determine the need to procure and supply chain management. The procurement, quality control, storage, and delivery of the health products should be well coordinated among the each tier (federal, provincial, and local) of the government. The practice of preparing annual procurement plan with well planned quantification and budget must be practiced without a fail in each procurement point with 100% need of the health products procured once in a year. Based on the budget standard bidding should practiced for procurement following national regulations and guidelines 28 at all level and direct purchase of health product should by minimized to the extent possible, unless in the time of emergency. For the procurement of quality drugs there is a need to strengthen regulatory capacity and accountability. 17 Ethical standard should be implemented by procurement staff to enhance their performances. 20 , 21 , 25 Capacity building program, ethical training 15 for public procurement should be budgeted and planned in each level of the government in close coordination with Public Procurement Monitoring Office (PPMO) with refresher program so that each staff responsible for procurement of the health institutions receives training on ethical public procurement 15 practice. Declarations Authors declare that the study was conducted in accordance with ethical standards. Written informed consent was obtained from all participants prior to engagement in the research. Objectives and scope of research was clarified in the beginning. References Acharya M, Dahal A. (2016), Free essential Medicines through Public Health Facilities in Nepal: A Qualitative study University of Arkansas for Medical Sciences, Little Rock, AR, USA, The University of Toledo, OH, USA Achyut Bikram Thapa, Rajani Shakya, Panna Thapa et. Al, (2025), WHO prequalification of medicines in low- and middle-income countries: Situational analysis of Nepali manufacturers and recommendations, Volume 21, Issue Adhikari B, Ranabhat K, Khanal P, Poudel M, Marahatta SB, Khanal S, et al. (2024). Procurement process and shortages of essential medicines in public health facilities: A qualitative study from Nepal. PLOS Glob Public Health 4(5). Ahmad K.; Singh J.; Singh R.A. (2023). Public Health Supply Chain for Iron Folic Acid supplementation in India, PLoS ONE. Alemu, A., Fenta, T., & Gebregeorgise, D. (2022). Public health supply chain performance of primary health care units, Gamo zone, Snnpr, Ethiopia. Almalki, S. (2024). 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(2020).;availability of tracer drugs and implementation of their logistic management information system in public health institutions of Dessie, north-east Ethiopia.; Integrated Pharmacy Research and Practice, Volume 9. Dhakal, N., Humagain, B., Bc, R., Jha, N., Sah, P., Pradhan, A. & Jha, A. (2023). Assessment of quality of essential medicines in public health care facilities of Nepal: findings of nationwide study. Plos Global Public Health, 3(5). DoHS Annual Report, (2022, 2024). Ministry of Health and Population. Donato S., Roth S., Parry J., (2016). Strong Supply Chains Transform Public Health By ensuring the efficient and effective delivery of medicines and commodities, supply chains support healthy populations and regional health security. ISBN 978-92-9257-654-7 (e-ISBN) Gaidhane, A. (2023). Ethical considerations in public health practice: addressing challenges and embracing opportunities. GFA Consulting Group GmBH (2009). Essential Drug Procurement and Management in Nepal - Current Challenges and How to Address Them. Kathmandu Nepal. Ghimire A (2025) Sub-standard medicines in Nepal: a crisis of access, equity, and a call for action. Front. Public Health Karim A.; Burri C.; Kila J.S.N.; Bambwelo N.; Bakukulu J.T.; de Savigny D. (2024). Systems Thinking for Supply Chains: Identifying Bottlenecks Using Process Mapping of a Child Health Intervention in the Democratic Republic of the Congo (DRC). Systems. Mbwasi R.; Mbepera D.; Mfuko W.; Makanzo J.; Kikwale M.; Canavan R.; Stoermer M.; Wiedenmayer K. (2022). Assessing public-private procurement practices for medical commodities in Dar E Salaam: a situation analysis. BMC Health Services Research. Moung Kee Aung, Amiya Bhaumik, Midhun Chakkaravarthy (2023). Analyzing ethic and procurement performance of humanitarian organizations in Myanmar. International Journal for Multidisciplinary Research. Muriru, S. (2018). Influence of procurement ethics on procurement performance in state corporations in Kenya. strategicjournals.com. Neupane, A., M, B., Tamang, S., & Giri, B. (2021). Incidences of poor-quality pharmaceutical products in Nepal. Public Procurement Act (2063) and Public Procurement Rules and Regulations (2064) of Nepal. Roshan Man Bajracharya. (2025). Basic Research Methods and Statistical Data Analysis. BP International. DOI: https://doi.org/10.9734/bpi/mono/978-81-990309-3-0 Rotich, J., Keitany, P., & Sang, H. (2021). Ethical principles and procurement management in selected public secondary schools in kericho county, kenya. East African Journal of Business and Economics. Sarawa, D. and Mas ud, A. (2020). Strategic public procurement regulatory compliance model with mediating effect of ethical behavior. Heliyon. Sharma RK., Kumari M, Baxi R. (2026). Supply chain management of health commodities and essential drug procurement systems at Sankhuwasabha and Kavrepalanchowk districts of federal Nepal. Journal of Public Health Research, https://doi.org/10.1177/22799036261418439 PMID: 41658009 Shrestha, M., Moles, R., Ranjit, E., & Chaar, B. (2018). Medicine procurement in hospital pharmacies of Nepal: a qualitative study based on the basel statements. Plos One. Wasti et al. Health Research Policy and Systems (2023). Graphs Graphs 1 to 8 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files g1.png g2.png g3.png g4.png g5.png g6.png g7.png g8.png Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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effective supply chains provide critical medicines, vaccines, and essential medicines to support communicable disease prevention, control, and response activities. They are critical inputs to national and regional health security\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Essential medicines which includes paracetamol and iron tablets are those medicines that cater the primary health care needs of the people\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The present Nepal\u0026rsquo;s budget allocations to the sub-national level result in a loss of efficiency of an estimated NRS 46.6\u0026nbsp;million due to additional transport costs and NRS 139.8\u0026nbsp;million due to economies of scale, compared to centrally managed procurement\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The procurement function provides critical opportunities to achieve supply chain cost effectiveness. For example, it is estimated that the government of Cambodia could have saved up to \u003cspan\u003e$\u003c/span\u003e50\u0026nbsp;million annually by more efficiency in purchasing health products, equipment, and medical supplies. The country was paying on average up to six times the international reference price of essential medicines\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Better coordination, increased procurement and distribution efficiencies, and rigorous needs assessment is needed.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Manufacturer are needed to improve their compliance with WHO prequalification standards.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e There are clear bottlenecks in supply chain such as forecasting, procurement, inventory management, and distribution.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e It was revealed that stock-outs were primarily caused by the inadequate quantification of supply needs and delays in distribution due to the international procurement.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere is bureaucratic and lengthy procurement with only small number of private prequalified suppliers receiving orders from public health institutions.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Quality deviated drugs have increased in Nepal since past decade indicating more strict inspection from regulatory bodies during the public procurement.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e There are research which validated the hypotheses for the strategic public procurement regulatory compliance model with mediation effect of ethical behavior.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Several systemic challenges includes: poor coordination between the tiers of government, delayed release of funds, maldistribution of staff, problems over procurement, and limited monitoring and supervision of the quality of service delivery and data reporting.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Procurement reforms and process improvements can minimize the risk of procurement errors, improve transparency, and reduce sourcing lead times. These improve supply chain performance and yield significant cost savings\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur aim is to address these gaps through this research to analyze existing procurement processes and systems, identify major gaps and propose practical, evidence-based solutions to improve pubic procurement efficiency, ensure timely delivery and availability of these two essential medicines. We hope that with the recommendations from the research will help support enhancing the overall public health supply chain system's responsiveness and increase timely availability of health products in health institutions.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eWe employed a mixed-methods approach, combining quantitative surveys with qualitative interviews. We collected data from a wide range of health institutions and stakeholders at sub-national levels, including provincial health offices, district health offices, municipalities, hospitals, primary healthcare centers, and health posts. We selected a sample size of 325 health institutions across all 7 provinces, covering diverse geographical settings. We used the formula n\u0026thinsp;=\u0026thinsp;Z\u003csup\u003e2\u003c/sup\u003e x p x (1 - p) / E\u003csup\u003e2\u003c/sup\u003e and adjusted using n\u003csub\u003eadjusted\u003c/sub\u003e = n/1\u0026thinsp;+\u0026thinsp;n\u0026thinsp;\u0026minus;\u0026thinsp;1/N. To ensure representative sampling, we applied stratification by dividing the total population into seven provincial subgroups. We then applied random sampling from each province. This blended approach ensured adequate representation of institutional type and geographic diversity, thus increasing the reliability of data and results.\u003c/p\u003e \u003cp\u003eThree hundred and twenty five samples were collected from 7 provinces and 44 districts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.) in following public health institutions (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTypes of Public Health Institutions and Number for Data Collection.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic Health Institution Name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcademic Institution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBHCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBasic Healthcare Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCity Healthcare Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDHO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistrict Health Office\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGaon Palika (Rural Municipality)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital of all levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealth Post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNagar Palika (Urban Municipality)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePHCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary Healthcare Cente\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e325\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eSources/suppliers of Procurement\u0026nbsp;\u003c/strong\u003e: On the question, \u0026ldquo;What types of suppliers do you procure/source these medicines from? (multiple answers)\u0026rdquo;, 40% of health institutions indicated that they procure from exporter, followed by stockist, local manufacturer, and pharmacy (shop) (\u003cstrong\u003e\u003cem\u003eGraph 1. Table 2.\u003c/em\u003e\u003c/strong\u003e). \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"284\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eTable 2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eHF Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003eLocal Mnf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003eExporter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003eStockist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003ePharmacy (shop)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eAI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eBHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eCHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eDHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003ePHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGrand Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 48px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 45px;\"\u003e\n \u003cp\u003e187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eBudget for procurement:\u003c/strong\u003e Regarding the question, \u0026ldquo;Do you have budget as per the quantified/forecast quantity for procurement?\u0026rdquo;, 64% constitutes the answer of \u0026lsquo;No\u0026rsquo; plus \u0026lsquo;Not Enough\u0026rsquo; from the health institutions only 36% of health facilities said the budget they have to procure paracetamol and iron tablets are adequate as per the forecast. (\u003cstrong\u003e\u003cem\u003eGraph 2.\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe chi-square test of independence showed the significant association between type of health facility and response category \u003cem\u003e(X\u003csup\u003e2\u003c/sup\u003e(16) = 72.36, p \u0026lt; 0.001).\u003c/em\u003e The strength of association was found moderate (Cramer\u0026rsquo;s V = 0.33) which indicates the meaningful differences in the response pattern from the type of health facility.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eFrequency of Procurement:\u003c/strong\u003e When asked, \u0026ldquo;How many times do you procure Paracetamol and Iron tablets?\u0026rdquo;, There was no systematic procurement pattern among the health institutions. 43% said they procure bi-annually followed by annually (28%), quarterly 19%, and monthly (10%) (\u003cstrong\u003e\u003cem\u003eGraph 3. Table 3.\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"276\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eTable 3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eHF Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003eMonthly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003eQtrly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003eBi-Annual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003eAnnual\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eBHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eCHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eDHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003ePHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eGrand Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 52px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 63px;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 49px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eA chi-square test of independence showed the statistically significant association between type of health institution and procurement frequency. t there was no association between health facility types and perceived reliability of the process, \u003cem\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u0026nbsp; = 75.23, \u0026nbsp; \u003cem\u003ep \u0026lt;\u003c/em\u003e 0.001, indicating that the procurement frequency vary significantly among the type of health facilities.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"239\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eTable 4.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eHF Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003eBidding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eQuotation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003eDirect \u0026nbsp;Purchae\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eAI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eBHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eCHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eDHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003ePHCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 72px;\"\u003e\n \u003cp\u003eGrand Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eMethods of Procurement:\u0026nbsp;\u003c/strong\u003eRegarding\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe inquiry, \u0026ldquo;What is the primary method of procurement of Paracetamol and Iron tablets? (multiple answers)\u0026rdquo;, 48% of the health institution said they use standard bidding for the procurement, followed by quotation (24%), direct purchase (28%), almost none for other method. (\u003cstrong\u003e\u003cem\u003eGraph 4. Table 4.\u003c/em\u003e\u003c/strong\u003e).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe chi-square test revealed that there is a statistically significant association between types of health facility and method of procurement (\u003cem\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e = 34.85, \u003cem\u003edf\u0026nbsp;\u003c/em\u003e= 16, \u003cem\u003ep =\u003c/em\u003e 0.0042). This indicates the way the procurement methods are used via. bidding, quotation, and direct purchase - varies meaningfully across different types of health institutions. \u0026nbsp;\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003eRevision of Procurement Budget:\u0026nbsp;\u003c/strong\u003eOn the query, \u0026ldquo;Can you alter/change your budget to procure based on the quantification/forecast of health products?\u0026rdquo;, the majority 59% of the health institution said they can not change or alter the allocated budget for the procurement of drugs and medicines, only 19% said they can revise it, and 22% of the health institution said they can but the process is very difficult (\u003cstrong\u003e\u003cem\u003eGraph 5.\u003c/em\u003e\u003c/strong\u003e).\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003e\u003cstrong\u003eSkill or capacity on public procurement:\u003c/strong\u003e When asked, \u0026ldquo;Are you formally trained on how to do procurement of health product?\u0026rdquo;, the massive 73% of the health institution staff said they did not have formal training on public procurement (\u003cstrong\u003e\u003cem\u003eGraph 6.\u003c/em\u003e\u003c/strong\u003e). The chi-square test of independence revealed a statistically significant association between types of health institution and outcome variable (Yes/No), (\u0026chi;\u0026sup2; (8, N = 325) = 25.87, p = 0.001). The distribution of Yes and No responses varied significantly across the types of the health institution.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Discussion","content":"\u003cp\u003eDelays in the procurement procedure\u003csup\u003e2\u003c/sup\u003e, mostly at the local level, were the main obstacles to the efficient management of essential drugs. Storage issues\u003csup\u003e5\u003c/sup\u003e can provide difficulties, mostly because of a lack of available storage capacity and the requirement to manage extra emergency related comorbidity\u003csup\u003e27\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eEfficient supply chain management require trained\u003csup\u003e3\u003c/sup\u003e and competent staff to execute operations and meet health system demands. The skills needed to manage a supply chain include product quantification/forecasting, inventory management and analysis, and procurement/contract management and monitoring\u003csup\u003e14\u003c/sup\u003e. Poorly coordinated supply chain system lead to high stock-out rate of health products.\u003csup\u003e8\u0026nbsp;\u003c/sup\u003ePre and in-service training with good record keeping practice is needed for health workers.\u003csup\u003e9\u0026nbsp;\u003c/sup\u003eStock assessment, streamlined procurement, supervision are needed to mitigate supply disruption.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eFor the sources or suppliers of procurement of health products there was no clear indication of the one major supplier as all the health institution buys from each of these suppliers. The logistics regression results:\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds Ratio (OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocal Manufacturer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.64 \u0026ndash; 1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExporter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.64 \u0026ndash; 1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStockist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.53 \u0026ndash; 1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePharmacy (shop)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e0.81 \u0026ndash; 1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 164px;\"\u003e\n \u003cp\u003eNot significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThis explained that the health facility type was not statistically significant predictor of using local manufacturer, exporter, stockist, or pharmacies (shops) (\u003cstrong\u003e\u003cem\u003eGraph 7.\u003c/em\u003e\u003c/strong\u003e). The practice of every health institution procuring medicines from pharmacy or shop is concerning because cost-wise it is higher and can not ensure the quality of product you are getting from the shop.\u003c/p\u003e\n\u003cp\u003eOn the health product procurement budget among 5 health facilities 3 did not have a adequate/dedicated budget\u003csup\u003e3\u003c/sup\u003e for the procurement as per their need or forecast budget. The difficult task of budget revision especially for the procurement of drugs and medicines in the health institution is a challenge for health staff to sufficiently supply the drugs and medicines for the people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIdeally the procurement frequency should be carried out once a year (annually) so that there is a economy of scale of the product, better price negotiations, and ensuring the quality of the drugs and medicines during the bulk procurement. The Public Procurement Act (2063) and Public Procurement Rules and Regulation (2064)\u003csup\u003e23\u003c/sup\u003e require a public entity to prepare procurement master plan and annual procurement plan for goods (drugs and medicines), services, and works that they plan to procure in the fiscal year. \u0026nbsp;This means the drugs and medicines should be included in the annual procurement plan with details like quantity and budget.\u003c/p\u003e\n\u003cp\u003eProcurement method is not randomly distributed among the type of health institutions, certain health institution prefers certain methods of procurement more than other (\u003cstrong\u003eGraph 8.\u003c/strong\u003e). For example HP, Hospital, and BHCC favors more direct purchase where and NP and GP prefers more bidding process.\u003c/p\u003e\n\u003cp\u003eThe preference of direct purchase method of procurement of drugs and medicines across all the health institutions poses a issue of cost, quality, and transparency of the procurement of drugs and medicines in the health facility.\u003c/p\u003e\n\u003cp\u003eThere was a serious gap on the skill set of health staff on the public procurement. \u0026nbsp;Among the 4 health institutions, almost 3 of their staff did not receive the training on public procurement.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePublic procurement practice of health products in Nepal has a lot of rooms for improvement. The practice of all types of health facilities indulging procurement of health products from the local pharmacy shop should be minimized. The three tiers of the government with must allocate adequate and flexible budget for procurement of health products and evidence based quantification/forecasting and health administration\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e should determine the need to procure and supply chain management. The procurement, quality control, storage, and delivery of the health products should be well coordinated among the each tier (federal, provincial, and local) of the government. The practice of preparing annual procurement plan with well planned quantification and budget must be practiced without a fail in each procurement point with 100% need of the health products procured once in a year. Based on the budget standard bidding should practiced for procurement following national regulations and guidelines\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e at all level and direct purchase of health product should by minimized to the extent possible, unless in the time of emergency. For the procurement of quality drugs there is a need to strengthen regulatory capacity and accountability.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Ethical standard should be implemented by procurement staff to enhance their performances.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Capacity building program, ethical training\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e for public procurement should be budgeted and planned in each level of the government in close coordination with Public Procurement Monitoring Office (PPMO) with refresher program so that each staff responsible for procurement of the health institutions receives training on ethical public procurement\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e practice.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eAuthors declare that the study was conducted in accordance with ethical standards. Written informed consent was obtained from all participants prior to engagement in the research. Objectives and scope of research was clarified in the beginning.\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAcharya M, Dahal A. (2016), Free essential Medicines through Public Health Facilities in Nepal: A Qualitative study \u0026nbsp;University of Arkansas for Medical Sciences, Little Rock, AR, USA, The University of Toledo, OH, USA\u003c/li\u003e\n \u003cli\u003eAchyut Bikram Thapa, Rajani Shakya, Panna Thapa et. Al, (2025), WHO prequalification of medicines in low- and middle-income countries: Situational analysis of Nepali manufacturers and recommendations, \u0026nbsp;Volume 21, Issue\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdhikari B, Ranabhat K, Khanal P, Poudel M, Marahatta SB, Khanal S, et al. (2024). Procurement process and shortages of essential medicines in public health facilities: A qualitative study from Nepal. PLOS Glob Public Health 4(5).\u003c/li\u003e\n \u003cli\u003eAhmad K.; Singh J.; Singh R.A. (2023). Public Health Supply Chain for Iron Folic Acid supplementation in India, PLoS ONE.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAlemu, A., Fenta, T., \u0026amp; Gebregeorgise, D. (2022). Public health supply chain performance of primary health care units, Gamo zone, Snnpr, Ethiopia.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAlmalki, S. (2024). Transforming healthcare through effective health administration practices: a systematic review. Journal of Ecohumanism, 3(7).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAsia Pacific Observatory on Health Systems and Policies. 2010. Health Systems Financing: The Path to Universal Health Coverage. Geneva: WHO. http://www.wpro.who.int/asia_pacific_observatory/hits/series/khm/en/\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBehera S.K.; Kannan S. (2018). Assessing the Performance of Multiple drug supply chain management in Odisha health services using LSAT score and stock-out situation. Cogent Business and Management.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBelachew, T. (2024). Evaluation of an auditable pharmaceutical transaction services program in Ethiopia: a case study evaluation design.\u003c/li\u003e\n \u003cli\u003eBilal, A. (2024). Effective supply chain strategies in addressing demand and supply uncertainty: a case study of Ethiopian pharmaceutical supply services. Pharmacy, 12(5), 132.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDemessie, M., Workneh, B., Mohammed, S., \u0026amp; Hailu, A. (2020).;availability of tracer drugs and implementation of their logistic management information system in public health institutions of Dessie, north-east Ethiopia.; Integrated Pharmacy Research and Practice, Volume 9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDhakal, N., Humagain, B., Bc, R., Jha, N., Sah, P., Pradhan, A. \u0026amp; Jha, A. (2023). Assessment of quality of essential medicines in public health care facilities of Nepal: findings of nationwide study. Plos Global Public Health, 3(5).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDoHS Annual Report, (2022, 2024). Ministry of Health and Population.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDonato S., Roth S., Parry \u0026nbsp;J., (2016). Strong Supply Chains Transform Public Health By ensuring the efficient and effective delivery of medicines and commodities, supply chains support healthy populations and regional health security. ISBN 978-92-9257-654-7 (e-ISBN)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGaidhane, A. (2023). Ethical considerations in public health practice: addressing challenges and embracing opportunities.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGFA Consulting Group GmBH (2009). Essential Drug Procurement and Management in Nepal - Current Challenges and How to Address Them. Kathmandu Nepal.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGhimire A (2025) Sub-standard medicines in Nepal: a crisis of access, equity, and a call for action. Front. Public Health\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKarim A.; Burri C.; Kila J.S.N.; Bambwelo N.; Bakukulu J.T.; de Savigny D. (2024). Systems Thinking for Supply Chains: Identifying Bottlenecks Using Process Mapping of a Child Health Intervention in the Democratic Republic of the Congo (DRC). Systems.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMbwasi R.; Mbepera D.; Mfuko W.; Makanzo J.; Kikwale M.; Canavan R.; Stoermer M.; Wiedenmayer K. (2022). Assessing public-private procurement practices for medical commodities in Dar E Salaam: a situation analysis. BMC Health Services Research.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMoung Kee Aung, Amiya Bhaumik, Midhun Chakkaravarthy (2023). Analyzing ethic and procurement performance of humanitarian organizations in Myanmar. International Journal for Multidisciplinary Research.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMuriru, S. (2018). Influence of procurement ethics on procurement performance in state corporations in Kenya. strategicjournals.com.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNeupane, A., M, B., Tamang, S., \u0026amp; Giri, B. (2021). Incidences of poor-quality pharmaceutical products in Nepal.\u003c/li\u003e\n \u003cli\u003ePublic Procurement Act (2063) and Public Procurement Rules and Regulations (2064) of Nepal.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRoshan Man Bajracharya. (2025). Basic Research Methods and Statistical Data Analysis. BP International. DOI: https://doi.org/10.9734/bpi/mono/978-81-990309-3-0\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRotich, J., Keitany, P., \u0026amp; Sang, H. (2021). Ethical principles and procurement management in selected public secondary schools in kericho county, kenya. East African Journal of Business and Economics.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSarawa, D. and Mas ud, A. (2020). Strategic public procurement regulatory compliance model with mediating effect of ethical behavior. Heliyon.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSharma RK., Kumari M, Baxi R. (2026). Supply chain management of health commodities and essential drug procurement systems at Sankhuwasabha and Kavrepalanchowk districts of federal Nepal. Journal of Public Health Research, https://doi.org/10.1177/22799036261418439 PMID: 41658009\u003c/li\u003e\n \u003cli\u003eShrestha, M., Moles, R., Ranjit, E., \u0026amp; Chaar, B. (2018). Medicine procurement in hospital pharmacies of Nepal: a qualitative study based on the basel statements. Plos One.\u003c/li\u003e\n \u003cli\u003eWasti et al. Health Research Policy and Systems (2023).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Graphs","content":"\u003cp\u003eGraphs 1 to 8 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Noida International University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Procurement, LMIS, Forecasting, Quantification, Supply Chain System","lastPublishedDoi":"10.21203/rs.3.rs-9329540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9329540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe procurement function provides critical opportunities to achieve supply chain cost effectiveness especially in public health logistics system where skill and capacity of the health staff are limited. The public health supply chain continues to face challenges, relating to consistent supply of these two essential drugs due to the inefficient forecasting and procurement processes. These gaps result in frequent stock-outs or overstock and expiry. This study aims to analyze existing procurement processes identify systemic gaps and propose practical, evidence-based solutions to improve procurement efficiency.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe research employed a mixed-methods approach, using quantitative surveys and qualitative interviews to gather data from various public health institutions. A sample size of 325 health institutions were selected across geographical settings. Data analysis involved both quantitative statistical and qualitative thematic analysis.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eProcurement practices, 40% of health institutions indicated that they procure from exporter, followed by stockist, local manufacturer, and pharmacy. Budget to procure paracetamol and iron tablets, 64% said \u0026lsquo;not enough\u0026rsquo; from the health institutions. Method of procurement, 48% of the health institution said they use standard bidding, followed by quotation, and direct purchase. Capacity, 3 among 4 health institution\u0026rsquo;s staff did not have formal training on public procurement.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePublic procurement practice of health products in Nepal has lot of rooms for improvement. The practice of procurement of health products from the local pharmacy shop should be minimized. The three tiers of the government should allocate adequate and flexible budget for procurement of health products and evidence based quantification/forecasting.\u003c/p\u003e","manuscriptTitle":"Understanding Public Procurement of Paracetamol and Iron tablets in Nepal’s Health System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 10:27:16","doi":"10.21203/rs.3.rs-9329540/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2b00475c-06a2-4913-b45c-549585370178","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65760535,"name":"Drug Delivery"}],"tags":[],"updatedAt":"2026-04-09T10:27:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 10:27:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9329540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9329540","identity":"rs-9329540","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}