Manufacturers on four continents currently produce ready-to-use therapeutic foods (RUTF). Some produce locally, near their intended users, while others produce offshore and ship their product long distances. Small quantity lipid-based nutrient supplements (SQ-LNS) such as Nutriset's Enov'Nutributter are not yet in widespread production. There has been speculation whether RUTF and SQ-LNS should be produced primarily offshore, locally, or both. We analyzed The United Nations Children's Fund (UNICEF) Supply Division data, reviewed published literature, and interviewed local manufacturers to identify key benefits and challenges to local versus offshore manufacture of RUTF. Both prices and estimated costs for locally produced product have consistently been higher than offshore prices. Local manufacture faces challenges in taxation on imported ingredients, low factory utilization, high interest rates, long cash conversion cycle, and less convenient access to quality testing labs. Benefits to local economies are not likely to be significant.Although offshore manufacturers offer RUTF at lower cost, local production is getting closer to cost parity for RUTF. UNICEF, which buys the majority of RUTF globally, continues to support local production, and efforts are underway to narrow the cost gap further. Expansion of RUTF producers into the production of other ready-to-use foods, including SQ-LNS in order to reach a larger market and achieve a more sustainable scale, may further close the cost and price gap. Local production of both RUTF and SQ-LNS could be encouraged by a favorable tax environment, assistance in lending, consistent forecasts from buyers, investment in reliable input supply chains, and local laboratory testing. KEYWORDSlipid-based nutrient supplement (LNS), local production, manufacturing, offshore production, ready-to-use therapeutic foods (RUTF)

Objective: To develop a mathematical tool for estimating medication requirement that would improve the uninterrupted supply of medications for large-scale hypertension control programs in low- and middle-income countries. Design and method: In a steady state, annual drug procurement forecasts can simply replicate the previous year's consumption. For a new or rapidly growing hypertension control program, however, forecasting drug requirement requires consideration of not only patients currently on medication, but also rates of new patient registration and drop-out. To forecast antihypertensive drug requirements, a simple mathematical tool was developed based on the morbidity method, requiring minimal inputs and assumptions. The tool hinges on use of a standard step-wise treatment protocol which uses specific medications and doses and considers hypertension prevalence, number of existing patients, expected new monthly enrollments, proportion of patients with controlled blood pressure at each protocol step, and expected loss-to-follow up over time. Outputs include forecasted quantities of specific medications for any specific time period and associated budgets. The tool provides flexibility for correction of projected requirements based on programmatic data, thus making the estimation more accurate. Results: The tool was implemented in an Indian hypertension control program starting with a priori assumptions and refined iteratively as program data became available. It was customised for use in specific Indian states based on their treatment protocol, population size and primary health care coverage. The monthly drug requirement projected by the tool helped to quantify drug volumes for periodic procurement, and to overcome shortages observed in some areas in first year of the program. More than 10 states in India have adopted this tool for procurement and budget planning. Conclusions: This simple, pragmatic antihypertension drug forecasting tool can help ensure prudent resource allocation in hypertension control programs and facilitate reliable delivery of medications for patients in low- and middle-income countries. This tool can also quantify the financial implications of alternative treatment protocols, inform protocol design, and be adapted to other chronic disease control programs.