Shortages of medical supplies such as masks, test kits, and personal protective equipment hampered the initial response to COVID-19 in many countries, but health supply chain problems are not new. Photo: Vincent Tremeau/World Bank.
The COVID-19 pandemic gave the world an insider’s view into global health supply chain weaknesses. Shortages of medical masks, test kits, personal protective equipment (PPE), and ventilators severely hampered the initial response in most countries.
But health supply chain problems—including drug and equipment shortages, expired drugs, broken medical equipment, and lack of infrastructure and manufacturing capability—are not new.
Examples of supply chain weaknesses abound. In Colombia , patients experienced shortages of 219 drugs from 2010 to 2021. In developing countries, an estimated 50-80 percent of medical equipment is not functioning.
Many low- and middle-income countries (LMICs) rely on compromised donated medicine. During one year, for example, 30 percent of drugs donated to the former Republic of Macedonia arrived either expired or about to expire.
Supply chain management (SCM), which involves planning and managing inventory, sourcing, financing, receiving, conducting quality control, warehousing, and distributing medical products to health clinics, pharmacies, and hospitals, has long been a neglected—but crucial—aspect of health care.
The World Bank’s Service Delivery Indicators (SDI) health team has a revamped, innovative survey that includes measurement of SCM—which makes the SDI the first large-scale, internationally comparable survey that assesses the resilience and performance of SCM in primary health care (PHC) facilities.
A matter of life and death
There are many reasons for weak health supply chains—lack of resources, untrained personnel, weak procurement practices, inadequate transportation systems, lack of storage facilities, low manufacturing capacity, and failure to be resilient to shocks. For example, supply chains may not anticipate the timely need for certain medications such as malaria pills during monsoon seasons. Certain medications may need to be refrigerated, while others must be stored in dry areas.
Health care workers cannot deliver appropriate care to patients without necessary supplies, which compromises health care and causes disruptions and even fatalities. At the beginning of the pandemic, PPE shortages of masks, gloves, and gowns were a global phenomenon caused by rising demand, panic buying, hoarding, and unprepared health systems. It put frontline health workers at grave risk of falling ill . The absence of medical supplies can force some patients to travel far to receive medical treatment or forgo care altogether.
Shortages of medications or the use of expired medications can have tragic outcomes. Among patients receiving combined anti-retroviral treatment for HIV in Côte d'Ivoire, drug stockouts impacted 11 percent of the population resulting in treatment discontinuation and doubling the risk of interruption in care or death. Stock shortages for medication, as evidenced in Uganda and Nigeria , can lead to disruptions in care, ultimately increasing the risk of antimicrobial resistance and treatment susceptibility, and furthering health inequity.
At a large district hospital in South Africa’s Mpumalanga province, “one patient nearly bled to death because of lack of a tourniquet” that worked properly, according to a hospital trauma nurse . In Kathmandu, Nepal, Sami Patuwar said, “Expired medicines killed my daughter-in-law, and I haven’t been able to comfort my son.” A postmortem report and police record attribute the death of daughter-in-law Soniya Tamang in 2011 to an expired muscle relaxant that she received before a medical procedure.
The innovative new SDI survey tackles supply chain challenges
The World Bank’s SDI health survey has been revamped to comprehensively measure PHC service delivery from the perspective of facilities, providers, and patients. To determine how to incorporate questions about supply chains into the SDI survey, we comprehensively reviewed the literature on best practices for SCM measurement.
These instruments included the ASCM Global Health Supply Chain Maturity Model , the Logistics Systems Assessment Tool (LSAT) , the Logistics Indicators Assessment Tool (LIAT), the National Supply Chain Assessment (NSCA) Toolkit, and the Supply Chain Information System Assessment Maturity Model Assessment (SCISMM).
We then generated questions for the survey tool to measure SCM performance in four broad areas: logistics management information system (LMIS), indent management, procurement during emergencies, and quality management.
Questions included, “Does this health facility dispense/use medicine and medical supply inventory first that has an earlier expiration ("first-expired, first-out" protocol)?” and does it “physically separate damaged/expired medicine and medical supply inventory and appropriately dispose of/destroy it?”
It is important to note that the SDI survey measures facility performance and thus doesn’t address weaknesses in larger health systems where SCM may take place, but only identifies weaknesses at the facility level.
This cutting-edge tool , which will be piloted in Ghana, Libya, and Tajikistan, holds promise to not only influence SCM practices within facilities but also to shape SCM policy at a system level to improve health outcomes.
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