What global health can teach us about supply chain resiliency

They were like scenes out of a dystopian movie—healthcare workers in Seattle and New York City, in the earliest days of the pandemic, dressed in garbage bags substituting for nonexistent isolation gowns, navigating crowded hospital corridors in the world’s wealthiest country. Even beauty salons were being ransacked for protective gear. The chaos was thick. It was clear that many hospitals and systems were unprepared for the medical demand and supply chain shortages. And it was also clear that the United States would need to change their approach to patient care and medical supplies in the event of future pandemics or natural disasters.

As the international community has committed unprecedented action and resources to strengthening global health security in the battle against COVID-19, what lessons have we learned about supply chain risks and ways to overcome them? And if we start to look into the international network that makes up the healthcare supply chain, what might we learn from our partners in global health that deal with supply chain problems as a matter of course? For example:

• How have global organizations worked to address disruptions and bring life-saving care to communities in need?
• What is being done now to shore up more resilient supply chains for future pandemics and other shocks?

Because of the level of disruption and shortages that supply chains in low-resource settings are accustomed to facing, their MacGyver-like strategies, conservation tips and on-the-ground supply management techniques taught us how to handle the disruptions we’ve faced during the pandemic and subsequent surges due to new variants. This article hopes to delve further into this discussion. It is the first in a series of three (the second dealing with the climate crisis and the third on addressing social determinants of health in our communities) focusing on how sustainability and community impact create a more resilient healthcare supply chain.

In the August 30th 2021 issue of The New Yorker, Atul Gawande, a surgeon and professor of public health, in an essay about the benefits of integrating public health and medical care in Costa Rica, wrote this:

In the United States and elsewhere, public health and individual medical care are largely separate enterprises, which leaves many providers in a constant state of reaction—pandemic or not. But in countries like Costa Rica, where the two are viewed as inseparable, positive, proactive changes are happening. Gawande’s essay elevates the debate about how we view public health in the US, but more interestingly, perhaps, it suggests something more intriguing: what can our vastly resource-rich nation learn from a much smaller country with much less resources, a sixth of the income of the Unites States, and a fraction of the per-capita healthcare costs. Life expectancy in Costa Rica is now approaching 81 years, whereas in the US, that age peaked at just under 79 years in 2014 and is now declining.¹ What are they doing differently? More accurately, what are they doing right?

Going beyond the topic of integrating public health and individual medical care, the COVID-19 pandemic has magnified other areas where we can learn from other countries or our partners in global health. Our commitment to social responsibility and sustainability has us working with nonprofit organizations and health facilities all over the world, where we create solutions that empower communities and free up the resources that healthcare providers need to deliver their best care. But in 2020, the shortages that are so commonplace in much of the world came to our front door. Worldwide supply shortages meant learning to operate with finite resources. And though the distance seemed greater than ever, we found ways to close it—providing remote support and developing online education opportunities to help ensure our commitment to global health equity continues. And in return, we learned a few lessons of our own.

In discussion with Georgia Winson, President and Executive Director of Hospital Sisters Mission Outreach, and Bob Beyer, Supply Chain VP for Hospitals Sisters Health System, the definition of sustainability is enriched by the health system’s overall value statement: “Rooted in our Franciscan mission, we will be the unique, high-quality health system providing exceptional care, centered on the whole person.” Beyer defines sustainability as stewardship—looking at all your resources and utilizing them in the best fashion or finding other outlets where someone can use them or recycle them. And this is not unique to hospitals with a religious affiliation or mission. It is how many organizations operate: looking at all avenues from procurement to disposal. For surgical centers or public clinics in low-resource setting, this becomes a powerful challenge, and not one experienced only within the confines of a pandemic.

For large systems and small centers alike, the product needs to be available, but it also needs to be affordable. In many countries, the products needed are just not available, period. And then there are other locations where the products might be available, but because the supply chain in those locations may be new or not well established, reliable delivery can be problematic. When operating in low resource countries, a key factor in supply chain sustainability is having accurate estimates of their per item usage—a task that can be difficult to achieve when working with a mix of purchased and donated medical supplies. Especially when working with donors or vendors. Both parties need to understand how much product is needed and of what type of product. The key to boosting sustainability relies on the following:

For-profit and not-for-profit businesses alike understand that issues around environmental concerns and sustainability are important, and not just for altruistic reasons. Many large systems across the world had to face shortage disruptions square in the eye and learn how to make do with what they had under dire circumstances.

A global supply chain means more integration. And an integrated global supply chain involves moving the supplies around, which is critically important for every health system. Further, a sustainable supply chain reduces stock-outs and allows adherence to standard procedure protocols needed for patient and staff safety. Like any business, medical supply chains create work and build community. And if the pandemic has taught us anything, it is that we need supply chain solutions that allow immediate access to adequate amounts (based on population and service history) of certain products and that we need standard product rotation guidelines and networks that move unused—but still useful—stock to meet local and global needs. The community of accredited medical surplus recovery organizations are collecting and donating product through recipient networks. We can better meet product needs of recipients and stewardship needs of donors if manufacturers, distributors and healthcare organizations provide predictable schedules of rotation.

Even before the pandemic, Medline hosted a supply chain roundtable with institutions involved in medical device donations or short-term relief trips. The roundtable took place late December 2019 at Medline’s headquarters in Northfield, Illinois, in an effort to move organizations to think more collaboratively. Nearly a dozen experts from varying groups attended, including medical surplus recovery organizations (MSROs), faith-based health organizations like Hospital Sisters Mission Outreach (HSMO) and Catholic Health Association, as well as Medline, supply chain partner to health systems around the world. Through its Global Health initiative, Medline brings its expertise and resources in supply chain management to healthcare facilities in low resource countries.

The value a sustainable organization brings to the supply chain is in creating avenues, reducing storage and benefiting entire communities, beyond the individual. Many believe there is an inherent social responsibility just by being a healthcare system, whether for-profit or not for profit—that it is the role of healthcare providers to bring good to the community and take care of not only its patients, but the communities where the customers live. This is where public health and individual medical care collide and become a larger, more potent discussion around what “sustainable healthcare” really means. It’s not all about the financials. It’s really about the larger infrastructure and how we look at social responsibility. Could it be that the health systems taking a more active role in sustainability and social responsibility are also creating a more resilient supply chain?

We see clearly through COVID-19 that none of us are untouched by those around us. A healthcare system in Oklahoma, for example, is very concerned about what is happening in Missouri. Even though they may not be serving Missouri patients, those who are sick in Missouri may interact with others in neighboring states. Sickness spreads. In the world of pandemics, when we invest locally, we must understand that we have a need to invest globally as well to really have control over what is happening. It’s no different in supply chain.

Healthcare systems throughout the US can learn the difference between supply requirements and supply preferences. Our partners in low to middle-income countries (LMIC) are not even considering clinician preferences—they are struggling to meet basic safety requirements. This is one area that has been profoundly affected by the pandemic. Health systems that never had a robust substitutions list are making that protocol now in their supply chain operations. Whereas clinicians and supply chain leaders have acted as silos in the past, they are working together all over the country and around the world to create more standardization and “clinically acceptable” lists in the case of shortages. Distributors like Medline have created pandemic programs that feature “spot buy” lists of alternate items that they have procured for their customers in light of supply chain disruptions for legacy items. One more thing that our global partners have been doing for years as a matter of course.

Adapting to the products we have and must use. That’s the one thing we have learned from other countries—figuring out how we can utilize all the resources around us as opposed to being very specific or wasteful at times about “preferred” products. That may have been the way we used to approach supply procurement, but we are learning that we don’t necessarily have to operate that way going forward.

It has become clear that we have become much better at adapting to the products we have and also conserving what we can, such as gloves, linens and PPE. When the CDC came out with guidelines of how to reuse masks, gloves and other PPE, with it came support for an overall adaptive approach to medical supplies. Healthcare providers in LMICs, along with nurses in nearly every setting, have often been considered the “MacGyvers” of healthcare, but the pandemic has forced everyone to conserve and adapt, ushering in sustainability perhaps before systems even realized they were adopting such methods.

Around 2015, Ravi Mehta, a professor at the University of Illinois, conducted six experiments with a co-author to determine how creativity thrives or changes under conditions of scarcity. The results showed that people are “more creative when they are forced to make the best of a situation, or to come up with alternative uses for objects with specific uses.” This is also a form of cognitive bias, or functional fixedness, which can cause a person to use an object only in a way they are accustomed to using it, affecting their ability to think outside the box. Once the pandemic hit in 2020, there was no way around it. Suppliers, manufacturers and health systems alike had to learn to think outside their normal parameters. People’s lives depended on it.

Efficiencies in supply chain, developed over the last few decades, will continue to thrive. Just-in-time processes have allowed things to be delivered to our door, on the day we need them. That’s how efficient we have become. And those efficiencies have saved money. But it is also clear that we’ve become entirely interdependent, as so many of those things we buy come from all over the world. We need to think strategically in a few ways:

We must find an intermediate approach right now—establishing a middle ground between JIT and on-hand inventory—so that if another crisis hits anywhere in the world, we are ready.
As health systems, manufacturers and distributors, a certain amount of product does need to be on hand in the future to meet potential crises, but we need to continue to look at the full rotation of product and develop a schedule, which allows products to be sent to organizations and outreaches while it’s still useful and usable.

Healthcare is no longer about what’s within the hospital walls. Rather than reacting to each individual case, we know that we are better when we look at entire communities—like in Costa Rica, as Atul Gawande writes—or even beyond our regions into a vastly interdependent global health system. Once we recognize that we are dependent on the health of other communities far from our own, our approach to healthcare and its critical supply chain will undoubtedly improve. A full circle and sustainable approach certainly won’t break the supply chain, rather it might just keep it moving in the right direction.