Building sustainable supply chains for healthcare – Building Blocks

Healthy and Productive populations are paramount to a happy and peaceful world. The Pandemic was an event that threatened both health and productivity in an unprecedented fashion.

?Supply Chains have been under the microscope since, because of the disruption that was caused to lives and economies around the world.

For India, there were some winning moments during the pandemic and since. The rapid response to the requirement for Test Kits, Protective Gear, Vaccines, Oxygen, Triage and other supply chain issues; deployment of tools like e-Sanjeevani and other telemedicine platforms, CoWin, eVin are just some of them.

The subsequent pilots of delivery with Drones, the rapid manufacturing of oxygenators, the deep overhaul of the active pharmaceutical ingredient supply chain, the rush to build a medical device ecosystem and the ABDM, ABHIM to rapidly improve medical infrastructure, The pilots with Drone based delivery systems, improvement in cold chains are all indicators of great intent in the ecosystem and governance.

?Globally, the Military has been a great example of resilient supply chains that resist stress. They work on the wisdom – The more you sweat in peace, the less you bleed in war.

?It is therefore a good time to take a sober and hard look at healthcare supply chains in view of their vital nature.

?What makes Healthcare Supply Chains different?

?While all discussions on supply chains are predicated with the pandemic, it is important to understand that the Pandemic may not be the most severe challenge that humanity could face. The world sits on a tinderbox of Nuclear, Chemical and Biological War materials and capabilities. Unconventional ways of war continue to surface, from conflicts around the world that are also breeding grounds for disruptive events. These could result in even more abrupt and severe disruptions very easily.

?There is also another layer of complexity that can come from climate based or other natural or industrial disasters requiring rapid responses to the unknown. We have seen some glaring examples of these around the world.

Healthcare is not just vital; but the most complex domain of activity for three principal reasons:

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1. Health is Non fungible in nature and clinical decisions follow a methodology which is completely subjective unlike the more empirical matrices possible in other domains like banking, insurance, food, or energy. It is a question of human lives not just material resource.
2. ?Healthcare is a vast, open ended, fragmented and diverse range of stakeholders’ archetypes and processes that grew organically and continues to change all the time. Their incentives may compete sometimes and yet there is a high degree of interdependence within, apart from the fact that there are not just backwards and forwards alignments. It is a 360 Degree continuum of stakeholders raging from Innovators, Research, Service Providers, Ancillary services and utilities, regulators, governance and so on.
3. While we perceive the challenges to be borne out of communicable diseases which tend to capture attention by their acuteness and ability to spread rapidly. Outcomes in treating these are determined by what is popularly referred to as Co-morbidities. Ironically co-morbidities are underlying health conditions that result from what we broadly call non-communicable disease which are more chronic in nature. These could also result from more local or personal factors like genetics, environment, cultural contributors, lifestyle choices and so forth. These need to be addressed on a sustained basis for positive outcomes in acute black swan events, of which the pandemic is the most recent example.

Building sustainability into systems in any case, is the art of designing them to doing, More with Less.

It would therefore be untenable, to address healthcare supply chains by just looking at the immediate and taking a transactional view of things, which may work on other more fungible domains as discussed earlier.

Any approach to building sustainable supply chains in healthcare would therefore need to develop the ability to spot challenges early, localize them and address them rapidly while still small. Then, perhaps go on to impart an intelligence to the systems to work in preemptive and predictive fashion.

?Which also means moving from a paradigm of epidemiology based on historic data, often of limited archetypes, poor quality and quantity to a paradigm of near real time data of a wide variety of data points, traceable provenance and high quality that is machine readable for response times that are of another order of speed and scale while offering visibility to all stakeholders to perform their functions in a nimble fashion.

?A logistical perspective often talks about preparedness and strategic stockpiling. These can only be enabled by the ability to answer questions of What, Where, When and How Much etc. which are a function of data near real time data.

?The key approaches would therefore be to make superior data available through Digitalisation and improve response times resilience on the material side by Localisation of supply chains.

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Digitalisation

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Digitalisation is about the ability to spot con-conforming events in the healthcare continuum quickly, being able to characterise them rapidly, forecast, provision, and respond effectively, precisely.

The deployment of IoT enabled equipment, Point of Care devices and various innovative ways in which patient data is captured today allows for the types, quality, quantum, and speed at which data can be available and actionable.

?This is about a determination to build Digital First Healthcare systems by leveraging Mobile First and Cloud First technologies.

?Debates around digitalisation are often plagued by a pessimistic view of Digital Infrastructure and its resilience, which is really amusing. The world in its remotest corners was playing Massive Multiple Player online Role Playing games like Mazewar (1974) Ultima Online (1997) on to Farmville and Candy Cush and other More complicated ware games in recent years.

?The early games were deployed using the dated cloud server architectures whereas the newer games make use of publicly available infrastructure like the cloud, generic mobile devices that the user already has, based on more nimble and resilient architectures like microservices. Instances like the popularity of Facebook, WhatsApp, TikTok and the virality of their adoption even in the remotest geographies is proof that the customised software and training needs and their attendant complexity and costs are no longer relevant arguments; Adoption can be very quick and organic, if we let a thousand flowers bloom by taking an inclusive approach.

India's National Digital Health Blueprint envisages just such an opensource, standards based, semantically interoperable ecosystem. We may just be a switch-of-mindset away from success in solving the digitalisation challenge.

We may just be overestimating the challenge.

?Let us also be mindful of the fact that the Interoperability with Integrated Medicine, OneHealth, Health Security and Biodefense, Precision Medicine, Improved Drug and Device Innovation going forward will also depend on the availability and use of data from healthcare systems.

?It therefore is imperative to ensure that Digital First Healthcare Systems find adoption quickly by incentivising it as a part of infrastructure initiatives like ABHIM and other policy measures that can enable rapid digitalisation.

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Localisation

The pandemic underlined the need for a graduated but rapid approach to localisation, as a path to mitigate the vulnerabilities of a globalised supply chain. This is a multidimensional problem.

Judicious Build versus Buy Decisions, gradual offshoring to near-shoring to localisation decisions, research, and capacity building initiatives in the realm of healthcare need to be made and suitably incentivised.

Some great initiatives have been seeded post pandemic and have already been discussed above.

?Risk Management

?An effective approach to localisation is perhaps also a subset of the Risk Assessment and Mitigation of Risk strategies which could determine Pipeline risks like Energy risks and costs, labor problems, IT Systems Challenges, Logistic Infrastructure, Leakages and Thefts etc. Environment Related risks like Disasters, Political Upheavals, Accidents etc. and Stakeholder related incidents like Trade Restrictions, Regulatory Challenges, Taxation issues, Quality Issues, Cash Flow and Funding Risks and so forth.

Each risk element needs contextualisation to identify its source, and impacted stakeholders, assessing risks in terms of likelihood, stakeholder impact and building consensus on its treatment. Treatment strategies would require prioritisation and approaches like Avoiding, Reducing, hedging or accepting these risks in order to optimise.

This would also allow developing a Risk performance Monitoring and Incident handling approaches to be standardised over time in the form of contingency plans, documentation, and case studies etc.

The importance of near real time data can hardly be overemphasised in the whole process.

?Building Capacity

Healthcare supply chains would need to be seen as a specialisation given its complex and interdisciplinary nature. Building capacity by including them in existing education programs would be a great step towards building sustainability in the system.

Perhaps we need to keep an eye on the evolution of healthcare value chains to build sustainability into its supply chains.

There are also then, the issues of greening supply chains to cut risks and costs to make them more sustainable, which are perhaps more generic in nature.