PPE, ventilators, vaccines – they’ve been the big hitters of Covid-19, providing lifelines during a pandemic that decimated entire economies. Also high up on the list of importance, though, are the medications necessary for hospitals to treat patients – and if coverage of the pharmaceutical sector over the past two years is anything to go by, it’s not just a surprise that supply chains kept functioning, but that they functioned at all.
Staving off wave after wave of infection, they adapted, defying predictions of total collapse as countless factories locked down in the face of an unimaginable global crisis. Dr Liz Breen, director of the University of Bradford’s Digital Health Enterprise Zone, which hosted phase III trials for Novavax, has spent the past 18 months analysing pharmaceutical supply chains. She says that, despite all the odds, they were able to adapt to meet the evolving needs of healthcare professionals.
“I think in general the supply chain has coped rather well during Covid. Business did continue as usual, but just in a very different way. There’s been huge demand and huge pressure with regards to certain items on the medtech side or certain drugs, but supply chains managed to cope.
“Coping seems to be the word of the day – whatever coping mechanisms were put in place, whether it be sourcing new suppliers, producing new contracts, or managing to get the suppliers to produce more, healthcare professionals have managed to do their jobs,” Breen says. “That obviously came with huge, huge stress, but they did an admirable job in the face of very traumatic and challenging times.”
She points out that while pressure points during Covid have been unprecedented, shortages and bottlenecks are not actually new, often resulting from quality control issues and recalls. “We know that disruptions happen within our pharmaceutical supply chain all the time – that’s not new. We’ve always had to find ways to adapt and to deal with it,” she continues.
Breen says there were clear problems in early 2020 in the procurement of ventilators and PPE, as well as shortages of hand sanitising gels and some drugs used to manage Covid and other illnesses. However, despite ongoing lumpiness in the vaccines space, the chain continues to absorb sustained pressure.
Covid forced supply chains to adapt to fresh demands from hospital systems worldwide, with Breen citing the NHS as a case in point. “The NHS became a much less conservative workforce and it’s now ultra-responsive – that came at a cost and it took its toll on the welfare of the workforce, but from a strategic point of view, it’s become very dynamic and the supply chains helped make that happen.”
Breen says trends within the pharmaceutical supply chain in recent years – including digitisation – had helped to build in resilience. The focus, she adds, must now be on adding additional agility and resilience across the network.
Resilience and agility
Digitisation will continue to play a critical role in post-Covid planning and preparedness, though real-time monitoring of pharmaceutical stock was already becoming par for the course prior to the pandemic. “I think we already have a fair amount of control and visibility – for example, in terms of what the wholesaler holds and the quantities distributed to communities, pharmacies and hospitals,” says Breen. “From my research and interactions with wholesalers, they’re very proud of the fact that they can source materials as quickly as they can – if it’s not available, then they will quickly try and switch an order to another site.”
She says AI, too, was already being widely integrated into systems prior to the pandemic. “I think there was already a huge appreciation of data mining, having good databases and learning from them. We’ve always had forecasting, but with AI and machine learning, the intelligence is much more profound and incredibly valuable in terms wof designing entire services and manufacturing schedules. A particular area of interest is the cold chain – the supply of pharmaceuticals that must be kept at a certain temperature – a particular concern right now with certain Covid vaccines. AI can aggregate several data types, like the weather along a delivery route and the packaging drugs are kept in, to predict the state of the product upon delivery.
“AI will keep offering an additional level of robustness in our actions and within our decisions within pharmaceutical supply chains. The information will be more targeted and more useful because it will give you the right information at the right time. You might see more of a ‘just in time’ scenario playing out,” says Breen.
Reducing risk
Post-Covid planning will also need to include widespread reviews of supply chain dependencies. Lessons must be learned and acted upon.
A 2016 pandemic ‘dry run’ coordinated by the UK government to test systemic healthcare vulnerabilities – dubbed ‘Exercise Cygnus’ – highlighted the need to source and stockpile PPE and ventilators. There is little evidence to suggest the report, which was never published, was ever acted on. Breen says disaster planning is vital. Paracetamol, for example, is an off-patent generic product – it’s a fundamental healthcare provision and should never be in short supply. “It will be a case of always having that contingency plan. So instead of only having one supplier that you can contract, you make sure you hedge your bets, and you have other parties that you can contract as well. I think, in general, we do tend to do that with our contracts anyway within the NHS. Trading with multiple wholesalers allows you the luxury of having variety and choice.”
That choice prior to Covid, however, was heavily dependent on supply chains linked to China and India, the sector’s two powerhouse manufacturing bases.
“That has come back to bite us – and that overreliance really should stop,” says Breen. “When I was asked about the impact of the pandemic really early doors, I said we would have no supply chains left if we did not focus on protecting the people. The virus was affecting people, and people would not be able to work in the factories or drive the trucks. And that’s exactly what happened.”
In China, factories closed as cities locked down; in India, the Serum Institute muddled through, taking on additional contracts amid rumblings of closures and export bans (the Indian government ultimately stopped exports of paracetamol and remdesivir, among other medications).
New manufacturers stepped in to engage with the pharmaceutical supply chain for the first time. Perfume and alcohol producers switched to hand sanitiser, avionics and auto manufacturers turned their attention to ventilators.
While not all this diversification will remain profitable once economies normalise, Breen does see Covid as a catalyst for a return to local manufacturing in order to minimise risk. She cites paracetamol and other generics as examples.
“If a generic company can be making all these products in another part of the world, why can’t we start making those products in the UK? Wherever we don’t have the talent, the skills, the manufacturing capability, or the technology to support it, we buy in. I think there is definitely now more focus on local supply chains and investing in UK pharmaceutical manufacturing – and we’re not the only ones doing it. It’s about finding where the weak spots are, working out what makes us vulnerable and trying to mitigate against that.”
Local vaccines manufacturing capacity will have long-term ramifications in terms of shaping supply chains. “I think, moving forward, we’re going to see that the investment isn’t just in a company and a vaccine, but also in the supplier, the talent management, the education of the engineers and biologists,” Breen says. Targeted investments in these areas, she adds, are what will allow us to “hit the ground running” in future pandemics. “I’m hoping that is what we get out of this pandemic – there are definitely things that we can learn. We need to really cash in and capitalise on that.”
Talking point: wastage in the supply chain
The supply chain does not end with the delivery of a medication or a device, but with its eventual use, and the topic of wasted vaccines continues to inspire news coverage. Breen doesn’t see the increased focus on Covid vaccine waste having any real impact on the supply chain long term. The system, she says, is already robust in terms of day-to-day medications, and some medicines and vaccines prove more challenging that others to distribute.
“We have always had waste within the pharmaceutical supply chain – and if you look at it, cumulatively, it's probably an awful lot of money. But our inventory management systems have become a lot more sophisticated over the years,” Breen adds. There are now teams and resources targeted at reducing wastage, which didn't used to be the case. “We are recording batch numbers, recording quantities, we have staff whose responsibility is to rotate drugs – the level of waste should be a lot lower now than it ever was,” says Breen. “It’s not a new phenomenon, but waste has probably been given more airtime because of Covid-19.”
Even so, a system is needed to ensure surplus medicines – and in particular Covid vaccines – are distributed to other parts of the world, be it via COVAX or other humanitarian channels. “We need to make sure we produce a product that’s going to be used – and if it's not used for its original purpose, then it should be repurposed,” says Breen.
