Securing health care supply chains in a pandemic with the help of a gamification approach
Prof. Susanne Wilpers, Herbert Streit
The SARS COVID 19 pandemic in the year 2020 has damaged large parts of the international economy in a way that hardly anyone could have foreseen. The disruptions of national and international supply chains as a consequence of the quarantine measures established made the situation even worse.
This article deals with the disruption of the supply chains in the health care sector, the resulting problems, the activities for mitigation with special emphasis on the EU region. We finally discuss how a gamification approach in healthcare logistics and supply chain management could help to be better prepared for the next crisis.
The first part of this article summarises the shortfalls and disruptions of the medical products supply chains that pushed some national health systems close to the abyss or even pushed them over the edge. The most important finding is that the nations’, the economic regions’ and the worldwide institutions’ first reactions were often selfish and awkward and it soon became clear that they were far from being prepared for such a pandemic. The underlying problems are revealed and possible proposals are listed to avoid these problems in the future.
The focus lies on appropriate training for our prospective and actual logistics experts and decision-makers. A gamification approach as an addition to theoretical learning is dis-cussed. A consistent digitisation of the health care system and the health care supply chain management is identified as an absolutely necessary part for implementation.
Keywords: health care, supply chain, logistics, critical infrastructure, the European Union, Pharma Supply Chain, hospital logistics, health care logistics
- Introduction – 3 –
- Impact on the SARS COVID 19 pandemic on the availability of pharmaceuticals and medical equipment – 4 –
2.1 Definition, characteristics and the spread of a pandemic – 4 –
2.2 Availability, bottleneck, alternatives, logistics, replenishment – 5 –
2.2.1 The situation for pharmaceuticals – 6 –
2.2.2 The situation regarding protective clothing – 6 –
2.2.3 The situation regarding medical devices – 7 –
2.2.4 The situation regarding the availability of health care personnel – 7 –
- Reactions, possible solutions and alternatives to the consequences of a pandemic – 8 –
3.1 Multiple sourcing, relocation of production and national reserves – 8 –
3.2 Availability of healthcare supply chains – 9 –
3.3 Digitalization of the healthcare supply chains – 9 –
- Mitigating the impact of a pandemic on the health logistics and supply chain with a gamification approach – 10 –
4.1 Database layer – 11 –
4.2 Analytics layer – 11 –
4.3 User level – 12 –
- Conclusion – 12 –
List of Figures:
The SARS COVID 19 pandemic has damaged large parts of the international economy in a way that no-one had expected. It has caused the largest global recession since the Great Depression in the 1930s (Gopinath, 2020)
One of the critical consequences was the disruption of national and international supply chains, which was one of the main reasons why the production and distribution of industrial and agricultural products were severely impaired or even stopped.
Even if economic growth already recovers in regions with lower infection rates and the supply chains slowly get restored, the impact on health care and health logistics however are much more dramatic.
The pandemic has so far (August 2020) claimed almost one million lives and still is in full swing (Dale and Stylianou, (2020). The real number of fatalities most likely exceeds the official numbers (Dunn, 2020). Healthcare systems and the healthcare logistics and supply chains in many countries have been overwhelmed by the special characteristics of the virus. As a consequence of this a lot of people, who would otherwise have had a realistic chance to survive, died because of the lack of health care resources (Gopinath, 2020).
The coronavirus pandemic has revealed problems in the healthcare supply chain management, with shortages in pharmaceutical, medical and personal protective equipment and equipment for intensive care. To make things worse, a lot of countries have cut back on their health systems for several reasons and now the ones who urgently need the help have to pay for it (Rowan and Lafey, 2020).
More investment in healthcare digitization, procurement strategies and logistics of efficient delivery systems must be a priority to prevent such setbacks in the future. Especially logistics and supply chain management of health care products from manufacturing to application play a key role in such a scenario. This applies to all organizations responsible on a national and international level.
This paper examines some of the most prominent problems that occurred in the field of Health Supply Management and Logistics during the pandemic. There have been a lot of helpful policies and initiatives during the pandemic that can serve as a blueprint for the future and a bunch of other promising ideas to prevent the shortage of healthcare products for the future.
Despite the fatal consequences, the COVID 19 pandemic can be used as a “model crisis” for future pandemics. But we have to be aware that it could even get worse next time. So, we should better see this as a wake-up call and do our homework.
Introducing a gamification approach in health logistics and supply chain management training could be a great idea to support our readiness for the future. Over the past years, the gamification model has become one of the leading topics for discussion if and how it can be applied to the training of pupils, students and staff in companies. According to Groh, the term “gamification” applies to the use of a game or desire to stimulate the involvement of a consumer (trainee) in a given activity.
Besides all the theoretical education, games and simulations can motivate trainees to do the extra step and create awareness of and valuable experience with a pandemic scenario.
Besides being a tool for training, such games can be of interest to health organizations where it can support the compilation of emergency plans and check them for robustness and justify their investment.
2. Impact on the SARS COVID 19 pandemic on the availability of pharmaceuticals and medical equipment
2.1 Definition, characteristics and the spread of a pandemic
A pandemic describes the spread of disease in humans across countries and continents, in the narrower sense the spread of an infectious disease (WHO, 2010). In contrast to an epidemic, a pandemic is not limited to a region (Robert Koch Institut, 2020).
With regard to influenza, the World Health Organization (WHO) stipulated in its guide-lines on pandemic influenza risk management, which was last revised in May 2017, that the declaration of a pandemic – i.e. the transition from an epidemic to a pandemic – is to be carried out by the WHO Director-General. This was declared for SARS COVID 19 on the 11th of March 2020 (WHO, 2020). Many countries, where the number of infections bounced up, started to introduce quarantine measures.
This new Coronavirus has the potential to generate a huge amount of seriously sick people who have to be hospitalized. This happens due to a long incubation period and a big amount of asymptomatic infections (Robert Koch Institut, 2020).
In consequence, every pandemic puts severe pressure on health care and demands a quick and flexible reaction.
2.2 Availability, bottleneck, alternatives, logistics, replenishment
The healthcare supply chain starts from manufacturing health products and ends at the places where these products support patients and clinical staff. Figure 1 shows a simplified version of this complex process.
Nowadays the manufacturing of healthcare products and their components is partially or even totally outsourced into countries with low labor costs, like China or India. However, if in the event of a crisis, when the factories might be closed down and the supply chains are disrupted, vital medical products might not be available in sufficient numbers, national medical services can quickly reach their limits. This disruption of flow of medical goods the manufacturers to the patients and clinicians had a dramatic effect on the rate of mortality in a lot of countries (Haleem et al., 2020).
Figure SEQ Figure \* ARABIC 1: Supply chain management process on healthcare systems
2.2.1 The situation for pharmaceuticals
The dependence on China for the production of API (active pharmaceutical ingredients)- active ingredients and the chemicals they contain or on India for generics, should be the wake-up call to realign the pharmaceutical and health supply chain and logistics and to establish a better weighting of production in Asia, Europe and the USA.
When the factory closures due to the lockdown measures in China started, the production of these ingredients slowed down. This has resulted in shortages and relatively higher costs for the materials required to produce generic drugs, thus leaving producers facing difficulties in making and supplying end products. India has decided to stop exporting 26 active pharmaceutical ingredients amid fears of shortages within the country. This had a worldwide impact, especially on supplies of paracetamol, antibiotics such as tinidazole and erythromycin, progesterone and vitamin B12 (Duffy et al., 2020).
Airfreight is a crucial part of the pharmaceutical supply chain. Pharmaceutical manufacturers rely on capacity in passenger flights (the so-called belly-flights) to move medicines and ingredients rapidly and securely. With the spread of COVID-19 and the lockdown measures, there was a dramatic reduction in passenger flights that normally carry pharmaceutical goods and alternatives had to be established (Medicines for Europe, 2020).
In countries with a highly developed healthcare system, it was possible to benefit from high stock levels in industry and pharmacy distribution centers (IBIS World, 2020).
2.2.2 The situation regarding protective clothing
Personal protective equipment is essential for both staff and patients to prevent the spread of an infectious agent like the Coronavirus. Appropriate use of gowns, aprons, surgical face masks (FFP3), eye protection and gloves are essential. Personal protective equipment in health care is mostly designed to be used once and must then be disposed of (International EnviroGuard, 2018).
In contrast to the relatively stable situation for most pharmaceuticals, there was a lack of sufficient amounts of personal high-quality equipment and disruptions at all stages of the supply chain, including manufacturing, procurement, and logistics of supply and distribution to hospitals, care homes and nursing homes. Consequently, a big amount of healthcare staff got infected or even died.
There are several reasons for the shortage of protective clothing.
Half of the world’s personal protective equipment is manufactured in China (Branswell, 2020). Although the production did not drop that much in the first two months of the year, the problems were with transport and competitive activities. As soon as it was clear that the world is facing a pandemic in early March, a run on global supplies of medical protective equipment started, where competing buyers were paying a significant premium over list price and finally left the stocks emptied (Chinazzi et al., 2020). When governmental measures against the spread of the pandemic materialized in lock-downs of factories, restrictions in international transport and even closures of borders, the whole supply chain for medical protective clothing got disrupted worldwide (Hahn, 2020). To make matters worse: a lot of countries had cut down their investment in health care and especially in stockpiling emergency supplies. Some of them even did not take the threat of a pandemic serious enough and did not organize any preventive measures like stockpiling health care products, when there was still time to act (Brown, 2020).
2.2.3 The situation regarding medical devices
At the start of the pandemic, it soon was clear that there were not enough machines for intensive care available, especially ventilators to keep the serious Corona cases alive. There is no way to manufacture them in a large amount within a short amount of time, as these machines are made of hundreds of smaller parts produced by companies all around the world. Again, the disrupted supply chains were the main problem. This set a limit even to the world’s largest makers of ventilators like Hamilton Medical in Switzerland or Dräger in Germany (Jacobs, 2020). In some countries, this resulted in a dramatic shortage of ventilators and in consequence that younger patients were prioritized for treatment while older patients had to be sent home to die (Basu, 2020).
2.2.4 The situation regarding the availability of health care personnel
Logistics cares about the transportation of goods, financial assets, information and people (Krieger, 2018). Health care personnel at the front line of the pandemic were challenged (and frustrated) by several factors at the same time.
Understaffed medicinal facilities caused extreme overtime work and additional hygiene measures take much more time to take care of patients than before. The lack of protective clothing puts them at a high risk to get infected and to pass on the infection to others. The lack of medical devices put them into an incriminating ethical conflict to decide who they would try to save and who they would leave to die (Han and Luc, 2020). At the beginning of the pandemic, there was even no tool available to monitor the free and occupied beds for intensive care (Geinitz, 2020).
3. Reactions, possible solutions and alternatives to the consequences of a pandemic
3.1 Multiple sourcing, relocation of production and national reserves
The outsourcing of the production of health care products mostly to China and India for saving costs has proven to be a major problem in times when the supply chains are disrupted, like in times of a pandemic.
However, complete relocation to national regions would create other problems. An ideal way would be a partial relocation and a reasonable stockpiling, especially for critical drugs and protective clothing. Surely this would entail additional costs, which would have a direct or indirect impact on the costs of the national health care systems.
In general, it’s not very popular to invest in the prevention of “low probability, high impact” events. However, the corona pandemic might have initiated a change of mind. Preventive measures are first and foremost the responsibility of international and national institutions, which ideally act in concert under the direction of the WHO.
Private companies can implement these prevention measures, but since they are profit-oriented, they might have to be subsidized by governments.
National reserves for medicines and medical equipment can safeguard the supply for a certain time in the event of a crisis. In June 2020, the Federal Republic of Germany passed a policy to support medical emergency reserves at the federal and state levels with a programme worth billions of euros (Pharmazeutische Zeitung, 2020). A certain number of local factories, especially for protective clothing and medical devices could increase their production immediately in the face of a pandemic.
When there was a shortage in disinfectants, especially hand sanitizers, several companies that usually produce alcoholic beverages could switch their production and jump into the gap (Schrieberg, 2020).
The attempt to let car companies produce respiratory ventilators did not really work well, because of the complexity of these devices. All kinds of temporary respiratory devices were put together, but fortunately, the worst-case scenario with a dramatic lack of ventilators did not last too long, as the pandemic peaked at different places at different times (Tempelton, 2020). Apart from all the political “market noise”: It is obvious that high-quality respiratory devices cannot be produced in large numbers within a few weeks by laymen (Harper, 2020). The underlying problem is the fact that due to cost cuts in some countries’ health care systems there was not enough emergency reserve for all kinds of health care products, especially for medical devices and protective clothing.
3.2 Availability of healthcare supply chains
The most important element in healthcare logistics is the personnel, doctors, nurses and technical support staff. A low personnel key, the ratio of the nursing staff per occupied bed, can lead to serious problems in times of a crisis. So it should be at a reasonable level at any time.
Even with a high ratio, there might be a point where there is no longer enough staff to provide safe patient care. Procedures to react to this should be prepared and be activated immediately without a time-consuming discussion about regional or national responsibilities.
Patients could be transferred to other facilities with adequate staffing. As a pandemic usually does not peak everywhere at the same time, patients could even be transferred to other countries.
Students of medicine, volunteer helpers and even the national army can take over a lot of tasks to relieve the medical staff. The financial, legal and insurance related aspects have to be clarified in advance.
3.3 Digitalization of the healthcare supply chains
Close cooperation and good communication between all supply chain partners are essential to agree on new developments in replenishment and capacity scaling.
The digitalization of the Health Supply Chain has already started and should be intensive under the impression of the impact the pandemic has caused. The midterm goal must be an uncompromising digitalization of the complete healthcare supply chain, where all supply chain partners from manufacturers to health care facilities can use a common data repository (Escritt and Siebold, 2020).
Such a repository of data would open a new world of possibilities like quality assurance, risk management, cost reduction, automatization, artificial intelligence, simulation and gamification of emergency scenarios like a pandemic.
4. Mitigating the impact of a pandemic on the health logistics and supply chain with a gamification approach
SARS COVID 19 is a new virus infection that most likely jumped from an animal reservoir to humans recently. A lot of other “candidates” with the potential to cause a pandemic are already identified (Gavi, 2020). There is a high risk that we will see more pandemics like this one in the future (Quammen, 2012).
We have seen a lot of problems in the health care logistics that have caused a high number of fatalities, but we also have seen a lot of great initiatives and smart ideas that were able to mitigate some of the stinging problems.
Our experiences will be documented in tons of books and terabytes of online documents. Governments all around the world will adapt their policies to be better prepared for future health crises like this.
One of the central parts that have to be changed is the health care logistics and supply chains. This has to be started at the universities. During academic training, every student of logistics learns about disruptions in the supply chain and their impact on companies. However, this bookish knowledge, although foundational, does not prepare one for all the potential contingencies and scenarios that a disaster like a pandemic can present.
A training tool to simulate such a scenario could be very useful to fill this gap.
Like in a flight simulator for pilots, as soon as the theoretical part of how to fly an airplane has been trained, it is time to get a hands-on tool to simulate a real flight. Starting with routine flights, they will be confronted with unexpected incidents like heavy weather or technical problems. They are provided with written procedures to solve the problem, but in the end, they have to make their own decisions to “survive”.
With such a gaming approach it would be possible to simulate a scenario for future pandemics and to test the emergency procedures for their feasibility, suitability and financial viability. The first target group for such a game would be the logistics students with a specialization on health care, who are the experts and decision-makers in the future.
The gamification approach would be a three-layer application.
4.1 Database layer
The quality and proximity to real-life of such a game depend very much on the data provided. This includes all possible data and metadata, structured or unstructured. This is known in industry and politics as Big Data (Gartner, 2020).
So, what we need is all kinds of data from the complete healthcare supply chain from production to patient. But also, the availability of emergency reserves and the number of staff available. Financial, legal, actuarial and all kinds of unstructured information are also essential.
In a students’ and trainees’ gaming environment, this would be artificially generated or anonymized data in a “frozen” data repository.
For experts working in health care institutions and in manufacturing companies all the data could be stored in a cloud application and accessible to those who are doing the da-ta analytics work.
Such a data repository is not just key for a game, but also very useful for other business solutions of companies, institutions and governmental offices.
The availability of the appropriate data is a matter of how fast the digitization of the health care system and the connected supply chains is driven forward. At the moment we are still in the initial stage. The medical production industry and the health care sector show the lowest degree of digitization (Hermes et al., 2020).
4.2 Analytics layer
The second layer of our gaming application would be the analytics layer. What we mean is a Business Intelligence approach (Dedic and Stanier, 2016).] Other common terms are Business Analytics (Beller and Barnett, 2009) or Data Mining (Holton, 2010).
These are different terms for similar procedures. It’s all about making sense of one’s data, that is produced during every business activity. To recognize patterns, improve quality and return on investment and getting support for business and governmental decisions
To create this layer is a task for data scientists, not for logistics students or experts – unless they are trained in both. The analytics layer is the place where all the linkages and calculations take place. This layer is fed by the data repository.
4.3 User level
This level presents the gaming interface to the (end)users: students, trainees or experts in health care logistics. It’s a graphical interface where the gamers can train how to do their daily job in logistics and supply chain management.
In an advanced state, they finally have the opportunity to master the challenges of a crisis like a pandemic with disrupted supply chains, locked down factories and a shortage in health care products.
The goal is to master the challenge with the least damage for the ones they are responsible for: the patients and the health care staff.
A pandemic, like the one we are just going through, puts health care systems under enormous stress, leading to a huge number of fatalities due to the shortage of material and personnel, rather than the virus itself. One of the major reasons for this was the disruption of supply chains due to quarantine measures.
Despite all the losses we have seen during the last months, the COVID 19 pandemic is a great opportunity to prepare ourselves for similar crises in the future. Besides all the writ-ten documentation that is already available and is still to be written, we have to train our prospective and actual health care logistics experts with the best tools available to be prepared for the next crisis.
Gamification approaches in logistics and supply chain management, especially in the health care sector, can do their share to provide experts with the appropriate knowledge and experience and can help to countercheck emergency routines for their practical feasibility. It is about learning the business of logistics and supply chain management, but it is also to train some sort of gut-feeling when making decisions. A game responds immediately, showing the impact of the player’s moves.
But we do not want to limit ourselves to students and trainees. Highly sophisticated versions of such a game, equipped with the appropriate data repository could also help logistics experts in companies and institutions to get their business prepared for the next crisis and to act on an experienced level in the next crisis.
Preventive measures cost money and this is why they are usually not very popular. Politicians will be busy trying to restore their country’s economy after the pandemic and will have to face a lower budget within the next few years. So most promises to better equip the health care system will soon be postponed and disappear.
Anyways, just pumping more money into the system cannot be the wisdom of the end. A thorough digitization of healthcare and the connected supply chains will even provide opportunities to provide better quality at the same costs. Every pandemic in the future takes their toll. But it is our decision if we want to give those a fair chance who have the physical condition to survive the disease.
Although the prevention of any other pandemic in the future should be the highest priority of the world community, it is more than questionable if the root causes, deforestation and wildlife trade, can be stopped.
So, it’s a good idea to prepare ourselves for the next pandemic. To train our future logistics and supply chain experts and policy makers to get prepared and act accordingly will be one of the most important missions. This can all be achieved with a comparatively low investment.
Finally, a sophisticated gamification approach could show the volume of investment in prevention compared to the loss of life in the case of doing no prevention at all.
Anyways, pumping more money into the system cannot be the wisdom of the end. A thorough digitization of healthcare and the connected supply chains will help to make the best use of the investment.
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The article is part of the development of a study on the application of the game approach in logistics and transport training (Output title O4) under the Erasmus+ strategic partnership project “Building an innovative network for sharing of the best educational practices, incl. game approach, in the area of international logistic and transport”, Project number: KA203/HE25/13.09.2019