Impact of COVID-19 pandemic on pharmaceutical systems and supply chain - a phenomenological study

Building a resilient health system for universal health coverage and health security: a systematic review

BACKGROUND

Resilient health system (RHS) is crucial to achieving universal health coverage (UHC) and health security. However, little is known about strategies towards RHS to improve UHC and health security. This systematic review aims to synthesise the literature to understand approaches to build RHS toward UHC and health security.

METHODS

A systematic search was conducted including studies published from 01 January 2000 to 31 December 2021. Studies were searched in three databases (PubMed, Embase, and Scopus) using search terms under four domains: resilience, health system, universal health coverage, and health security. We critically appraised articles using Rees and colleagues' quality appraisal checklist to assess the quality of papers. A systematic narrative synthesis was conducted to analyse and synthesise the data using the World Health Organization's health systems building block framework.

RESULTS

A total of 57 articles were included in the final review. Context-based redistribution of health workers, task-shifting policy, and results-based health financing policy helped to build RHS. High political commitment, community-based response planning, and multi-sectorial collaboration were critical to realising UHC and health security. On the contrary, lack of access, non-responsive, inequitable healthcare services, poor surveillance, weak leadership, and income inequalities were the constraints to achieving UHC and health security. In addition, the lack of basic healthcare infrastructures, inadequately skilled health workforces, absence of clear government policy, lack of clarity of stakeholder roles, and uneven distribution of health facilities and health workers were the challenges to achieving UHC and health security.

CONCLUSIONS

Advanced healthcare infrastructures and adequate number of healthcare workers are essential to achieving UHC and health security. However, they are not alone adequate to protect the health system from potential failure. Context-specific redistribution of health workers, task-shifting, result-based health financing policies, and integrated and multi-sectoral approaches, based on the principles of primary health care, are necessary for building RHS toward UHC and health security.

Evaluation of a Pilot: Inspection Facilitation and Collaboration Using a Mixed Reality Device

The COVID-19 pandemic forced industry and national regulatory authorities (NRAs) to think about innovative ways to ensure business continuity, including Good Manufacturing Practices (GMP) inspections. Even prior to COVID-19, it was understood that GMP site inspections, especially redundant inspections, are a time and resource-intensive process for both industry and regulators in high-income countries and often prohibitive to resource-challenged countries. Thus, we investigated the use of a mixed reality device and Microsoft (MS) Teams as a platform for mixed reality (hybrid) remote inspection. This pilot involved a mock GMP inspection of a drug manufacturing facility in the United States. The mock inspection was conducted by two former USFDA (US Food and Drug Administration) investigators, facilitated by representatives from Northeastern University along with The Bill and Melinda Gates Foundation. Also participating in the inspection were inspectors from national regulatory agencies (NRAs) from the African continent, including Nigeria, South Africa, Uganda, and Zimbabwe, and representatives from the Pre-Qualification Inspection Unit at the World Health Organization (WHO). Harmonized inspectional guidance from PIC/s (GMP Guide) and WHO (TRS 823) were used as the standards for conducting the mock inspection. We found that mixed reality, used in conjunction with a collaborative text messaging system, is a viable tool to facilitate remote inspections and allows inspectors participating remotely to write their own independent inspection reports.

Impact of the COVID-19 Pandemic on Medical Product Procurement, Prices, and Supply Chain in Zimbabwe: Lessons for Supply Chain Resiliency

BACKGROUND

The COVID-19 pandemic has disrupted global health supply chains including manufacturing, storage, and delivery of essential medicines, testing kits, personal protective equipment, and laboratory reagents. We sought to document how pandemic impacted the procurement, prices, and supply chain of medical products in Zimbabwe.

METHODS

We conducted semistructured in-depth key informant interviews with 36 health system stakeholders in Zimbabwe involved in medicine procurement. Respondents included pharmacists, regulatory officers, and procurement and supply chain management professionals from public and private sectors.

RESULTS

Before the COVID-19 pandemic, respondents described experiencing long-standing resource constraints, medicine shortages, foreign currency shortages, and supply chain inefficiencies. The pandemic exacerbated this situation due to supply constraints, export restrictions, medicine shortages, and movement restrictions that disrupted logistical and stock management systems. Competitive bidding and tendering processes experienced reduced participation by international suppliers. Significant price increases were initially observed among internationally shipped medicines and for personal protective equipment to cover additional freight costs. COVID-19 pandemic impacts were moderated by reduced patient demand and lower health services utilization, resulting in fewer supply shocks and less price volatility. Further, health system adaptations such as switching treatment regimens, modifying dispensing schedules based on stock availability, redistributing stock of medicines among facilities, and new service delivery models such as integrated outreach services helped ensure continued patient access to medicines.

CONCLUSIONS

Our findings highlight the need for policies that ensure continuity in access to health services and medical products, even during a pandemic, by avoiding blanket restrictions on medical product exports and imports. Pooled procurement, especially at regional and global levels, with long-term service agreements may help achieve greater resiliency to supply and price shocks from supply chain disruptions. Interventions across manufacturing, trade, and regulatory policy and service delivery models are also needed for supply chain resiliency.

Impact of COVID-19 on the supply chain of essential health commodities: a mixed method study, in Dar es Salaam, Tanzania

BACKGROUND

The outbreak of COVID-19 in the late 2019 led to major global health crises, including morbidities and mortalities. The pandemic has adversely affected the supply chain of essential health commodities globally. However, such data from sub-Saharan Africa including Tanzania are largely limited. We assessed the impact of COVID-19 on the supply chain of essential health commodities in Tanzania.

METHOD

A cross-sectional study with pragmatic mixed method design was conducted in Dar es Salaam region from January to June 2021. Grounded theory was adopted to purposeful select key informants (n = 15) from importers of essential health commodities and local pharmaceutical manufacturers. Community pharmacy dispensers (n = 242) were also recruited for the quantitative part of this study. The prices of selected tracer health commodities were extracted from the Tanzania Medicine and Medical Device Authority (TMDA) Regulatory Information Management system. The mean unit prices 1 year before the pandemic were compared with the mean prices 1 year during the pandemic using paired t test. Thematic analysis was used for qualitative data.

RESULTS

The information regarding the impact of COVID-19 on the supply chain of essential health commodities was synthesized into three main themes namely, reduced availability of health commodities, increased price of health commodities and increased lead time for imported essential health commodities during COVID-19. Majority (90%) of community pharmacy dispensers reported that COVID-19 reduced the availability of essential health commodities. Azithromycin, Paracetamol, Multivitamin and Vitamin C tablets were the highly demanded products and their mean unit prices increased significantly during COVID-19 as compared to 1 year before the pandemic (p < 0.05).

CONCLUSIONS

COVID-19 led to shortage, increased prices and delayed delivery of essential health commodities. This might happen in the future whenever unexpected crises causing disruption in the supply chain occur underscoring the need for the country preparedness measures.

COVID-19 impacts on healthcare access in sub-Saharan Africa: an overview

This overview aimed to describe the situation of healthcare access in sub-Saharan Africa, excluding South Africa, during the COVID-19 pandemic. A PubMed^® search from March 31, 2020, to August 15, 2022, selected 116 articles. Healthcare access and consequences of COVID-19 were assessed based on comparisons with months before its onset or an identical season in previous years. A general reduction of healthcare delivery, associated with the decline of care quality, and closure of many specialty services were reported. The impact was heterogeneous in space and time, with an increase in urban areas at the beginning of the pandemic (March-June 2020). The return to normalcy was gradual from the 3^rd quarter of 2020 until the end of 2021. The impact of COVID-19 on the health system and its use was attributed to (a) conjunctural factors resulting from government actions to mitigate the spread of the epidemic (containment, transportation restrictions, closures of businesses, and places of entertainment or worship); (b) structural factors related to the disruption of public and private facilities and institutions, in particular, the health system; and (c) individual factors linked to the increase in costs, impoverishment of the population, and fear of contamination or stigmatization, which discouraged patients from going to health centers. They have caused considerable socio-economic damage. Several studies emphasized some adaptability of the healthcare offer and resilience of the healthcare system, despite its unpreparedness, which explained a return to normal activities as early as 2022 while the COVID-19 epidemic persisted. There appears to be a strong disproportion between the moderate incidence and severity of COVID-19 in sub-Saharan Africa, and the dramatic impact on healthcare access. Several articles make recommendations for lowering the socioeconomic consequences of future epidemics to ensure better management of health issues.

[Impact of COVID-19 on public health in sub-Saharan Africa]

Objective

This work aimed to assess the impact of COVID-19 on healthcare supply in sub-Saharan Africa except South Africa.

Method

A search through PubMed® between April 2020 and August 2022 selected 135 articles. The impact of COVID-19 was assessed on comparisons with the months prior to the onset of COVID-19 or an identical season in previous years.

Results

The decline of health services, associated with a reduction in their quality, and the closure of specialized health units have been reported. Many control programs and public health interventions have been interrupted, with the risk of an increase of the corresponding diseases. Social disorganization has generated mental health issues among the population, including health personnel. The impact was heterogeneous in space and time. The main causes were attributed to containment measures (transport restrictions, trade closures) and the lack of human and material resources. The increase in costs, in addition to the impoverishment of the population, and the fear of being contaminated or stigmatized have discouraged patients from going to health centres. The studies mention the gradual return to normal after the first epidemic wave and the resilience of the healthcare system.

Conclusion

Several articles make recommendations aimed at reducing the impact of future epidemics: support for community workers, training of health workers and reorganization of services to improve the reception and care of patients, technological innovations (use of telephones, drones, etc.) and better information monitoring.

In-Vial Detection of Protein Denaturation Using Intrinsic Fluorescence Anisotropy

The conventional quality control techniques for identifying the denaturation of biopharmaceuticals includes sodium dodecyl sulfate-polyacrylamide gel electrophoresis for identifying fragmentation, ion exchange chromatography and isoelectric focusing for identifying deamidation, reverse-phase high-performance liquid chromatography (HPLC) for identifying oxidation, and size-exclusion HPLC for identifying aggregation. These stability assessments require essential processes that are destructive to the product tested. All these techniques are lab based and require sample removal from a sealed storage vial, which can breach the sterility. In this work, we investigate the heat- and surfactant-induced denaturation of an in-vial-stored model protein, bovine serum albumin (BSA), by analyzing its intrinsic fluorescence without removing the sample from the vial. A lab-based bespoke setup which can do the measurement in vial is used to demonstrate the change in fluorescence polarization of the protein to determine the denaturation level. The results obtained are compared to circular dichroism and size-exclusion HPLC measurements. The results prove that in-vial fluorescence measurements can be performed to monitor protein denaturation. A cost-effective portable solution to provide a top-level overview of biopharmaceutical product stability from manufacture to the point of patient administration can be further developed using the same technique.

Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium

INTRODUCTION

Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID-19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented.

METHODS

From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1-4.9% and ≥5%) and country income levels.

RESULTS

Questions about pandemic-related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low- (n = 57), lower-middle (n = 79), upper-middle (n = 39) and high- (n = 50) income countries. Most sites reported being subject to pandemic-related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID-19 services, record-keeping interruptions and suspension of partner support. Almost all sites in low-prevalence and high-income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high-prevalence and lower-income settings. Few sites in high-prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi-month dispensing of ART (95%) and designating community ART pick-up points (44%). While few sites (5%) reported stockouts of first-line ART regimens, 10-11% reported stockouts of second- and third-line regimens, respectively, primarily in high-prevalence and lower-income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings.

CONCLUSIONS

While many sites in high HIV prevalence settings and lower-income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID-19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.

The Impact of International Nonproprietary Names Integration on Prescribing Reimbursement Medicines for Arterial Hypertension and Analysis of Medication Errors in Latvia

The use of international nonproprietary names (INNs) has been mandatory for prescriptions of state-reimbursed drugs in Latvia since 1 April 2020. In a retrospective analysis, we aimed to examine the impact of the new regulation on changes in the prescribing and dispensing practice of antihypertensive agents with an example of bisoprolol or/and perindopril and their combinations. All state-reimbursed bisoprolol and/or perindopril prescriptions for arterial hypertension were evaluated in two time periods: 1 April 2018 to 31 March 2019 and 1 April 2020 to 31 March 2021. The proportion of INN prescriptions increased from 2.1% to 92.3% (p < 0.001, φ = 0.903). The rate of fixed-dose combinations (FDCs) increased from 60.8% to 66.5% (p < 0.001, φ = 0.059). The rate of medication errors was 0.6%. The most common (80.6%) error was that the dispensed medicine dose was larger or smaller than indicated on the prescription. In addition, prescribing an FDC medicine increased the chance of making an error by 2.5 times on average. Regulatory changes dramatically affected the medicine-prescribing habits of INNs. The increase in FDC prescription rates may align with the recommendations of the 2018 ESC/ESH guidelines. The proportion of total errors is estimated as low, but control mechanisms are needed to prevent them.

Surveillance for substandard and falsified medicines by local faith-based organizations in 13 low- and middle-income countries using the GPHF Minilab

This study evaluates the use of the Global Pharma Health Fund (GPHF) Minilab for medicine quality screening by 16 faith-based drug supply organizations located in 13 low- and middle-income countries. The study period included the year before the COVID-19 pandemic (2019) and the first year of the pandemic (2020). In total 1,919 medicine samples were screened using the GPHF Minilab, and samples showing serious quality deficiencies were subjected to compendial analysis in fully equipped laboratories. Thirty-four (1.8%) of the samples were found not to contain the declared active pharmaceutical ingredient (API), or less than 50% of the declared API, or undeclared APIs, and probably represented falsified products. Fifty-four (2.8%) of the samples were reported as substandard, although the true number of substandard medicines may have been higher due to the limited sensitivity of the GPHF Minilab. The number of probably falsified products increased during the COVID-19 pandemic, especially due to falsified preparations of chloroquine; chloroquine had been incorrectly advocated as treatment for COVID-19. The reports from this project resulted in four international WHO Medical Product Alerts and several national alerts. Within this project, the costs for GPHF Minilab analysis resulted as 25.85 € per sample. Medicine quality screening with the GPHF Minilab is a cost-effective way to contribute to the global surveillance for substandard and falsified medical products.

Tracer Pharmaceuticals Availability and Distribution Trends Prior to and During the Covid-19 Pandemic: A Comparative Study

Background

Coronavirus disease 2019 (Covid-19) has had an unprecedented impact on the health products delivery system. To maintain routine health services, tracer pharmaceuticals (TPs) should always be available and accessible in healthcare institutions. Thus, this study aimed to explore the influence of the Covid-19 on TPs availability and distribution trends in the context of the Covid-19 pandemic in Ethiopia.

Methods

An institution-based comparative study was undertaken on 25 TPs in the pharmaceutical supply agency. From the agency’s logistical data, we collated the amount of TPs ordered, received, and distributed, as well as the stock status, by using an observation checklist. The collated data were recorded in Microsoft Excel and transferred to SPSS for analysis. A frequency and percentage analysis were performed to evaluate the fill rate, product availability, and stock-out duration. A dependent t-test was used to compare if there was a significant mean difference in TPs distribution before and after the Covid-19 at a p-value less than 5%.

Results

Before Covid-19, 18 (72%) of the TPs were refilled above 80% of amount ordered. After the pandemic, however, the fill rate dropped to 48%. The availability of TPs during the Covid-19 was 60%. During the six months of Covid-19, the average stock-out duration for all TPs was 34.68 days, with Cimetidine 200mg/mL injectable (line-item fill rate = 0, days out of stock = 180 days) being the most stocked-out item. Tracer pharmaceuticals distribution before Covid-19 (M = 81,317, SD = 139,274) were significantly different after the pandemic (M = 60,212, SD = 94,966) at the 5% significance level (t (24) = 2.289, p = 0.031).

Conclusion

This survey reveals how Covid-19 has influenced service providers’ logistics systems. Following the pandemic, the line fill rate fell below half with a three-fifths availability of products. To effectively manage supply chain disruptions experienced in Covid-19 and beyond, the agency in collaboration with stakeholders should make an effort to enhance end-to-end inventory visibility, establish a resilient logistics system, strengthen domestic manufacturers’ capabilities, and develop contingency plans with supplying partners.

Extent of and Factors Associated with Self-Medication among Clients Visiting Community Pharmacies in the Era of COVID-19: Does It Relieve the Possible Impact of the Pandemic on the Health-Care System?

Background

Self-medication is one aspect of self-care that has been shown to benefit primary health care. When done correctly, it provides significant benefits to customers, such as self-reliance and cost savings. Inappropriate methods, on the other hand, such as incorrect self-diagnosis and therapy selection, can be disastrous. The COVID-19 pandemic context may benefit the community in easing the burden on the health system. There have been no studies conducted on this possibility in the context of COVID-19 in a selected area, hence the purpose of this study was to determine the extent of and factors associated with self-medication among clients visiting community pharmacies in west Harerghe, Ethiopia from June 1 to 30, 2020.

Methods

This institution-based cross-sectional study used a systemic random sample of 416 community-pharmacy clients. To collect data, face-to-face interviews were conducted using pretested semistructured questionnaires modified from established techniques. EpiData 3.1 was used to enter data and SPSS 24 for analysis. To determine factors associated with self-medications, bivariate and multivariate logistic regression analyses were performed. AORs with 95% CIs are used to report associations, and the level of significance was set at P<0.05.

Results

The proportion of people self-medicating was 73.6% (95% CI 69.2%–77.9%). Self-medications were significantly associated with age 18–24 years (AOR 9.28, 95% CI 3.56–24.21) and 25–34 years (AOR 3.54, 95% CI 1.35–9.27), Amhara ethnicity (AOR 1.72, 95% CI 1.01–2.94), current single status (AOR 0.28, 95% CI 0.15–0.51), government employment (AOR 0.31, 95% CI 0.12–0.82), and limited knowledge (AOR 2.31, 95% CI 1.40–3.79).

Conclusion

Three in four participants practiced self-medication in the era of COVID-19. Repetition was significantly associated with age, ethnicity, current marital status, type of occupation, and knowledge about self-medications. An alternative medical care–delivery system by all health-care providers and increasing community awareness should be promoted.