Laboratory services are an often under-recognized, yet vital component of any health care system. Though the impact of these services goes unseen for the vast majority of patients, it is estimated that about 75% of clinical decisions in general hospital services are guided by laboratory findings [1]. Studies also suggest that laboratory costs account for less than 5% of health system costs but in turn affect the remaining 95% of costs [2]. In simple terms, a proper investment in laboratory service provision is a low-cost way to improve health outcomes many times over. Health care laboratories working as part of healthcare delivery can not only generate revenue to cover their own costs, but also generate surplus revenue to cover other hospital needs. Improving funds utilization through appropriate and timely evidence-based treatment, cutting back on unnecessary hospitalization, and reducing antibiotic resistance are just some examples of the positive outcomes that can result from well-placed investment in laboratory services.
One of the most important factors in guaranteeing that health care providers and their patients have regular access to laboratory services is a reliable health care supply chain system. Faulty supply chain systems can lead to suboptimal treatment and increased hospital stays due to unavailability of needed medicines and diagnostics.
What is a health care supply chain system?
A health care supply chain system covers the entire flow of health-related supplies from manufacturer to end user. It involves everything surrounding the acquisition, management, and delivery of these health supplies and commodities from manufacturers, purchasers, governments, regulatory bodies, insurance companies and providers [3]. A suitable health care supply chain system works to serve the satisfaction of both health care workers and their patients.
However, like any complex system with many moving parts, health care supply chain systems are often extremely bureaucratic since they are subject to rigorous regulatory procedures at all stages including the identification, shipping, and delivery of supplies. Unfortunately, delays are common. Without the supplies necessary to collect samples and make accurate and timely diagnoses, the entire health system is stopped in its tracks early in the chain, creating what are known as bottlenecks.
In some situations, despite the availability of laboratory supplies, patients have not been able to get the required services when laboratory practitioners do not have the minimal required personal protective equipment (PPE) such as gloves and surgical face masks. In my work in Tanzania, I have seen how these deficiencies can have real-life consequences. In one laboratory, a stock out of gloves meant that patients had to buy their own pair in order to receive services which were otherwise free of cost. As a result, in at least one instance, a patient was turned away, unable to have their blood collected due to an inability to pay for the gloves.
While so many important medical decisions need a diagnosis, that is only possible if laboratories have all the supplies they need. In resource limited settings, that often is not the case, with reported stock outs and laboratory supplies not present in the places they are needed. Medical treatment based on signs and symptoms (clinical diagnosis) rather than a laboratory confirmed diagnosis is common practice. But errors can be made if a diagnosis is only clinical and based on signs and symptoms alone. A laboratory confirmed diagnosis ensures the accuracy of diagnosis, limiting the possibility of misdiagnoses or delayed diagnosis, and the unnecessary prescription of medications such as antibiotics, further leading to the spread of antimicrobial resistance (AMR). Additionally, laboratory customers such as clinicians and patients tend to lose trust when there is inconsistency in laboratory services provision.
There is also a notable disparity in access to laboratory services based on geographic location (urban vs. rural), level of a health facility (referral hospital, health center, or dispensary), and limited human resources. Even places that offer laboratory services can face serious supply chain challenges. Frequent stockouts interfere with a laboratory’s capacity to operate smoothly. Over quantification also happens when a laboratory requests more commodities than it needs which leaves other laboratories with less, wastes funds, and leads to commodities expiring on the shelves before they can be used. When availability of vital supplies required by health laboratories in developing countries is limited, several issues follow.
Top 5 Issues with the Current System & Proposed Solutions
1. Staff not well-oriented in supplies management
Experience from the field shows that many laboratories do not have a dedicated store manager, meaning that staff responsible for managing the laboratory stores are also responsible for their own day-to-day tasks. This creates difficulties for technicians to keep up with tracking supplies on top of their other duties. Staff are also not well-oriented on supply chain issues as it is not included in most college curricula.
The solution: Dedicated store staff and on the job training of laboratory technicians
A qualified storekeeper is necessary and can help with day-to-day activities but would need to work under close supervision of a laboratory expert who understands safety, consumption trends, and storage conditions for laboratory supplies. These staff can be assigned with other duties, but their primary role should be managing commodities to avoid inventory management falling on staff who are busy with their own duties.
If the hiring of a store manager is not feasible, the laboratory technicians who are custodians of the supplies they use in day-to-day activities also need to be trained on inventory management and other supply chain related issues. Through regular trainings and mentorships, these laboratory professionals will better understand how to manage their supplies. If supply chain management is codified into their duties and other activities on their plates slightly reduced, they will also have the bandwidth to do so effectively.
2. Weak inventory management systems
Above all, a strong health supply chain management system depends on accurate and timely inventory management data. Most laboratories do not have electronic logistics management systems that can validate and cross-check entered data, though the systems are sometimes designed to give an alert in real-time when stock is about to run out or expire. The most common system used in health facilities is paper-based logistic tools such as ledgers and bin cards which are then used to feed monthly data to national databases. From my experience in Tanzania, primary health facilities do not have direct access to the national logistics database and therefore send their paper-based data to their district coordinators for entry into the national database. These paper-based data from the primary health facilities are prone to human error and may misrepresent the actual needs, leading to overstocking or understocking in some of the facilities during supplies prediction, procurement, and distribution.
The solution: Deployment of a national logistics management database.
Digital health solutions— such as digital tools for reporting disease outbreaks or SMS reminders for patients to remind them to attend their appointments or pick up their prescriptions— are becoming increasingly critical to the success of strong, modernized health systems. Therefore, it is no surprise I recommend that primary health facilities which also provide data for predicting consumption should use electronic systems. Direct access to these systems increases accountability and ownership of the data and the entire process of estimating supplies needed based on the data entered.
Using mobile phones, health care providers can report their stock status which will directly be logged into the main database and reflected in the national dashboard. This reduces errors and data incompleteness that are likely contributed by paper-based systems. There are many ways to make such an electronic system accessible and user-friendly. In Tanzania, telecommunication companies provide unstructured supplementary service data (USSD) codes for individuals to dial on their smartphones to access a variety of services, like making payments for water or electricity bills. This same technology has been advanced to use in health care, and could be implemented in a laboratory setting by dialing USSD code numbers dedicated for outbreaks, stock status, and other parameters. While deploying technology to enhance old systems is a good idea in the abstract, rolling out use of this database should be a step-by-step process to address operational challenges such as potential network and connectivity issues.
3. Seasonal complications and infrastructural challenges
Most supplies are delivered by road. When roads are not passable during the rainy seasons (25% of the time in some countries) for example, supplies cannot be delivered. In some cases, there are not enough vehicles for supplies distribution, further increasing delivery times.
The solution: Request enough buffer stock to cover seasonal complications.
Central stores need to liaise with facilities located in remote areas so that they can be given special consideration to order more supplies than others. This additional amount, known as buffer stock, will help the health facilities— including the laboratories— to have enough supplies even with seasonal infrastructure challenges.
Reverse supply chain is also a solution among laboratories. This is a process where facilities with enough stock redistribute some to those with low or no stock. This process is also important for ensuring there is no wastage of supplies due to products reaching their expiration date without being used. Regional and district health managers are the key players in coordinating information across facilities and ensure redistribution plans are effective.
4. Lack of equipment and techniques standardization
As in normal life, it is easier to get a spare part for a vehicle that is widely used in a particular area due to high demand leading to high supply. In resource limited settings, most of the equipment and technologies available at the hospitals are sourced internationally, either bought by governments or donated by different stakeholders around the world. Due to the variety of donation sources, there is rarely one standardized make or model which is widely used in all facilities. Lack of standardization creates difficulties with the government to source suppliers when there is a need to do repairs, buy additional supplies, or change some parts. Government procurement agencies face challenges in getting all the required commodities from one source, and in most cases, are only able to supply a few items that can easily be accessed but may not be the exact item that is needed.
The solution: Standardization of laboratory equipment and techniques.
Standardization is a process whereby a country can decide to use certain type of equipment for specific tests; this helps with uniformity of testing and maintenance. Standardization also would make it easier to ensure that supplies are available for laboratory tests and bundled procurement programs can also save money as the costs of equipment and supplies may be less. For example, some countries decided that they will screen for malaria using rapid test kits and invest in that while reducing efforts of buying microscopes across the country. Recently, the Ministry of Health of Tanzania through the Medical Stores Department (MSD) partnered with a company to design MSD branded laboratory machines for blood tests (Hematology & Biochemistry). The machines are all over the country, specifically fitted for resource limited settings and can use supplies and reagents from any other supplier. Bulk procurement of common supplies from a single supplier is much easier and reduces costs compared to small procurement from multiple suppliers.
5. Unavailability of supplies at the national/central stores
Even with all systems within a laboratory functioning perfectly, there can also be stock outs at national stores. In most resource limited countries, national stores are responsible for procuring and distributing health supplies to all publicly owned facilities. The shortage may be due to shipping delays or global shortages caused by high demand worldwide, as most resource limited countries do not have manufacturing industries and must outsource. The global shortage of PPE when the COVID-19 pandemic was announced is a recent example.
The solution: Introduction of local, small-scale manufacturing companies.
Overdependence on developed countries for some of the basic supplies will continue to jeopardize health services provisions, particularly laboratory services. For example, in many developing economies, items like urine containers, stool containers, and wooden sticks which are used for basic laboratory procedures are all imported. There is need for political will and a call for investors to establish small-scale manufacturing industries for such items. This has proven to be possible especially during the COVID-19 pandemic where most resource limited countries started producing basic items like face masks. In Tanzania, there are now small industries for gloves, face masks and wooden sticks. In Kenya, some of the companies have entered into flagship agreements to produce some of the laboratory reagents while getting raw materials from the principal companies.
Conclusion
The supply chain is an essential backbone to allow access to comprehensive, affordable, and timely access to diagnostic services. The entire supply chain process not only focuses on what can be offered today at a certain hospital but can help predict and adjust for future needs. Reforms of health supply chain systems, especially in resource-constrained settings, is now more necessary than ever. While a well-functioning health care supply chain is always important, there is an urgent need to reform the system, so it is better aligned to support emergency response efforts to global pandemics like COVID-19. Reforms such as those recommended above, need to be coupled with sustained financing to provide the funds needed to ensure an effective and full-coverage supply chain system; this should be viewed as an investment in the health of the country. While fixing global and national supply chains may seem daunting, starting with locally led solutions— training and supporting laboratory staff, working with national health care systems to standardize technologies and commodities required to service them, and investment in local manufacturing of supplies— could go a long way towards building robust and sustainable health care systems in the communities they are needed most.
References
[1] Beastall, G. H. (2013). Adding value to laboratory medicine: a professional responsibility. Retrieved April 6, 2022, from http://eprints.gla.ac.uk/75419/1/75419.pdf
[2] Hallworth, M. J. (2011). The ‘70% claim: What is the evidence base? Annals of Clinical Biochemistry. https://doi.org/10.1258/acb.2011.011177
[3] Arora, M., Gigras, Y. (2018). Importance of Supply Chain Management in Healthcare of Third World Countries. International Journal of Supply and Operations Management, 5(1), 101-106. doi: 10.22034/2018.1.7
