Practical suggestions to overcome hurdles in supply chain management which created unsurmountable problems for the administrative and medical communities during the second wave.

An efficient supply chain enabled by state of the art technology is an important part of any industry or government. It is critical to operations of any organisation including the healthcare sector. Recent challenges to the healthcare system including deficiency of Oxygen in India highlighted how a fragile Supply Chain can result in a national health emergency with international ramifications. It is often said that ‘every crisis offers an opportunity’. Therefore, it would be prudent to draw lessons from this crisis to work out an effective healthcare supply chain for the country.

Causes of the Current Crisis

While the healthcare experts are best placed to analyse medical issues which resulted in the present healthcare crisis during the second wave, one of the important reasons which caused shortage of Oxygen was failure of the supply chain. Existing healthcare supply chain in India runs as an unorganised sector and operates in an adhoc manner on as required basis.

The main cause for shortage of Oxygen which left people gasping for breath was failure of the supply chain. While analysing the entire supply chain from manufacturers to the end users (hospitals) it is evident that there was adequate availability and provisioning despite the galloping demand. It goes to the credit of the union government that immediate orders were passed to divert Oxygen from industrial to medical use. This ensured that there was no shortage of Oxygen at the national level.

However, the crisis occurred due to inefficient transportation and distribution of Oxygen. In India, most of the Oxygen plants are co-located with the steel plants which are situated in eastern part of the country in states like Jharkhand and Orissa. Consumption centres (hospitals) are located all over the country in population centres. Travel time to some of them could be a couple of days to a week by an Oxygen load carrier. During normal times when the demand for Oxygen is steady and predictable, transportation resources deployed and the resultant turnaround time to meet the demand is satisfactory. However, these resources were grossly inadequate when the demand increased exponentially in a noticeably short duration.

Since the sources of Oxygen were located far away, there was a need to create local resources in the form of Oxygen generators within the premises of the hospitals. Despite instructions by the union government in Oct 2020 to establish almost 500 Oxygen generation plants, the follow up action to establish the same was not undertaken. Had this been implemented, Oxygen shortages would have been easily overcome. There was simply no resource audit to take corrective action.

Nevertheless, to minimise the adverse impact of Oxygen shortages strict monitoring of distribution to prevent hoarding and black marketing was imperative. There was a need for better synergy and crisis management skills to reduce the impact. Coordination and communication with the stakeholders and citizens would have helped scotch rumours and prevented panic.

Way Ahead

An effective and efficient supply chain must be reliable, have the required agility to cater for unforeseen contingencies besides meeting the routine requirements. While putting in place a supply chain, movement of stores should take place as composite loads and not through dedicated supply chains for each sector.  Hence the need to integrate it with the national and global supply chain. In the current business environment, besides transportation, the stake holders need real time information on production, warehousing and location of the consignment through tracking systems.

Some of the suggestions are :-

Data Bank of Resources.  There is a need to create a data bank of all available healthcare resources including those in the pipeline. Details of manufacturers and distributors of all healthcare items must be documented. Capacity of each source and their ability to surge capacity in emergent situations must be obtained and continuously updated. Information about sources of critical components or drugs from other countries must be uploaded on this platform. Preparation must be made by having standing operating procedures (SOPs) and coordination exercises with concerned authorities.

Mapping and Digital Network.  All medical resources and the consumers (Hospitals) must be mapped to create a digital network which will ensure transparency, speed in communication, decision making and its implementation. The resource mapping should include manufacturers of Oxygen, medical instruments and drugs with capacity and location, transportation resources, warehouse locations with storage capacity, distribution centres and their capacity. Monitoring movement of stores, warehousing and distribution must be automated and an integrated dashboard which must be available to the concerned authorities.

Communication and Coordination. Multiple means of Communication will enhance reliability and asset visibility in the supply chain and ensure effective coordination between all stakeholders. This will go a long way in ensuring an efficient and effective supply chain as also restore confidence of the affected population.

Turnaround.  Means of transport and turnaround time must be constantly reviewed and bottlenecks that impede movement must be addressed. Mechanical loading/ unloading or transfer from bulk to retail packaging would enhance efficiency. Providing additional drivers and staff to man the load carrying vehicles and distribution facilities round the clock will also improve the output during a crisis. Another method of reducing the turnaround time is to use transportation model to find the fastest routes and means to connect manufacturers to consumers.

Multi modal Transportation.  Ingenuous methods including ‘Roll on Roll off’ with tankers loaded on trains besides ships and cargo aircrafts keeping in mind the technical and safety restrictions can help build capacity and velocity in the supply chain. Nationwide green corridors to expedite movement need to become a norm during this crisis.

Transparency in Distribution. Distribution, if systematically implemented, can offset the shortages to large extent. Distribution must be very strictly monitored and micromanaged at appropriate levels to ensure efficiency, thus preventing panic. By using technology, each Oxygen cylinder or medical equipment/drugs can be monitored by using RFID or similar technologies. A well-organized system must operate in an institutionalized manner and discretion must be minimized. Total transparency in distribution to win over confidence of the citizens must be ensured. Wastage, hoarding or black marketing must be strictly dealt with.

Mobile Clinics and labs for Rural Healthcare. It may not be viable to create state of the art healthcare infrastructure with specialists in rural areas where the number of patients during normal times are not enough to deploy so many doctors. To meet the challenges of emergencies or pandemic, it is important to cater for rural areas through ‘in situ’ healthcare support by deploying mobile clinics/ laboratories which can deliver basic healthcare at the door steps of the rural population.

Reserves. A national policy regarding holding of reserves at appropriate levels based on the number of beds in a hospital must be implemented. All the hospitals in the country having more than 100 beds should be mandated to have captive non-cryogenic Oxygen generating plants viz; Pressure Swing Absorption (PSA)/ Vacuum Swing Absorption (VSA) within their premises. Emergency purchase and procurement procedures especially with the government agencies must be simplified to speed up procurement. Healthcare is a critical sector for the country. Therefore, the supply chain and reserves may have to operate on the principle of ‘just in case’ which gives higher assurance levels than ‘just in time’ which is economical. Like in the military, the supply chain for healthcare should operate on ‘Push Model’ in which the frontline establishments do not have to look over their shoulders for stocks.

Contingency Planning. In order to plan for future emergencies, it is pertinent to be prepared for various medical contingencies. Healthcare authorities must wargame likely future scenarios and plan for them in a scientific manner seeking inputs from experts. Decisions taken by the authorities must be followed up and implemented to minimize adverse effects of any future pandemic or surge of the existing one. Lessons must be learnt from adverse situations so that the same are not repeated. Periodic emergency drills will help the healthcare sector to be better prepared to meet the future pandemic like situations. Remember, the next crisis will generally not be the same as last one.

Balancing Healthcare Resources.  Keeping the industrial and environment factors in mind, Oxygen manufacturing units must be set up throughout the country especially at locations where voids exist. An Oxygen grid must be created so that Oxygen is available to all hospitals of the country within a reasonable turnaround time. It must be established on an economically sustainable model. Industry must be incentivized to produce Oxygen generators, concentrators and other healthcare resources indigenously

Use of Technology. Use of latest technology, a lot of which is available ‘off the shelf’ can transform the supply chain to make it effective and responsive. Consignment tracking on real time basis and information on availability of Oxygen/healthcare stores and drugs at various locations must be updated using latest technology to facilitate correct decisions and their implementation.

Supply Chain management is more about implementation than just planning as the acid test lies in delivering the right stores at the right place in right quantity at the right time. Success of supply chain often does not attract much attention during normal times but its failure is disastrous, be it war or healthcare sector.

Psycho Social Impact of the Pandemic

Rhea Sharma

Trauma felt by individuals and the Society. Certain Dos and Don’ts

As the COVID-19 crisis continues to evolve in India with a second wave, stories and data from across the country have indicated high levels of psychological distress and huge gaps in ability to access healthcare and mental health services through the pandemic. This will further intensify the mental health crisis we were already facing in India.

The burden of mental illness in India has been studied and reported on extensively, with the latest report by the World Health Organization (WHO) estimating that approximately 20 percent of India’s population will suffer from mental illnesses by the end of 2021.

India’s National Institute of Mental Health & Neurosciences (NIMHANS) suggested in their country wide mental health survey, that this prevalence rate is much higher with 150 million individuals requiring mental health interventions and care, both short term and long term. This number is alarming enough on its own, without taking into consideration that the study excluded children and adolescents. We are home to the largest adolescent population in the world, with mental health conditions being among the leading causes of disability among adolescents, and suicide being the number one cause of death among young people.

Impact of Covid on Mental Health on Individuals/Societal level Across Age Groups

The COVID-19 pandemic has had an immediate and deep impact on the mental health of people across their life course, with different age groups being affected in different ways.

Starting with young children in the age group of 0-5 years and going up till old age; some common key issues are isolation, loss of loved ones, being impacted by stress (parental, school, job and financial, relationships, and career stress), coping with significant changes to routine, difficulty in accessing support networks, healthcare and fear of COVID-19.

There are a range of harmful impacts both in the short to long-term. In the short-term (for the duration of the pandemic), people of different age groups may experience the following:-

►           Anxiety, worry and fear due to concerns about the pandemic and risk of infection;

►           Depression, low mood and loneliness due to self and mandatory isolation and social distancing, lack of exercise, loss of routine, added pressure of caring for self/loved one;

►           Stress caused by changes to daily life;

►           School, work, relationships, adjusting to new routines and financial insecurity;

►           Risk of suicide and self-harm, physical, sexual and verbal abuse, especially if in isolation/lockdown with an abusive person;

►           Stigma for those who have contracted the virus.

In the medium-long term (two years or longer), there is likely to be an additional burden of mental health problems. Medium term issues may include:-

►           Heightened stress, anxiety, depression exacerbated by the pandemic’s impact in the 2nd wave,

►           Isolation, feeling of loneliness,

►           Loss of hope and motivation,

►           Uncertainty about the future,

►           Increased risk of suicide and self-harm,

►           Breakdown of relationships,

►           Grief due to the loss of a loved one to the pandemic,

►           Previously experienced mental health problems reoccurring,

►           Worsening of other health conditions and emotional well-being,

►           Behavioral issues in children and young people caused by isolation and changes in routine,

►           Development of mental health disorder.

At a societal level the consequences have meant an increased demand and cost to government and non-government services, stressing an already strained healthcare system, economic consequences to the workplace due to employees mental health being affected and the exceedingly high death toll causing generational and intergenerational trauma.

Adding to the already fragile landscape of mental health needs in India has been the Government’s response. The 2021 budget dedicated less than 01 percent (0.8 percent to be exact) of the total budget allocated to the Ministry of Health and Family Welfare(MoHFW) towards mental health. Of this mental health fund, 93 percent was received by only two major mental health institutions in the country. A meagre 7 percent was allocated to the National Mental Health Programme, with 500 crores and 57 crores going to NIMHANS in Bangalore and Lokpriya Gopinath Bordoloi Regional Institute of Mental Health(LGBRIMH), Tezpur respectively.

Way forward

With this being the current situation for mental health, the current situation and way forward seems bleak, but there are measures that can and must be taken; and these ought to be preventive and proactive, not curative or remedial, if we are to prevent a mental health epidemic of the same intensity as the pandemic we are currently grappling with.

We need increased investment towards mental health that will support the development and implementation of evidence based mental health interventions that target the entire population as well as support the creation of adequate, licensed training programs to train different levels of mental health service providers such as non-specialist health workers, so that the burden is lifted from specialists.

The government needs to have mental health equity in mind when planning for the future, as these inequalities in mental health will exacerbate the risk for certain at-risk communities and people already impacted by Covid-19.

Everyone has a right to good mental health and investing in it implies an investment in yourself and everyone around you.

Rhea Sharma is a Psychologist specializing in young people’s mental health and is currently an Intervention Director at SANGATH