Creating Sex/Gender-Responsive Health Supply Chains: COVID-19 Reminds Us Again
By Lynn Lieberman Lawry, Senior Gender Advisor, and Emmanuel Nfor, Technical Director, USAID MTaPS
The COVID-19 pandemic has highlighted historic inequities in access to medicines and health technologies in low- and middle-income countries. While amassing by richer countries can be to blame for inequitable access to Covid vaccines in resource-constrained settings, among other factors, supply chain management weaknesses, including nongender-responsive practices, can aggravate the access issue. Sex (biological factors), gender (socially constructed roles and behaviors), and authority all affect practices and decisions in the supply and distribution of medical products. COVID-19 has underscored the need for supply chain management practices to be sex and gender-responsive.
The US Agency for International Development (USAID) Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program provides technical assistance to help countries improve supply chain systems and supports Ministries of Health, donors, and supply chain stakeholders to design and implement resilient supply chain management solutions that lead to county-led initiatives and sustainable local capacity development.
Sex and Medicine Utilization
Sex matters in supply chain decisions
Sex-mediated factors (e.g., body weight, blood volume, and fat distribution differences between sexes) have biological effects on how medicines are absorbed, distributed, metabolized, and eliminated. For example, females require 22% less vecuronium, a neuromuscular blocker used for anesthesia, than males. With shortages of medicines for sedation during the pandemic, it is vital to understand the pharmacokinetic and pharmacodynamic sex differences and appropriately tailor procurement, allocation, and use of medicines needed to care for patients, especially those requiring mechanical ventilation.
Hormones also influence supply chain utilization
Low levels of testosterone in elderly males have been associated with upregulation of inflammatory markers, which creates an increased need for assisted ventilation. Although the reasons for higher COVID-19 mortality rates among males are multifactorial, hormones may play a role. More males on ventilators means higher quantities of sedatives required.
Medicine prioritization aggravates sex inequities in supply and access
Supply chain inequities go beyond the logistics of managing them to the inputs that inform what medicines are procured and how they are distributed.
The WHO’s essential medicines list (EML) is a guide for determining what medicines to fund, stock, prescribe, and dispense, but that doesn’t mean the EML is equitable with regard to medicine needs, decisions, or access. For example, 78% of the autoimmune disease population is female. Many of the top grossing medications that treat these disorders have a disproportionate effect on utilization and access for females who, globally, have less access to insurance coverage or the ability to pay for medicines. Many of the expensive but highly effective medications to treat autoimmune disorders are not on the EML, leaving only second-line medicines available.
Further, medicines that treat X-linked (thus mostly males) rare diseases, such as hemophilia, are not included in EMLs as they are unaffordable for many countries. The medicines used to treat these disorders are 25 times more expensive than traditional medicines and have had a 26-fold increase in prices over the last few decades, creating sex inequity in access, which can have dire consequences on their mortality.
COVID-19 created another sex-based access inequity as governments stockpiled hydroxychloroquine without documented evidence that it could treat COVID-19, which disproportionately affected females as the drug is used to treat autoimmune diseases that are more common in women.
Gender in the Workforce
Supply chain management issues also impact gender in the workforce inequitably. Globally, men make up the majority of physicians, dentists, and pharmacists in the workforce, and women make up 70% of the health care and social services workforce on the frontlines. They often serve without adequate personal protective equipment (PPE) against epidemics and pandemics while also acting as caregivers for those who become sick at home.
One size does not fit all
The majority of PPE that is available is designed for men, leaving women with poorly fitted PPE, especially oversized gloves, goggles, and masks. Men and women are impacted differently by shortages, especially when women have less bargaining power with mostly male administrators, which may contribute to unequal distribution of PPE. Gendered impact on supply has deadly consequences—during this pandemic and in Ebola outbreaks, PPE shortages are a contributing factor to infections and deaths of thousands of health care workers.
Tyranny of the Urgent
Tyranny of the urgent is where nonurgent, normal primary care is deprioritized due to an urgent/emergent situation, which has significant gender impacts. For example, the reproductive health needs of pregnant individuals suffer during pandemics and epidemics. Production delays and backlogs, crowded shipping lanes, slow customs clearance, and lack of transportation have all contributed to medical stock-outs, including disruptions to family planning and contraceptive services for 12 million women during the current pandemic. These stock-outs resulted in an estimated 1.4 million unintended pregnancies worldwide.
An increase in gender-based violence, especially during the pandemic, and subsequent sexually transmitted diseases among women, men, and sexual and gender minorities (SGMs) and global shortages of antibiotics increases the risk of undertreatment; self-treatment; and antimicrobial resistance, especially among women.
Tyranny of the urgent affects SGMs disproportionately, including through supply chain interruptions for HIV and TB treatment, pre-exposure prophylaxis, and time-sensitive puberty suppression for gender-affirming care and transition.
What Does All This Mean for Supply Chain Management?
Understanding how nonsex- and nongender-responsive supply chains create access inequities and inefficiencies in times of crises and addressing those gaps is paramount to ensuring that supply chains are equitable to limit morbidity and mortality.
Practical Suggestions for Sex- and Gender-Responsive Supply Chain Management:
Data
Collect and analyze accurate sex/gender/age-disaggregated data, which are crucial for supply planning and forecasting to ensure that the right quantities of medicines are forecasted and made available for equitable distribution and use.
Where possible, use electronic health information systems that enable more accurate and timely forecasting and supply planning and incorporate sex and gender considerations.
Training
Train the workforce on sex and gender nuances in supply and distribution to allow early recognition of inequitable access. With training, administrators will be more aware of the disproportionate effects of supply inequity and the need for equitable distribution.
Guidelines
Create and implement guidelines and plans that designate medicines (e.g., family planning) as essential services for forecasting, procurement, customs clearance, transportation, and distribution to improve the equity and resilience of supply systems.
Implement guidelines that allow supply chain process adjustments during crises, such as dispensing a three-month supply of contraceptives, HIV medicines, and other essential commodities to limit inequitable sex and gender impacts.
Innovation
Practice service delivery innovations such as prepositioning stock closer to those at risk and finding ways to deliver remotely.
Leverage new programs for informed decision-making like D-RISC to ensure equitable distribution of medicines and commodities.
Broad stakeholder engagement
A holistic pharmaceutical systems approach that addresses inequities in medicine prioritization as inputs into the supply chain is essential to enable sex- and gender-responsive supply chains. Broad stakeholder engagement can help achieve this.
By linking sex and gender-disaggregated data to decisions on medicine prioritization, procurement, forecasting, supply planning, and distribution, countries can stem the fallout from the tyranny of the urgent and avert stock-outs of essential medications and products that inequitably affect sex- and gender-vulnerable populations.