Research paper

Exploring and understanding Indian

Market (Covid supplies) in pandemic!

Context: Planning the unplanned! – Novel COV’19

(Assessing supply chain impact at unit level hospital having 250 +ve patients)

Purpose of study: Exploring and understanding Indian Market in COVID 2020 pandemic
and then balancing the demand supply gap of given unit as a sample.

Sample Study: Exhaustive and practical study done on the usages of essential covid supplies
i.e. Personal protective equipments (PPE) at COVID Unit, 250 bedded Hospital, Delhi NCR
from the month of April and May 2020.

Study Period: 2 months period and also data forecasted for entire year provided Corona virus
stays for that long. However, we wish that this pandemic ends or eradicate soon as possible.

Type of Study: Visits to covid storage supplies areas (2nd line). No patient interaction been
done in this study due to safety reasons. However, exhaustive and interactive feedback from
Doctors and nurses are taken and captured.

Concept used: TTR (Time taken to recovery) concept applied from reference books and
links used and given below. External guide support of Dr S. P. Reddy, Indian School of
Business is taken for this study.

SUBMITTED TO: SUBMITTED BY:

Ms. Manisha Dalal, Convener
& Ms Sapna, Co-ordinator
P.I.G., Govt College for Women,
Jind, Haryana
sapna3698@gmail.com
1. Mrs. Deepti Kalra (Asst. Professor)
Govt. College, Tigaon, Faridabad
Mb: 9818052005 deeptikalra_16@yahoo.com
2. Mr. Amit K Arora (Professor)
Max Institute of Medical Excellence (MIME)
Mb:9818033552,
amitkarora@maxhealthcare.com
Introduction and brief explanation of covid supplies market: As the corona virus disease
2019 (COVID-19) pandemic accelerates, global health care systems have become
overwhelmed with potentially infectious patients seeking testing and care. Preventing spread
of infection to and from health care workers (HCWs) and patients relies on effective use of
personal protective equipment (PPE)—gloves face masks, air-purifying respirators, goggles,
face shields, respirators, and gowns. A critical shortage of all of these is projected to develop
or has already developed in areas of high demand. PPE, formerly ubiquitous and disposable
in the hospital environment, is now a scarce and precious commodity in many locations when
it is needed most to care for highly infectious patients. An increase in PPE supply in response
to this new demand will require a large increase in PPE manufacturing, a process that will
take time many health care systems do not have, given the rapid increase in ill COVID-19
patients

In its current guidance to optimize use of face masks during the pandemic, the Centres for
Disease Control and Prevention (CDC) identify 3 levels of operational status: conventional,
contingency, and crisis. During normal times, face masks are used in conventional ways to
protect HCWs from splashes and sprays. When health care systems become stressed and
enter the contingency mode, CDC recommends conserving resources by selectively
cancelling nonemergency procedures, deferring non urgent outpatient encounters that might
require face masks, removing face masks from public areas, and using face masks for
extended periods if feasible.

When health systems enter crisis mode, the CDC recommends cancellation of all elective and
non urgent procedures and outpatient appointments for which face masks are typically used,
use of face masks beyond the manufacturer-designated shelf life during patient care activities,
limited reuse, and prioritization of use for activities or procedures in which splashes, sprays,
or aerosolization are likely. When face masks are altogether unavailable, the CDC
recommends use of face shields without masks, taking clinicians at high risk for COVID-19
complications out of clinical service, staffing services with convalescent HCWs presumably
immune to SARS-CoV-2 (severe acute respiratory syndrome corona virus 2), and use of
homemade masks, perhaps from bandanas or scarves if necessary.

A frequent proposal was to acquire PPE from existing supplies in non–health care industries
and settings such as construction, research laboratories, nail salons, dentists, veterinarians,
and farms, and redirect them to the health care system via charitable appeals, community
organizing, financial incentives, or government mandate. One endeavour is Project N95, a
national COVID-19 medical equipment clearinghouse to identify high-need regions and to
source and distribute PPE and other equipment where it is needed most.

Numerous proposals suggested sterilization of used PPE with agents ranging from ethylene
oxide, UV or gamma irradiation, ozone, and alcohol. There were also novel proposals such as
mask-fiber impregnation with copper or sodium chloride. These are not new ideas; work was
performed after prior viral epidemics to determine the feasibility of sterilizing PPE. Most
commenter’s acknowledged uncertainty about the effects of these sterilizing agents on the
structural integrity of PPE, and there is some evidence the fibers in masks and respirators that
filter viral particles can degrade and lose their efficacy with PPE reprocessing.

A few people advocated for use of positive pressure airflow helmets; proposals ranged from
creating devices from plastic bags insufflate using compressed air and nasal cannula tubing to
adoption of commercially available devices used in the welding industry. An advantage of
this approach is that by not relying on filters, positive airflow devices can be cleaned and
reused indefinitely.

Many proposals reflect an era when PPE was made of cloth and laundered. Health care might
be made greener if reusable PPE was employed where feasible. Cloth gowns and masks are
easily created and stored, and laundry capacity could easily be expanded by recruiting
commercial launderers that service hotels and other large organizations who currently sit idle.
Many contributors wrote of sewing masks, creating them out of clothing, using novel
materials to make them, and using cloth sleeves to extend the use of N95 respirators. As with
re-sourced material, most commenter’s acknowledged uncertainty about the ability of these
handmade solutions to filter infectious agents and weather repeated cleaning, although
common sense suggests they are better than no PPE at all.

Conservation of existing PPE is important, as recommended by the CDC. Some commenter’s

called for suspending practices that consume large amounts of PPE and are of uncertain
effectiveness, such as contact precautions for some infectious diseases, to free up
supplies. The idea of using HCWs who have recovered from clinical illness or who have
stayed healthy but test positive and are presumed immune and are no longer infectious is an
age-old and appealing solution. Hoarding of PPE and other supplies has occurred during the
current COVID-19 pandemic, and some proposals suggested rationing or controlling the
supply chain through limited, controlled allocation of supplies.

Sample survey key notes after (TTR) Time taken to recovery applied:

The first step in assessing the risk associated with a particular supplier is to calculate time to
recovery (TTR) for each of its sites under various disruption scenarios. We, from sample case
taken at Saket, developed a simple Survey to collect key data, including:

Sample case of PPE (Personal Protective Equipment) for COVID SCM planning for a 250
bedded hospital.

1 Supplier

 11 Site Locations
(City, region, country)
09 – Delhi, NCR, India
01 – Mumbai, MH, India
01 – Germany, GbH.

2 Parts from this site

 Part number and description – Known.

 Part cost – VEPR known and defined part wise in HIS
 Annual volume for this part – 2 months data known with volume
 Inventory information - Known
(days of supply) for this part
 Total spend (per year) – Extrapolated and known. 50-60 lakhs per
month for 150-250 bedded COVID unit.

3 End products:

 OEM’s end product (s)
That uses this part.
 Profit margin for the end product(s) 25%
PPE Coverall, Fluid Shield mask, Sterile
Gloves, Goggles, and surgical masks 3 ply, 1
N95 mask.

4 Lead Times form supplier site to OEM Site

 Days – Local 5 days, National 10 days, International
– 15 days.
 (Days of supply) for this part. M, T, W, T, F – 5 days a week.
5 TIMES TO RECOVERY (TTR)

The time it would take for the site to be restored to full functionality

 if the tooling is lost – The TTR would be 2 days if unit level to be restored and
this would be from CMS (Central medical store).

6 COST OF LOSS

Is expediting components form other locations possible? If so, what is the cost? PRICE
VARIATION impact by more than 15% if in urgency purchased from other sources.

 Can additional resources (Overtime, more shifts, and alternate capacity) be organized
to satisfy demand? If so, what is the cost?
a) Cost of overtime – Rs 1.5 Lakhs per month.
b) Cost of stock holdings – 20% of ICC of Rs 50 Lakhs = Rs 10 lakhs per unit

7 SUPPLER’S RISK ASSESSMENT

 Does the supplier produce only from a single source? No – Varied sources
 Could alternate Vendor4s Supply the part? Yes – Various sources
 Is the supplier financially stable? Yes but stressing on advance
policy.
 Is there variability in performance (lead time, fill rate, quality)?
Yes 2/11 vendors reported
variability in performance.

8 MITIGATION STRATEGIES FOR THIS SUPPLIER PART COMBINATION

 Alternate Suppliers – <11 diff sources.

 Excess Inventory – <10 days inventory.
 Other – 01 Central Warehousing provision kept despite inventories at Unit level.

These scores and all comments are insightful, many have references, provide links to
websites and videos with illustration and instructions, and readers should spend time
determining which, if any, might best fit their needs and situations. But the ingenuity
displayed in the contributions needs to be placed in context. First, few of the ideas can be
successful independent of the broader health care enterprise and its vulnerabilities. The
commonly suggested process of cohorting low-risk patients for PPE preservation, for
example, requires rapid testing to be accurate and efficient; a requirement regrettably not yet
met in most US health systems. More important, PPE shortages are a problem for HCWs, but
not a problem HCWs are trained to address or should be expected to solve; it’s become cliché
to point out that fire-fighters are not asked to source their own equipment before entering
burning buildings. Hospital administrators, health system media relations departments,
university leadership, elected officials and government agencies have a role to play in
reaching out to suppliers and organizing a response and develop a reliable supply system.
Hospitals successful at procuring supplies should employ rational use of PPE. Better-
resourced institutions and some clinician advocates have considered policies requiring all
staff to wear face masks in public spaces regardless of high-risk exposures, despite little
evidence that this is a judicious use of resources.

Actions taken to expand the service levels and also monitoring the trends during
COVID times ensuring motive of being VOCAL ABOUT LOCAL is as follows:

1. Make or buy decisions: In these tough times, wherein many companies are re-thinking
on their strategic plans, make or buy decision to be carefully crafted again. E.g. taking the
basic action on commonly-used 3-ply, 2-layer surgical masks where the impact on
financial can be enormous for us.

The surgical masks during COV’19

increased from Rs 0.67/- to whopping Rs
5.25/- per mask. However, this in-house
decision to make masks from HP WRAP
SMMMS having AN EN ISO 13485:2016
certified company costs around Rs 3.5/- per
mask. The production in house started from
100 masks per day to 1000 qty from just 2
manpower only.

Impact:
a. Reduced cost against volume.
b. Savings to Unit Hospital as well as entire PAN-MAX units.
c. Assurance of uninterrupted supply chain by having more 1 option.
d. Boost for internal employees for showing INTRAPRENEURIAL skills and
innovations.
2. Product consumption control: During the scarcity of COVID supplies wherein
everything majorly is outsourced and seldom MAKE IN INDIA; the companies to start
adopting control techniques as well. For e.g. we did
experiment using sanitizer dispensing spray
technology in Handrub bottles by replacing the
caps by nozzle. The new nozzle is being used.

Impact:
1. Reduced consumption and better control.
2. Savings by 60% i.e. tune of Rs 5 lakhs
per month per unit.
3. Longer usages and less logistical
movements.
4. Organizational benefits in this tough time
of cost and expenses.

3. Optimizing Quality: The current PPE used

comprising of 6 components which was suddenly stopped by vendors due to non-
availabilities issue. This gave us the opportunity to source these 6 components separately
from different vendors. The new process now is:

Step 1: Insertion of coverall suit.

Step 2: Insertion of Goggles.
Step 3: Insertion of sterile gloves.
Step 4: Insertion of fluid shield masks.
Step 5: Insertion of long shoe covers.
Step 6: Testing and quality re-check with
sanitization of kit.

Impact:
a) Sourcing best quality.
b) Reduced cost of PPE from Rs 950/-
to Rs 550 to Rs 650/- per kit.
Savings of Rs 8 lakhs p.m. per unit.
c) Organizational benefits in this
tough time of cost and expenses.

4. Forecasting tool: We started using forecasting tool based on the LIVE data collected and
number of COVID patients admitted plus suspected. It is based on the linear
programming and probability of upward growing trend.
Summary: Total of Sr 1-4 financial savings tabulation (taking sample PPE & others
initiative):

Sr Nomenclature Existing Volume New Volume Savings per annum

Rs
1 Make or buy 120000 qty x 5.25/- 120000 qty x 3.5/- 25.20 Lakhs per
decision = 630000 per = 420000 per annum
month month
2 Product control 11 lakhs per month 06 lakhs per month 60.00 Lakhs per
annum
3 Cost optimization 950 x 8000 per 650 x 8000 per 288.00 Lakhs per
and bargain savings month month annum
4 Forecasting ICC cost 950 x 8000 per 650 x 8000 per 57.60 Lakhs per
month month annum
Total Savings p.a. Rs. 430.80 Lakhs
p.a.
The savings is calculated on 2 months actuals (April and May 2020) and 10 months
extrapolated if COVID remains. However, we pray that this doesn’t remain so far with us 

NATURE INITIATIVES: Not only the financial savings, we did a lot of work involving
environment and nature impact of going back to basics. EARTHING BASICS were applied
here. Watch this movie when free

https://www.youtube.com/watch?v=44ddtR0XDVU

The movies talk about that human beings are and must always connected to mother earth. If
any person, talks for around ½ to 1 hour BAREFOOT daily connecting him or herself with
mother earth; then the NEURONs get charged and healing takes place by its own.

We did personally experiment this on my hospital colleagues who got COVID +ve and
found enormous difference in their healing. For e.g. Mr Sandeep (full name not
disclosed) got +ve 10 days back and after daily walking barefoot early morning at sharp
6 am; now today he got his result as –ve and fit to work. Of course, he did adhere to his
medications, diet, and exercise regularly and on time.

This brings a different dimension altogether in saving human life via connecting and
sourcing back to nature.

Concluding remarks: When health systems pass this stress test, the
operations, organizations, and profession will have learned a thing or
two, and be stronger for it.
References: Guidelines from Ministry of Health and Family Welfare:

Ministry of Health and Family Welfare

Directorate General of Health Services
[Emergency Medical Relief]

Novel Coronavirus Disease 2019 (COVID-19): Additional guidelines on rational use of Personal
Protective Equipment (setting approach for Health functionaries working in non-COVID areas)

1. About this guideline:

This guideline is for health care workers and others working in Non COVID hospitals and Non-COVID
treatment areas of a hospital which has a COVID block. These guidelines are in continuation of
guidelines issued previously on ‘Rational use of Personal Protective Equipment’
(https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf). This
guideline uses “settings” approach to guide on the type of personal protective equipment to be
used in different settings.

2. Rational use of PPE for Non COVID hospitals and Non-COVID treatment areas of a hospital
which has a COVID block

The PPEs are to be used based on the risk profile of the health care worker. The document
describes the PPEs to be used in different settings.

2.1. Out Patient Department

S.No. Setting Activity Risk Recommended PPE Remarks

1 Help desk/ Provide Mild risk Triple layer Physical distancing

Registration information to medical mask to be followed at all
counter patients Latex examination times
gloves
2 Doctors Clinical Mild risk Triple layer No aerosol
chamber management medical mask generating
Latex examination procedures should
gloves be allowed.
 3 Chamber of Clinical Moderate N-95 mask Aerosol generating
Dental/ENT management risk Goggles procedures
doctors/ Latex examination anticipated.
Ophthalmology gloves
doctors
+ face shield Face shield, when a
splash of body fluid
is expected
4 Pre- anesthetic Pre-anesthetic Moderate N-95 mask * Only
check-up clinic check-up risk Goggles* recommended when
Latex examination close examination of
gloves oral cavity/dentures
is to be done
5 Pharmacy Distribution of Mild risk Triple layer Frequent use of
counter drugs medical mask hand sanitizer is
Latex examination advised over gloves.
gloves

6 Sanitary staff Cleaning Mild risk Triple layer

frequently medical mask
touched surfaces/ Latex examination
Floor gloves

#All hospitals should identify a separate triage and holding area for patients with Influenza like
illness so that suspect COVID cases are triaged and managed away from the main out-patient
department.

2.2. In-patient Department (Non-COVID Hospital &Non-COVID

treatment areas of a hospital which has a COVID block)

S.No. Setting Activity Risk Recommended PPE Remarks

1 Ward/individual Clinical Mild risk Triple layer Patients stable.

rooms management medical mask No aerosol
Latex examination generating
gloves activity.
2 ICU/ Critical care Critical care Moderate N-95 mask Aerosol generating
management risk Goggles activities performed.
Nitrile
examination
gloves

+Face shield Face shield, when a

splash of body fluid
is expected
3 Ward/ICU Dead body Low Risk Triple Layer
/critical care packing medical mask
Latex examination
gloves
4 Ward/ICU/ Dead body Low Risk Triple Layer
Critical care transport to medical mask
(Non-COVID) mortuary Latex examination
gloves
5 Labor room Intra-partum care Moderate Triple Layer Patient to be
Risk medical mask masked
Face shield in the Labor room
Sterile latex gloves

N-95 mask*

*If the pregnant

woman is a resident
of containment zone
6 Operation Performing Moderate Triple Layer Already OT staff
Theater surgery, Risk medical mask shall be wearing
administering Face shield
general (wherever
anaesthesia feasible)
Sterile latex gloves

+ Goggles For personnel

involved in aerosol
generating
procedures

N-95 mask* *If the person being

operated upon is a
resident of
containment zone
7 Sanitation Cleaning Low Risk Triple Layer
frequently medical mask
touched surfaces/ Latex examination
floor/ changing gloves
linen

2.3. Emergency Department (Non-COVID)

S.No. Setting Activity Risk Recommended PPE Remarks

1 Emergency Attending Mild risk Triple Layer No aerosol

emergency cases medical mask generating
Latex examination procedures are
gloves allowed
2 Attending to High risk
severely ill of PPE (N-95
patients while mask, coverall,
performing goggle, Nitrile
aerosol generating examination
procedure gloves, shoe
cover)

2.4. Other Supportive/ Ancillary Services

S.No. Setting Activity Risk Recommended PPE Remarks

1. Routine Sample collection Mild risk Triple layer

Laboratory and transportation medical mask
and testing of Latex
routine examination
(nonrespiratory) gloves
samples
Respiratory Moderate N-95 mask
samples risk Latex
examination
gloves
2 Radiodiagnosis, Imaging services, Mild risk Triple layer
Blood bank, blood bank medical mask
etc. services etc. Latex
examination
gloves
3 CSSD/Laundry Handling linen Mild risk Triple layer
medical mask
Latex
examination
gloves

4 Other Administrative Low risk ** Engineering and

supportive Financial dietary service
services incl. Engineering** and personnel visiting
Kitchen dietary** treatment areas will
services,etc. wear personal
protective gears
appropriate to that
area

2.5. Pre-hospital (Ambulance) Services

S.No. Setting Activity Risk Recommended PPE Remarks

1 Ambulance Transporting Low risk Triple layer

Transfer to patients not medical mask
designated on any Latex examination
hospital assisted gloves
ventilation
Management of High risk While performing
SARI patient of PPE (N-95 aerosol generating
mask, coverall, procedure
goggle, latex
examination
gloves, shoe
cover)
Driving the Low risk Triple layer Driver helps in
ambulance medical mask shifting patients to
Latex examination the emergency
gloves

Points to remember while using PPE:

 1. Standard precaution to be followed at all times
2. PPEs are not alternative to basic preventive public health measures such as hand
hygiene, respiratory etiquettes which must be followed at all times.
3. Always follow the laid down protocol for disposing off PPEs as detailed in infection
prevention and control guideline available on website of MoHFW.

In addition, patients and their attendants to be encouraged to put on face cover.

In case a COVID-19 patient is detected in such Non-COVID Health facility, the MoHFW guidelines
for the same has to be followed (Available at:

https://www.mohfw.gov.in/pdf/GuidelinestobefollowedondetectionofsuspectorconfirmedCOVID19
ca se.pdf)

SUBMITTED TO: SUBMITTED BY:

Ms. Manisha Dalal, Convener
& Ms Sapna, Co-ordinator
PIG, Govt College for Woman,
Jind, Haryana
sapna3698@gmail.com
1. Mrs. Deepti Kalra (Asst. Professor)
Govt. College, Tigaon, Faridabad
Mb: 9818052005 deeptikalra_16@yahoo.com
2. Mr. Amit K Arora (Professor)
Max Institute of Medical Excellence (MIME)
Mb:9818033552,
amitkarora@maxhealthcare.com