This is an excerpt from Medically Necessary, a health care supply chain newsletterSubscribe here.

The task: The recent surge of COVID-19 cases in India led to shortages of drugs, personal protective equipment and oxygen. The Indian government and health care providers reached out to organizations in the United States for help.

Daily COVID-19 cases in India peaked at about 400,000 in early May. The U.S. government has sent supplies worth $100 million to India, including drugs, oxygen and test kits. Many private companies have also donated supplies.

But getting those products to patients who need them requires an enormous amount of cooperation. Humanitarian aid leaders say working with trusted partners in the destination country is key.  

Step one in the health care supply chain for humanitarian aid is gathering information about what patients need, says Thomas Tighe, CEO of the nonprofit health care distributor Direct Relief.

“We do, basically, a market analysis. The commercial companies, their market analysis is, ‘What’s the commercial demand?’ … They don’t go looking for: ‘Who’s not going to buy our product?’” he told FreightWaves. “That’s where we start. … But we have to do it precisely.”

In May, Direct Relief shipped more than 3,500 oxygen concentrators on two flights donated by FedEx to a hospital system in India.

Often, those on-the-ground needs assessments come from partners that aid organizations already have a relationship with, according to Eric Cioe-Peña, director of the Center for Global Health at Northwell Health, a hospital system based in New York. 

“You really can’t just give money or give supplies blindly. It’s important to have these relationships, to know where the supplies are going, to know the information on the ground,” he told FreightWaves.

Northwell and the American Association of Physicians of Indian Origin recently coordinated the delivery of 1,000 oxygen concentrators to health care providers in India.

For the recent shipments to India, Direct Relief communicated with Tata Memorial Hospital, a large health system based in Mumbai the organization had worked with previously, to determine what to send. 

“It’s roughly akin to plugging into Kaiser. … They have a preestablished network. It’s not sending into a black hole,” he said. “They have far better current information than anyone from outside could.” 

Northwell received requests for supplies from the Indian Ministry of Health. The organization also worked with the American Association of Physicians of Indian Origin to identify specific health care providers that needed supplies.

Both Direct Relief and Northwell say they only send materials health care providers are requesting to avoid clogging up logistics networks. 

In 2010, Cioe-Peña went to Haiti to help with relief efforts after an earthquake. He remembers seeing lots of unneeded supplies, and he strives to make sure his organization doesn’t repeat those mistakes.

“Having 15,000 cans of corn is really a logistical problem for NGOs that are trying to get supplies that are actually needed,” he said.  

Gathering supplies: Organizations like Direct Relief or Northwell Health can use several different strategies to gather supplies. 

That includes asking for-profit companies to donate products or services, using the inventory they have on hand or simply using their privileged access to medical supplies to speed up the process.

The Indian Ministry of Health asked Northwell for help buying oxygen concentrators. As a large health system with an existing vendor relationship, Cioe-Peña said Northwell could issue a purchase order right away.

“We fronted the money,” Cioe-Peña said. “We were able to get them in the warehouse ready to be sent to India before the Indian government … had even figured out how to pay us.”

Direct Relief often leans on manufacturers or suppliers for donations. The organization has strong relationships with private companies and a decades-long track record of successfully delivering medical supplies, so those requests often yield results.

But Tighe said it’s important to present companies with information about needs and make a specific request.

“You can’t just say, ‘People need what you’re making,’” Tighe said. “They’re going to say, ‘How much … product? Where is it going to go?’ That’s what we try to do.”

Oxygen concentrators await transportation at Direct Relief’s California headquarters. (Photo: Direct Relief)

So far, a number of private companies have committed resources or signed commercial deals to help address the outbreak in India.

Drugmaker Gilead donated vials of the antiviral remdesivir and committed to helping local manufacturers scale up production of the drug. AmerisourceBergen, which distributes remdesivir for Gilead, also coordinated with the U.S. government to transport antiviral treatments to India. Eli Lilly coordinated with Direct Relief to donate doses of a monoclonal antibody drug used to treat COVID-19 and pledged to help local manufacturers increase production.

The U.S. Agency for International Development collaborated with private companies and the state of California to gather supplies for India. The agency also used its own funding to purchase oxygen concentrators in India.

With so many moving pieces, it’s important that all these organizations are on the same page. 

Northwell didn’t collaborate directly with USAID but keeps USAID informed about its actions so there’s “situational awareness,” Cioe-Peña said.   

Getting it there: Most nonprofits don’t own a fleet of planes, so Cioe-Peña said humanitarian aid organizations typically ask airlines or cargo companies to transport donated materials.

Tighe said FedEx’s offer to donate the use of its massive Boeing 777 spurred Direct Relief to find enough supplies to fill it.

“It became a catalyzing event for us to scale up what we otherwise would have been able to do,” Tighe said. 

Northwell, which sometimes partners with Direct Relief, also sent some supplies on the same plane. But Cioe-Peña said it’s usually easy to work with airlines during a disaster.

“There’s often a lot of people trying to leave the country of a disaster but not many people trying to fly in,” he said.  

USAID sent medical supplies on six separate flights to India using the world’s largest military plane, which departed from a U.S. Air Force base.

Last mile: Getting medical supplies from the belly of a cargo plane into the hands of health care providers is often the most challenging step in this supply chain, according to Cioe-Peña.

“Logistics became the name of the game,” he said. “Having a local partner … can help you on the receiving end, making sure things aren’t going to sit at an airport or some storage facility.” 

USAID sent its materials to the Indian Red Cross so there would be a centralized distribution point. 

In India, Direct Relief is sending most of its supplies to Tata Memorial Hospital, which will then be responsible for the final mile. 

“Normally we would be arranging order fulfillment to the end user,” Tighe said. “[In] emergencies like this, the hub-and-spoke model emerges because it has to, because of the scale.”

According to Direct Relief, the supplies from its first shipment cleared customs and were distributed to more than 40 hospitals by Tata Memorial Hospital within two days of arriving.

A Direct Relief shipment arrives in Delhi, India. (Photo: Direct Relief)

Cioe-Peña said some of the providers receiving supplies from Northwell wanted to pick up their portions of the shipment at the airport, but that wasn’t possible because they were bundled into pallets.

“We really had to reset expectations. This is air freight,” he said. “You can’t just go to the airport and pick up your 10 concentrators.”

A freight forwarding company had to bring those pallets to a hospital with the capacity to receive large shipments. At minimum that initial distribution point needed a forklift, a loading dock and a bay to store the shipment.

Once those pallets are broken down, the process becomes a lot more variable. A larger hospital might hire a truck to pick up 100 oxygen concentrators. Pickups for smaller allotments might look simpler.

“Especially for the grassroots organizations or the really small hospitals in small towns, they’re coming with an SUV or a pickup truck and they’re putting 10 oxygen concentrators in the back,” Cioe-Peña said. 

The pandemic presented an enormous challenge for organizations that deliver medical supplies for humanitarian disasters. 

Most emergencies, like a hurricane or an earthquake, have a geographical component. It’s possible to pull supplies from areas outside the disaster zone and direct them to patients who need them. 

“That’s not possible when a crisis emerges everywhere. Everyone needs what they’ve got and then some,” Tighe said. 

When the disaster is everywhere, it becomes a bit harder to distinguish between the supply chains for commercial health care and humanitarian aid.