Garbage in = garbage tracked

Barcoded tracking systems are being touted as a great protection against fake COVID-19 vaccines. But they don’t protect against substandard products.

(DoD photo by Lisa Ferdinando)

As more countries start receiving shipments of COVID-19 vaccines, concern about theft and falsification is also growing. So I was really pleased to see the issue is on the radar in countries such as South Africa, which is just now receiving its first batches of vaccine from the Serum Institute of India.

This I learned (like so much else) from the always excellent health reporting from Bhekisisa. Their report explains how end-to-end track and trace systems can safeguard medicine quality. It also makes it clear that in the case of South Africa, the potential of barcoding won’t be fully realised just yet.

As South African pharmaceutical policy researcher Andy Gray said: “It’s truly bizarre to think that every single item in a supermarket has a barcode on it, and yet we don’t have barcodes on our medicines.” Well, yes and no. Barcoding is technically easy (though according to Bhekisisa the Serum Institute isn’t doing it for COVID-19 vaccines because they are in such a rush to get the vials filled and shipped). But however simple it is technically, implementing a nation-wide system that clocks medicines at every point in the supply chain is politically very hard to achieve. In fact, as far as I know, only one country — Turkey — has managed it, although several others, including China and the US, have tried and failed.

How did Turkey succeed? For the full story, read this interesting paper from MedsWatch colleague Koray Parmaksiz (disclosure: I’m a co-author).
To summarise, Turkey had:

  • a government whose credibility was tied up with achieving universal health coverage
  • a national health insurance system beset by fraud which undermined that goal
  • a huge and growing market for medicines, which manufacturers were keen to access
  • a generous single payer health system, which reimburses medicines against proof of sale

Together, those factors add up to a government with a strong political incentive to impose an initially expensive system on reluctant but ultimately willing producers; strong incentives for everyone within the legitimate supply chain to play ball; and no incentive for patients to buy outside of the legitimate supply chain, because they get all the medicines they need for free. Not many countries have that constellation of factors; in countries where incentives are not so neatly aligned, it’s a lot harder to ram through end-to-end barcode tracking systems.

Good track and trace systems have the potential to reduce (even eliminate) falsified medicine within the regulated supply chain. But they don’t garantee the quality of medicines in that supply chain at all. Substandard medicines — those that were bad when they left the factory, or that are poorly formulated or packaged so that they degrade before reaching the patient — will travel through each barcoded gateway in the supply chain quite happily, a classic case of garbage in = garbage out. And of course barcoding systems don’t protect against even falsified medicines if you buy them outside of the regulated supply chain. In countries with very poor or inequitable health financing systems, such as the United States, many people can’t afford to buy medicines from hospitals or pharmacies, and end up taking their chances on the internet. There, all bets are off.

So yes, let’s be positive about the potential that technology offers to protect against fake medicines sneaking in to the supply chain. But let’s not under-estimate the political capital needed to make that happen, or forget that you will still have to assure the quality of medicine before they ever leave the factory.

Author: Elizabeth Pisani

Dr. Elizabeth Pisani is the convenor of the MedsWatch group. She’s an epidemiologist by training and a political economist by persuasion, and is most interested in the messy places where biomedical evidence clashes with politics, money and culture.

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