Resilience and Adaptability in Paracetamol Supply Chains: A Systems Perspective on COVID-19 Challenges and Responses in Ethiopia

Abstract

Background: The COVID-19 pandemic exposed vulnerabilities in global supply chains, including those for essential medicines like paracetamol. This study aimed to assess the resilience and adaptability of Ethiopia’s paracetamol supply chain during the pandemic. Methods: A mixed-methods approach was employed, combining semi-structured interviews with key stakeholders and analysis of secondary data on paracetamol availability and supply chain disruptions. The study employed systems thinking and supply chain resilience frameworks, utilizing causal loop diagrams to visualize system dynamics. Results: Eighteen stakeholders, representing seven pharmaceutical manufacturers, five import companies, and five wholesalers, participated in the study. These participants had between three and fourteen years of experience in their respective roles. The study revealed complex interactions within the paracetamol supply chain, highlighting both challenges and adaptive responses. While 500 mg paracetamol tablets were readily available, shortages of other formulations were observed due to a range of factors, including limited product diversification, political instability, inflation, and reduced production efficiency. Conclusions: The resilience and adaptability of stakeholders, particularly manufacturers and importers, were crucial in maintaining the supply of 500 mg paracetamol tablets. Key strategies included regional sourcing, increased production, and improved partnerships. Understanding the interconnectedness of factors within the supply chain is essential for developing effective strategies to enhance its resilience and ensure sustained access to paracetamol in the future.

1. Introduction

1.1. Background

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, drastically altered the lives of individuals [1] and the daily operations of global organizations [2,3]. The resulting pandemic has had profound impacts on global and local healthcare systems, supply chains, and labor markets [4,5]. As explored by Hegedűs et al. [6] and Dajnoki et al. [7], the pandemic created unprecedented challenges that have required rapid adaptations in organizational practices, crisis management measures, and human resource approaches across sectors. In the healthcare domain specifically, the pandemic exacerbated existing supply chain vulnerabilities and created new shortages of critical medical products [8]. The pandemic exposed several weaknesses in the healthcare system, including the lack of contingency plans, limited visibility, and inadequate collaboration among stakeholders [9,10]. The sudden surge in demand for essential health products such as paracetamol, ventilators, and other critical drugs, coupled with disruptions in global logistics and transportation, created significant challenges in ensuring timely and adequate supply [11,12]. As a result, many countries faced shortages, which led to increased mortality rates and overwhelmed healthcare systems [12,13].

Ethiopia’s healthcare supply system faces significant challenges due to its limited resources, infrastructure gaps, and a complex distribution network [14]. As a low-income country with a large rural population, Ethiopia struggles to maintain consistent access to essential medicines across its diverse regions. The public sector dominates healthcare provision, but supply chain inefficiencies often lead to stock-outs of critical drugs, including paracetamol [15]. Paracetamol, also known as acetaminophen, is a widely used over-the-counter (OTC) medication for the relief of pain and management of fever [16,17]. It is considered an essential medicine by the World Health Organization (WHO) and is commonly used for a variety of conditions, including headaches, muscle aches, menstrual cramps, and symptoms of the common cold [16,18]. Paracetamol is particularly important in resource-limited settings, where it serves as an affordable and accessible alternative to more expensive analgesics [19]. During public health emergencies, particularly in the COVID-19 pandemic, the demand for paracetamol surges as it can help manage symptoms associated with viruses, including fever and body aches [20,21].

The disruption to global supply chains caused by the pandemic has affected the availability and distribution of essential medicines, such as paracetamol products. This has raised concerns about the healthcare system’s ability to meet the increased demand for paracetamol during the pandemic. Previous studies [22,23] have indicated significant shortages of essential medicines at public supply agencies and hospitals during the pandemic. However, while some products experienced significantly more stock-outs, others increased in availability. For instance, the availability of 500 mg paracetamol tablets increased, while significant shortages were reported for paracetamol syrup and suppositories at service delivery points in Ethiopia [22]. The controversy surrounding the availability of paracetamol products during the pandemic revolves around the contrasting experiences of the increased availability of 500 mg tablets and significant shortages of other formulations such as syrup. The research questions center on understanding this paradoxical situation whereby the availability of 500 mg paracetamol tablets increased while other formulations experienced significant shortages. To explore such adaptive responses and challenges at the system level through a systems thinking approach, it is crucial to investigate how different local and international interventions, as well as supply chain challenges, contributed to these discrepancies. This perspective will help identify the underlying factors and potential solutions to improve the resilience of the healthcare supply chain in the COVID-19 setting and beyond.

1.2. Theoretical Framework

Systems thinking has been widely applied in various fields, including healthcare, to analyze complex systems and identify leverage points for intervention. According to De Savigny and Adam (2009) [24], systems thinking enables a comprehensive understanding of health systems by considering the interdependence and feedback mechanisms among different components. Holmberg (2000) [25] further emphasizes the value of a systems perspective in supply chain management as it helps identify potential bottlenecks and opportunities for improvement. To provide a solid theoretical foundation for our study, we adopt a systems thinking approach and supply chain resilience frameworks. Systems thinking allows us to understand the complex and interconnected nature of supply chains, particularly in the context of healthcare logistics. This approach is well-suited for analyzing the dynamic interactions and feedback loops within the paracetamol supply chain during the COVID-19 pandemic. Systems thinking is a holistic approach that considers the entire system rather than individual components in isolation. It emphasizes the importance of understanding the relationships and interactions between different elements within a system. This approach is particularly relevant for supply chain management, where multiple stakeholders, processes, and external factors interact in complex ways [24,25].

Supply chain resilience is another critical theoretical framework that underpins our study. This framework provides additional theoretical support by focusing on the ability of supply chains to withstand and recover from disruptions. These frameworks highlight key dimensions of resilience, such as flexibility, adaptability, and collaboration, which are critical for maintaining the availability of essential medicines during crises. Resilience refers to the ability of a supply chain to anticipate, prepare for, respond to, and recover from disruptions. Ivanov (2021) [11] identifies four major adaptation strategies for supply chain resilience: redundancy, flexibility, collaboration, and visibility. These strategies are essential for ensuring the continuous availability of essential medicines, such as paracetamol, during the COVID-19 pandemic.

The application of systems thinking and supply chain resilience frameworks in healthcare logistics has been extensively studied. For instance, Scala and Lindsay (2021) [4] highlight the importance of supply chain resilience in the healthcare sector, particularly during pandemic disruptions. Their study emphasizes the need for flexible and adaptive supply chain strategies to address the challenges posed by sudden increases in demand and supply chain disruptions. Chowdhury et al. (2021) [5] provides a systematic review of COVID-19 pandemic-related supply chain studies, identifying key factors that contribute to supply chain resilience. Their findings underscore the importance of collaboration among stakeholders, diversification of supply sources, and investment in supply chain visibility and monitoring systems.

1.3. Model Justification

The causal loop diagrams (CLDs) used in our study are grounded in the theoretical frameworks of systems thinking and supply chain resilience [26]. The CLDs visually represent the dynamic interactions and feedback loops [27,28] within the paracetamol supply chain, highlighting the complex relationships between various factors. The CLDs have the following key components:

(a)

Nodes (variables): The variables or factors within the system; these could be physical quantities, processes, or other relevant elements.

(b)

Edges (links): The connecting lines between nodes. They represent the relationships between variables. An arrow indicates the direction of influence.

(c)

Signs on links (polarity): Each edge has a sign (+ or −) indicating whether it represents a positive or negative relationship. Positive links indicate that when one variable increases, the other also increases (reinforcing loop), while negative links indicate an inverse relationship (balancing loop).

(d)

Loops: The arrangement of nodes and edges forms loops within the diagram. These loops represent feedback mechanisms. Reinforcing loops (R) amplify changes within the system, while balancing loops (B) tend to stabilize or balance the system.

By adopting a systems thinking approach, we can better understand the interconnectedness of different elements within the supply chain and identify potential leverage points for intervention. The supply chain resilience framework further supports our analysis by providing insights into the strategies and practices that enhance the resilience and adaptability of the supply chain. In summary, the theoretical frameworks of systems thinking and supply chain resilience provide a robust foundation for our study. They help justify the use of CLDs and support the observed interactions and feedback loops within the paracetamol supply chain during the COVID-19 pandemic. Therefore, in this study, we aimed to identify the key drivers, challenges, and potential solutions in the paracetamol supply chain. We explored the interconnected factors that impact the accessibility and distribution of paracetamol, providing valuable insights for policymakers, healthcare stakeholders, and supply chain managers.

2. Materials and Methods

2.1. Study Setting

The study area encompasses selected stakeholders within the pharmaceutical sector, including pharmaceutical manufacturers, importers, wholesalers, and health facilities in Ethiopia. These entities operate across different regions of the country, contributing to the overall supply and distribution of medicines throughout the country. The Ethiopian healthcare supply system is a network of public and private institutions that work together to provide healthcare services to the country’s population. The paracetamol supply chain in Ethiopia involves several actors, including manufacturers, wholesalers, distributors, and retailers. The paracetamol that is marketed in Ethiopia is manufactured by both local and foreign companies. Importers are responsible for purchasing large quantities of paracetamol from manufacturers and distributing them to distributors or directly to retailers. Distributors are responsible for delivering paracetamol to retailers, such as pharmacies and drug stores, in specific regions. Retailers are the final link in the supply chain, selling or dispensing products directly to consumers. These include pharmacies, drug stores, and rural drug vendors. Overall, the paracetamol supply chain in Ethiopia is complex and involves multiple actors at different levels.

2.2. Research Design and Period

This study utilized a mixed-methods approach, incorporating both primary and secondary data sources. The primary data consisted of semi-structured interviews conducted with key stakeholders in the Ethiopian pharmaceutical manufacturing industry, import companies, and private wholesalers. The qualitative survey employed a phenomenological approach to understand the experiences surrounding paracetamol production, import, and distribution before and during the COVID-19 pandemic. The interviews were carried out from September to December 2022. The secondary data included information on paracetamol availability and supply chain disruptions obtained from health facilities and public pharmaceutical supply agencies [22,23].

2.3. Data Collection Procedure

To obtain qualitative primary data, a total of 18 interviewees—eight from seven pharmaceutical manufacturers, five from import companies, and five from wholesalers that varied in size and type of pharmaceutical product (formulation)—were invited to participate in the interviews. The participant recruitment process for this study focused on selecting key informants who could provide valuable insights into their organization’s production, supply, and distribution capacity for paracetamol products. These participants were chosen based on their professional qualifications or experience in their current positions within their respective organizations. The selection aimed to include individuals from companies that varied in size and type of pharmaceutical product formulation. The diverse selection of participants allowed for a comprehensive understanding of the challenges and responses in the paracetamol supply chain during the COVID-19 pandemic from various perspectives. The interviews were semi-structured and conversational in tone and style. We began each interview by explaining the research aims, and how the data would be used, and by obtaining written consent. The following key concepts were addressed during the interview:

▪

Challenges and disruptions in the paracetamol supply chain during the COVID-19 pandemic;

▪

Strategies and interventions adopted to maintain paracetamol availability;

▪

Perceptions of the effectiveness of these strategies;

▪

Suggestions for improving the resilience of the paracetamol supply system.

A flowchart of the interview process is provided in Figure 1. The study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [29].

2.4. Data Analysis

Two of the authors (TM and ZM) reread the transcripts while listening to the recordings. The research team members discussed themes to establish relevance and reliability. The field notes taken during the interviews were reviewed along with the recordings. Three research team members (TM, ZM, and GTT) agreed on a coding framework to create the main themes. Codes were refined and organized into emerging themes and subthemes. NVivo 14.0 software was used to manage and analyze data.

Based on the data collected from the secondary sources, and primary data collection, causal loop diagrams were constructed to visualize the dynamic relationships and feedback loops within the paracetamol supply system in Ethiopia. Key variables, such as production, distribution, demand, and government policies, were identified and the causal linkages between them were established.

2.5. Creation and Presentation of CLDs

Three issues were considered during the development of CLDs from primary and secondary data. The first pertained to the targeted response of supply chain actors to shortages of paracetamol products during COVID-19. The second focused on challenges encountered in the production and supply of these products. The third issue addressed the future solutions proposed by stakeholders to mitigate shortages of the products. The ultimate variable of interest in this study was the supply situation of paracetamol products at service delivery points. The CLDs were validated through discussions with subject matter experts to ensure their accuracy and comprehensiveness. For the CLD construction, we used Vensim PLE software (version 9.3.5x 64) to complete the causal loop analysis and present a system view of the interplay between the identified variables or processes.

2.6. Ethical Considerations

Participants provided personal information and written consent. The semi-structured interviews were digitally recorded, anonymized, and transcribed verbatim. All identities of the informants and the companies and organizations for which they work remain anonymous throughout this paper. Ethical permission was granted by the Institutional Review Board (IRB) of the Institute of Health, Jimma University, Ethiopia (reference number: JHRPG/1043/2020).

3. Results

3.1. Characteristics of the Study Participants

The study included eighteen participants from seven pharmaceutical manufacturers, as well as five each from pharmaceutical importers and wholesalers. The participants’ experience ranged between 3 and 14 years (

Table 1. Characteristics of the study participants.

Participant ID	Organization	Role	Experience (yrs.)
P1	Pharmaceutical manufacturer	Executive supply chain lead	14
P2	Pharmaceutical manufacturer	Production plan officer	6
P3	Pharmaceutical manufacturer	Production manager	7
P4	Pharmaceutical manufacturer	Quality control officer	5
P5	Pharmaceutical manufacturer	Production manager	11
P6	Pharmaceutical manufacturer	Production manager	9
P7	Pharmaceutical manufacturer	Production manager	5
P8	Pharmaceutical manufacturer	Warehouse officer	5
P9	Import company	Manager	6
P10	Import company	Manager	5
P11	Import company	Manager	7
P12	Import company	Warehouse officer	4
P13	Import company	Warehouse officer	4
P14	Wholesale	Manager	5
P15	Wholesale	Manager	3
P16	Wholesale	Manager	5
P17	Wholesale	Manager	6
P18	Wholesale	Manager	3

NB: Two participants were from the same pharmaceutical manufacturer.

).

Figure 2 highlights the production and/or supply capacity of different pharmaceutical companies for specific formulations of paracetamol. This information provides insight into the market availability and distribution of different paracetamol formulations. It shows that all of the interviewed Ethiopian pharmaceutical manufacturers, importers, and wholesalers provide 500 mg paracetamol tablets. However, only one pharmaceutical manufacturer produces 100 mg paracetamol tablets, and none of the importers or wholesalers supply this dosage. Paracetamol suppositories were produced by two pharmaceutical manufacturers and supplied by four importers and five wholesalers. Two pharmaceutical manufacturers produce paracetamol syrup, with supplies from four importers and five wholesalers (Figure 2).

Figure 3, Figure 4, Figure 5 and Figure 6 are CLDs that visually represent the complex interrelationships and feedback loops within the paracetamol supply chain during the COVID-19 pandemic. The figures aim to illustrate the factors that contribute to the resilience and adaptability of the supply chain, as well as the challenges faced. They highlight the intricate relationships between various processes and variables—with COVID-19 acting as a central disruptive force—and the role of collaborative efforts, government support, and external aid in mitigating its impact on the availability of the products. The thematic analysis of the primary (qualitative) data resulted in 10 main themes.

3.2. Challenges in the Supply of Products

During COVID-19, health systems faced the competing pressures of surging demand, supply chain and production disruptions, and cost pressures. Effective supply responses required the leveraging of multiple balancing loops, such as product changes, technology, regional cooperation, and government support, to overcome the reinforcing disruptions from the pandemic and political dynamics in the setting. The central variable of interest was the “availability of paracetamol products”, which was influenced by factors such as inflation, price hikes, manufacturing efficiency, inventory planning and management, and healthcare financing. Figure 5 shows that the COVID-19 pandemic had a direct impact on the availability of paracetamol. Furthermore, our interviews identified some of the challenging factors in the production, importation, and distribution of pharmaceutical products. These factors created a challenging environment for health facilities, suppliers, and distributors operating in the country. The specifics of these challenges and the causal linkages between processes were elaborated and are depicted in Figure 3, Figure 4 and Figure 5.

3.2.1. Limited Product Portfolio

Investment policies, such as taxes and tariffs, (in)directly impact return on investment (Figure 3, R1), which influences the overall attractiveness of the manufacturing industry for investors. Favorable investment policies attract multinational pharmaceutical companies, which leads to increased local production and manufacturing efficiency. Product diversification and portfolio management also contribute to the industry’s resilience and ability to adapt to changing market conditions. If national pharmaceutical production addresses the diverse formulation requirements of products, it can help reduce shortages of the same medication but in different dosage forms, such as pediatric formulations. The interviewees expressed concerns regarding the limited range of formulations of locally manufactured pharmaceutical products. Pharmaceutical production firms were found to have a lack of product diversification, predominantly focusing on oral solid dosage forms. This has significant implications for local manufacturing efficiency and affects product availability at health facilities. One production manager described the scenario of the shortage and stock-out of paracetamol syrup as follows:

“Our pharmaceutical market is more focused on solid dosage forms; oral liquids accounted for less production volume.”

A participant from an import company also stated that:

“In Ethiopia, not much liquid medicine is produced locally, and most are imported. This means that it might be harder to find, and people might not be able to get such medicine during lockdown at health facilities.”

3.2.2. Political Instability

Political stability plays a crucial role in the system, as it influences regional collaboration and national production. Stable political conditions can foster a supportive environment for manufacturing growth and investment. All interviewees noted the impact of political instability in the country, which disrupts supply chains, creating difficulties for suppliers and/or distributors. This has led to limited production of paracetamol products and shortages of other pharmaceutical products for some pharmaceutical manufacturers. Among the consequences of political instability are market inflation, decreased efficiency in manufacturing, and shortages of products at service delivery points. Coupled with inflation, political instability had a significant impact on the supply chain, making it difficult for firms to operate efficiently (Figure 4). An interviewee from wholesale described the scenario as follows:

“In addition to COVID-19, the political issue in our country has caused disruption and market inflation. We have seen shortages of medicine, which has led to an increase in prices.”

3.2.3. Market Inflation

Currency inflation increases production costs, which has a significant impact on the product’s consumer price. It also makes products more expensive to import and distribute to service delivery points, which further exacerbates shortages. All our interviewees described the rapid fluctuation in the unit price of pharmaceutical products, which has affected the efficiency of essential medicines supply, including paracetamol to health facilities (Figure 4). This affected the ability of pharmaceutical wholesalers to supply health facilities at the initial bid price. A wholesale manager stated:

“The price changes during the COVID-19 pandemic have significantly impacted our ability to supply health facilities with essential medicines and medical supplies at the initial bid price … I remember … due to increase in unit prices of paracetamol … we canceled bid and … unable to supply the product to the health facility.”

3.2.4. Decrease in Production Efficiency

The COVID-19 pandemic also significantly impacted the pharmaceutical industry, with an observed decrease in production efficiency. The interviewees reported a production efficiency of less than 20 percent, which significantly impacted the industry’s ability to meet the demand for pharmaceutical products. The pandemic disrupted global supply chains, leading to shortages of raw materials and other essential inputs (Figure 4). This made it challenging for pharmaceutical companies to maintain production levels, resulting in delays and reduced output. In this regard, the executive supply chain lead described the scenario as follows:

“The pandemic has created uncertainty in the supply chain. We have seen disruptions in transportation, logistics, and manufacturing activities. This has made it difficult for us to procure the raw materials and other inputs needed for our production processes.”

3.2.5. COVID-19 and Its Prevention and Control Measures

The COVID-19 pandemic impacted the supply and distribution of pharmaceutical products as lockdowns and restrictions made it difficult to transport goods across the country. The supply and logistics of products were severely affected by COVID-19 and its control measures. The panic buying (hoarding) of critical medicines used to manage COVID-19 symptoms, such as paracetamol products, increased demand, thus exacerbating shortages, together with limited supply responses (Figure 5). The wholesale warehouse officer expressed the impact of panic buying as follows:

“Because of the COVID-19 pandemic, it is hard to get medicine to people because of lockdowns and restrictions … we have been through unclear situations … COVID-19, politics, hard currency limitation …”

All of the participants in our interview pointed to the impact that COVID-19, political instability, and currency inflation in the country had on the availability of and access to critical medicines such as paracetamol during the pandemic. These were the “triple-whammy” effects, which had significant direct and indirect impacts on the shortages of pharmaceutical products.

3.3. Supply Response and Adaptation

During the COVID-19 pandemic, various supply chain interventions were implemented to support the availability of paracetamol products in Ethiopia. These were (1) providing financial support to suppliers to enable continued production and supply despite economic challenges; (2) technical and financial assistance from parent companies to their subsidiaries or affiliates in Ethiopia to ensure availability of paracetamol; (3) collaboration among pharmaceutical manufacturers to purchase excipients in bulk, reducing costs and supporting supply; (4) suppliers adapting their processes to respond quickly to changes in demand and supply disruptions; and (5) supporting local manufacturers to enhance their production capacity and produce paracetamol products domestically. These interventions were critical in maintaining the availability of paracetamol products (especially 500 mg tablets) during the pandemic. The details of these interventions and their causal relationships are described further in Figure 6.

3.3.1. Local Production

At the center of Figure 6 is the “local production” node, which is impacted by various processes, including COVID-19, raw material availability, and demand. The COVID-19 node has a negative influence on local production, likely due to disruptions caused by the pandemic, such as lockdowns or supply chain issues. Increased raw material availability supports higher production levels (R5), and this availability can be enhanced through pooled procurement and regional/local joint supply operations (collaborative partnerships). The demand node also has a positive influence on local production, suggesting that higher demand drives increased production efforts. The importation node represents the ability to supplement local production with imported products and inputs, which is influenced by supply availability and can help meet demand. Despite a decrease in the overall production efficiency of pharmaceutical products during the pandemic, only two of the seven pharmaceutical companies had an adequate stock of paracetamol (500 mg) at the time of data collection. The growing demand from health facilities, importers, and wholesalers, along with requests from the Ministry of Health, has drawn attention to the need for increased production of this specific item. The increase in consumer demand for the specific products in the market motivated the increase in the production of 500 mg paracetamol tablets. The production plan officer from a large pharmaceutical manufacturer producing 500 mg paracetamol tablets stated:

“During the market assessment, we have seen increased demand for our paracetamol product. The customers gave a special name to the product—” paracetamol Bale— ambessa” –which motivates us to continue the large production of the item during this needy time. The product-specific preference and the clinical need for paracetamol have ramped up our production and efforts to ensure adequate supply.”

3.3.2. Supplier Credit Allocation

Figure 6 also shows the role of government support, such as supplier credit allocation (B5), which positively impacted local production and helped mitigate the effects of COVID-19. The supplier credit provided by the National Bank of Ethiopia played a crucial role in supporting the supply of paracetamol and essential medicines during the pandemic. The credit helped companies import finished paracetamol products and raw materials. All the interviewees from pharmaceutical importers and manufacturers mentioned that supplier credit allowed them to import pharmaceutical inputs and finished products, pay for transportation costs, and cover other expenses related to the supply chain. Moreover, the supplier credit provided by private banks also helped importers and pharmaceutical companies access working capital and maintain operations during the pandemic. The executive supply chain lead from the pharmaceutical manufacturer explained the issues as follows:

“We have tried to access the supplier credit scheme through national and private banks such as Abyssinia Bank, which has been an interesting opportunity. This has supported us to import some raw materials used for production, including packaging materials.”

3.3.3. Support from the Parent Company

Another intervention was support from parent companies, where companies that had subsidiaries or affiliates in Ethiopia provided technical and financial assistance to ensure the availability of paracetamol products. One major reinforcing loop involves mother/parent company support, which is linked to the role that multinational pharmaceutical companies play in boosting local production. In the interviews, some pharmaceutical manufacturers that had subsidiaries or affiliates in Ethiopia, such as those from China, had an advantage in managing supply situations of essential medicines, including paracetamol products. These parent companies provided support by supplying inputs or sourcing production materials for the local pharmaceutical manufacturer (Figure 6, R7). A production manager working in one of the pharma manufacturers described the support of the parent company as follows:

“Our parent company in China was very supportive during the pandemic. It helped us source raw materials and provide technical support, such as market audit and forecasting, to maintain our operations. This support was crucial in ensuring that we could continue producing and meeting the demand during the pandemic.”

3.3.4. Pooled Procurement

Pooled procurement had a positive influence on raw material availability, suggesting that coordinated procurement efforts can help secure necessary inputs. It is also important to consider the impact of regional or joint supply operations, known as collaborative partnerships, which facilitate pooled procurement and potentially improve raw material availability. Raw material availability and regional/local joint supply operations (collaborative partnerships) positively influence local production, which reflects the importance of access to raw materials and collaborative supply chain partnerships in supply resilience and adaptability during the pandemic. From the pharmaceutical manufacturers’ perspective, all reported that active pharmaceutical ingredients (APIs), excipients, and packaging materials are usually imported from abroad, mainly from the Indian and Chinese pharmaceutical markets. However, some initiatives focused on the local manufacturing of suspension or syrup bottles, packaging materials, and empty gelatine capsules. Some pharmaceutical companies also used the strategy of pooled procurement to obtain inputs for production. The collaborative efforts of the pharmaceutical industry association in Ethiopia supported the purchase of raw materials in bulk, thereby reducing costs and increasing availability. This approach was particularly effective in ensuring the availability of essential excipients such as starch during the pandemic (Figure 6, R6). A production plan officer from a pharmaceutical manufacturer described the situation as follows:

“Some of the pooled procurement experiences were ‘game-changers’ for us. Looking at our recent experience during COVID-19, we were able to secure a large quantity of starch at a much lower cost than if we had tried to procure it individually. This has helped us maintain our production levels.”

3.3.5. Supply Chain Flexibility

Overall, these interventions were indicative of supply chain flexibility, where each actor implemented tailored interventions to mitigate the shortage of products. Flexibility in the supply chain is crucial for adapting to disruptions. It is influenced by regional collaborations and R&D investments, which can improve supply chain operations and efficiency. In this study, we have highlighted the importance of a flexible supply chain through regional sourcing of pharmaceutical inputs during the pandemic. This supported production and prevented the stock-outs of some products. This strategy will help diversify the supply chain and reduce the reliance on a single source of production inputs (Figure 6, R4). One pharmaceutical manufacturer production manager described their experience as follows:

“The pandemic has been a wake-up call for us in the pharmaceutical industry. We have realized that we need to be more prepared for unexpected disruptions in our supply chain. I remember that we obtained the active pharmaceutical ingredient from Kenya when China limited international flights during the pandemic. Obtaining production inputs from our region has supported our production.”

The interviewees highlighted practical interventions and future solutions to enhance resilience and adaptability in the pharmaceutical supply chain. The following themes were identified from the interviews. One way to ensure a stable supply of essential medicines is to increase domestic production capacity; this can reduce the country’s dependence on imports and make it more self-sufficient in terms of meeting its healthcare needs. To achieve this, the government can incentivize and support local pharmaceutical companies to invest in research and development, upgrade their manufacturing facilities, and improve their quality control systems. One of the pharmaceutical manufacturer managers stated:

“I think it is time for the government to capitalize on the initiative started at Kilinto Pharmaceutical Industry Park to support national production.”

The ability to quickly adapt and respond to changing circumstances is crucial to ensure a stable supply of essential medicines and medical supplies during emergencies. This requires a flexible supply chain that can quickly adjust to market disruptions, such as shortages or unexpected demand spikes. One participant described this as follows:

“As a wholesaler, I know it’s important to have a supply chain that can easily adjust to different situations. With constantly changing customer demands and limited supplies, it’s crucial to have a supply chain that can quickly adapt to these changes.”

Similarly, one of the participants from an importer added the importance of an adaptable supply chain as follows:

“… in supplying products, it is important to have a flexible system for getting things to people. Since the market keeps changing … there’s not always enough of what we need; it is truly important to have a system that can change quickly to keep up.”

Our interviews identified the significance of a collaborative responses (local/regional) for immediate intervention and future solutions. Collaboration among pharmaceutical suppliers can help address shortages and ensure a steady supply of essential medications. Diversifying the supply chain to reduce reliance on a single region or country is paramount to supply sustainability. Remembering the sourcing of API from Kenya, one of our interviewees stated:

“Collaboration is a key. We need to work together to ensure a stable supply chain and avoid overreliance on a single source of raw materials. This will help us mitigate the risks of shortages … recently, we imported raw material from a company based in Kenya.”

In summary Figure 7 illustrates numerous feedback loops, both reinforcing and balancing, that contribute to the system’s complexity and the need for a holistic approach to addressing shortages. The system shows how paracetamol shortages were not an isolated issue but part of a complex system involving multiple interconnected factors. The pandemic’s central role in disrupting supply chains and creating challenges is depicted. In the current study, elements like supply chain flexibility, supplier credit allocation, regional collaborations, and local production efficiency represent resilience-building factors. Changes in supply chain operations showcase adaptability in the face of challenges. By understanding these relationships, stakeholders can develop strategies to enhance the resilience and adaptability of the pharmaceutical supply chain, addressing the challenges posed by the pandemic. This systems perspective is crucial for ensuring the continuous availability of essential medicines like paracetamol in times of crisis.

4. Discussion

In this study, we gathered first-hand information on the supply situation and responses by pharmaceutical manufacturers, import companies and wholesalers. We gained an understanding of the challenges faced by companies and targeted responses to ensure the supply of essential medicines, specifically paracetamol products. The analysis of the interviews and data collected revealed several key insights into the challenges and adaptive strategies within the paracetamol supply chain in Ethiopia. The primary challenges identified include limited product diversification, political instability, inflation, and decreased production efficiency. Limited product diversification and the reliance on imports were key factors contributing to shortages of paracetamol products in Ethiopia. The study revealed that there were shortages of paracetamol syrup and paracetamol suppositories [22], findings that were similar to reports from Australia [30] and Europe [31,32]. This may be associated with a decrease in attention towards the supply of pediatric paracetamol products due to the milder symptoms of COVID-19 in children. This decreased demand has resulted in less attention being paid to the availability of these products in healthcare facilities [33]. Moreover, in Ethiopia, the national production is more focused on solid formulations, leading to a limited product portfolio for syrup and suppository formulations. The findings of this study align closely with global research on pharmaceutical supply chain disruptions during the COVID-19 pandemic. For instance, studies showed that the pandemic caused significant delays in production and distribution, leading to shortages in various countries, including those in Africa and Asia [34,35]. The increased demand, coupled with disruptions in the supply chain, also led to shortages and price hikes [36].

In the interviews, the participants mentioned that the COVID-19 pandemic and its control measures had a significant impact on the paracetamol supply chain, causing disruptions and challenges at various levels. As demand for paracetamol surged due to its use in managing COVID-19 symptoms, manufacturers faced difficulties in meeting the increased global need. Simultaneously, lockdowns and travel restrictions disrupted production and transportation networks, leading to shortages of raw materials and finished products [37,38]. Political instability and inflation further complicated the situation, creating a challenging environment for suppliers and manufacturers. Furthermore, studies [39,40] have highlighted the impact of political instability and inflation on pharmaceutical supply chains in low- and middle-income countries, which resonates with our findings on the effects of these factors in Ethiopia. As illustrated in the CLDs, these factors have created a cycle of self-reinforcing processes that have further impacted the availability of these products.

The availability of products was also influenced by the number of suppliers or manufacturers in the market. Interviews with seven pharmaceutical manufacturers revealed that only one of them produces 100 mg paracetamol tablets. Having a limited number of manufacturers can put the supply of specific products at risk. Some products are supplied through donations or imports, which may not always be reliable sources. The lack of market competition also means that manufacturers are less incentivized to invest in producing these products, leading to potential supply disruptions [41,42]. The pandemic has shown that disruptions in one part of the world can significantly impact the availability of essential medicines globally [43,44]. This highlights the importance of having multiple suppliers and manufacturers to ensure a consistent and reliable supply of essential medications such as paracetamol.

Despite these challenges, stakeholders demonstrated resilience and adaptability through various strategies, such as regional sourcing, increased production, and improved partnerships. One significant insight is the critical role of local production in maintaining the supply of essential medicines. The study found that local manufacturers were able to increase the production of 500 mg paracetamol tablets to meet the heightened demand during the COVID-19 pandemic. This was facilitated by government support, such as supplier credit allocation, and technical and financial assistance from parent companies. The interviews with industry experts and importers revealed that the government’s intervention in allocating supplier credit for manufacturing and importing has played a crucial role in the supply of these products. The increase in demand from consumers, healthcare facilities, importers, and wholesalers, along with requests from the Ministry of Health, has driven attention toward increasing production. The role of government and stakeholders in overcoming shortages of essential medicines during crises has been pivotal in various global contexts. Similarly, local production was implemented as one of the priority interventions for the COVID-19 response in other settings. Some manufacturers ramped up production to meet the increased demand, while others tried to diversify the sourcing of raw materials and establish alternative supply routes to mitigate the impact of disruptions in the country [45,46,47,48,49]. The present study also found that pharmaceutical manufacturers with a parent company outside Ethiopia or a regional African branch were able to source essential production materials. Support from parent companies provided the resources necessary to maintain and enhance the supply of paracetamol products.

Another key insight is the importance of collaboration among supply chain actors. The study highlighted the effectiveness of pooled procurement and regional collaborations in securing raw materials and reducing costs. These collaborative efforts were crucial in maintaining the availability of paracetamol products during the pandemic in the setting. Similarly, the study by Latonen et al. [50] emphasized the importance of stakeholder collaboration in supporting local manufacturing to enhance supply chain resilience. Our research corroborates this claim by showing that partnerships among manufacturers, importers, and government entities were vital for maintaining the supply of paracetamol during the crisis. Similarly, studies from India [51,52] and Nigeria [39] have reported that local production capacity and regional cooperation significantly influenced the availability of essential medicines during disruptions. By leveraging their global supply chains, these companies can source necessary production materials or APIs and provide them to their local subsidiaries or partners [53,54]. This not only helps maintain the supply of essential medicines like paracetamol but also enhances it. In times of crisis, their resources, expertise, and networks become particularly valuable in responding to supply disruptions and ensuring a steady supply of essential medicines. This underscores the importance of fostering strong partnerships and collaborations between local manufacturers and their parent or partner companies located outside of the region.

It is interesting to note that the initiative of pooled procurement supported the efficiency of pharmaceutical manufacturers during the pandemic. By purchasing raw materials in bulk, companies can reduce costs and increase product availability. This collaborative approach not only allows companies to negotiate better prices but also contributes to lower production costs and increased access to essential medicines. It is a strategic response to industry challenges like rising production costs and disruptions in the global supply chain. This finding aligns with other studies [55,56,57,58] that have underscored the benefits of such initiatives. Furthermore, the shift towards more flexible supply chains has been a crucial strategy in ensuring a product supply. This approach not only reduces dependence on international suppliers but also allows for quick adjustments in response to changing demands and supply constraints. Generally, the pharmaceutical manufacturers, importers, and wholesale channels played crucial roles in ensuring the availability of paracetamol products in Ethiopia during the pandemic. The success of these interventions underscores the value of systems thinking—a holistic approach that considers the interconnectedness of different elements in a system—in identifying and addressing supply chain challenges. The effective implementation of these interventions was made possible by recognizing the interdependencies within the supply chain and leveraging them to support the supply response of paracetamol products.

Overall, the main contribution of the present study lies in the application of causal loop diagrams to visualize and analyze the interconnected factors influencing paracetamol availability, providing valuable insights for policymakers and supply chain managers. This systems-based perspective reveals the resilience strategies employed by pharmaceutical manufacturers, importers, and wholesalers, such as regional sourcing, increased production, and enhanced partnerships, while also highlighting the challenges posed by limited product diversification, political instability, and inflation. By elucidating these complex relationships and feedback mechanisms, the study offers a comprehensive understanding of the Ethiopian pharmaceutical supply system, enabling more effective decision-making and management in the face of global health crises. This proactive stance enhances our resilience to future disruptions and ensures uninterrupted access to vital medications when needed.

Based on the current findings, the following propositions are developed to enhance the resilience and adaptability of the paracetamol supply chain in Ethiopia and other African countries: (1) Strengthening regional collaboration among pharmaceutical manufacturers, importers, and wholesalers can enhance supply chain resilience. By pooling resources and sharing information, stakeholders can better anticipate and respond to disruptions. (2) Implementing pooled procurement strategies can reduce costs and improve the availability of raw materials. This approach allows companies to negotiate better prices and secure larger quantities of essential inputs. (3) Increasing local production capacity is essential for reducing dependence on imports and ensuring a reliable supply of essential medicines, which is crucial for a quick response to health emergencies.

Strengths and Limitations

This study has several strengths. The study incorporates views from various stakeholders, including pharmaceutical manufacturers, importers, and wholesalers. The systems view enables an examination of the supply chain as a complex, interconnected system, revealing how disruptions in one part had ripple effects throughout the entire system. This approach allows for a more nuanced understanding of supply chain dynamics and helps explain the interconnected factors influencing it. The data from diverse stakeholders, including manufacturers, suppliers, distributors, and healthcare providers, provide a holistic understanding of the challenges faced by different actors. The findings are particularly relevant to the Ethiopian context, providing actionable insights that can inform policies and interventions. However, a limitation of the study is that it only reflects the situation during the COVID-19 pandemic, and the findings may not capture the long-term changes or adaptations in the supply chain over time.

5. Conclusions

The complex relationships and feedback mechanisms within the supply chain show the importance of understanding these interconnections for effective decision-making and management in the face of challenges. Collaborative efforts, government support, and local production capacity were essential for ensuring the availability of critical medicines like paracetamol during the pandemic. This study underscores the critical role of pharmaceutical manufacturers, importers, and wholesalers in ensuring the availability of paracetamol. Although these entities have faced challenges related to complexity and evolving market demands, they have shown resilience and adaptability.

Key interventions, such as supplier credit allocation, increased production, diversification of raw material sourcing, and alternative supply routes, were crucial in mitigating disruptions caused by the pandemic. The support from parent companies outside Ethiopia and regional African branches was instrumental in maintaining and enhancing the supply of paracetamol products, highlighting the importance of strong partnerships and collaborations. Pooled procurement initiatives and a shift towards more flexible supply chains and local production have also emerged as one of the strategies. However, this study also highlights areas of concern, such as the limited product portfolio for syrup and suppository formulations and the risks associated with having a limited number of manufacturers.