Research Project

Measures for Improved Availability of medicines and vaccines (MIA)

Ensuring availability of essential medicines, vaccines and health commodities is one of today’s critical societal challenges

The MIA project 2020-2024

BI Norwegian Business School, INSEAD, Jimma University, Lancaster University, Norwegian Institute of Public Health, Rotterdam School of Management, St. Paul's Hospital Millennium Medical College

Objectives and background

Ensuring availability of essential medicines and vaccines is one of today’s critical societal challenges. While the COVID-19 pandemic exposed the vulnerability of medicine supply chains at full scale, medicine shortages were already an increasing global problem in normal times before the pandemic, particularly off-patent (i.e. generic) medicine shortages. When medicine supply chains break down, it can lead to serious injury and death. The primary objective of MIA was to help key stakeholders make evidence-based decisions that sustainably reduce medicine and vaccine shortages, addressing a key societal challenge to ensure future health and care services. Secondary objectives were:

To contribute to improved supply security, i.e. access to medicine and vaccine services in Norway and the UK.
To provide policy makers and other key stakeholders with a holistic and rigorous analysis of the direct and indirect costs and benefits of measures for enhanced supply security, thus contributing to more efficient and effective health services.
To provide a basis for comparative studies in other countries by developing baseline data, research design protocols, and analytical and pedagogical models and tools.

Results achieved

Our research shows that although policymakers discussed strategies to address shortages, few had implemented them by the time the pandemic struck. There is increased governmental interest in the vulnerability of supply and the level of preparedness. However, the numerous stakeholders differ in goals and incentives in terms of focusing cost, quality, service, and/or sustainability. The supply chains are complex with many global actors involved. Furthermore, supply chains are vulnerable due to specialization, few buffers, and outsourcing to low-cost countries. Focus on low prices for generics, while reducing public spending for medicine and improving access for more people, has led to many medicines with very few suppliers. This, in addition to lack of transparency and information sharing, means that fixing the causes of shortage problems is easier said than done. Particularly we provide knowledge concerned with the type of interventions used to avoid shortages in normal and abnormal times and the role of policymakers in selecting and implementing these interventions. We have brought the government perspective into OSCM and vice versa and demonstrated the need for a cross-disciplinary approach to medicine shortage. We have provided insights on how to prepare medicine and medical equipment supply chains for future epidemics/pandemics in the long-term and presented practical conclusions and implications with recommendations for policymakers and direct supply chain members. A key finding is the need to combine preparedness with adaptability in response through process modularity; resource interaction in cross-sectorial/disciplinary collaboration; the interplay between temporary and permanent organizing; the use of a mixed set of risk mitigation strategies and differentiation depending on drug characteristics beyond medical criticality. Policymakers can use our frameworks, tools and findings to improve the availability of generic medicines in (ab)normal times. To answer the research questions, we conducted the following sub-projects:

1. Focusing normal situations

Reviewed academic research and practitioners’ reports published before the COVID-19 pandemic on causes and solutions to shortages - a knowledge baseline (de Vries et al. 2021).
Mapped cause-and-effect relationships in drug shortages, identifying three solution archetypes—market-driven approaches, alternative sourcing, and regulatory flexibility. This systems-view highlights how the interactions between these archetypes can create ambiguities and unintended consequences. It clearly showcases the importance of integrating supply chain risk management with government and economic strategies to enhance resilience, providing a comprehensive approach to understanding how stakeholders perceive the problem and offers clearer paths for the development of interventions to address drug shortages (van Oorschot et al. 2022).
Årdal (2023) and Årdal et al. (2024) on vulnerability in the antibiotics supply chain.

2. Focusing abnormal situations/disruptions

Cross-national collaboration during crises like COVID-19 demonstrated how resource sharing, particularly diagnostic tests, can flatten infection curves and ensure equitable distribution. A simulation model across countries provided important strategies for cross-national stockpiling systems, addressing misalignments, cost-sharing, and equitable allocation mechanisms. Highlights the role of collaborative approaches and the importance of adjusting policies based on different pandemic phases to optimize resource use and reduce shortages (van Oorschot et al. 2022).
Interventions before/after COVID-19 in paracetamol, using supply chain risk management. Provided an understanding of policymakers’ role. Included data from seven countries (Ahlqvist et al. 2022).
Analysis of how decision-makers navigated the effects of an event with knowable implications (UK's European Union exit) followed by an event with unknowable implications (COVID-19 pandemic). Contribute by developing a theory of system-level strategic agility and the adaptation processes that underpin it (Dube et al., 2024).
Building local capacity in Frennesson et al. (2022); The bridging role of the pharmacist in Jahre and Walter (2025); Conceptual work on the importance of resource interaction in Bygballe et al. (2023).

3. Strategic stock/prepositioning

Typically, the policies for minimum stocks are (almost) the same for all medicines, while medicines differ strongly along many dimensions. Such differences argue against a “one-size-fits-all” approach. Developed a model to develop tailored policies for minimum stock levels, results suggesting that smart tailoring can reduce inventory holding costs and shortages by 20% in the Netherlands (de Vries et al. 2025 work-in-progress).
Show that potential for cross-national stockpiling is unmistakable there and provides novel research directions for realizing this potential (de Vries et al., 2024).

4. Procurement

While tendering can improve affordability, it is argued to increase shortages. However, strong evidence is lacking. We developed models and used datasets from the Netherlands to examine this. Our results confirm that, while tendering reduces drug prices, it also concentrates the market and substantially increases drug shortages (Vafa Arani et al. 2025 under revision).
Analysis of the effects of including environmental criteria in tendering of medicines (Jahre et al. 2025 under revision).
The role of contracting in medicine supply chain resilience (Selviaridis et al. 2025 work-in-progress).
Pricing models and methods (Brekke et al., 2023a/b; Brekke et al., 2022).
Purchasing and supply management in ‘business-not-as-usual” (Knight et al. 2022).

5. Applications in Low- and Middle-Income Countries

Pathogen genomic sequencing supply chains in sub-Saharan Africa face operational challenges in disease surveillance. System dynamics modeling showed that while the common practice of in-kind donations can address immediate crises, it fosters dependency, hampering long-term improvements. Building supply chain management capabilities instead ensure sustainable improvements by empowering laboratories.
The challenges imposed by the pandemic on vaccine supply chains in Ethiopia (Adilo et al. 2022).
Medicine availability before and during COVID-19 in Ethiopia (Mekonnen et al. 2023; Melaku et al., 2024a/b).

6. Tools

The Access for Drugs (A4D) framework is an innovative, simple visual tool that translates supply chain principles into concrete actions to mitigate drug shortages. It is effective not only for disruptions but also for severe and prolonged shortages caused by chronic supply chain issues, such as reliance on single suppliers. The framework emphasizes stakeholder alignment, ensuring coordinated decision-making across supply chains and fostering resilience and equitable access to medicines. Central to A4D is its four-step process—Analyze, Assess, Act, and Align—designed for the unique challenges of pharmaceutical supply chains. A core feature is its classification matrix, which categorizes drugs based on medical criticality and supply chain risk. This allows stakeholders to visualize differences across drugs and prioritize interventions for high-risk, high-criticality drugs, ensuring resources are focused where they will have the greatest impact while avoiding excessive stockpiling or inefficiencies (Breugem et al. 2024).
Data analytics tool for analysis of shortage data and the causes (Gaviano and Viana, 2022).
Tool simulating collaborative interventions to flatten the COVID-19 curve and their effects (van Oorschot, 2022).
Tool simulating mitigation strategies for reducing paracetamol shortages (van Oorschot, 2021).

Most important R&D tasks conducted including researcher groups

The project combined expertise from Operations and Supply Chain Management (OSCM) with global/public health, and pharmacy for the purpose of providing policymakers with evidence-based decision-support, data, and tools. The core team consisted of one researcher from the Norwegian Institute of Public Health, 3 from BI Norwegian Business School (OSCM), 2 from RSM (OSCM), 2 from Lancaster (OSCM), 3 from INSEAD (OSCM) and 3 from Jimma University (Pharmacy/Public Health). All studies were set up in collaboration between two or more partners and made use of mixed research methods combining qualitative (for example through news reports, interviews, and surveys) and quantitative (stock reports, databases, and evaluation reports) data with modelling such as simulation and optimization. All studies had different types of outputs including tools, reports, scientific presentations and publications, teaching and dissemination to users and the general public.

Assessment of project implementation and use of resources

Each sub-project was set up with a project leader using project planning tools and calling for frequent zoom meetings. Due to the pandemic, it took 1,5 years before we could have a physical meeting between the participants. It was quite challenging and resource demanding to get to know one another and setting up the communication/collaboration structure in each sub-project in the beginning. The co-authoring of papers and reports was done by using e-mail and dropbox-folders and worked quite well because responsibilities were clear, and sub-project leaders followed up. All sub-projects were completed. Substantial data were collected in all studies despite challenges related to the pandemic. Due to the pandemic, less travelling between the partner institutions and to conferences took place.

Research stays abroad & contribution

One researcher from Lancaster to BI for 1 month resulted in important progress of one of the papers and a draft of a new research proposal for continued funding. One researcher from Jimma to BI for 1 month allowed for exchange of knowledge from pharmacy to OSCM and transfer of knowledge regarding approaches, models and tools developed in the MIA-project to LMIC.

Anticipated significance/benefits of results

Significant results from the project

We see/anticipate the following significant results from the project in relation to the calls in our two baseline papers (de Vries et al., 2021 and van Oorschot et al., 2022). We have expanded the knowledge base by introducing OSCM/strategy expertise, widening academic scope and toolset for more nuanced interventions, tailored for cost-effectiveness/impact built on experiences from other industries, introducing business acumen. Our innovative approaches and developed models on system-level effects have contributed to clarifying challenges and trade-offs:

Analytical models at system level for; 1) Tailored policies on minimum stock levels; 2) Impact of tendering on prices; (3) Effects of including environmental criteria in tenders; 4) Effects of cross-country collaboration for resource sharing during crises; 5) Effects of building SCM capabilities for sustainable improvements.
Approaches for; 1) Illustrating 3 solution archetypes for drug shortages, highlighting how their interactions can create ambiguities and unintended consequences, showcasing the importance of integrating supply chain risk management with government and economic strategies to enhance resilience.; 2) Drug risk (medical/supply chain) categorization: the Access for Drugs (A4D) framework effective not only for disruptions but also for severe and prolonged shortages caused by chronic supply chain issues.

Our developed digital tools include an innovative practical tool for drug categorization based on medical critically and supply chain risk to prioritize and optimize resources fostering stakeholder alignment and equitable access; a simulation tool on effects of different interventions; and a data analytics tool enabling comparison of drug shortages, their causes, and effects. Further, we have developed extensive materials (case/pedagogical tool) and implemented these in teaching in pharmaceutical MSc-programs, at Bachelor, MSC, MBA levels in the UK, Netherlands, Norway, Ghana, and Ethiopia.

In addition to our scientific impact, we have been able to draw practical conclusions and implications and have informed ongoing strategy work, particularly in the Netherlands, the UK, Norway and Ethiopia as well as at the European Union level:

Update of Dutch policy January 2024 to differentiate stock requirements & grant for follow-up project
Tendering research in Dutch government and updated insurance companies’ procurement practices
Commission study for NHS England’s medicine and Access Directorate
Informing EU/European countries policymaking on antibiotics
Informing pricing policies
Policy implications discussed with e.g. Royal Pharmaceutical Society (UK); Directorate for Medicine Procurement (Norway)
Helping to develop resilience-oriented procurement approach in the NHS
Presented results in Global health/SCM/Pharma conferences in various countries
Close and continued engagement with stakeholders

Plans for further dissemination and utilization of results

Our 20 peer-reviewed international articles have been published in 18 different journals in OSCM, disaster management and health and already created a lot of scientific impact. We have trained master students in OSCM and pharmacy by supervising in total 21 MSc-theses in UK, Netherlands, and Norway. We have also disseminated results from the project in bachelor, master, and executive teaching programs. We have conducted more than 50 workshops and seminars with users, and have close to 50 popularized articles, see The MIA Project. We will continue dissemination and use of results, for example through supervision of PhD students, continued interaction with stakeholders and other researchers. A European Researcher network on medicine supply chains is in the making, with the two first workshops conducted in 2024.

Expected results to be finalized after project completion

Numerous propositions and suggestions for future research opportunities have been developed. Additional 10 scientific publications are either under revision, under review in journals or under development. Participants continue to develop new papers for presentation at conferences. Interaction with stakeholders continues. We have acquired funding for two postdocs and one PhD student who will continue to work based on MIA-results and data for another 4 years. New proposals for additional funding are under development.