Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Open Access Original Article DOI: 10.7759/cureus.54258 Country of Origin of Medical Products and Risk of Labour Rights Abuse: A Cross-Sectional Analysis Review began 11/18/2023 Using Four Procurement Datasets Review ended 01/28/2024 Jasmin Abbott , Chantelle Rizan , James N. Smith , Merete Loeken , Mei L. Trueba , 2 Published 02/15/2024 2, 5 © Copyright 2024 Mahmood F. Bhutta Abbott et al. This is an open access article distributed under the terms of the Crea1. Internal Medicine, University Hospitals Sussex National Health Service (NHS) Foundation Trust, Brighton, GBR 2. Commons Attribution License CC-BY 4.0.,Global Health and Infection, Brighton and Sussex Medical School (BSMS), Brighton, GBR 3. Public Health and Primary which permits unrestricted use, distribCare, University of Cambridge, Cambridge, GBR 4. Category Analysis, The Norwegian Hospital Procurement Trust, and reproduction in any medium, provided the original author and source are credited.-Eastern Norway Division, Vadsø, NOR 5. Otolaryngology - Head and Neck Surgery, University Hospitals Sussex National Health Service (NHS) Foundation Trust, Brighton, GBR Corresponding author: Jasmin Abbott, jna30@cantab.ac.uk Abstract Background Case studies have highlighted labour rights abuse in the manufacture of several healthcare products, but little is known about the scale of the problem or the specific products involved. We aimed to quantify and compare the overall and product-specific risks of labour rights abuse in the manufacture of healthcare products supplied to high-income settings using multiple datasets on the product country of origin (COO). Methods Public procurement data from South-Eastern Norway (n=23,972 products) were compared to datasets from three other high-income settings: procurement data from Cambridge University Hospitals, trade data from UN Comtrade, and registry data from the US Food and Drug Administration (FDA). In each dataset, the product COO was matched to the International Trade Union Confederation risk rating for labour abuse and deemed high-risk when rated 4, 5, or 5+. Results In the Norway data, 55.4% of products by value had a COO declared, 49.1% of which mapped as high-risk of labour rights abuses. COO was identified for 70/100 products in the Cambridge data, with COO matching high-risk at 59.9% by value. The level of risk for specific medical product categories varied between the Norway, US FDA, and UN Comtrade datasets, but those with higher proportional risk included medical/surgical gloves and electrosurgical products. Conclusion Evidence of high-risk of labour rights abuse in the manufacture of healthcare products present in these data indicates a likely high level of risk across the sector. There is an urgent need for global legislative and political reform, with a particular focus on supply chain transparency as a key mechanism for tackling this issue. Categories: Other, Occupational Health, Health Policy Keywords: sustainable healthcare system, healthcare policy and management, occupational health and safety, transparency, risk assessment tools, health system research, supply chain management, ethical procurement, healthcare supply chains Introduction Reports in the last 15 years have documented multiple cases of labour rights abuses in the manufacture of medical products. This includes sweatshop and child labour in the manufacture of steel surgical instruments in Pakistan [1] and endemic forced migrant labour in medical glove manufacturing in Malaysia [2]. It also includes state-sponsored forced labour in China: in the manufacture of masks in the Xinjiang province using forced Uyghur labour and of medical gowns in Dandong using alleged forced North Korean labour [3]. Together, these reports suggest labour abuse could be widespread in the medical product sector. However, risk analysis of labour rights abuses in this sector to date has been limited [4], despite medical goods being amongst the top 20 traded globally, with annual trade in 2021 estimated at US$150 billion [5]. Medical products have unique specifications, and supply chains have a mix of public and private stakeholders, yet the impact of these factors on the risk of labour rights abuse is poorly understood. Assumptions of risk made in other sectors [6] should not be presumed. Determining, quantifying, and qualifying this risk has implications for researchers, supply chain stakeholders, governments, and How to cite this article Abbott J, Rizan C, Smith J N, et al. (February 15, 2024) Country of Origin of Medical Products and Risk of Labour Rights Abuse: A Cross-Sectional Analysis Using Four Procurement Datasets. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 international policymakers in how they evaluate and target such issues through their activities. Challenges for risk analysis include the sector’s scale, poor public data availability on medical product procurement, and associated risks or actual incidents of labour abuse [7]. However, existing guidance in ethical procurement suggests the risks of labour rights abuse are highest when manufacturing occurs in a country known to have weak legislation, policies, or a track record of protecting workers [8]. Thus, the country of origin (COO) of a product can serve as a suitable proxy for the risk of labour abuse and is a method already used by government and inter-governmental agencies to assess supply chain risk in other sectors. An analysis of 100,000 audits on the Sedex platform (a risk assessment tool built by a UK-based company using supplier environmental, social, and governance data) found that the COO was predictive of the risk of labour rights abuse [9]. Here, we quantify the risk of labour rights abuses in the manufacture of medical products supplied to a high- income country (Norway) based on product COO and compare this with COO data on medical products purchased in other high-income settings to assess the generalisability of our findings. We compare risk at the level of the whole dataset and for specific product categories. Specifically, we analysed four datasets on COO for medical products purchased for use in high-income countries: procurement data for South-Eastern Norway and Cambridge University Hospitals (England), global trade data from the UN Comtrade database, and registry data from the US Food and Drug Administration (FDA) database. We focused on high-income contexts due to the high level of consumption of medical goods in these countries and chose to focus on Norway given the quality of data available for this region. However, given the nature of globalised supply chains, our study is relevant to those in countries of all income levels who procure or supply medical products. We argue that if there is evidence of a prevalent risk of labour rights abuses across these multiple datasets, this indicates likely risk in the sector as a whole. Parts of the work underlying this article were previously presented as a poster at the 2019 Public Health@Cambridge Network Showcase meeting on November 15, 2019, and as a conference abstract with an accompanying oral presentation at the 2021 Sustainable Healthcare Academic Research and Enterprise Conference on May 1, 2021. This article was also presented as an abstract with an accompanying oral presentation at the Brighton and Sussex Health Research Partnership conference on October 19, 2023. Materials And Methods Primary dataset: medical products purchased by the South-Eastern Norway Regional Health Authority In the 2015-16 financial year (and only this year), suppliers to publicly funded hospitals in the South-Eastern region of Norway (around half of Norway’s population or >2.5 million people) were contractually required by the regional health authority (Sykehusinnkjop) to self-declare the production location of the main component of the products they supplied. This included products classified as 'medical consumables' or 'surgical products', excluding medicines, medical aids, laboratory products, and supplies through local contracts with individual hospitals. We will refer to this data as the ‘Norway dataset’. These data were supplied to the senior author (MFB) on request (in accordance with Norwegian law that obligates the sharing of data related to public expenditure). This dataset was analysed using a stepwise approach. First, we assigned products to categories based on intended usage. Categories were not pre- specified, as there is no validated approach for assigning medical products to such categories, and the contents of the data were unknown prior to exploration. Aberrant or out-of-remit products, non-medical products (e.g., kitchenware, cleaning products, packaging), capital goods (e.g., sterilisation equipment), and medicines were excluded. We assigned the remaining product categories to ‘super-categories’ based upon similarities in material composition and physical design, on the assumption that such products would likely be manufactured in similar factories. For example, metal surgical instruments and metal laryngoscope blades are made in the same factories in Pakistan, and plastic kidney dishes and plastic specimen containers are made in the same factories in Mexico [10]. Multi-component products (e.g., procedure packs) were assigned a separate category. Efforts to reduce categorisation bias included cross-checking of excluded product categories and assignation to product super-categories by two authors (JA and MFB), with disagreements resolved by discussion. For all products, we equated the self-declared location of production to the product COO. We determined a product to be at high-risk of labour rights abuse where the COO was one with known systematic violations of worker rights (rating 4) or no guarantee of rights (rating 5 or 5+) as defined by the International Trade Union Confederation (ITUC) Global Rights Index for 2016 [11]. This rating scale enables comparison of risk between datasets and utilises a variety of sources on real rights abuse instances alongside assessment of each country’s legal processes to inform contemporaneous risk ratings, minimising bias compared to supplier reporting [12,13]. We calculated the proportion of products at high-risk of labour abuse for all medical products and the proportion within each super-category. The Norway data are, to our knowledge, the most comprehensive and granular data on the origin of medical products used within healthcare systems in high-income countries. To ascertain congruity and relevance to other contexts, we obtained data from three other high-income settings and cross-analysed the findings to 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 2 of 32 compare the overall risk and the risk for specific product lines. We call these ‘comparative datasets’. Comparative dataset on overall risk: hospital procurement data from Cambridge, England We obtained procurement data for the 2018-19 financial year for Cambridge University Hospitals NHS Trust (a tertiary-level healthcare provider in England, providing core care to a local population of half a million and regional specialist services to six million) through finance (Qlikview, Qlik, Pennsylvania) and inventory (Powergate, GHX, Louisville) databases. We call this the ‘Cambridge dataset’. We extracted the top 100 items by spend under the categories 'medical or surgical equipment' and 'dressings', excluding capital purchases (which could skew data). For products in this dataset, we followed a standardised method of data collection. One author (JA) physically examined product packaging for statements in English on the country of manufacture (=COO), including statements using the terms 'made in', 'manufactured in', or 'assembled in' and any location identified through a manufacturer symbol and listed address. JA also searched supplier and manufacturer websites and performed Google searches using a systematic method to corroborate data on packaging. Where there was a discrepancy between the packaging and online sources, the COO on the packaging was used. Mirroring our analysis for the primary Norwegian dataset, for the Cambridge dataset we matched COO to classification on the ITUC Global Rights Index but for 2019 [14] (the financial year of this analysis) to ascertain the overall proportion of goods classified as high-risk (ITUC rating 4, 5, or 5+). For multi- component products, we assigned the product to the highest ITUC rating for the COO of any of its components. Where we could obtain data on only some components, we recorded COO as 'partially available'. Comparative datasets on risk for specific product lines: global trade data and US registry for medical products We know of two public databases documenting the COO of products that contain data on some medical products: (1) the United Nations (UN) Statistics Division Commodity Trade database (UN Comtrade), built on import and export data supplied by member countries of the UN [15], and (2) the US FDA Medical Devices Product Registration database, which registers all producers or distributors of medical devices intended for sale in the USA (where registration is a legal requirement) [16]. From each database, we extracted information on medical products also present in the Norway dataset. We searched the UN Comtrade database using the World Integrated Trade System (WITS, The World Bank, Washington, DC) online platform for exports in 2019. We identified medical products using World Customs Organisation HS 2017 nomenclature [17] and subtracted 're-exports' from 'gross exports' to calculate net exports. For countries with a net export, we assumed the product was manufactured in that country (=COO), and export volumes equated to the quantity manufactured and supplied to the global market. We matched the COO to the 2019 ITUC ratings [14] and calculated the proportion of products at high-risk of labour abuse (rating 4, 5, or 5+). During October and November 2021, we conducted a search of records on the FDA database for all product categories that comprised >2.5% of contract value (spend) in the Norway dataset, aiming to identify all product codes related to that category. We extracted all 'contract manufacturers' or 'manufacturers' listed on the database under these product codes and equated the COO of the product to the manufacturer’s registered address. The FDA database does not include trade volumes. To estimate the proportion of a product coming from each country, we assumed every registered manufacturer of a particular product supplied equal volumes of that product. We matched the COO to 2021 ITUC ratings [18] and calculated the proportion of products at high-risk of labour abuse (rating 4, 5, or 5+). For both comparator datasets, product codes were identified by one author (JA) with a review by a second (MFB). We compared the proportion of each product category or super-category in the Norway dataset to the equivalent product categories in other datasets. Results Primary dataset There were 23,972 products in the Norway dataset, 22,739 after excluding out-of-remit products (see the Appendices section for a list of out-of-remit products). COO was declared by the supplier for 55.4% of these by value (Table 1). COO Value of contract (€) Proportion of total value (%) ITUC rating (2016) Not available 55,879,804 44.61 - USA 21,802,238 17.41 4 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 3 of 32 Germany 5,167,919 4.13 1 France 4,642,393 3.71 2 Costa Rica 3,664,715 2.93 2 Malaysia 3,465,949 2.77 4 China 3,254,196 2.60 5 Ireland 2,968,309 2.37 1 Czech Republic 2,351,823 1.88 2 UK 2,149,468 1.72 3 Mexico 2,130,759 1.70 5 Japan 1,825,733 1.46 2 Switzerland 1,738,484 1.39 2 Canada 1,338,649 1.07 2 Hungary 1,323,035 1.06 3 Dominican Republic 1,204,289 0.96 2 Portugal 1,160,267 0.93 2 Singapore 1,028,794 0.82 2 Poland 1,025,388 0.82 3 Spain 969,137 0.77 3 Finland 942,033 0.75 1 Thailand 936,572 0.75 4 Sweden 909,776 0.73 1 Austria 703,751 0.56 1 Cambodia 423,026 0.34 5 Philippines 346,912 0.28 5 Slovakia 329,545 0.26 - Denmark 275,063 0.22 1 India 263,448 0.21 5 Italy 238,267 0.19 1 Puerto Rico 187,891 0.15 4 Belgium 163,716 0.13 1 Netherlands 73,612 0.06 1 Swaziland 67,815 0.05 4 South-Korea 57,895 0.05 5 Total 125,249,863.57 100 TABLE 1: COO of medical products supplied to the South-Eastern Norway Regional Health Authority in 2015-16 ranked by order of value of contracts (Euros, €) and proportion of the total value of all contracts The 2016 ITUC rating is also shown [11], and cells representing ITUC ratings of 4, 5, or 5+ are equated to a high-risk of labour abuse.Adash in the ITUC column represents there is no ITUC rating for that country or that the COO is unknown. Countries supplying <0.5% of the total value of contracts are not shown COO: country of origin, ITUC: International Trade Union Confederation 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 4 of 32 The most common COOs were the USA (17.4% of contracts by value), Germany (4.1%), France (3.7%), Costa Rica (2.9%), Malaysia (2.8%), and China (2.6%). All other countries had contracts worth <2.5% of the total. By continent, 24.2% of COOs were in North America, 21.7% in Europe, 9.3% in Asia, and 0.05% in Africa. Where COO was declared, the total proportion of purchases at high-risk of labour abuse was 49.1% (€34,028,154/€69,370,059 of purchasing), comprising 42.6% from countries rated ITUC 4 and 6.5% rated ITUC 5 (none rated ITUC 5+). Products from the Norway dataset were classified into 294 categories and 17 super-categories (see the Appendices section for the value of contracts for product super-categories and the product categories they contain from the analysis of the Norway dataset). Table 2 lists the COO for products in each super-category and the proportion by value of the contract with a high-risk of labour abuse. While total purchase value and missing data varied, where COO was present, certain super-categories showed higher proportional risk (e.g., gloves (82.3%) and electrical peripherals (78.0%)), while others showed lower risk (e.g., procedure packs (6.7%), fluid-based (32.3%), and non-sheet plastic products (33.2%)). Within super-categories, levels of risk and missing data also varied; for example, super-category ‘textiles’ includes ‘operating drapes’ (70.5% by value high-risk, 21.5% missing), ‘surgical gowns’ (91.7% high-risk, 8.3% missing), and ‘uniform’ (3.8% high- risk, 6.7% missing). Percentage of Value of Percentage of ITUC Percentage of Percentage of purchasing Product super- total the total value purchasing where where COO is declared with a COO contract rating category purchasing % of super- COO not declared % high-risk of labour abuse % (value in €) (€) category (%) (2016) (value in €) (value in €) USA 2,350,155 15.4 4 Singapore 1,026,721 6.7 3 Cannulae, Germany 791,104 5.2 1 12.2 catheters, and 52.8 (8,071,637) 41.0 (2,962,727) balloons (15,296,728) Ireland 711,654 4.7 2 Japan 617,749 4.0 2 Hungary 388,722 2.5 3 Cement and 0.9 (1,116,235) France 122,501 11.0 1 86.9 (969,748) 2.8 (4,066) scaffolds USA 2,316,909 19.6 4 Costa Rica 2,270,162 19.2 2 Electrical 9.4 (11,824,629) 51.0 (6,029,446) 47.3 (2,741,339) devices Germany 783,681 6.6 1 Mexico 424,429 3.6 4 USA 3,212,528 34.1 4 Electrical peripherals and 7.5 (9,419,939) Poland 868,808 9.2 4 43.3 (4,082,178) 78.0 (4,163,321) attachments Germany 764,770 8.1 1 Malaysia 2,816,014 71.1 4 Gloves 3.2 (3,962,190) Austria 657,358 16.6 1 6.5 (257,844) 82.3 (3,046,988) Thailand 228,567 5.8 4 Portugal 217,327 20.1 2 USA 164,559 15.3 4 Denmark 148,920 13.8 1 Liquids, sprays, 0.9 (1,078,793) Puerto Rico 83,157 7.7 4 28.8 (310,488) 32.3 (247,953) and gels UK 59,068 5.5 3 Switzerland 50,874 4.7 2 Germany 40,938 3.8 1 USA 6,882,686 29.1 4 France 2,541,637 10.7 1 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 5 of 32 18.9 Metal implants Ireland 862,379 3.6 2 49.1 (11,612,682) 58.1 (6,974,394) (23,668,647) Switzerland 590,019 2.5 2 Germany 578,366 2.4 1 USA 470,645 15.2 4 Japan 309,658 10.0 2 Metal instruments 2.5 (3,088,575) Germany 160,941 5.2 1 56.3 (1,737,362) 57.7 (780,391) Malaysia 155,074 5.0 4 Poland 106,580 3.5 4 USA 2,390,187 22.6 4 Multi-material Dominican 101,6301 9.6 2 Republic products and 8.5 (10,584,943) 47.4 (5,012,078) 49.7 (2,767,801) miscellaneous Spain 859,242 8.1 3 Japan 296,900 2.8 2 USA 243,316 19.6 4 Needles 1.0 (1,241,097) Japan 83,904 6.8 2 66.0 (819,136) 71.6 (302,312) Mexico 58,995 4.8 4 France 692,041 13.9 1 USA 690,079 13.9 4 Non-metallic 4.0 (4,969,816) 60.5 (3,008,528) 37.9 (742,554) implants Switzerland 248,949 5.0 2 Germany 165,014 3.3 1 USA 1,115,132 10.4 4 France 825,457 7.7 1 Germany 745,289 6.9 1 Finland 533,279 5.0 1 Non-sheet Switzerland 481,233 4.5 2 8.6 (10,744,866) 40.0 (4,294,371) 33.2 (2,142,338) plastic Portugal 454,265 4.2 2 Canada 438,468 4.1 2 Malaysia 347,865 3.2 4 The Philippines 346,912 3.2 5 Mexico 520,853 24.1 4 UK 244,660 11.3 3 Germany 182,740 8.4 1 Plastic sheets, USA 168,664 7.8 4 1.7 (2,164,665) 29.3 (634,795) 53.2 (814,336) films, and bags Slovakia 148,964 6.9 1 Dominican 89,070 4.1 2 Republic China 76,464 3.5 5 Czech Republic 2,105,346 23.9 2 Ireland 840,147 9.5 2 Procedure packs and multi- 7.0 (8,821,407) Hungary 696,633 7.9 3 42.2 (3,720,874) 6.7 (339,481) 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 6 of 32 component Portugal 465,183 5.3 2 products France 264,940 3.0 1 Sweden 217,862 2.5 1 China 2,439,147 35.6 5 Canada 807,812 11.8 2 Sweden 536,800 7.8 1 Cambodia 423,026 6.2 5 Textiles 5.5 (6,842,401) 20.2 (1,383,064) 59.1 (3,225,590) Mexico 267,741 3.9 4 Germany 225,584 3.3 1 UK 192,394 2.8 3 Switzerland 168,985 2.5 2 USA 868,533 12.8 4 Costa Rica 806,685 11.9 2 Thailand 539,799 7.9 4 Wires and stents 5.4 (6,801,498) 46.7 (3,179,236) 44.6 (1,614,037) Ireland 488,399 7.2 2 Japan 295,671 4.3 2 Germany 286,097 4.2 1 UK 702,272 19.4 3 USA 638,456 17.6 4 China 467,321 12.9 5 Wound 2.9 (3,623,426) Finland 359,788 9.9 1 20.9 (756,331) 39.4 (1,128,733) dressings Switzerland 180,143 5.0 2 Germany 167,745 4.6 1 Costa Rica 156,818 4.3 2 TABLE 2: COO of medical products supplied to the South-Eastern Norway Regional Health Authority in 2015-16 grouped by product ‘super-categories’ and ranked by order of value of contracts (value in Euros, €) Countries supplying <2.5% of the value of contracts for that ‘super-category’ are not shown. COO is mapped to the 2016 ITUC country rating for labour rights risk [11], with an ITUC rating of 4, 5, or 5+ equated to a high-risk of labour abuse COO: country of origin, ITUC: International Trade Union Confederation Comparative datasets In the Cambridge dataset, four items (of 100) were excluded as capital goods. Packaging was available for 83/96 items and supplier and manufacturer websites for 95/96 items (one website was under maintenance). Seventy items (70/96; 73.0%) had information available on COO, including six multi-component products with partially available information (see the Appendices section for the item categories and associated annual spend for products included in the Cambridge dataset). For 10 products, online data were incomplete or did not match product packaging. Of the 70 products for which the COO was identified (Table 3), 52.7% of annual spend came from COOs Mexico, the USA, or China. Thirty-nine (39/70; 55.7%) products had a COO of high-risk of labour rights abuse (ITUC rated 4 = 17 products; 5 = 22 products), equating to 59.9% of products by value (ITUC rated 4 = 26.0%; ITUC rated 5 = 33.8%) where there was a COO available. 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 7 of 32 COO Number of products with COO Summed value of contracts (£) Proportion of total value (%) ITUC rating (2019) Unknown 26 3,713,620 27.0 - Mexico 14 2,179,449 15.9 5 USA 12 1,981,895 14.4 4 China 7 1,126,414 8.2 5 Switzerland 6 734,879 5.4 2 Ireland 3 546,343 4.0 1 Malta 1 506,225 3.7 Not recorded Malaysia 4 414,604 3.0 4 Costa Rica 2 323,040 2.4 2 Germany 3 272,188 2.0 1 Dominican Republic 2 247,268 1.8 2 Bosnia and Herzegovina 1 212,132 1.5 4 Israel 1 211,000 1.5 2 France 1 197,496 1.4 2 Estonia 2 182,710 1.3 2 UK 2 172,159 1.3 3 Spain 2 165,044 1.2 2 European Community 2 158,842 1.2 Not recorded India 1 92,964 0.7 5 Australia 1 85,260 0.6 3 Singapore 1 79,200 0.6 2 Canada 1 72,964 0.5 2 Japan 1 68,536 0.5 2 Grand total 96 13,744,239 100 TABLE 3: COO of top 100 medical consumables (with four items excluded as per the main text description) by spend in the financial year April 2018-April 2019 supplied to Cambridge University Hospitals NHS Trust by annual spend (termed value of contracts, value in British Pounds, £) and ITUC rating In this dataset, for products of ‘multiple’ COOs, the highest ITUC-rated country is used to represent the product. COO is mapped to the 2019 ITUC country rating for labour rights risk [14], with ITUC rating 4, 5, or 5+ equated with a high-risk of labour rights abuse. Note: Malta and the European Community are not included in ITUC 2019 ratings, so the ITUC rating is listed as 'not recorded' COO: country of origin, ITUC: International Trade Union Confederation Eight medical product codes were identified in the UN Comtrade database with equivalent products in the Norway dataset (see the Appendices section for the UN Comtrade product categories and codes). The COO for these products compared to the nearest equivalent product in the Norway dataset is summarised in Table 4. UN Norway Comtrade data: UN UN data: Norway Percentage UN Norway Comtrade Comtrade Percentage Norway data: by value UN Comtrade Norway data data: data: net data: by value 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 8 of 32 product Norway data: percentage ITUC with a Comtrade UN exports percentage data: with a contract of total high-risk product Comtrade ITUC (category/super- data: COO rating value per of total net high-risk category) value per contract (2016) of labour (HS 2017 data: COO COO exports rating of labour COO (€) value per of COO abuse code) (1,000 per COO (2019) abuse COO (%) (COO ITUC USD) (%) per COO (COO ITUC 4, 5, or 5+) 4, 5, or 5+) (%) (%) Malaysia 1,128,140 50.7 4 Malaysia 377,704 25.2 4 Austria 657,358 29.5 1 China 280,536 18.7 5 Not available 233,513 10.5 - Thailand 271,886 18.1 4 Thailand 207,090 9.3 4 Surgical Germany 152,902 10.7 1 Surgical gloves rubber 60.0 Belgium 85,834 5.7 2 66.4 (category) gloves (401511) European 60,487 4.0 - Union Austria 53,973 3.6 1 Netherlands 49,074 3.3 1 India 39,261 2.6 5 Not European 8,071,637 52.8 - 6,583,973 19.0 - available Union USA (and USA 2,350,155 15.4 4 US 5,195,227 5.0 4 territories) Singapore 1,026,721 6.7 2 Netherlands 4,909,036 14.1 1 Cannulae, Catheters, catheters, and cannulae, Germany 791,104 5.2 1 41.0 Ireland 4,212,700 12.1 1 25.7 balloons (super- and the like category) Ireland 711,654 4.7 1 (901839) Germany 2,466,240 7.1 1 Japan 617,749 4.0 2 China 1,481,413 4.3 5 Hungary 388,722 2.5 3 Costa Rica 1,479,283 4.3 2 Belgium 1,330,903 3.8 2 Japan 1,066,423 3.0 2 USA 742,500 28.7 4 China 829,242 13.9 5 USA (and Not available 682,668 26.3 - US 785,444 13.2 4 territories) European Canada 438,468 16.9 2 Union 775,804 13.0 - Syringes, with or France and Syringes Philippines 346,912 13.4 5 575,173 9.7 2 (category) 57.1 without Monaco 32.7 needles Switzerland 245,065 9.5 2 (901831) Germany 511,759 8.6 1 Belgium 80,596 3.1 1 Switzerland 350,883 5.9 2 Netherlands 288,602 4.9 1 Belgium 278,888 4.7 2 Italy 228,845 3.8 2 Not 819,136 66.0 - European 495,018 15.4 - available Union USA 243,316 19.6 4 Belgium 331,923 10.4 2 USA (and 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 9 of 32 Japan 83,904 6.8 2 US 325,418 10.2 4 territories) Mexico 58,995 4.8 5 China 270,886 8.5 5 Tubular metal Germany 216,340 6.6 1 Needles (super- 76.9 needles and 31.0 category) needles for Japan 209,084 6.5 2 sutures Ireland 167,994 5.2 1 (901832) Denmark 114,561 3.6 1 Thailand 111,168 3.5 4 Singapore 98,877 3.4 2 Republic of 105,562 3.5 5 Korea Switzerland 98,877 3.1 2 European China 379,781 22.0 5 777,116 16.6 - Union Not 370,741 21.5 - China 518,065 11.1 5 available USA 288,679 16.7 4 Germany 480,313 10.3 1 Finland 180,570 10.5 1 Dressings, UK 473,461 10.1 3 adhesive, USA (and and other Adhesive Germany 165,897 9.6 1 US 379,833 8.1 4 articles dressings 49.4 territories) 25.7 having an (category) Switzerland 155,838 9.0 2 adhesive Japan 258,519 5.5 2 layer UK 152,990 8.9 3 Belgium 201,514 4.3 2 (300510) France and Monaco 180,463 3.9 2 Netherlands 171,235 3.7 1 Hungary 169,465 3.6 3 Finland 159,636 3.4 1 Not 130,324 31.9 - China 1,040,541 21.7 5 available UK 74,544 18.2 3 European 782,434 16.3 - Union China 58,651 14.3 5 UK 372,432 7.8 3 Norway 31,116 7.6 1 Germany 347,336 7.2 1 Wadding, Canada 29,612 7.2 2 Netherlands 307,823 6.4 1 gauze, Non-adhesive bandages, dressings Finland 28,086 6.9 1 26.2 Belgium 303,799 6.3 2 31.5 and similar (category) articles Czech Italy 19,052 4.7 1 (300590) Republic 291,588 6.1 2 USA (and Hungary 18,461 4.5 3 US 264,133 5.5 4 territories) Ireland 145,708 3.0 1 France and Monaco 135,127 2.8 2 European UK 33,336 45.7 3 63,135 17.8 - Union USA (and 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 10 of 32 Not 23,489 32.2 - US 59,606 16.8 4 available territories) Denmark 16,056 22.0 1 UK 28,026 7.9 3 Gel preparations Germany 23,719 6.6 1 Ultrasound and designed to China 22,135 6.3 5 be used in examination gel 0.0 38.0 human or Thailand 20,163 5.7 4 (category) veterinary medicine Ireland 18,777 5.3 1 (300670) Netherlands 18,532 5.2 1 Spain 12,994 3.7 2 Turkey 10,582 3.0 5 Italy 9,865 2.8 2 Austria 8,884 2.5 1 Not European 2,635,018 66.8 - 1,696,745 25.9 - available Union USA 1,309,438 33.2 4 Ireland 1,098,954 16.7 1 Switzerland 827,188 12.6 2 Cardiac Pacemakers pacemakers and excluding Germany 813,276 12.4 1 implantable 100 parts and 8.7 defibrillators accessories Belgium 573,602 8.7 2 (category) (902150) Malaysia 491,712 7.5 4 Netherlands 431,391 6.6 1 France and 310,200 4.7 2 Monaco TABLE 4: Comparison of COO for equivalent product categories/super-categories in the 2015-16 Norway and 2019 UN Comtrade datasets COO is compared for equivalent product categories/super-categories in the 2015-16 Norway dataset and the 2019 UN Comtrade database[15]. The first six columns relate to the Norway dataset: the name of the product category or super-category is shown in column 1 (with category/super-category in brackets indicating which of these is true for this group), columns 2-5 list the COO by contract value (in Euros, €) and the proportion of products from that COO alongside its ITUC rating, column 6 describes the overall proportion by value of that group from high-risk COO. The last six columns (columns 7-12) relate to data drawn from the UN Comtrade database, with column 7 listing the HS 2017 product code [17] used to search the database (shortened names are used in this table, see theAppendices section for the full category code name used in HS 2017 nomenclature). The value of net exports in column 9 is reported in US Dollars (USD), where a value of 1 in the table equates to 1000 USD. For both datasets, countries supplying <2.5% of the value of contract/net exports are not shown, percentage by value with a high-risk of labour abuse includes only products with a recorded COO (i.e., missing is excluded), and high-risk COO is defined as matching ITUC rating 4, 5, or 5+. COO is mapped to the 2016 (Norway data) and 2019 (UN Comtrade data) ITUC country rating for labour rights risk [11,14]. Note: the European Union is not included in the 2019 ratings and the value of contracts/exports values are listed in their respective reported currencies rather than being converted to a common denominator COO: country of origin, ITUC: International Trade Union Confederation Codes for five medical products were identified in the FDA database (see the Appendices section for the FDA product category codes and descriptors). Table 5 summarises the COO for these products compared to the nearest equivalent in the Norway dataset. Norway data: FDA data: Norway percentage Equated FDA Norway percentage of Norway data: by value FDA FDA data: FDA data: data: data: manufacturers Norway Norway data: percentage ITUC with a category FDA data: number of Percentage of ITUC with a high- product contract of total high-risk codes manufacturers all rating data: COO rating COO risk of labour category value per contract of labour with listed per manufacturers (2021) COO (€) value per (2016) abuse search COO per COO (%) of abuse (COO of COO ITUC 4, 5, or COO (%) (COO ITUC results COO 5+) (%) 4, 5, or 5+) 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 11 of 32 (%) Not DZL, available 6,905,008 83.6 - GWO, USA 3,644 59.7 4 GXN, Orthopaedic USA 723,143 8.8 4 Switzerland 1,021 16.7 2 nails, plates HRS, HWC, and screws, Switzerland 454,446 5.5 2 53.7 Germany 528 8.7 1 66.7 JDS, including NDF, France 250 4.1 2 cannulas NDH, NDJ, China 205 3.4 5 NQW USA 2,882,307 41.3 4 BWA, USA 1,198 52.0 4 DWG, Not EKZ, available 2,251,794 32.3 - Germany 301 13.1 1 FAR, Poland 868,808 12.4 3 FAS, China 162 7.0 5 FDI, Germany 572,654 8.2 1 FDJ, Mexico 135 5.9 3 GEI, Costa Rica 86 3.7 2 HGI, HQO, HQP, HQR, Electrosurgical JOS, 62.2 KGE, 63.3 products KNS, MUL, NEY, NLU, NTB, UK 60 2.6 3 NUJ, NWI, OCL, ODR, ONQ, PUL, QAG, QEC France 2,107,199 37.8 2 JDD, USA 4,246 63.8 4 JDG, USA 1,245,794 22.4 4 JDI, JDL, Switzerland 528 7.9 2 Ireland 861,543 15.5 1 KMC, Ireland 454 6.8 1 KWA, Not KWB, 602,748 10.8 - China 362 5.4 5 available KWL, KWY, Germany 329,842 5.9 1 Germany 267 4.0 1 KWZ, UK 290,366 5.2 3 KXA, UK 278 4.2 3 LPH, Hip prosthesis 26.5 LWJ, 70.6 LZO, LZY, MAY, MBL, MEH, MRA, France 178 2.7 2 NXT, OQG, OQH, OQI, OVO, PBI Not DRO, 2,635,018 66.8 - USA 306 64.8 4 available DTB, DXY, USA 1,309,438 33.2 4 Malaysia 47 10.0 5 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 12 of 32 JOQ, Switzerland 25 5.3 1 KRG, Pacemakers LWP, Germany 24 5.3 2 LWS, and 100 75.6 defibrillators MRM, Ireland 18 3.8 1 NIK, Singapore 12 2.5 2 NVN, NVY, OJX, Mexico 12 2.5 3 OSR, OVJ, PNJ USA 2,934,576 84.8 4 DSS, USA 422 56.8 4 FZP, Not FZQ, available 290,645 8.4 - Mexico 105 14.1 3 GDT, Germany 104,993 3.0 1 GDW, China 56 7.5 5 Clips and HQW, 94.2 67.0 staples JDR, Germany 44 5.9 1 MCH, Switzerland 31 4.2 2 MNU, NCA, NMJ, France 21 2.8 2 PKL TABLE 5: Comparison of COO for equivalent product categories between the Norway and FDA datasets COO is compared across equivalent product categories in the 2015-16 Norway dataset and the October/November 2021 FDAMedical Devices Database [16]. The first six columns relate to the Norway dataset: the name of the product category is shown in column 1 (no super-categories are included in this table); columns 2-5 list the COO and ITUC rating by contract value and the proportion of product by value (in Euros, €) from that COO; and column 6 describes the overall proportion by value of that product category from high-risk COO. The last six columns (columns 7-12) relate to data drawn from the October/November 2021 FDAMedical Devices Database: column 7 lists the category codes used to search the database for items equated to the Norway product category; columns 8-11 list the COO and ITUC rating by number of manufacturers listed and the proportion of manufacturers from that COO; and column 12 describes the overall proportion of manufacturers listed from high-risk COO. For both datasets, countries supplying <2.5% of the value of contract or number of total manufacturers listed are not shown, percentage by value with a high-risk of labour abuse includes only products with a recorded COO (i.e., missing is excluded) and high-risk COO is defined as matching ITUC rating 4, 5, or 5+. COO is mapped to the 2016 (Norway data) and 2021 (FDAdata) ITUC country rating for labour rights risk [11,18]. See theAppendices section for the descriptors of FDAdatabase category codes COO: country of origin, ITUC: International Trade Union Confederation, FDA: Food and DrugAdministration Discussion Risk of labour rights abuse in healthcare supply chains This is the first study to comprehensively evaluate the risk of labour abuse in healthcare supply chains. The use of the Norway dataset alongside three comparative datasets on COO from different global contexts is a key strength of this study. The Norway data is a large sample containing granular information on product types, including volumes, value, and COO. The size and granularity of the Norway data increase its suitability in assessing risk for the region. The product types in the Norway data are likely similar for many high-income contexts, although this has not been formally assessed. Data from the Norway and Cambridge datasets (Table 1, Table 3) indicate that for medical products with known COO, approximately half are manufactured in countries where there is a high-risk of labour rights abuse (COO rating of ITUC 4 or 5 at 49.1% of products by value in Norway and 59.9% in Cambridge). Across both datasets, the main countries contributing to this risk are the USA, Mexico, Malaysia, and China. When this risk is broken down by product type (Table 2, Tables 4-5), the proportion of products manufactured in any country (and the proportion at high-risk of labour abuse) varied across datasets. For example, the only listed COO for cardiac pacemakers and implantable defibrillators in the Norway data is the USA (contract value €1,309,438), with the majority of COOs for this category missing. While the USA does make up the biggest number of manufacturers in the FDA data (Table 5), there are several other COOs listed here, and the UN Comtrade data (Table 4) does not include the USA as a COO. Variation in the proportion of each product type manufactured in any country likely relates to the supplier used (since suppliers use networks of manufacturers across different locations) and is also impacted by missing data. Moreover, individual supplier practices, including policies on preventing modern slavery and relations with manufacturers, will vary. For most products, therefore, it would be erroneous to generalise the level of risk from each category in the Norway dataset and make blanket statements on the level of risk: assessment should be related back to the supplier chosen for a product and their responsible business practices. 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 13 of 32 In contrast, our data show most medical gloves are manufactured in South and South-East Asia (Malaysia, Thailand, and China; Table 4), where issues of forced labour have long been documented. Therefore, this product category should be considered high-risk for the majority of suppliers. These issues were made evident during the COVID-19 pandemic when supply chains for personal protective equipment gained media and political interest, leading to the USA banning imports of gloves from several manufacturers in Malaysia, which in turn spurred improvements to working conditions [19]. While caution is needed in making comparisons between datasets to ascertain the specific levels of risk (as described above and in the following section), comparative datasets also suggest certain product categories, in addition to gloves, may be at higher (electrosurgical products, clips, and staples) or lower-risk (non-adhesive dressings and examination gel) of labour rights abuse, although even ‘lower-risk’ items contain significant contributions from countries with high ITUC ratings. We note that China is the top site of production of medical textiles in the Norway data (with contracts totaling €2.4 million), despite having been noted as a location for forced labour by Uyghur populations in picking cotton (although we recognise many medical textiles are made of plastic polymers) [20]. The only preceding study with an assessment of risk in healthcare supply chains is a recent policy paper from the NHS in England on the risk of modern slavery (including slavery, servitude, forced labour, and human trafficking) in its supply chain [21]. Predominantly informed by a supplier questionnaire, this assessment investigated whether companies reported supplying any of the five medical products previously highlighted (including by our group [10]) as at risk of modern slavery: face masks, gloves, gowns, surgical instruments, and uniforms. That report found 21% of suppliers to be at risk of modern slavery. In comparison, our study has looked at the proportion of products (not suppliers) at risk of labour abuse and includes the full range of medical products and all forms of labour abuse (beyond those that define modern slavery). Our approach enables the identification of risk in medical supply chains where products might not previously have been highlighted as high-risk of labour rights abuses and allows for variation in risk between suppliers supplying the same products. This is important given the dynamic nature of supply chains, where the supplier chosen is subject to constant change. Limitations to assessment of risk There are little or no data on actual working conditions at the site of manufacture for the products we have included, and so our findings are an estimation of labour abuse risk. While there are strong pieces of evidence for instances of labour rights abuses in medical product manufacture from case studies [1-3], we are not aware of previous studies that have analysed the COO of medical products and their associated risk of labour rights abuses. Countries rated by the ITUC as 4, 5, or 5+ show persistent or repeated failures to protect workers, and prior evidence suggests using COO is predictive of real-world labour rights issues [9]. However, there are caveats: where manufacturing is largely mechanised and automated, the risk of labour rights infringement is normally lower than where products are largely manufactured through unskilled labour [22]. Conversely, our methodology highlights the proportion of products from high-risk COOs (i.e., ITUC rating of 4 or more), but this does not exclude risk where the COO is one with a lower ITUC rating (e.g., ITUC rating of 3, which indicates known ‘regular violations of rights’). Our study is a cross-sectional analysis where each dataset represents only a sample of activity within complex medical supply chains and has its own strengths and limitations. Differences in the construction and recording of these data between the four locations could limit comparison and generalisability. Although we compare the overall risk between the Norway and Cambridge datasets, the Cambridge dataset is a relatively small sample and derives from a specialist centre, which could have different procurement activities than other hospitals in England. There are also some unbalanced data contributions. For example, electrical devices, peripherals, and attachments constituted 50.5% of spend in the Cambridge dataset (see the Appendices section for the item categories and associated annual spend for products included with the Cambridge dataset), but only around 17% in the Norway dataset. We correlated the proportion of products at risk to expenditure, which could be unduly influenced by very high-cost items, such as cardiac pacemakers. The FDA database does not include data on quantity or value of trade; our assumption that manufacturers supply equal volumes is unlikely to reflect reality, and we recognise the limitations in comparing these proportions to the Norway data. Additionally, our assumption that export volumes in the UN Comtrade dataset equate to COO and quantity supplied to the global market may not always be true due to the complexities of global supply chains. Our analysis relies on COO reporting by supply chain stakeholders, and our datasets contain incomplete or potentially inaccurate data. Importantly, we note the scale of the missing data. Suppliers to Norway did not declare the COO of their products for nearly half of the products by value, despite this being mandated. It is likely that in many instances, the supplier was not aware of where their product was manufactured or did not wish to declare it, circumstances often associated with poor labour practices [23]. It is possible, therefore, that the proportion of medical products at high-risk of labour abuse is even higher than estimated here. Even where the COO was declared, this may represent a superficial or misleading statement. For example, the USA is a major site for the manufacture of medical products, supported by federal legislation that promotes the purchase of products wholly manufactured or substantially transformed in the USA. This policy does not, however, guarantee that products are actually manufactured in the USA; for instance, the medical suppliers Smith & Nephew and Medtronic have both received substantial fines for falsely stating 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 14 of 32 medical products to be made in the USA when they were in fact manufactured in Malaysia or China [24,25]. We should also be concerned about multi-component products, where those components may come from different countries, but the country of final assembly is stated as the COO, masking the risk. In the Norway data, the Czech Republic was stated as the COO of nearly a quarter of procedure packs and multi-component products, yet other data in this paper suggest that the Czech Republic is not a manufacturer of the typical constituents of such packs (including gloves, gauze, cannulae, or catheters). We should also show caution towards electrical devices, peripherals, and attachments, whose manufacture is stated to be predominantly in the USA, Europe, and Central America. It is highly likely that some (or even the majority) of components for these products are manufactured elsewhere; for example, although USA companies are responsible for 49% of global sales of semiconductors, they only manufacture 12%, with most made in China and East Asia [26]. Finally, there is a risk of selection and misclassification biases in the methods to categorise products in the Norway dataset, to identify product COOs in the Cambridge dataset, and to identify equivalent codes in the comparator datasets. However, these should not significantly affect the assessment of overall risk, and the use of multiple datasets as comparators acts towards mitigating this. Implications for research, policy, and practice Our analysis provides strong evidence that many medical goods purchased in high-income countries are at high-risk of labour rights abuse in their manufacture. Around half of the products by value in the Norway data with known COO derived from countries at high-risk of labour rights abuse, constituting contracts of over €34 million in 12 months, and we found evidence of such risk in data from different global contexts. These contexts included a smaller procurement sample from an acute hospital in a high-income country where the overall level of risk was comparable to that in the Norway data and two large global trade datasets that demonstrated significant risk for specific product categories. Despite the limitations of our study, this suggests that the overall high-risk of labour rights abuses in the manufacture of medical products identified in the Norway data based on COO is likely representative of the sector. The EU recently published proposals for a new directive on mandatory human rights and environmental due diligence for companies established in the EU, recognising as high-risk sectors the textile, clothing, footwear, food, agriculture, forestry, fisheries, and extractive industries [27]. The data available to public buyers here establishes that medical goods are also a high-risk industry, implicating the need for coordinated, multi-disciplinary approaches involving researchers, policymakers, and supply chain stakeholders focusing on this sector. Our study also highlights the potential utility of identifying high-risk products through COO as an initial approach to identifying risk, which could then be complemented by a rigorous investigation of potential high-risk areas [12]. However, in spite of our analysis being to date the most comprehensive assessment of the risk of labour rights abuses in medical supply chains, our attempts to identify high-risk products were limited by poor availability and transparency of COO data. The volumes of production by each COO and the exact level of risk for most products remain largely unknown. Further approaches to identifying high-risk products, including by ethical procurement practitioners, would require improvements to the availability and reliability of data on product COO. Thus, we believe that the proposed EU (and UK) diligence could be furthered by including the mandatory public declaration of product COO, which is already in place in countries such as Australia, Canada, South Korea, and the USA, but not the UK or EU [28]. Given the complexity of some products, in particular those with multiple components, the depth and granularity of transparency on COO will need to be sensitive to the particular product type and associated risk and also not simply focus on the first tier of a supply chain [12]. Transparency on COO will also help in quantifying and addressing environmental risks, given that typically 88% of the carbon footprint of single-use medical products is due to production [29]. Transparency in the COO should be seen as a first and necessary step in evaluating and tackling labour abuses in medical supply chains. What is also important is the governance in place to tackle such risks once identified, as well as the incentives and barriers to change through strategies of compliance or cooperation [30]. This would be complemented by further research into how supplier practices and supply chain stakeholders influence the risk of rights abuse, paying attention to the nuances specific to medical product supply chains. Our study does not include procurement data from middle- or low-income countries; future studies could assess if there are differences in the types and proportions of products purchased in these contexts and whether this impacts the level of risk taken on by the purchaser. Our analysis also did not include pharmaceuticals, but this is an important area for future research: major global sites of pharmaceutical production include China, India, and the USA, which are countries rated 4 or 5 on the latest (2023) ITUC Global Rights Index. Together, these approaches could enable a more comprehensive, validated assessment of risk at the level of specific medical products and specific supply chains, which would provide valuable information to supply chain practitioners and policymakers in all countries towards ending the practice of labour rights abuses in medical supply chains. Conclusions There has been previous case-based evidence of labour rights issues in the manufacture of specific medical products, but our analysis (using multiple data sources) suggests high-risk across this entire sector. We add insight into the way that public procurers could undertake risk assessments of their medical supply chains and highlight limitations. Our findings demonstrate a critical and urgent need for greater transparency in 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 15 of 32 global supply chains for medical products, which could be addressed through legislative or regulatory reform. Appendices The following supplementary materials provide further supporting information and analysis to aid in the interpretation of the associated manuscript. As per the data availability statement, further original data and analysis are available upon reasonable request to the corresponding author. The appendices use the same nomenclature to refer to each dataset and reference as described in the main text. The methods used to obtain these data are described in the main manuscript. Product category name Category description Alcohol gel Alcohol gel for hand cleaning Aluminium foil Aluminium foil, generally used within a kitchen for food preparation/storage Autoclave tape Tape designed to be used to seal boxes to be put into an autoclave Products including pacifiers, bottles, and nipple protectors designed for Baby care products baby care. Excludes nappies Baking paper Baking paper for use in cooking Barrier cream Topical cream used to create a barrier between the skin and skin irritants Blood bottles Bottle for blood collection Cardboard container Cardboard container Cleaning brush Brushes for cleaning instruments and surfaces Cleaning cloths Cloths for cleaning instruments and surfaces Clingfilm and clingfilm dispensers Clingfilm and clingfilm dispensers Coffee filter Coffee filter Cooking pans and tools Cooking pans and tools Crystalloid fluids Crystalloid fluids for use in infusions Cup holder Holder for drinking cup Cushion cover Cover for cushions (furniture) Cutlery Cutlery Disinfectant Disinfectant liquids for cleaning surfaces and equipment Draft barrier Item for theatres. Excludes drafts from outside room Equipment maintenance products other than specialist cleaning products, Equipment maintenance products other than specialist cleaning products, cleaning brushes, clothes, and oil cleaning brushes, clothes, and oil Floor mats and covers Matts of varied materials for floor protection Fortified drinks for patient consumption Fortified drinks for patient consumption Gloves dispenser Dispenser for holding non-sterile gloves Hairnets Hairnets for use in food-handling areas Hygiene bag dispenser Dispenser for hygiene bags Labels and label applicators Labels and applicators for those labels, generally used to label boxes Medications and products for injection Medications and products for injection Metal containers and instrument organisers Metal containers and instrument organisers, e.g., as used for sterilisation Microbiology products Microbiology products, used during microbiological lab analysis of samples Nail polish remover Nail polish remover Oil for equipment maintenance Oil for equipment maintenance 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 16 of 32 Oral hygiene care (toothbrushes, picks, and others) Patient products for oral hygiene care (toothbrushes, picks, and others) Plastic packaging for sterilisation Plastic packaging for sterilising equipment Paper Paper for general use Paper towel Paper towel Parent code only Products with parent code only, not a product in itself Patient wristband Wristbands for patient identification Personal hygiene products (other than oral and toiletries) Patient personal hygiene products (other than oral and toiletries) Plastic bag Plastic bag, unspecified use Plastic containers Plastic containers, unspecified use Plastic cups Plastic cups for drinking Plates (for food) Plates for food Product for return Unspecified product to be returned Refrigerant Refrigerant Repair kit Repair kit for equipment maintenance Room lighting Room lighting Sack wire Wire for closing bags Sandwich bags Paper/plastic bags designed to hold food contents Shelving and racks Shelving and racks Shoe covers Shoe covers, used to maintain area hygiene Skin lotion and moisturiser Skin lotion and moisturiser Soap Soap Soap dispenser Soap dispenser Specialist equipment cleaning products Specialist equipment cleaning products Paper or other device that indicates when the sterilisation process is Sterilisation indicator completed Sterilisation machine component Sterilisation machine component Sterilisation paper Paper used to wrap products for sterilisation Table cover Non-sterile table covers Thermal cup Cup for keeping contents at the desired temperature Tissue dispenser Tissue dispenser Tissues and napkins Tissues and napkins Toiletries for patient care Toiletries for patient care other than oral care products Urine bottle stand Urine bottle stand Wet wipes Wet wipes for non-medical purposes Wall mount Wall mount for device storage TABLE 6: Excluded product categories from the Norway dataset Medical products supplied to the South-Eastern Norway Regional HealthAuthority in 2015-16, identified product categories that were excluded prior to analysis, and descriptors of those categories Super-categories and the product categories they contain Contract value (€) 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 17 of 32 Cannulae, catheters, and balloons 15,296,728.50 Adaptors between tubes and syringes, plus end caps 822,041.49 Cardiac ablation catheters and related products 840,068.00 Cardiac catheters 2,994,374.48 Central arterial cannulae 54,167.00 Central venous cannulae 1,068,037.95 Endoscope sheaths and overtubes 84,216.10 Endoscope suction/biopsy channel 261,779.10 Endoscopic balloon catheter 613,860.92 Epidural catheters and other epidural products 458,060.77 ERCP catheter 65,596.30 Gastrostomy tubes and extension sets 1,479,875.75 Gel implant sizer 12,029.70 Haemostasis products (wound compression device) 558,464.70 Irrigation/suction/lavage catheter 538,921.08 Kit delivery catheters 6,458.00 Nasogastric, -duodenal, and - jejunal tubes 211,680.74 Occlusion catheters 230,622.13 Peripheral arterial cannulae 163,339.92 Peripheral venous cannulas 1,312,484.00 Rectal catheter 9,201.30 Spinal access ports 75.00 Spinal cannulae and lumbar puncture needles 58,746.78 Stent placement tools (endoscopy) 44,078.94 Surgical and non-surgical drains and drainage catheters 1,061,724.41 Uridom 239.56 Urinary catheters 518,643.23 Urinary dilatation catheters 29,265.70 Urinary occluder catheters 28,047.20 Uterine catheters 78,745.00 Vascular catheters 1,189,028.36 Veneports 186,448.00 Ventricular shunt and access ports 297,857.20 Vertebral body stents 18,549.70 Cement and scaffolds 1,116,235.17 Cement and related products/devices 890,398.17 Resorbable bone implants, bone matrix scaffolds 225,837.00 Electrical devices 11,824,629.67 Arthroscopic products 847,326.59 Cardiac pacemakers and implantable defibrillators 3,944,457.34 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 18 of 32 Computer for portable telemetry 166,200.23 Deep brain, spinal cord, and peripheral nerve stimulation 2,861,334.01 Electric device: irrigation, suction, and lavage 165,371.60 Electric drills 141,415.87 Electric saws 19,303.50 Electric thermometers 58,050.95 Endoscopes 84,200.00 Endoscopic capsule 291,110.90 Implantable cardiac monitor 684,055.14 Implantable drug pump 384,175.00 Infusion controller/pump 172,628.00 Invasive monitoring: pressure gauges and cable 824,774.41 Ophthalmoscope 8,393.00 Pen torches 19,769.60 Pulse oximeters 666,790.53 Ureteroscope 16,123.00 Ventricular assist device 469,150.00 Electrical peripherals and attachments 9,419,939.81 Battery packs 78,612.22 Bulbs for equipment 1,325.37 Defibrillator pads 111,556.61 ECG electrodes 426,138.22 ECG leads 75,970.59 Electric wires and cables 38,614.50 Electrosurgical grounding 5,054.40 Electrosurgical products 6,979,301.24 Endoscopic ultrasound and fine needle aspiration probes 3,144.78 Equipment and tools for use with cardiac leads and pacing devices 211,490.34 Fetal monitoring 4,713.80 Magnet for ICD deactivation 911.86 Neurosurgical electrodes 115,587.30 Ocular tonometry 268.20 Pacing leads 1,153,315.08 Pacing leads stylet 205.05 pH catheters 57,459.10 Pressure monitoring probes (manometry, intravascular, and intracranial) 119,793.15 Temperature probe for continuous monitoring 36,478.02 Gloves 3,962,190.74 Non-sterile examination gloves 1,736,087.81 Surgical gloves 2,226,102.94 Liquids, sprays, and gels 1,078,793.71 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 19 of 32 Gel for catheter insertion 25,955.00 Haemostasis products (liquid and gauze-based products) 562,638.05 Liquid wound closure preparations 131,266.47 Pastes, powders, and creams for stoma care 2,305.23 Pre-operative wash kit 238,179.29 Stoma bag removal spray 2.27 Ultrasound and examination gel 72,882.33 Wound cleaning products 45,565.06 Metal implants 23,668,647.81 Aneurysm clips 63,223.75 Clips and staples for surgical closure 3,458,589.13 Fixation and compression devices (orthopaedic) 277,479.11 Glenohumeral prosthesis 423,512.35 Hip prosthesis 5,567,753.07 Knee prosthesis 3,101,916.23 K-wire 192,063.10 Mechanical heart valve prosthesis 1,710,697.99 Metal orthopaedic implants other than prostheses 40,638.60 Nail end caps (orthopaedic) 50,927.05 Nuts, bolts, and washers 3,078.94 Orthopaedic nails, plates, and screws including cannulas 8,259,213.04 Other orthopaedic products 92,260.50 Wires and cables for orthopaedic procedures 427,294.95 Metal instruments 3,088,575.15 Biopsy curette 62.01 Biopsy forceps 352,654.10 Clamps 35,433.82 Laryngoscope 12,958.79 Manual drills and drill attachments 409,133.77 Manual saws and blades 860,653.16 Mixed orthopaedic tools 454,091.50 Obstetric forceps 2,594.30 Orthopaedic reamer 73,068.88 Orthopaedic templates 74.04 Skin graft carriers 11,721.80 Staple remover 701.42 Surgical retractors 76,946.59 Surgical tool organising 12,300.80 Surgical tools 775,643.81 Tuning fork 1,490.33 Vaginal specula 9,046.02 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 20 of 32 Multimaterial products and miscellaneous 10,584,943.16 Balloon inflation device 115,555.76 Biopsy gun/punch 161,448.72 Biopsy products, unspecified 2,987.53 Blood pressure cuffs 2,782.80 Blunt scissors 111,388.59 Cable and line organiser 157,627.41 Case for telemetry device 140,243.00 Catheter introducers and sheaths 833,809.34 Chin support 16,916.99 Clip applicator 391,218.49 CO2 insufflation needles 41,782.64 Cold/hot compress 79,565.97 Cutting block 260.71 Cytology brush 21,591.50 Depth gauge 49,297.50 Emergency blanket 535.87 Endoscopic ligation bands 44,624.88 Endoscopic tools 122,158.90 ENT stents 909.90 Filters for irrigation, suction, and lavage 29,463.62 Handles for irrigation/suction/lavage device 9,528.00 Identification loops for surgery 21,500.39 Infusion stand 9,733.70 Intraocular glide sheet 47.60 Laparoscopic accessories (excluding electrosurgical) 266,000.12 Ligamentous and tendon repair products 692,529.29 Marker pens 28,796.55 Medical tape 230,184.34 Nail brush 148,210.30 Ophthalmology eye spears 5,163.00 Ophthalmology lenses 18,576.90 Orthopaedic spacers 42,071.60 Patient warmers (blanket, self-warming) 38,318.00 Personal protective equipment: hoods 141,340.80 Plaster casts and related products 315,605.50 Pregnancy test 211.50 Repaired instruments 114,268.84 Safety pins 8,915.06 Sanding 28,004.40 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 21 of 32 Saw blade guard 843.90 Schirmer test paper 948.60 Screens for radiation protection 38,355.61 Screwdriver and screwdriver tips 12,266.51 Seal for irrigation, suction, and lavage 56.40 Shaving equipment 27,783.05 Smoke extraction device filter 50,154.00 Stapling machine 504,626.08 Sterile ruler 265.40 Stethoscopes 25,727.90 Suction system silencer 367.48 Supports and orthoses 234,116.27 Sutures 2,016,057.49 Tendon hammer 4,499.50 Tongue spatula 3,144.30 Tourniquet 53,915.30 Tracheostomy cleaning brush 7,420.97 Tracheostomy filter/vent 34,989.95 Tracheostomy pressure monitoring device 945.00 Trocars 1,843,273.77 Unknown 991,498.08 Ureteral access sheaths 186,115.00 Urinalysis kits 34,542.50 Urine bottle 10,224.49 Vomit bag 59,629.62 Needles 1,241,097.73 Biopsy needles 517,341.20 Endoscopy needles 221,012.50 Needles, unspecified 146,858.29 Suture needles 204,730.24 Transeptal needles 151,155.50 Non-metallic implants 4,969,816.21 Breast implants and tissue expanders 671,490.90 Endobronchial valves 55,796.40 ENT prosthesis 1,100.70 Nasal splints and septal buttons 1,957.40 Penile and testicular implants 104,199.60 Plastic orthopaedic implants other than prostheses 45,782.70 Septal occluders for ASD/VSD repair 154,370.00 Surgical mesh 1,197,600.89 Urethra slings 324,316.80 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 22 of 32 Vascular and cardiac repair grafts 2,413,200.82 Non-sheet plastic 10,744,866.57 Airways 625,903.04 Biopsy valves 294,640.90 Bite guard and tooth protectors 32,044.00 Breathing circuit 728,991.88 Breathing filters and exchangers 496,303.29 Catheter clamps 3,662.06 CO2 insufflation tubing 298,064.93 CPAP and BiPAP tubing and masks 471,982.77 Dosette box 6,830.22 Endoscope distal attachments 44,740.80 Fluid draining wick ophthalmology 42.00 Fluid warmer disposable cartridge 166,934.00 Guidewire delivery device 26,580.00 Hose for irrigation, suction, and lavage 557,175.85 Infusion burette 1,780.70 Infusion drip chamber and filters 678,705.04 Infusion tubing (without drip chamber, spikes, etc.) 946,118.61 Nasal cannulae 333,642.32 Nebulizer chambers and masks (not electrical devices) 127,334.90 Obstetric ventouse 466.00 Operation patient positioning 60,628.00 Otoscope disposables 23,874.74 Oxygen masks 192,975.92 Personal protective equipment: goggles and glasses 7,400.58 Plastic eye shield (post-ophthalmology surgery) 2,508.80 Rectoproctoscopes 64,202.40 Rigid collars and boards for trauma 37,714.31 Sharps bins 227,509.13 Specimen pots 37,398.61 Stoma bridge 17.20 Syringes 2,590,946.62 Tracheostomy tubes (inner and outer) 146,048.45 Tracheostomy valve 3,661.11 Uterine mobilisers 41,050.40 Valves for irrigation, suction, and lavage 27,057.56 Waste bins (other than sharps) 915,760.09 Water container for irrigation, suction, and lavage 524,169.36 Plastic sheets, films, and bags 2,164,665.83 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 23 of 32 Collection bag for stool 194,670.13 Corpse bag 9,405.90 Equipment covers 154,418.19 Infusion cuff 16,922.80 Laparoscopic wound protectors 13,841.50 Patient warmers (blanket, fillable) 422,696.86 Personal protective equipment: aprons 47,905.11 Personal protective equipment: face shields 4,822.38 Specimen retrieval bags 443,211.90 Stoma bags 83,577.65 Stoma rinsing sleeve 264.00 Ultrasound probe covers 198,101.94 Urinary catheter bags 380,527.47 Waste bags 194,300.00 Procedure packs and multi-component products 8,821,407.24 Catheter accessory kit 51,556.80 Cricothyroidectomy kit 3,122.86 Donation and cell-salvage kits 97,606.02 Irrigation, suction, and lavage kits 423,933.54 IV/SC administration set (including drip chamber, filters, spike, tubing) 1,690,497.36 PEG insertion kits 45,165.95 Procedure packs 5,932,723.83 Resuscitation kit 170.00 Robot-assisted surgery packs 48,642.00 Syringe kits 336,840.00 Tracheostomy insertion kit 5,5012.42 Tracheostomy suction kit 136,136.45 Textiles 6,842,401.28 Absorbent sheets for bed/chair protection 478,214.44 Alcohol wipes 25,033.38 Compression stockings 24,1652.16 Cotton wool and cotton buds 13,564.13 Fluid warmer strap 5,499.00 Menstrual and incontinence pads 734,143.27 Nappies 1,812.60 Neurosurgical patties 49,471.90 Operating drapes 1,598,803.67 Patient clothing 101,781.87 Patient transfer sheet 17,145.34 Patient warmers (other, textile) 236,990.64 Personal protective equipment: respirators 179,742.43 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 24 of 32 Personal protective equipment: surgical facemasks 225,270.76 Scrubs and uniform 361,179.10 Stoma belt 12,649.59 Surgical caps 209,063.52 Surgical gown 1,834,821.15 Surgical swabs 477,124.34 Tracheostomy neck strap 38,438.00 Wires and stents 6,801,498.92 Biliary and pancreatic stents 367,002.69 Breast tissue marker 13,913.00 Endovascular coils 384,950.90 Guidewires 2,143,142.71 Oesophageal and intestinal stents 258,222.00 Polypectomy wire 310,119.56 Renal stone basket 201,824.20 Sphincterotomes (for use in endoscopy) 539,595.91 Tracheobronchial stents 19,987.50 Ureteral stents 193,578.00 Vascular and cardiac stents 2,369,162.45 Wound dressings 3,623,426.08 Adhesive dressings 1,723,589.85 Epistaxis pack 18,747.20 Non-adhesive dressings 408,882.45 Specialised dressings 467,746.08 Stoma dressings 2,864.20 Stoma sealing rings 118.82 Vacuum dressings 1,001,477.48 Grand Total 125,249,863.57 TABLE 7: Value of contracts for product super-categories and the product categories they contain from the analysis of the Norway dataset Medical products supplied to the South-Eastern Norway Regional HealthAuthority in 2015-16 and the categories included in the final analysis, breakdown of assigned product categories contained within each super-category (super-category name and total contract value in bold), and the value of contracts per product category in Euros (€) Number of items in the Super-category or product category Annual spend of financial year 2018 (£) category Cannulae, catheters, and balloons 6 501,200.93 Cardiac catheters 1 68,536.17 Peripheral venous cannulae 1 112,690.48 pH catheters 2 158,644.00 Surgical and non-surgical drains and drainage catheters 1 88,504.32 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 25 of 32 Ventricular shunt and access ports 1 72,825.96 Electrical devices 28 4,355,974.40 Cardiac pacemakers and implantable defibrillators 11 1,932,464.50 Cochlear implant components 7 1,125,685.60 Deep brain, spinal cord, and peripheral nerve stimulation 4 543,618.00 Endoscopes 2 189,438.30 Other direct imaging equipment 1 211,000.00 Pulse oximeters 2 210,668.00 Ureteroscope 1 143,100.00 Electrical peripherals and attachments 14 2,587,145.51 ECG leads 1 90,045.00 Electrosurgical products 10 2,111,946.67 Fetal monitoring 1 115,057.84 Neurosurgical electrodes 1 72,600.00 Pacing leads 1 197,496.00 Gloves 6 573,951.63 Non-sterile examination gloves 4 412,416.68 Surgical gloves 2 161,534.96 Liquids, sprays, and gels 3 859,427.29 Haemostasis products (liquid and gauze-based products) 2 406,177.29 Organ transplant media 1 453,250.00 Metal implants 4 385,878.62 Clips and staples for surgical closure 4 385,878.62 Multi-material products and miscellaneous 11 1,345,357.75 Clip applicator 1 96,673.50 Laparoscopic accessories 5 585,399.03 Other equipment accessories 1 210,000.00 Stapling machine 2 275,887.23 Trocars 1 92,327.41 Urine bottle 1 85,070.58 Needles 1 77,550.00 Biopsy needles 1 77,550.00 Non-sheet plastic 11 1,296,972.14 Breathing circuit 3 257,014.00 Infusion tubing (without drip chamber, spikes, etc.) 3 537,675.45 Operation patient positioning 2 204,088.82 Syringes 3 298,193.87 Plastic sheets, films, and bags 1 71,318.40 Specimen retrieval bag 1 71,318.4 Procedure packs and multi-component products 7 1,246,935.16 IV/SC administration set (including drip chamber, filters, spike, t4bing) 945,521 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 26 of 32 Neurosurgical shunt insertion kit 1 128,650 Procedure packs 1 92,964.16 Wound care pack 1 79,800 Textiles 2 254,157.75 Compression stockings 1 78,207.75 Operating drapes 1 175,950.00 Wires and stents 2 188,370.00 Sphincterotomes (for use in endoscopy) 1 120,120.00 Ureteral stents 1 68,250.00 Grand total 96 13,744,239.58 TABLE 8: Item categories and associated annual spend for products included in the Cambridge dataset Breakdown by item category of the top 100 medical consumables (excluding four out of remit products as described in the main manuscript) by spend in the yearApril 2018-April 2019 supplied to Cambridge University Hospitals NHS Trust. The numbers of items in each category and the related annual spend in British Pounds (£) are provided. The item categories and super-categories are chosen based on the same categories used in the Norway dataset analysis, except for new categories of ‘other direct imaging equipment’, ‘organ transplant media’, and ‘wound care pack’ which have been assigned to appropriate super-categories. Super-categories and the total in that category are listed in bold, with item categories contributing to that category listed directly underneath Shortened name used in Category UN Comtrade category name these documents code Surgical rubber gloves Surgical rubber gloves 401511 Catheters, cannulae, and the Medical, surgical instruments and appliances; catheters, cannulae, and the like 901839 like Medical, surgical instruments and appliances; syringes, with or without needles (901831) Syringes with or without 901831 needles Medical, surgical instruments and appliances; tubular metal needles and needles for sutures (code Tubular metal needles and 901832) needles for sutures 901832 Dressings, adhesive; and Dressings, adhesive; and other articles having an adhesive layer, packed for retail sale for medical, other articles having an 300510 surgical, dental, or veterinary purposes (code 300510) adhesive layer Wadding, gauze, bandages, and similar articles; (excluding adhesive dressings), impregnated or coated Wadding, gauze, bandages, with pharmaceutical substances, packaged for retail sale (code 300590) (henceforth ‘non-adhesive and similar articles 300590 dressings’) Pharmaceutical goods; gel preparations designed to be used in human or veterinary medicine as a Gel preparations designed to lubricant for parts of the body for surgical operations or physical examinations or as a coupling agenbe used in human or 300670 between the body and medical instruments veterinary medicine Pacemakers excluding parts Pacemakers; for stimulating heart muscles (excluding parts and accessories) and accessories 902150 TABLE 9: UN Comtrade product categories and codes Medical product category names and code from HS 2017 [17] nomenclature that was explored and data obtained from UN Comtrade[15] via World Integrated Trade System (WITS, The World Bank, Washington, DC) online platform (as per method in associated manuscript). The table also describes the shorthand names used throughout the manuscript and supplementary information (which was generated by the authors) to refer to these categories FDA product code FDA product description 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 27 of 32 MQZ Prosthesis, nail JDS Nail, fixation, bone NDH Nail, fixation, bone, metallic NDF Plate, fixation, bone, non-spinal, metallic HRS Plate, fixation, bone GXN Plate, cranioplasty, preformed, non-alterable GWO Plate, cranioplasty, preformed, alterable NQW Orthosis, spine, plate, laminoplasty, metal HWC Screw, fixation, bone NDJ Screw, fixation, bone, non-spinal, metallic DZL Screw, fixation, intraosseous FAR Unit, electrosurgical BWA Unit, electrosurgical and coagulation, with accessories EKZ Unit, electrosurgical, and accessories, dental KNS Unit, electrosurgical, endoscopic (with or without accessories) NLR Unit, electrosurgical, endoscopic (with or without accessories), reprocessed OEK Water-induced thermotherapy system, benign prostatic hyperplasia OCL Surgical device, for cutting, coagulation, and/or ablation of tissue, including cardiac tissue NEY System, ablation, microwave and accessories NTB System, ablation, ultrasound and accessories OEJ Transurethral electrosurgical unit, benign prostatic hyperplasia FDI Snare, flexible NLT Snare, flexible, reprocessed FDJ Snare, rigid self-opening PUL Apparatus, cutting, radiofrequency, electrosurgical, AC-powered NCR Apparatus, cutting, radiofrequency, electrosurgical, battery-powered NVJ Applicator, transurethral, radio frequency, for stress urinary incontinence in women FHZ Desiccator, transurethral JOS Electrode, electrosurgical FAS Electrode, electrosurgical, active, urological NLW Electrode, electrosurgical, active, urological, reprocessed ONQ Electrosurgical coagulation for aesthetic DWG Electrosurgical device NWI Electrosurgical electrode kit ODR Electrosurgical patient return electrode MUK Electrosurgical radiofrequency system, stress urinary incontinence, female, transvaginal or laparoscopic, pelvic tissue PDG Electrosurgical vessel and/or tissue sealer. With built-in generator GEI Electrosurgical, cutting & coagulation & accessories NUJ Electrosurgical, cutting & coagulation accessories, laparoscopic & endoscopic, reprocessed QAG Endoscopic electrosurgical clip cutting system KGE Forceps, biopsy, electric 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 28 of 32 QEC Forceps, biopsy, electric surgical hemostasis within tracheobronchial tree NLU Forceps, biopsy, electric, reprocessed MUL Generator, electrosurgical, coagulation, cancer HGI Electrocautery, gynecologic (and accessories) HIM Electrocautery, endoscopic and accessories HQO Unit, cautery, thermal, ac-powered HQP Unit, cautery, thermal, battery-powered HQQ Apparatus, cautery, radiofrequency, battery-powered HQR Apparatus, cautery, radiofrequency, ac-powered NCR Apparatus, cutting, radiofrequency, electrosurgical, battery-powered PUL Apparatus, cutting, radiofrequency, electrosurgical, AC-powered OQG Hip prosthesis, semi-constrained, cemented, metal//polymer, + additive, porous, uncemented OQI Hip, semi-constrained, cemented, metal/ceramic/polymer + additive, porous uncemented OQH Hip, semi-constrained, cemented, metal/polymer + additive, cemented MAY Prosthesis, hip, semi-constrained, metal/ceramic/polymer, cemented or non-porous cemented, osteophilic finish KWZ Prosthesis, hip, constrained, cemented or uncemented, metal/polymer PBI Prosthesis, hip, constrained, cemented or uncemented, metal/polymer, + additive KXD Prosthesis, hip, constrained, metal JDG Prosthesis, hip, femoral component, cemented, metal KXA Prosthesis, hip, femoral, resurfacing KWB Prosthesis, hip, hemi-, acetabular, cemented, metal KWL Prosthesis, hip, hemi-, femoral, metal LZY Prosthesis, hip, hemi-, femoral, metal ball KWY Prosthesis, hip, hemi-, femoral, metal/polymer, cemented or uncemented JDH Prosthesis, hip, hemi-, trunnion-bearing, femoral, metal/polyacetal KXB Prosthesis, hip, pelvifemoral resurfacing, metal/polymer OCG Prosthesis, hip, pelvifemoral resurfacing, metal/polymer, uncemented JDL Prosthesis, hip, semi-constrained (metal cemented acetabular component) KWA Prosthesis, hip, semi-constrained (metal uncemented acetabular component) KMC Prosthesis, hip, semi-constrained, composite/metal OVO Prosthesis, hip, semi-constrained, ceramic-on-metal articulation LPF Prosthesis, hip, semi-constrained, metal/ceramic/ceramic, cemented MRA Prosthesis, hip, semi-constrained, metal/ceramic/ceramic/metal, cemented or uncemented LZO Prosthesis, hip, semi-constrained, metal/ceramic/polymer, cemented or non-porous, uncemented NXT Prosthesis, hip, semi-constrained, metal/metal, resurfacing JDI Prosthesis, hip, semi-constrained, metal/polymer, cemented LPH Prosthesis, hip, semi-constrained, metal/polymer, porous uncemented LWJ Prosthesis, hip, semi-constrained, metal/polymer, uncemented MEH Prosthesis, hip, semi-constrained, uncemented, metal / polymer, non-porous, calcium phosphate MBL Prosthesis, hip, semi-constrained, uncemented, metal/polymer, porous 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 29 of 32 JDD Prosthesis, upper femoral NIK Defibrillator, automatic implantable cardioverter, with cardiac resynchronization (CRT-D) MRM Defibrillator, implantable, dual-chamber LWS Implantable cardioverter defibrillator (non-CRT) NVY Permanent defibrillator electrodes JOQ Generator, pulse, pacemaker, external programmable (for electrophysiological studies only) DXY Implantable pacemaker pulse-generator LWP Implantable pulse generator, pacemaker (non-CRT) PNJ Leadless pacemaker DRO Pacemaker, cardiac, external transcutaneous (non-invasive) OSR Pacemaker/icd/crt non-implanted components DTB Permanent pacemaker electrode KRG Programmer, pacemaker OVJ Pulse generator, external pacemaker, dual chamber HGB Clip, tubal occlusion DSS Clip, vascular PKL Hemostatic metal clip for the GI tract HQW Clip, tantalum, ophthalmic FZP Clip, implantable MCH Clip, hemostatic NCA Clip, implantable, for coronary artery bypass graft (CABG) NJC Clip, vas deferens NMJ Clip, implantable, reprocessed FZQ Clip, removable (skin) MNU Staple, absorbable JDR Staple, fixation, bone NDI Staple, fixation, bone, metallic GDW Staple, implantable NLL Staple, implantable, reprocessed GDT Staple, removable (skin) TABLE 10: FDA product category codes and descriptors Medical product category codes from the FDAproduct code database [16] that were identified and data was collected as in Table 5 of the main manuscript.All these codes were those identified in searching the FDAproduct code database for equivalent product categories that comprised >2.5% of contract value for spend in the Norway dataset following the exclusion of out-of-remit products Additional Information Author Contributions All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work. Concept and design: Jasmin Abbott, James N. Smith, Mahmood F. Bhutta, Chantelle Rizan Acquisition, analysis, or interpretation of data: Jasmin Abbott, Merete Loeken, Mei L. Trueba, 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 30 of 32 Mahmood F. Bhutta, Chantelle Rizan Drafting of the manuscript: Jasmin Abbott, Mahmood F. Bhutta Critical review of the manuscript for important intellectual content: Merete Loeken, James N. Smith, Mei L. Trueba, Mahmood F. Bhutta, Chantelle Rizan Supervision: James N. Smith, Mahmood F. Bhutta, Chantelle Rizan Disclosures Human subjects:All authors have confirmed that this study did not involve human participants or tissue. Animal subjects:All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Jasmin Abbott declare(s) employment from York and Scarborough Teaching Hospitals NHS Foundation Trust. During data analysis and drafting of the manuscript, Jasmin Abbott was employed by York and Scarborough Teaching Hospitals NHS Foundation Trust; however, there was no time provision or funding as part of this role for work done on this manuscript. Mahmood F. Bhutta declare(s) non-financial support from BMA Medical Fair and Ethical Trade Group. Mahmood F. Bhutta is a co-founder of the BMA Medical Fair and Ethical Trade Group, a group that investigates and supports the improvement of working conditions in medical supply chains. Jasmin Abbott and Mahmood F Bhutta declare(s) non-financial support and employment from University Hospitals Sussex NHS Foundation Trust. During the final stages of preparation of this manuscript, Jasmin Abbott applied for and accepted employment at University Hospitals Sussex NHS Foundation Trust in a post where Mahmood F. Bhutta provides supervision as part of his role as Green Clinical Lead and was part of the interview panel for the post. James N. Smith declare(s) employment from Department of Public Health and Primary Care, University of Cambridge. James N. Smith participated in the project and supported Jasmin Abbott as part of a paid role for the Department of Public Health and Primary Care. Merete Loeken declare(s) employment from Norwegian Hospital Procurement Trust. Merete Loeken provided a substantial contribution to data acquisition for data relating to Norwegian Hospital Procurement and was employed by the Norwegian Hospital Procurement Trust during the acquisition of data underlying this manuscript. Chantelle Rizan, Mei L. Trueba, and Mahmood F. Bhutta declare(s) employment from Brighton and Sussex Medical School. Chantelle Rizan, Mei L. Trueba, and Mahmood F. Bhutta all hold academic positions at Brighton and Sussex Medical Group in the Department of Global Health and Infection; however, there was no specific grant allocated for supporting this piece of work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. Acknowledgements Data underlying this article are available on reasonable request to the corresponding author for the purpose of further research. Thanks to the Procurement Team at Cambridge University Hospitals, in particular Ian Hooper and Janek Truszkowski, for enabling access to their databases. References 1. Shaukat Z, Hisam Z, Din NU, et al.: Labour standards in Pakistan’s surgical instruments sector: a synthesis report. Berman C (ed): The Ethical Trade Initiative (ETI) and The Pakistan Institute of Labour Education and Research (PILER), UK; 2020. 2. Bhutta MF, Bostock B, Brown J, et al.: Forced labour in the Malaysian medical gloves supply chain before and during the COVID-19 pandemic: evidence, scale and solutions. Modern Slavery and Human Rights Policy and Evidence Centre and Arts & Humanities Research Council, UK; 2021. 10.13140/RG.2.2.12680.75520 3. British Medical Association: Labour rights abuse in global supply chains for PPE through COVID-19 - issues and solutions. British Medical Association, London, UK; 2021. https://www.bma.org.uk/media/4288/ppe- labour-rights-abuse-in-global-chains-for-ppe-through-covid-july-2021.pdf. 4. Gereffi G: What does the COVID-19 pandemic teach us about global value chains? The case of medical supplies. J Int Bus Policy. 2020, 3:287-301. 10.1057/s42214-020-00062-w 5. Medical Instruments. (2022). Accessed: April 21, 2022: https://oec.world/en/profile/hs/medical- instruments. 6. Gold S, Trautrims A, Trodd Z: Modern slavery challenges to supply chain management. Supply Chain Manag. 2015, 20:485-94. 10.1108/scm-02-2015-0046 7. Dai T, Bai G, Anderson GF: PPE supply chain needs data transparency and stress testing. J Gen Intern Med. 2020, 35:2748-9. 10.1007/s11606-020-05987-9 8. British Medical Association: Ethical procurement for health: workbook 2.0. British Medical Association, London, UK; 2017. https://www.bma.org.uk/media/2409/ethical_procurement_for_health_workbook_20_final_web.pdf. 9. Sedex: Recognising forced labour risks in global supply chains: Sedex findings from 100,000 social audits. Sedex, London, UK; 2021. https://www.antislaverycommissioner.co.uk/media/1683/sedex-recognising- forced-labour-risks-in-global-supply-chains-oc.... 10. Bhutta MF: Time for a global response to labour rights violations in the manufacture of health-care goods . Bull World Health Organ. 2017, 95:314. 10.2471/BLT.17.193417 11. International Trade Union Confederation: 2016 ITUC global rights index: the world’s worst countries for 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 31 of 32 workers. International Trade Union Confederation, Brussels, Belgium; 2016. https://www.ituc- csi.org/IMG/pdf/survey_ra_2016_eng.pdf. 12. Ishaya BJ, Paraskevadakis D, Bury A, Bryde D: A systematic literature review of modern slavery through benchmarking global supply chain (Preprint). Benchmarking. 2023, 10.1108/bij-09-2022-0554 13. Kucera D, Sari D: New labour rights indicators: method and trends for 2000-15 . Int Labour Rev. 2018, 158:419-46. 10.1111/ilr.12084 14. International Trade Union Confederation: 2019 ITUC global rights index: the world’s worst countries for workers. International Trade Union Confederation, Brussels, Belgium; 2019. http://www.ituc- csi.org/IMG/pdf/2019-06-ituc-global-rights-index-2019-report-en-2.pdf. 15. United Nations: UN Comtrade international trade statistics database. (2022). Accessed: April 21, 2022: https://comtrade.un.org/. 16. U.S. Food and Drug Administration: FDA device registration and listing. (2022). Accessed: April 21, 2022: https://www.fda.gov/medical-devices/how-study-and-market-your-device/device-registration-and-listing. 17. World Customs Organization: HS nomenclature 2017 edition. (2022). Accessed: April 21, 2022: http://www.wcoomd.org/en/topics/nomenclature/instrument-and-tools/hs-nomenclature-2017- edition.aspx. 18. International Trade Union Confederation: 2021 ITUC global rights index: the world’s worst countries for workers. International Trade Union Confederation, Brussels, Belgium; 2021. https://files.mutualcdn.com/ituc/files/ITUC_GlobalRightsIndex_2021_EN_Final.pdf. 19. Hughes A, Brown JA, Trueba ML, et al.: Global value chains for medical gloves during the COVID-19 pandemic: confronting forced labour through public procurement and crisis. Glob Netw. 2022, 23:1-18. 10.1111/glob.12360 20. China accused of forcing 570,000 people to pick cotton in Xinjiang . (2020). Accessed: April 21, 2022: https://www.reuters.com/article/china-cotton-forced-labour-trfn-idUSKBN28P2CM. 21. Review of risk of modern slavery and human trafficking in the NHS supply chain . (2023). Accessed: January 15, 2024: https://www.gov.uk/government/publications/review-of-risk-of-modern-slavery-and-human- trafficking-in-the-nhs-supply-c.... 22. Sedex: A guide to risk assessment in supply chains. Sedex, London, UK; 2020. https://www.sedex.com/app/uploads/2023/02/Sedex-Risk-assessment-in-supply-chains.pdf. 23. van Nierop P, Schönenberg L, Terziev P, et al.: Counteracting undeclared work and labour exploitation of third-country national workers. European Labour Authority, Bratislava, Slovakia; 2021. 24. United States of America et al v. Smith & Nephew, Inc. . (2010). Accessed: April 21, 2022: https://docs.justia.com/cases/federal/district-courts/tennessee/tnwdce/2:2008cv02832/51948/45. 25. Settlement Agreement: United States of America; Medtronic and Relators . (2015). Accessed: April 21, 2022: https://www.justice.gov/usao-mn/file/776976/dl?inline. 26. Varas A, Varadarajan R, Goodrich J, Yinug F: Strengthening the global semiconductor supply chain in an uncertain era. Semiconductor Industry Association, Washington (DC); 2021. 27. European Commission: proposal for a directive on corporate sustainability due diligence and annex . (2022). Accessed: April 21, 2022: https://commission.europa.eu/publications/proposal-directive-corporate- sustainability-due-diligence-and-annex_en. 28. Fochesato E: Origin marking in the European Union: mandatory or voluntary?. Glob Trade Customs J. 2018, 13:263-6. 10.54648/gtcj2018028 29. Drew J, Christie SD, Tyedmers P, Smith-Forrester J, Rainham D: Operating in a climate crisis: a state-of- the-science review of life cycle assessment within surgical and anesthetic care. Environ Health Perspect. 2021, 129:76001. 10.1289/EHP8666 30. Gardner TA, Benzie M, Börner J, et al.: Transparency and sustainability in global commodity supply chains. World Dev. 2019, 121:163-77. 10.1016/j.worlddev.2018.05.025 2024 Abbott et al. Cureus 16(2): e54258. DOI 10.7759/cureus.54258 32 of 32