Pharmaceutical Supply Chain Vulnerabilities and Access to Diabetes Medicines in Puerto Rico: Chain-Business-Trade (CBT) Analysis

Abstract

Puerto Rico plays a dual role in the global pharmaceutical system. It serves both as a manufacturing and export hub and as a healthcare system reliant on imported essential medicines. This dissertation analyzes the structure, concentration, and trade dependency of pharmaceutical supply chains for diabetes medicines in Puerto Rico. The analysis integrates import and export flows using the Chain-Business-Trade (CBT) framework and extends it to address sustainability. The study relies on shipment-level Bill of lading (BoL) data, Harmonized System (HS) codes, Broad Economic Categories (BECs), and trade statistics. These sources are used to map pharmaceutical supply chains and trade flows. The dissertation includes two empirical articles on import and export supply chains for diabetes treatment. The first article analyzes supply chains for insulin and imported oral antidiabetic medications. Findings show that most pharmaceutical imports arrive from European and Caribbean ports. Finished insulin products under HS code 30043100 mainly come from the United States. Concentration indices and the Herfindahl-Hirschman Index (HHI) are used to measure concentration at the supplier, logistics firm, port-of-lading, and route levels. Results highlight vulnerabilities in affordability, trade dependency, and limited redundancy in supply routes. These have the potential to impact access to medicines and the sustainability of the health system under Sustainable Development Goal 3 (SDG 3). The second article studies the export supply chains of diabetes medicines, related pharmaceuticals, and medical devices from Puerto Rico to global markets. Results show that Puerto Rico acts as an export hub in global pharmaceutical distribution networks. These networks reach Asia, Europe, Latin America, and the Caribbean. Export flows are moderately concentrated among destination ports and logistics intermediaries. This means reliance on a limited number of international routes and distribution centers. This dissertation advances the Chain-Business-Trade (CBT) method as a replicable approach to map pharmaceutical supply chains. By integrating trade, logistics, and shipment-level data, the CBT method enables comprehensive analysis. This study contributes to research on supply chains, trade dependency, and sustainability. It shows how the CBT framework reveals structural factors shaping access to and sustainability of the health system, especially in island contexts like Puerto Rico.