Last year, the Department of Health requested the Health Information and Quality Authority (HIQA) to review emergency stockpiling strategies in European countries to inform its development of a national stockpiling strategy for Ireland.
Over 20 years ago, in 2001, the European Commission established the European Union (EU) Civil Protection Mechanism with an aim of protecting EU citizens through the coordination of responses to natural and man-made disasters and crises. In 2019, this mechanism was upgraded with the creation of rescEU, a reserve of assets hosted in 10 EU countries (Belgium, Croatia, Denmark, Germany, Greece, Hungary, Romania, Slovenia, Sweden, and The Netherlands), which may be deployed in response to crises in Europe. This reserve includes shelters, transport and logistics assets, energy supply items, and a stockpile of medical countermeasures (MCMs), (such as vaccines, medicines, medical equipment and diagnostics), to be used in response to health emergencies.
The COVID-19 pandemic further highlighted the need to improve preparedness for emerging health threats. At EU level, the Health Emergency Preparedness and Response Authority (HERA) was established in September 2021 to prevent, detect and rapidly respond to health emergencies; this has included increasing medical, or MCM stockpiling capacity. At a national level, the World Health Organization (WHO) has identified strategic health stockpiles as one of the resources that may be deployed as part of a national response to health emergencies and disasters. Furthermore, both the WHO and HERA have recommended that individual countries develop national MCM stockpiling strategies.
To inform the review for the Department of Health, HIQA looked at stockpiling for public health emergencies in five countries: France, Latvia, Lithuania, the Netherlands and Norway.
We approached this task by interviewing experts from each of the five countries to find out how stockpiling works in their countries. We asked them what they stockpiled in the past, what type of stockpiles they currently have, and how they decide what items to include in their stockpiles. We also asked them how they manage their stockpiles, how they review the cost of stockpiling and how they are linked with European stockpiles.
All five countries reported previous experience in stockpiling, with stockpiles generally evolving over time from a focus on mass casualty incidents to also covering the following: anti-microbial resistance; chemical, biological, radiological and nuclear threats; and pandemic threats. This was very much in line with what we had seen at an EU level as well.
In our report, ‘public health emergencies’ were defined as significant public health events such as the COVID-19 pandemic, where supplies of certain items such as medicines, vaccines, laboratory supplies or other healthcare equipment may be needed quickly in the future.
There are two main approaches to stockpiling, and these include physical or virtual stockpiles. Physical stockpiles are stored in warehouses by governments or institutions, ready for deployment when required. The other main approach is virtual stockpiling; this involves access to a virtual data warehouse where available stock held by various suppliers can be purchased on demand when required.
Our report found that all five countries reviewed use physical stockpiles. These were mainly held by governments, with four countries stating that medical institutions similar to our HSE, also held their own stockpiles. Stockpiles varied in size from a six-week supply to a six-month supply and the majority of stockpiles involved stock rotation, that is, stock was rotated for use prior to its expiry date. They did this via donation to hospitals or charities where goods were close to expiration.
Countries noted that their national stockpiles included products such as: anti-viral medicines, personal protective equipment, intravenous antibiotics, medical devices, and medical countermeasures for chemical, biological, radiological and nuclear threats.
To date, the countries examined have considered physical stockpiles to be less costly and quicker to access than using a virtual stockpile. The countries in this report were not using virtual stockpiles at present, as they found that they were associated with higher costs and there is a risk that stock may not be available very quickly. The use of virtual stockpiles was previously considered by four countries, but none of the countries had implemented this. At the time of interview, these countries were still assessing how this might be implemented. However, a significant number of barriers have been identified, namely cost and storage requirements. One expert described the challenges with implementing virtual stockpiling in their country to date. They explained that the costs quoted by industry for providing a virtual stockpile were prohibitive.
The COVID-19 pandemic changed what some countries include in their stockpiles, with countries stockpiling items such as facemasks, gloves and ventilators since the pandemic. These countries are now deciding if they should keep doing this due to the high costs involved as well as waste from unused stock.
The COVID-19 pandemic changed what some countries include in their stockpiles, with countries stockpiling items such as facemasks, gloves and ventilators since the pandemic.
Three of the countries included in this report had stockpiles of general medicines in place. Legislation requires wholesalers in these countries to hold a minimum amount of stock for certain general medicines. The amount of stock they were required to hold varied from a six-week supply to a four-month supply. Some countries provided compensation to wholesalers to hold these stockpiles, while others imposed fines if wholesalers did not adhere to the stockpiling requirements.
For two of the countries, stockpiling was a longstanding tradition due to geographical and political reasons. Both countries reported that work is currently ongoing to modernise the stockpiling approach.
In one country, historically, the state-owned wholesaler was required to hold a physical stockpile to cover the entire country. This system was reviewed in 2012 and legislation in relation to a new stockpiling approach was enacted in 2015. This legislation mandated that stockpiles for a few critical medicines should be held by commercial wholesalers on behalf of the government. Hospitals and outpatient services were also required to look after their own stockpiling needs. This legislation also put an end to non-rotating stockpiles as they were found to be associated with large amounts of waste.
Another country developed their stockpiling approach in the 1970s, with an initial focus on emergency medicine. This originated from the need to be prepared for mass casualty events, such as major road accidents or industrial incidents. There was a realisation of the need for a fast response and stockpiles were generally linked to emergency services in the main hospitals. This evolved into the development of a centralised national physical stockpile in the 1980s, which also covered pandemic threats. This country now has national non-rotating stockpiles held by the government, which are mainly centralised.
Stockpile locations varied in all five countries. Locations were influenced by factors such as security, required speed of deployment, and stockpile distribution. These are factors worth deep consideration when planning for stockpiles in Ireland.
All five countries had national legislation related to stockpiling, with three countries having regulations requiring wholesalers to hold stockpiles of general medicines while two countries had legislation regulating stockpiles held by government and other public bodies. Procurement methods were different for every country, with three countries reporting the use of national procurement mechanisms or international joint procurement agreements depending on the products required and time constraints. Yet they still faced challenges, such as problems with acquiring sufficient supplies given global shortages of certain products, long lead-in times for products such as vaccines and concerns regarding suppliers’ capacities to honour advance purchase agreements in the event of a crisis.
In two countries, stockpile procurement was the responsibility of national agencies with experience in stockpiling and preparedness. In another country, a hospital procurement group was involved in the process.
All five countries reported that government ministries were ultimately responsible for the governance of national stockpiles. Stockpile management was the responsibility of the associated governing body in most countries. However, one country employed a national stockpile management group, financed by its department of health. Operational delivery, including stockpile distribution, took place through mechanisms such as ministries of health and inter-ministerial collaboration, wholesaler distribution networks, and the national emergency medical service.
Two countries aligned their stockpiling approaches with national pandemic preparedness plans. Five countries participated in EU stockpiling initiatives and four countries reported participation in the European joint procurement agreement. All EU countries stated that having a national stockpile was the highest priority, and that EU stockpiling initiatives complement, rather than replace, national stockpiles. Two countries reported collaborating with neighbouring countries to share certain medical countermeasures. A lack of oversight or coordination of national stockpiles at EU level was noted as a gap in international coordination.
Some countries had suggestions for how Ireland should go about stockpiling. These suggestions included having an expert group to decide what threats to stockpile for, and having a specific team to manage the stockpile on a day-to-day basis. Another suggestion was that stockpiles should be stored in different locations in case access to a particular location is not possible in an emergency situation.
In summary, HIQA’s examination of stockpiling strategies across these five countries offered Ireland a valuable insight into the complexities, challenges, and adaptive measures necessary for effective national preparedness in facing diverse public health emergencies. National stockpiles are a key resource that may be deployed as part of a response to public health emergencies and disasters. However, different approaches to stockpiling are observed internationally, and may be linked to factors including an individual nation’s threat identification, geographical location and healthcare system. As nations navigate evolving threats, the lessons gleaned from these experiences serve as a guidepost for refining and strengthening future stockpiling strategies in Ireland.
Read the full report on hiqa.ie.
Dr Eimear Burke
Public Health Fellow,
Health Technology Assessment Directorate, HIQA
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