While Estonia has had a stockpile model in place for a year, adapted from Finland, Latvia hopes to start stockpiling medicines for general use only next year. Why does Latvia not have a stock of medicines for emergencies? When will the necessary stocks be ready?
Ukrainian pharmacist's experience
"My life before the war was my best, most wonderful life, which is now sadly in the past. We were not prepared for what happened!" Oksana, a Ukrainian woman, begins her story about the Russian invasion of Ukraine more than two years ago in a telephone conversation. "The mass media reported that it was possible. The possibility of an attack was postponed several times, so people started to believe less that it was possible. It was seen as an attempt to intimidate."
At the time, the 29-year-old woman lived with her parents, sister, and grandmother in a private house in the suburb of Kherson, five kilometers from the city center. "But there were people who started collecting alert bags, started building a mini-pharmacy - essential medicines, heart medicine, sedatives. Chronic patients started to build up savings. But there were people who didn't pay much attention."
Oksana is a pharmacist and was a pharmacy manager in Kherson.
On the morning of February 24, she did not go to work. The bombing and chaos had begun. Some workers did come to the pharmacy. Oksana, as the manager, telephoned the staff to ask them to decide whether to leave the approaching front or to stay and work.
"Not all the pharmacies could open because the staff were not going to work. Some pharmacies were even closed for several days. We had to change staff. If a worker lives closer to another pharmacy, he goes to work there."
Shortages of certain medicines quickly began in the early days of the war. Some pharmacies in Kherson never opened and their stock of medicines was not available. People soon broke into them.
"As our town did not produce medicines, we had medicines brought in from other towns. We don't have big warehouses either. We were working with the leftovers we had until February 23. After that, we did not receive any more goods. There were long queues at the pharmacies.
"What I was doing was that our pharmacy chain had an internal accounting system where I could see the leftovers in my pharmacy and also in other pharmacies. I set up a list of regular customers on Viber and coordinated where they could get the medicines they needed. This went some way to reducing unreasonable queues at pharmacies, as people would queue for 2-3 hours in the hope of getting their medicine, but the pharmacy didn't have it at all."
Every day, the pharmacy was running out of more and more medicines.
"We were basically working with leftovers. What we could, we replaced with appropriate medicines. What we couldn't replace... People already started looking for volunteers to deliver medicines along the dangerous roads that connected Kherson with the rest of Ukraine. There was a shortage of antibiotics, dressings. There was a shortage of hormonal preparations to improve thyroid function. Diabetics were very badly affected, because their drugs were bought up first."
People with chronic diagnoses died for lack of medicines. Especially elderly people without a carer by their side.
How long did it take for this to start happening? "Well, you know, I can't give you one hundred percent statistics, but after about three months, when the shortage was felt. A shortage of medicines. When the hospitals started to run out of medicines, yes. After three months," recalls Oksana.
Most state-of-the-art pharmacy in Latvia
Riga East Clinical University Hospital (RAKUS) has the most modern hospital pharmacy in Latvia. It was built during Covid-19. The new multi-storey reinforced concrete building is built into the hospital complex. It is connected by long corridors to the Latvian Oncology Centre and Gaiļezers hospitals, as well as to the Emergency Medicine and Admission Clinic.
"The range of medicines... It's huge. It ranges from ophthalmology, where there are eye drops, to oncology medicines," says Haralds Plaudis, a member of the RAKUS board. "We have 1,500 items in the procurement, but there are around 700 different active substances inside, with different dosage forms," adds Laila Eglīte, Head of Pharmacy Services at RAKUS.
The hospital treats 60,000 inpatients a year, 300,000 outpatients.
The spacious warehouse has shelves along the walls with pyramids and stacks of different medicine packages. Almost every room has unpacked or partially unpacked pallets of medicines in the middle.
Solutions occupy a larger area in the warehouse. Solution is the most common thing in hospitals. The volumes are extremely high.
"With those reserves, it's probably also important to understand that to store and provide tablets for three months, that's one volume. But infusion solutions, let's say what we consume in a week or a month [..] Well, let's be honest, we don't have a solution for three months. We would need another building like this to store it all," said the RAKUS board member.
Besides medicines and solutions, the hospital also needs equipment and materials. Unlike medicines, the law does not require keeping a large reserve. Although the two are inextricably linked.
"To give you an idea of what these volumes are. It's a proper basketball court," says Plaudis. Eglīte adds, "All the goods and devices are here, because - what good is it if you have the medicine but you can't get it into the patient? The fact that we are always talking about stocking medicines is one story, but when it comes to running a hospital, we have to think about that too."
Have the Cabinet regulations during Covid-19 that the hospital should keep a reserve of medicines to cover three months been complied with? "70 percent of it is!" says Eglīte. Professor Plaudis, however, is more optimistic, saying that medicines can be interchanged.
"Infusional solutions - sure, I don't think any hospital can say they have three months' worth of fluids. Then I would be happy to go and see what it looks like," says Plaudis.
Gailezers is a relatively wealthy, well-resourced hospital. What about reserves for smaller hospitals? Jevgēņijs Kalējs, head of the board of the Latvian Hospital Association, said "there are no special funds for this. We reimburse hospitals according to the work done, according to the tariff. And the tariff is €1.4 per day for medicines. That is all. You cannot make any reserves out of that if there is no additional funding. And 1.4 a day... well, you can imagine how much an aspirin costs."
Latvia has lists and working groups
The most important public health issues are assessed at the legislative level by the Subcommittee on Public Health of the Saeima's Social and Labor Affairs Committee. Is this a topical issue for MPs? Andris Bērziņš (Greens and Farmers Union), member of the Subcommittee on Public Health of the Social and Labor Affairs Committee of the Saeima, says: "What about the reserves, this issue has not been discussed in the commission. It has not been discussed."
He agrees that there should be reserves and promises to take decisive action. "It is just like the oil reserves, there are reserves linked to medicines. It is for the Cabinet and the ministry to resolve together. We can monitor it and push them and ask them regularly - yes, it is our responsibility, and that is what we will do!"
The Ministry of Health has a dedicated Sector Crisis Management Unit. It is headed by Juris Raudovs, Head of the Sector Crisis Management Unit at the Ministry of Health (MoH). He says that although Latvia does not have a pharmacy drug reserve system like Estonia, we are not completely without reserves. Latvia also has a multi-tier stock system. "There is an individual level that people have to keep for themselves at home," he says.
It is recommended that everyone who needs to take medicine regularly keep a three-month supply at home.
"The next is the institutional level, hospitals, other medical institutions, where it is stipulated in the relevant laws and regulations where a reserve of one to three months should be kept for continuity of operations. This is already established now. We have made a survey, the results are there, they are also stockpiling these medicines. I am thinking of hospitals," Raudov said, admitting that not all hospitals have a reserve of three months.
The state material reserves under the Ministry of the Interior are also included in the levels of stockpiling of medicines. "Then we have the warehouses of the state material reserves, where it is also planned to replenish both their nomenclature, taking into account the geopolitical situation, and the issue of requesting additional funding, which has been less significantly allocated year after year," Raudovs said.
At the beginning of the conversation, the official is vague about the reserves. However, towards the end he becomes more open. "The fact that there has not been enough funding allocated for this purpose so far, or you could say practically not allocated, then there is the answer. That is why we are talking about it, that is what has been said publicly, and there is nothing to hide here."
Asked whether there are in fact no reserves, Raudovs said: "No, it's not that they are not there - they are not filled to the extent that is required."
Raudov is optimistic that work is progressing rapidly on the pharmacy stock system. A list of critical medicines that should then be stockpiled has now been drawn up.
"[The list] has been prepared, it is not publicly available. There is a working group in the Ministry of Health where sub-groups are reviewing it, and there are consultations with Estonia, Lithuania and Ukrainian colleagues to improve the list so that we are, as they say, on the same page," said Raudovs.
The owners of four large pharmacy chains, which are united in the Pharmaceutical Care Association, are unhappy with the delays by officials. Kristine Jučkoviča is its executive director: "Questions from pharmacists in different companies - what to do when there is a socio-political crisis, such as an attack? What to do then? And then the question arises for managers at different levels - do we have any rules, do we know what to do? And we came to the conclusion that we don't have that information."
These things need to be in order, she says. "When we go to Estonia and see that it is there, we feel a bit sorry why we don't have it," Jučkoviča says.
"In Estonia, it is absolutely clear that pharmacy is also this critical infrastructure, that in time there will be such a national mapping where pharmacies will be, GP practices are also there. In Estonia it has been a political decision where they have set up these processes which are also very well managed and work well," says the executive director of the Latvian Pharmaceutical Care Association.
