How Covid-19 disrupts vital supplies
During the Covid-19 outbreak, one of the things that has been top of mind for me as a GP has been whether our national ‘‘stockpile’’ of medications will be adequate to see us through the coming months until the world returns to something closer to normality.
Every few days I receive some form of communication from a pharmacy, a patient or Pharmac, stating that a particular drug has no or limited availability, and it has made me acutely aware of how vulnerable as a country we are to disruptions of global supply chains.
The reality is that New Zealand is a very small and geographically isolated country, and it buys only 0.1 per cent of the world’s pharmaceutical products.
Nearly all the medicines we consume are manufactured overseas, which means we are vulnerable to global issues that can interfere with the production of these drugs and their distribution.
This can happen for a variety of reasons: natural disasters, unexpected lack of raw materials, industrial issues at manufacturing plants, changes in international regulations, fluctuations in demand for particular drugs from other countries, as well as pandemics.
As is the case with Covid-19, these events are usually outside our control, and ensuring that we have a planned, safe and thoughtful approach to managing our national medication stocks is the only way to deal with these unexpected crises.
New Zealand’s supply chain for medicines differs from those of many other countries and, in the main, I think works pretty well, given our size and relative unimportance as a global buyer.
Pharmac is the government agency that decides which medicines and medical products are funded, a role that involves wide consultation with specialty groups of providers and consumers.
Once it has made those decisions, Pharmac then needs to ensure that the medications it has chosen to fund are readily accessible to the people who will benefit from them.
It does this by entering into supply agreements with different pharmaceutical companies around the world. These agreements set out the price we will pay for a particular drug, and also put the responsibility for managing the supply of stocks on to the drug companies, not us.
For most medicines, these agreements include an assurance that two months’ worth of stock will be available in New Zealand at any one time and, on top of this, there is usually another few weeks’ extra in the supply chain (for example, sitting on pharmacists’ shelves).
In normal times, this is usually plenty to enable alternative arrangements to be made if a glitch occurs.
During the Covid-19 outbreak, multiple disruptions have occurred all over the world, meaning that ‘‘business as usual’’ in the supply chain of medications just isn’t happening.
Huge manufacturing countries like China have been ‘‘frozen’’ for weeks in lockdown and production of drugs has been halted.
Transport has been paralysed and, as an island nation, air and sea freight is particularly crucial for us. Add to this, the tendency for us all to ‘‘stockpile’’ a bit at the moment, and it’s easy to see how supplies could be running low.
The good news is that we do have visibility around what is available and what isn’t, and we usually have a ‘‘heads up’’ if there will be a shortage, enabling us to put contingency plans into place.
At present, the list of drugs affected isn’t huge, thankfully. It includes among others, an antibiotic, some contraceptives (for which there are similar alternatives available), condoms, a drug used to treat Parkinson’s disease, a second-line drug for ADHD, and paracetamol.
Business as usual in the supply chain of medications just isn’t happening.
The full list is updated regularly for anyone who is interested.
To pre-empt shortages – and manage supply of the medications on that list – Pharmac has already brought into play a number of protective measures. These include:
■ Ensuring that suppliers notify Pharmac if there is the possibility of stocks running low for any medication. This effectively gives time for Pharmac to come up with contingency plans and look for alternative drugs if needed (and as per the contracts, the onus is then on the supplier to fund these alternatives until the original medication is available again).
■ Limiting amounts of regular medicines that can be dispensed by pharmacies to avoid the temptation to stockpile. As of March 26, pharmacists are now only able to dispense a month’s worth of any medication at a time. The only exception to this is the oral contraceptive pill, where three months’ supply at one time is allowed. Before lockdown, usual amounts were three months for routine medicines and six months for the contraceptive pill. This move should ensure that everyone has plenty of supply, yet no-one runs out before our stocks are replenished.
■ Limiting quantities of paracetamol to a smaller amount than usual. Unfortunately, the manufacturing plants in China that produce paracetamol have been shut temporarily because of Covid-19. To deal with the likely reduction in supply, there is now a limit on the amount of this medicine that can be dispensed. Instead of being able to hand out the maximum quantity that someone might use in a three-month period, pharmacists are limited now to dispensing
100 tablets at a time.
■ Removing some ‘‘special authority’’ clauses that exist for certain medicines. Pre-lockdown, there were a number of medications that required approval by a specialist before they could be prescribed. This process takes time, as scripts need to be requested much earlier by patients, and actioned more quickly by GPs, before the medicine actually is dispensed by the pharmacy. To try to streamline this – and avoid patients missing out during lockdown – many of these ‘‘special authorities’’ have been temporarily waived.
■ Considering suitable alternatives when supplies do get low. A good example of this is a medication called Noriday, a progestogerone-only contraceptive. The supplier, Pfizer, had issues around incoming stocks of Noriday before Covid-19 and this has now been exacerbated by global lockdown. Pharmac has consulted with its advisers and has been informed that another similar pill, called Microlut, is equally effective and works in much the same way, with the same side-effect profile.
It is possible that supplies of many medications might be impacted, temporarily or even permanently, in the coming months, as the world grapples with the ongoing effects of Covid-19.
Ensuring we are all properly informed about this in a timely way, and have access to good advice and support from our GPs and other health providers, will be crucial to enable us to adapt with the minimal amount of harm.